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1.
Medicine (Baltimore) ; 98(33): e16809, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415395

RESUMO

Patients with peripheral artery disease (PAD) are a heterogeneous population and differ in risk of mortality and low extremity amputation (LEA), which complicates clinical decision-making. This study aimed to develop a simple risk scale using decision tree methodology to guide physicians in managing critical limb ischemia (CLI) patients who will benefit from endovascular therapy (EVT).A total of 736 patients with CLI, Rutherford classification (RC) stage ≥4, and prior successful EVT were included. Variables significantly associated with LEA by univariate analysis (P < .05) were selected and put into classification tree analysis using the Classification and Regression Tree (CART) model with a dependent variable, amputation, and depth of tree = 3. Four risk groups were generated according to the order of amputation rate. The amputation-free survival (AFS) times between groups were compared using the Kaplan-Meier curve with the log-rank test.Patients were classified as high risk for amputation (G4) (WBC counts ≥10,000/µl, and platelet-lymphocyte ratio (PLR) ≥130.337); intermediate risk group 1 (G3) (WBC < 10,000/µl and RC stage before EVT > 5); intermediate risk group 2 (G2) (WBC count ≥ 10,000/µl, and PLR < 130.337) and low-risk group (G1) (WBC < 10,000/µl, RC before EVT ≤ 5). G2, G3, and G4 risk groups had shorter AFS time (range, 58.7 to 65.5 months) than the G1 risk group (100 months) (P < .05). Risk of LEA was significantly higher in the G4, G3, and G2 groups than in the G1 group (P ≤ .05). The G4 group had the highest risk of amputation (odds ratio = 6.84, P < .001).This simple risk scale model can help healthcare professionals more easily identify and appropriately treat patients with CLI who are at different levels of risk for LEA following endovascular revascularization.


Assuntos
Amputação/mortalidade , Isquemia/mortalidade , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/etiologia , Isquemia/cirurgia , Estimativa de Kaplan-Meier , Extremidade Inferior/cirurgia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Doença Arterial Periférica/etiologia , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
2.
Braz J Cardiovasc Surg ; 34(3): 279-284, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-31310465

RESUMO

OBJECTIVE: The purpose of this study was to compare the operative mortality rate and outcomes of endovascular aneurysm repair (EVAR) between young and geriatric people in a single center. METHODS: Eighty-five patients with abdominal aortic aneurysms who underwent EVAR between January 2012 and September 2016 were included. Outcomes were compared between two groups: the young (aged < 65 years) and the geriatric (aged ≥ 65 years). The primary study outcome was technical success; the secondary endpoints were mortality and secondary interventions. The mean follow-up time was 36 months (3-60 months). RESULTS: The study included 72 males and 13 females with a mean age of 71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18 (21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years old. There was no statistically significant correlation between chronic disease and age. We found no statistically significant difference between aneurysm diameter, neck angle, neck length, or right and left iliac angles. The secondary intervention rate was 7% (six patients). The conversion to open surgery was necessary for only one patient and only three deaths were reported (3.5%). There was no statistically significant difference in the mortality and reintervention rates between the age groups. The three deaths occurred only in the geriatric group and two died secondary to rupture. Kidney failure was observed in three patients in the geriatric group (4.5%). CONCLUSION: Our single-center experience shows that EVAR can be used safely in both young and geriatric patients.


Assuntos
Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/métodos , Distribuição por Idade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/cirurgia , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/cirurgia , Valores de Referência , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/cirurgia , Estudos Retrospectivos , Distribuição por Sexo , Resultado do Tratamento
3.
Vasc Med ; 24(4): 332-338, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31195896

