Maximiano Albers

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.

Assessment of quality of life of patients with severe ischemia as a result of infrainguinal arterial occlusive disease

The purpose of this cohort study was to assess the quality of life of patients with severe ischemia as a result of infrainguinal arterial occlusive disease. Spitzers QL-INDEX was selected to measure quality of life at baseline and at 3, 6, and 12 months. On the basis of initial treatment, 61 patients were grouped as follows: IC (conservative, n = 31), IR (arterial reconstruction, n = 14), and IA (major amputation, n = 16). After 12 months of follow-up, 48 patients were similarly regrouped according to ultimate treatment as follows: UC (n = 19), UR (n = 9), and UA (n = 20). At 12 months the mean score was significantly higher than the baseline in IC (6.43 vs 3.84, p less than 0.0001) as well as IR (5.64 vs 3.57, p less than 0.01), but not in IA (4.43 vs 3.62). The QL-INDEX mean score was lower in UA than in UC (4.15 vs 6.58, p less than 0.01) or UR (4.15 vs 7.11, p less than 0.0001). The correlation between QL-INDEX and an arbitrary scale was also high (r = 0.726, p less than 0.001). In conclusion, quality of life of patients with limb ischemia can be confidently assessed, improves during the first year of follow-up if major amputation is avoided, and improves and is sustained by a functioning graft.

Meta-analysis of polytetrafluoroethylene bypass grafts to infrapopliteal arteries

CONTEXT Reports of polytetrafluoroethylene (PTFE) bypass grafting to the infrapopliteal arteries have often used survival analysis of acceptable quality to describe a wide range of long-term results. In theory, these results may be combined if variability between series and time intervals is considered. OBJECTIVE Meta-analysis was performed to gain insight into long-term graft patency and foot preservation after PTFE bypass grafting to infrapopliteal arteries. DATA SOURCE Studies published from 1982 through 2001 were identified from the PubMed database and pertinent original articles. STUDY SELECTION Three investigators selected 43 studies that used survival analysis, reported 2-year patency rates, and included at least 15 bypass procedures. Data extraction and transformation: Based on standard life-tables or survivor curves, an interval success rate was calculated for each month in each series. The monthly success rates were combined across series, enabling construction of pooled survivor curves. DATA SYNTHESIS Random-effects meta-analysis yielded 5-year pooled estimates (SE) of 30.5% (7.6%) for primary graft patency, 39.7% (5.5%) for secondary graft patency, and 55.7% (5.0%) for foot preservation. During the entire follow-up, pooled estimates were slightly higher for series of PTFE grafts with adjunctive procedures compared with series of PTFE grafts only. Sensitivity analysis: A simulation using only unfavorable assumptions showed a decrease of less than 5% at 5 years for all outcomes, and smaller differences at subgroup meta-analysis. Funnel plots suggested that publication bias was unlikely. CONCLUSION This meta-analysis indicated moderate success for PTFE bypass grafts to infrapopliteal arteries, but the role of adjunctive procedures at the distal anastomosis remains uncertain.

Walking ability and quality of life as outcome measures in a comparison of arterial reconstruction and leg amputation for the treatment of vascular disease

OBJECTIVES To compare the walking ability and the quality of life of patients with severe limb ischaemia treated with an arterial reconstruction (AR) or a primary below-knee amputation (BKA). DESIGN A cohort study of patients with the first episode of ischaemia. SETTING University tertiary referral centre. PATIENTS Thirty-eight (AR 22, BKA 16) patients were studied over a 12-month period with a complete follow-up. CHIEF OUTCOME MEASURES Walking ability was assessed with a subjective scale and quality of life was measured with the Spitzer QL-INDEX. The results were assessed for patients still alive (Step 1) as well as for all patients (Step 2). RESULTS Walking ability was better in the AR group at 3 (OR = 10.37; CI 2.12; 50.74; p = 0.004), 6 (OR = 6.47; CI 1.83, 22.79; p = 0.004), and 12 (OR = 3.82; CI 1.20, 12.15; p = (0.03) months. Quality of life was significantly better for AR patients at 3 (OR = 4.32; CI 1.55, 12.02; p = 0.005) and 6 (OR = 4.40; CI 1.68, 11.53; p = (0.003) months, but not at 12 months (OR = 2.44; CI 0.95, 6.26; p = 0.06). the 12 month foot salvage rate was 68%. CONCLUSION Walking ability and quality of life are better for AR patients than for BKA patients, even with a moderate food salvage rate.

Outcome and quality of life of patients with severe chronic limb ischaemia: A cohort study on the influence of diabetes

OBJECTIVE To determine the influence of diabetes on the use of arterial reconstruction, the rate of amputation and death, and the quality of life of patients with severe limb ischaemia. DESIGN A prospective study of patients with the first episode of ischaemia. SETTING University tertiary referral centre. METHODS Thirty-seven patients with diabetes and 50 without diabetes, were studied over a 12 month period with complete follow-up. MAIN OUTCOME MEASURES The proportion of patients undergoing an arterial reconstruction, amputation rate, death rate, and quality-of-life scores. RESULTS Patients with diabetes underwent an arterial reconstruction less often than patients without diabetes (7/37 vs. 18/50). The odds of patients with diabetes having a higher incidence of adverse outcome was 1666:1 for minor amputation, 26:1 for major amputation, and 4.7:1 for death. There was a tendency towards a lower quality of life for patients with diabetes at 3 (OR 1.94, p = 0.036), 6 (OR 1.58, p = 0.117), and 12 (OR 1.47, p = 0.185) months. CONCLUSIONS In patients with diabetes, (1) the opportunity of undergoing an arterial reconstruction is lower, (2) morbidity and mortality are higher, and (3) the quality of life tends to be worse.

