Objective The efficacy of angiosome-targeted revascularization to achieve healing of ischemic tissue lesions of the foot and limb salvage is controversial. This issue has been investigated in this ...meta-analysis. Methods A systematic review of the literature and meta-analysis of data on angiosome-targeted lower limb revascularization for ischemic tissue lesions of the foot were performed. Results Nine studies reported on data of interest. No randomized controlled study was available. There were 715 legs treated by direct revascularization according to the angiosome principle and 575 legs treated by indirect revascularization. The prevalence of diabetes was >70% in each study group and three studies included only patients with diabetes. The risk of unhealed wound was significantly lower after direct revascularization (HR 0.64, 95% CI: 0.52–0.8, I2 0%, four studies included) compared with indirect revascularization. Direct revascularization was also associated with significantly lower risk of major amputation (HR 0.44, 95% CI: 0.26–0.75, I2 62%, eight studies included). Pooled limb salvage rates after direct and indirect revascularization were at 1 year 86.2% vs. 77.8% and at 2 years 84.9% vs. 70.1%, respectively. The analysis of three studies reporting only on patients with diabetes confirmed the benefit of direct revascularization in terms of limb salvage (HR 0.48, 95% CI: 0.31–0.75, I2 0%). Conclusions The results of the present meta-analysis suggest that, when feasible, direct revascularization of the foot angiosome affected by ischemic tissue lesions may improve wound healing and limb salvage rates compared with indirect revascularization. Further studies of better quality and adjusted for differences between the study groups are needed to confirm the present findings.
Critical limb ischemia (CLI) is a significant morbid condition among the elderly. The epidemiology and natural history of this condition are poorly defined.
Systematic review and meta-analysis of ...studies evaluating the prevalence, incidence and natural history of CLI were performed.
Six studies reported on the prevalence of severe lower limb ischemia (ABI <0.60, ankle pressure <70 mmHg or Fontaine III-IV) in 82,923 subjects and its pooled prevalence was 800/100,000 population (95%CI 300-1400). The Oxford Vascular Study assessed the incidence of vascular events in the general population and estimated an incidence of CLI of 22/100,000 population per year (95%CI 17-28). Two studies reported an incidence of CLI in subjects >65 years old of 113 and 200/100,000 population per year, respectively. Nine studies reported on the treatment strategy in 2144 legs with CLI: the pooled rate of any revascularization procedure was 70.4%, of primary amputation 8.4%, and of conservative treatment 20.3%. After conservative treatment for CLI, one-year pooled leg salvage rate was 57.4% (95%CI 45.1-69.7%, ten studies reporting on 734 legs included), survival 75.4% (95%CI 59.2-91.6%, four studies included) and amputation-free survival 51.4% (95%CI 32.7-71.2%, five studies included).
The incidence of CLI in the elderly is rather high. Series reporting on treatment strategies in these patients showed that a revascularization is attempted in 70% of cases. Conservative treatment in patients with unreconstructable CLI, high operative risk and/or refusing any revascularization procedure is associated with acceptable one year leg salvage.
New evidence about first-line radiofrequency catheter ablation (RFA) in symptomatic atrial fibrillation (AF) has emerged. In a single study the comparative treatment effect is potentially diminished ...by the high rate of cross-over to the alternative therapy. Therefore, we conducted a systematic review and meta-analysis of the available data to further evaluate the efficacy and safety of RFA vs. antiarrhythmic drugs (AADs).
Five databases were searched for randomized controlled trials comparing RFA and AAD therapy as first-line treatment of AF in August 2014. Three studies with 491 patients with recurrent symptomatic AF were included. The patients were relatively young and the majority of them had paroxysmal AF (98.7%) and no major comorbidity. Radiofrequency catheter ablation was associated with significantly higher freedom from AF recurrence compared with AAD therapy risk ratio (RR) 0.63, 95% confidence interval (CI) 0.44-0.92, P = 0.02. The difference in the rate of symptomatic AF recurrences was not statistically significant (RR 0.57, 95% CI 0.30-1.08, P = 0.09). There was one procedure-related death and seven tamponades with RFA, whereas symptomatic bradycardia was more frequent with AAD therapy.
Radiofrequency catheter ablation seems to be more effective than medical therapy as first-line treatment of paroxysmal AF in relatively young and otherwise healthy patients, but may also cause more severe adverse effects. These findings support the use of RFA as first-line therapy in selected patients, who understand the benefits and risks of the procedure.
Type II endoleak is a common condition occurring after endovascular repair of abdominal aortic aneurysms (EVAR), and may result in aneurysm sac growth and/or rupture in a small number of patients. A ...prophylactic strategy of inferior mesenteric artery (IMA) embolization before EVAR has been advocated, however, the benefits of this strategy are controversial. A clinical vignette allows the authors to summarize the available data about this issue and discuss the possible benefits and risks of prophylactic IMA embolization before EVAR. The authors performed a meta-analysis of available data which showed that the pooled rate of type II endoleak after IMA embolization was 19.9% (95% CI 3.4–34.7%, I2 93%) whereas it was 41.4% (95% CI 30.4–52.3%, I2 76%) in patients without IMA embolization (5 studies including 596 patients: p < .0001, OR 0.369, 95% CI 0.22–0.61, I2 27%). Since treatment for type II endoleaks is needed in less than 20% of cases and this complication can be treated successfully in 60–70% of cases resulting in an aneurysm rupture risk of 0.9%, these data indicate that embolization of patent IMA may be of no benefit in patients undergoing EVAR.
