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M Lepantalo - One of the best experts on this subject based on the ideXlab platform.

  • infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first line strategies in critical Leg Ischemia a propensity score analysis
    Annals of Surgery, 2010
    Co-Authors: Maria Soderstrom, Fausto Biancari, Anders Alback, M Lepantalo, E Arvela, M Korhonen, Karoliina Halmesmaki, Maarit Venermo
    Abstract:

    Introduction: Recently, endovascular revascularization (percutaneous transluminal angioplasty [PTA]) has challenged surgery as a method for the salvage of critically ischemic Legs (CLI). Comparison of surgical and endovascular techniques in randomized controlled trials is difficult because of differences in patient characteristics. To overcome this problem, we adjusted the differences by using propensity score analysis. Materials and Methods: The study cohort comprised 1023 patients treated for CLI with 262 endovascular and 761 surgical revascularization procedures to their crural or pedal arteries. A propensity score was used for adjustment in multivariable analysis, for stratification, and for one-to-one matching. Results: In the overall series, PTA and bypass surgery achieved similar 5-year Leg salvage (75.3% vs 76.0%), survival (47.5% vs 43.3%), and amputation-free survival (37.7% vs 37.3%) rates and similar freedom from any further revascularization (77.3% vs 74.4%), whereas freedom from surgical revascularization was higher after bypass surgery (94.3% vs 86.2%, P < 0.001). In propensity-score-matched pairs, outcomes did not differ, except for freedom from surgical revascularization, which was significantly higher in the bypass surgery group (91.4% vs 85.3% at 5 years, P = 0.045). In a subgroup of patients who underwent isolated infrapopliteal revascularization, PTA was associated with better Leg salvage (75.5% vs 68.0%, P = 0.042) and somewhat lower freedom from surgical revascularization (78.8% vs 85.2%, P = 0.17). This significant difference in the Leg salvage rate was also observed after adjustment for propensity score (P = 0.044), but not in propensity-score-matched pairs (P = 0.12). Conclusions: When feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized.

  • the influence of the characteristics of ischemic tissue lesions on ulcer healing time after infrainguinal bypass for critical Leg Ischemia
    Journal of Vascular Surgery, 2009
    Co-Authors: Maria Soderstrom, M Lepantalo, P S Aho, Anders Alback
    Abstract:

    Objective Ulcer healing is a seldom reported outcome in studies of critical Leg Ischemia (CLI). The aim of this study was to analyze local factors affecting ulcer healing time after infrainguinal bypass surgery (IBS) for CLI Fontaine IV. Methods In this prospective single center cohort study, 110 patients (113 Legs) undergoing IBS due to CLI with ischemic tissue defects during year 2006 were followed prospectively for 1 year after the bypass. Ulcer location, duration, presence of gangrene, and the University of Texas wound classification (UTWCS) were determined at presentation. Healing time of the ischemic tissue defects, Leg salvage, patency, and survival were calculated. The characteristics of the ischemic tissue lesions and patient comorbidities were analyzed to determine risk factors for adverse outcome. Results Complete ulcer healing (±SE) was achieved in 74% ± 5% of the Legs 12 months after IBS. Median ulcer healing time was 186 days (range, 11 to >365 days). Leg salvage, secondary patency, and survival at 12 months were 87% ± 3%, 82% ± 4%, and 76% ± 5%, respectively. Amputation-free survival with healed ulcers was attained in 55% at 12 months. Ischemic tissue lesions located in the mid- and hindfoot had significantly prolonged ulcer healing time (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.1 to 0.9, P = .044). None of the UTWCS classes predicted either ulcer healing time or Leg salvage. Median ulcer duration before IBS was 68 days, range, 6 to 1154 days. Ulcer duration did not correlate with ulcer healing time (Spearman r = 0.138, P = .267). Ischemic ulcers with gangrene were not associated with prolonged ulcer healing time ( P = .353). Conclusion The location of the ischemic tissue lesions influences ulcer healing time. According to our study UTWCS can be used as descriptive classification of ischemic ulcers but it does not predict the ulcer healing time or Leg salvage after infrainguinal bypass surgery.