RESUMO

Loss to follow-up (LTF) has been associated with worse outcomes after procedures. We sought to identify differences in lower extremity peripheral vascular intervention (PVI) patients with and without LTF, and to determine if LTF impacted survival. Patients in the PVI registry of the Vascular Quality Initiative (VQI) were included (n = 39,342), where t-test and chi-squared analysis were used to compare those with and without LTF. Multivariable logistic regression was used to identify factors associated with LTF while Cox regression analysis was applied to compare survival among those with and without LTF. The overall 1-year follow-up rate was 91.6%. LTF patients were more often male, Hispanic, of black race, and had a higher rate of diabetes, coronary artery disease, congestive heart failure, and dialysis. LTF patients had a higher prevalence of critical limb ischemia, underwent popliteal or distal intervention, and were intervened upon urgently. There was also a higher rate of postoperative complications, and a lower rate of technical success for LTF patients. After controlling for center effects, the independent variables associated with LTF included male sex, age, diabetes, dialysis dependence, ASA class 3 or greater, as well as complications requiring admission. Preoperative aspirin, preadmission home living status, prior carotid intervention, and discharge aspirin were protective against LTF. Adjusted survival analysis showed decreased survival in LTF, with those returning face-to-face surviving longer than those with phone follow-up. Efforts should be focused on understanding these differences to improve follow-up rates and help improve overall survival.


Assuntos
Perda de Seguimento , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos
5.
J Vasc Surg ; 69(6S): 126S-136S, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31159976

RESUMO

BACKGROUND: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. METHODS: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. RESULTS: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. CONCLUSIONS: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.


Assuntos
Implante de Prótese Vascular , Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Veia Safena/transplante , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Intervalo Livre de Progressão , Medição de Risco , Fatores de Risco , Veia Safena/fisiopatologia , Stents , Fatores de Tempo , Grau de Desobstrução Vascular
6.
J Vasc Surg ; 69(6S): 3S-125S.e40, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159978

RESUMO

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.


Assuntos
Cardiologia/normas , Medicina Baseada em Evidências/normas , Isquemia/terapia , Doença Arterial Periférica/terapia , Técnicas de Imagem Cardíaca/normas , Doença Crônica , Consenso , Testes de Função Cardíaca/normas , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Fatores de Risco , Terminologia como Assunto , Resultado do Tratamento
7.
J Vasc Surg ; 69(6): 1863-1873.e1, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159987

RESUMO

BACKGROUND: The overall use of intensive care units (ICUs) in the United States has been steadily increasing and is associated with tremendous health care costs. We suspect that the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) procedures is high, despite relatively low risks of complications in the immediate postoperative period. We sought to identify the burden of ICU utilization after elective LEB in patients with claudication. METHODS: We queried the Premier Healthcare Database for all adult patients undergoing first recorded elective infrainguinal LEB for claudication from 2009 to 2015. Baseline characteristics and ICU utilization on postoperative day 0 (POD 0) were identified for each patient using Premier room and board chargemaster codes. A bivariate logistic regression was performed and postestimation concordance statistics were calculated to identify predictors of postoperative ICU vs regular surgical floor admission immediately after surgery. RESULTS: There were 6010 patients who met the selection criteria, of whom 2772 (46.1%) were admitted to the ICU and 3238 (53.9%) to the regular surgical floor on POD 0. Whereas patient-level factors were responsible for minor differences found in postoperative admission to the ICU after elective LEB, hospital characteristics made up the majority of variation in admission practices. Specifically, patients undergoing elective infrainguinal LEB in rural, nonteaching, small hospitals and those in certain geographic regions were more likely to be admitted to the ICU than to the floor (all, P < .001). Patient-level factors were poorly predictive of admission to the ICU immediately postoperatively, with C statistics ranging from 0.50 to 0.53. In contrast, hospital-level factors had higher C statistics ranging from 0.51 to 0.66, with geographic location being the strongest predictor of post-LEB ICU admission. There were no significant differences in the incidence of postoperative wound complications, major adverse limb events, major adverse cardiac events, or in-hospital mortality between groups (all, P ≥ .32). The median total hospital cost was $2340 higher for ICU compared with floor admission ($13,273 [interquartile range, $10,136-$17,883] vs $10,927 [interquartile range, $8342-$14,523]; P < .001). CONCLUSIONS: Nearly half of patients are admitted to an ICU directly after elective infrainguinal LEB for claudication. This practice is associated with significantly higher hospital cost and is predominantly influenced by hospital-level rather than by patient-level factors. Perioperative morbidity and mortality were similar regardless of postoperative disposition. To minimize ICU utilization, postoperative care intensity should be determined by clinical severity of the patient rather than by hospital routine.


