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Background: Acute myocardial infarction (AMI) is a critical cardiovascular disease with high morbidity and mortality. Identifying practical parameters for predicting long-term mortality is crucial in this patient group. The percentage of mean arterial pressure (%MAP) is a useful parameter used to assess peripheral artery disease. It can be easily calculated from ankle pulse volume recording. Previous studies have shown that %MAP is a useful predictor of all-cause mortality in specific populations, but its relationship with mortality in AMI patients is unclear. Methods: In this observational cohort study, 191 AMI patients were enrolled between November 2003 and September 2004. Ankle-brachial index (ABI) and %MAP were measured using an ABI-form device. All-cause and cardiovascular mortality data were collected from a national registry until December 2018. Cox proportional hazards model and Kaplan-Meier survival plot were used to analyze the association between %MAP and long-term mortality in AMI patients. Results: The median follow-up to mortality was 65 months. There were 130 overall and 36 cardiovascular deaths. High %MAP was associated with increased overall mortality after multivariable analysis (HR = 1.062; 95% CI: 1.017-1.109; p =0.006). However, high % MAP was only associated with cardiovascular mortality in the univariable analysis but became insignificant after the multivariable analysis. Conclusions: In conclusion, this study is the first to evaluate the usefulness of %MAP in predicting long-term mortality in AMI patients. Our study shows that %MAP might be an independent predictor of long-term overall mortality in AMI patients and has better predictive power than ABI.
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Índice Tobillo Braquial , Presión Arterial , Infarto del Miocardio , Humanos , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Masculino , Femenino , Anciano , Persona de Mediana Edad , Estimación de Kaplan-Meier , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Factores de Riesgo , Pronóstico , Modelos de Riesgos Proporcionales , Estudios de CohortesRESUMEN
BACKGROUND: Although femoropopliteal-specific stents have durable patency, stent thrombosis (ST) may occur, which can lead to acute limb ischaemia (ALI). AIMS: We aimed to investigate the clinical features and outcomes of ALI caused by femoropopliteal ST in patients with lower extremity artery disease. METHODS: This multicentre retrospective study included 499 patients with ALI - of whom 108 patients had ALI caused by femoropopliteal ST (ST-ALI) and 391 patients had ALI caused by other aetiologies (de novo ALI) - who underwent treatment between September 2011 and March 2023. Clinical features and outcomes were compared between the two groups. The primary outcome measure was 12-month amputation-free survival; factors associated with amputation or death were investigated using multivariate Cox proportional hazards regression analysis. RESULTS: Patients with ST-ALI were significantly more likely to exhibit conventional atherosclerotic risk factors, including diabetes mellitus (63% vs 26%) and haemodialysis (51% vs 10%) compared to patients with de novo ALI, whereas patients with de novo ALI were older (80 years vs 74 years) and more likely to have atrial fibrillation (49% vs 18%) than patients with ST-ALI. The 12-month amputation-free survival rate was significantly lower in the ST-ALI group than that in the de novo ALI group (51% vs 76%; p<0.001). Multivariate analysis revealed that ST-ALI, older age, haemodialysis, atrial fibrillation, the presence of a wound, peak C-reactive protein level, and non-ambulatory status all have an independent, positive association with death or major amputation. CONCLUSIONS: The current study revealed that patients with ST-ALI had worse clinical outcomes than those with de novo ALI, highlighting the need to maximise ST prevention.
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Amputación Quirúrgica , Arteria Femoral , Isquemia , Enfermedad Arterial Periférica , Arteria Poplítea , Stents , Trombosis , Humanos , Masculino , Anciano , Femenino , Estudios Retrospectivos , Arteria Poplítea/cirugía , Isquemia/terapia , Isquemia/mortalidad , Isquemia/etiología , Isquemia/cirugía , Arteria Femoral/cirugía , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Anciano de 80 o más Años , Persona de Mediana Edad , Trombosis/etiología , Trombosis/mortalidad , Resultado del Tratamiento , Factores de Riesgo , Recuperación del Miembro , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Extremidad Inferior/irrigación sanguínea , Enfermedad Aguda , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: Lower extremity arterial disease (LEAD) and increased aortic stiffness are associated with higher mortality in patients with chronic coronary syndrome, while their prognostic significance after an acute coronary syndrome (ACS) is less known. METHODS: We analyzed prevalence, clinical phenotypes and association of LEAD - assessed by the ankle-brachial index (ABI) - and increased aortic stiffness - assessed by the aortic pulse wave velocity (PWV) - with all-cause mortality and major adverse cardiovascular events (MACE) in patients admitted with an ACS. RESULTS: Among 270 patients admitted for ACS (mean age 67âyears, 80% males), 41 (15%) had an ABI ≤0.9, with 14 of them (34%) presenting with intermittent claudication (symptomatic LEAD). Patients with symptomatic LEAD, compared with those with asymptomatic LEAD or without LEAD, had higher prevalence of cardiovascular risk factors, lower estimated glomerular filtration rate and higher high-sensitivity C-reactive protein. Patients with LEAD, either symptomatic or asymptomatic, more frequently presented with non-ST-elevation myocardial infarction and more frequently had multivessel coronary artery disease. Both symptomatic and asymptomatic LEAD were significantly associated with all-cause mortality after adjustment for confounders, including multivessel disease or carotid artery disease (hazard ratio 4.03, 95% confidence interval 1.61-10.08, P â<â0.01), whereas PWV was not associated with the outcome in the univariable model. LEAD and PWV were not associated with a higher risk of MACE (myocardial infarction or unstable angina, stroke, or transient ischemic attack). CONCLUSIONS: LEAD, either clinical or subclinical, but not increased aortic stiffness, is an independent predictor of all-cause mortality in patients admitted for ACS.