  • Infrainguinal endovascular and bypass surgery for critical Leg Ischemia in patients on long-term dialysis
    Annals of Vascular Surgery, 2002
    Co-Authors: Fausto Biancari, Anders Alback, Ilkka Kantonen, Sorjo Matzke, Wolf-dieter Roth, Johan Edgren, M Lepantalo
    Abstract:

    Lower limb revascularization has been shown to be worthwhile for treatment of critical Leg Ischemia in uremic patients, but poor results are expected in patients on long-term dialysis. We have retrospectively evaluated the results of a series of 21 consecutive patients on long-term dialysis who underwent 20 infrainguinal bypass graft and 5 endovascular procedures for critical Leg Ischemia to identify factors contraindicating any infrainguinal revascularization attempt in this patient population. At 2-year follow-up, the patency rate was 74%, Leg salvage rate was 85%, and survival rate was 23%, whereas 23% of patients were alive with salvaged Leg. Patients on hemodialysis achieved better survival outcome than patients on peritoneal dialysis ( p =0.02). Multivariate analysis showed that low serum level of albumin ( p =0.009; p =0.005) and coronary artery disease ( p =0.0002; p =0.001) had an adverse effect on the survival rate and on the rate of patients alive with salvaged Leg, respectively. Patients without coronary artery disease achieved an alive-with-salvaged-Leg rate at 1- and 2-year follow-up of 68% and 41%, respectively, whereas 12% of patients with coronary artery disease survived with salvaged Leg after 1 year, but none of them survived with salvaged Leg at 2-year follow-up ( p =0.003). In conclusion, infrainguinal revascularization for lower extremity Ischemia in dialysis patients is hardly indicated in the presence of coronary artery disease and severe hypoalbuminemia.

  • limits of infrapopliteal bypass surgery for critical Leg Ischemia when not to reconstruct
    World Journal of Surgery, 2000
    Co-Authors: Fausto Biancari, Anders Alback, Ilkka Kantonen, Michael Luther, Sorjo Matzke, M Lepantalo
    Abstract:

    The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical Leg Ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the Leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged Leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p= 0.03), postoperative cardiac complications (p= 0.02), Leg salvage (p= 0.009), amputation with patent graft (p= 0.009), and patients who survived with a salvaged Leg (p= 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on Leg salvage (p= 0.02) and on patients alive with salvaged Leg rates (p= 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical Leg Ischemia, as these patients are at high risk for early postoperative Leg or life loss.

  • factors affecting the results of surgery for chronic critical Leg Ischemia a nationwide survey
    Journal of Vascular Surgery, 1998
    Co-Authors: Ilkka Kantonen, M Lepantalo, Michael Luther, Juhapekka Salenius, K Ylonen
    Abstract:

    Abstract Purpose: To assess the factors affecting immediate outcome of surgery for chronic critical Leg Ischemia, especially the influence of surgeon's caseload and hospital volume. Methods: The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical Leg Ischemia during 1991 to 1994. Results: The 30-day postoperative Leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeon's annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical Leg Ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure. Conclusions: A surgeon's caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical Leg Ischemia. (J Vasc Surg 1998;27:940-7.)

Anders Alback - One of the best experts on this subject based on the ideXlab platform.

  • infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first line strategies in critical Leg Ischemia a propensity score analysis
    Annals of Surgery, 2010
    Co-Authors: Maria Soderstrom, Fausto Biancari, Anders Alback, M Lepantalo, E Arvela, M Korhonen, Karoliina Halmesmaki, Maarit Venermo
    Abstract:

    Introduction: Recently, endovascular revascularization (percutaneous transluminal angioplasty [PTA]) has challenged surgery as a method for the salvage of critically ischemic Legs (CLI). Comparison of surgical and endovascular techniques in randomized controlled trials is difficult because of differences in patient characteristics. To overcome this problem, we adjusted the differences by using propensity score analysis. Materials and Methods: The study cohort comprised 1023 patients treated for CLI with 262 endovascular and 761 surgical revascularization procedures to their crural or pedal arteries. A propensity score was used for adjustment in multivariable analysis, for stratification, and for one-to-one matching. Results: In the overall series, PTA and bypass surgery achieved similar 5-year Leg salvage (75.3% vs 76.0%), survival (47.5% vs 43.3%), and amputation-free survival (37.7% vs 37.3%) rates and similar freedom from any further revascularization (77.3% vs 74.4%), whereas freedom from surgical revascularization was higher after bypass surgery (94.3% vs 86.2%, P < 0.001). In propensity-score-matched pairs, outcomes did not differ, except for freedom from surgical revascularization, which was significantly higher in the bypass surgery group (91.4% vs 85.3% at 5 years, P = 0.045). In a subgroup of patients who underwent isolated infrapopliteal revascularization, PTA was associated with better Leg salvage (75.5% vs 68.0%, P = 0.042) and somewhat lower freedom from surgical revascularization (78.8% vs 85.2%, P = 0.17). This significant difference in the Leg salvage rate was also observed after adjustment for propensity score (P = 0.044), but not in propensity-score-matched pairs (P = 0.12). Conclusions: When feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized.

