Peripheral endovascular stents serve as a durable scaffold to limit abrupt vessel closure following balloon angioplasty. Their performance is not only derived from basic physical and three-dimensional properties but also influenced by their composition-features that include metallic alloy, stent geometry, and type of coating. In addition, peripheral stents are divided into balloon-expandable (BX) and self-expanding subtypes, each with specific physical characteristics that direct their use in distinct vascular beds. This study also evaluates the clinical use of various BX and self-expandable stent brands with contemporary, real-world data.

Chronic limb-threatening ischemia (CLTI) is the end-stage presentation of peripheral artery disease and requires comprehensive care. Despite advancements in treatments, providing timely and equitable care remains challenging. Ongoing research and interdisciplinary collaboration are vital for improving outcomes. Implementing strategies that combine appropriate diagnostics, advanced and innovative revascularization techniques, guideline-directed medical therapies, and efforts to tackle socioeconomic disparities can better address patient needs and enhance quality and quantity of life. This multifaceted approach offers promise for improved long-term outcomes in CLTI patients.

Background: Aortoiliac disease, a subset of peripheral artery disease (PAD), frequently necessitates revascularization. While surgical bypass has long been the standard of care, endovascular intervention using stents is increasingly utilized. This study compared long-term outcomes in patients with aortoiliac PAD undergoing revascularization with endovascular intervention vs surgical bypasses. Methods: We conducted a retrospective cohort study using the TriNetX research network to identify patients with aortoiliac PAD who underwent lower extremity revascularization between January 1, 2010, and December 31, 2020. Patients were stratified by intervention type (endovascular interventions vs. surgical bypass) and matched 1:1 using propensity scores. Outcomes in propensity score matched cohort was evaluated at 3 and 5 years including all-cause mortality, major and minor amputations, repeat revascularization and chronic limb-threatening ischemia (CLTI) analyzed using Kaplan–Meier estimates and Cox proportional hazards models. Results: Of 28,825 patients with PAD, 14,576 received endovascular intervention and 14,245 received surgical bypass. Endovascular intervention recipients were older (Mean: 67 vs 65 years; P= 0.001) and males (60.9% vs 60.7%; p<0.001) and had higher prevalence of hypertension (66.3% vs 64.5%;p=0.005), hyperlipidemia (56.6% vs 53.9%; p<0.001), and diabetes (37.6% vs 33.7%; p=0.007). After matching (N = 10,232 per group), baseline demographics and comorbidities were well balanced. No significant differences existed in all-cause mortality (HR 1.03;0.952-1.119; p = 0.457), major amputation(0.97;0.87-1.08;p=0.42) minor amputation(1.040;0.9-1.2; p=0.87), chronic limb threatening ischemia (HR 0.995;0.88–1.12; p=0.970) and repeat revascularization (HR 1.095;0.995-1.205, p = 0.066) between the endovascular intervention and surgical bypass cohorts. A male-specific sensitivity analysis showed no significant difference in survival (mean difference +1.19%; 95% CI= −0.17% to +2.61%) Conclusion: Endovascular intervention and surgical bypass demonstrated comparable long-term outcomes in this large, real-world cohort. These findings support endovascular therapy as a viable alternative to surgical revascularization, even in anatomically complex aortoiliac lesions. Further randomized controlled trials are warranted to guide treatment strategies in this population.

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable’s aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.

•Restricted mean survival time is an alternative to the hazard ratios for reporting the effect of an intervention.•CABG is associated with a significant and time-dependent delay of MACCE compared to PCI up to 5 years of follow up.•In patients with <3years of life expectancy, PCI and CABG may have equivalent outcomes.