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Síndrome Coronario Agudo , Índice Tobillo Braquial , Enfermedad Arterial Periférica , Análisis de la Onda del Pulso , Rigidez Vascular , Humanos , Masculino , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/complicaciones , Femenino , Anciano , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/complicaciones , Pronóstico , Persona de Mediana Edad , Prevalencia , Factores de RiesgoRESUMEN
INTRODUCTION: All-cause mortality and cardiovascular mortality (CVM) risk can be very high in adults with type 2 diabetes mellitus (DM2) with previous cardiovascular disease (CVD). Our objective was to determine this risk among the different clinical spectrum of CVD. MATERIAL AND METHODS: The DIABET-IC trial is a multicenter, prospective, observational, and analytical study. Consecutive subjects with DM2 attending our outpatients' clinics were recruited. Data on clinical features, lab test results, and echocardiographic measures were collected. Patients were categorized depending on the presence and type of CVD: heart failure (HF), coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral artery disease (PAD). All-cause mortality and CVM were the dependent variables analyzed. Mortality rate was expressed as deaths per 1000 patients-year. Cox proportional hazards regressions models were used to establish the mortality risk associated with every type of CVD. RESULTS: We studied a total of 1246 patients (mean age, 6.3 (SD, 9.9) years; 31.6%, female) with an initial prevalence of CVD of 59.3%. A total of 122 deaths (46 due to CVD) occurred at the 2.6-year follow-up. All-cause and MCV rates associated with the presence of PAD (85.6/1000 and 33.6/1000, respectively) and HF (72.9/1000 and 28.7/1000 respectively) were the most elevated of all. In multivariate analysis, HF increased all-cause mortality risk (HR, 1.63; CI 95% 1.03-2.58; P=.037) and the risk of CVM (HR, 3.41; 95% CI, 1.68-6.93; P=.001). CONCLUSIONS: Mortality among DM2 patients is highly increased in the presence of HF and PAD. This justifies the screening of these conditions to intensify therapeutic strategies.
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Enfermedades Cardiovasculares , Diabetes Mellitus Tipo 2 , Humanos , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/mortalidad , Femenino , Masculino , Estudios Prospectivos , Enfermedades Cardiovasculares/mortalidad , Persona de Mediana Edad , Anciano , Causas de Muerte , Enfermedad Arterial Periférica/mortalidad , Angiopatías Diabéticas/mortalidad , Insuficiencia Cardíaca/mortalidad , AdultoRESUMEN
BACKGROUND: Lower extremity peripheral arterial disease is a potentially lethal cardiovascular complication in patients undergoing hemodialysis. Anemia is a risk factor for cardiovascular disease among the hemodialysis population. However, whether blood hemoglobin concentration is associated with the risk of peripheral arterial disease progression in this population remains undetermined. METHODS AND RESULTS: This is an extension of a 4-year multicenter, prospective, observational cohort study to 10 years. A total of 3504 Japanese patients undergoing maintenance hemodialysis were recruited between 2006 and 2007. The primary exposure was blood hemoglobin concentration at baseline. The main outcome was the first-ever incidence of major adverse limb events (MALE), composed of endovascular treatment, bypass surgery, and amputation. Multivariable-adjusted Cox proportional hazards model, Fine-Gray subdistribution hazards model, restricted cubic spline analysis, and restricted mean survival time analysis were used to determine the association of blood hemoglobin concentration with the incidence of MALE. During a median follow-up of 8.0 years, 257 patients experienced MALE. A Cox proportional hazards model showed that the risk of MALE in patients with blood hemoglobin concentrations <10.0 g/dL was significantly higher than in patients with concentrations of 11.0 to 11.9 g/dL, even after adjusting for confounding factors. In contrast, elevated hemoglobin concentration (≥12.0 g/dL) was not significantly associated with increased risk of MALE. Similar associations were observed when the Fine-Gray subdistribution regression model was used by setting all-cause mortality as the competing risk. CONCLUSIONS: A low blood hemoglobin concentration is an independent risk factor for peripheral arterial disease progression in patients undergoing maintenance hemodialysis.
