Anai Espinelli S. Durazzo

Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia

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

Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes?

OBJETIVO: Avaliar como pacientes com doenca arterial obstrutiva periferica tem sido tratados, em nosso meio, com relacao aos fatores de risco e comorbidades. METODO: Questionario sobre pesquisa e tratamento da dislipidemia, diabetes, exercicio, uso de anti-plaquetarios, tabagismo e hipertensao arterial no paciente com doenca arterial obstrutiva periferica foi aplicado entre os medicos presentes na reuniao mensal de marco de 2004 da Sociedade Brasileira de Angiologia e Cirurgia Vascular - Regional Sao Paulo. RESULTADOS: Dos 102 questionarios distribuidos, 75 foram respondidos (taxa de resposta de 73,5%). Entre os consultados, 82% pesquisam rotineiramente perfil lipidico e 20% visam alvo de LDL-colesterol abaixo de 100 mg/dl; 94% realizam pesquisa para diabetes melito; 97% recomendam exercicio; 79% prescrevem aspirina; 97% aconselham que os pacientes parem de fumar e 60% se restringem ao aconselhamento isoladamente; 18% nao realizam a medida da pressao arterial durante a consulta e 19% visam alvo pressorico de 130 x 80 mmHg. Considerando todas as avaliacoes em conjunto - intervencao no estilo de vida, no sentido de parar de fumar, orientacao de exercicios, uso de anti-plaquetarios, realizacao de pesquisa para diabetes melito, controle rigoroso da pressao arterial e lipides - observou-se que 7% dos entrevistados seguem todas essas recomendacoes como uma rotina estabelecida. CONCLUSAO: O presente estudo demonstrou que, em nosso meio, a pesquisa e o tratamento dos fatores de risco e comorbidades nos pacientes com doenca arterial obstrutiva periferica estao sendo sub-realizados.

Preferential use of nonreversed vein grafts in above-knee femoropopliteal bypasses for critical ischemia: midterm outcome.

We evaluated nonreversed vein grafts in above-knee bypasses for chronic critical limb ischemia in a retrospective study with intention-to-treat analysis in patients who underwent above-knee bypass grafting. During a 4-year period, 51 patients (men, 32; women, 19; mean age = 66 years) with 53 critically ischemic lower extremities underwent above-knee femoropopliteal bypass grafting. The follow-up evaluation consisted of clinical examination, assessment of the ankle-brachial systolic blood pressure index, and, whenever necessary, duplex scanning. Three (5.7%) deaths occurred within 30 days, two from myocardial infarction and one from an undetermined cause. The 2-year cumulative success rate was 82.5 +/- 9.6% for primary patency, 84.6 +/- 8.9% for secondary patency, 90.1 +/- 7.3% for tertiary patency, 86.9 +/- 7.6% for limb salvage, 77.7 +/- 8.4% for survival, 68.0 +/- 11.1% for composite patency, and 68.4 +/- 9.3% for amputation-free survival; the corresponding estimates for vein grafts alone were 86.6 +/- 9.2%, 88.9 +/- 8.6%, 89.0 +/- 8.5%, 88.1 +/- 8.1%, 81.1 +/- 9.1, 76.8 +/- 11.1%, and 72.6 +/- 10.2%. Three prosthetic grafts failed and were replaced with an arm vein graft. Nonreversed vein bypass grafts in above-knee revascularization of critically ischemic limbs are justified.

Limb Salvage Using Bypass to the Perigeniculate Arteries

OBJECTIVE To describe bypass to perigeniculate vessels for limb salvage. DESIGN Retrospective cohort study. MATERIAL AND METHODS Between 1995 and 2009, 47 bypass procedures to perigeniculate collateral arteries were performed in 46 patients (15 women, 31 men; median age, 68 years). All patients presented with critical ischaemia (tissue loss in 87.5%, rest pain in 12.5%). Mean ankle brachial index was 0.27 ± 0.17. The site of distal anastomosis was the descending genicular artery (DGA) in 23 bypasses (1 bilateral) and the medial sural artery (MSA) in 24. Proximal anastomosis was to the external iliac artery in 2 cases, common femoral artery in 23 cases, superficial femoral artery in 8 cases, deep femoral artery in 8 cases, above-knee poplitaeal artery in 2 cases, and previous graft in 4 cases. RESULTS There were four deaths during the immediate postoperative period. Mean follow-up duration was 27 months. Ten patients required major amputation. Mean ankle brachial index post-operatively was 0.60 ± 0.21. At 3 years, primary patency was 74.7 ± 7%, secondary patency was 83.4 ± 8%, and the limb salvage and survival rates were 73.5 ± 7% and 77.4 ± 7%, respectively. CONCLUSION Bypass to perigeniculate arteries is a viable treatment option for critical limb ischaemia in selected patients.