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Background/aim: Scapular osteosarcoma is a rare malignancy, and the understanding of its optimal treatment strategies and long-term outcomes remains limited. The purpose of the current study was to evaluate our institutional experience., Patients and Methods: We reviewed 14 patients (8 females, 5 males; mean age 44±17 years) treated for scapular osteosarcoma from 1985 to 2022. Tumors were confirmed histologically and treated with a multidisciplinary approach, including chemotherapy and surgery with a median follow-up of 10 years., Results: Surgical complications occurred in eight patients, leading to repeat procedures in four. Complications were associated with the use of implants or allografts (p<0.01). Mean shoulder forward elevation and external rotation at follow-up were 42±61° and 12±16°, with a mean MSTS93 score of 61±19%. The 10-year disease-specific survival rates was 76%. Local recurrence was associated with worse survival (HR=13.19, p=0.04)., Conclusion: Scapular osteosarcoma is rare, and with multidisciplinary management, local control is essential to patient survival., (Copyright © 2025 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: This study aimed to assess the 1-year clinical outcomes and predictors of technical success in acute limb ischemia (ALI) treatment., Methods: A sub-analysis of the REtroSpective multiCenter study of endovascUlar or surgical intErvention for ALI (RESCUE ALI) study involved 185 patients with ALI and technical success (n = 131) or failure (n = 54) treated via surgical, endovascular, or hybrid revascularization between January 2015 and August 2021. The primary endpoint was 1-year amputation-free survival (AFS), and the secondary endpoints included preoperative complications and 1-year reintervention., Results: The technical success group had a significantly higher 1-year AFS rate than the technical failure group (79% vs. 44%, p < 0.001). Perioperative complications rate showed no significant difference between the two groups. The incidence of reintervention was lower in the technical success group (17% vs. 30%, p = 0.049). Age ≥ 80 years, time from onset ≥ 24 h, no below-the-knee artery runoff, and preoperative c-reactive protein ≥ 5 mg/dL were negatively associated with technical success across all procedures. In surgical revascularization, no below-the-knee artery runoff was negatively associated with technical success. For endovascular revascularization, onset-to-treatment time ≥ 48 h was negatively related and thromboembolism in atrial fibrillation was positively related to technical success. In hybrid revascularization, supra- to infrapopliteal lesions were negatively associated with technical success., Conclusions: Technical success in ALI treatment significantly enhances 1-year AFS rates. Thus, choosing the appropriate revascularization procedure based on predictors of technical success is crucial for improving patient outcomes., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Ethical decision-making in the amputation versus limb salvage context requires consideration of respect for patient autonomy, beneficence, and nonmaleficence. The surgical options demonstrate near equivalent outcomes for traumatic indications, while reconstruction is generally favored for threatened limbs due to diabetic complications. The decision for amputation versus limb salvage must be considered in each individual patient's situation, with a shared decision-making process of paramount importance. Discussion should involve the best, worst, and most likely case for each surgical option to allow the patient to better understand the range of potential postoperative courses and make an informed decision., Competing Interests: Disclosure No funding has been received in support of this study. The authors have no disclosures to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The comorbidity-polypharmacy score (CPPS) was created to evaluate the clinical burden of comorbidities in geriatric patients. It represents an objective tool to stratify patients' risk in different settings. The study aimed to evaluate CPPS in predicting mortality and amputation in patients undergoing elective revascularization procedures in chronic limb-threatening ischemia (CLTI) patients., Methods: This is a 2-year retrospective single-center study. We included all patients undergoing elective lower-limb revascularization procedures admitted with CLTI diagnosis. Four CPPS groups were defined: mild, moderate, severe, and morbid. The primary early and long-term outcomes were 30-day overall mortality, 30-day amputation rate, and overall survival and limb salvage, respectively., Results: A total of 442 patients were enrolled in the study. Mean age was 76.5 ± 9.9 years, and 61.5% (272/442) were male. CPPS was calculated: 22.6% (100/442) have mild CPPS, 54.3% (240/442) moderate, 21.9% (97/442) severe, and 1.2% (5/442) morbid. Kaplan-Meier curves for overall survival stratified by CPPS grade highlighted a strong statistically significant difference (P < 0.0001) among the 4 CPPS classes. Mild CPPS has a significantly higher limb salvage rate among moderate, severe, and morbid CPPS groups (P < 0.0001). Limb salvage for mild and severe CPPS, at 36 months was 95% vs. 85.1%, respectively. Stepwise multivariable Cox-analysis revealed that mortality was independently associated with dialysis, Rutherford Classification V, age, and CPPS. Male sex, multilevel arterial disease, and hybrid surgical repair were independently associated with amputations., Conclusions: CPPS is a straightforward tool to evaluate the patient's complexity and could be used as an adjuvant tool to stratify early- and long-term outcomes in CLTI patients undergoing elective revascularization procedures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To identify predictors of clinical success in invasive treatment for femoropopliteal arterial disease aiding clinical decision-making., Materials and Methods: A retrospective analysis was performed on 676 consecutive patients who underwent a first episode of invasive treatment for femoropopliteal disease, either endovascular therapy (EVT) or femoropopliteal bypass (FPB), between 2004 and 2015. Primary end points were primary and secondary clinical patency and amputation rate. Kaplan-Meier curves were used to evaluate clinical patency. A Cox proportional hazard model explored predictors of primary end points., Results: Most patients (58%) underwent EVT as primary intervention, while 42% underwent FPB. Median follow-up was 43 months. The only independent predictor for loss of primary clinical patency was critical limb-threatening ischemia (CLTI) (P = .008; hazard ratio [HR], 1.25; 95% CI, 1.07-1.47). Secondary clinical patency was positively associated with FPB surgery (P = .037; HR, 0.66; 95% CI, 0.44-0.97), a higher pre-interventional ankle-brachial index (P = .029; HR, 0.43; 95% CI, 0.20-0.92), more distal runoff vessels (P = .036; HR, 0.77; 95% CI, 0.60-0.98), and the absence of ischemic heart disease (P = .006; HR, 1.69; 95% CI, 1.16-2.47). In patients with CLTI, chronic renal failure predicted loss of primary and secondary clinical patency and increased amputation risk., Conclusions: In this cohort, CLTI was independently associated with decreased primary clinical patency in invasive treatment for femoropopliteal disease. Secondary clinical patency was positively associated with FPB, higher ankle-brachial index, more runoff vessels, and the absence of ischemic heart disease., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Significant practice variability exists regarding the management of intermittent claudication (IC) across anatomic segments. We sought to answer the question of whether the safety, efficacy, and durability outcomes of an endovascular approach with or without common femoral endarterectomy for complex aortoiliac occlusive disease (AIOD) justify a surgical approach in patients presenting with IC., Methods: A retrospective single-center review of all patients who were treated using an endovascular approach for AIOD with or without common femoral artery endarterectomy (CFE) from 2010 to 2020 was conducted. The review was limited to those with symptoms of IC. Patient- and limb-level preoperative presentations were reviewed. The outcomes were postoperative complications and patency rates in addition to freedom from re-intervention. Subgroup analyses were conducted to compare patients who underwent endovascular and hybrid procedures., Results: A total of 245 limbs in 180 consecutive patients were analyzed. The mean age was 65 years, and 61% were males. Of 176 patients, 101 (57%) had trans-atlantic inter-society consensus (TASC) class D and 18 (10%) had class C. Eleven limbs (7.4%) had access site complications, 12 (7.9%) had surgical wound complications, and below-the-knee amputation was observed in 2 limbs (0.82%) (2 patients). Two (1.0%) patients had perioperative myocardial infarction (MI), 1 (0.5%) stroke, 1 (0.5%) AKI that progressed to dialysis, and no 30-day mortality. Rutherford's classification was improved during the follow-up period. The 1-, 2-, and 5-year primary patency rates were 94%, 77%, and 58%; primary-assisted patency rates were 98%, 91%, and 79%, respectively; and secondary patency rates were 100% for all follow-up periods. Patients who had concurrent CFE were likely to have hypertension, hyperlipidemia, and anatomically more diffuse disease. No significant differences in patency or reintervention-free survival were observed, though event rates were low in both outcomes and trended toward a protective effect with CFE., Conclusions: Endovascular management for complex AIOD with or without CFE for IC patients is safe, effective, and durable. These results justify an active, patient-centered approach for this advanced anatomic disease pattern. The morbidity of a hybrid approach in the CFE subset is low, and treatment vessel patency is excellent. The presence of anatomically advanced AIOD is not prohibitive for the treatment of patients with IC; however, careful patient selection is essential., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Angiitis-induced chronic limb-threatening ischemia (AICLTI) is defined as chronic limb-threatening ischemia caused by thromboangiitis obliterans or other arteritis-related autoimmunological diseases. In the current study, we aimed to report the 10-year outcomes of AICLTI patients who underwent purified cluster of differentiation 34 positive (CD34 + ) cells (PCCs) transplantation., Methods: AICLTI patients who underwent PCCs transplantation at our center from May 2009 to September 2011 were retrospectively enrolled. The main outcome was major amputation-free survival (MAFS); other outcomes included Rutherford classification, intolerable pain-free walking time, Wong-Baker Faces Pain Rating Scale, recurrence, new lesions, quality of life and patients' posttransplantation work conditions., Results: Twenty-four patients were enrolled with a mean age of 41.5 ± 7.8 years. Three underwent major amputation during the follow-up, and the 10-year MAFS was 87.5%. Eight were observed to have recurrence, and 2 had new lesions; the 10-year recurrence-free rate was 66.1%. All patients were unable to work at admission, 17 (70.8%) patients were reemployed after transplantation., Conclusions: The current study further demonstrated satisfactory long-term efficacy of PCCs transplantation, with a 10-year MAFS of 87.5%. However, the 10-year recurrence-free rate of 66.1% suggested that strict and regular long-term follow-up is necessary., (Copyright © 2024. Published by Elsevier Inc.)