Assuntos
Cuidados Críticos/economia , Custos Hospitalares , Claudicação Intermitente/economia , Claudicação Intermitente/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/economia , Doença Arterial Periférica/cirurgia , Enxerto Vascular/economia , Idoso , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/mortalidade , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/economia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
8.
Diabetes Res Clin Pract ; 152: 9-15, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31078668

RESUMO

AIM: To evaluate the impact of below-the-ankle (BTA) arterial disease in people with ischemic diabetic foot ulcers (DFUs). METHODS: Patients with ischemic DFUs treated by a pre-set limb salvage protocol including peripheral revascularization were included. They were divided in two groups according to the involvement of BTA arteries (BTA+) or not (BTA-). Not healing, minor amputation, major amputation and mortality have been evaluated as primary outcome. Revascularization failure has been evaluated as secondary outcome. RESULTS: The study group was composed of 272 patients, 120 (44.1%) belonging to BTA+ group and 152 (55.9%) to BTA-. After 1 year of follow-up the outcomes for BTA+ and BTA- were respectively: not healing (40.8 vs 17.8%, p < 0.0001), minor amputation (80.8 vs 20.4%, p < 0.0001), major amputation (18.3 vs 6.6%, p = 0.002), mortality (16.7% vs 10.5%, p = 0.001). The rate of revascularization failure was respectively 38.3 vs 11.2%, p < 0.0001. At the multivariate analysis BTA arterial disease resulted an independent predictor of not healing [OR 3.5 (CI 95% 2.3-6.1) p = 0.0001], minor amputation [OR 3.1 (1.5-5.9) p < 0.0001] and revascularization failure [OR 3.5 (1.9-6.3) p = 0.0001]. BTA+ patients with successful BTA revascularization showed lower rate of not healing (37.8 vs 89.1%) p < 0.0001, minor amputation (74.3 vs 91.3%) p = 0.002 and major amputation (8.1 vs 34.8%) p = 0.0003 in comparison to patients with unsuccessful BTA revascularization. CONCLUSION: BTA arterial disease severely impairs the outcomes of diabetics with ischemic foot ulcers. BTA revascularization reduces the rate of not healing, minor and major amputation.


Assuntos
Tornozelo/irrigação sanguínea , Pé Diabético/complicações , Pé Diabético/diagnóstico , Isquemia/complicações , Isquemia/diagnóstico , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Amputação , Tornozelo/patologia , Articulação do Tornozelo/fisiopatologia , Estudos de Coortes , Pé Diabético/mortalidade , Pé Diabético/cirurgia , Feminino , Humanos , Isquemia/mortalidade , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/mortalidade , Prognóstico , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Cicatrização/fisiologia
9.
J Cardiovasc Surg (Torino) ; 60(4): 433-438, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31058479

RESUMO

When the FDA approved the use of a paclitaxel-coated stent in the peripheral arteries in November of 2012, a new era in the treatment of peripheral arterial disease (PAD) emerged. This marked, for the first time in the United States, that a drug-eluting device was available to treat this complex arterial bed, and has likely changed forever how PAD is treated. Prior to this, US physicians had been using drug-eluting stents (DES) in the coronary arteries for 8 years with exceptional results in both safety and efficacy. Since the Zilver®PTX® (Cook Medical, Bloomington, IN USA) was released, multiple drug-coated balloons (DCB) with paclitaxel have been approved in the US, as has another DES, the Eluvia™ stent (Boston Scientific, Minneapolis, MN USA).


