Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass
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Authors
Nolan, Brian W.De Martino, Randall R.
Stone, David H.
Schanzer, Andres
Goodney, Philip P.
Walsh, Daniel W.
Cronenwett, Jack L.
UMass Chan Affiliations
Department of SurgeryDocument Type
Journal ArticlePublication Date
2011-09-01Keywords
AgedAmputation
Angioplasty
Chi-Square Distribution
Critical Illness
Female
Graft Occlusion, Vascular
Hospital Mortality
Humans
Ischemia
Kaplan-Meier Estimate
Limb Salvage
Lower Extremity
Male
New England
Patient Selection
Proportional Hazards Models
Registries
Reoperation
Retrospective Studies
Risk Assessment
Risk Factors
Time Factors
Treatment Failure
Vascular Grafting
Surgery
Metadata
Show full item recordAbstract
BACKGROUND: Although open surgical bypass remains the standard revascularization strategy for patients with critical limb ischemia (CLI), many centers now perform peripheral endovascular intervention (PVI) as the first-line treatment for these patients. We sought to determine the effect of a prior ipsilateral PVI (iPVI) on the outcome of subsequent lower extremity bypass (LEB) in patients with CLI. METHODS: A retrospective cohort analysis of all patients undergoing infrainguinal LEB between 2003 and 2009 within hospitals comprising the Vascular Study Group of New England (VSGNE) was performed. Primary study endpoints were major amputation and graft occlusion at 1 year postoperatively. Secondary outcomes included in-hospital major adverse events (MAE), 1-year mortality, and composite 1-year major adverse limb events (MALE). Event rates were determined using life table analyses and comparisons were performed using the log-rank test. Multivariate predictors were determined using a Cox proportional hazards model with multilevel hierarchical adjustment. RESULTS: Of 1880 LEBs performed, 32% (n = 603) had a prior infrainguinal revascularization procedure (iPVI, 7%; ipsilateral bypass, 15%; contralateral PVI, 3%; contralateral bypass, 17%). Patients with prior iPVI, compared with those without a prior iPVI, were more likely to be women (32 vs 41%; P = .04), less likely to have tissue loss (52% vs 63%; P = .02), more likely to require arm vein conduit (16% vs 5%; P = .001), and more likely to be on statin (71% vs 54%; P = .01) and beta blocker therapy (92% vs 81%; P = .01) at the time of their bypass procedure. Other demographic factors were similar between these groups. Prior PVI or bypass did not alter 30-day MAE and 1-year mortality after the index bypass. In contrast, 1-year major amputation and 1-year graft occlusion rates were significantly higher in patients who had prior iPVI than those without (31% vs 20%; P = .046 and 28% vs 18%; P = .009), similar to patients who had a prior ipsilateral bypass (1 year major amputation, 29% vs 20%; P = .022; 1 year graft occlusion, 33% vs 18%; P = .001). Independent multivariate predictors of higher 1-year amputation and graft occlusion rates were prior iPVI, prior ipsilateral bypass, dialysis dependence, prosthetic conduit and distal (tibial and pedal) bypass target. CONCLUSIONS: Prior iPVI is highly predictive for poor outcome in patients undergoing LEB for CLI with higher 1-year amputation and graft occlusion rates than those without prior revascularization, similar to prior ipsilateral bypass These findings provide information, which may help with the complex decisions surrounding revascularization options in patients with CLI. rights reserved.Source
J Vasc Surg. 2011 Sep;54(3):730-5; discussion 735-6. Epub 2011 Jul 29. Link to article on publisher's site
DOI
10.1016/j.jvs.2011.03.236Permanent Link to this Item
http://hdl.handle.net/20.500.14038/49694PubMed ID
21802888Related Resources
Link to Article in PubMedae974a485f413a2113503eed53cd6c53
10.1016/j.jvs.2011.03.236