Background: Inframalleolar bypass still preserves its role in the modern endovascular era. Aim of this study was to evaluate the mid-term outcomes of "short" inframalleolar vein bypasses in patients with chronic limb-threatening ischemia (CLTI) after the previously failed tibial endovascular recanalization., Methods: Between January 2015 and December 2021,107 CLTI patients in 3 Italian Departments of Vascular Surgery underwent "short" inframalleolar vein bypass after failed tibial endovascular recanalization. Early (30-day) and 3-year outcomes were evaluated in terms of survival, primary patency, primary assisted patency, secondary patency, and amputation-free survival. Univariate analysis of the perioperative factors affecting outcomes were performed by the means of log-rank test. The associations of procedure variables were sought based on a multivariate Cox regression analysis., Results: Distal anastomosis (inframalleolar) was mostly performed on dorsal pedis (64, 59.8%). At 30 days, bypass occlusion was recorded in 5 cases (4.6%). The mean follow-up period was 20.5 ± 17.9 months. The estimated 3-year overall survival was 66.7%. Three-year estimates of primary patency, primary assisted patency, secondary patency, and amputation-free survival were 68.5%, 70.1%, 70.2%, and 76.7%, respectively. Multivariate analysis showed a negative association of insulin treatment with primary patency (HR 4.3, P = 0.04), primary assisted patency (HR 5.1, P = 0.02), and secondary patency (HR 5.1, P = 0.02). The negative association of long-term corticosteroid use was also found with primary patency (HR 7.8, P = 0.005), primary assisted patency (HR 8.7, P = 0.003), secondary patency (HR 8.7, P = 0.003), and amputation-free survival (HR 3.9, P = 0.05)., Conclusions: Short" vein bypasses to the foot arteries in CLTI patients yielded good mid-term overall patency and limb salvage rates after a failed tibial endovascular recanalization. Insulin-dependent diabetes mellitus and long-term corticosteroid use seemed to affect the outcomes., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Chronic limb-threatening ischemia (CLTI) represents the most severe form of peripheral artery disease. While previous studies have focused on gender and racial disparities, there is lack of evidence regarding the impact of housing status. The aim of this analysis was to identify disparities in inpatient management and outcomes of CLTI based on housing status., Methods: In this retrospective, descriptive study, we analyzed patients admitted with CLTI who underwent revascularization, as identified by International Classification of Diseases, 10th Revision, Clinical Modification codes, between 2016 and 2021, using the National Inpatient Sample database. The patients were stratified by their housing status and a detailed, propensity-matched analysis was conducted to compare the demographics, comorbidities, mortality rates, types of intervention, resource utilization, and inpatient outcomes., Results: During the study, 2,667,294 patients were admitted with CLTI, and 17% (463,435) underwent revascularization. Among these, 0.4% (1,790) was unhoused. Males were overrepresented in the unhoused group (83.5% vs. 62.5%, P < 0.001). Unhoused patients were more likely to receive endovascular revascularization (adjusted odds ratio [AOR] 1.77, 0.45-0.90, P = 0.003) but less likely to undergo open surgical intervention (AOR 0.64, 0.45-0.90, P = 0.010). They were also more likely to undergo aortoiliac interventions, while housed patients underwent more distal interventions. The mean adjusted length of stay was 4 days longer and inflation-adjusted costs were $8,501 higher for unhoused patients (P < 0.001). Unhoused patients were also more likely to leave against medical advice and be transferred to skilled nursing facilities., Conclusions: This study highlights significant disparities in CLTI management and outcomes between housed and unhoused patients, underscoring the need for targeted interventions to address these inequities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Pedal medial arterial calcification (pMAC) is a potential predictor of major adverse limb events (MALEs) among patients with critical limb-threatening ischemia (CLTI). This study aims to validate the prognostic value of the pMAC score in predicting major lower-limb amputation (MLLA) and need for redo revascularisation., Methods: A single-center study involving 196 patients diagnosed with CLTI, reviewed between 2012 and 2022. Patients' pMAC scores were obtained through X-ray assessments. Correlations between pMAC scores and the incidence of MALE and redo revascularization, were analyzed. A power analysis using G∗ Power 3 software determined a needed sample size of 157 participants. Statistical analysis employed SPSS 26, utilizing descriptive statistics, Chi Square, Mann-Whitney, Kaplan-Meier with log-rank test, and Cox regression for predictor identification., Results: The cohort was predominantly male (79.1%) and diabetic (59.2%). Redo revascularization need was 15.3%, increasing with pMAC scores: 3.3% (low), 24.5% (medium), and 50% (high) (P < 0.001). MLLA frequency also rose with pMAC scores: 6.7%, 27.5%, and 50% respectively (P < 0.001). Higher pMAC scores correlated with a higher incidence of MALE (P = 0.029). Multivariate analysis showed medium pMAC (hazard ratio (HR) 4.159, P = 0.002), high pMAC (HR 7.366, P = 0.015), and Global Limb Anatomic Staging System (GLASS) stage 3 (HR 3.529, P = 0.011) as independent MLLA predictors. Redo revascularization predictors included female sex (HR 2.106, P = 0.063), Black race (HR 64.498, P = 0.001), medium pMAC (HR 6.812, P = 0.002), high pMAC (HR 11.455, P = 0.008), and GLASS stage 3 (HR 2.899, P = 0.037)., Conclusions: The pMAC score effectively predicts MALE in CLTI patients and enhances risk stratification. Using both, pMAC scores and GLASS stages enhances predictive accuracy, identifying patients at higher risk for MLLA, informing clinical decision-making and therapeutic strategies., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Background: Acute upper limb ischemia (AULI) is a medical emergency with high perioperative complication rates; however, these are poorly reported. The aim of this study is to report the complication rates following surgical revascularization in AULI., Methods: Retrospective analysis of all patients undergoing brachial embolectomy for AULI from January 2010 to October 2021 was included. Data for baseline demographic characteristics, site of arterial occlusion, cancer status, and the potential underlying etiology were included. Outcomes included technical success, early reintervention, local and systemic complications, functional limb outcome at follow-up, and amputation., Results: 96 patients were identified. Computed tomography angiography was the first line diagnostic imaging modality, with the brachial bifurcation as the most common location for obstruction. The initial technical success rate was 76.4% (n = 73). Major adverse events occurred in 11.5% patients (n = 11); 8.3% had perioperative stroke and 7.3% resulted in in-hospital death (4.2% had both). Local complications occurred in 24%; 7.3% had site hematoma, 11.5% had early thrombosis, and 4.2% had 30-day thrombosis. 2.1% resulted in amputation. No variables were identified as having significant association with local surgical complications., Conclusions: AULI is often associated with underlying systemic and cardiac disorders. An evidence based approach to guide the nonoperative management of AULI is lacking. In appropriately selected patients, Fogarty thrombectomy has a reasonable technical success rate; however, the associated perioperative complication rate is high, both locally and systemically. Further studies of larger sample size are needed to identify negative predictors and reduce perioperative complications in this challenging cohort., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Background: In one-fifth of patients with chronic limb-threatening ischemia, there are no revascularization options. In those cases, venous arterialization could be a last resort for limb salvage. This study examines the clinical outcome of 17 patients with nonhealing wounds (Fontaine 4), who underwent great saphenous vein (GSV) arterialization, leaving the distal saphenous side branches open and avoiding incisions in the lower leg and foot., Methods: In this retrospective study, all the patients who underwent GSV arterialization between January 1, 2020, and October 1, 2023, were included. During the procedure, a small incision was made in the groin to identify the GSV and superficial femoral artery. The GSV was detached from the deep venous system, the upper leg side branches were ligated, and the side branches distal to the knee joint were left open to create a pressure drop. Valvulotomy of the GSV down to the foot was performed in all patients. This approach does not necessitate the use of grafts or stents so that a severely infected foot can also be treated. For this study, we have analysed the limb salvage, wound healing, and mobility after treatment and observed preoperative and postoperative skin oxygenation over a 1-year period., Results: This intervention resulted in a limb salvage rate of 46% and a secondary patency of 88% after 1 year in cases where amputation would have otherwise been necessary. Preoperative and postoperative TcPO2 measurements indicated a gradual but consistent increase in skin oxygenation in 71% of the patients with a GSV larger than 3 mm, highlighting the importance of future patient selection. All patients who successfully received arterialization achieved complete wound healing and improved mobility., Conclusions: This study introduced a promising approach to venous arterialization in patients with severe chronic limb threatening ischemia who have no other treatment options, with the potential to significantly reduce disease burden and improve quality of life., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Diabetes is strongly correlated with the development of critical limb ischemia, with a predilection for below-the-knee and below-the-ankle patterns of arterial disease. The angiosome concept, described as a potential framework for targeted revascularization in critical limb ischemia, has generated divergent opinions over the last decades. This study aims to evaluate the implication of angiosome-targeted revascularization in wound healing in diabetic patients., Methods: This is a single-center retrospective study including diabetic patients with ischemic ulcers admitted for invasive vascular study and revascularization between January and December 2019. The primary outcome was to evaluate the impact of angiosome-targeted revascularization in wound healing. Limb-based patency and amputation-free survival according to Global Limb Anatomic Staging System stage and revascularization procedures were considered secondary outcomes., Results: Data from 117 limbs of 114 diabetic patients with neuroischemic diabetic foot were evaluated. There was no significant difference between targeted and nontargeted angiosome-revascularization in wound healing at 12 months. However, angiosome-targeted revascularization was associated with shorter healing times. The severity of the infection was the only variable with an impact on healing time. Endovascular surgery did not show inferior patency to open surgery, even in patients with more complex arterial disease (GLASS III)., Conclusions: Although angiosome-guided revascularization did not demonstrate significantly higher healing rates at 12 months, there appears to be a trend toward faster healing., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Single-segment great saphenous vein (ssGSV) is the gold standard conduit for femoral-tibial bypasses in patients with critical limb-threatening ischemia (CLTI). In the absence of a good single-segment saphenous vein, alternative options are prosthetic grafts or spliced-vein (SpV) conduits. Although SpV conduits may provide better long-term patency/limb salvage, prosthetic grafts are more often the chosen conduit due to shorter operative and presumably better immediate postoperative outcomes; nevertheless, there are little data supporting this practice. In this study, we compared 30-day outcomes between SpV and prosthetic conduits in CLTI bypass using a national registry., Methods: CLTI patients who underwent lower extremity bypass using SpV or prosthetic conduits only were selected from the National Surgical Quality Improvement Program targeted database. A 1:5 propensity score matching was conducted between SpV and prosthetic groups to address preoperative differences. Thirty-day outcomes, including primary patency, reintervention, major amputation, mortality, major morbidity, transfusion, and wound complications, were compared between the 2 groups., Results: There were 886 patients who underwent femoral-tibial bypass without ssGSV (104 SpV and 782 prosthetic grafts). All SpV patients were propensity score matched to 445 prosthetic patients. SpV exhibited significantly better 30-day primary patency than prosthetic (87.5% vs 74.38%, P = 0.004). SpV was associated with significantly longer operative time (346 min vs 222 min, P < 0.001) and higher transfusion (43.3% vs 27.87%, P = 0.003), but those did not translate into higher 30-day mortality or major systemic complications. There was no difference in wound complications or 30-day limb loss., Conclusions: SpV conduit affords significantly better 30-day primary patency than prosthetic grafts without increased mortality and morbidities. Therefore, despite greater procedural complexity and longer operative time, SpV conduit should be considered when available. Future prospective studies are needed to investigate the long-term outcomes of these 2 conduits., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In the Heart Outcomes Prevention Evaluation study, investigators found that ramipril was associated with improved survival as well as decreased MI and stroke rates in patients with peripheral arterial disease. Nonetheless, their effect on chronic limb-threatening ischemia (CLTI)-specific outcomes is unclear. We aim to assess the effect of ACEIs/ARBs on amputation-free survival in patients with CLTI undergoing peripheral vascular intervention (PVI) in a Medicare-linked database., Methods: Patients undergoing PVI in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database were included. Primary outcomes included amputation-free survival. Kaplan-Meier survival and multivariable Cox regression analyses were used to assess 1-year outcomes., Results: A total of 34,284 patients were included, 46.3% of whom were discharged on ACEIs/ARBs. Patients discharged on ACEIs/ARBs were more likely to be smokers, have diabetes, and have hypertension. They were also more likely to present with rest pain. The overall 1-year survival rate for patients on ACEIs/ARBs vs those who are not was (79.1% vs 69.4%; P < .001). Freedom from amputation was 87.8% for patients on ACEIs/ARBs vs 84.2% for those who were not (P < .001). Amputation-free survival was 70.5% vs 59.5% for ACEIs/ARBs vs no ACEIs/ARBs (P < .001). After adjusting for potential confounders, ACEIs/ARBs use was associated with lower 1-year mortality (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.7-0.8; P < .001), amputation (HR, 0.89; 95% CI, 0.8-0.9; P < .001), and amputation or death (HR, 0.79; 95% CI, 0.76-0.8; P < .001)., Conclusions: ACEIs/ARBs were associated independently with lower amputation, improved survival, and amputation-free rates survival at 1 year in patients with CLTI undergoing PVI. The fact that more than one-half the patients were not discharged on these medications presents an area for potential quality improvement., Competing Interests: Disclosures None., (Published by Elsevier Inc.)