Assuntos
Angioplastia com Balão/instrumentação , Stents Farmacológicos , Paclitaxel/administração & dosagem , Doença Arterial Periférica/terapia , Aprovação de Equipamentos , Stents Farmacológicos/efeitos adversos , Humanos , Paclitaxel/efeitos adversos , Paclitaxel/farmacocinética , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/cirurgia , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos , United States Food and Drug Administration
10.
Clin Chim Acta ; 495: 215-220, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30981846

RESUMO

BACKGROUND: Peripheral artery disease (PAD) becomes more prevalent with advancing age and is associated with elevated risk of cardiovascular events and shortened life expectancy. We investigated the prognostic performance of cardiac and vascular biomarkers in a cohort of PAD patients. METHODS: A total of 95 PAD patients were enrolled (mean age 68 years, range 47 to 86 years, 73 males). Carotid intima-media thickness (cIMT), ankle brachial index (ABI), high sensitive cardiac troponin T, and N-terminal pro-B-type Natriuretic Peptide (NT-proBNP) were measured. RESULTS: During a median follow-up time of 9.5 years, 44 patients died and 51 patients survived. Upon Kaplan-Meier survival analysis hs-TnT (P < .001) or NT-proBNP levels (P < .001) above the median but not cIMT above the median (P = .488) or ABI below the median (P < .436)were associated with reduced survival rate. Upon univariate cox regression and after adjustment for age, gender, prior cerebral artery disease, and diabetes mellitus only the association between hs-cTnT and mortality remained significant (HR 1.93, 95% CI 1.33-2.79, P < .001). In receiver operating curve analysis hs-cTnT (area under the curve [AUC]: 0.77, 95% CI: 0.67-0.87, P < .001) NT-proBNP (AUC: 0.74, 95% CI: 0.64-0.84, P < .001) as well as hs-cTnT, and NT-proBNP combined (AUC: 0.79, 95% CI: 0.69-0.88, P < .001) were superior to cIMT (AUC: 0.64, 95%, CI: 0.53-0.76, P = .022) and ABI (AUC: 0.57, 95% CI: 0.44-0.68, P = .313) in discriminating risk for mortality. CONCLUSION: hs-cTnT and NT-proBNP should be taken into account for prognosis of patients with PAD.


Assuntos
Miocárdio/metabolismo , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Idoso , Idoso de 80 Anos ou mais , Índice Tornozelo-Braço , Aterosclerose/complicações , Biomarcadores/sangue , Espessura Intima-Media Carotídea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Doença Arterial Periférica/sangue , Doença Arterial Periférica/complicações , Prognóstico
11.
J Cardiovasc Surg (Torino) ; 60(4): 456-459, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30994309

RESUMO

Superficial femoral and popliteal artery disease are commonly involved in the development of symptomatic PAD. As time has gone on drug coated stents and drug coated balloons have supplanted the plain balloon angioplasty corner stone of therapy with superiority proven in randomized trials. Device approval trials are typically characterized by simple lesions that are less common than the longer complex disease. Registry data has demonstrated benefit of both technologies though drug coated balloons typically require a significant amount of adjunctive stenting in more complex disease. Recently published randomized data is starting to help proceduralists define when each therapy may be more optimal.


Assuntos
Angioplastia com Balão , Arteriopatias Oclusivas/terapia , Stents Farmacológicos , Artéria Femoral/cirurgia , Doença Arterial Periférica/terapia , Artéria Poplítea/cirurgia , Arteriopatias Oclusivas/cirurgia , Aterosclerose/terapia , Procedimentos Endovasculares , Humanos , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/cirurgia , Polímeros , Desenho de Prótese , Resultado do Tratamento , Grau de Desobstrução Vascular
13.
Vasc Med ; 24(3): 251-260, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30823859

