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OBJECTIVE: Our study aims to examine the role of multi-disciplinary surgical pause committees (MDSPC) in perioperative planning to reduce adverse postoperative events and mortality rates. SUMMARY BACKGROUND DATA: Frail patients could benefit from preoperative MDSPCs when utilizing risk-benefit ratios for the proposed surgical plan. We examined whether MDSPCs improved clinical outcomes by developing individualized care plans and stratifying patients based on their level of frailty and ability to overcome external stressors. METHODS: We retrospectively collected patient information after MDSPC evaluation, at our medical center for 12 years since 2011. Patient's frailty risk assessment index (RAI) scores were calculated, and survival status was updated. MDSPCs plans were put into the following categories: proceed with the planned surgery (G1), proceed after medical optimization (G2), reduce invasiveness of surgery or anesthesia plan (G3), or adopt a non-surgical approach (G4). Chi-square and independent t-tests were used for categorical and numerical data, respectively. Survival analysis for 30-day (primary endpoint), one-year, and overall mortality rates used Kaplan-Meier. The alpha was set at 0.05. RESULTS: Clinical information was accessed from 12 women and 382 men. The average age was 71±11 years. 87.3% of planned surgical operations were stratified as ASA class III and IV. RAI scores were 36.4±9.6 (G1), similar to 37.4±10.8 (G2) but lower than 41.4±9.3 (G3) and 44.2±9.7 (G4) (P<0.001). Average survival duration was 35 months (G1), 35 months (G2), both significantly longer than 20 months (G3) and 18 months (G4) (P<0.001). CONCLUSION: Medical optimization improved overall survival and reduced death within 30 days and one year to be comparable to G1. Additionally, reducing the surgical invasiveness only improved survival advantage for six months, after which it was comparable to those in G4 with the worst outcome. RAI scoring is an excellent tool to predict the outcome of surgery, and it was used successfully in critically ill patients.
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OBJECTIVE: BEST-CLI, an international randomised trial, compared bypass surgery with endovascular treatment in chronic limb threatening ischaemia (CLTI). In this substudy, overall amputation rates and risk of major amputation as an initial or subsequent outcome were evaluated. METHODS: A total of 1 830 patients were randomised to receive surgical or endovascular treatment:(1) patients with adequate single segment great saphenous vein (SSGSV) (n = 1 434); and (2) patients without adequate SSGSV (n = 396). Differences in time to first event and number of amputations were evaluated. RESULTS: In cohort 1, 410 (45.6%) total amputation events occurred in the surgical group vs. 490 (54.4%) in the endovascular group (p = .001) during mean follow up of 2.7 years. Every third patient underwent minor amputation after index revascularisation: 31.5% of the surgical group vs. 34.9% in the endovascular group (p = .17). Subsequent major amputation was required significantly less often in the surgical group compared with the endovascular group (15.0% vs. 25.6%; p = .002). The first amputation was major in 5.6% of patients in the surgical and 6.0% in the endovascular group (p = .72). Major amputation was required in 10.3% (n = 74/718) of patients in the surgical group and 14.9% (n = 107/716) in the endovascular group (p = .008). In cohort 2, 199 amputation events occurred in 132 (33.3%) patients during mean follow up of 1.6 years: 95 (47.7%) in the surgical vs. 104 (52.3%) in the endovascular group (p = .49). Major amputation was required in 15.2% (n = 30/197) of the patients in the surgical and 14.1% (n = 28/199) in the endovascular group (p = .74). CONCLUSION: In patients with CLTI, surgical bypass with SSGSV was more effective than endovascular treatment in preventing major amputations because of a decrease in major amputations subsequent to minor amputations.
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OBJECTIVE: Optimizing medical management and risk factor modification are underused strategies in patients with chronic limb-threatening ischemia (CLTI), despite evidence of improved outcomes. The Vascular Quality Initiative (VQI) registry is a tool to improve quality of vascular care. In this study, we used the VQI to evaluate trends in medical management in patients with CLTI undergoing peripheral vascular interventions (PVI), and the impact of changes in management on overall survival (OS), amputation-free survival (AFS), and limb salvage (LS). METHODS: Patients undergoing index PVI for CLTI between 2012 and 2016, with ≥24 months of follow-up were identified from the national VQI registry. Patient details including smoking status and medication use, OS, LS, and AFS were analyzed with linear-by-linear association, t test, and logistic regression. RESULTS: There were 12,370 PVI completed in 11,466 patients. There was a significant increase in infrapopliteal interventions (from 29.8% to 39.0%; P < .001) and PVI performed for tissue loss (from 59.1% to 66.5%; P < .001). The percentage of current smokers at time of PVI decreased (from 36.2% to 30.7%; P = .036). At discharge, statins were initiated in 25%, aspirin in 45%, and P2Y12 therapy in 58% of patients not receiving these medications before PVI. Over the course of follow-up, dual antiplatelet therapy (DAPT) (from 41.1% to 48.0%; P < .001), angiotensin-converting enzyme (ACE) inhibitor (from 46.2% to 51.3%; P < .001), and statin (from 70.4% to 77.5%; P < .001) use increased. Combined DAPT, ACE inhibitor and statin use increased from 33.6% to 39.6% (P ≤ .001). Significant improvement in 24-month OS and AFS was noted (OS, from 90.9% to 93.7% [P = .002]: AFS, from 81.2% to 83.1% [P = .046]), but not LS (from 89.6% to 89.0%; P = .83). Combined therapy with P2Y12 inhibitors, statins and ACE inhibitors was an independent predictor of improved OS (hazard ratio, 0.61; 95% confidence interval, 0.39-0.96; P = .034). DAPT was independent predictor of improved LS (hazard ratio, 0.83; 95% confidence interval, 0.79-0.87; P < .007). CONCLUSIONS: Antiplatelet, ACE inhibitor, and statin use increased over the study period and was associated with improved OS and AFS. LS trends did not change significantly over time, possibly owing to the inclusion of patients with a greater disease burden or inadequate medical management. Medical management, although improved, remained far from optimal and represents an area for continued development.