Objective: Poor glycemic control in the perioperative period has been reported to be associated with early and late major adverse limb events (MALEs). However, these studies were mostly from large databases or lacked long-term outcomes. We examined the long-term effects of high hemoglobin A1c (HbA1c) level on patency, MALE, limb salvage (LS) and survival after lower extremity revascularization procedures in patients with diabetes., Methods: Patients with diabetes who underwent revascularization for Rutherford class 3 to 6 ischemia between May 2002 and December 2018 were identified. Patients with an HbA1c of ≤7% were compared with those with an HbA1c of >7% for patency, MALE, survival, LS, and amputation-free survival., Results: Of 706 patients, 699 had HbA1c data (775 limbs), with 311 (357 limbs) in the HbA1c ≤7% and 388 (418 limbs) in the HbA1c >7% groups. Patients with an HbA1c of >7% were younger (69.9 ± 10.2 years vs 71.7 ± 9.5 years; P = .011), had higher lipid levels, insulin use (70% vs 49%; P < .01), American Society of Anesthesiologists classification of 4, and had a lower prevalence of chronic kidney disease (32% v s41%; P = .023). Patients with an HbA1c of >7% were more likely to present with chronic limb-threatening ischemia (CLTI) (79% vs 72%; P = .019) and undergo infrapopliteal interventions (49% vs 42%; P = .005), with no difference in anatomical complexity (TransAtlantic Inter Society Consensus class C/D, 75% vs 77%; P = .72) or type of revascularization (24% vs 18% open, 66% vs 70% endovascular, 10% vs 12% hybrid; P = .236). Patency and freedom from MALE were significantly lower in patients with an HbA1c of >7% for infrainguinal revascularizations, whereas amputation-free survival and overall survival were similar. In patients with chronic limb-threatening ischemia, LS rates at 5 years were significantly lower in patients undergoing open revascularization (HbA1c > 7%: 64% ± 6% vs HbA1c < 7%:86% ± 5%; P = .020), whereas it was similar after endovascular interventions (HbA1c > 7%:79% ± 4% vs HbA1c < 7%:77% ± 3%; P = .631). Seventy patients with an HbA1c of >7% lost limbs vs 38 patients with an HbA1c of ≤7% (P = .007). In multivariate analysis, HbA1c was associated significantly with primary patency. HbA1c, insulin use, level of intervention, and angiotensin-converting enzyme inhibitor use were associated with MALE., Conclusions: A perioperative HbA1c of >7% is associated with poorer patency rates and increased MALE, especially at the infrainguinal level revascularization in patients with diabetes, with no significant impact on survival. LS is impacted after open, but not after endovascular revascularization., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Developed by the Global Vascular Guidelines committee, the Global Limb Anatomic Staging System (GLASS) is an angiographic scoring system used for quantifying infrainguinal disease extent and predicting treatment success with endovascular techniques (EVT). Currently, no other risk prediction model is available for patients with chronic limb threatening ischemia (CLTI) undergoing EVT. GLASS' validation and adoption outside academic institutions for research are limited. Thus, this longitudinal multicenter prospective study aims to examine GLASS' validity and reliability in predicting major acute limb events and overall survival (OS) in patients with CLTI undergoing EVT., Methods and Analysis: This prospective, international, multicenter, observational study will include patients with CLTI undergoing EVT (PROMOTE-GLASS) (ClinicalTrials.gov; ID: NCT06186544) identified through routine clinical referrals and emergency visits to vascular units in participating centers. Only patients who are referred for EVT will be recruited. The primary outcomes are immediate technical success, immediate technical failure, and 1-year limb base patency. The secondary outcomes are major adverse limb events, major lower limb amputation, and OS in patients presenting with CLTI who undergo EVT up to 1 year after the procedure. Clinical and imaging data will be analyzed at the end of follow-up to validate risk prediction. This protocol outlines our approach for identifying cases, GLASS score calculation, outcome measures assessment, and a statistical analysis plan., Anticipated Implications: PROMOTE-GLASS holds significant implications and can potentially revolutionize clinical decision-making by assisting clinicians in identifying patients who are likely to benefit from EVT. Ultimately, reduce the need for more invasive procedures and improve patient outcomes. Furthermore, PROMOTE-GLASS can provide useful information, including patient selection, for future randomized controlled trials (RCTs) investigating EVT for CLTI. PROMOTE-GLASS anticipated implications on the vascular community are rooted in its potential to improve patient care, inform future research, and address limitations in existing literature regarding CLTI treatment outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Optimal medical therapy (OMT) is a modifiable factor that decreases mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized that preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates after elective endovascular revascularization for intermittent claudication (IC)., Methods: Using the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and nonsmoking status defined OMT components and created three groups: complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR)., Results: There were 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2127 [5.4%] no OMT) who met our criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (P < .0001). Patients without OMT were more likely to be Black or with Medicare or Medicaid (P < .05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; P < .001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; P < .001) were decreased by partial or complete OMT compared with no OMT. Complete OMT significantly decreased the adjusted odds of reintervention and MALE by 28% (aOR, 0.72, 95% confidence interval [95% CI], 0.59-0.88) and 30% (aOR, 0.70; 95% CI, 0.58-0.85), respectively, compared with no OMT. Partial OMT decrease the adjusted odds of reintervention and MALE by 24% (aOR, 0.76; 95% CI, 0.63-0.92) and 26% (aOR, 0.74; 95% CI, 0.62-0.89), respectively., Conclusions: Preintervention OMT is an underused, modifiable risk factor associated with improved 1-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC before revascularization to optimize patient outcomes., Competing Interests: Disclosures None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: To review the current literature and establish a consensual recommendation on duplex ultrasound (DUS) surveillance after endovascular treatment of the femoropopliteal tract., Methods: This systematic review conducted literature searches on DUS surveillance after endovascular treatment of the femoropopliteal tract, and event rates. The primary end point was primary assisted patency. Secondary end points were primary patency, secondary patency, and limb salvage for double-armed studies, and sensitivity and specificity of DUS compared with other surveillance methods for single-armed studies. PubMed, Embase, and the Cochrane Library were searched. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Articles were eligible if they compared DUS surveillance others surveillance methods. Prospective, large cohort studies reporting on long-term events after endovascular treatment were also included., Results: The initial search resulted in 5 studies. Only one double-armed nonrandomized study compared DUS surveillance with ankle-brachial index (ABI) follow-up after femoropopliteal stenting. The DUS group demonstrated improved primary assisted patency (84% vs. 76% at 12 months and 68% vs. 38% at 36 months, P = 0.008) and limb salvage (97% vs. 83% at 12 months and 90% vs. 50% at 36 months, P < 0.001) compared with ABI follow-up. In one single-armed study, DUS surveillance showed a high sensitivity (91%) and specificity (100%) in detecting restenosis. ABI and clinical follow-up demonstrated a low sensitivity (55-67% and 52-64%, respectively) but reasonable specificity (80-85% and 82-88%, respectively) in detecting restenosis., Conclusions: The scarce available evidence suggests a clinical benefit of DUS surveillance after endovascular treatment of the femoropopliteal tract., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In 2021, Ferraresi et al. created a novel scoring system based on the impact of small artery disease (SAD) and medial arterial calcification (MAC) on wound healing. SAD and MAC scores functioned similar to Wound, Ischemia, and foot Infection (WIfI) but with minimal resource expenditure. Despite its potential, few studies have expanded on the original dataset. We aim to validate SAD's impact and MAC's impact on wound healing outcomes and determine their utility in relation to current predictive models., Methods: Single-institution retrospective review was used to identify amputations for chronic (>1 month) podiatric wounds between 2015 and 2020. Foot X-ray (MAC) or angiography (SAD) < 6 months of index procedure was required. Primary outcomes included major amputation, wound healing, major adverse limb events, and amputation-free survival (AFS). Statistical analysis included chi-squared, 1-way analysis of variance, nonparametric correlation, Kaplan-Meier, Cox regression, and Akaike/Bayesian Inclusion Criteria model comparison., Results: Of 136 limbs, 67 received SAD scores (0-2) and 128 received MAC scores (0-2). SAD cohorts exhibited similar comorbidity profiles with exception of coronary disease, heart failure, and chronic kidney disease. MAC cohorts were notably disparate in prevalence of multiple conditions. High mean SAD/MAC scores were seen in severe (3-vessel) below-ankle disease (P = 0.001∗ [SAD], P = 0.041∗ [MAC]). Both SAD and MAC correlated with lower mean toe pressure (P = 0.043∗ [SAD], P ≤ 0.001∗ [MAC]), while only MAC correlated with higher overall WIfI score (P = 0.029∗). No significant procedural differences were noted. However, higher readmission rates (73.9% [2] vs. 46.9% [0], P = 0.014∗) and all-cause mortality (65.2% [2] vs. 26.0% [0], P = 0.002∗) were noted with higher MAC. Survival analysis revealed higher 1-year major amputation rates (P = 0.036∗), impaired wound healing (P < 0.001∗), and lower AFS (P = 0.001∗) with increasing MAC severity. Additionally, MAC-2 patients underwent amputation at faster rates than MAC-0 patients (hazard ratio 5.25, 95% confidence interval [1.82, 9.77]) with longer times to wound healing (hazard ratio 0.21, 95% confidence interval [0.08, 0.53]). Model comparison suggested a combination of WIfI and MAC could improve accuracy of predicted time to major amputation, wound healing, and AFS., Conclusions: MAC scoring showed significant promise both as individual predictor and adjunct to current predictive models of long-term wound healing outcomes. Routine use of MAC scoring in chronic limb-threatening ischemia evaluation, especially when noninvasive testing is unavailable, could promote timely referral for intervention and efficient resource utilization in limited-resource or critical care settings. Furthermore investigation is necessary to determine MAC's impact on revascularization and how scoring can be used to guide surgical decision-making., (Published by Elsevier Inc.)