Each year at the Society for Cardiovascular Angiography & Interventions (SCAI) Annual Scientific Sessions meeting, collaborative Think Tanks involving interventional cardiologists, administrative partners, and members of industry are convened for each SCAI clinical practice area to discuss topics of particular interest to the group. This document presents the proceeding of the 2022 peripheral session, which focused on value-based peripheral vascular interventions (PVI). The primary clinical role of PVI is to improve quality of life (QOL) for patients with claudication and limb preservation for those with chronic limb-threatening ischemia; however, PVI trials have historically focused on short-term procedure-related outcomes, resulting in few rigorous high-quality data on QOL or economic outcomes. The metrics of limb preservation are often reported, but typically without cost data, resulting in a lack of consensus on accepted measures of value in PVI. In this session, the group explored how to transition from a focus on episodic care of peripheral artery disease (PAD) to a more holistic strategy including QOL benefits, long-term health care economics, as well as patient- and society-centered value metrics. This effort should prioritize value for a diverse set of stakeholders, including patients, physicians, insurers and/or payers, hospital systems and/or outpatient-based laboratories, and industry (Figure 1). Think Tank members identified several critical themes for moving toward a value-based strategy. First, value and effectiveness are poorly defined by different stakeholders who measure costs and benefits along varied time scales and are driven by unique incentives; however, there is the potential for advancing quality PAD care when individual and collective goals are balanced in the long-term interests of the patients (Figure 2). It has been noted that defining value is dependent on perspective. The consensus opinion was that patient's perspective should be prioritized, with sustained QOL improvement and limb salvage as the predominant goal. A challenge facing the field is how to best define quality measures that accurately reflect these outcomes. Once defined, outcomes should be aligned with physician interests. In the current system, short-term outcomes may be prioritized over long-term value. With the alignment of incentives for all stakeholders in patient care (physicians, hospitals, payers or insurers, government, industry, etc) toward a well-defined value-based intervention, the currently diverse set of goals can be aligned to maximize impact for patients. Payers represent important stakeholders whose goals include lowering cost per PVI and/or hospitalization. However, payers should also prioritize patient-focused outcomes. By rewarding value-based care, payers should not penalize more expensive therapies that demonstrate improved longer-term outcomes with regard to QOL and limb salvage, which is especially relevant in therapies for PAD. For all sites of service, including hospitals, outpatient-based laboratories, and ambulatory surgical centers, the current goal is often cost containment per service, which favors short-term procedural safety and success over longer-term patient outcomes. These goals can conflict with patients' interests. If payers shift reimbursement to reward performance based on patient-centered value-based metrics, system goals would come into alignment with those of patients and physicians. From the perspective of industry, there is benefit in aligning the goals of payers, sites of service, physicians, and patients to help narrow market needs and drive innovation of high-quality devices that meet those shared goals. Clarifying the heterogeneous perspectives on value-based health care provides industry with motivation to improve quality and effectiveness, and this ultimately promotes devices with demonstrated durability and longevity in PAD treatment. Unifying the needs of stakeholders—patients, physicians, payers, and hospitals—also affords industry the possibility to better refine their approach to clinical studies and informs the selection of clinically-meaningful end points in future studies. Ultimately, this may position industry as a better partner to physicians in helping to define a PAD treatment algorithm focused on value, longevity, and QOL for patients. Finally, patients, who are at the center of this model, should remain engaged in their treatment and accountable regarding known risk factor modifications, including smoking cessation, participation in supervised exercise therapy, and adherence to evidence-based medical therapies, so that invasive therapies are applied in the context of best medical care. Taken together, the overlap between all these stakeholders occurs in therapies and devices that are most cost effective for the longest term, based on well-defined patient-centered measures of value. This allows each stakeholder to identify individual strategies that also contribute to the collective goal of high-value patient-centric care. As the first step, long-term patient-centered measures of value must be clearly defined and widely adopted. Once defined, incentives for all stakeholders can be targeted to promote these outcomes. Patients should be encouraged to take health ownership of risk factor modification prior to PVI, as this will benefit their goals of sustained QOL and limb outcomes from PVI. If interventions are needed beyond this, patients should be engaged as partners in discussions about