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Procedimientos Endovasculares , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Enfermedad Arterial Periférica , Humanos , Isquemia Crónica que Amenaza las Extremidades , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Medición de Riesgo , Procedimientos Endovasculares/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/terapia , Isquemia/diagnóstico , Isquemia/terapia , Factores de Riesgo , Recuperación del Miembro , Inhibidores de la Enzima Convertidora de Angiotensina , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Statin therapy is recommended in all patients with peripheral arterial disease (PAD). Its impact on reduction in mortality has been well-documented, yet effect on limb-specific outcomes has been less conclusive. Differences among PAD subgroups or variability of statin use may contribute to the inconsistent findings. We evaluated statin use in patients who underwent peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI) and its impact on overall survival (OS), amputation-free survival (AFS) and limb salvage (LS). METHODS: The national Vascular Quality Initiative was queried for the index PVI for CLTI during the period 2010-2016; follow-up (FU) through 2020. Demographics, comorbidities, operative details, and FU status were recorded. Patients were categorized as E-Statin: statin use pre-PVI through discharge (D/C) and FU or N-Statin: No statins pre-PVI, at D/C or any time during FU. The propensity score matched model (PSM) was constructed. Groups were compared using chi-square, Kaplan-Meier survival and Cox regression analysis. RESULTS: There were 9,089 index PVI in 8,402 patients; E-Statin: 7149 index PVI in 6,591 patients; and N-Statin: 1940 index PVI in 1811 patients. The mean age was 69 ± 12 years and 58% were male. Statin use was associated with improved 3-year OS-E Statin: 92.9% ± 0.9 versus N Statin: 91.1% ± 2.2%; P = 0.003; hazard ratio (HR): Exp (B) (95% confidence interval): 0.66 (0.44-0.99); P = 0.047 and remained significant following PSM: E Statin: 95.1% ± 0.2% versus 90.8% ± 0.3%; P = 0.02; HR: 0.50 (0.27-0.92); P = 0.025. No significant differences in 3-year LS or AFS were noted between the prematched groups; LS: E Statin: 83.7% ± 0.8 versus N Statin: 84.0% ± 1.7%; P = 0.89; HR: 1.09 (0.88-1.35); P = 0.44; AFS-E Statin: 77.2% ± 1.1% versus 76.1% ± 2.5%; P = 0.17; HR: 0.97 (0.79-1.18); P = 0.74. or following PSM: AFS: 80.2% ± 2.8% vs. 74.7% ± 3.9%; P = 0.53, HR: 0.92 (0.72-1.19); P = 0.54; LS 85.3% ± 1.9% vs. 83.5% ± 2.6%; P = 0.51, HR: 1.08 (0.83-1.4); P = 0.57. Statins significantly improved LS among those with renal failure: 67.8% ± 2.6% vs. 59.7% ± 4.4%; P = 0.003; HR: 56 (0.40-0.79); P = 0.001. CONCLUSIONS: Statins are independently associated with improved OS in patients who undergo PVI for CLTI and should be considered for all barring intolerance. Statin use was associated with improved LS in patients with end-stage renal disease. Additional research is needed in this area, particularly, the impact of statin therapy in high-risk CLTI subgroups.
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Procedimientos Endovasculares , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Enfermedad Arterial Periférica , Humanos , Masculino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Femenino , Recuperación del Miembro , Isquemia Crónica que Amenaza las Extremidades , Factores de Riesgo , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Procedimientos Endovasculares/efectos adversos , Resultado del Tratamiento , Isquemia/diagnóstico por imagen , Isquemia/terapia , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/terapia , Estudios RetrospectivosRESUMEN
OBJECTIVE: The objective of the present study was to evaluate radiation safety practices, radiation training, and radiation exposure among senior vascular residents and fellows in Accreditation Council for Graduate Medical Education-accredited programs across the United States. METHODS: Anonymous surveys were sent to all Accreditation Council for Graduate Medical Education program directors to be distributed to postgraduate year 4 to 7 vascular trainees for completion. The survey questions focused on program type (single vs multiple hospital site), familiarity with their radiation officer, formal radiation training, frequency of radiation feedback, use of safety equipment, and adherence to as low as reasonably achievable principles. RESULTS: A total of 95 trainees responded (27% response rate). Of the 95 trainees, 49 (51.6%) had reported they had never met their radiation safety officer, 74 (77.9%) reported they had received formal radiation safety education, 50 (53%) reported receiving feedback regarding their monthly radiation exposure, and 24 (25%) reported never having received such feedback. All the findings were more common among the multiple hospital site program respondents. CONCLUSIONS: It should be of significant concern that such a high number of trainees have been exceeding radiation exposure limits. Programs should strive to reduce radiation exposure through formal training, provision of safety equipment, modeling by attendings of adherence to as low as reasonably achievable principles, and timely feedback on radiation exposure.