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Hemoglobinas , Extremidad Inferior , Enfermedad Arterial Periférica , Diálisis Renal , Humanos , Masculino , Enfermedad Arterial Periférica/epidemiología , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Diálisis Renal/efectos adversos , Femenino , Hemoglobinas/metabolismo , Hemoglobinas/análisis , Incidencia , Anciano , Persona de Mediana Edad , Estudios Prospectivos , Extremidad Inferior/irrigación sanguínea , Japón/epidemiología , Factores de Riesgo , Amputación Quirúrgica/estadística & datos numéricos , Factores de Tiempo , Modelos de Riesgos Proporcionales , Anemia/epidemiología , Anemia/sangre , Fallo Renal Crónico/terapia , Fallo Renal Crónico/sangre , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/complicaciones , Biomarcadores/sangre , Factores Sexuales , Progresión de la Enfermedad , Medición de Riesgo/métodosRESUMEN
BACKGROUND: While existing literature reports variable results of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing lower extremity amputation (LEA), the effect of RA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this vulnerable population. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program files between 2005 and 2022, all patients receiving LEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. The association between anesthesia modality and post-operative outcomes was studied using multivariable logistic regression analysis. RESULTS: A total of 5,831 patients (4,779 undergoing GA, 1,052 undergoing RA) with a diagnosis of CHF undergoing LEA were identified. On multivariable logistic regression analysis, RA was associated with lower mortality (adjusted odds ratio [aOR] 0.79, 95% CI 0.65-0.97), pneumonia (aOR 0.76, 95% CI 0.58-0.99), septic shock (aOR 0.64, 95% CI 0.47-0.88), post-operative blood transfusion (aOR 0.82, 95% CI 0.70-0.97), and 30-day readmission (aOR 0.79, 95% CI 0.64-0.97). CONCLUSIONS: This study demonstrates that RA for LEA in patients with CHF is associated with decreased morbidity and mortality compared to GA. While furthermore research is needed to confirm this association, RA should be at least considered in CHF patients undergoing LEA when feasible.
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Amputación Quirúrgica , Anestesia de Conducción , Anestesia General , Bases de Datos Factuales , Insuficiencia Cardíaca , Extremidad Inferior , Complicaciones Posoperatorias , Humanos , Masculino , Femenino , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/diagnóstico , Anciano , Anestesia de Conducción/mortalidad , Anestesia de Conducción/efectos adversos , Resultado del Tratamiento , Amputación Quirúrgica/efectos adversos , Amputación Quirúrgica/mortalidad , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Factores de Riesgo , Estudios Retrospectivos , Persona de Mediana Edad , Factores de Tiempo , Estados Unidos , Anestesia General/efectos adversos , Anestesia General/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/diagnóstico , Anciano de 80 o más Años , Medición de Riesgo , Distribución de Chi-CuadradoRESUMEN
BACKGROUND: To examine the influence of liver function on patients with chronic limb-threatening ischemia (CLTI), we classified patients with CLTI after revascularization according to their modified albumin-bilirubin (ALBI) grades. METHODS: We retrospectively analyzed single-center data of patients who underwent revascularization for CLTI between 2015 and 2020. Patients were classified with ALBI grades 1, 2a, and 2b and 3 according to the ALBI score, which was calculated, based on serum albumin and total bilirubin levels. The endpoints were the 2-year amputation-free survival (AFS) and 1-year wound healing rates. RESULTS: We included 190 limbs in 148 patients, and 50, 54, and 86 cases were assigned as grade 1, 2a, and 2b and 3, respectively. The 2-year AFS rates for the grade 1, 2a, and 2b and 3 groups were 79 ± 6%, 66% ± 7%, and 45 ± 6%, respectively (P < 0.01). One-year cumulative wound healing rates for grade 1, 2a, and 2b and 3 groups were 68 ± 7%, 69% ± 6%, and 48% ± 5%, respectively (P = 0.01). Multivariate Cox proportional hazard analyses identified age (≥75 years), dependent ambulatory status, and modified ALBI grades 2b and 3 compared with grades 1 and 2a as significant independent predictors of AFS. The dependent ambulatory status and Wound, Ischemia, and foot Infection classification stage 4 were significant negative predictors of wound healing. CONCLUSIONS: Many patients with CLTI had high modified ALBI grades, and impaired liver function classified as modified ALBI grade 2b and 3 is a robust negative predictor of AFS.
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Amputación Quirúrgica , Bilirrubina , Biomarcadores , Recuperación del Miembro , Enfermedad Arterial Periférica , Valor Predictivo de las Pruebas , Albúmina Sérica Humana , Cicatrización de Heridas , Humanos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Bilirrubina/sangre , Albúmina Sérica Humana/análisis , Biomarcadores/sangre , Factores de Tiempo , Persona de Mediana Edad , Factores de Riesgo , Anciano de 80 o más Años , Medición de Riesgo , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/cirugía , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/sangre , Isquemia Crónica que Amenaza las Extremidades/diagnóstico , Isquemia Crónica que Amenaza las Extremidades/mortalidad , Resultado del Tratamiento , Supervivencia sin Progresión , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Pruebas de Función Hepática , Isquemia/sangre , Isquemia/diagnóstico , Isquemia/cirugía , Isquemia/fisiopatología , Isquemia/mortalidadRESUMEN
BACKGROUND: The aim of this study is to present short- and long-term outcomes after lower extremity bypass (LEB) surgery in patients with chronic limb-threatening ischemia and chronic kidney disease (CKD), differentiated by peripheral artery disease (PAD) Fontaine stage III and IV. METHODS: Retrospective analysis of anonymized data from a nationwide German health insurance company (AOK). Data from 22,633 patients (14,523 men) who underwent LEB from 2010 to 2015 were analyzed, presenting 18,271 with CKD stage 1/2, 2,483 patients with CKD stage 3, and 1,879 with CKD stage 4/5. RESULTS: Perioperative mortality (60-day mortality) was 7.2% for CKD stage 1/2, 12.4% for CKD stage 3, and 19.8% for CKD stage 4/5. Patients with PAD stage IV had significantly higher perioperative mortality (10.3%) than patients with PAD stage III (4.5%). The perioperative major amputation rate depended significantly on PAD stage IV (odds ratio [OR]: 2.57 confidence interval [CI]: 2.16-3.05, P < 0.001), the LEB level below the knee and crural/pedal (OR: 2.49 CI: 2.14-2.90, P < 0.001), CKD stage 4/5 (OR: 1.28, CI: 1.06-1.54, P = 0.009), and the presence of diabetes mellitus type 2 (OR: 1.19, CI: 1.05-1.36, P = 0.007). Kaplan-Meier estimated long-term survival of up to 9 years after surgery was 31.7% for patients with CKD stage 1 and 2, 14.3% for CKD stage 3, and only 10.1% for CKD stage 4 and 5 (P < 0.001). PAD Fontaine stage IV versus III (hazard ratio: 1.64, CI: 1.56-1.71, P < 0.001), but not bypass level, had an independent adverse influence on long-term survival. CONCLUSION: CKD and PAD stage were equally significant independent predictors of patient survival and major adverse cardiovascular events with higher PAD and CKD stages associated with less favorable long-term outcomes.
