classification has been developed as a tool to help clinical decision making in patients with CLTI. This systematic review shows that the WIfI classification can, to some extent, predict major amputation after one year. However, the current evidence is not sufficient for the instrument to be helpful in clinical decision making for patients with CLTI. Objectives: The Society for Vascular Surgery has proposed the Wound, Ischaemia, and foot Infection (WIfI) classification system as a prognostic tool for the one year amputation risk and the added value of revascularisation in patients with chronic limb threatening ischaemia (CLTI). This systematic review summarises the current evidence on the prognostic value of the WIfI classification system in clinical practice. Design: Systematic review and meta-analysis following the PRISMA guidelines. Materials: The Embase, MEDLINE, and Cochrane databases were searched up to June 2018. Methods: All studies using the WIfI classification for patients with CLTI were eligible. Outcomes of interest were major amputation, limb salvage, and amputation free survival in relation to WIfI clinical stage. The methodological quality of studies was appraised with the Quality in Prognosis Studies (QUIPS) tool. If possible, data were pooled and analysed using a random effects model. Study selection, quality assessment, and data extraction were carried out by two authors independently. Results: The search yielded 12 studies comprising 2669 patients, most of whom underwent endovascular or open revascularisation. Overall study quality was moderate. All but one were retrospective studies, including a variety of subpopulations of patients with CLTI, such as only haemodialysis dependent, diabetic or non-diabetic patients. The WIfI classification was derived from chart data or prospectively maintained databases, both documented before the WIfI classification was published. Estimated one year major amputation rates from four studies comprising 569 patients were 0%, 8% (95% CI 3e21%), 11% (95% CI 6e18%) and 38% (95% CI 21e58%), for WIfI stages IeIV, respectively. Conclusions: The likelihood of an amputation after one year in patients with CLTI increases with higher WIfI stages, which is important prognostic information. Prospective evaluations are needed to determine its role in clinical practice.
Driveline infection is one of the most frequent complications following left ventricular assist device (LVAD) treatment and there is no consensus for its management. The standard approach to treat foreign-body infection is complete device ablation, which is not always feasible and therefore not an elected method for LVAD driveline infections. Here we share the results from a series of cases successfully treated for driveline infection by negative pressure wound therapy (NPWT) therapy. Between 2016 and 2020, five male patients were hospitalized in our unit with a driveline infection of HeartMate III-LVAD®. Ultrasonography and/or thoraco-abdominal CT confirmed the diagnosis, infection localization, and abscess formation. Following an antibiotic treatment, an urgent surgical abscess drainage and debridement of the infected tissues were performed. At the end of the procedure, NPWT was applied. NPWT re-dressing and debridement of wound was performed every 3–4 days. The wound was closed surgically after obtaining negative culture results and good healing. The patients were discharged in good condition, without signs of infection. Two patients underwent successful heart transplantation after 1 and 13 months. Other patients did not show any residual or recurrent infection during the follow-up within 25 months. Driveline infection following LVAD implantation is a significant complication and a challenging in terms of management for both; the surgical team and the patient. These results from our case series report a successful and less invasive approach by using NPWT for the treatment of LVAD driveline infections.
Introduction: Over the short term endovascular aneurysm repair (EVAR) is associated with superior outcomes compared with open repair; however, the progression of renal function after EVAR remains unknown because of the use of inconsistent reporting measures. The aim was to define long term renal decline following elective EVAR using estimated glomerular filtration rate (eGFR). Methods: The prospectively maintained in house database was used to identify consecutive patients having elective EVAR who had been followed up for more than five years. Overall, 275 patients (23 females, 8%; mean age, 75 years) who were not previously on renal replacement therapy (RRT) were included (January 2000 to July 2010). Pre-operative, postoperative, and most recent eGFR values were evaluated using the chronic kidney disease epidemiology collaboration equation. The primary outcome was change in eGFR at latest follow up. Results: Patients were followed up over a median of 9 years (range 5e17 years). Their mean eGFR dropped from a pre-operative value of 67 mL/min/ 1.73 m 2 (standard deviation [SD]: 9.4) to 52 mL/min/1.73 m 2 (SD 7.7), which amounts to a yearly loss of 1.7 units; six patients (2%) required RRT (dialysis) during late follow up. Patients requiring RRT and those with an eGFR loss exceeding 20% at latest follow up compared with baseline were more likely to die during late follow up (odds ratio 2.4 and 3.3 respectively, p < .001). Conclusion: This analysis, with some of the longest available follow up to date, suggests that patients undergoing EVAR may experience a significant long term decrease in renal function. This needs to be taken into account when offering EVAR in younger patients; renal follow up and preservation should be optimised in this patient group.
We pooled IPD from 11 of 32 eligible studies. From the remaining 21 studies, IPD could not be retrieved because of no response (n¼7), no IPD available (n¼12) and data from randomized controlled trial (n¼2) which resulted in a response rate of >75%. The total patient cohort consist of 703 patients of which 334 (48%) were treated with a carotid endarterectomy (CEA), 227 (32%) with carotid artery stenting (CAS) and 142 (20%) with BMT. Within 30 days, any stroke/death was reported in 8 patients (2.4%) in the CEA group, in 5 patients (2.2%) in the CAS group, and in 7 patients (4.9%) in the BMT group. These results were not significantly different between the three groups. Long-term outcome analysis will be available at the time of the ESVS conference. Conclusion-Based on these preliminary results, procedural outcome of CEA or CAS was within ranges of revascularization in low risk patients. However, outcomes of CEA or CAS were not significantly different from BMT treatment. Long-term outcome analysis will be available at the time of the ESVS conference.
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