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Internado y Residencia , Exposición a la Radiación , Educación de Postgrado en Medicina , Humanos , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Encuestas y Cuestionarios , Estados Unidos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/educaciónRESUMEN
OBJECTIVE: Antiplatelet therapy is recommended in patients with peripheral arterial disease to reduce cardiovascular risk and improve outcomes. However, issues including the drug of choice and use of dual antiplatelet therapy (DAPT) vs monotherapy remain unclear. This study aims to compare the impact of aspirin (ASA) monotherapy, P2Y12 monotherapy, and DAPT on limb salvage (LS), amputation-free survival (AFS), and overall survival (OS) in patients undergoing lower extremity peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). METHODS: The Vascular Quality Initiative PVI registry was used to identify index procedures completed for CLTI between March 1, 2010 and September 30, 2017. Patients were categorized by antiplatelet use at the time of last follow-up. Patients not on antiplatelet therapy were compared with ASA, P2Y12 monotherapy, and DAPT. Propensity score-matched samples were created for direct ASA vs P2Y12 and P2Y12 vs DAPT comparisons; veracity was confirmed by χ2 and Hosmer-Lemeshow tests. Kaplan-Meier and Cox regression were performed for OS, AFS, and LS. RESULTS: A total of 12,433 index PVI were completed for CLTI in 11,503 subjects in the pre-matched sample. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12, and 43% DAPT. Median follow-up was 1389 days. P2Y12 monotherapy was associated with improved outcomes as compared with ASA monotherapy, OS (87.8% vs 85.5%l P = .026; Cox hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.98; P = .03), AFS (79.6% vs 74.8%; P < .001; Cox HR, 0.75; 95% CI, 0.65-0.86; P < .001) and LS (89.5% vs 86.8%; P = .013; Cox HR, 0.74; 95% CI, 0.60-0.91; P = .004). P2Y12 monotherapy and DAPT had comparable OS (87.8% vs 88.9%; P = .62; Cox HR, 0.94; 95% CI, 0.77-1.14; P = .50), AFS (79.6% vs 81.5%; P = .33; Cox HR, 0.92; 95% CI, 0.78-1.07; P = .28), and LS (91.7% vs 89.4; P = .03; Cox HR, 0.80; 95% CI, 0.64-1.00; P = .06). CONCLUSIONS: P2Y12 monotherapy was associated with superior OS, AFS, and LS as compared with ASA monotherapy, and comparable OS, LS, and AFS with DAPT in patients undergoing PVI for CLTI. P2Y12 monotherapy may be considered over ASA monotherapy and DAPT in patients with CLTI, especially in patients with high bleeding risk.
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Aspirina , Enfermedad Arterial Periférica , Aspirina/efectos adversos , Isquemia Crónica que Amenaza las Extremidades , Humanos , Isquemia/diagnóstico , Isquemia/tratamiento farmacológico , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/efectos adversos , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: Patients can choose between open repair and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). However, the factors associated with patient preference for one repair type over another are not well-characterized. Here we assess the factors associated with preference of choice for open or endovascular AAA repair among veterans exposed to a decision aid to help with choosing surgical treatment. METHODS: Across 12 Veterans Affairs hospitals, veterans received a decision aid covering domains including patient information sources and understanding preference. Veterans were then given a series of surveys at different timepoints examining their preferences for open versus endovascular AAA repair. Questions from the preference survey were used in analyses of patient preference. Results were analyzed using χ2 tests. A logistic regression analysis was performed to assess factors associated with preference for open repair or preference for EVAR. RESULTS: A total of 126 veterans received a decision aid informing them of their treatment choices, after which 121 completed all preference survey questions; five veterans completed only part of the instruments. Overall, veterans who preferred open repair were typically younger (70 years vs 73 years; P = .02), with similar rates of common comorbidities (coronary disease 16% vs 28%; P = .21), and similar aneurysms compared with those who preferred EVAR (6.0 cm vs 5.7 cm; P = .50). Veterans in both preference categories (28% of veterans preferring EVAR, 48% of veterans preferring open repair) reported taking their doctor's advice as the top box response for the single most important factor influencing their decision. When comparing the tradeoff between less invasive surgery and higher risk of long-term complications, more than one-half of veterans preferring EVAR reported invasiveness as more important compared with approximately 1 in 10 of those preferring open repair (53% vs 12%; P < .001). Shorter recovery was an important factor for the EVAR group (74%) and not important in the open repair group (76%) (P = .5). In multivariable analyses, valuing a short hospital stay (odds ratio, 12.4; 95% confidence interval, 1.13-135.70) and valuing a shorter recovery (odds ratio, 15.72; 95% confidence interval, 1.03-240.20) were associated with a greater odds of preference for EVAR, whereas finding these characteristics not important was associated with a greater odds of preference for open repair. CONCLUSIONS: When faced with the decision of open repair versus EVAR, veterans who valued a shorter hospital stay and a shorter recovery were more likely to prefer EVAR, whereas those more concerned about long-term complications preferred an open repair. Veterans typically value the advice of their surgeon over their own beliefs and preferences. These findings need to be considered by surgeons as they guide their patients to a shared decision.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Procedimientos Endovasculares/efectos adversos , Factores de Riesgo , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Oportunidad Relativa , Selección de Paciente , Resultado del Tratamiento , Estudios Retrospectivos , Implantación de Prótesis Vascular/efectos adversosRESUMEN
