Angiographic scoring of vascular occlusive disease in the diabetic foot: Relevance to bypass graft patency and limb salvage

Toursarkissian, Boulos; D’Ayala, Marcus; Stefanidis, Dimitri; Shireman, Paula K.; Harrison, Amy; Schoolfield, John; Sykes, Mellick T.

doi:10.1067/mva.2002.120046

Cited by 57 publications

(28 citation statements)

References 5 publications

(11 reference statements)

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“…Our series adds important data points to previous studies and also confirms findings from those studies. [7][8][9][10][11][12] In 1998, Faglia et al 8 reported that half of their patients with diabetic foot ulcers had stenoses in the popliteal and tibial arteries only; however, no data are provided specific to occlusions present in these vessels. In 2002, van der Feen et al 12 confirmed that lower limb atherosclerosis in DM is more severe in distal arteries, but this study population included patients with and without CLI.…”

Section: Discussionmentioning

confidence: 97%

“…5,6 Previous work on patterns of arterial occlusion in CLI has focused on patients with diabetes mellitus (DM). [7][8][9][10][11][12] Although 60% to 70% of patients with CLI have DM, 13,14 a third do not, which limits the available database that would fully characterize the population. A more comprehensive description of disease location and anatomy would facilitate the planning of clinical trials, such as angiogenesis studies, that could use specific disease distribution information.…”

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confidence: 97%

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Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: Implications for clinical trial design

Rueda

Nehler

Perry³

et al. 2008

Journal of Vascular Surgery

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More than half of critical limb ischemia patients undergoing infrainguinal revascularization have arterial occlusions in the popliteal or tibial arterial segments, or both, with associated critical stenoses in the femoral arterial segments, which is even greater in the subgroups with diabetes mellitus, end-stage renal disease, and Fontaine stage IV. Knowledge of such occlusive patterns is important for the development of novel infrainguinal endovascular and angiogenesis therapies for critical limb ischemia.

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Section: Discussionmentioning

confidence: 97%

mentioning

confidence: 97%

Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: Implications for clinical trial design

Rueda

Nehler

Perry³

et al. 2008

Journal of Vascular Surgery

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“…Traditional study end points for these patients have included graft patency, 1,2 limb salvage, 3,4 or death. 5,6 More recently, however, alternative end points have emerged that include amputation-free survival, 7–9 major adverse cardiovascular events, 9 target limb revascularization, 10 quality of life, 11 and functional outcomes such as the ability to ambulate or to live independently after surgery.…”

mentioning

confidence: 99%

Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia

Simons

Goodney

Nolan

et al. 2010

Journal of Vascular Surgery

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Objective Studies of infrainguinal lower extremity bypass for critical limb ischemia (CLI) have traditionally emphasized outcomes of patency, limb salvage, and death. Because functional outcomes are equally important, our objectives were to describe the proportion of CLI patients who did not achieve symptomatic improvement 1 year after bypass, despite having patent grafts, and identify preoperative factors associated with this outcome. Methods The prospectively collected Vascular Study Group of Northern New England database was used to identify all patients with elective infrainguinal lower extremity bypass for CLI (2003 to 2007) for whom long-term follow-up data were available. The primary composite study end point was clinical failure at 1 year after bypass, defined as amputation or persistent or worsened ischemic symptoms (rest pain or tissue loss), despite a patent graft. Variables identified on univariate screening (inclusion threshold, P < .20) were included in a multivariable logistic regression model to identify independent predictors. Results Long-term follow-up data were available for 1012 patients who underwent infrainguinal bypasses for CLI, of which 788 (78%) remained patent at 1 year. Of these, 79 (10%) met criteria for the composite end point of clinical failure: 21 (2.7%) for major amputations and 58 (7.4%) for persistent rest pain or tissue loss. In multivariable analysis, significant predictors of clinical failure included dialysis dependence (odds ratio [OR], 3.74; 95% confidence interval [CI], 1.84–7.62; P < .001) and preoperative inability to ambulate independently (OR, 2.17; 95% CI, 1.26–3.73; P = .005). A history of coronary artery bypass graft or percutaneous coronary intervention was protective (OR, 0.52; 95% CI, 0.29–0.93; P = .03). Conclusions After infrainguinal lower extremity bypass for CLI, 10% of patients with a patent graft did not achieve clinical improvement at 1 year. Preoperative identification of this specific patient subgroup remains challenging. To improve surgical decision making and the overall care of CLI patients, further emphasis needs to be placed on functional outcomes in addition to traditional surgical end points.

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“…Baseline risk estimation is important for the evaluation of treatment outcome in patients with peripheral arterial disease. 33,34 Definition of the patient populations in studies assessing the efficacy of therapies of peripheral arterial disease is often complex and previously defined criteria and estimation of baseline risk have been disputed. 26,27 Comparison of studies is therefore difficult.…”

Section: Discussionmentioning

confidence: 99%

A prognostic model for amputation in critical lower limb ischemia

et al. 2009

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In a (negative) multicenter randomized trial on management for inoperable critical lower limb ischemia, comparing spinal cord stimulation and best medical treatment, a number of pre-defined factors were analyzed for prognostic value. We included a radiological arterial disease score, modified from the SVS/ISCVS runoff score. The purpose of this analysis was to evaluate clinical factors and commonly used circulatory measurements for prognostic modeling in patients with critical lower limb ischemia. We determined the incidence of amputation and its relation to various pre-defined risk factors. A total of 120 patients with critical limb ischemia were included in the study. The integrity of circulation in the affected limb was evaluated on five levels: suprainguinal, infrainguinal, popliteal, infrapopliteal and pedal. A total radiological arterial disease score was calculated from 1 (full integrity of circulation) to 20 (maximally compromised state). We used Cox regression analysis to quantify prognostic effects and differential treatment (predictive) effects. Major amputation occurred in 33% of the patients at 6 months and in 51% at 2 years. The presence of ischemic skin lesions and the radiological arterial disease score were independent prognostic factors for amputation. Patients with ulcerations or gangrene had a higher amputation risk (hazard ratio 2.38, p = 0.018 and 2.30, p = 0.036 respectively) as well as patients with a higher radiological arterial disease score (hazard ratio 1.17 per increment, p = 0.003). We did not observe significant interactions between prognostic factors and the effect of spinal cord stimulation. In conclusion, in patients with critical lower limb ischemia, the presence of ischemic skin lesions and the described radiological arterial disease score can be used to estimate amputation risk.

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Angiographic scoring of vascular occlusive disease in the diabetic foot: Relevance to bypass graft patency and limb salvage

Cited by 57 publications

References 5 publications

Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: Implications for clinical trial design

Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: Implications for clinical trial design

Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia

A prognostic model for amputation in critical lower limb ischemia

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