JOURNAL OF VASCULAR SURGERY June Supplement 2016
120S Abstracts
Table II. One-year outcomesa Bypass w/ Bypass P Adjusted HR endarterectomy, % only, % value (95% CI)b Survival Claudication CLI Tissue loss only Amputation-free survival Claudication CLI Freedom from major amputation Claudication CLI Freedom from MALE Claudication CLI
89 97 85 81
88 96 83 79
.16 .40 .16 .41
0.85 (0.67-1.1)
0.83 (0.68-1.01) 96 80
95 76
.27 .03 0.77 (0.55-1.1)
99 91
98 87
.45 .048
78 71
81 68
.29 .31
1.0 (0.85-1.2)
CI, Confidence interval; CLI, critical limb ischemia; HR, hazard ratio; MALE, major adverse limb events, includes thrombectomy/lysis, revision, or major amputation. a Overall median 313 days (IQR, 76-39 days). b Too few events in claudication group to stratify adjusted analysis, so symptom status included in adjustment and overall HR with respect to adjunct endarterectomy represented above. CLI- only HRs are therefore similar to overall.
68%; P ¼ .31; adjusted HR, 1.0; 95% CI, 0.9- 1.2; Table II). Adjunctive endarterectomy was associated with improved freedom from major amputation (91% vs 87%; P ¼ .05) and amputation-free survival (80% vs 76%; P ¼ .03) in CLI patients, but this difference did not remain significant after adjustment (HR, 0.8; 95% CI, 0.6-1.1; HR, 0.8; 95% CI, 0.7-1.04, respectively). Conclusions: Adjunctive femoral endarterectomy with lower extremity bypass is safe, with no difference in perioperative or 1-year mortality compared to bypass alone, despite its association with increased risk for blood transfusion, wound infection, and MI during the index admission. Author Disclosures: S. E. Deery: Nothing to disclose; C. T. Healey: Nothing to disclose; J. Kalish: Nothing to disclose; N. Kansal: Endologix: consulting fees (eg, advisory boards); M. L. Schermerhorn: AnGes, Cordis, and Endologix: consulting fees (eg, advisory boards); K. E. Shean: Nothing to disclose; P. A. Soden: Nothing to disclose; S. L. Zettervall: Nothing to disclose.
IP203. Distal Peroneal Artery Branch Angioplasty: An Alternative Approach to Access Tibial Revascularization Below the Ankle Anita Quintas, MD1, Goncalo Alves, MD2, José Aragão Morais, MD3, Frederico Bastos Gonçalves, MD, PhD4, Maria E. Ferreira, MD2, Joao A. Castro, MD2, Luis M. Capitao, MD2. 1 Santa Marta Hospital, CH Lisboa Central, Maia, Porto, Portugal; 2Santa Marta Hospital, CHLC, Lisbon, Portugal; 3 Santa Marta Hospital, CH Lisboa Central, Lisboa, Portugal; 4 Santa Marta Hospital, CHLC, Lisboa, Portugal Objectives: The presence of noncrossable long chronic occlusion of the tibial arteries occurs in many
Fig.
diabetic and end-stage renal disease patients with critical limb ischemia. The peroneal artery is frequently the least and the last diseased runoff vessel, but a direct straightline flow to a pedal artery is recommended to achieve healing of ischemic tissue loss. The anterior and posterior perforating branches of the distal peroneal artery can be an access to the pedal arteries (dorsalis pedis and posterior tibial retromalleolar artery) and complete a below-theankle revascularization. We report two case examples of the value of perforating distal peroneal branches angioplasty to access pedal arteries in the foot. This can be a valid endovascular approach to respect wound angiosome and increase limb salvage rates. Methods: Cases ReportdPatient 1: A 59-year-old man with a history of diabetes mellitus, hypertension, hypercholesterolemia, and smoking, was referred with critical limb ischemia category 5 of Rutherford Classification (Fig 1). The duplex ultrasound study raveled severe tibioperoneal occlusive disease, and he underwent endovascular revascularization. Angiographic findings showed only an anterior tibial artery in the leg and no pedal vessel in the foot. After unsuccessful recanalization of the anterior tibial
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Abstracts 121S