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Amputación Quirúrgica , Enfermedad Crítica , Recuperación del Miembro , Extremidad Inferior , Enfermedad Arterial Periférica , Insuficiencia Renal Crónica , Humanos , Masculino , Femenino , Alemania , Estudios Retrospectivos , Factores de Tiempo , Anciano , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Resultado del Tratamiento , Factores de Riesgo , Persona de Mediana Edad , Extremidad Inferior/irrigación sanguínea , Anciano de 80 o más Años , Medición de Riesgo , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/mortalidad , Isquemia Crónica que Amenaza las Extremidades/complicaciones , Isquemia/cirugía , Isquemia/mortalidad , Isquemia/diagnóstico , Bases de Datos Factuales , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: The aim of this study was to investigate the illness trajectories of patients with peripheral artery disease (PAD) after revascularization and estimate the independent risks of major amputation and death (from any cause) and their interaction. METHODS: Data from Hospital Episode Statistics Admitted Patient Care were used to identify patients (≥50 years of age) who underwent lower limb revascularization for PAD in England from April 2013 to March 2020. A Markov illness-death model was developed to describe patterns of survival after the initial lower limb revascularization, if and when patients experienced major amputation, and survival after amputation. The model was also used to investigate the association between patient characteristics and these illness trajectories. We also analyzed the relative contribution of deaths after amputation to overall mortality and how the risk of mortality after amputation was related to the time from the index revascularization to amputation. RESULTS: The study analyzed 94 690 patients undergoing lower limb revascularization for PAD from 2013 to 2020. The majority were men (65.6%), and the median age was 72 years (interquartile range, 64-79). One-third (34.8%) of patients had nonelective revascularization, whereas others had elective procedures. For nonelective patients, the amputation rate was 15.2% (95% CI, 14.4-16.0) and 19.9% (19.0-20.8) at 1 and 5 years after revascularization, respectively. For elective patients, the corresponding amputation rate was 2.7% (95% CI, 2.4-3.1) and 5.3% (4.9-5.8). Overall, the risk of major amputation was higher among patients who were younger, had tissue loss, diabetes, greater frailty, nonelective revascularization, and more distal procedures. The mortality rate at 5 years after revascularization was 64.3% (95% CI, 63.2-65.5) for nonelective patients and 33.0% (32.0-34.1) for elective patients. After major amputation, patients were at an increased risk of mortality if they underwent major amputation within 6 months after the index revascularization. CONCLUSIONS: The illness-death model provides an integrated framework to understand patient outcomes after lower limb revascularization for PAD. Although mortality increased with age, the study highlights patients <60 years of age were at increased risk of major amputation, particularly after nonelective revascularization.
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Amputación Quirúrgica , Enfermedad Arterial Periférica , Humanos , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Amputación Quirúrgica/mortalidad , Amputación Quirúrgica/estadística & datos numéricos , Anciano , Masculino , Femenino , Persona de Mediana Edad , Factores de Riesgo , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Procedimientos Quirúrgicos Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/efectos adversos , Inglaterra/epidemiología , Medición de Riesgo , Anciano de 80 o más Años , Resultado del TratamientoRESUMEN
BACKGROUND: Hemodialysis (HD) patients with peripheral arterial disease (PAD) are at heightened risk of adverse vascular events, and aspirin positively affects those outcomes. We aimed to investigate the association between different patterns of aspirin use and clinical vascular events in chronic HD patients with PAD. METHODS: This retrospective nationwide cohort study enrolled 758 chronic HD patients who had been diagnosed with PAD between January 1, 2008, and December 31, 2012, and followed up until the end of 2020. Patients were divided into three groups according to medication possession ratio (MPR) and continued use of aspirin (i.e., low MPR, high MPR but discontinuous prescription, and high MPR and continuous prescription). Percutaneous transluminal angioplasty (PTA), surgical bypass, lower leg amputation, cardiovascular events, cerebrovascular events, and all-cause mortality were evaluated. RESULTS: High MPR and continuous aspirin use had the lowest incidence of all-cause mortality and cardiovascular events compared with the two other groups, and it was significantly associated with low risk of PTA, surgical bypass, cardiovascular events, and all-cause mortality (aHR: 0.58 [0.41-0.83], 0.49 [0.25-0.95], 0.57 [0.40-0.81], and 0.70 [0.55-0.88], respectively). Kaplan-Meier analysis revealed that event-free rates of PTA, cardiovascular events, and all-cause mortality of patients with high MPR and continuous aspirin treatment were the highest among the three groups (p < 0.05). CONCLUSION: Among HD patients with PAD, high MPR and continuous aspirin use significantly reduced the risk of PTA, surgical bypass, cardiovascular events, and all-cause mortality and improved the event-free rates of PTA, cardiovascular events, and all-cause mortality during long-term follow-up.
