National trends of hybrid lower extremity revascularization in the ACS-NSQIP database

Objectives Despite reports of increasing use of hybrid surgery for lower extremity revascularization in Europe, little is known about the performance of hybrid procedures in the U.S. This study aims to investigate contemporary national trends in frequency and operator distribution of hybrid lower extremity revascularization and compare the perioperative outcomes of independent vascular surgeons and other surgical specialists. We hypothesized that hybrid procedures are increasingly performed, and independent vascular surgeons have superior outcomes compared to other surgical specialists. Methods The 2005–2015 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was used to identify patients undergoing open or hybrid lower extremity revascularization based on Current Procedural Terminology codes. Only patients treated for peripheral artery disease, based on International Classification of Diseases codes-9, were included. A trend of yearly hybrid lower extremity revascularization compared to open lower extremity revascularization was obtained. The most commonly performed hybrid procedure was identified as well as the specialties of the primary operators. Operators were categorized as “independent vascular surgeons” and “other surgeons” if the primary operator was a non-vascular surgeon or a vascular surgeon assisted by a second specialist as part of a team. Patients undergoing this hybrid lower extremity revascularization by independent vascular surgeons were selected and matched (2:1) to the patients who underwent the same procedure by other surgical specialists. Matching was based on age, gender, functional status, American Society of Anesthesiologists classification, transfer status, emergent surgery, and indication. The characteristics and perioperative outcomes of those two groups were compared. Results The overall rate of hybrid procedures increased from 4% in 2005 to 14% in 2015 ( p < 0.0001). During this period, vascular surgeons independently performed 92.9% of all hybrid surgeries, with no significant change in the yearly trend ( p = 0.15). Femoral endarterectomy with retrograde aortoiliac intervention was identified as the most common procedure, accounting for 35.7% and 33.3% of hybrid lower extremity revascularization performed by independent vascular surgeons and other surgeons, respectively. After propensity matching, there were 212 patients treated by independent vascular surgeons and 106 patients treated by other surgeons, with no significant difference in demographics or comorbidities. There was no difference between independent vascular surgeons and other surgeons in mortality (1.4% and 2.8%, respectively, p = 0.30), overall morbidity (19.3% and 18.9% respectively, p = 0.91), and other complications. Conclusion Hybrid lower extremity revascularization for peripheral artery disease has been increasingly used and is performed primarily by independent vascular surgeons. Simple hybrid procedures may be performed safely by vascular surgeons as well as other trained surgical specialists.

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Guideline-Oriented Therapy of Lower Extremity Peripheral Artery Disease (PAD) – Current Data and Perspectives

RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren ◽

10.1055/a-0690-9365 ◽

2019 ◽

Vol 191 (04) ◽

pp. 311-322 ◽

Cited By ~ 3

Author(s):

Jonas Kersting ◽

Lars Kamper ◽

Marco Das ◽

Patrick Haage

Keyword(s):

Lower Extremity ◽

Peripheral Artery Disease ◽

Bypass Surgery ◽

Interdisciplinary Approach ◽

Current Data ◽

Arterial System ◽

Peripheral Artery ◽

Vascular Surgeon ◽

Technical Developments ◽

Artery Disease

Background Because of the demographic change, lower extremity peripheral artery disease (PAD) is becoming increasingly relevant with respect to health economics. PAD patients often suffer from multiple diseases. Consequently, therapy is commonly complex and requires an interdisciplinary approach. Because of rapid technical developments, interventional endovascular therapy regimens play an increasingly important role. Method Review and literature search on the basis of the current German S3 guidelines on the therapy of PAD as well as international guidelines. In terms of state-of-the-art therapies, relevant current studies were considered. Results Knowledge of existing guidelines and recommendations as well as new therapeutic approaches is essential for the adequate therapy of PAD patients. A close cooperation between the interventional radiologist and the vascular surgeon is the key to success. In addition to established conservative approaches and invasive bypass surgery, the endovascular approach has been a mainstay in the TASC A and B environment for years. It has recently shown promising results in advanced PAD conditions, such as TASC C and D. An endovascular-first strategy is defined in most guidelines. Conclusion A primarily endovascular-first strategy has become the standard in the majority of even complex lesions of the lower extremity arterial system. Regarding the crural segment, a decrease in mortality compared to bypass surgery has been demonstrated. Further evidence can be expected from ongoing randomized multicenter trials. Key Points: Citation Format