Abstract Objectives Endovascular treatment (EVAR) of abdominal aortic aneurysm (AAA) is thought to be of benefit, particularly in patients aged ≥80 years. This issue was investigated in the present ...meta-analysis. Design The study design involved a systematic review of the literature and meta-analysis. Methods Systematic review of the literature and meta-analysis of data on elective EVAR vs. open repair of AAA in patients aged ≥80 years were performed. Results Six observational studies reporting on 13 419 patients were included in the present analysis. Pooled analysis showed higher immediate postoperative mortality after open repair compared with EVAR (risk ratio 3.87, 95% confidence interval (CI) 3.19–4.68; risk difference, 6.2%, 95%CI 5.4–7.0%). The pooled immediate mortality rate after open repair was 8.6%, whereas it was 2.3% after EVAR. Open repair was associated with a significantly higher risk of postoperative cardiac, pulmonary and renal complications. Pooled analysis of three studies showed similar overall survival at 3 years after EVAR and open repair (risk ratio 1.10, 95%CI 0.77–1.57). Conclusions The results of this meta-analysis suggest that elective EVAR in patients aged ≥80 years is associated with significantly lower immediate postoperative mortality and morbidity than open repair and should be considered the treatment of choice in these fragile patients. These results indicate also that, when EVAR is not feasible, open repair can be performed with acceptable immediate and late survival in patients at high risk of aneurysm rupture.
Objective The aim of this study was to evaluate the impact of angiosome targeted revascularization according to the revascularization method. Design Retrospective observational study. Materials and ...methods This study cohort comprised 744 consecutive patients who underwent infrapopliteal endovascular or surgical revascularization between January 2010 and July 2013. Differences in outcomes after bypass surgery and PTA were adjusted by estimating a propensity score, which was employed for one to one matching as well as adjusted analysis. Results Cox proportional hazards analysis showed that angiosome-targeted revascularization (HR 1.29, 95% CI 1.02–1.65), bypass surgery (HR 1.79, 95% CI 1.41–2.27), C-reactive protein ≤10 mg/dL (HR 1.42, 95% CI 1.11–1.81), and the number of affected angiosomes (HR 0.85, 95% CI 0.74–0.98) were independent predictors of improved wound healing. When adjusted for the number of affected angiosomes and C-reactive protein ≤10 mg/dL, angiosome-targeted bypass surgery was associated with a significantly higher rate of wound healing than non-angiosome-targeted angioplasty (HR 2.27, 95% CI 1.61–3.20). This was confirmed in propensity score adjusted analysis (HR 1.72, 95% CI 1.35–2.16). Among patients who underwent angiosome-targeted revascularization, the propensity score adjusted analysis showed that bypass surgery was associated with a significantly better rate of wound healing (HR 154, 95% CI 1.09–2.16) but similar limb salvage rates when compared with angioplasty (HR 0.79, 95% CI 0.44–1.43). Conclusion Rates of wound healing and limb salvage in patients with critical limb ischemia (CLI) were significantly better after angiosome-targeted revascularization, bypass surgery achieving significantly better wound healing than angioplasty.
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 <3 (HR 1.37, 95% CI 1.01–1.84) was associated with improved wound healing, whereas wound healing was poorest after indirect PTA ( p = .001). When Cox proportional hazard analysis was adjusted for the number of affected angiosomes, direct bypass gave the best wound healing (p = 0.003). The overall amputation rate was 25.1% at 1 year of follow-up, and the Cox proportional hazards analysis indicated that haemodialysis compared with patients with no haemodialysis (HR 2.55, 95% CI 1.49–4.38), C-reactive protein ≥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.
The aim of this meta-analysis is to summarise the results of prospective, randomised studies comparing miniaturised (Mini-CPB) versus conventional cardiopulmonary bypass (C-CPB).
Meta-analysis of ...randomised trials.
After retrieval from literature search of 33 comparative studies, 13 studies have been included in this meta-analysis.
There were 562 patients in the Mini-CPB group and 599 in the C-CPB group. Mini-CPB was associated with a somewhat lower mortality during the immediate postoperative period (1.1% vs 2.2%, OR 0.58, 95% CI 0.23 to 1.47, p = 0.25). Postoperative stroke rate was significantly lower in the Mini-CPB group (0.2% vs 2.0%, OR 0.25, 95% CI 0.06 to 1.00, p = 0.05). The length of stay in intensive care unit was similar in the study groups (mean difference: -0.01, 95% CI -0.14 to 0.12, p = 0.87). Mini-CPB was associated with a significantly lower amount of postoperative blood loss (mean difference: -96.55, 95% CI -147.48 to -45.62, p = 0.0002) along with a higher platelet count 6 h after surgery (mean difference: 23 480, 95% CI 2 130 to 44 830, p = 0.03). The risk of resternotomy for bleeding was similar in the study groups (OR 1.06, 95% CI 0.32 to 3.57, p = 0.92).
This meta-analysis suggests that the use of Mini-CPB may be associated with lower risk of postoperative stroke and blood losses and with a somewhat decreased mortality. However, due to the large heterogeneity of methods and the small number of studies and patients evaluated so far, larger and homogeneous studies should be performed to obtain more conclusive results on the safety and efficacy of Mini-CPB.
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