Background: Acute limb ischemia (ALI) is a morbid and deadly diagnosis. However, existing epidemiologic studies describing ALI predate the introduction of the Affordable Care Act in 2010 and direct oral anticoagulants in 2011. Thus, we synergized the National Inpatient Sample (NIS) and United States Census to define contemporary trends in the incidence, treatment, and outcomes of ALI in the US., Methods: We included emergent admissions of adults with primary diagnosis of lower extremity ALI in survey-weighted NIS data (2005-2020). Mann-Kendal trend test evaluated ALI incidence (primary outcome), anticoagulation usage, insurance coverage, revascularization type, and in-hospital amputation/death. Multivariable logistic regression quantified covariate associations with in-hospital amputation/death., Results: Of the 582,322,862 estimated hospitalizations in the NIS, 227,440 met the inclusion criteria (mean age 68.80 years, 49.94% women, 76.66% White). ALI incidence peaked in 2006 (7.16/100,000 person-years) but has declined since 2015 to 4.16/100,000 person-years in 2020 (p trend  = 0.008). Endovascular revascularization, anticoagulation, and Medicaid coverage increased, while self-pay insurance decreased (p trend < 0.05). Amputation rates significantly decreased from 8.04 to 6.54% (p trend  = 0.01) while death rate remained at 5.59% (p trend  = 0.16) over the study period. Prehospitalization anticoagulation was associated with decreased amputation (adjusted odds ratio [aOR] = 0.74 (95% confidence interval [CI] 0.65-0.84)) and death (aOR = 0.50 (95% CI 0.43-0.57)). When controlling for covariates, women had a higher risk of death (aOR = 1.17 (95% CI 1.07-1.27), P < 0.0001), while Black patients had a higher risk of amputation (aOR = 1.24 (95% CI 1.10-1.41), P < 0.0001)., Conclusions: Our US population based epidemiological study demonstrates that ALI incidence and in-hospital amputation rates are decreasing, while mortality remains unchanged. We further highlight the ongoing need for ALI investigation specifically as it relates to access to care, antithrombotic therapy use, treatment strategy, and strategies to combat gender and racial disparities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Reports of large series of hybrid iliofemoral revascularization for chronic lower limb ischemia are scarce. The aims of this study were to evaluate outcomes for staged and nonstaged procedures, and to evaluate risk factors for outcomes at 90 days., Methods: Patients were consecutively included between 2013 and 2023. Surgical site infection (SSI) was defined by the ASEPSIS criteria and major adverse limb events (MALE) as onset of acute or continuing or worsening chronic limb ischemia or major amputation. Factors associated with outcomes were tested in a multivariable logistic regression analysis and expressed in odds ratios (ORs) with 95% confidence intervals (CIs)., Results: Patients undergoing nonstaged procedures (n = 124) had higher Trans-Atlantic Inter-Society Consensus (TASC) class representing anatomical occlusive complexity, more often through-and through femoral guidewire access, more endoprosthesis, more covered stents, longer procedure time with open groin wounds, and less contralateral femoral access, than those undergoing staged procedures (n = 31). The median time interval between the staged procedures was 1 day, and iliac stenting was done first in 77%. The median in-hospital stay was nonsignificantly longer in staged procedure (8 vs. 6 days, P = 0.053). The overall SSI and MALE rates were 25.8% and 20.0%, respectively, without differences between groups. Diabetes mellitus (OR 3.7, 95% CI 1.2-7.2]) and presence of a foot ulcer (OR 3.7, 95% CI [1.5-9.4]) were independently associated with MALE at 90 days. Postoperative hyperglycemia was nonsignificantly associated with SSI (OR 2.1 (95% CI 1.0-4.5), P = 0.066) in multivariable analysis., Conclusions: The risks of SSI and MALE after elective hybrid iliofemoral revascularization were high. There appears to be no benefit in performing staged as opposed to nonstaged procedures. The extent of iliofemoral occlusive disease according to the TASC classification had little influence on outcomes whereas diabetes mellitus and presence of a foot ulcer had greater impact on MALE., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Ilizarov technology is highly effective in addressing complex orthopedic challenges. This study aims to describe our experience with distraction osteogenesis in managing bone tumors in the lower extremity, focusing on composite bone defects and associated complications., Methods: A retrospective clinical study was conducted to analyze patients with primary bone tumors who underwent distraction osteogenesis using the Ilizarov method from 2010 to 2020. Some young children received epiphyseal distraction and bone transport as part of their sarcoma surgical treatment. Additionally, external fixation, bone transport, or limb lengthening were employed to address complex postoperative complications associated with bone tumors. The clinical outcomes assessed included the patient's general information, the location of bone defects, the length of bone repair, the status of bone healing, and limb function., Results: Eleven patients were followed up for an average of 66 months (range, 24-132 months). The average length of repaired bone defects was 13 cm (range, 2.5-32 cm). The cohort comprised three females and eight males, with ages at presentation ranging from 6 to 42 years (mean, 18 years). The sites of involvement included the distal femur (n = 4), femoral diaphysis (n = 3), proximal tibia (n = 2), and the distal tibia (n = 2). Nine patients were diagnosed with osteosarcoma, while one presented with Ewing's sarcoma and another with a giant cell tumor of bone. Three young children were successfully treated with epiphyseal stretching; however, one patient experienced treatment failure. Additionally, seven patients underwent external fixation to address complex postoperative complications, including infection, bone defects, and limb shortening. At the last follow-up, with the exception of one failure, the average Musculoskeletal Tumor Society (MSTS) limb function scores for the remaining 10 patients were 25 (range, 21-30). Three months post-fixator removal, the Asociación Latinoamericana de Oncología (ASAMI) bone score was rated as excellent in 63.6% (7/11) of patients, whereas the ASAMI function score was excellent in 36.4% (4/11) and good in 54.5% (6/11) of cases., Conclusion: The Ilizarov method demonstrates some clinical value in the resection and reconstruction of bone tumors, as well as in the management of postoperative complications associated with such tumors., (© 2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Background: Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease (PAD). Patients with diabetes mellitus (DM) have a faster progression of PAD and a fourfold increased risk of CLTI compared to patients without DM. Epidural spinal cord stimulation (SCS) has been used as a method to improve microcirculation, relieve ischemic pain and reduce the number of amputations in patients with PAD. This is a retrospective small cohort analysis of patients with diabetes and the long-term treatment effect of spinal cord stimulation., Methods: As the main outcome of the study, we evaluated the survival and amputation of 13 diabetic patients with chronic lower-limb ischemia who were not eligible for surgical or interventional therapy. Secondary outcomes included ankle-brachial index (ABI), ischemic pain intensity, quality of life, use of analgesic medications and skin wound outcomes analyzed during long-term follow-up., Results: Between January 2010 and January 2017, 13 patients underwent SCS implantation in our vascular center. At 1-year follow-up, the limb salvage rate was 92.3% (12 of 13 patients), and limb ulcers healed in 75% of patients (6/8). No patient died during the one-year follow-up. A total of 4 of patients (31%) experienced major amputation during long-term follow-up, all of them were Fontaine stage IV. Pain intensity and quality of life improved significantly at 6-month follow-up ( p  < 0.05). ABI measurements were unaffected by SCS treatment. There were no complications related to the procedure or device., Conclusions: SCS is a promising treatment option for diabetic patients unsuitable for endovascular or surgical revascularization. The method improves limb survival in diabetic patients with critical limb ischemia, provides significant pain control, and improves patients' quality of life. However, more studies are needed to clarify the indications for SCS and clarify its effects on the vascular system., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Cyrek, Koch, Pacha and Radunz.)

Objective: Diabetic foot ulcer (DFU) is a common complication in patients with diabetes. With current treatment, only two-thirds of patients heal, with a median duration of 3-6 months. Hard-to-heal DFUs are a major source of morbidity and mortality. Improving wound healing via soft tissue reconstruction may be the key to improving clinical outcomes. Thus, the Diabetic Limb Salvage (DLS) service in Sengkang General Hospital, Singapore, was established to provide patients with a streamlined, one-stop, comprehensive service dedicated to DFU soft tissue reconstruction. The reconstruction was carried out using secondary closure, skin grafting, local flaps or free flaps, depending on the severity of the wound and patient suitability. This study aims to audit the early outcomes of the DLS service., Method: Patients with DFUs treated by the DLS service were compared with patients with DFUs treated prior to the launch of the DLS service (control). Outcomes including major and minor amputation rates, wound healing rate, mortality and DFU recurrence rates were analysed statistically., Results: A total of 103 patients took part in the study (50 in the DLS service cohort and 50 in the control cohort). There was no significant difference in demographics, comorbidities and wound profiles between the two cohorts. All (100%) patients in the DLS service cohort received soft tissue reconstruction versus only 13% in the control group. The DLS service cohort had a significantly higher healing rate (96% versus 68%, respectively), shorter healing duration (77±30 days versus 111±43 days, respectively), reduced major amputation rate (0% versus 9%, respectively), and reduced recurrence rate (6% versus 25%, respectively) compared with the control cohort within the one-year follow-up., Conclusion: The findings of this study showed that an orthoplastic multidisciplinary approach focused on DFU soft tissue reconstruction improved wound healing rates, shortened healing duration and, as a result, lowered amputation rates and reduced recurrence.

