A Percutaneous Crossing Algorithm for Femoropopliteal and Tibial Artery Chronic Total Occlusions (PCTO Algorithm).

Peripheral artery chronic total occlusions (PCTOs) are frequently encountered during endovascular treatment of peripheral artery disease. Failure to successfully cross PCTOs accounts for the majority of unsuccessful endovascular procedures and associated complications. This review outlines a contemporary ultrasound-based approach to crossing femoropopliteal (FP) PCTOs based on a review of prospectively collected case report surveys, published evidence, and expert opinion compiled by the writing group members. The authors describe optimal imaging of PCTO lesions as well as key angiographic and ultrasound imaging features for determining the choice of antegrade, retrograde, or hybrid techniques, initial guidewire selection, guidewire escalation, and dissection re-entry approaches. These concepts are illustrated using clearly defined hierarchical steps and case examples. The writing group members recognize that while the algorithm provided may not encompass all clinical situations, it will serve as a foundation for establishing a systematic procedural strategy for crossing PCTOs to maximize crossing efficiency, treatment success, and patient safety.

Explaining Racial Disparities in Amputation Rates for the Treatment of Peripheral Artery Disease (PAD) Using Decomposition Methods.

INTRODUCTION: While studies have documented racial and ethnic disparities in amputation rates for patients with peripheral artery disease (PAD), the importance of specific factors has not been quantified. This research seeks to provide such evidence and to quantify how much of the difference reflects observable versus unexplained factors. METHODS: This study used the nationally representative HCUP inpatient database from 2006 to 2013 for patients with a primary diagnosis of PAD who were either Caucasian, African-American, or Hispanic. Multivariable logistic regression models were estimated to identify the determinants of amputation rates. RESULTS: Multivariable results revealed that African-Americans and Hispanics are approximately twice as likely to be amputated as are Caucasians. Observed factors in the models collectively account for 51 to 55 % of the disparities for African-Americans and 64 to 69 % for Hispanics. The results suggest that African-Americans and Hispanics have less access to care, because they are being admitted when sicker and more likely on an emergent basis. CONCLUSIONS: Racial and ethnic disparities in amputation rates are substantial, with disease severity and hospital admission source being key factors.

Patient education level affects functionality and long term mortality after major lower extremity amputation.

BACKGROUND: The aim of this study was to examine the relationship between patient education level and 5-year mortality after major lower extremity amputation. METHODS: The records of all patients who underwent above-knee or below-knee amputation at the Nashville Veterans Affairs Medical Center by the vascular surgery service between January 2000 and August 2006 were retrospectively reviewed. Formal levels of education of the study patients were recorded. Outcomes were compared between those patients who had completed high school and those who had not. Bivariate analysis using χ(2) and Student's t tests and multivariate logistic regression were performed. RESULTS: Five-year mortality for patients who had completed high school was lower than for those who had not completed high school (62.6% vs 84.3%, P = .001), even after adjusting for important clinical factors (odds ratio for death, .377; 95% confidence interval, .164-.868; P = .022). CONCLUSION: Patients with less education have increased long-term mortality after lower extremity amputation.