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Ticagrelor Compared With Clopidogrel in Patients With Prior Lower Extremity Revascularization for Peripheral Artery Disease

Journal of Vascular Surgery ◽

10.1016/j.jvs.2017.02.012 ◽

2017 ◽

Vol 65 (4) ◽

pp. 1239

Author(s):

W.S. Jones ◽

I. Baumgartner ◽

W.R. Hiatt ◽

G. Heizer ◽

M.S. Conte ◽

...

Keyword(s):

Lower Extremity ◽

Peripheral Artery Disease ◽

Peripheral Artery ◽

Artery Disease ◽

Lower Extremity Revascularization

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Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization

Vascular Medicine ◽

10.1177/1358863x20952856 ◽

2020 ◽

Vol 25 (6) ◽

pp. 527-533

Author(s):

Tanner I Kim ◽

Anand Brahmandam ◽

Timur P Sarac ◽

Kristine C Orion

Keyword(s):

Human Immunodeficiency Virus ◽

Lower Extremity ◽

Hospital Costs ◽

Major Amputation ◽

Perioperative Outcomes ◽

Hiv Status ◽

Immunodeficiency Virus ◽

Multivariable Regression ◽

Artery Disease ◽

Lower Extremity Revascularization

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 ( p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

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Effect of vorapaxar on cardiovascular and limb outcomes in patients with peripheral artery disease with and without coronary artery disease: Analysis from the TRA 2°P-TIMI 50 trial

Vascular Medicine ◽

10.1177/1358863x19892690 ◽

2020 ◽

Vol 25 (2) ◽

pp. 124-132 ◽

Cited By ~ 1

Author(s):

Arman Qamar ◽

David A Morrow ◽

Mark A Creager ◽

Benjamin M Scirica ◽

Jeffrey W Olin ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Lower Extremity ◽

Peripheral Artery Disease ◽

Absolute Risk ◽

Major Adverse Cardiovascular Events ◽

Number Needed To Treat ◽

Peripheral Artery ◽

Artery Disease ◽

Lower Extremity Revascularization

Intensive antithrombotic therapy reduces major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with peripheral artery disease (PAD). Recent studies have suggested heterogeneity in risk and benefit in those with and without concomitant coronary artery disease (CAD) and peripheral revascularization. We evaluated the risk of MACE and MALE in patients with PAD stratified by history of concomitant CAD and prior peripheral revascularization and whether the efficacy and safety of vorapaxar were similar in these subgroups. The TRA 2°P-TIMI 50 trial randomized 26,449 patients with prior MI, ischemic stroke, or PAD to vorapaxar or placebo. This analysis examined the effect of vorapaxar in a broad population of 6136 patients with PAD. Overall, vorapaxar significantly reduced MACE (HR 0.85, 95% CI 0.73, 0.99; p = 0.034) and MALE (HR 0.70, 95% CI 0.53, 0.92; p = 0.011) in patients with PAD. The absolute risk reduction (ARR) for MACE was greater in patients with PAD and CAD versus those with PAD alone (–2.2% vs 0.1%: number needed to treat (NNT) 45 vs 1000). Conversely, the ARR for MALE was higher in those with prior lower extremity revascularization (2.5% vs 0.2%: NNT 40 vs 500). Vorapaxar increased major bleeding (HR 1.39, 95% CI 1.12, 1.71; p = 0.003). The net clinical outcome in all patients with PAD was reduced with vorapaxar (HR 0.82, 95% CI 0.72, 0.94; p = 0.004), with benefits driven by reductions in MACE for those with CAD and by reductions in MALE for those with prior peripheral revascularization. Among patients with PAD, vorapaxar resulted in a net clinical benefit; however, the drivers of benefit were heterogeneous, with greater reductions in MACE in those with concomitant CAD and greater reductions in MALE in those with prior lower extremity revascularization, and unclear benefit in patients with neither. These clinical characteristics may be useful in identifying the subgroups of patients with PAD most likely to benefit from potent antithrombotic therapies. ClinicalTrials.gov Identifier: NCT00526474