End-stage renal disease is an independent risk factor for the development of peripheral arterial disease, with considerably worse outcomes in patients with concomitant diseases. It is important to realize the widespread, yet frequently asymptomatic, nature of peripheral arterial disease in patients with end-stage renal disease due to the presence of other comorbidities that decrease activity levels and sensation to allow for early recognition and timely medical management to try and mitigate otherwise poor outcomes. Despite their high risk, properly selected patients derive benefit from revascularization; both open and endovascular approaches provide similar outcomes in terms of overall survival, amputation-free survival, and limb salvage, with perhaps a slight preference toward open repair. This narrative review of the literature evaluates the epidemiology, pathophysiology, outcomes, and management strategies that provide the best possible outcomes for patients with peripheral arterial disease and end-stage renal disease., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In lower extremity sarcoma treatment, limb salvage approaches present superior alternatives to amputation due to reduced postoperative morbidity and improved quality of life. This study provides a novel analysis of socioeconomic disparities that may affect reception of limb-sparing surgery., Methods: Patients with lower extremity bone or soft tissue sarcoma who received either limb-sparing surgery or amputation from 2007 to 2021 were identified in the Surveillance, Epidemiology and End Results (SEER) database. Demographic, socioeconomic, and oncologic variables were collected for each patient. Multivariate binary logistic regression was conducted to assess preoperative demographic and oncologic risk factors for amputation (p < 0.05)., Results: A total of 6465 patients were identified in the final cohort, 586 (9.1%) of whom received amputation. After controlling for tumor size, stage, and neoadjuvant therapy administration, non-Hispanic American Indian/Alaskan Native race/ethnicity predicted the highest odds of amputation (OR: 1.78, 95% CI: 1.12-2.85, p = 0.015). Nonmetropolitan residence (OR: 1.69, 95% CI: 1.43-2.00, p < 0.001) also conferred higher risk of amputation compared with residence in a large metropolitan area. Overall, amputation was associated with a higher risk of ten-year cancer-specific mortality (p < 0.001) even when controlled by sociodemographic and clinical characteristics., Conclusions: There are significant disparities in limb-sparing surgery and amputation rates in lower extremity sarcoma management, even when accounting for differences in baseline oncologic characteristics. Further study into socioeconomic drivers of these trends will allow the development of initiatives that improve disparities in reconstructive outcomes., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Patients with chronic limb-threatening ischemia (CLTI) and infected leg ulcers are at risk of amputation and postinterventional sepsis., Methods: This retrospective, single-center study included patients with CLTI and infected leg ulcers who underwent endovascular treatment (EVT) between 2012 and 2021., Results: The study included 712 patients, 286 (40.2%) of whom underwent amputation (minor, n = 212; major, n = 74). Gram-negative bacteria (GNB) were significantly more prevalent in amputees (36.4% vs 30.9%, p < 0.05). Patients with gram-positive bacteria (GPB) had a 4-year freedom from any amputation rate of 72% (95% CI 64-81%) compared to 52% (95% CI 42-66%) in patients with GNB identification ( p < 0.05). Cox proportional regression analysis showed that GNB, male sex, mean Wound, Ischemia, and foot Infection (WIfI) score, diabetes mellitus, and end-stage renal disease were independently and positively associated with amputation ( p < 0.05). The mean WIfI score and end-stage renal disease were independently and positively associated with death from any cause ( p < 0.05). Staphylococcus aureus or GNB, end-stage renal disease, and diabetes mellitus were independent risk factors for sepsis after EVT ( p < 0.05). Inpatient-administered antibiotic regimes had significantly higher microbiological activity in cases of GPB identification compared to GNB identification (28% vs 9%, p < 0.05)., Conclusion: Although the isolation of both GNB and S. aureus is a risk factor for sepsis following EVT, the isolation of GNB is independently associated with higher rates of amputation, demonstrating the importance of identifying pathogens to recognize patients at high risk., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: In peripheral arterial disease, patency, limb salvage, and survival rates are mostly reported using Kaplan-Meier analyses. When comparing different revascularisation techniques, these methods have limitations in analysing complex patient flows over time. This study aimed to present, illustrate, and discuss new concepts based on multistate models of analysing outcome parameters in peripheral arterial disease., Methods: Previously published data from a single centre, randomised controlled trial (RCT) with 218 cases that underwent either vein bypass surgery (bypass group, n = 109) or nitinol stent angioplasty (stent group, n = 109) of long femoropopliteal lesions were re-analysed using non-homogeneous Markov models. A step by step description of the concepts of states, state space, definitions, and illustration of transition probability curves as well as the benefits of multistate models is given. The RCT was registered at ISRCTN.com (ISRCTN18315574)., Results: Transition probability curves over time showed similar patterns in the bypass and stent groups. Significant differences in the transition probabilities were found for transitions from primary patency as well as secondary patency to end of patency. The transition probability for patients with preserved primary patency at 24 months who moved to end of patency at 48 months was 19.9% in the stent group vs. 6.4% in the bypass group (p < .001)., Conclusion: The proposed method can answer important questions, such as: Did patients after femoropopliteal stenting with preserved primary patency at two years lose their patency more quickly within the following years compared with bypass surgery? And did stent patients after a re-intervention to maintain patency at one year lose their patency more quickly compared with bypass surgery within the following years? Completely new research questions can now be raised and answered to optimise treatment and follow up strategies; this might lead to better identification of subgroups at higher risk of clinical deterioration following revascularisation procedures., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Isolated limb infusion (ILI) treats unresectable extremity malignancies with high-dose regional chemotherapy limited to the limb. This study assessed long-term outcomes after ILI for limb-threatening sarcomas., Methods: A retrospective review analyzed patients with an extremity sarcoma who underwent ILI with melphalan and dactinomycin from 2008 to 2023 at a single institution., Results: The study identified 61 patients (52.5% female; median age, 73 years; range, 20-94 years). Of these patients, 68.9% had lower-extremity disease. The median follow-up period was 6.9 years. The overall response rate was 48.3% (complete response [CR], 21.7%; partial response [PR], 26.7%), and the disease control rate (DCR: CR + PR + stable disease [SD]) was 65%. The median progression-free survival (PFS) for the patients with CR/PR/SD/progressive disease (PD) was respectively 16.8/9.6/4.8/2.4 months (P < 0.0001). The responders (CR + PR) had significantly longer PFS than the non-responders (SD + PD) (hazard ratio [HR], 6.3; 95% confidence interval [CI], 3.1-12.9; P < 0.001). The median in-field PFS times for CR/PR/SD/PD were respectively 16.8/12/4.8/2.4 months (P < 0.001). The responders had a significantly longer risk of in-field PFS than the non-responders (HR, 5.9; 95% CI 2.9-12.0; P < 0.001). The median distant relapse PFS for CR/PR/SD/PD was not reached (NR)/NR/44.4/40.8 months (P = 0.02). The responders had a significantly longer distant relapse PFS than the non-responders (HR, 2.7; range, 1.1-6.8; P = 0.04). The median overall survival (OS) was 8.6 years for the responders and 4.1 years for the non-responders (P = 0.02). The disease-specific survival (DSS) rates were 87% at 1 year, 71% at 3 years, and 64% at 5 years. The median DSS was not reached for the responders and was 4.1 years for the non-responders (P = 0.003). The limb salvage rates at 6 months were 85% at 1 year, 80% at 3 years, and 70% at 5 years. The patients with PD had a higher risk of requiring amputation than the patients with CR + PR + SD (HR, 3.0; 95% CI 1.0-8.7; P = 0.04)., Conclusions: The 5-year limb salvage rates after ILI are notably high, reaching 70%. After ILI, the responders had significantly better in-field and distant relapse PFS, OS, and DSS., (© 2024. Society of Surgical Oncology.)

Objective: Nutritional status plays a complex role in the pathophysiology and outcomes of chronic limb threatening ischaemia (CLTI). Undernutrition may be a modifiable risk factor. Given the variability in nutritional status concepts in CLTI outcomes studies, a systematic review examining the association between undernutrition and outcomes in patients with CLTI was conducted., Data Sources: A systematic literature search of nine databases (Allied and Complementary Medicine Database [AMED], CINAHL Complete, Cochrane Library, Google Scholar, Ovid Medline, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection databases) was conducted up to 23 May 2023., Review Methods: Inclusion criteria were randomised controlled trials, cohort studies, and case control studies of patients with CLTI conducted after 1982 that reported the effect size for a nutritional status measure and the outcomes of death, amputation, or a composite of the two. Two reviewers independently performed screening, data extraction, and quality assessment, with a third independent reviewer resolving conflicts., Results: A total of 6 818 citations were screened, with 49 observational studies (31 from Japan) included in the review. The mean patient age ranged from 56.0 - 86.9 years. Most included patients were undergoing revascularisation. Unidimensional indicators of undernutrition (including low serum albumin, low body mass index, and zinc deficiency) as well as multidimensional measures (such as nutritional screening tool scores indicating undernutrition) were found to be associated with a statistically significant increased risk of death, amputation, and composite events in most studies. Effect sizes of the association were generally larger when multidimensional nutritional screening tools were used. However, the quality of evidence was poor, and certainty of evidence very low., Conclusion: Undernutrition is consistently associated with an increased risk of death and amputation in patients with CLTI, regardless of the measure used. Broader efforts to understand the framework of nutritional status and validation of nutritional screening tools in CLTI populations are needed., (Copyright © 2024. Published by Elsevier B.V.)