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Aspirina , Enfermedad Arterial Periférica , Inhibidores de Agregación Plaquetaria , Diálisis Renal , Humanos , Aspirina/uso terapéutico , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/complicaciones , Masculino , Femenino , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Fallo Renal Crónico/terapia , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/mortalidadRESUMEN
BACKGROUND: To examine whether prior gestational diabetes mellitus (GDM) is associated with prevalent coronary heart disease (CHD), cerebrovascular disease (CeVD) and peripheral arterial disease (PAD), and all-cause mortality, in community-based women with type 2 diabetes. METHODS: Baseline prevalences of CHD/CeVD/PAD/prior GDM were determined in 718 females (mean ± SD age 65.5 ± 11.9 years) from the Fremantle Diabetes Study Phase II. Deaths between baseline (2008-2011) and end-2016 were ascertained. Cox regression identified predictors of mortality with GDM as a candidate variable. RESULTS: Compared to the 673 women without GDM, the 39 (5.4 %) with prior GDM were younger, more likely Aboriginal, smokers and obese, had longer diabetes duration and higher HbA1c levels, and were more dyslipidemic (P ≤ 0.046). Prevalences of CHD (24.6 versus 23.1 %), CeVD (7.5 % versus 2.6 %) and PAD (27.5 % versus 23.7 %) were not significantly different in those without versus with prior GDM (P ≥ 0.35). There were 116 deaths (16.2 %) during 6.8 ± 1.6 years of follow-up. Age, Aboriginal ethnicity, marital status, current smoking, heart rate, estimated glomerular filtration rate, CHD and PAD were independently associated with all-cause mortality (P ≤ 0.023); GDM status did not add to the most parsimonious model (P = 0.62). CONCLUSIONS: Prior GDM does not increase CVD risk or all-cause mortality in women with type 2 diabetes.
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Enfermedades Cardiovasculares , Diabetes Mellitus Tipo 2 , Diabetes Gestacional , Humanos , Femenino , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/mortalidad , Embarazo , Diabetes Gestacional/epidemiología , Persona de Mediana Edad , Anciano , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/mortalidad , Prevalencia , Factores de Riesgo , Enfermedad Arterial Periférica/epidemiología , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/complicacionesRESUMEN
OBJECTIVE: Vascular surgeons work long, unpredictable hours with repeated exposure to high-stress situations. Inspired by general surgery acute care surgery models, we sought to organize the care of vascular emergencies with the implementation of a vascular acute care surgery (VACS) model. Within this model, a surgeon is in-house without elective cases and assigned for consultations and urgent operative cases on a weekly basis. This study examined the impact of a VACS model on postoperative mortality and surgeon efficiency. METHODS: This was a retrospective cohort analysis of institutional Vascular Quality Initiative data from July 2014 to July 2023. Patients undergoing lower extremity bypass, peripheral vascular intervention, or amputation were included. There was a washout period from January 2020 to January 2022 to account for COVID-19 pandemic practice abnormalities. Patients were separated into pre- or post-VACS groups. The primary clinical outcomes were 30-day and 2-year mortality. Secondary clinical outcomes included 30-day complications and 30-day and 1-year major adverse limb events (MALE). Separate analyses of operating room data from July 2017 to February 2024 and fiscal data from fiscal year 2019 to fiscal year 2024 were conducted. A washout period from January 2020 to January 2022 was applied. Efficiency outcomes included monthly relative value units (RVUs) per clinical fraction full-time equivalent (cFTE) and daytime (0730-1700, Monday-Friday) operating room minutes. Patient factors and operative efficiency were compared using appropriate statistical tests. Regression modeling was performed for the primary outcomes. RESULTS: There were 972 and 257 patients in the pre- and post-VACS groups, respectively. Pre-VACS patients were younger (66.8 ± 12.0 vs 68.7 ± 12.7 years; P = .03) with higher rates of coronary artery disease (34.6% vs 14.8%; P < .01), hypertension (88.4% vs 82.2%; P = .01), and tobacco history (84.4% vs 78.2%; P = .02). Thirty-day mortality (2.4% pre-vs 0.8% post-VACS; P = .18) and Kaplan-Meier estimation of 2-year mortality remained stable after VACS (P = .07). VACS implementation was not associated with 30-day mortality but was associated with lower 2-year mortality hazard on multivariable Cox regression (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.9; P = .01). Operative efficiency improved post-VACS (median, 850.0; interquartile range [IQR], 765.7-916.3 vs median, 918.0; IQR, 881.0-951.1 RVU/cFTE-month; P = .03). Daytime operating minutes increased (469.1 ± 287.5 vs 908.2 ± 386.2 minutes; P < .01), whereas non-daytime minutes (420.0; IQR, 266.0-654.0 vs 469.5; IQR, 242.0-738.3 minutes; P = .40) and weekend minutes (129.0; IQR, 0.0-298.0 vs 113.5; IQR, 0.0-279.5 minutes; P = .59) remained stable. CONCLUSIONS: A VACS model leads to improvement in surgeon operative efficiency while maintaining patient safety. The adoption of a vascular acute care model has a positive impact on the delivery of comprehensive vascular care.
