Browsing by Subject "BYPASS-SURGERY"

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  • Noronen, Katariina; Saarinen, Eva; Albäck, Anders; Venermo, Maarit (2017)
    Objectives: The number of elderly people is increasing; inevitably, the result will be more patients with critical limb ischaemia (CLI) in the future. Tissue loss in CLI is related to a high risk of major amputation. The aim of this study was to analyze the treatment process from referral to revascularisation, to discover possible delays and reasons behind them, and to distinguish patients benefitting the most from early revascularisation. Methods: A retrospective analysis was performed of 394 consecutive patients with a combined 447 affected limbs, referred to the outpatient clinic during 2010-2011 for tissue loss of suspected ischaemic origin. Results: For 246 limbs revascularisation was scheduled. After changes in the initial treatment strategy, endovascular treatment (ET) was performed on 221 and open surgery (OS) on 45 limbs. Notably there was crossover after ET in 17.0% of the procedures, and re-revascularisations were required in 40.1% after ET and 31.1% after OS. The median time from referral to revascularisation was 43 days (range 1-657 days) with no significant difference between ET and OS. For 29 (11.8%) patients the ischaemic limb required an emergency operation scheduled at the first visit to the outpatient clinic. For 25 (10.2%) patients the situation worsened while waiting for elective revascularisation and an emergency procedure was performed. Diabetic patients formed the majority of the study population; with 159 diabetic feet undergoing revascularisation. In multivariate analysis, diabetes was associated with poor limb salvage. When revascularisation was achieved within 2 weeks, no difference was seen in limb salvage. However, when the delay from first visit to revascularisation exceeded 2 weeks, limb salvage was significantly poorer in diabetic patients. Conclusions: Diabetic ulcers always require vascular evaluation, and when.ischaemia is suspected the diagnostics should be organised rapidly to ensure revascularisation without delay, according to this study within 2 weeks from the first evaluation. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
  • Spillerova, K.; Settembre, N.; Biancari, F.; Albäck, A.; Venermo, M. (2017)
    Introduction: This study aimed to evaluate the impact of angiosome targeted (direct) revascularisation according to revascularisation method in patients with diabetes. Materials and methods: This retrospective study cohort comprised 545 diabetic patients with critical limb ischaemia and tissue loss (Rutherford 5, 6). All patients underwent infrapopliteal endovascular (PTA) or open surgical revascularisation between January 2008 and December 2013. Differences in the outcome after direct revascularisation, bypass surgery, and PTA were investigated by means of Cox proportional hazards analysis. The endpoints were wound healing, leg salvage, and amputation free survival. Results: Overall, 60.3% of the ischaemic wounds healed during 1 year of follow-up. The highest wound healing rate was achieved after direct bypass (77%) and the worst after indirect PTA (52%). The Cox proportional hazards analysis showed that the number of affected angiosomes = 10 mg/dL (HR 2.05, 95% CI 1.45-2.90), atrial fibrillation (HR 1.54, 95% CI 1.05-2.26), and number of affected angiosomes >3 (HR 1.75, 95% CI 1.24-2.46) were significantly associated with poor leg salvage. Direct PTA was associated with a lower rate of major amputation compared with indirect PTA (HR 0.57 95% CI 0.37-0.89). Conclusion: In diabetics, indirect endovascular revascularisation leads to significantly worse wound healing and leg salvage rates compared with direct revascularisation. Therefore, endovascular procedures should be targeted according to the angiosome concept. In bypass surgery, however, the concept is of less value and the artery with the best runoff should be selected as the outflow artery. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
  • Settembre, Nicla; Biancari, Fausto; Spillerova, Kristyna; Albäck, Anders; Söderström, Maria; Venermo, Maarit (2020)
    Introduction In the context of chronic limb threatening ischemia (CLTI), the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated. Materials and method This series includes 580 patients who underwent endovascular (n=407) and surgical revascularization (n=173) of the infrapopliteal arteries for CLTI associated with foot ulcer or gangrene. The risk of major amputation after infrapopliteal revascularization was assessed by a competing risk approach. A subanalysis was made separately for patients who underwent endovascular or open surgical revascualrization. Results At 2 years, survival was 65.1% and leg salvage was 76.1%. Multivariable competing risk analysis showed that C-reactive protein≥ 10 mg/dL, diabetes, rheumatoid arthritis, increased number of affected angiosomes and the incomplete or total absence of pedal arch compared to complete pedal arch were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (SHR 2.131, 95%CI 1.282-3.543) and no visualized pedal arch (SHR 3.022, 95%CI 1.553-5.883) compared to complete pedal arch. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of complete pedal arch had a lower risk of major amputation (adjusted SHR 0.463, 95%CI 0.240-0.894) compared to angiosome-directed revascularization without complete pedal arch. In the subanalysis, among patients who underwent endovascular revascularization, complete pedal arch (SHR 0.509, 95%CI 0.286-0.905) and angiosome-targeted revascularization (SHR 0.613, 95%CI 0.394-0.956) were associated with a lower risk of major amputation. Conclusions Competing risk analysis showed that a patent pedal arch had significant impact on leg salvage and that the subset of patients undergoing endovascular procedure may most benefit of an angiosome-targeted revascularization.