Background: When dealing with complex femoropopliteal lesions, there is a growing preference for the utilization of drug-coated balloons (DCBs) or stents. However, in real-world scenarios, a greater number of elderly patients with longer lesion lengths are encountered. The purpose of our study was to compare the efficacy and safety of different interventional strategies, including the utilization of Supera stent and DCB, in a real-world setting., Methods: This was a retrospective study that collected treatment and follow-up data of patients with complex femoropopliteal artery lesions treated between January 2019 and March 2022. All patients were categorized into 3 groups: "non-Supera stent group," "Supera stent group," and "Supera stent + DCB group." The primary effectiveness outcome was primary patency at 12 months, defined as duplex ultrasound peak systolic velocity ratio < 2.5 at the 12-month visit. Other outcomes included improvements in Rutherford categories and safety., Results: A total of 162 patients were enrolled in this study. Compared with non-Supera group (47.6%) in the primary patency rate at 12 months, Supera group (58.7%) or Supera + DCB group (60.0%) showed no significant difference. There were no significant differences in all-cause death, major amputation of the target limb, and target lesion revascularization between the groups. Supera group showed a significant improvement in Rutherford category without target lesion revascularization at 12 months compared with non-Supera group (73.3% vs. 54.8%, P = 0.041). In 12-month follow-up, more than 65% of patients maintained a Rutherford category of 3 or in the following, particularly in Supera group where 74.7% of patients had mild symptoms., Conclusions: The Supera stent has demonstrated its efficacy and safety in treating complex peripheral artery disease. However, combining Supera stent with DCB did not provide a significant advantage. Furthermore research is necessary to validate these findings in a larger patient population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Premature peripheral arterial disease (PAD) (age ≤50 years) has been shown to negatively impact the outcomes of lower extremity revascularization (LER). Patients with premature PAD have an increased risk of major amputation compared with older patients. The primary goal of this study is to compare the frequency of reinterventions after LER in patients with premature PAD to their older counterparts with common age of presentation (ie, 60-80 years)., Methods: A retrospective review of consecutive patients undergoing LER for PAD in a single center was performed. Clinical, procedural, and socioeconomic characteristics were compared between patients with premature PAD and the older group. Perioperative and long-term outcomes were captured and compared including mortality, major amputation, reintervention rate and frequency, as well as major adverse limb events., Results: There were 1274 patients who underwent LER (4.3% premature, 61.8% age 60-80). Patients with premature PAD were more likely to be females of racial minorities. Notably, the mean Distressed Communities Index score was significantly higher in the premature PAD group compared with the older patients. Patients with premature PAD were significantly more likely to have end-stage renal disease but less likely to have hypertension, hyperlipidemia, and coronary artery disease compared with older patients. There was no significant difference in perioperative complications. After a mean follow-up of 5 years, patients with premature PAD were significantly more likely to undergo more frequent reinterventions compared with older patients. Kaplan-Meier curves showed similar overall survival and major adverse limb event-free survival between the two groups., Conclusions: Patients with premature PAD are likely to undergo more frequent reinterventions after initial LER and have similar 5-year survival curves compared with patients at least 20 years older. Demographic and socioeconomic differences impacting patients with premature PAD, even in this relatively underpowered institutional experience, are striking and warrant further investigation., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: A team approach for treatment of patients with CLTI is used worldwide. However, the quality of team medicine is a concern. The Global Vascular Guidelines provide recommendations for high quality team medicine, but there is limited knowledge of the significance of team quality in CLTI treatment. The objective of this study is to evaluate the effects of team quality on clinical outcomes after infrapopliteal bypass., Methods: A retrospective analysis was performed in 337 patients who underwent 414 infrapopliteal bypasses under a team medicine approach at a single center between 2009 and 2021. In 2017, team medicine was reorganized for improvement of quality. Comparisons were made between before (Group 1; 160 patients, 195 limbs) and after (Group 2; 177 patients, 219 limbs) reorganization. The primary endpoints were limb salvage and wound healing after infrapopliteal bypass., Results: The patients included 227 males (67%) and had a median age of 76 [68-83] years. Diabetes mellitus was present in 67% and end-stage renal disease with hemodialysis in 37%. The follow-up rate was 96% in a mean follow-up period of 31±30 months. The 3-year limb salvage rate was significantly lower in Group 1 (before reorganization) than in Group 2 (after reorganization) (84% vs 95%, p = .001). The wound healing rates in the whole cohort were 72% at 6 months and 85% at 12 months, with no significant differences between the groups. In multivariate analysis, the risk factors for major amputation were treatment before reorganization (HR 2.68; p = .017), hemodialysis (HR 2.27; p = .017), and non-ambulatory status (HR 2.63; p = .005)., Conclusions: A reorganized team approach with the goal of higher quality was independently associated with reduced major amputation for patients with CLTI treated with infrapopliteal bypass. This result indicates the importance of a high quality team approach for success of this treatment., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This systematic literature review compares the clinical outcomes of heparin-bonded expanded polytetrafluoroethylene with autologous saphenous vein in the management of patients undergoing below-the-knee bypass to treat peripheral arterial disease., Methods: An electronic literature search was conducted in MEDLINE and Embase to identify comparative studies in patients who underwent below-the-knee surgical bypass. Studies were screened at abstract and full text review using predefined inclusion criteria by two independent reviewers and critically appraised for risk of bias. Meta-analyses were conducted using Review Manager 5 software (Nordic Cochrane Centre)., Results: Eight retrospective cohort studies were identified. Meta-analysis of primary patency demonstrated no significant difference between heparin-bonded expanded polytetrafluoroethylene and autologous saphenous vein grafts after 1 (odds ratio: 0.91, 95% confidence interval: [0.52-1.59]; P = .74), 2 (1.12 [0.60-2.10]; P = .77), 3 (0.62 [0.26-1.48]; P = .28), and 4 years (0.70 [0.36-1.39]; P = .31). Similarly, for secondary patency, no significant difference was detected at 1 (0.62 [0.33-1.15]; P = .13), 2 (0.83 [0.32-2.13]; P = .69), 3 (0.60 [0.27-1.32]; P = .20), and 4 years (0.66 [0.32-1.36]; P = .26). There was no significant difference between autologous veins and heparin-bonded expanded polytetrafluoroethylene for limb salvage and mortality at all time points. A sensitivity analysis to compare outflow vessels was conducted in only tibial bypass and identified no differences. All analyses were considered at high-risk bias because of heterogeneity in study populations and attrition in follow-up., Conclusions: This meta-analysis demonstrates similar outcomes between autologous saphenous vein and heparin-bonded expanded polytetrafluoroethylene for patency, limb salvage, and mortality through 4 years. The use of heparin-bonded expanded polytetrafluoroethylene synthetic grafts is a satisfactory option to prevent amputation, particularly when autologous saphenous vein grafts are not available. Controlled clinical studies are needed to further inform future decision-making and economic modeling related to the choice of conduit for below-the-knee graft construction., Competing Interests: Disclosures D.J.D. is a clinical investigator for Gore Medical. F.O. is a former employee of W. L. Gore and Associates. R.F.N is on the WL Gore Scientific Advisory Board., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: In some patients, revascularization is not possible or is not effective. For these, percutaneous deep vein arterialization (p-DVA) could be considered an alternative treatment. The aim of this study is to evaluate the long-term results of an intravascular ultrasound (IVUS)-guided technique that has only one percutaneous access., Materials and Methods: This is a prospective monocentric study on 18 no-option CLTI limbs treated with an IVUS-guided p-DVA. The primary outcome measures are: the freedom from major adverse events (MAEs) and survival at 30 days; limb salvage and amputation free survival (AFS) at 30 days, 6 months, 12 months and 24 months. The secondary outcome measures are: procedural success, survival, patency and wound healing., Results: We treated 14 patients with no-option CLTI, carrying out 18 p-DVA. Median age was 74,4 years (60-87). All these patients had a previous failed angioplasty of the tibial and foot arteries. Procedural success rate, defined as the establishment of arterial flow into the venous system of the foot, was 100%. No deaths and MAEs recorded at 30 days. Survival was 100%, 83.4% and 77.8%; limb salvage was 88.9%, 77.8% and 77.8%; AFS was 88.9%, 61.1% and 55.6% at 6, 12 and 24 months. Complete wound healing was 18.7% at 6 months, 80.0% at 12 months and 100% at 24 months., Conclusion: Based on these results, the IVUS-guided p-DVA seems to be safe and effective for no-option CLTI patients, with no mortality related to the intervention, an acceptable limb salvage rate and amputation free survival., Competing Interests: Declarations. Conflict of interests: Following potential conflicts of interest with respect to the research, authorship and/or publication of this article. Consent for publication: Consent for publication was obtained for every individual person’s data included in the study. Concise and informative title: This study is a prospective monocentric study, on a continuous series of 18 limbs, to evaluate the safety and the efficacy of p-DVA, obtained by the off-the-shelf PiPeR-technique, to treat no-option CLTI patients. The different end-points are evaluated at 30-days, 6-months, 12- months and 24-months Ethical Approval: All procedures were in accordance with the ethical standards of the Institutional and/or National Research Committee (the study received the approval of the Verona-Rovigo Ethical Committee, n°6106, 30.01.2020) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent: Informed consent was obtained from all individual participants included in the study., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

Background: There is a general agreement that arterial calcification affects the results of endovascular therapy for peripheral arterial disease (PAD). In addition to lacking evidence for their impact, existing calcification scores are complex, and not practical in everyday decision making. The global limb anatomic staging system (GLASS) adopted dichotomous grouping of calcification grades., Objective: In this study we aim to investigate the impact of peripheral arterial calcification scoring after dichotomous grouping on midterm outcomes following endovascular therapy for PAD., Methods: This prospective study included all consecutive patients with PAD indicated for endovascular therapy procedure who presented to our tertiary referral center in the period between October 2020 and October 2021. Patients were grouped into Group A ( n = 40): with no-to mild calcification (PACSS grade 0,1 and 2), and Group B ( n = 53): with severe calcification (PACSS grades 3 and 4). Primary endpoints included technical success rate, primary patency rates, and major adverse limb events rate (MALE) during 2 years of follow-up., Results: The mean age of the studied cases ( n = 93) was 59.31 ± 6.46 years (range 50-75). 