  • arm vein conduit vs prosthetic graft in infrainguinal revascularization for critical Leg Ischemia
    Journal of Vascular Surgery, 2010
    Co-Authors: E Arvela, Anders Alback, Maarit Venermo, Maria Soderstrom, P S Aho, M Lepantalo
    Abstract:

    Background One-piece great saphenous vein (GSV) is the conduit of choice in infrainguinal revascularizations for critical limb Ischemia (CLI). Unfortunately, adequate length of usable GSV is not always available. Despite inferior patency rates compared with GSV, prosthetic and arm vein conduits are generally considered usable. The purpose of this study was to compare the outcome of infrainguinal arm vein and prosthetic bypass. Material and methods We retrospectively reviewed 290 consecutive infrainguinal bypasses for CLI using arm vein conduit (n = 130) or prosthetic graft (n = 160) during January 2000 and December 2006 at our institution. The groups were compared for risk factors, indication for surgery, and runoff score. Survival, Leg salvage, and patency rates were calculated with the Kaplan-Meier method. Results Median surveillance time was 35 months (range 0-118 months). The age, gender, and usual risk factors were similar in arm vein and prosthetic groups, except cerebrovascular disease that was more common in the prosthetic group ( P = .011). Indication for surgery was CLI. In the arm vein group, more than two-thirds (70.2%) of the procedures were for ischemic ulcer or gangrene, whereas in the prosthetic group the main indication was ischemic rest pain (51.3%). When the outcome of femoropopliteal bypasses was analyzed, the difference between groups was not statistically significant. However, in infrapopliteal revascularizations primary patency, assisted primary patency, and secondary patency rates at 3 years were significantly better in the arm vein group: 28.3% (SE ± 6.3%) vs 9.6% (SE ± 8.1%) ( P = .031), 56.8% (SE ± 6.6%) vs 10.4% (SE ± 8.7%) ( P = .000), and 57.4% (SE ± 6.6) vs 11.2% (SE ± 9.3%) ( P = .000), respectively. Leg salvage and survival at 3 years were 75.0% (SE ± 4.9%) vs 57.1% (SE ± 8.8%) ( P = .005) and 58.8% (SE ± 5.1%) vs 39.5% (SE ± 7.7%) ( P = .007), respectively. Conclusion Arm vein conduits, even when spliced, are superior to prosthetic grafts in terms of midterm assisted primary patency, secondary patency, and Leg salvage in infrapopliteal bypasses for CLI.

  • the influence of the characteristics of ischemic tissue lesions on ulcer healing time after infrainguinal bypass for critical Leg Ischemia
    Journal of Vascular Surgery, 2009
    Co-Authors: Maria Soderstrom, M Lepantalo, P S Aho, Anders Alback
    Abstract:

    Objective Ulcer healing is a seldom reported outcome in studies of critical Leg Ischemia (CLI). The aim of this study was to analyze local factors affecting ulcer healing time after infrainguinal bypass surgery (IBS) for CLI Fontaine IV. Methods In this prospective single center cohort study, 110 patients (113 Legs) undergoing IBS due to CLI with ischemic tissue defects during year 2006 were followed prospectively for 1 year after the bypass. Ulcer location, duration, presence of gangrene, and the University of Texas wound classification (UTWCS) were determined at presentation. Healing time of the ischemic tissue defects, Leg salvage, patency, and survival were calculated. The characteristics of the ischemic tissue lesions and patient comorbidities were analyzed to determine risk factors for adverse outcome. Results Complete ulcer healing (±SE) was achieved in 74% ± 5% of the Legs 12 months after IBS. Median ulcer healing time was 186 days (range, 11 to >365 days). Leg salvage, secondary patency, and survival at 12 months were 87% ± 3%, 82% ± 4%, and 76% ± 5%, respectively. Amputation-free survival with healed ulcers was attained in 55% at 12 months. Ischemic tissue lesions located in the mid- and hindfoot had significantly prolonged ulcer healing time (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.1 to 0.9, P = .044). None of the UTWCS classes predicted either ulcer healing time or Leg salvage. Median ulcer duration before IBS was 68 days, range, 6 to 1154 days. Ulcer duration did not correlate with ulcer healing time (Spearman r = 0.138, P = .267). Ischemic ulcers with gangrene were not associated with prolonged ulcer healing time ( P = .353). Conclusion The location of the ischemic tissue lesions influences ulcer healing time. According to our study UTWCS can be used as descriptive classification of ischemic ulcers but it does not predict the ulcer healing time or Leg salvage after infrainguinal bypass surgery.

  • Infrainguinal endovascular and bypass surgery for critical Leg Ischemia in patients on long-term dialysis
    Annals of Vascular Surgery, 2002
    Co-Authors: Fausto Biancari, Anders Alback, Ilkka Kantonen, Sorjo Matzke, Wolf-dieter Roth, Johan Edgren, M Lepantalo
    Abstract:

    Lower limb revascularization has been shown to be worthwhile for treatment of critical Leg Ischemia in uremic patients, but poor results are expected in patients on long-term dialysis. We have retrospectively evaluated the results of a series of 21 consecutive patients on long-term dialysis who underwent 20 infrainguinal bypass graft and 5 endovascular procedures for critical Leg Ischemia to identify factors contraindicating any infrainguinal revascularization attempt in this patient population. At 2-year follow-up, the patency rate was 74%, Leg salvage rate was 85%, and survival rate was 23%, whereas 23% of patients were alive with salvaged Leg. Patients on hemodialysis achieved better survival outcome than patients on peritoneal dialysis ( p =0.02). Multivariate analysis showed that low serum level of albumin ( p =0.009; p =0.005) and coronary artery disease ( p =0.0002; p =0.001) had an adverse effect on the survival rate and on the rate of patients alive with salvaged Leg, respectively. Patients without coronary artery disease achieved an alive-with-salvaged-Leg rate at 1- and 2-year follow-up of 68% and 41%, respectively, whereas 12% of patients with coronary artery disease survived with salvaged Leg after 1 year, but none of them survived with salvaged Leg at 2-year follow-up ( p =0.003). In conclusion, infrainguinal revascularization for lower extremity Ischemia in dialysis patients is hardly indicated in the presence of coronary artery disease and severe hypoalbuminemia.

  • limits of infrapopliteal bypass surgery for critical Leg Ischemia when not to reconstruct
    World Journal of Surgery, 2000
    Co-Authors: Fausto Biancari, Anders Alback, Ilkka Kantonen, Michael Luther, Sorjo Matzke, M Lepantalo
    Abstract:

    The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical Leg Ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the Leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged Leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p= 0.03), postoperative cardiac complications (p= 0.02), Leg salvage (p= 0.009), amputation with patent graft (p= 0.009), and patients who survived with a salvaged Leg (p= 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on Leg salvage (p= 0.02) and on patients alive with salvaged Leg rates (p= 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical Leg Ischemia, as these patients are at high risk for early postoperative Leg or life loss.

Martin B Leon - One of the best experts on this subject based on the ideXlab platform.

  • percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis first human case description
    Circulation, 2002
    Co-Authors: Alain Cribier, H.élène Eltchaninoff, Assaf Bash, Nicolas Borenstein, Christophe Tron, Fabrice Bauer, Genevieve Derumeaux, Frederic Anselme, Francois Laborde, Martin B Leon
    Abstract:

