Dink A. Legemate

Diagnostic Performance of Computed Tomography Angiography in Peripheral Arterial Disease: A Systematic Review and Meta-analysis

CONTEXT Computed tomography angiography (CTA) is an increasingly attractive imaging modality for assessing lower extremity peripheral arterial disease (PAD). OBJECTIVE To determine the accuracy of CTA compared with intra-arterial digital subtraction angiography (DSA) in differentiating extent of disease in patients with PAD. DATA SOURCES AND STUDY SELECTION Search of MEDLINE (January 1966-August 2008), EMBASE (January 1980-August 2008), and the Database of Abstracts of Reviews of Effectiveness for studies comparing CTA with intra-arterial DSA for PAD. Eligible studies compared multidetector CTA with intra-arterial DSA, included at least 10 patients with intermittent claudication or critical limb ischemia, aimed to detect more than 50% stenosis or arterial occlusion, and presented either 2 x 2 or 3 x 3 contingency tables (< or = 50% stenosis vs > 50% stenosis or occlusion), or provided data allowing their construction. DATA EXTRACTION Two reviewers screened potential studies for inclusion and independently extracted study data. Methodological quality was assessed by using the QUADAS instrument. DATA SYNTHESIS Of 909 studies identified, 20 (2.2%) met the inclusion criteria. These 20 studies had a median sample size of 33 (range, 16-279) and included 957 patients, predominantly with intermittent claudication (68%). Methodological quality was moderate. Overall, the sensitivity of CTA for detecting more than 50% stenosis or occlusion was 95% (95% confidence interval [CI], 92%-97%) and specificity was 96% (95% CI, 93%-97%). Computed tomography angiography correctly identified occlusions in 94% of segments, the presence of more than 50% stenosis in 87% of segments, and absence of significant stenosis in 96% of segments. Overstaging occurred in 8% of segments and understaging in 15%. CONCLUSION Computed tomography angiography is an accurate modality to assess presence and extent of PAD in patients with intermittent claudication; however, methodological weaknesses of examined studies prevent definitive conclusions from these data.

Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.

Objective: Randomized comparison of endovascular repair (EVAR) with open repair (OR) in patients with a ruptured abdominal aortic aneurysm (RAAA). Background: Despite advances in operative technique and perioperative management RAAA remains fraught with a high rate of death and complications. Outcome may improve with a minimally invasive surgical technique: EVAR. Methods: All patients with a RAAA in the larger Amsterdam area were identified. Logistics for RAAA patients was changed with centralization of care in 3 trial centers. Patients both fit for EVAR and for OR were randomized to either of the treatments. Nonrandomized patients were followed in a prospective cohort. Primary endpoint of the study was the composite of death and severe complications at 30 days. Results: Between April 2004 and February 2011, we identified 520 patients with a RAAA of which 116 could be randomized. The primary endpoint rate for EVAR was 42% and for OR was 47% [absolute risk reduction (ARR) = 5.4%; 95% confidence interval (CI): −13% to +23%]. The 30-day mortality was 21% in patients assigned to EVAR compared with 25% for OR (ARR = 4.4% 95% CI: −11% to +20%). The mortality of all surgically treated patients in the nonrandomized cohort was 30% (95% CI: 26%–35%) and 26% (95% CI: 20% to 32%) in patients with unfavorable anatomy for EVAR, treated by OR at trial centers. Conclusions: This trial did not show a significant difference in combined death and severe complications between EVAR and OR. Mortality for OR both in randomized patients and in cohort patients was lower than anticipated, which may be explained by optimization of logistics, preoperative CT imaging, and centralization of care in centers of expertise.

START Trial: a pilot study on STimulation of ARTeriogenesis using subcutaneous application of granulocyte-macrophage colony-stimulating factor as a new treatment for peripheral vascular disease.

Background—Granulocyte-macrophage colony-stimulating factor (GM-CSF) was recently shown to increase collateral flow index in patients with coronary artery disease. Experimental models showed beneficial effects of GM-CSF on collateral artery growth in the peripheral circulation. Thus, in the present study, we evaluated the effects of GM-CSF in patients with peripheral artery disease. Methods and Results—A double-blinded, randomized, placebo-controlled study was performed in 40 patients with moderate or severe intermittent claudication. Patients were treated with placebo or subcutaneously applied GM-CSF (10 &mgr;g/kg) for a period of 14 days (total of 7 injections). GM-CSF treatment led to a strong increase in total white blood cell count and C-reactive protein. Monocyte fraction initially increased but thereafter decreased significantly as compared with baseline. Both the placebo group and the treatment group showed a significant increase in walking distance at day 14 (placebo: 127±67 versus 184±87 meters, P=0.03, GM-CSF: 126±66 versus 189±141 meters, P=0.04) and at day 90. Change in walking time, the primary end point of the study, was not different between groups. No change in ankle-brachial index was found on GM-CSF treatment at day 14 or at day 90. Laser Doppler flowmetry measurements showed a significant decrease in microcirculatory flow reserve in the control group (P=0.03) and no change in the GM-CSF group. Conclusions—The present study does not support the use of GM-CSF for treatment of patients with moderate or severe intermittent claudication. Issues that need to be addressed are dosing, the selection of patients, and potential differences between GM-CSF effects in the coronary and the peripheral circulation.

Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture.

Purpose: To report a collapsed stent-graft used to treat a traumatic aortic rupture. Case Report: A Gore TAG stent-graft was placed in a 20-year-old man with multiple injuries. Postimplantation computed tomographic angiography (CTA) demonstrated no contrast extravasation and total exclusion of the traumatic rupture. Routine CTA 3 months after implantation revealed a collapsed stent-graft located in the outer curve of the distal aortic arch. A Talent stent-graft was placed successfully within the collapsed prosthesis. Postimplantation CTA demonstrated no contrast extravasation and good apposition of the endograft to the aortic wall. At 6 months, the repair remains secure; there is no sign of graft collapse or endoleak. Conclusions: Collapse of stent-grafts can occur after treatment for traumatic aortic ruptures; endovascular methods can be used to restore a satisfactory luminal contour.

Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis.

Objective:To summarize the evidence available on the effects of decision aids in surgery. Background:When consenting to treatment, few patients adequately understand their treatment options. To help patients make deliberate treatment choices, decision aids provide evidence-based information on the disease, treatment options, and their associated benefits and harms. Although decision aids are not designed to direct patients toward a particular treatment option, it is possible that their introduction will change the proportion of patients that opt for surgery. Methods:We searched electronic databases for studies that evaluated a decision aid in patients offered both surgery and alternative treatment options, regarding the effect on the actual treatment choices made. In addition, we documented effects on knowledge, decisional conflict, anxiety, quality of life, patient involvement, satisfaction, mortality, morbidity, and costs. Results:Seventeen studies were included. Overall, methodological study quality was good. Patients in the decision aid group less often chose to undergo invasive treatment [risk ratio = 0.80; 95% confidence interval, 0.67–0.95), had more knowledge about treatment options [mean difference = 8.99; 95% confidence interval, 3.20–14.78), and experienced less decisional conflict (mean difference = −5.04; 95% confidence interval, −7.10 to −2.99). Levels of anxiety and quality of life were similar. Conclusions:Offering a decision aid increases the number of patients who prefer conservative or less invasive treatment options. As decision aids improve patient knowledge and lower decisional conflict without raising anxiety levels, they have a place in surgery to help surgeons and patients achieve well-considered and shared treatment decisions.

Value of Duplex scanning in the selection of patients for percutaneous transluminal angioplasty

Duplex scanning is becoming increasingly important in the diagnosis and follow-up of arterial lesions, though most surgeons and radiologists currently still prefer diagnostic angiography prior to percutaneous transluminal angioplasty (PTA). We performed PTA based on Duplex scanning alone in 31 selected patients during the last 6 months of 1991. Seventeen patients were treated for lower extremity ischemia and 14 for (a)-symptomatic stenosis in a peripheral bypass. Results of Duplex scanning were compared to the finding of PTA to assess the value of Duplex scanning done prior to PTA. Duplex scanning showed 51 lesions eligible for PTA, in 48 of 51 lesions (94%) the location as found with Duplex scanning was in agreement with the findings of the angiogram during PTA. Of a total of 31 patients scheduled for PTA, Duplex scanning predicted the indication for PTA adequately in 26 patients (84%). No complications were seen. Duplex scanning proved to be a valuable tool in the detection of lesions suitable for PTA. Furthermore, puncture site and route can be determined by means of Duplex scanning.

Evaluation of toe pressure and transcutaneous oxygen measurements in management of chronic critical leg ischemia: a diagnostic randomized clinical trial☆