BACKGROUND: Evaluate outcomes following urinary catheter (UC) versus no urinary catheter (NUC) insertion in elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: Retrospective record review of all elective EVAR at a university affiliated medical center over a 5-year period. Statistical analysis included Chi Sq, Independent Student t Test. RESULTS: Six surgeons performed 272 elective EVAR. Three surgeons preferred selective insertion of indwelling UC, such that 86 (32%) EVAR were completed without indwelling urinary catheters (NUC). Differences between NUC versus UC included; male: (86% vs. 70%; P = 0.004), CAD: (45% vs. 33%; p = 0.046), conscious sedation: (36% vs. 8%; P < 0.001), bilateral percutaneous EVAR (PEVAR): (100% vs. 90%; P = 0.01), within ProglideTM IFU guidelines (87% vs 75%; P = .05), major adverse operative event (MAOE): (3.5% vs. 10%; P = 0.05) and mean operative time (185 ± 73 vs. 140 ± 37; P < 0.001). Intra-operative catheterization was never required among NUC. Postoperative adverse urinary events (AUE) were more common among UC (11.4% vs. 8.1%; P = 0.41); with longer times to straight catheterization/reinsertion (1575 ± 987 vs, 522 ± 269 min; P = 0.015) and lower likelihood of eligibility for same day discharge (SDD); (41% vs. 59%; P = 0.008). Ineligibility for SDD was due to AUE in 18% of UC patients. CONCLUSION: Selective preoperative UC insertion should be considered for EVAR, with particular consideration to no preoperative catheterization in men meeting Proglide IFU. Adverse urinary events occurred less frequently among NUC and were identified/ treated earlier. Moreover, AUEs were the most common reason for potential SDD ineligibility among UC patients. Selective policies may facilitate SDD.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/etiología , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Catéteres de Permanencia , Procedimientos Endovasculares/efectos adversos , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Cateterismo Urinario , Catéteres UrinariosRESUMEN
OBJECTIVE: Plateletcrit (PCT) reflects the total platelet mass in blood and can be calculated from a complete blood count. We examined the effect of PCT on outcomes of endovascular and open interventions for chronic limb ischemia. METHODS: Patients who underwent revascularization for chronic limb ischemia (Rutherford categories 3-6) between June 2001 and December 2014 were retrospectively identified. PCT on admission was recorded. Patients and limbs were divided into tertiles of low (0.046-0.211), medium (0.212-0.271), and high (0.272-0.842) PCT. Patency, limb salvage, major adverse limb events, major adverse cardiac events, and survival rates were calculated using Kaplan-Meier analysis and compared with log-rank test. Cox regression analysis was used for multivariate analysis. RESULTS: A total of 1431 limbs (1210 patients) were identified and divided into low PCT (477 limbs in 407 patients), medium PCT (477 limbs in 407 patients), and high PCT (477 limbs in 396 patients) groups. The patients in the high tertile were 2 years older that the patients in the other two tertiles (P = .009). Five-year primary patency was 65% ± 3% in the low-PCT group compared with 55% ± 3% and 51% ± 3% in the medium and high PCT groups, respectively (P = .004). Five-year secondary patency was 81% ± 2% in the low PCT group compared with 82% ± 2% and 72% ± 3% in the medium and high PCT groups, respectively (P = .02). Five-year limb salvage rate was 86% ± 2% in the low PCT group compared with 79% ± 3% and 74% ± 3% in the medium PCT and high PCT groups, respectively (P = .004). Multivariate regression analysis showed that low PCT was independently associated with primary patency after endovascular interventions (hazard ratio, 0.67 [0.47-0.95]; P = .02) but not after open interventions (hazard ratio, 0.72 [0.43-1.21]; P = .21). CONCLUSIONS: High PCT is associated with poor patency and limb salvage rates after interventions for lower extremity chronic limb ischemia. Multivariate regression analysis confirmed association of low PCT with improved primary patency after endovascular interventions but not after open interventions. High PCT may be a marker of increased platelet reactivity and could be used to identify patients at high risk for early thrombosis and failure after interventions.
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Plaquetas , Procedimientos Endovasculares/efectos adversos , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Pruebas de Función Plaquetaria , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Anciano , Amputación Quirúrgica , Enfermedad Crónica , Bases de Datos Factuales , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/sangre , Isquemia/diagnóstico , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
OBJECTIVE: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) reduce the risk of cardiovascular events in patients with peripheral artery disease. However, their effect on limb-specific outcomes is unclear. The objective of this study was to assess the effect of ACE inhibitors/ARBs on limb salvage (LS) and survival in patients undergoing peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). METHODS: The Vascular Quality Initiative registry was used to identify patients undergoing PVI for CLTI between April 1, 2010, and June 1, 2017. Patients with complete comorbidity, procedural, and follow-up limb and survival data were included. Propensity score matching was performed to control for baseline differences between the groups. LS, amputation-free survival (AFS), and overall survival (OS) were calculated in matched samples using Kaplan-Meier analysis. RESULTS: A total of 12,433 limbs (11,331 patients) were included. The ACE inhibitors/ARBs group of patients had significantly higher prevalence of coronary artery disease (31% vs 27%; P < .001), diabetes (67% vs 57%; P < .001), and hypertension (94% vs 84%; P < .001) and lower incidence of end-stage renal disease (7% vs 12%; P < .001). Indication for intervention was tissue loss in 64% of the ACE inhibitors/ARBs group vs 66% in the no ACE inhibitors/ARBs group (P = .005). Postmatching survival analysis at 5 years showed improved OS (81.8% vs 79.9%; P = .01) and AFS (73% vs 71.5%; P = .04) with ACE inhibitors/ARBs but no difference in LS (ACE inhibitors/ARBs, 88.3%; no ACE inhibitors/ARBs, 88.1%; P = .56). After adjustment for multiple variables in a Cox regression model, ACE inhibitors/ARBs were associated with improved OS (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .03) and AFS (hazard ratio, 0.92; 95% confidence interval, 0.84-0.99; P = .04). CONCLUSIONS: ACE inhibitors/ARBs are independently associated with improved survival and AFS in patients undergoing PVI for CLTI. LS rates remained unaffected. Further research is required to investigate the use of ACE inhibitors/ARBs in this population of patients, especially CLTI patients with other indications for therapy with ACE inhibitors/ARBs.