long-term goals of interventions and the potential risks and benefits of various treatment modalities available to them. Physicians must, therefore, consistently engage with patients as partners in risk factor modification and decision making around PVI. This physician-patient relationship centered on long-term patient outcomes is far more likely to be adopted if payers structure reimbursement to reward patient outcomes relative to the established definitions of value and shared metrics for success of PAD therapy. This should include reimbursement for preventive programs, including application of noninvasive therapies (eg, smoking cessation, supervised exercise therapy, application of medical therapies, including anticoagulant therapy) as well as high-quality invasive therapies and devices. Conversely, payers may consider financial disincentives to PVIs for patients who are not medically optimized and readmission penalties for PVI if the best therapies (medical and invasive) are not applied. In conjunction, the sites of service must similarly select and promote technologies and devices with demonstrated durable benefits to the health and QOL of patients. This means that hospital systems, outpatient-based laboratories, and ambulatory surgical centers should identify metrics of longer-term cost effectiveness so that the potentially high costs of durable index revascularization do not prevent the implementation of more effective therapies. This can be accomplished by tracking PVI readmissions and reinterventions associated with current therapies. Additionally, industry should closely engage with patients and physicians around important questions relevant to defining procedural and long-term success in PVI, with a focus on durable, value-driven patient-related outcomes and limb salvage. Additionally, a collaborative trial design featuring cardiovascular risk factor modification can move toward mortality improvement in this high-risk patient population. Importantly, moving forward, studies should ensure adequacy of racial, ethnic, sex, and geographic diversity to understand the differential impacts of deprivation on treatment strategies in order to improve care overall. Principal investigators should be actively engaged, along with community partners, to address gaps in noninvasive and invasive care of PAD. Ultimately, the members agreed on several important concepts. The first is the need to address and define value, balancing the perspectives and needs of key stakeholders while prioritizing patients. Second, the members identified that assignation of value had an important time-based component given the chronic disease course of PAD. Ultimately, all agreed that there needs to be alignment of incentives toward value-based rather than fee-for-service–based care in the treatment of chronic PAD. Given his role as Associate Editor, Sahil A. Parikh had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Alexandra J. Lansky. S. Elissa Altin, Lyndon C. Box, Tony Das, Dmitriy N. Feldman, Sasanka Jayasuriya, Andrew J. Klein, Faisal Latif, Jun Li, Sahil A. Parikh, Eric A. Secemsky, and Rajesh V. Swaminathan reported no financial interests. Ellie Boutin is an employee at Terumo. Fely Canorea-Vega and James Hasegawa are employees at Abbott. Anjan K. Chakrabarti is an employee at Inari Medica. Nicole Howie is an employee at Medtronic. Toni Kohler and Holly M. Lauridsen are employees at WL Gore & Associates. Oscar Perez and Novena Rangwala are employees at GE Healthcare. Michele Schicchi and Laurie Zinn are employees at Cordis. Margaret Taber is an employee at Boston Scientific. John Venditto is an employee at AstraZeneca Pharmaceuticals. Jude Wimberger is an employee at Philips Healthcare. This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Purpose: Multiple randomized clinical trials have shown superiority of drug-eluting stents (DES) over bare-metal stents (BMS) for infrapopliteal disease. However, real-world data on DES utilization and outcomes in infrapopliteal chronic limb-threatening ischemia (CLTI) patients are unknown. Materials and Methods: We utilized the Nationwide Readmission Database (NRD) from 2016 to 2017 to extract patients undergoing infrapopliteal intervention with stents (BMS and DES) for CLTI using appropriate ICD-10 codes. Multilevel logistic regression with hospital ID as random effect was used to assess DES utilization. Primary outcome was the composite of target limb major amputation (TLmajA) and target limb revascularization (TLR). Multivariate Cox-proportional hazard regression was used to adjust for confounders. Results: Our study included a total of 1817 patients. Of these patients, 1056 patients (58.1%) received DES; DES utilization was stable (relative change: +2.5%, p-trend: 0.867) between 2016 and 2017 and was higher in teaching hospitals (adjusted odds ratio [aOR] = 1.28, 95% CI = 1.03–1.61, p=0.029] and medium (aOR = 3.13, 95% CI = 2.17–4.55, p≤0.001) and large (aOR = 1.56, 95% CI = 1.14–2.17, p=0.005) bed–sized hospitals. Inter-class correlation was 0.44 suggesting ~44% variation in DES utilization between any 2 random hospitals; DES was associated with lower rate of the primary composite outcome (aHR = 0.75, 95% CI = 0.62–0.92, p=0.004) compared with BMS. Conclusion: In patients undergoing infrapopliteal intervention for CLTI, DES demonstrated significant underutilization despite supportive evidence of their superiority compared with BMS; DES was associated with improvement in the primary composite outcome compared with BMS.