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Cirugía de Cuidados Intensivos , Extremidad Inferior , Procedimientos Quirúrgicos Vasculares , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cirugía de Cuidados Intensivos/organización & administración , Cirugía de Cuidados Intensivos/estadística & datos numéricos , Amputación Quirúrgica , Eficiencia Organizacional , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/diagnóstico , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Cirujanos , Factores de Tiempo , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Carga de Trabajo/estadística & datos numéricosRESUMEN
BACKGROUND: Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) is a validated self-explanatory score applied in cardiac or noncardiac surgeries. This study aims to assess the predictive value of the MICA score for cardiovascular events after aortoiliac revascularization. METHODS: This prospective cohort underwent elective aortoiliac revascularization between 2013 and 2021. Patients' demographic, clinical characteristics, and outcomes were registered. The patients were divided into 2 groups according to the MICA score using optimal binning. Survival analysis to test for time-dependent variables and multivariate Cox regression analysis for independent predictors were performed. RESULTS: This study included 130 patients with a median follow-up of 55 months. Preoperative MICA score was ≥6.5 in 41 patients. MICA ≥6.5 presented a statistically significant association, with long-term occurrence of acute heart failure (HR = 1.695, 95% CI 1.208-2.379, P = 0.002), major adverse cardiovascular events (HR = 1.222, 95% CI 1.086-1.376, P < 0.001), and all-cause mortality (HR = 1.256, 95% CI 1.107-1.425, P < 0.001). Multivariable Cox regression confirmed MICA as a significant independent predictor of long-term major adverse cardiovascular events (aHR = 1.145 95% CI 1.010-1.298, P = 0.034) and all-cause mortality (aHR = 1.172 95% CI 1.026-1.339, P = 0.020). CONCLUSIONS: The MICA score is a quick, easy-to-obtain, predictive tool in identifying patients with a higher risk of postaortoiliac revascularization cardiovascular events, such as acute heart failure, major adverse cardiovascular events, and all-cause mortality. Additional research for the validation of the MICA score in the context of aortoiliac revascularization and specific interventions is necessary.
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Paro Cardíaco , Infarto del Miocardio , Valor Predictivo de las Pruebas , Humanos , Masculino , Femenino , Anciano , Medición de Riesgo , Persona de Mediana Edad , Factores de Tiempo , Estudios Prospectivos , Factores de Riesgo , Resultado del Tratamiento , Paro Cardíaco/mortalidad , Paro Cardíaco/diagnóstico , Paro Cardíaco/etiología , Infarto del Miocardio/mortalidad , Infarto del Miocardio/etiología , Infarto del Miocardio/diagnóstico , Arteria Ilíaca/cirugía , Arteria Ilíaca/diagnóstico por imagen , Técnicas de Apoyo para la Decisión , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/cirugía , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/complicaciones , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidadRESUMEN
BACKGROUND: The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS: We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS: During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSIONS: Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.
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Amputación Quirúrgica , Bases de Datos Factuales , Isquemia , Extremidad Inferior , Enfermedad Arterial Periférica , Humanos , Masculino , Femenino , Isquemia/mortalidad , Isquemia/terapia , Isquemia/diagnóstico , Isquemia/cirugía , Estudios Retrospectivos , Anciano , Extremidad Inferior/irrigación sanguínea , Factores de Riesgo , Factores de Tiempo , Persona de Mediana Edad , Resultado del Tratamiento , Enfermedad Aguda , Anciano de 80 o más Años , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico , Readmisión del Paciente , Medición de Riesgo , Recuperación del Miembro , Michigan/epidemiología , Sistema de Registros , Tiempo de InternaciónRESUMEN
INTRODUCTION: Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass. METHODS: Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes. RESULTS: Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass. CONCLUSIONS: Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes.
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Amputación Quirúrgica , Oclusión de Injerto Vascular , Enfermedad Arterial Periférica , Humanos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Amputación Quirúrgica/estadística & datos numéricos , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/epidemiología , Recuperación del Miembro/estadística & datos numéricos , Recuperación del Miembro/métodos , Injerto Vascular/métodos , Injerto Vascular/mortalidad , Injerto Vascular/estadística & datos numéricos , Injerto Vascular/efectos adversos , Factores de Riesgo , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/mortalidad , Supervivencia sin ProgresiónRESUMEN
INTRODUCTION: This study aims to assess the association of operative time with the postoperative length of stay and unplanned return to the operating room in patients undergoing femoral to below knee popliteal bypasses, stratified by autologous vein graft or polytetrafluoroethylene (PTFE). MATERIALS AND METHODS: A retrospective analysis of vascular quality initiative database (2003-2021). The selected patients were grouped into the following: vein bypass (group I) and PTFE (group II) patients. Each group was further stratified by a median split of operative time (i.e., 210 min for autologous vein and 155 min for PTFE) to study the outcomes. The outcomes were assessed by univariate and multivariate approach. RESULTS: Of the 10,902 patients studied, 3570 (32.7%) were in the autologous vein group, while 7332 (67.3%) were in the PTFE group. Univariate analysis revealed autologous vein and PTFE graft recipients that had increased operative times were associated with a longer mean postoperative length of stay and a higher incidence of all-cause return to the operating room. In PTFE group, patients with prolonged operative times were also found to be associated with higher incidence of major amputation, surgical site infection, and cardiovascular events, along with loss of primary patency within a year. CONCLUSIONS: For patients undergoing femoral to below knee popliteal bypasses using an autologous vein or PTFE, longer operative times were associated with inferior outcomes. Mortality was not found to be associated with prolonged operative time.