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Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Procedimientos Endovasculares , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Comorbilidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Recuperación del Miembro , Masculino , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: To identify candidates undergoing elective endovascular aneurysm repair (EVAR) of asymptomatic infrarenal abdominal aortic aneurysm who are eligible for early (≤6 hours) hospital discharge or to have EVAR performed in free-standing ambulatory surgery centers. METHODS: A retrospective medical record review of all elective EVAR performed at a university medical center over 5 years was undertaken. Potential candidates for early discharge or to have EVAR performed in a free-standing ambulatory surgery setting were defined as those who used routine monitoring services only or had self-limited minor adverse events (AE) that were identified, treated, and resolved within 6 hours of surgery. Risk factors for ineligibility were determined by logistic regression. Sensitivity, specificity, negative and positive predictive values were measured to determine the veracity of the risk factor profile. RESULTS: There were 272 elective EVARs; the mean patient age was 74 years (range, 52-94 years), and 75% were male. Twenty-five operative major AEs (MAE) occurred in 21 patients (7.7%): bleeding (5.9%), thrombosis (1.8%), and arterial injury (1.8%). Percutaneous EVAR (PEVAR) attempted in 260 patients (96%) was successful in 238 (88%). Failed PEVAR was associated with operative MAE (P < .001). Combined operative/postoperative MAE occurred in 43 patients (15.8%); 17 (6%) required intensive care admission; 88% directly from the operating room/postanesthesia care unit. Only two MAE (0.7%) occurred beyond 6 hours; (congestive heart failure at 24 hours, thrombosis/reoperation at 15 hours). Other AE included nausea (17%), blood pressure alteration (15%), and urinary retention (13%). Need for nonroutine services or treatment of other AE occurred in 131 (48%) patients with 79 (29%) developing or requiring treatment ≥6 hours postoperatively. However, 22 (8%) were treated/resolved in <6 hours; 30 (11%) patients required monitoring only and 36% had no complications, so, overall eligibility for same-day discharge/free-standing ambulatory surgery center was 55%. Failed PEVAR (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.25-4.49; P = .008), PEVAR performed outside of instructions for use (IFU) criteria (OR, 2.84; 95% CI, 1.07-7.56; P = .037), Endologix AFX graft (OR, 1.66; 95% CI, 1.19-2.33; P = .003) were independent predictors of MAE or AE occurring/requiring treatment >6 hours postoperatively; EVAR, which did not require an additional aortic cuff, was associated with a lower incidence (OR, 0.17; 95% CI, 0.04-0.65; P = .01). Neither aortic nor limb IFU were independent predictors. Profiles using PEVAR IFU, PEVAR failure, and graft type demonstrated only moderate sensitivity (63%), specificity (71%), positive predictive value (70%), and negative predictive value (63%). CONCLUSIONS: More than one-half of all patients who undergo EVAR are ready for discharge within 6 hours postoperatively. Failed PEVAR, aortic cuffs, and Endologix AFX graft were independent predictors of MAE or AE occurring/requiring treatment for ≥6 hours. However, sensitivity parameters of this profile were insufficient to advocate EVAR in free-standing ambulatory surgical units at this time, but hospital-based ambulatory admission with same-day discharge would be a viable option because of easy inpatient transition for those requiring continued care.
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Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Endovasculares/efectos adversos , Complicaciones Intraoperatorias/epidemiología , Selección de Paciente , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Aorta Abdominal/cirugía , Enfermedades Asintomáticas/terapia , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Procedimientos Endovasculares/estadística & datos numéricos , Femenino , Humanos , Complicaciones Intraoperatorias/etiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Medición de Riesgo/estadística & datos numéricos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Shared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. METHODS: We performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. RESULTS: Preliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). CONCLUSIONS: Patients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.