    Background— The design of a percutaneous implantable prosthetic heart valve has become an important area for investigation. A percutaneously implanted heart valve (PHV) composed of 3 bovine pericardial leaflets mounted within a balloon-expandable stent was developed. After ex vivo testing and animal implantation studies, the first human implantation was performed in a 57-year-old man with calcific aortic stenosis, cardiogenic shock, subacute Leg Ischemia, and other associated noncardiac diseases. Valve replacement had been declined for this patient, and balloon valvuloplasty had been performed with nonsustained results. Methods and Results— With the use of an antegrade transseptal approach, the PHV was successfully implanted within the diseased native aortic valve, with accurate and stable PHV positioning, no impairment of the coronary artery blood flow or of the mitral valve function, and a mild paravalvular aortic regurgitation. Immediately and at 48 hours after implantation, valve function was excellent, resulting in marked hemodynamic improvement. Over a follow-up period of 4 months, the valvular function remained satisfactory as assessed by sequential transesophageal echocardiography, and there was no recurrence of heart failure. However, severe noncardiac complications occurred, including a progressive worsening of the Leg Ischemia, leading to Leg amputation with lack of healing, infection, and death 17 weeks after PHV implantation. Conclusions— Nonsurgical implantation of a prosthetic heart valve can be successfully achieved with immediate and midterm hemodynamic and clinical improvement. After further device modifications, additional durability tests, and confirmatory clinical implantations, PHV might become an important therapeutic alternative for the treatment of selected patients with nonsurgical aortic stenosis.

Fausto Biancari - One of the best experts on this subject based on the ideXlab platform.

  • limits of infrainguinal bypass surgery for critical Leg Ischemia in high risk patients finnvasc score 3 4
    Annals of Vascular Surgery, 2012
    Co-Authors: Aristotelis Kechagias, K Ylonen, Georgios Kechagias, Tatu Juvonen, Fausto Biancari
    Abstract:

    Background The aim of the present study was to compare the early- and midterm outcomes after infrainguinal bypass surgery in the treatment of low- and high-risk patients with critical limb Ischemia (CLI) (Finnvasc score 0-2 and 3-4, respectively), and to evaluate limits of infrainguinal bypass surgery in treatment of the latter group. Methods Two hundred seventy-four infrainguinal bypass procedures performed in 218 patients were retrospectively reviewed. The Finnvasc score (range: 0-4) was calculated by assigning one point to each of four preoperative risk factors, that is, coronary artery disease, diabetes, urgency of the procedure, and gangrene. Major outcome end points were survival, limb salvage, and amputation-free survival. Results Among 274 infrainguinal bypass procedures performed for CLI, 92 procedures (33.6%) were performed in patients with Finnvasc score 3-4. They had significantly lower Leg salvage (at 3-year follow-up, 53.7 vs. 70.6%; log-rank: p = 0.004), survival (at 3-year follow-up, 49.7 vs. 69.7%; log-rank: p p 150 μmol/L had 1-year amputation-free survival of 12.5%, whereas patients with lower level of creatinine had 1-year amputation-free survival of 53.1% ( p = 0.028). Conclusions Infrainguinal bypass revascularization in CLI patients who present with Finnvasc score 3-4 can be considered at higher risk of poor intermediate outcome in terms of survival, Leg salvage, and amputation-free survival. Poor outcome is particularly expected in patients with Finnvasc score 3-4 and renal failure. In this subgroup of patients, primary amputation should be considered.

  • infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first line strategies in critical Leg Ischemia a propensity score analysis
    Annals of Surgery, 2010
    Co-Authors: Maria Soderstrom, Fausto Biancari, Anders Alback, M Lepantalo, E Arvela, M Korhonen, Karoliina Halmesmaki, Maarit Venermo
    Abstract:

    Introduction: Recently, endovascular revascularization (percutaneous transluminal angioplasty [PTA]) has challenged surgery as a method for the salvage of critically ischemic Legs (CLI). Comparison of surgical and endovascular techniques in randomized controlled trials is difficult because of differences in patient characteristics. To overcome this problem, we adjusted the differences by using propensity score analysis. Materials and Methods: The study cohort comprised 1023 patients treated for CLI with 262 endovascular and 761 surgical revascularization procedures to their crural or pedal arteries. A propensity score was used for adjustment in multivariable analysis, for stratification, and for one-to-one matching. Results: In the overall series, PTA and bypass surgery achieved similar 5-year Leg salvage (75.3% vs 76.0%), survival (47.5% vs 43.3%), and amputation-free survival (37.7% vs 37.3%) rates and similar freedom from any further revascularization (77.3% vs 74.4%), whereas freedom from surgical revascularization was higher after bypass surgery (94.3% vs 86.2%, P < 0.001). In propensity-score-matched pairs, outcomes did not differ, except for freedom from surgical revascularization, which was significantly higher in the bypass surgery group (91.4% vs 85.3% at 5 years, P = 0.045). In a subgroup of patients who underwent isolated infrapopliteal revascularization, PTA was associated with better Leg salvage (75.5% vs 68.0%, P = 0.042) and somewhat lower freedom from surgical revascularization (78.8% vs 85.2%, P = 0.17). This significant difference in the Leg salvage rate was also observed after adjustment for propensity score (P = 0.044), but not in propensity-score-matched pairs (P = 0.12). Conclusions: When feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized.