RESUMO

Peripheral artery disease (PAD) represents a major health care burden. Despite the advent of screening and interventional procedures, the long-term clinical outcomes remain suboptimal, especially in patients with chronic kidney disease (CKD). While CKD and PAD share common predisposing factors, emerging studies indicate that their co-existence is not merely an association; instead, CKD represents a strong, independent risk factor for PAD. These findings implicate CKD-specific mediators of PAD that remain incompletely understood. Moreover, there is a need to understand the mechanisms underlying poor outcomes after interventions for PAD in CKD. This review discusses unique clinical aspects of PAD in patients with CKD, including high prevalence and worse outcomes after vascular interventions and the influence of renal allograft transplantation. In doing so, it also highlights underappreciated aspects of PAD in patients with CKD, such as disparities in revascularization and higher peri-procedural mortality. While previous reviews have discussed general mechanisms of PAD pathogenesis, focusing on PAD in CKD, this review underscores a need to probe for CKD-specific pathogenic pathways that may unravel novel biomarkers and therapeutic targets in PAD and ultimately improve the risk stratification and management of patients with CKD and PAD.


Assuntos
Doença Arterial Periférica/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Nível de Saúde , Humanos , Incidência , Rim/fisiopatologia , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/cirurgia , Prevalência , Prognóstico , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/terapia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos Vasculares
14.
Ann Vasc Surg ; 58: 54-62, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30910650

RESUMO

BACKGROUND: Sex-related differences in outcomes have been identified in patients with peripheral artery disease (PAD). We hypothesized that women with PAD would have equivalent inpatient mortality with men after vascular intervention. METHODS: Patients with a primary diagnosis of critical limb ischemia (CLI) or lifestyle-limiting claudication (LLC) receiving endovascular (EV) or open surgical repair from 2003-2012 were identified from the Nationwide Inpatient Sample. Demographics, comorbidities, and inpatient mortality were analyzed by chi-squared tests of independence and independent-samples t-tests. Logistic regression analysis was performed to identify predictors of inpatient mortality. SPSS 24 software was used with P < 0.05 considered statistically significant. RESULTS: We identified 139,435 (59,432 women and 80,003 men) individuals meeting the aforementioned criteria. Women were older than men (71.5 years vs. 68.2, P < 0.001). There were no differences in racial distribution but women had lower rates of diabetes (38.6% vs. 39.7%, P < 0.001), chronic obstructive pulmonary disease (17.9% vs. 19.5%, P < 0.001), and coronary artery disease (38.6% vs. 47.4%, P < 0.001), while having a higher rate of hypertension (60.0% vs. 56.1%, P < 0.001). There was no sex-related difference in the rate of chronic renal failure. Women had higher inpatient mortality than men after vascular intervention (1.3% vs. 1.1%, P < 0.001). When stratified by surgical technique, women also had higher inpatient mortality after EV repair (1.0% vs. 0.8%, P < 0.05) and open repair (1.9% vs 1.3%, P < 0.001). When separated by admitting diagnosis, women with CLI had higher inpatient mortality than men after open surgery (2.3% vs. 1.9%, P < 0.05) but not after EV intervention. Women with LLC had higher inpatient mortality after both open (0.6% vs. 0.3%, P < 0.05) and EV surgery (0.3% vs. 0.1%, P < 0.05). Regression analysis revealed female sex as an independent predictor of inpatient mortality in patients with LLC (OR, 1.74; 95% CI 1.30-2.32, P < 0.001) but not CLI. CONCLUSIONS: Women had higher inpatient mortality than men after vascular intervention for PAD. Women were also older and more likely to have EV intervention than men. Subgroup analysis suggests that these sex-related differences in inpatient mortality are more pronounced in patients with LLC than with CLI. Furthermore, regression analysis shows that sex is a significant predictor for patients diagnosed with LLC but not with CLI. Treatment guidelines should include consideration of sex in their indications for revascularization, particularly for patients diagnosed with LLC.