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Aneurisma de la Aorta Abdominal , Conocimientos, Actitudes y Práctica en Salud , Anciano , Aneurisma de la Aorta Abdominal/cirugía , Femenino , Humanos , Conducta en la Búsqueda de Información , Masculino , Estudios Prospectivos , AutoinformeRESUMEN
BACKGROUND: Angiotensin-converting enzyme Inhibitors and Angiotensin II Receptor Blockers (ACEI/ARB) reduce the risk of cardiovascular events and mortality in patients with peripheral arterial disease (PAD). However, their effect on limb-specific outcomes is unclear. The objective of this study is to assess the effect of ACEI/ARB on patency and limb salvage in patients undergoing interventions for critical limb ischemia (CLI). METHODS: Patients undergoing infrainguinal revascularization for CLI (Rutherford 4-6) between 06/2001 and 12/2014 were retrospectively identified. Primary Patency (PP), Secondary Patency (SP), Limb Salvage (LS), major adverse cardiac events (MACE), and survival rates were calculated using Kaplan-Meier. Multivariate analysis was performed using Cox regression. RESULTS: A total of 755 limbs in 611 patients (311 ACEI/ARB, 300 No ACEI/ARB) were identified. Hypertension (86% vs. 70%, P < 0.001), diabetes (68% vs. 55%, P = 0.001) and statin use (61% vs. 45%, P < 0.001) were significantly greater in the ACEI/ARB group. Interventions were performed mostly for tissue loss (83% ACEI/ARB vs. 84% No ACEI/ARB, P = 0.73). Comparing ACEI/ARB versus No ACEI/ARB, in femoropopliteal interventions, 60-month PP (54% vs. 55%, P = 0.47), SP (76% vs. 75%, P = 0.83) and LS (84% vs. 87%, P = 0.36) were not significantly different. In infrapopliteal interventions, 60-month PP (45% vs. 46%, P = 0.66) and SP (62% vs. 75%, P = 0.96) were not significantly different. LS was significantly greater in ACEI/ARB (75%), as compared to No ACEI/ARB (61%) (P = 0.005). Cox regression identified diabetes (HR 2.4 (1.4-4.1), P = 0.002), ESRD (HR 3.5 (2.1-5.7), P < 0.001), hypertension (HR 0.4 (0.2-0.6), P < 0.001), and ACEI/ARB (HR 0.6 (0.4-0.9), P = 0.03), as factors independently associated with LS after infrapopliteal interventions. Freedom from MACE (ACEI/ARB 37% vs. 32%, P = 0.82) and overall survival (ACEI/ARB 42% vs. 35% No ACEI/ARB, P = 0.84) were not significantly different. CONCLUSIONS: ACEI/ARB is associated with improved limb salvage in CLI patients undergoing infrapopliteal interventions, but not after femoropopliteal interventions. ACEI/ARB had no impact on patency rates. They were also associated with a trend toward improved survival and freedom from MACE. Our findings suggest that the use of ACEI/ARB may improve outcomes in the high-risk CLI patient population.
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Angioplastia de Balón , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Endarterectomía , Arteria Femoral/cirugía , Recuperación del Miembro , Enfermedad Arterial Periférica/terapia , Arteria Poplítea/cirugía , Vena Safena/trasplante , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Antagonistas de Receptores de Angiotensina/efectos adversos , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Constricción Patológica , Bases de Datos Factuales , Endarterectomía/efectos adversos , Endarterectomía/mortalidad , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Recuperación del Miembro/efectos adversos , Recuperación del Miembro/mortalidad , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Supervivencia sin Progresión , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Grado de Desobstrucción VascularRESUMEN
For patients with abdominal aortic aneurysm (AAA), randomized trials have found endovascular AAA repair (EVAR) is associated with lower perioperative morbidity and mortality than open surgical repair (OSR). However, OSR has fewer long-term aneurysm-related complications, such as endoleak or late rupture. Patients treated with EVAR and OSR have similar survival rates within two years after surgery, and OSR does not require intensive surveillance. Few have examined if patient preferences are aligned with the type of treatment they receive for their AAA. Although many assume that patients may universally prefer the less-invasive nature of EVAR, our preliminary work suggests that patients who value the lower risk of late complications may prefer OSR. In this study, called The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial, we describe a cluster-randomized trial to test if a decision aid can better align patients' preferences and their treatment type for AAA. Patients enrolled in the study are candidates for either endovascular or open repair and are followed up at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine patients' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will assess alignment between patients' preferences and the repair type elected and then compare the impact of a decision aid on this alignment between the intervention and control groups. This study will help us to accomplish two goals. First, we will better understand the factors that affect patient preference when choosing between EVAR and OSR. Second, we will better understand if a decision aid can help patients be more likely to receive the treatment strategy they prefer for their AAA. Study enrollment began on June 1, 2017. Between June 1, 2017 and November 1, 2018, we have enrolled 178 of a total goal of 240 veterans from 20 VA medical centers and their vascular surgery teams across the country. We anticipate completing enrollment in PROVE-AAA in June 2019, and study analyses will be performed thereafter.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Conducta de Elección , Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares , Prioridad del Paciente , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Estudios Multicéntricos como Asunto , Complicaciones Posoperatorias/etiología , Valor Predictivo de las Pruebas , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Estados Unidos , Servicios de Salud para VeteranosRESUMEN
Hepatic artery aneurysm (HAA) is a rare form of visceral artery aneurysm. Historically, most HAAs were ruptured at presentation, but advances in imaging have led to an increase in the diagnosis of asymptomatic HAAs. Description of the natural history of patent HAAs has been difficult because of their rarity, even more so for less common thrombosed HAAs. We report the case of a 74-year-old man who experienced the rupture of a previously thrombosed HAA. He was successfully surgically treated with ligation of the aneurysm. Our case provides insight into the progression and management of thrombosed HAAs.
