Nelson De Luccia

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.

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.

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.

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.

Risk factors for infectious and noninfectious complications of totally implantable venous catheters in cancer patients

OBJECTIVE The aim of this study was to investigate the risk factors for complications of totally implantable catheters in a referral cancer center. METHODS This was a retrospective study of prospectively collected data of all consecutive cancer patients undergoing port placement, with a primary outcome of interest of major complication and subanalysis of the types of complications. RESULTS We studied 1255 nonvalved implanted port catheters inserted in 1230 patients, for a combined total of 469,882 catheter-days of use. Venous puncture was ultrasound (US)-guided in 1049 cases (84%). Inadvertent arterial puncture occurred in 14 cases (1.1%) and was more frequent in procedures not guided by US (P = .045). Among the outpatients, 90 (9%) developed infection, and 75 (29%) of the hospitalized patients (P < .001) developed infections. Infection was diagnosed in 131 catheters (13%) implanted through the internal jugular vein (IJV), 23 catheters (14%) implanted in the subclavian vein (SCV), 1 catheter (5%) implanted in the external jugular vein, and 10 catheters (31%) implanted in the femoral vein (P = .044). In the multivariate analysis, only the hospitalization regimen maintained statistical significance, with hospitalization presenting as a risk factor for infection (P < .001). Regarding the introduction site, ambulatory patients in whom the femoral vein was the site of access had more infections than the others (28.6% vs 9.4% of the IJV, 4.8% of the SCV, and 4.8% of the external jugular vein; P = .019), which did not occur among the hospitalized patients (33.3% vs 26.5% of IJV and 39.5% of the SCV; P = .218). CONCLUSIONS Not using US is a risk factor for iatrogenic arterial puncture. Port implantation in hospitalized patients and the use of femoral access are risk factors for infection.

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.

Prediction of major cardiac events after vascular surgery

Objective: Predicting cardiac events is essential to provide patients with the best medical care and to assess the risk‐benefit ratio of surgical procedures. The aim of our study was to evaluate the performance of the Revised Cardiac Risk Index (Lee) and the Vascular Study Group of New England Cardiac Risk Index (VSG) scores for the prediction of major cardiac events in unselected patients undergoing arterial surgery and to determine whether the inclusion of additional risk factors improved their accuracy. Methods: The study prospectively enrolled 954 consecutive patients undergoing arterial vascular surgery, and the Lee and VSG scores were calculated. Receiver operating characteristic curves for each cardiac risk score were constructed and the areas under the curve (AUCs) compared. Two logistic regression models were done to determine new variables related to the occurrence of major cardiac events (myocardial infarction, heart failure, arrhythmias, and cardiac arrest). Results: Cardiac events occurred in 120 (12.6%) patients. Both scores underestimated the rate of cardiac events across all risk strata. The VSG score had AUC of 0.63 (95% confidence interval [CI], 0.58–0.68), which was higher than the AUC of the Lee score (0.58; 95% CI, 0.52–0.63; P = .03). Addition of preoperative anemia significantly improved the accuracy of the Lee score to an AUC of 0.61 (95% CI, 0.58–0.67; P = .002) but not that of the VSG score. Conclusions: The Lee and VSG scores have low accuracy and underestimate the risk of major perioperative cardiac events in unselected patients undergoing vascular surgery. The Lee scores accuracy can be increased by adding preoperative anemia. Underestimation of major cardiac complications may lead to incorrect risk‐benefit assessments regarding the planned operation.