Superficial femoral eversion endarterectomy combined with a vein segment as a composite artery-vein bypass graft for infrainguinal arterial reconstruction☆☆☆

OBJECTIVE The purpose of this study was to determine the results of composite artery-vein bypass grafting for infrainguinal arterial reconstruction. METHODS This study was designed as a retrospective case series in two tertiary referral centers. Forty-eight of 51 patients underwent the procedure of interest for the treatment of ischemic skin lesions (n = 42), rest pain (n = 3), disabling claudication (n = 1), and infected prosthesis (n = 2). The intervention used was infrainguinal composite artery-vein bypass grafting to popliteal (n = 18) and infrapopliteal (n = 30) arteries, with an occluded segment of the superficial femoral artery prepared with eversion endarterectomy and an autogenous vein conduit harvested from greater saphenous veins (n = 43), arm veins (n = 3), and lesser saphenous veins (n = 2). The main outcome measures, primary graft patency rates, foot salvage rates, and patient survival rates, were described by means of the life-table method for a mean follow-up time of 15.5 months. RESULTS The cumulative loss during the follow-up period was 6% and 24% at 6 and 12 months, respectively. The primary graft patency rates, the foot salvage rates, and the patient survival rates for patients with popliteal grafts were 60.0% +/- 9.07%, 75.7% +/- 9.18%, and 93.5% +/- 6.03%, respectively, at 1 month; 53.7% +/- 11.85%, 68.9% +/- 12.47%, and 85. 0% +/- 9.92% at 1 year; and 46.7% +/- 18.19%, 68.9% +/- 20.54%, and 53.1% +/- 17.15% at 5 years. For infrapopliteal grafts, the corresponding estimates were 72.4% +/- 7.06%, 72.9% +/- 6.99%, and 92.7% +/- 4.79% at 1 month; 55.6% +/- 10.70%, 55.4% +/- 10.07%, and 77.9% +/- 9.02% at 1 year; and 33.6% +/- 22.36%, 55.4% +/- 30.20%, and 20.8% +/- 9.89% at 5 years. CONCLUSION The composite artery-vein bypass graft is a useful autogenous alternative for infrainguinal arterial reconstruction when a vein of the required quality is not available or when the procedure needs to be confined to the affected limb.

Reducing cross-clamping duration in aortoiliac reconstruction after renal transplantation. A case report.

A fifty-two-year-old male renal transplant patient underwent aortoiliac reconstruction with a bifurcated prosthesis for treatment of hypertension and deteriorating allograft function. A modified technique was used that reduced aortic cross-clamping time to twelve minutes. This simple technique is applicable to most patients, reduces warm ischemia to a minimum, and saves time for a careful aortoiliac reconstruction.

Importance of the arteriographic anatomy of the descending genicular artery and sural arteries in patients with atherosclerotic occlusion of the popliteal artery.

Bypasses to the descending genicular artery (DGA) or the medial sural artery (MSA) have been performed with acceptable rates of midterm success. The arteriographic appearance of the DGA, the MSA, and the lateral sural artery (LSA) was described and the applicability of bypass to these vessels was investigated. The arteriograms of 45 patients who had occlusion of the below-knee popliteal artery were analyzed to determine the presence, dominance, and extension of collaterals for each perigeniculate branch, which were used to assess the applicability of a perigeniculate bypass. A dominant perigeniculate artery was found in 26 arteriograms and corresponded to 13 DGAs, 9 MSAs, and 4 LSAs. Of 14 applicable perigeniculate bypasses, 2 would be an obligatory bypass and 12 would be an alternative to a conventional infrapopliteal bypass. Although rarely an obligatory solution, a bypass to a perigeniculate branch artery represents a valuable alternative.

Long-Term Comparison of in Situ and Nonreversed Saphenous vein Grafts for Infrapopliteal Reconstruction

The nonreversed saphenous vein bypass graft has become a reasonable alternative to the standard in situ technique for infrainguinal arterial reconstruction. The objective of this study was to compare the long-term results obtained with these techniques in patients with severe limb ischemia. Fifty-five in situ and 57 nonreversed saphenous vein bypass grafts to the infrapopliteal arteries were compared for secondary graft function, preser vation of the foot, and patient survival. The crude relative risk of secondary failure for nonreversed grafts was 1.03 (95% confidence interval [95%CI] 0.62-1.69). Stratified analysis showed a stable relative risk of 1.04 (95%CI 0.58-1.86) in the stratum of 33 nonreversed and 47 in situ grafts done with both a good vein and a high origin. Conflicting results were found in the other strata as a result of small stratum size. The relative risks for major amputation and death were 0.60 (95%CI 0.35-1.05) and 0.44 (95%CI 0.25-0.79), respectively.

Post-Exercise Penile Blood Pressure in the Diagnosis of Vasculogenic Impotence

Doppler velocimetry4 and penile blood pressure2,:3,5 have been tried with some success, but all these methods fail in demonstrating mild genital vascular insufficiency. Penile erection demands an increase in blood flow, and patients with mild vascular lesions in the internal iliac territory may have normal blood flow and pressure at rest, but not enough to achieve an erection. The principle of post-exercise blood pressure was first established to the lower limbs.9 When blood supply is somewhat impaired, the vasodilatation produced by muscle activity leads to a drop in arterial pressure. As the internal iliac arterial system supplies not only the penis, but also several muscles in the pelvis and buttocks, a hypothesis has been made that exercising these muscles would cause a fall in the pressure of the hypogastric territory as a whole, including the penile arteries, when arterial obstruction or stenosis is present. To test this hypothesis was the aim of the present study.