Assuntos
Mortalidade Hospitalar , Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Admissão do Paciente , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/mortalidade , Fatores Etários , Idoso , Comorbidade , Estado Terminal , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Disparidades nos Níveis de Saúde , Mortalidade Hospitalar/tendências , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/mortalidade , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/tendências
15.
Ann Vasc Surg ; 58: 63-77, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30910651

RESUMO

BACKGROUND: Lower extremity revascularization is the gold standard for treatment of symptomatic peripheral arterial disease. The objective of this study was to examine the impact of race on 30-day outcomes among patients with peripheral arterial disease who have undergone open lower extremity bypass. METHODS: Data were obtained from the 2013 American College of Surgeons National Surgical Quality Improvement Program database using Procedure Participant User File. Patients were divided into three groups based on race: white, African American, and Hispanic. Bivariate analysis was done for preoperative, intraoperative, and postoperative risk factors among races. Multivariable analysis was used to determine associations of independent variables with mortality and lower extremity amputation as primary outcomes. RESULTS: A total of 2,381 patients (31.9% Females, 68.1% Males) were identified in the National Surgical Quality Improvement Program database who underwent lower extremity bypass in the year 2013. Among these patients, 1,732 (72.74%) were non-Hispanic white, 488 (20.50%) were non-Hispanic African American, and 161 (6.76%) were Hispanic. African American patients were more likely to have hypertension, be on dialysis, and present with rest pain and tissue loss (P < 0.001). They were also more likely to be readmitted within 30 days (P = 0.003). On multivariable analysis, the following factors were found to have significant association with amputation: African American race (vs. white race, OR 2.8, CI 1.76-4.56, P < 0.001), elective surgery (OR 2.5, CI 1.59-3.93, P < 0.001), dialysis (OR 2.36, CI 1.28-4.37, P = 0.006), and major reintervention on the bypass (OR 11.56, CI 6.99-19.12, P < 0.001). Factors that have significant associations with mortality in the multivariable analysis include 60-69 years of age (vs. <60 years of age, OR 13.6, CI 2.40-77.21, P = 0.005), 70-79 years of age (vs. <60 years of age, OR 10.22, CI 1.74-59.90, P = 0.005), ≥80 years of age (vs. <60 years of age, OR 23.85, CI 3.94-144.30, P = 0.005), dialysis (OR 12.71, CI 6.14-26.33, P < 0.001), stroke or cardiovascular accident (OR 11.48, CI 2.05-64.40, P = 0.006), cardiac arrest requiring cardiopulmonary resuscitation (OR 145.09, CI 54.46-386.54, P < 0.001), acute renal failure postoperatively (OR 31.59, CI 7.53-132.51, P < 0.001), and return to the operating room (OR 2.66, CI 1.27-5.57, P = 0.009). CONCLUSIONS: African American patients were more likely than white and Hispanic patients to undergo major amputation after open lower extremity bypass. Unlike previously published data, this study does not show any difference in mortality.


Assuntos
Afro-Americanos , Amputação , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Enxerto Vascular/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Amputação/efeitos adversos , Amputação/mortalidade , Bases de Dados Factuais , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Humanos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/etnologia , Doença Arterial Periférica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Enxerto Vascular/mortalidade
17.
Vasc Endovascular Surg ; 53(5): 365-372, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30879396

RESUMO

BACKGROUND: Little is known about the relative impact of the preoperative symptoms rest pain and tissue loss, and of the arterial segment revascularized, on amputation rate and mortality in patients with chronic limb-threatening ischemia (CLTI). We wanted to investigate this topic further. METHOD: This population-based observational cohort study involved 10 419 patients revascularized for CLTI in Sweden, 2008 to 2013. Data were collected from health-care registries and medical records. The effect of preoperative symptoms and revascularized arteries was determined using Cox regression models. A competing risk analysis was used to determine the effect of symptoms on the combined endpoint "amputation or death". RESULTS: The amputation rate during a mean follow-up of 2 years was 7.5% in patients with rest pain, 15.6% in patients with tissue loss only, and 20.1% when both symptoms were present. Mortality was 39% lower in patients with rest pain only than in those with both symptoms. Revascularizations targeted the aortoiliac, femoropopliteal, and infrapopliteal segments in 19.4%, 76.8%, and 30.6%, respectively. Distal revascularizations were associated with a higher amputation rate, but this difference disappeared after adjustment for comorbidities. Aortoiliac revascularizations were associated with high mortality. Competing risk analysis showed that mortality became the major determinant of amputation-free survival outcomes from 1 year after revascularization. CONCLUSIONS: Tissue loss implies a clearly worse prognosis compared to rest pain for patients with CLTI. Most revascularizations for CLTI are done in the femoropopliteal segment. Infrapopliteal procedures are associated with a higher amputation rate, whereas aortoiliac revascularizations are associated with higher mortality.