70 patients (75.3%) were males, and 23 (24.7%) were females. There was no statistically significant difference between the two groups regarding technical success rate (97.5% in group A versus 94.33% in Group B , p = .457). The Primary patency rate after 1 year was lower in group B (74%) compared to group A (89.7%), but this difference was not statistically significant ( p = .059). However, the 2-year primary patency rate was significantly lower in group B compared to group A (64% versus 84.6% respectively, p = .034). MALE rate after 2 years was significantly higher in group B (28%) as compared to group A (10.4%), P = .048. Studying suspected risk factors revealed that severe calcification was more common in patients with ischemic heart disease (34%) and chronic kidney disease (11%), P= .003 and .002 respectively. Logistic regression analysis showed that patients suffered from IHD and those with length of lesion ≥ 5 cm are about five times more likely to have severe calcification compared to their counterparts (OR = 4.875, 95%CI = 1.293-18.383, p = .019, and OR = 4.513, 95% CI = 11.138-17.893, p = .032), respectively., Conclusion: The presence of severe calcification is associated with significantly lower midterm primary patency rates and higher rate of major adverse limb events after endovascular intervention for lower limb denovo arterial lesions., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: When antegrade recanalization of femoropopliteal and/or infrapopliteal occlusions fails, retrograde access has become an established option. To evaluate the results of combined antegrade and retrograde recanalization of femoropopliteal and infrapopliteal occlusions, patients undergoing secondary retrograde recanalization attempts were analyzed retrospectively., Methods: The primary end point was the success of the procedure (successful occlusion crossing using the antegrade/retrograde technique). Secondary end points include complication rate, primary patency and target lesion revascularization (TLR) rate, amputation rate, changes in ankle-brachial index, and Rutherford-Becker class. Predictors for procedure failure and TLR were analyzed., Results: We included 888 patients: 362 with femoropopliteal (group 1), 353 with infrapopliteal (group 2), and 173 with multilevel (group 3) recanalization. Critical limb-threatening ischemia was present in group 1, 2, and 3 in 36%, 62%, and 76% of patients, respectively. The intervention was successful in 92.5%, 93.8%, and 90.8% of the respective cases (P = .455). The overall peri-interventional complication rate was 7.2%. At 6, 12, and 24 months, primary patency was highest in group 1 (63.9%, 45.8%, and 33.3%), followed by group 3 (59.8%, 46.1%, and 33.3%), and group 2 (58.5%, 43.1%, and 30.4%; P = .537). The risk of undergoing repeated TLR within 24 months was 31.4% for group 1, 39.1% for group 2, and 45.7% for group 3. At 24 months, the survival rates in groups 1, 2, and 3 were 93.8%, 79.4%, and 87.5%, respectively. Over 24 months, 75 patients (8.4%) had to undergo amputation. Significant improvements in both ankle-brachial index and Rutherford-Becker class were present at discharge as well as at 6, 12, and 24 months (P < .001). Dialysis dependency was a predictor of unsuccessful antegrade/retrograde recanalization (P = .048). Lesion length (P = .0043), dialysis (P = .033), and recanalization level (P = .013) increase the risk of TLR., Conclusions: Using a combined antegrade/retrograde access, recanalization of occluded femoropopliteal and/or infrapopliteal arteries can be achieved in a large number of cases. Owing to the high rate of repeated TLR across all lesion localizations, the indication for antegrade and retrograde recanalization may be limited to patients with critical limb-threatening ischemia., Competing Interests: Disclosures E.N. reports honoraria received from Bard-BD, Boston Scientific Corp, Abbott Vascular, Medtronic, ShockWave, and iVascular. T.Z. reports honoraria received from Abbott Vascular, Veryan, Biotronik, Boston Scientific Corp., Cook Medical, W. L. Gore & Associates, Medtronic, Philips-Spectranetics, and Shockwave. T.Z. has consulted for Boston Scientific Corp., W. L. Gore & Associates, Medtronic, Veryan, Intact Vascular, Shockwave, Bayer, and Vesper Medical and has received Research, clinical trial, or drug study funds received from 480 biomedical, Bard Peripheral Vascular, Veryan, Biotronik, Cook Medical, W. L. Gore & Associates, Medtronic, Philips, Terumo, TriReme, Shockwave, Med Alliance, Intact Vascular, and B. Braun. T.Z. Owns common stock in QT Medical. D.W. reports honoraria received from Abiomed, AstraZeneca, Boston, Biotronik, Böhringer, Novartis, and Medtronic., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of this study is to report the early and late outcomes of cryopreserved saphenous vein (CSV) in redo infrainguinal bypass and to investigate possible predictors of primary patency loss., Methods: All patients who underwent a redo bypass for critical limb ischemia from January 2010 to December 2020 were reviewed. Early and late complications were analyzed and included. The endpoints of the study were all cause mortality, major limb amputation, and primary patency (PP)., Results: Data were collected from 95 patients. Among the entire cohort, 16 (16.8%) patients received a cryopreserved vessel bypass with anastomosis in the popliteal artery and 79 (83.2%) patients had cryopreserved vessel bypasses with distal anastomosis in tibial vessels. Median duration of follow-up was 73 months; during this, period estimated survival at 5 years was 80.5 ± 4% (95% CI, 78.0-91.2) and estimates of freedom from limb amputation was 90.3 ± 3.2% (95% CI, 87.3-98.1). Overall, the estimated primary patency of the bypass was 43.7 ± 6.7% (95% CI, 30.2-51.4). On multivariable analysis, intraprocedural tibial vessel angioplasty (HR = 2.3, p = 0.01), distal anastomosis in tibial vessels (HR = 3.6, p = 0.36), and the use of a composite graft (HR = 2.4, p = 0.01) were independently associated with loss of PP., Conclusions: The use of CSV in redo bypass is an effective strategy in salvaging threatened lower extremities and in preventing or delaying limb amputation. Our results confirm that further attempts at revascularization are generally appropriate, even in technically changing patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Sustained clinical and hemodynamic benefit after revascularization for chronic limb-threatening ischemia (CLTI) is needed to resolve symptoms and prevent limb loss. We sought to compare rates of clinical and hemodynamic failure as well as resolution of initial and prevention of recurrent CLTI after endovascular (ENDO) vs bypass (OPEN) revascularization in the Best-Endovascular-versus-best-Surgical-Therapy-in-patients-with-CLTI (BEST-CLI) trial., Methods: As planned secondary analyses of the BEST-CLI trial, we examined the rates of (1) clinical failure (a composite of all-cause death, above-ankle amputation, major reintervention, and degradation of WIfI stage); (2) hemodynamic failure (a composite of above-ankle amputation, major and minor reintervention to maintain index limb patency, failure to an initial increase or a subsequent decrease in ankle brachial index of 0.15 or toe brachial index of 0.10, and radiographic evidence of treatment stenosis or occlusion); (3) time to resolution of presenting CLTI symptoms; and (4) incidence of recurrent CLTI. Time-to-event analyses were performed by intention-to-treat assignment in both trial cohorts (cohort 1: suitable single segment great saphenous vein [SSGSV], N = 1434; cohort 2: lacking suitable SSGSV, N = 396), and multivariate stratified Cox regression models were created., Results: In cohort 1, there was a significant difference in time to clinical failure (log-rank P < .001), hemodynamic failure (log-rank P < .001), and resolution of presenting symptoms (log-rank P = .009) in favor of OPEN. In cohort 2, there was a significantly lower rate of hemodynamic failure (log-rank P = .006) favoring OPEN, and no significant difference in time to clinical failure or resolution of presenting symptoms. Multivariate analysis revealed that assignment to OPEN was associated with a significantly lower risk of clinical and hemodynamic failure in both cohorts and a significantly higher likelihood of resolving initial and preventing recurrent CLTI symptoms in cohort 1, including after adjustment for key baseline patient covariates (end-stage renal disease [ESRD], prior revascularization, smoking, diabetes, age >80 years, WIfI stage, tissue loss, and infrapopliteal disease). Factors independently associated with clinical failure included age >80 years in cohort 1 and ESRD across both cohorts. ESRD was associated with hemodynamic failure in cohort 1. Factors associated with slower resolution of presenting symptoms included diabetes in cohort 1 and WIfI stage in cohort 2., Conclusions: Durable clinical and hemodynamic benefit after revascularization for CLTI is important to avoid persistent and recurrent CLTI, reinterventions, and limb loss. When compared with ENDO, initial treatment with OPEN surgical bypass, particularly with available saphenous vein, is associated with improved clinical and hemodynamic outcomes and enhanced resolution of CLTI symptoms., Competing Interests: Disclosures M.T.M. is the advisor for Janssen. A.F. grants from Novo Nordisk Foundation; is a consultant for Sanifit, LeMaitre, and BioGenCell; and is on the advisor board of Dialysis-X and iThera Medical. L.C.C. is a consulting speaker for Cook Medical. P.A.S. is a consultant for Medtronic, Boston Scientific, Philips, Silk Road, Surmodics, Cagent, and Limflow. B.M.H. reports research grants (site PI for clinical trials, no compensation) from Boston Scientific and NIH/NHLBI. M.D.D. is a consultant for Cook Medical, W.L. Gore, and Boston Scientific. K.R. receives income as a consultant or member of a scientific advisory board for the following entities: Abbott Vascular, Althea Medical, Angiodynamics, Auxetics, Becton-Dickinson, Boston Scientific, Contego, Crossliner, Innova Vascular, Inspire MD, Janssen/Johnson and Johnson, Magneto, Mayo Clinic, MedAlliance, Medtronic, Neptune Medical, Penumbra, Philips, Surmodics, Terumo, Thrombolex, Truvic, Vasorum, and Vumedi; and owns equity or stock options in the following entities: Access Vascular, Aerami, Althea Medical, Auxetics, Contego, Crossliner, Cruzar Systems, Endospan, Imperative Care/Truvic, Innova Vascular, InspireMD, JanaCare, Magneto, MedAlliance, Neptune Medical, Orchestra, Prosomnus, Shockwave, Skydance, Summa Therapeutics, Thrombolex, Vasorum, and Vumedi. K.R. or his institution (on his behalf) receives research grants from the following entities: NIH, Abiomed, Boston Scientific, Novo Nordisk Foundation, Penumbra, and Gettinge-Atrium. He serves as a member of the Board of Directors of the following organization: The National PERT Consortium. M.S.C. has a relationship with Abbott Vascular DSMB. The remaining authors report no conflicts., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, a vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below-knee popliteal and tibial bypasses compared to prosthetic bypass alone., Methods: A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjuncts were compared. Inclusion criteria included age ≥18 years, and bypass to below-knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below-knee popliteal and tibial subgroups., Results: A cohort of 3,939 patients underwent bypass to the below-knee popliteal artery, with 287 (7.3%) receiving vein adjuncts. More patients were male (68.8 vs. 57.8%, P < 0.001) and had higher rates of congestive heart failure (21.1 vs. 16.0%, P = 0.040) within the below-knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs. 17.1%, P = 0.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjuncts. Within the tibial group, patients were similar in age, body mass index, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, P = 0.005) and amputation (20.5 vs. 15.9%, P = 0.048) rates at 2 years were worse for patients who did not receive a distal vein adjunct to tibial arteries., Conclusions: Distal vein adjuncts are associated with improved freedom from occlusion, amputation, major adverse limb events, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the Vascular Quality Initiative. A vein adjunct was not associated with improved freedom from occlusion in below-knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to determine if there is an association between statin-use and prosthetic mobility and long-term survival in patients receiving rehabilitation after major amputation for lower limb arterial disease., Methods: A retrospective analysis of prospectively maintained data (2008-2020) from a centre for rehabilitation was performed. Patients were grouped by statin-use status and sub-grouped by the combination of statin and antithrombotic drugs (antiplatelets or anticoagulants). Outcomes were prosthetic mobility (SIGAM score, timed-up-go and 2-min walking distance) and long-term survival. Regression, Kaplan-Meier and Cox-proportional hazard analyses were performed to test associations adjusted to confounders., Results: Of 771 patients, 499 (64.7%) were on a statin before amputation or prescribed a statin peri-operatively. Rate of statin-use was significantly lower among female (53.3%) compared to male (68.2%) patients, P < 0.001. Statin-use was associated with significantly better prosthetic independence (53.1% vs 44.1%, P = 0.017), timed-up-go (mean difference of 4 s, P = 0.04) and long-term survival HR 0.59 (0.48-0.72, P < 0.001). Significance persisted after adjusting for confounding factors and in subgroup analyses. The combination of statin with antiplatelet was associated with the most superior survival, HR 0.51 (0.40-0.65, P < 0.001). Sensitivity analysis (exclusion of non-users of prosthesis) showed that statin-use remained a significant indicator of longer survival, maximally when combined with antiplatelet use HR 0.52 (0.39-0.68, P < 0.001)., Conclusions: Statin-use is associated with better mobility and long-term survival in rehabilitees after limb loss, particularly when used in combination with antiplatelets. Significantly lower rates of statin-use were observed in female patients. Further research is warranted on gender disparities in statin-use and causality in their association with improved mobility and survival., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate tibial single access in treatment of chronic total occlusions (CTO) in patients with ipsilateral chronic-limb ischemia (CLTI)., Materials and Methods: In this retrospective