  • Infrainguinal endovascular and bypass surgery for critical Leg Ischemia in patients on long-term dialysis
    Annals of Vascular Surgery, 2002
    Co-Authors: Fausto Biancari, Anders Alback, Ilkka Kantonen, Sorjo Matzke, Wolf-dieter Roth, Johan Edgren, M Lepantalo
    Abstract:

    Lower limb revascularization has been shown to be worthwhile for treatment of critical Leg Ischemia in uremic patients, but poor results are expected in patients on long-term dialysis. We have retrospectively evaluated the results of a series of 21 consecutive patients on long-term dialysis who underwent 20 infrainguinal bypass graft and 5 endovascular procedures for critical Leg Ischemia to identify factors contraindicating any infrainguinal revascularization attempt in this patient population. At 2-year follow-up, the patency rate was 74%, Leg salvage rate was 85%, and survival rate was 23%, whereas 23% of patients were alive with salvaged Leg. Patients on hemodialysis achieved better survival outcome than patients on peritoneal dialysis ( p =0.02). Multivariate analysis showed that low serum level of albumin ( p =0.009; p =0.005) and coronary artery disease ( p =0.0002; p =0.001) had an adverse effect on the survival rate and on the rate of patients alive with salvaged Leg, respectively. Patients without coronary artery disease achieved an alive-with-salvaged-Leg rate at 1- and 2-year follow-up of 68% and 41%, respectively, whereas 12% of patients with coronary artery disease survived with salvaged Leg after 1 year, but none of them survived with salvaged Leg at 2-year follow-up ( p =0.003). In conclusion, infrainguinal revascularization for lower extremity Ischemia in dialysis patients is hardly indicated in the presence of coronary artery disease and severe hypoalbuminemia.

  • limits of infrapopliteal bypass surgery for critical Leg Ischemia when not to reconstruct
    World Journal of Surgery, 2000
    Co-Authors: Fausto Biancari, Anders Alback, Ilkka Kantonen, Michael Luther, Sorjo Matzke, M Lepantalo
    Abstract:

    The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical Leg Ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the Leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged Leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p= 0.03), postoperative cardiac complications (p= 0.02), Leg salvage (p= 0.009), amputation with patent graft (p= 0.009), and patients who survived with a salvaged Leg (p= 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on Leg salvage (p= 0.02) and on patients alive with salvaged Leg rates (p= 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical Leg Ischemia, as these patients are at high risk for early postoperative Leg or life loss.

  • extra anatomic bypass surgery for critical Leg Ischemia a review
    Journal of Cardiovascular Surgery, 1998
    Co-Authors: Fausto Biancari, M Lepantalo
    Abstract:

    Since an aggressive revascularisation policy for critical limb Ischemia (CLI) has been shown to lower morbidity and mortality, to improve quality of life and to be cost-effective in comparison to amputation, extra-anatomic bypass (EAB) grafts may be indicated whenever hostile local conditions or severe medical diseases contraindicate an aortofemoral reconstruction. Most series report limb-salvage rates markedly higher than the related patency rates, as revascularisations may often heal the ischemic extremity before the graft occludes. A large review of data from the literature suggests that EAB grafting for CLI may achieve gratifying results in a subgroup of patients with multilevel obstructive disease and not suitable for conventional aortofemoral repair.

Maria Soderstrom - One of the best experts on this subject based on the ideXlab platform.

  • infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first line strategies in critical Leg Ischemia a propensity score analysis
    Annals of Surgery, 2010
    Co-Authors: Maria Soderstrom, Fausto Biancari, Anders Alback, M Lepantalo, E Arvela, M Korhonen, Karoliina Halmesmaki, Maarit Venermo
    Abstract:

    Introduction: Recently, endovascular revascularization (percutaneous transluminal angioplasty [PTA]) has challenged surgery as a method for the salvage of critically ischemic Legs (CLI). Comparison of surgical and endovascular techniques in randomized controlled trials is difficult because of differences in patient characteristics. To overcome this problem, we adjusted the differences by using propensity score analysis. Materials and Methods: The study cohort comprised 1023 patients treated for CLI with 262 endovascular and 761 surgical revascularization procedures to their crural or pedal arteries. A propensity score was used for adjustment in multivariable analysis, for stratification, and for one-to-one matching. Results: In the overall series, PTA and bypass surgery achieved similar 5-year Leg salvage (75.3% vs 76.0%), survival (47.5% vs 43.3%), and amputation-free survival (37.7% vs 37.3%) rates and similar freedom from any further revascularization (77.3% vs 74.4%), whereas freedom from surgical revascularization was higher after bypass surgery (94.3% vs 86.2%, P < 0.001). In propensity-score-matched pairs, outcomes did not differ, except for freedom from surgical revascularization, which was significantly higher in the bypass surgery group (91.4% vs 85.3% at 5 years, P = 0.045). In a subgroup of patients who underwent isolated infrapopliteal revascularization, PTA was associated with better Leg salvage (75.5% vs 68.0%, P = 0.042) and somewhat lower freedom from surgical revascularization (78.8% vs 85.2%, P = 0.17). This significant difference in the Leg salvage rate was also observed after adjustment for propensity score (P = 0.044), but not in propensity-score-matched pairs (P = 0.12). Conclusions: When feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized.

  • arm vein conduit vs prosthetic graft in infrainguinal revascularization for critical Leg Ischemia
    Journal of Vascular Surgery, 2010
    Co-Authors: E Arvela, Anders Alback, Maarit Venermo, Maria Soderstrom, P S Aho, M Lepantalo
    Abstract:

    Background One-piece great saphenous vein (GSV) is the conduit of choice in infrainguinal revascularizations for critical limb Ischemia (CLI). Unfortunately, adequate length of usable GSV is not always available. Despite inferior patency rates compared with GSV, prosthetic and arm vein conduits are generally considered usable. The purpose of this study was to compare the outcome of infrainguinal arm vein and prosthetic bypass. Material and methods We retrospectively reviewed 290 consecutive infrainguinal bypasses for CLI using arm vein conduit (n = 130) or prosthetic graft (n = 160) during January 2000 and December 2006 at our institution. The groups were compared for risk factors, indication for surgery, and runoff score. Survival, Leg salvage, and patency rates were calculated with the Kaplan-Meier method. Results Median surveillance time was 35 months (range 0-118 months). The age, gender, and usual risk factors were similar in arm vein and prosthetic groups, except cerebrovascular disease that was more common in the prosthetic group ( P = .011). Indication for surgery was CLI. In the arm vein group, more than two-thirds (70.2%) of the procedures were for ischemic ulcer or gangrene, whereas in the prosthetic group the main indication was ischemic rest pain (51.3%). When the outcome of femoropopliteal bypasses was analyzed, the difference between groups was not statistically significant. However, in infrapopliteal revascularizations primary patency, assisted primary patency, and secondary patency rates at 3 years were significantly better in the arm vein group: 28.3% (SE ± 6.3%) vs 9.6% (SE ± 8.1%) ( P = .031), 56.8% (SE ± 6.6%) vs 10.4% (SE ± 8.7%) ( P = .000), and 57.4% (SE ± 6.6) vs 11.2% (SE ± 9.3%) ( P = .000), respectively. Leg salvage and survival at 3 years were 75.0% (SE ± 4.9%) vs 57.1% (SE ± 8.8%) ( P = .005) and 58.8% (SE ± 5.1%) vs 39.5% (SE ± 7.7%) ( P = .007), respectively. Conclusion Arm vein conduits, even when spliced, are superior to prosthetic grafts in terms of midterm assisted primary patency, secondary patency, and Leg salvage in infrapopliteal bypasses for CLI.