Despite the evolution of stent technology, there is a non-negligible risk of in-stent restenosis (ISR) after Percutaneous coronary intervention (PCI). Large-scale registry data on the prevalence and clinical management of ISR is lacking.The aim was to describe the epidemiology and management of patients with ≥1 ISR lesions treated with PCI (ISR PCI). Data on characteristics, management and clinical outcomes were analyzed for patients undergoing ISR PCI in the France-PCI all-comers registry.Between January 2014 and December 2018, 31,892 lesions were treated in 22,592 patients, 7.3 % of whom underwent ISR PCI. Patients undergoing ISR PCI were older (68.5 vs 67.8; p < 0.001), and more likely to have diabetes (32.7 % vs 25.4 %, p < 0.001), chronic coronary syndrome or multivessel disease. ISR PCI concerned drug eluting stents (DES) ISR in 48.8 % of cases. Patients with ISR lesions were more frequently treated with DES than drug eluting balloon or balloon angioplasty (74.2 %, 11.6 % and 12.9 %, respectively). Intravascular imaging was rarely used. At 1 year, patients with ISR had higher target lesion revascularization rates (4.3 % vs. 1.6 %; HR 2.24 [1.64–3.06]; p < 0.001).In a large all-comers registry, ISR PCI was not infrequent and associated with worse prognosis than non-ISR PCI. Further studies and technical improvements are warranted to improve the outcomes of ISR PCI.

Chronic limb-threatening ischemia (CLTI) is the advanced stage of peripheral artery disease (PAD) characterized by rest pain or tissue loss. Up to 2 million individuals have this condition in the United States, and prevalence is anticipated to grow owing to aging of the population and increase in atherosclerotic risk factors such as diabetes and renal disease.1 In addition to the threat of limb dysfunction and amputation, patients with CLTI are at a high risk of cardio- and cerebrovascular morbidity and mortality, with risk that exceeds that of most other cardiovascular patients.

The current use of intravenous epoprostenol in patients with severe idiopathic, heritable or anorexigen-use associated pulmonary arterial hypertension (IHA-PAH) was investigated.This observational study evaluated newly diagnosed (≤ 1 year) patients with IHA-PAH, enrolled in the French pulmonary hypertension (PH) registry between 2006 and 2010 and treated with epoprostenol. Among 209 consecutive patients receiving epoprostenol for the treatment of severe PH, 78 had IHA-PAH, including 43 patients naïve of previous PAH-specific treatment.After 4 months of epoprostenol therapy, improvement was observed for treatment naïve patients (n = 43) and for patients who had received previous PAH-specific therapy (n = 35): NYHA functional class improved in 79% and 44% of these patients, respectively, 6-minute walk distance increased by 146 (p < 0.0001) and 41 m (p = 0.03), cardiac index increased by 1.2 (p < 0.0001) and 0.5 L·min− 1·m− 2 (p = 0.006), and pulmonary vascular resistance decreased by 700 (p < 0.0001) and 299 dyn·s·cm− 5 (p = 0.009). In the treatment-naïve patient group, upfront combination of epoprostenol and oral PAH therapy tended to be more beneficial compared with epoprostenol monotherapy and was associated with improvement in cardiac index (p = 0.03).The observed 1- and 3-year survival estimates from epoprostenol initiation were 84% and 69%, respectively. The highest survival rates were observed for treatment-naïve patients receiving upfront combination of epoprostenol and oral PAH therapy (92% and 88% at 1 and 3 years, respectively).First-line therapy with epoprostenol, especially when combined with oral PAH treatment, was associated with a substantial improvement in clinical and hemodynamic status and favorable survival estimates in patients with severe IHA-PAH.