  • Wessels, Lars; Fekonja, Lucius Samo; Achberger, Johannes; Dengler, Julius; Czabanka, Marcus; Hecht, Nils; Schneider, Ulf; Tkatschenko, Dimitri; Schebesch, Karl-Michael; Schmidt, Nils Ole; Mielke, Dorothee; Hosch, Henning; Ganslandt, Oliver; Gräwe, Alexander; Hong, Bujung; Walter, Jan; Güresir, Erdem; Bijlenga, Philippe; Haemmerli, Julien; Maldaner, Nicolai; Marbacher, Serge; Nurminen, Ville; Zitek, Hynek; Dammers, Ruben; Kato, Naoki; Linfante, Italo; Pedro, Maria-Teresa; Wrede, Karsten; Wang, Wei-Te; Wostrack, Maria; Vajkoczy, Peter (2020)
    Background and objective The main challenge of bypass surgery of complex MCA aneurysms is not the selection of the bypass type but the initial decision-making of how to exclude the affected vessel segment from circulation. To this end, we have previously proposed a classification for complex MCA aneurysms based on the preoperative angiography. The current study aimed to validate this new classification and assess its diagnostic reliability using the giant aneurysm registry as an independent data set. Methods We reviewed the pretreatment neuroimaging of 51 patients with giant (> 2.5 cm) MCA aneurysms from 18 centers, prospectively entered into the international giant aneurysm registry. We classified the aneurysms according to our previously proposed Berlin classification for complex MCA aneurysms. To test for interrater diagnostic reliability, the data set was reviewed by four independent observers. Results We were able to classify all 51 aneurysms according to the Berlin classification for complex MCA aneurysms. Eight percent of the aneurysm were classified as type 1a, 14% as type 1b, 14% as type 2a, 24% as type 2b, 33% as type 2c, and 8% as type 3. The interrater reliability was moderate with Fleiss's Kappa of 0.419. Conclusion The recently published Berlin classification for complex MCA aneurysms showed diagnostic reliability, independent of the observer when applied to the MCA aneurysms of the international giant aneurysm registry.