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Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Arteria Hepática , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Anciano , Medios de Contraste , Progresión de la Enfermedad , Humanos , Ligadura , Masculino , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Pre-emptive selective embolization of inferior mesenteric artery (IMA), lumbar arteries (LAs), and perigraft sac for prevention of type II endoleak (T2EL) has not been widely adopted. We perform pre-emptive nonselective perigraft aortic sac embolization with coils (PNPASEC) in patients at high risk for development of T2EL (four or more patent LAs, patent IMA ≥3 mm, and ≥30-mm aortic flow lumen). The goal of this study was to see whether PNPASEC decreases T2ELs requiring reinterventions. METHODS: All 266 patients undergoing elective endovascular aneurysm repair between September 1, 2007, and October 31, 2015, were retrospectively evaluated from a prospectively maintained database. Patients (N = 212; 211 men) with preoperative and postoperative contrast-enhanced computed tomography scans were included. Our PNPASEC technique involves leaving a wire in the sac after cannulation of the contralateral gate and inserting large (0.035-inch) coils into the sac after bifurcated graft deployment. T2EL and reintervention rates were compared between patients who underwent PNPASEC (group I) and those who met the criteria but did not have PNPASEC (group II) and those who did not meet the criteria (Group III). RESULTS: Forty-seven (22.2%) patients were PNPASEC candidates and 165 (77.8%) patients (group III) were not. Among PNPASEC candidates, 16 (7.5%) underwent PNPASEC (group I) and 31 (14.6%) did not (group II). There were no significant differences between groups in terms of comorbidities, aneurysm size, and anatomic and neck characteristics. Mean number of patent LAs was similar between group I (4.5 ± 0.8) and group II (4.5 ± 0.9), which was significantly greater than in group III (1.9 ± 1.3; P < .001); 43.6% of group III patients had patent IMA. Mean follow-up was 44 ± 25 months. T2EL at 6 months was observed in 48.4% in group II, 3.0% in group III, and 6.3% in group I (P < .001). Sac diameter increase was seen in 38.7% in group II vs 6.1% in group III and 6.3% in group I (P < .001), with complete sac shrinkage in 23.3% in group II vs 23.8% in group III and 50.0% in group I (P = .09). T2EL-related interventions were performed in 29.0% in group II vs 1.2% in group III and 6.3% in group I (P < .001). Any endoleak at last follow-up was seen in 25.8% in group II vs 2.4% in group III and none in group I (P < .001). CONCLUSIONS: Nonselective perigraft sac coil embolization in patients at high risk for T2EL (20% of patients undergoing endovascular aneurysm repair) is effective in preventing development of T2EL and is associated with decrease in sac size and reintervention rates.
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Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular , Embolización Terapéutica/instrumentación , Endofuga/prevención & control , Procedimientos Endovasculares , Vértebras Lumbares/irrigación sanguínea , Arteria Mesentérica Inferior , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Bases de Datos Factuales , Embolización Terapéutica/efectos adversos , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Masculino , Arteria Mesentérica Inferior/diagnóstico por imagen , Arteria Mesentérica Inferior/fisiopatología , Persona de Mediana Edad , Factores Protectores , Flujo Sanguíneo Regional , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Implantación de Prótesis Vascular , Endofuga , Procedimientos Endovasculares , Humanos , Endofuga/prevención & control , Endofuga/etiología , Endofuga/diagnóstico por imagen , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Resultado del Tratamiento , Implantación de Prótesis Vascular/efectos adversos , Factores de Riesgo , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Stents , Masculino , Prótesis Vascular , AncianoRESUMEN
BACKGROUND: Surgical revascularization is the mainstay treatment in treating most traumatic arterial injuries, and autologous great saphenous vein is widely regarded as the conduit of choice. However, the use of the great saphenous vein may be limited by many factors, and there are little data to guide management in this setting. Bovine carotid artery graft (Artegraft, Inc., North Brunswick, NJ, USA) is a biologic conduit that has been used in select trauma cases at our center. The objective of this study was to review and compare our experience with autologous vein and bovine carotid artery in traumatic arterial injuries requiring bypass or interposition. METHODS: This is a retrospective review of all patients with a traumatic arterial injury repaired with autologous vein or bovine carotid artery graft at a single center between April 2014 and October 2016. Outcomes of interest included differences in duration of ischemia, operative times, patency, limb salvage, graft-related complications, and functional status. RESULTS: Thirty patients were included in this study. Seventeen (57%) injuries were to the lower extremity (LE) and 13 (43%) to the upper extremity. Bovine carotid artery graft was used as a conduit in 12 (40%) cases, while autologous vein was used in 18 (60%) patients. Patients were predominantly male (90%). Mean age was 31 ± 15 years. Comorbidities did not differ significantly between the groups. Mean follow-up duration was 19 ± 13 months. Overall primary patency was 82%: bovine versus autologous vein (78% vs. 85%; P = 0.68). Overall secondary patency was 91%: bovine versus autologous vein (78% vs. 100%; P = 0.16). Overall limb salvage was 90%: bovine versus autologous vein (82% vs. 94%; P = 0.28). When comparing bovine carotid artery graft to autologous vein in LE interventions, primary patency (50% vs. 71%; P = 0.40), secondary patency (75% vs. 100%; P = 0.23), and limb salvage (80% vs. 86%; P = 0.76) did not differ significantly. There were no early or late graft infections with either conduit. There were no significant differences in ambulatory status at discharge by graft type. Overall survival was 100%. CONCLUSIONS: In this series, there is a trend toward improved patency and limb salvage with autologous vein. Autologous vein should be the standard of care for revascularization of traumatic arterial injuries. Bovine carotid artery graft appears be a viable alternative, especially in patients requiring urgent revascularization, that does not significantly compromise patency, limb salvage, or functional outcomes.