The drug-coated balloon (DCB) is an emerging percutaneous coronary intervention (PCI) device that delivers drugs to diseased vessels to decrease the rate of vascular stenosis. Recent clinical studies have demonstrated that DCBs tend to have both good safety and efficacy profiles, leading to extended application indications in the clinic, including in-stent restenosis (ISR) for metal stents such as drug-eluting stents (DESs), small vascular disease, bifurcation disease, large vascular disease, acute coronary syndrome (ACS), and high bleeding risk. However, some previous clinical data have suggested that DCBs performed less effectively than DESs. No studies or reviews have systematically discussed the improvement strategies for better DCB performance until now. Drug loss during the process of delivery to the target lesion and inefficient delivery of the coating drug to the diseased vascular wall are two key mechanisms that weaken the efficiency of DCBs. This review is the first to summarize the key influencing factors of DCB efficiency in terms of balloon structure and principles, and then it analyzes how these factors cause outcomes in practice based on current clinical trial studies of DCBs in the treatment of different types of lesions. We also provide some recommendations for improving DCBs to contribute to better DCB performance by improving the design of DCBs and combining other factors in clinical practice.

HomeCirculation: Cardiovascular InterventionsVol. 15, No. 1Impact of Interdisciplinary System-Wide Limb Salvage Advisory Council on Lower Extremity Major Amputation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBImpact of Interdisciplinary System-Wide Limb Salvage Advisory Council on Lower Extremity Major Amputation Mehdi H. Shishehbor, DO, MPH, PhD, Tarek A. Hammad, MD, Tonia J. Rhone, MS, Ahmad Younes, MD, Norman Kumins, MD, Abdullah Abdullah, MD, Jun Li, MD, Karem Harth, MD, Teresa L. Carman, MD, Heather L. Gornik, MD, Peter J. Pronovost, MD, PhD and Vikram S. Kashyap, MD Mehdi H. ShishehborMehdi H. Shishehbor Correspondence to: Mehdi H. Shishehbor, DO, MPH, PhD, Case Western Reserve University School of Medicine, UH Harrington Heart and Vascular Institute, 11100 Euclid Ave, Lakeside 3rd floor, Cleveland, OH 44106. Email E-mail Address: [email protected] https://orcid.org/0000-0002-4888-2431 Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Tarek A. HammadTarek A. Hammad Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Tonia J. RhoneTonia J. Rhone Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Ahmad YounesAhmad Younes Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Norman KuminsNorman Kumins Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Abdullah AbdullahAbdullah Abdullah https://orcid.org/0000-0001-8870-0690 Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Jun LiJun Li Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Karem HarthKarem Harth Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Teresa L. CarmanTeresa L. Carman Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Heather L. GornikHeather L. Gornik Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. , Peter J. PronovostPeter J. Pronovost Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. and Vikram S. KashyapVikram S. Kashyap https://orcid.org/0000-0003-1780-979X Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH. Originally published21 Dec 2021https://doi.org/10.1161/CIRCINTERVENTIONS.121.011306Circulation: Cardiovascular Interventions. 2022;15:e011306Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 21, 2021: Ahead of Print One diabetes-related lower extremity amputation occurs every 30 seconds worldwide. Along with the cost to the health care system, there is an unaccounted cost to individual patients, including disability, emotional stress, and social burden.1 Despite the recommendations for an interdisciplinary approach in the care for complex patients with critical limb-threatening ischemia (CLTI), clinical decisions of amputation are frequently made in isolation by an individual team. A real-time intervention to host a multispecialty discussion enforcing multisocietal consensus recommendations2,3 and harnessing the advantage of diverse inputs has yet to be routinely implemented due to cultural and logistic barriers. At our integrated health system which includes 10-acute care