  • the consequences of an outbreak of multidrug resistant pseudomonas aeruginosa among patients treated for critical Leg Ischemia
    Journal of Vascular Surgery, 2009
    Co-Authors: Maria Soderstrom, P S Aho, M Lepantalo, Pirkka Vikatmaa, Elina Kolho, T Ikonen
    Abstract:

    Objective This retrospective matched case-control study evaluated the consequences of multidrug-resistant Pseudomonas aeruginosa (MDR Pa) in critical Leg Ischemia (CLI) patients treated with infrainguinal bypass surgery (IBS). Methods An outbreak of MDR Pa occurred on our vascular surgical ward during a 13-month period. Bacteria cultures positive for MDR Pa were obtained from 129 patients, and 64 CLI patients treated with IBS formed the study group. A control group of 64 was retrospectively matched from MDR Pa-negative patients treated with IBS in the same unit according to sex, age, presence of diabetes, Fontaine class, graft material, and site of the distal anastomosis. The most frequent sites of initial positive MDR Pa culture were the incisional wound in 30 (47%) and ischemic ulcer in 23 (36%). Median time between the positive MDR Pa-culture and IBS was 14 days (range, 56 days pre-IBS to 246 days post-IBS). Graft patency, survival, Leg salvage, and amputation-free survival were assessed. Results One-year amputation-free survival (± standard error) was 52% ± 6% in the MDR Pa group vs 75% ± 5% in the control group ( P = .02). Five-year amputation-free survival was 29% ± 6% in the MDR Pa group and 32% ± 6% in the control group ( P = .144). For MDR Pa and control groups, the 1-year survival was 69% ± 6% and 82% ± 5% ( P = .063), respectively, and 5-year survival was 36% ± 6% and 36% ± 6% ( P = .302), respectively. For the MDR Pa and control groups, Leg salvage was 79% ± 5% and 92% ± 4% at 1 year ( P = .078) and 73% ± 7% and 87% ± 5% at 5 years ( P = .126), respectively. The overall secondary patency rate at 1 year was 72% ± 7% in the MDR Pa group vs 81% ± 6% in the control group ( P = .149). Local wound surgery was more frequent in MDR Pa patients than in controls ( P = .002). Conclusions The MDR Pa outbreak was associated with a decreased short-term amputation-free survival after IBS for CLI in patients with positive MDR Pa culture. The potential risks of MDR Pa should be seriously considered whenever a positive culture is obtained in a vascular patient with CLI.

  • the influence of the characteristics of ischemic tissue lesions on ulcer healing time after infrainguinal bypass for critical Leg Ischemia
    Journal of Vascular Surgery, 2009
    Co-Authors: Maria Soderstrom, M Lepantalo, P S Aho, Anders Alback
    Abstract:

    Objective Ulcer healing is a seldom reported outcome in studies of critical Leg Ischemia (CLI). The aim of this study was to analyze local factors affecting ulcer healing time after infrainguinal bypass surgery (IBS) for CLI Fontaine IV. Methods In this prospective single center cohort study, 110 patients (113 Legs) undergoing IBS due to CLI with ischemic tissue defects during year 2006 were followed prospectively for 1 year after the bypass. Ulcer location, duration, presence of gangrene, and the University of Texas wound classification (UTWCS) were determined at presentation. Healing time of the ischemic tissue defects, Leg salvage, patency, and survival were calculated. The characteristics of the ischemic tissue lesions and patient comorbidities were analyzed to determine risk factors for adverse outcome. Results Complete ulcer healing (±SE) was achieved in 74% ± 5% of the Legs 12 months after IBS. Median ulcer healing time was 186 days (range, 11 to >365 days). Leg salvage, secondary patency, and survival at 12 months were 87% ± 3%, 82% ± 4%, and 76% ± 5%, respectively. Amputation-free survival with healed ulcers was attained in 55% at 12 months. Ischemic tissue lesions located in the mid- and hindfoot had significantly prolonged ulcer healing time (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.1 to 0.9, P = .044). None of the UTWCS classes predicted either ulcer healing time or Leg salvage. Median ulcer duration before IBS was 68 days, range, 6 to 1154 days. Ulcer duration did not correlate with ulcer healing time (Spearman r = 0.138, P = .267). Ischemic ulcers with gangrene were not associated with prolonged ulcer healing time ( P = .353). Conclusion The location of the ischemic tissue lesions influences ulcer healing time. According to our study UTWCS can be used as descriptive classification of ischemic ulcers but it does not predict the ulcer healing time or Leg salvage after infrainguinal bypass surgery.