  • Björkman, Patrick; Peltola, E.; Albäck, Anders; Venermo, Maarit (2017)
    Background and Aims: The objective of this study is to analyze outcomes of the first experiences with drug-eluting balloons in native arteries, vein grafts, and vascular accesses. The study is also a pilot for our future prospective, randomized, and controlled studies regarding the use of drug-eluting balloons in the treatment of the stenosis in bypass vein graft and dialysis access. Materials and Methods: A total of 93 consecutive patients were retrospectively analyzed and in the end 81 were included in the study. Inclusion criteria included at least one previous percutaneous angioplasty to the same lesion. Patients were divided into three groups according to the anatomical site of the lesion: native lower limb artery, vein bypass graft, or vascular access. Time from the previous percutaneous angioplasty to the drug-eluting balloon was compared to the time from the drug-eluting balloon to endpoint in the same patient. Endpoints included any new revascularization of the target lesion, major amputation, or new vascular access. Results: The median time from the drug-eluting balloon to endpoint was significantly longer than the median time from the preceding percutaneous angioplasty to drug-eluting balloon in all three groups. This difference was clearest in native arteries and vein grafts, whereas the difference was smaller from the beginning and disappeared over time in the vascular access group. No significant differences were seen between the groups with regard to smoking, antiplatelet regime, diabetes, Rutherford classification, or sex. Conclusion: Although the setup of this study has several limitations, the results suggest that there could be benefit from drug-eluting balloons in peripheral lesions. Very little data have been published on the use of drug-eluting balloons in vein grafts and vascular accesses, and randomized and controlled prospective studies are needed to further investigate this field.
  • Kandolin, Riina M.; Wiefels, Christiane C.; Mesquita, Claudio Tinoco; Chong, Aun-Yeong; Boland, Paul; Glineur, David; Sun, Louise; Beanlands, Rob S.; Mielniczuk, Lisa M. (2019)
    This review describes the current evidence and controversies for viability imaging to direct revascularization decisions and the impact on patient outcomes. Balancing procedural risks and possible benefit from revascularization is a key question in patients with heart failure of ischemic origin (IHF). Different stages of ischemia induce adaptive changes in myocardial metabolism and function. Viable but dysfunctional myocardium has the potential to recover after restoring blood flow. Modern imaging techniques demonstrate different aspects of viable myocardium; perfusion (single-photon emission computed tomography [SPECT], positron emission tomography [PET], cardiovascular magnetic resonance [CMR]), cell metabolism (PET), cell membrane integrity and mitochondrial function (201Tl and 99mTc-based SPECT), contractile reserve (stress echocardiography, CMR) and scar (CMR). Observational studies suggest that patients with IHF and significant viable myocardium may benefit from revascularization compared with medical treatment alone but that in patients without significant viability, revascularization appears to offer no survival benefit or could even worsen the outcome. This was not supported by 2 randomized trials (Surgical Treatment for Ischemic Heart Failure [STICH] and PET and Recovery Following Revascularization [PARR] -2) although post-hoc analyses suggest that benefit can be achieved if decisions had been strictly based on viability imaging recommendations. Based on current evidence, viability testing should not be the routine for all patients with IHF considered for revascularization but rather integrated with clinical data to guide decisions on revascularization of high-risk patients with comorbidities.
  • Spillerova, Kristyna; Biancari, Fausto; Settembre, Nicla; Albäck, Anders; Venermo, Maarit (2017)
    Background: The definition of angiosome-targeted revascularization is confusing, especially when a tissue lesion affects several angiosomes. Two different definitions of direct revascularization exist in the literature. The study aim was (1) to compare the 2 definitions of direct revascularization in patients with foot lesions involving more than one angiosome and (2) to evaluate which definition better predicts clinical outcome. Methods: This study cohort comprises 658 patients with Rutherford 5-6 foot lesions who underwent infrapopliteal endovascular or surgical revascularization between January 2010 and July 2013. We compared the 2 angiosome-targeted definitions using multivariate analysis; the impact of each angiosome-targeted definition was adjusted for a propensity score obtained by means of nonparsimonious logistic regression. Results: Direct revascularization according to definition A was performed in 367 cases (55.8%) versus 198 cases (30.1%) with definition B. The propensity-score-adjusted analysis showed that definition A of direct revascularization was associated with significantly better wound healing (P <0.044, hazard ratio [HR] 1.291) and lower amputation rates (P <0.047, HR 0.706), whereas definition B was associated only with significantly better wound healing (P <0.029, HR 1.321). The prognostic ability of direct revascularization according to definition A was confirmed in a Cox proportional hazard analysis. Conclusions: Definition A of direct revascularization was associated with a significantly higher wound healing and leg salvage rate than indirect revascularization in both series. Therefore, it seems that, if the wound spreads over several angiosomes in the forefoot or heel, any angiosome involved in the wound can be targeted.