Assuntos
Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Amputação , Doença Crônica , Feminino , Gangrena , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/mortalidade , Claudicação Intermitente/fisiopatologia , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Extremidade Inferior/patologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Sistema de Registros , Medição de Risco , Fatores de Risco , Suécia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
18.
J Vasc Surg ; 69(6): 1840-1847, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30852037

RESUMO

BACKGROUND: Bypass surgery (BS) remains the gold standard revascularization strategy in patients with chronic limb-threatening ischemia (CLTI) owing to infrainguinal disease. The Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-1 trial showed that, in patients with CLTI who survived for 2 years or more, BS resulted in better clinical outcomes. Despite this finding, there has been an increasing trend toward an endovascular-first approach to infrainguinal CLTI. Our aim was to investigate whether changes in practice have impacted the clinical outcomes of BS in our unit 10 years after BASIL-1. METHODS: Data for patients who underwent femoropopliteal (FP) BS in BASIL-1 (1999-2004) were retrieved from trial case record forms. The comparator contemporary series (CS) comprised all patients undergoing FP BS for CLTI in our unit between 2009 and 2014. Demographic and clinical outcome data on patients in the CS were collected from the prospectively collected hospital electronic notes. Anatomic patterns of disease in the BASIL-1 and CS cohorts were scored using the Bollinger and GLASS criteria. Statistical analysis was performed in SAS v9.4. RESULTS: There were 128 patients from BASIL-1 and 50 patients in the CS. Baseline age, gender, affected limb, and diabetes prevalence were similar, as were days spent in hospital out to 12 months and length of follow-up. BASIL-1 patients were more likely to be current smokers (P = .000) and had a higher creatinine (P = .04). The 30-day morbidity and mortality were higher in BASIL-1 (45.3% vs 22%; P = .004). There was no significant difference between BASIL-1 and CS with regard to run-off Bollinger (37.7 vs 32.1; P = .167) and IP GLASS (0 vs 0; P = .390) scores, with both groups having a median of two runoff vessels. Amputation-free survival (62% vs 28%; hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.18-2.93; P = .007), limb salvage (85% vs 69%; HR, 2.31; 95% CI, 1.14-4.68; P = .02), overall survival (69% vs 35%; HR, 1.66; 95% CI, 1.00-2.74; P = .05) and major adverse limb events (67% vs 47%; HR, 1.93; 95% CI, 1.15-3.22; P = .01) were all significantly better in BASIL-1. CONCLUSIONS: Although 30-day mortality and morbidity were significantly lower, all of the examined longer term clinical outcomes after FP BS were significantly worse in the CS group a decade on from BASIL-1. Further research in the form of prospective cohort studies and randomized controlled trials is urgently required to determine if the CS data reported herein are generalizable to current vascular surgical practice and, if so, to determine the reasons for these unexpected outcomes.