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Tiempo de Internación , Extremidad Inferior , Tempo Operativo , Politetrafluoroetileno , Humanos , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Extremidad Inferior/cirugía , Extremidad Inferior/irrigación sanguínea , Tiempo de Internación/estadística & datos numéricos , Resultado del Tratamiento , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis Vascular/mortalidad , Venas/trasplante , Venas/cirugía , Injerto Vascular/métodos , Injerto Vascular/estadística & datos numéricos , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidadRESUMEN
BACKGROUND: The epidemic of obesity and associated cardiovascular morbidity continues to grow, attracting public attention and healthcare resources. However, the impact of malnutrition and being underweight continues to be overshadowed by obesity, especially in patients with peripheral arterial disease (PAD). This study assesses the characteristics and outcomes of patients with low body mass index (BMI ≤ 18.5) compared to patients with nonobese BMI undergoing peripheral vascular interventions (PVI). METHODS: A retrospective analysis of patients undergoing PVI due to PAD registered in the Vascular Quality Initiative database. Patients were categorized into underweight (BMI ≤ 18.5) and nonobese BMI (BMI = 18.5-30). Patients in both groups were matched 3:1 for baseline demographic characteristics, comorbidities, medications, and indications. Kaplan-Meier analysis was done for long-term outcomes. RESULTS: A total of 337,926 patients underwent PVI, of whom 12,935 (4%) were underweight, 215,728 (64%) were nonobese, and 109,263 (32%) were obese. Underweight patients were more likely to be older, female, smokers, with chronic obstructive pulmonary disorder, and more likely to present with chronic limb-threatening ischemia than nonobese patients. After propensity matching, there were 18,047 nonobese patients and 6,031 underweight patients. There were no significant differences in matched characteristics. Perioperatively, underweight patients were more likely to require a longer hospital length of stay. Underweight patients had statistically significantly higher 30-day mortality compared to patients with nonobese BMI (3% vs. 1.6%, P < 0.001) and a higher rate of thrombotic complications. As for long-term outcomes, underweight patients had a higher rate of reintervention (20% vs. 18%, P < 0.001) and major adverse limb events (27% vs. 22%, P < 0.001). The 4-year rate of amputation-free survival was significantly lower in underweight patients (70% vs. 82%, P < 0.001), and the 2-year freedom from major amputation (90% vs. 94%, P < 0.001) showed similar trends with worse outcomes in patients who were underweight. CONCLUSIONS: Underweight patients with PAD are disproportionally more likely to be African American, females, and smokers and suffer worse outcomes after PVI than PAD patients with nonobese BMI. When possible, increased scrutiny and optimization of nutrition and other factors contributing to low BMI should be addressed prior to PVI.
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Índice de Masa Corporal , Bases de Datos Factuales , Procedimientos Endovasculares , Extremidad Inferior , Enfermedad Arterial Periférica , Delgadez , Humanos , Femenino , Masculino , Estudios Retrospectivos , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/cirugía , Anciano , Factores de Riesgo , Factores de Tiempo , Persona de Mediana Edad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Delgadez/mortalidad , Delgadez/complicaciones , Delgadez/diagnóstico , Extremidad Inferior/irrigación sanguínea , Medición de Riesgo , Recuperación del Miembro , Amputación Quirúrgica , Anciano de 80 o más Años , Resultado del Tratamiento , Estados Unidos/epidemiología , Supervivencia sin Progresión , Obesidad/complicaciones , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidadRESUMEN
BACKGROUND: In India, a significant scarcity of published data exists regarding chronic limb-threatening ischemia (CLTI) and its management, especially among the elderly population. CLTI, often accompanied by frailty poses a significant healthcare challenge. While endovascular interventions offer hope, there remains a dearth of outcome data for this age group. This study seeks to address this critical gap by investigating the impact of frailty on outcomes, emphasizing amputation-free survival (AFS), wound healing, and health-related quality of life (HRQoL). METHODS: Our study included 131 elderly CLTI patients aged ≥70 years who underwent infrainguinal endovascular interventions between April 2018 and August 2021, with a follow-up period of 2 years. Among the patients, 93.9% had diabetes mellitus and 82.4% had hypertension. Clinical frailty was assessed using the clinical frailty scale (CFS). Patients were categorized into group 1 (CFS 1-5) and group 2 (CFS 6-9). Primary outcomes were AFS, wound healing, HRQoL, and their association with frailty. Secondary outcomes included technical success, procedure-related complications, major adverse limb events, major adverse cardiac events, vessel patency, re-intervention rates, and mortality rates including periprocedural and overall mortality. RESULTS: Technical success was achieved in 86.3% of patients, with frailty significantly influencing this outcome. Group 2 exhibited reduced technical success (80.8%) compared to group 1 (93.1%). The major amputation rate was 9.2%, with higher rates in group 2 [univariate hazard ratio: 5.20; P = 0.033]. Similarly, group 2 showed elevated overall mortality [univariate hazard ratio: 5.18; P < 0.001]. AFS at 1 and 2 years were 67.9% and 55%, respectively, with higher rates in group 1. Wound healing was achieved in 76.1% of patients (83/109), with frailty significantly associated with delayed wound healing (P < 0.001). Vessel patency at 1 year was observed in 88.8% of patients. HRQoL significantly improved postintervention, with vascular quality of life questionnaire-6 (VascuQol-6) scores increasing from an average of 9 of 24 at baseline to 20 of 24 at 2 years. Frailty score significantly correlated with VascuQol-6 scores at 1 and 2 years (P < 0.0012). Group 1 exhibited higher VascuQol-6 scores than group 2, indicating improved HRQoL during follow-up. CONCLUSIONS: Successful endovascular treatments in high-risk CLTI patients promote improved wound healing and post-treatment quality of life. Frailty should be assessed before endovascular interventions as it correlates with adverse outcomes, including amputations and mortality. While revascularization holds promise, caution is advised for frailer patients, emphasizing the importance of personalized care and tailored treatments for elderly CLTI patients.
