PMID- 31200047
OWN - NLM
STAT- MEDLINE
DCOM- 20191223
LR  - 20221207
IS  - 1615-5947 (Electronic)
IS  - 0890-5096 (Linking)
VI  - 60
DP  - 2019 Oct
TI  - Long-term Outcomes of an Endovascular-First Approach for Diabetic Patients With 
      Predominantly Tibial Disease Treated in a Multidisciplinary Setting.
PG  - 315-326.e2
LID - S0890-5096(19)30378-4 [pii]
LID - 10.1016/j.avsg.2019.04.001 [doi]
AB  - BACKGROUND: Randomized studies suggest that open lower extremity 
      revascularization procedures are associated with improved outcomes compared with 
      endovascular peripheral vascular interventions (PVIs). However, advances in 
      endovascular technologies and treatment by multidisciplinary limb preservation 
      teams have shown improved outcomes. The aim of our study was to compare 
      perioperative and long-term outcomes after open versus PVI procedures in diabetic 
      patients with chronic limb-threatening ischemia (CLTI) treated in a 
      multidisciplinary setting. METHODS: All patients presenting to our 
      multidisciplinary diabetic limb-preservation service from 6/2012 to 07/2018 were 
      enrolled in a prospective database. Patients who underwent either an open lower 
      extremity bypass (LEB) or a PVI for CLTI were included in the analysis. 
      Perioperative (30-day) complications and 4-year patency and limb salvage rates 
      were compared between PVI and LEB using chi-squared tests, Kaplan-Meier curve 
      analyses, and stepwise multivariable Cox proportional hazards models. RESULTS: A 
      total of 195 lower extremity revascularization procedures were performed in 120 
      patients (mean age: 65.0 +/- 1.0 years, 61.7% male, 63.3% black), including 53 
      (27.2%) open procedures and 142 (72.8%) PVIs. Nearly two-thirds of procedures 
      (65.6%) treated multilevel diseases, while 27.2% treated isolated tibial disease 
      and 7.2% treated isolated femoropopliteal disease. More than half of the 
      procedures (53.3%) were performed for Wound, Ischemia, and foot Infection (WIfI) 
      classification stage 4 limbs, 25.1% for stage 3, and 21.6% for stage 1/2. In the 
      LEB group, 67.9% of targets were infrapopliteal. In the PVI group, 63.4% of 
      procedures were isolated tibial interventions or were multilevel interventions 
      including the tibial segment. Perioperative complications occurred in 52.8% of 
      LEB versus 12.0% of PVI (P < 0.001). At 4 years postoperatively, there was no 
      significant difference in crude (unadjusted) primary patency for PVI versus LEB 
      (34.5 +/- 6.6% vs. 49.6 +/- 8.1, P = 0.89). Secondary patency was better for the LEB 
      group (50.3 +/- 7.4% vs. 55.4 +/- 7.5%; P = 0.04), but amputation-free survival was 
      similar (65.1 +/- 6.7% vs. 60.9 +/- 9.7%; P = 0.79). After adjusting for baseline 
      differences between groups, primary patency (hazard ratio [HR]: 0.61; 95% 
      confidence interval [CI]: 0.34 to 1.10) and amputation-free survival (HR: 1.51; 
      95% CI: 0.71 to 2.34) remained similar for PVI versus LEB, but secondary patency 
      was persistently lower for PVI (HR: 0.35; 95% CI: 0.14 to 0.90). CONCLUSIONS: In 
      this cohort of diabetic patients with CLTI undergoing predominantly tibial 
      interventions, open revascularization was associated with a higher risk of 
      perioperative complications than PVIs. While secondary patency rates were better 
      after LEBs, our data suggest that an endovascular-first approach results in 
      equivalent long-term amputation-free survival for diabetic patients treated in a 
      multidisciplinary setting.
CI  - Copyright (c) 2019 Elsevier Inc. All rights reserved.
FAU - Hicks, Caitlin W
AU  - Hicks CW
AD  - Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD; 
      Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University 
      School of Medicine, Baltimore, MD.
FAU - Canner, Joseph K
AU  - Canner JK
AD  - Center for Surgical Trials and Outcomes Research, Department of Surgery, The 
      Johns Hopkins Hospital, Baltimore, MD.
FAU - Lum, Ying W
AU  - Lum YW
AD  - Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University 
      School of Medicine, Baltimore, MD.
FAU - Black, James H 3rd
AU  - Black JH 3rd
AD  - Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University 
      School of Medicine, Baltimore, MD.
FAU - Abularrage, Christopher J
AU  - Abularrage CJ
AD  - Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD; 
      Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University 
      School of Medicine, Baltimore, MD. Electronic address: cabular1@jhmi.edu.
LA  - eng
PT  - Comparative Study
PT  - Journal Article
DEP - 20190612
PL  - Netherlands
TA  - Ann Vasc Surg
JT  - Annals of vascular surgery
JID - 8703941
SB  - IM
MH  - Aged
MH  - Amputation, Surgical
MH  - Chronic Disease
MH  - Databases, Factual
MH  - Diabetic Angiopathies/diagnostic imaging/physiopathology/*therapy
MH  - *Endovascular Procedures/adverse effects
MH  - Female
MH  - Humans
MH  - Interdisciplinary Communication
MH  - Ischemia/diagnostic imaging/physiopathology/*therapy
MH  - Limb Salvage
MH  - Male
MH  - Middle Aged
MH  - *Patient Care Team
MH  - Peripheral Arterial Disease/diagnostic imaging/physiopathology/*therapy
MH  - Progression-Free Survival
MH  - Risk Factors
MH  - *Tibial Arteries/diagnostic imaging/physiopathology
MH  - Time Factors
MH  - *Vascular Grafting/adverse effects
MH  - Vascular Patency
EDAT- 2019/06/15 06:00
MHDA- 2019/12/24 06:00
CRDT- 2019/06/15 06:00
PHST- 2019/01/22 00:00 [received]
PHST- 2019/04/04 00:00 [revised]
PHST- 2019/04/05 00:00 [accepted]
PHST- 2019/06/15 06:00 [pubmed]
PHST- 2019/12/24 06:00 [medline]
PHST- 2019/06/15 06:00 [entrez]
AID - S0890-5096(19)30378-4 [pii]
AID - 10.1016/j.avsg.2019.04.001 [doi]
PST - ppublish
SO  - Ann Vasc Surg. 2019 Oct;60:315-326.e2. doi: 10.1016/j.avsg.2019.04.001. Epub 2019 
      Jun 12.