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Arterias Carótidas/trasplante , Injerto Vascular , Lesiones del Sistema Vascular/cirugía , Venas/trasplante , Adolescente , Adulto , Animales , Autoinjertos , Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/fisiopatología , Bovinos , Femenino , Supervivencia de Injerto , Xenoinjertos , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Grado de Desobstrucción Vascular , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/fisiopatología , Venas/diagnóstico por imagen , Venas/fisiopatología , Adulto JovenRESUMEN
BACKGROUND: The incidence of cardiovascular and limb-specific adverse outcomes is higher in peripheral arterial disease (PAD) patients with diabetes. Metformin is associated with improved cardiovascular morbidity and mortality. However, the effect of metformin on limb-specific outcomes is unclear. The objective of this study was to assess the effect of metformin on outcomes after intervention for PAD. METHODS: Patients who underwent revascularization for chronic limb ischemia (Rutherford 3-6) between June 2001 and December 2014 were retrospectively identified. Primary patency (PP), secondary patency (SP), limb salvage (LS), major adverse limb events (MALE), major adverse cardiac events (MACE), and survival rates were compared using Kaplan-Meier and Cox regression. RESULTS: One thousand sixty-four limbs in 1204 patients were identified (147 metformin, 196 other hypoglycemics [OH], 216 insulin, and 645 nondiabetics (nondiabetes mellitus [DM]). Non-DM had significantly lower incidence of CAD (46%) than insulin (65%), metformin (56%), and OH groups (63%) (P < 0.001). Insulin patients (17%) had significantly higher incidence of end-stage renal disease (ESRD) than non-DM (3%), metformin (1.4%), and OH groups (8%) (P < 0.001). Ninety four percent of patients in the metformin group were on aspirin, which was significantly higher than non-DM (86%), OH (83%), and insulin groups (86%) (P = 0.02). Similarly, statin use was significantly higher in the metformin group (71%) than in OH (64%), insulin (61%), and non-DM groups (55%) (P = 0.002). Majority of patients in the insulin group presented with critical limb ischemia (CLI) (93%), which was significantly greater than the metformin (59%), OH (72%), and non-DM groups (50%) (P < 0.001). Sixty-month PP was significantly greater in non-DM group (62%) (P = 0.005) in overall comparison with no significant difference between metformin (56%), OH (60%), and insulin (51%) groups (P = 0.06). Sixty-month SP was similar in metformin (76%), OH (85%), insulin (76%), and non-DM (80%) groups (P = 0.27). LS was significantly worse in insulin group (62%) (P < 0.001) with no significant difference between metformin (84%), OH (83%), and non-DM (87%) groups (P = 0.45). Freedom from MALE at 60 months was 53% in the insulin group, which was significantly worse as compared with metformin (71%), OH (70%), and non-DM (67%) groups (P = 0.001). Sixty-month survival was significantly improved in metformin (60%) and non-DM (60%) groups as compared with that in OH (41%) and insulin groups (30%) (P < 0.001). Freedom from MACE was significantly greater in metformin (44%) and non-DM (52%) groups than that in OH (37%) and insulin groups (25%) (P < 0.001). Metformin use (HR, 0.7 [0.5-0.9]; P = 0.008) was an independent factor associated with freedom from mortality. CONCLUSIONS: Metformin is associated with improved survival and decreased incidence of adverse cardiac events in PAD patients. However, it did not have an impact on patency or LS rates after open and endovascular interventions. LS was worse in diabetic patients primarily treated with insulin.
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Diabetes Mellitus/tratamiento farmacológico , Procedimientos Endovasculares , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Isquemia/cirugía , Recuperación del Miembro , Metformina/uso terapéutico , Enfermedad Arterial Periférica/cirugía , Injerto Vascular , Grado de Desobstrucción Vascular/efectos de los fármacos , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Enfermedad Crónica , Comorbilidad , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Hipoglucemiantes/efectos adversos , Incidencia , Insulina/efectos adversos , Isquemia/diagnóstico , Isquemia/mortalidad , Isquemia/fisiopatología , Masculino , Metformina/efectos adversos , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidadRESUMEN
The neutrophil-lymphocyte ratio (NLR), as a marker of inflammation, is associated with the severity of peripheral artery disease (PAD). The role of the NLR on predicting future complications after elective revascularization for patients with PAD remains unknown. We aimed to examine the role of the NLR in the development of major adverse limb events (MALE) and the long-term mortality of these patients. We evaluated 1708 revascularization procedures from May 2001 to December 2015 at the Veterans Affairs Western New York Healthcare System from a prospectively maintained vascular database that included demographics, comorbidities and pre-procedural medications. Peri-procedural laboratory findings including complete blood cell count and metabolic panel were further retrieved from the electronic health record. The NLR was calculated, and the patients were categorized into tertiles according to NLR cut-off points. Multivariate Cox regression analysis was performed to determine MALE and 10-year mortality. The primary endpoint of the study was MALE, and the secondary endpoint included 10-year mortality. A total of 1228 patients were included for final analyses. Patients in the third NLR tertile were more likely to experience MALE during the follow-up period ( p<0.001). In addition, fewer patients in tertile 3 survived over the follow-up period compared to tertiles 1 and 2 ( p<0.0001). Patients in tertile 3 tended to be older with a higher frequency of hypertension, diabetes, chronic kidney disease, coronary artery disease and congestive heart failure. Our multivariate analysis demonstrated that the NLR was independently associated with higher rates of MALE in the affected vessels following revascularization procedures. Similarly, the NLR was revealed to be an independent predictor of higher long-term mortality in these patients.