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Amputación Quirúrgica , Isquemia Crónica que Amenaza las Extremidades , Procedimientos Endovasculares , Anciano Frágil , Fragilidad , Recuperación del Miembro , Enfermedad Arterial Periférica , Calidad de Vida , Cicatrización de Heridas , Humanos , Anciano , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Fragilidad/complicaciones , Fragilidad/diagnóstico , Fragilidad/mortalidad , Fragilidad/fisiopatología , Masculino , Femenino , Isquemia Crónica que Amenaza las Extremidades/cirugía , Anciano de 80 o más Años , Factores de Tiempo , Factores de Riesgo , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico , Resultado del Tratamiento , Medición de Riesgo , Estudios Retrospectivos , Factores de Edad , Evaluación Geriátrica , India , Supervivencia sin ProgresiónRESUMEN
BACKGROUND: The frequency of distal lower extremity bypass (LEB) for infrapopliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. METHODS: We queried the Vascular Quality Initiative infrainguinal database from 2003 to 2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular reintervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. RESULTS: We identified 2331 LEB procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003-3.51% in 2021 (P < 0.001). The majority of cases presented with tissue loss (81.25. Common postoperative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Postoperative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56% ± 3.6%, MALE was 63.49% ± 3.27%, and amputation-free survival was 71.71% ± 0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than great saphenous vein (P < 0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (P = 0.015), and lower MALE (P = 0.021) at 2 years. CONCLUSIONS: Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize reinterventions.
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Amputación Quirúrgica , Bases de Datos Factuales , Recuperación del Miembro , Extremidad Inferior , Enfermedad Arterial Periférica , Supervivencia sin Progresión , Insuficiencia del Tratamiento , Injerto Vascular , Grado de Desobstrucción Vascular , Humanos , Masculino , Femenino , Anciano , Factores de Tiempo , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/mortalidad , Factores de Riesgo , Persona de Mediana Edad , Estudios Retrospectivos , Extremidad Inferior/irrigación sanguínea , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Medición de Riesgo , Isquemia/cirugía , Isquemia/fisiopatología , Isquemia/mortalidad , Estados Unidos , Anciano de 80 o más Años , Enfermedad Crítica , ReoperaciónRESUMEN
BACKGROUND: This study aimed to analyze the clinical outcomes after revascularization for chronic limb-threatening ischemia (CLTI) in patients aged ≥ 80 years and < 80 years. METHODS: We retrospectively analyzed multicenter data of 789 patients who underwent infrainguinal revascularization for CLTI between 2015 and 2021. The end points were 2-year overall survival (OS), amputation-free survival (AFS), limb salvage (LS), and postoperative complications. RESULTS: A total of 90 patients aged ≥ 80 years and 200 patients aged < 80 years underwent bypass surgery (BSX), and 205 patients aged ≥ 80 years and 294 patients aged < 80 years underwent endovascular therapy (EVT). Before the propensity score matching, multivariate analyses showed that age ≥ 80 years, lower body mass index and serum albumin levels, nonambulatory status, and end-stage renal disease were independent risk factors for 2-year mortality in the BSX and EVT groups. After propensity score matching, the 2-year OS was better in the < 80 years cohort than in the ≥ 80 years cohort in both the BSX and EVT groups (P = 0.018 and P = 0.035, respectively). There was no difference in the 2-year LS rates between the < 80 years and the ≥ 80 years cohorts in both the BSX and EVT groups (P = 0.621 and P = 0.287, respectively). According to the number of risk factors, except for age ≥ 80 years, there was no difference in the 2-year AFS rates between the < 80 years and ≥ 80 years cohorts for the BSX and EVT groups with 0-1 risk factor (P = 0.957 and P = 0.655, respectively). However, the 2-year AFS rate was poor, especially in the ≥ 80 years cohort in the BSX with 2-4 risk factors (P = 0.015). The Clavien-Dindo ≥ IV complication rates tended to be higher in the ≥ 80 years cohort than in the < 80 years cohort only in the BSX with 2-4 risk factors (P = 0.056). CONCLUSIONS: Patients with CLTI aged ≥ 80 years had poorer OS than those aged < 80 years. However, there was no difference in LS between the ≥ 80 years and < 80 years cohorts in both the BSX and EVT groups. Although age ≥ 80 years was associated with poorer OS, patients with 0-1 risk factor may benefit from revascularization, including BSX, because no difference was observed in AFS or Clavien-Dindo ≥ IV complications.