Assuntos
Angioplastia/tendências , Artéria Femoral/cirurgia , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Enxerto Vascular/tendências , Amputação/tendências , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Doença Crônica , Humanos , Isquemia/mortalidade , Salvamento de Membro/tendências , Doença Arterial Periférica/mortalidade , Intervalo Livre de Progressão , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Reino Unido/epidemiologia , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
19.
Int Angiol ; 38(1): 54-61, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30860341

RESUMO

BACKGROUND: Indications for the revascularization treatment of peripheral arterial disease (PAD) generate much discussion, and practice varies significantly among hospitals. This study looked at patients with PAD admitted to all hospitals of the Catalan Health Service and analyzed patterns of revascularization techniques with subsequent amputation procedures. METHODS: We used the clinical-administrative registry of admissions of all patients in the hospitals of Catalonia, north-east Spain, between 2009 and 2014. We analyzed the clinical course of patients admitted with PAD throughout their successive hospital admissions. Variability between hospitals was described for the revascularization techniques and amputations performed. Endovascular outcomes were compared with those from open surgery. RESULTS: Annually, there were 9,828 admissions with PAD and 631 major amputations. Eight hospitals accounted for 52% of all admissions, and endovascular techniques occurred predominantly in high-tech, high-resolution or reference hospitals. The ratio of admissions involving endovascular techniques/open surgery varied from 0.02 to 3.73 according to the hospital, and had a correlation of -0.175 (P=0.447) with the percentage of performed major amputations and of 0.122 (P=0.598) ratio of minor / major amputations. At the end of the 6 studied years, endovascular revascularization resulted in lower patency and more minor amputations than open surgery, but had the same percentage of major amputations (10.3% vs. 10.7%, P=0.526) and lower in-hospital mortality (7.1% vs. 9.5%, P<0.0001). CONCLUSIONS: Interventions of PAD are centralized in complex hospitals and have an important variability depending on the treating hospital. Hospital variability in revascularization techniques seems to have no impact on leg salvage. Endovascular and surgical revascularization would result in similar percentages of major amputations.


Assuntos
Amputação/estatística & dados numéricos , Procedimentos Endovasculares/estatística & dados numéricos , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação/tendências , Procedimentos Endovasculares/tendências , Feminino , Mortalidade Hospitalar , Humanos , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/tendências , Padrões de Prática Médica/tendências , Medição de Risco , Fatores de Risco , Espanha/epidemiologia , Análise de Sobrevida , Adulto Jovem
20.
Ann Vasc Surg ; 58: 151-159, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30769064

RESUMO

BACKGROUND: To evaluate the short-term outcomes of percutaneous mechanical thrombectomy (PMT) in patients with acute lower limb ischemia (ALI) and to analyze the effect of ALI of different etiologies on the limb salvage. MATERIALS AND METHODS: From January 2015 to December 2017, a retrospective analysis was performed on 112 patients (mean age: 66.5 years; 117 limbs in total; 66 limbs in 61 males) with ALI treated with PMT at 2 vascular institutions. Of the 117 limbs, 44 (41 patients) had acute arterial embolism, 36 (34 patients) had acute arterial thrombosis, and 37 (37 patients) had acute stent (31 limbs in 31 patients) or graft (6 limbs in 6 patients) thrombosis. The primary end point was limb salvage rate, and subgroups were analyzed by etiological factors. The secondary end points included patency rates, major bleeding complications, 30-day mortality, and reintervention rates. RESULTS: The 30-day mortality rate was 3.6%. The incidence of major bleeding complications was 2.7%. During the follow-up, the limb salvage rates at 1 year and 2 years were 83.8% and 74.7%, respectively. Subgroup analysis showed that the limb salvage rate in patients with acute arterial embolism was 92.9% at 2 years after PMT, which was higher than that in patients with acute arterial thrombosis (73.3%, P = 0.04, hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 1.1-11.7) and acute stent/graft thrombosis (62.5%, P = 0.01, HR: 4.7, 95% CI: 1.5-13.6). CONCLUSIONS: PMT in patients with ALI is effective in preventing amputations over the 3-year study period with a reasonable safety profile, especially in patients with acute arterial embolism.


Assuntos
Isquemia/cirurgia , Salvamento de Membro , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Trombectomia/métodos , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação , China , Feminino , Humanos , Incidência , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Complicações Pós-Operatórias/mortalidade , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
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