hospitals, we prospectively evaluated the impact of creating a novel system-wide interdisciplinary team, Limb Salvage Advisory Council (LSAC), on amputation rates in patients >18 years with CLTI who were already scheduled for major amputation. Study was approved by our institutional review board, and informed consent was waived. Data are available upon request.The LSAC includes primary team, vascular surgeons, endovascular interventionalists, vascular medicine specialists, podiatrists, and wound care experts. Once a patient who is scheduled for a major amputation is identified, the treating physician may elect to notify a designated coordinator who arranges for an urgent virtual LSAC meeting. The primary team prepares an audiovisual presentation. During the meeting, LSAC members critically review and discuss available data including comorbidities, functional status, extent of tissue loss, relevant imaging studies, and prior interventions with the goal of providing diversified thoughtful inputs and double-check stop on major amputation. Eventually, LSAC participants reach a consensus for one of 2 dispositions: Limb is salvageable, revascularization is feasible and appropriate, and correspondingly limb salvage efforts, including advanced revascularization, foot reconstruction, or alternative therapy, are discussed and planned. Otherwise, the patient is approved to proceed with his/her originally scheduled major amputation (Figure [A]). The primary outcome was the rate of major amputation at 6 months. Death, target limb revascularization, and wound healing represented the secondary outcomes. Baseline characteristics, comorbidities, ambulatory status, number of wounds, and Rutherford class for each patient were also captured. Data were collected using prospective chart review along with follow-up clinic visits, and outcomes were evaluated using descriptive statistics.Download figureDownload PowerPointFigure. Ideal model of care, disposition, and 6-mo outcomes for critical limb-threatening ischemia (CLTI) patients originally scheduled for major amputation.A, While patients with CLTI may be initially seen by individual specialties independently, the addition of the Limb Salvage Advisory Council (LSAC) allows for an interdisciplinary discussion, collaboration, and disposition to prevent limb loss. B, The consensus of the LSAC was either salvageable or unsalvageable due to extensive tissue loss. All 3 patients whose limbs deemed unsalvageable had below-knee amputation (BKA). Those with salvageable limbs underwent successful revascularization (n=15) except one patient whose revascularization was unsuccessful and subsequently had planned above-knee amputation (AKA). After excluding those who were lost to follow-up (n=2) and those who died (n=2), only 2 out of 11 successfully revascularized patients had BKA at 6 mo. Seven out of the 9 surviving patients with preserved limbs had wounds at baseline, and the majority of these completely healed or had measurable reduction in wound size.A total of 19 patients underwent LSAC evaluation between January 2019 and September 2019. The mean age was 63 years with 47% females. The majority of patients were Rutherford class V and VI. Importantly, 84% of the cohort had a prior leg intervention. Three patients were deemed unsalvageable due to extensive tissue loss and proceeded with their originally scheduled major amputation, whereas the other 16 patients were reconsidered for limb salvage and 15 (94%) had successful angiosome-directed revascularization. Retrograde tibial access was needed in 31% of the cases. Of the 16 revascularized patients, 2 patients were lost to follow-up, 2 others died at 5 months, and 9 (75%) of the remaining 12 patients had not undergone major amputation at 180 days. Of these 9 patients, 7 had varying degrees of tissue loss at baseline and 6 (86%) of them had complete healing or significant reduction in wound size at 180 days (Figure [B]). Repeat revascularization occurred in only 3 (19%) of the 16 patients.This is the first study investigating the impact of a novel and proactive interdisciplinary intervention, LSAC, on patients already planned for a major amputation due to CLTI. Excluding those who died or were lost to follow-up, only one-quarter of the patients formerly scheduled for a major amputation and managed by the LSAC actually lost a limb at 