artery to the dorsalis pedis, a balloon angioplasty was performed of the peroneal artery, its posterior perforating branch, and of the plantar arch (Fig). Patient 2: A 79year-old woman, with medical history of type 2 insulintreated diabetes mellitus and hypercholesterolemia, developed critical limb ischemia with toes gangrene and was referred to our department presenting occlusive arterial disease of the below-the-knee arteries. A digitally subtracted angiography confirmed occlusion of the tibial and peroneal arteries in the leg. Balloon angioplasty was performed of the peroneal artery and its anterior perforating branch to the dorsalis pedis. Results: In both patients good angiographic results were achieved, with a straight-line flow to the foot, through the peroneal artery and the posterior perforating branch and plantaris communis in the first patient (Fig 1); and the anterior perforating branch and dorsalis pedis in the second patient. Good perfusion of the foot allowed the healing of transmetatarsal amputations. Conclusions: Angioplasty of the peroneal artery and its anterior and posterior distal branches to pedal arteries is a valid and feasible endovascular approach that can be effective for limb salvage in patients presenting tissue loss. Therefore this can be considered an alternative when tibial arteries CTOs that cannot be recanalized. Author Disclosures: F. Bastos Gonçalves: Nothing to disclose; J. Morais: Nothing to disclose; A. Quintas: Nothing to disclose. IP205. Lifelong Limb Salvage: A Patient-Centered Description of Lower Extremity Arterial Reconstruction Outcomes Katie E. Shean, MD1, Peter A. Soden, MD2, Marc L. Schermerhorn, MD2, Sara L. Zettervall, MD2, Sarah E. Deery, MD3, Allen D. Hamdan, MD2, Richard Amdur, PhD4, Frank W. LoGerfo, MD2. 1Beth Israel Deaconess Medical Center, Billerica, Mass; 2Beth Israel Deaconess Medical Center, Boston, Mass; 3Massachusetts General Hospital, Boston, Mass; 4George Washington University, Washington, D.C. Objectives: Life expectancy is short for patients with critical limb ischemia (CLI), many of whom may fear amputation more than death. In light of the reduced life expectancy of these patients, the traditional 5-year freedom from amputation (FFA) statistic may not accurately address their concern. To better answer the question, “Will I ever lose my leg?” we developed a more relevant calculation of major amputation risk over a patient’s remaining lifetime. Methods: We identified all limbs undergoing firsttime intervention for CLI in a large institutional database from 2005 to 2013. We calculated the traditional metrics of amputation-free survival (AFS, where failure is death or amputation) and freedom from amputation (FFA, where failure is amputation but deaths are censored and removed from further analysis). Additionally, we propose a new term: lifelong limb salvage (LLS). LLS defines amputation as failure, but deaths are not censored and therefore reflect that LLS has been irrevocably achieved. All deaths <30 days were considered a failure in all three metrics, reflecting the risk of surgery.
Fig.
Results: A total of 1011 limbs were identified as having first time intervention for CLI (23% rest pain, 48% ulcer, 29% gangrene; 46% treated by angioplasty with or without stenting, 54% bypass). Using life-table analysis, 7-year event rates were AFS: 620 events (12%), FFA: 123 (77%) and LLS: 123 (86%). Events rates were similar between angioplasty and bypass (LLS: 86% vs 85%). Sevenyear event rates were further evaluated within each indication group. For rest pain, events were AFS, 13%; FFA, 84%; and LLS, 91%. Within the ulcer population they were AFS, 14%; FFA, 77%; and LLS, 86%. Finally, in those with gangrene: AFS, 10%; FFA, 68%; and LLS, 78%. Using LLS, a patient presenting with an ulcer can be told that while we cannot guarantee how long they will live, there is approximately an 86% chance they will not lose their leg. Conclusions: The results above show that the durability of our limb salvage procedures often exceeds that of our patients. Using LLS as an outcomes assessment provides a more accurate answer to the patient’s question, “If I have this procedure, will I ever lose my leg?” Author Disclosures: R. Amdur: Nothing to disclose; S. E. Deery: Nothing to disclose; A. D. Hamdan: Nothing to disclose; F. W. LoGerfo: Nothing to disclose; M. L. Schermerhorn: AnGes, Cordis, and Endologix: consulting fees (eg, advisory boards); K. E. Shean: Nothing to disclose; P. A. Soden: Nothing to disclose; S. L. Zettervall: Nothing to disclose. IP207. Delayed Revascularization for Acute Lower Extremity Ischemia Leads to Increased Mortality Khanjan H. Nagarsheth, MD, MBA, Naiem Nassiri, MD, Randy Shafritz, MD, Saum Rahimi, MD. Rutgers University, New Brunswick, NJ Objectives: Acute lower extremity ischemia carries an increased risk of postoperative morbidity and mortality,