OBJECTIVE The definition of critical limb ischemia (CLI) requiring vascular intervention is still under debate. The clinical eye of the physician and ankle blood pressure measurements used so far may fall short in appreciation of the severity of disease, which makes decision-making for a vascular intervention subjective. In previous studies two simple functional tests, ie, transcutaneous oxygen pressure (tcPo(2)) and toe blood pressure (TP) measurements, provided reliable information about the need for vascular intervention. Therefore we evaluated the diagnostic value of tcPo(2) and TP in management of clinically suspected critical leg ischemia. Study design This was a diagnostic randomized controlled clinical trial. Subjects were ambulatory and hospitalized patients in a referral university hospital. METHODS Ninety-six patients (128 legs) with clinically suspected critical limb ischemia were referred to the vascular laboratory for routine investigation. Two diagnostic management strategies were compared: conventional strategy, ie, clinical judgment and ankle pressure determined the diagnostic and therapeutic approach, and a new strategy in which tcPo(2) and TP determined the diagnostic and therapeutic approach. Main outcome measures included clinical outcome, defined as pain relief, wound healing, and limb survival. RESULTS At 18-month follow-up, 26 of 62 legs treated with the conventional approach and 28 of 66 legs treated with the new approach were treated conservatively. The new method did not score significantly different from the conventional method insofar as clinical outcome: pain score, 50 versus 48; number of amputations, 8 versus 10; and number of deaths, 11 versus 8 deaths, respectively. CONCLUSION Two simple objective diagnostic tests, TP and tcPo(2), did not improve clinical outcome when incorporated into routine management of suspected critical limb ischemia. Nevertheless, these techniques might still be helpful for physicians less experienced with treating critical limb ischemia and who are in doubt regarding the need for vascular intervention.

The use of color-coded duplex scanning in the selection of patients with lower extremity arterial disease for percutaneous transluminal angioplasty: a prospective study

PurposeTo exploit the potential benefits of percutaneous transluminal angioplasty (PTA) in patients with short obstructive lesions in the lower extremity, it is preferable to select patients suitable for PTA before proceeding to hospital admission and angiography. The aim of this prospective study was to evaluate the role of color-coded duplex scanning in the correct selection of patients for PTA and its influence on planning the approach to the lesion.MethodsOn the basis of clinical history, physical examination, pressure indices, and ultrasound duplex scanning, 109 patients were scheduled for PTA.ResultsThe indication for PTA was correct in 103 patients (94%), while the procedure was performed successfully in 98 patients (90%). The approach to the lesion was planned successfully in the majority of patients.ConclusionThis study shows that it is justifiable to plan PTA on the basis of information obtained by duplex scanning. Results of the duplex scan may guide the catheterization route.

Percutaneous Transluminal Angioplasty of Peripheral Bypass Stenoses

AbstractPurpose: To assess the success of percutaneous transluminal angioplasty (PTA) in treating peripheral bypass stenoses. Methods: Patients who received a femoropopliteal or femorocrural bypass graft for limb ischemia were included in a duplex surveillance program. If duplex ultrasound revealed a short (<2 cm) severe (peak systolic velocity ratio ≥4.5) stenosis, patients were scheduled for arteriography and PTA. Fifty-eight peripheral bypass stenoses in 39 grafts in 37 patients were treated with PTA. The cumulative primary patency of treated stenoses was calculated. Results: During the first year after PTA 31 (53%) treated lesions remained patent, 15 (26%) lesions restenosed at a median interval of 5.0 (range 1–12) months and 4 (7%) bypasses occluded. The cumulative primary patency of 58 treated graft stenoses at 1 year was 60% [95% confidence interval (CI) 46%–74%] and 55% (95% CI 41%–70%) at 2 years. Graft body stenoses showed a better 2-year cumulative primary patency (86%; 95% CI 68%-100%) compared with juxta-anastomotic lesions (45%; 95% CI 29%–62%; p<0.05). Conclusion: PTA is justifiable as the initial treatment of peripheral bypass stenoses. Nevertheless, the restenosis rate is rather high, especially in juxta-anastomotic lesions. Continuation of duplex surveillance after PTA and timely reintervention is recommended.

Effect of β-blockers on peripheral skin microcirculation in hypertension and peripheral vascular disease

Abstract Objective This study was undertaken to investigate the possible negative effect of β-blockers on skin microcirculation in patients with intermittent claudication and hypertension. Methods and materials In this clinical crossover study, 20 patients with mild to moderate hypertension, treated with long-term β-blockade, and intermittent claudication or ischemic rest pain, underwent assessment of peripheral circulation before and after 2-week withdrawal of β-blocking therapy and again 2 weeks after restarting therapy. Replacement therapy (calcium antagonist) was given if considered necessary to control hypertension. Skin microcirculation was assessed with three noninvasive techniques: capillary microscopy of the hallux nailfold, transcutaneous oximetry of the forefoot, and laser Doppler fluxmetry of the great toe. Results Mean initial blood pressure was 163/81 mm Hg. Mean heart rate significantly increased with withdrawal of β-blocker, from 65 bpm to 85 bpm. No significant differences in skin microcirculation and blood pressure were found between measurements obtained before, during, and after withdrawal of β-blocking therapy. Patients experienced no change in symptoms during the study. Conclusion β-Blockers do not appear to have a negative effect on peripheral skin microcirculation and are therefore not contraindicated to treat hypertension when intermittent claudication or ischemic rest pain is also present.