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Letter by Moris et al Regarding Article, “Ticagrelor Compared With Clopidogrel in Patients With Prior Lower Extremity Revascularization for Peripheral Artery Disease”

Circulation ◽

10.1161/circulationaha.116.026865 ◽

2017 ◽

Vol 135 (23) ◽

Author(s):

Demetrios Moris ◽

Nikolaos Patelis ◽

Stavros Kakkos

Keyword(s):

Lower Extremity ◽

Peripheral Artery Disease ◽

Peripheral Artery ◽

Artery Disease ◽

Lower Extremity Revascularization

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Comparative effectiveness study of self-directed walking exercise, lower extremity revascularization, and functional decline in peripheral artery disease

Journal of Vascular Surgery ◽

10.1016/j.jvs.2012.09.068 ◽

2013 ◽

Vol 57 (4) ◽

pp. 990-996.e1 ◽

Cited By ~ 14

Author(s):

Mary M. McDermott ◽

Melina Kibbe ◽

Jack M. Guralnik ◽

William H. Pearce ◽

Lu Tian ◽

...

Keyword(s):

Lower Extremity ◽

Peripheral Artery Disease ◽

Comparative Effectiveness ◽

Functional Decline ◽

Effectiveness Study ◽

Peripheral Artery ◽

Comparative Effectiveness Study ◽

Walking Exercise ◽

Artery Disease ◽

Lower Extremity Revascularization

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Ankle-Brachial Index for Risk Stratification in Patients With Symptomatic Peripheral Artery Disease With and Without Prior Lower Extremity Revascularization: Observations From the EUCLID Trial

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.120.009871 ◽

2021 ◽

Author(s):

William R. Hiatt ◽

Connie N. Hess ◽

Marc P. Bonaca ◽

Sarah Kavanagh ◽

Manesh R. Patel ◽

...

Keyword(s):

Lower Extremity ◽

Peripheral Artery Disease ◽

Ankle Brachial Index ◽

Cubic Spline ◽

Hazard Ratio ◽

Acute Limb Ischemia ◽

Peripheral Artery ◽

Increased Risk ◽

Artery Disease ◽

Lower Extremity Revascularization

Background: A reduced ankle-brachial index (ABI) is a measure of atherosclerosis and is associated with ischemic risk in the general population. Whether this relationship is maintained in peripheral artery disease after lower extremity revascularization (LER), which can modify ABI, is unknown. Methods: The EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) enrolled 13 885 patients with symptomatic peripheral artery disease; 57% with prior LER, and 43% with ABI ≤0.80. The primary major adverse cardiovascular events (MACE) outcome was a composite of cardiovascular death, myocardial infarction, or ischemic stroke. Major adverse limb events (MALE) included acute limb ischemia and major amputation. An adjusted Cox proportional hazards model demonstrated a nonlinear relationship between ABI and outcomes. A restricted cubic spline model with 4 knots was developed to identify the best fitting model to describe the relationship between ABI and MACE and MALE risk. Results: Baseline ABI (mean±SD) was 0.77±0.21 in participants with prior LER and 0.63±0.14 in those without prior LER ( P <0.0001). There was no statistical interaction between prior LER and ABI, meaning the shapes of the cubic spline models were similar between groups. In those with prior LER, for every 0.10 unit lower ABI below an ABI of 1.00, the hazard ratio for MACE was 1.08 (95% CI, 1.04–1.12; P <0.0001), below an ABI of 0.80 the hazard ratio for MALE was 1.32 (95% CI, 1.21–1.43; P <0.0001). In patients without prior LER, every 0.10 unit lower ABI below an ABI of 0.70 was associated with increased risk for MACE (hazard ratio, 1.14 [95% CI, 1.06–1.23]; P =0.0004) and MALE (hazard ratio, 1.27 [95% CI, 1.08–1.49]; P =0.003). Conclusions: Patients with established peripheral artery disease, particularly those with prior LER, have an increased risk of MACE and MALE. The ABI remains a strong predictor of MACE and MALE ischemic events with an inverse relationship below an ABI threshold for patients with and without prior LER. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01732822.

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