180 days with remarkable wound healing results. Two studies have reported on the adoption of multidisciplinary care in CLTI and improved outcomes; however, both were retrospective and had revascularization proceduralists from a single specialty.4,5 Our interdisciplinary LSAC is unique as it involves not just multiple teams, including endovascular interventionalists and vascular surgeons, but often multiphysicians within the same specialty. Every patient deserves at least a second and even a third revascularization attempt using various approaches and sometimes different skill sets to save his/her limb.In launching a successful interdisciplinary limb salvage team, a culture of patient-centered cooperation and education, is essential, with mutual trust and respect among various specialties, rather than competition and judging. Using CPT codes, we identified 80 patients with CLTI on whom LSAC was not activated and underwent major amputation during the same time period. Our findings may have significant policy implications if all patients scheduled for major amputation were mandated to receive an interdisciplinary team evaluation such as LSAC. This could be implemented as part of a medical necessity or prior authorization program. Broad implementation of this policy could significantly reduce amputations rate across the United States and the resultant cost and morbidity. Future research should explore how to move the referral to LSAC further upstream to allow early intervention.Article InformationSources of FundingSupported by the Angela and James Hambrick Chair in Innovation.DisclosuresNone.Nonstandard Abbreviations and AcronymsCLTIcritical limb-threatening ischemiaLSAClimb salvage advisory councilFootnotesFor Sources of Funding and Disclosures, see page 109.Correspondence to: Mehdi H. Shishehbor, DO, MPH, PhD, Case Western Reserve University School of Medicine, UH Harrington Heart and Vascular Institute, 11100 Euclid Ave, Lakeside 3rd floor, Cleveland, OH 44106. Email mehdi.[email protected]orgReferences1. Prompers L, Huijberts M, Schaper N, Apelqvist J, Bakker K, Edmonds M, Holstein P, Jude E, Jirkovska A, Mauricio D, et al.. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study.Diabetologia. 2008; 51:1826–1834. doi: 10.1007/s00125-008-1089-6CrossrefMedlineGoogle Scholar2. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, et al.. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2017; 135:e726–e779. doi: 10.1161/CIR.0000000000000471LinkGoogle Scholar3. Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, et al.; GVG Writing Group for the Joint Guidelines of the Society for Vascular Surgery (SVS); European Society for Vascular Surgery (ESVS); World Federation of Vascular Societies (WFVS). Corrigendum to “Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischaemia” [Eur J Vasc Endovasc Surg 58 (1S) (2019) 1-109>].Eur J Vasc Endovasc Surg. 2020; 60:158–159. doi: 10.1016/j.ejvs.2020.04.033CrossrefMedlineGoogle Scholar4. Chung J, Modrall JG, Ahn C, Lavery LA, Valentine RJ. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia.J Vasc Surg. 2015; 61:162–169. doi: 10.1016/j.jvs.2014.05.101CrossrefMedlineGoogle Scholar5. Hioki H, Miyashita Y, Miura T, Ebisawa S, Motoki H, Izawa A, Tomita T, Koyama J, Ikeda U. Prognostic improvement by multidisciplinary therapy in patients with critical limb ischemia.Angiology. 2015; 66:187–194. doi: 10.1177/0003319714523113CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2022Vol 15, Issue 1Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.121.011306PMID: 34930016 Originally publishedDecember 21, 2021 Keywordshospitalslimb salvagelower extremityamputationmusculoskeletal systemPDF download Advertisement SubjectsPeripheral Vascular DiseaseQuality and OutcomesRevascularizationVascular Disease

目的 探讨股腘动脉硬化闭塞症膝下动脉逆行开通的安全性和有效性.方法 收集2015—2016年在我院治疗的TASCⅡC/D型股腘动脉硬化闭塞症病人,其中接受膝下动脉逆行腔内介入(REI)治疗者33例(REI组),常规经股动脉开通治疗者97例(TFA组),比较两组的技术成功率、手术并发症发生率、血管通畅率、保肢率.结果 REI组与TFA组的技术成功率分别为78.8％和90.2％.REI组与TFA组并发症发生率分别为9.1％和6.9％,差异无统计学意义(P>0.05).术后平均随访19.8个月(1～30月),REI组和TFA组的一期通畅率术后1年时分别为48.4％和54.2％,术后2年时分别为29.4％和50.6％;REI组和TFA组的辅助一期通畅率术后1年时分别为63.1％和73.3％,术后2年时分别为36.3％和58.4％.TFA组一期通畅率和辅助一期通畅率相对较高,但差异均无统计学意义(P>0.05).REI组术后1、2年时的保肢率分别为93.0％和87.5％,TFA组分别为100.0％和95.4％,两组保肢率比较差异无显著性(P>0.05).结论 膝下动脉REI与常规经股动脉开通治疗TASCⅡC/D型股腘动脉硬化闭塞症,随访期间血管通畅率相当,且远端穿刺部位并发症很少发生,因此REI可作为常规经股动脉入路开通失败后的补救治疗手段.