study, data was collected on patients treated for ipsilateral CTO via a tibial artery access between March 2017 and March 2021. Fifty-nine limbs in 57 patients, (42 men, average age 73 years; range 47-96) were treated. Patient's symptoms were classified in accordance with the Rutherford category. The end points were freedom from major amputation and the need for reintervention up to 1 year of follow up., Results: Out of the 59 treated limbs, technical success was achieved in 57 (97%). The treated multilevel segments involved 5 common and 12 external iliac arteries, 23 common and 37 superficial femoral arteries, 23 femoropopliteal segments, 14 popliteal arteries, and 4 bypasses. Mean length of occlusion was 186 mm (range 7-670). Rutherford classification of the treated limbs was category 5 and 6 in 45 patients and category 4 in 14 patients. Three procedural complications occurred and were successfully treated during the same procedure. No immediate post-procedural complication was encountered. Median follow-up was 13 months (range 1-45.3). Reintervention was required in 9 limbs, after an average of 6 months. One year free from amputation rate was 91.2%., Conclusions: Single access via the ipsilateral tibial artery can be a useful, effective, and safe approach for treating CTO in CLTI patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The impact of sex upon outcomes in acute limb ischemia (ALI) remains disputed. We aim to quantify the effect of sex upon amputation-free survival (AFS) after a percutaneous-first approach for ALI., Methods: This was a two-center retrospective review of ALI managed via a percutaneous-first approach. Demographics, comorbidities, and clinical characteristics were analyzed. The Kaplan-Meier and Cox regression were used to estimate AFS, limb salvage, and overall survival., Results: Over 9 years, 170 patients (n = 87, 51% males; median age, 67 [interquartile range (IQR), 59-77 years) presented with ALI. Rutherford classification was I in 56 (33%); IIa in 85 (50%); IIb in 20 (12%), and III in 9 (5%). Thirty-day mortality, major amputation rate, and fasciotomy rates were 8% (n = 13); 6.5% (n = 11), and 4.7% (n = 8), respectively. Among revascularized limbs, 92% were patent at 30 days. Length of stay was 7 days (IQR, 3-11 days). Complications included 13 bleeding episodes (8%), four cases of atrial fibrillation (2%), and three re-thrombosis/clot extension events (1.7%). No differences were noted in complication rates when stratified by sex. Females were older than males (median age, 70 [IQR, 62-79] vs 65 [IQR, 56-76 years]; P = .02) and more likely to present with atrial fibrillation (20.5% vs 8%; P = .02) and hyperlipidemia (72% vs 57%; P = .04). Females also more frequently presented with multi-level thrombotic/embolic burden compared with males (56% vs 43%; P = .03) and required both aspiration thrombectomy and thrombolysis (27% vs 14%; P = .02). Kaplan-Meier estimated median AFS, limb salvage, and overall survival were 425 days (IQR, 140-824 days); 314 days (IQR, 72-727 days); and 342 days (IQR, 112-762 days). When stratified by sex, females had worse survival (median, 270 days [IQR, 92-636 days] vs 406 days [IQR, 140-937 days]; P = .005) and limb salvage (median, 241 days [IQR, 88-636 days] vs 363 days [IQR, 49-822 days]; P = .04) compared with males. Univariate Cox regression showed female sex (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.04-2.05; P = .03), multi-level thrombotic/embolic burden (HR, 1.64; 95% CI, 1.17-2.31; P = .004), and Rutherford class (HR, 1.37; 95% CI, 1.08-1.73; P = .009) predicted major amputation/death. By multivariable Cox regression, multi-level thrombotic/embolic burden (HR, 1.54; 95% CI, 1.09-2.17; P = .01), Rutherford class (HR, 1.34; 95% CI, 1.07-1.69; P = .01), and female sex (HR, 1.45; 95% CI, 1.03-2.05; P = .03) were each independently predictive of major amputation/death., Conclusions: A percutaneous-first strategy is safe and efficacious in the overall ALI population. Similar to prior works, female vs male patients with ALI in our cohort have higher rates of mortality and major amputation. In our multivariable model, multi-level thrombotic/embolic burden was independently associated with a greater than 45% increased hazard of major amputation/death at last follow-up. Further prospective analysis is warranted to elucidate the underlying factors contributing to the higher prevalence of multi-level thrombotic/embolic burden in female patients with ALI, and to further define the optimal percutaneous-first approach for ALI in consideration of patient sex and extent of clot burden., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Popliteal artery injuries (PAIs) may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following PAIs in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries., Methods: A retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with PAIs were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation., Results: One hundred eighty eight patients with PAIs were identified; 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (P = 0.0132) and neurologic deficits on arrival (P = 0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N = 93), there was no significant difference in amputation rates between those who had vein repair (P = 0.21) and those who underwent ligation (P = 0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (P = 0.20) or skin graft area (P = 0.48) based on linear regression analysis., Conclusions: Our study suggests that major amputations following PAIs are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Patients with chronic limb-threatening ischemia (CLTI) have a high risk of lower limb amputation and loss of walking independence. Minor amputations play a key role in ensuring walking independence and they represent a challenge in terms of timing and level for vascular surgeons. A major cause of re-amputation is a defect in wound healing and a possible predictor of re-amputation for non-healing wounds could be the incorrect timing of minor amputation after revascularization. The lack of evidence in the literature leads to a wide variability of choices in clinical practice. The purpose of this study was to try to find the optimal timing analysing the risk of re-amputation in CLTI patients who have undergone successful revascularization and minor amputation focussing on timing of minor amputation., Methods: We conducted a single centre retrospective analysis on a cohort of 151 patients consecutively admitted to our hospital for CLTI (Rutherford 5) between January 2014 and April 2022. All the enrolled patients underwent successful revascularization of lower limbs and a minor amputation for dry acral necrosis. The characteristics of the patients and the revascularization procedures were collected and analysed. Patients were divided into two groups based on the timing of minor amputation performed before (group 1) or after the day (group 2) that best predicts the risk of re-amputation according to a Receiver Operating Characteristic (ROC) curve analysis. The primary outcome of this study was the risk of re-amputation during the first 60 days of follow-up after a primary minor amputation, with revascularization still effective. The impact of the timing of minor amputation after revascularization, the type of revascularization and the presence of risk factors known to prolong the wound healing process were evaluated in a uni- and multi-variable logistic regression model., Results: Systemic hypertension, and type of revascularization (i.e. open vs endovascular) were independent predictors of the risk of re-amputation at 60 days (HR 4.26, 95% CI 1.30-14.04, p = .017 and HR 2.35, 95% CI 1.16-4.78, p = .018, respectively). Moreover, time ≤14 days between revascularization and first amputation was associate with a clear, albeit not statistically significant, trend toward increased risk of re-amputation (HR 2.09, 95% CI 0.97-4.51, p = .06)., Conclusions: In a cohort of patients who underwent a successful revascularization for CLTI and a minor amputation for dry gangrene in the first 14 days after revascularization, a higher -although not significant-risk of re-amputation was reported. In this cohort of patients, a delayed demolitive procedure should be considered to allow better tissue perfusion and to reduce the risk of re-amputation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The optimal anti-thrombotic management of patients after lower extremity bypass has yet to be fully elucidated, in part due to significant heterogeneity in patient presentation and practice patterns. The Wound, Ischemia, and foot Infection (WIfI) score is a validated scoring system to assist in the management of patients with chronic limb threatening ischemia (CLTI). We hypothesized that performing a restriction analysis based on WIFI scores would assist in the postoperative anti-thrombotic management of patients undergoing infrainguinal bypass., Methods: A retrospective cohort of infrainguinal bypass procedures completed at a single hospital system between January 2018 and January 2021 was selected, and preoperative WIfI scores were extracted for each patient. Patients with either Wound scores of 2 and 3, or Ischemia Scores of 0 and 1, or Foot Infection Scores of 3 were excluded. Based on the type of anti-thrombotic regimen on discharge, demographics, comorbidities, type of bypass, 30-day rates of graft occlusion, major amputation, mortality, and major adverse limb events (MALE) were analyzed. Statistical analysis included t-tests, chi square tests, and time-to-event survival analysis., Results: 230 procedures were included in the study. 69 (30.0%) patients were discharged on single antiplatelet therapy (SAPT), compared to 161 (70.0%) who were discharged on either dual antiplatelet therapy or anticoagulation (DAPT/AC). There was a higher prevalence of bypasses using prosthetic conduit in the DAPT/AC group (45.9 vs 31.8%, p = .047); no other demographic or procedural variable analyzed had any significant differences. At 30-days postoperatively, there was no significant difference in postoperative reintervention rates, however, the DAPT/AC group had significantly lower rates of mortality (1.2 vs 7.2%, p = .01), major amputation (1.2% vs 5.8%, p = .04), and MALE (3.7 vs 13.0%, p < .01). There were no significant differences in bleeding complications. Survival analysis demonstrated that MALE-free survival was higher in the DAPT/AC group compared to the SAPT group ( p < .01). On Cox regression analysis, DAPT/AC was associated with significantly decreased rates of MALE + mortality (Hazard Ratio (HR) 0.20 [0.06 - 0.66])., Conclusion: Lower extremity bypasses patients with low Wound and low foot Infection scores who are discharged on DAPT/AC postoperatively have a significantly higher 30-day MALE-free survival rate compared to patients discharged on SAPT; consideration could be made to preferentially discharge such post-bypass patients on DAPT/AC., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Vascular deserts, regions without vascular providers, previously described targets for limb salvage efforts. The Comprehensive Heart and Multidisciplinary Limb Preservation Outreach Networks (CHAMPIONS) programs targeted regions for outreach and evaluated the population using desert maps., Methods: At 2 events targeting underserved regions between 2022 and 2023, providers screened and educated participants on peripheral arterial and cardiovascular disease (PACD). Demographics and cardiovascular risk factors were collected. Using Arc geographic information system, vascular surgeons, and Vascular Quality Initiative (VQI) participating facilities were mapped with a 30-mile buffer. Participants were mapped with census data, and the healthy places index (HPI) was overlayed for population and social determinants of health data analysis in medical service study areas (MSSA), a geographical analysis unit. (Figure 1) Results were compared to prior statewide deserts., Results: Outreach program participants' mean age was 56 (range 6-88); 39% were male, and the majority were Hispanic (86%). 27% had no primary care provider (PCP). 30% had diabetes, 10% undiagnosed before the event, 38% had hypertension, 40% undiagnosed prior to the event, and 21% described intermittent claudication. 81% made <$30,000 annually, and 28% reported no health insurance. Similarities were observed when comparing program participant demographics to the population-level data from the targeted regions. Patients were more frequently Hispanic than other desert regions (68% vs. 36%, P < 0.001). Compared to other vascular desert regions, the target population was more disadvantaged in all HPI domains, including economic (18 vs. 38%, P < 0.001), education (21 vs. 39%, P < 0.001), and transportation (30 vs. 40%, P < 0.001). Worse education, financial, and transportation resources correspond to decreased care access due to poor literacy and travel burdens., Conclusions: CHAMPIONS programs successfully targeted populations needing care based on vascular care desert maps, demonstrating that at-risk populations can be successfully identified and screened for cardiovascular disease., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Patient travel distance to the hospital is a key metric of individual and social disadvantage and its impact on the management and outcomes following intervention for chronic limb-threatening ischemia (CLTI) is likely underestimated. We sought to evaluate the effect of travel distance on outcomes in patients undergoing first-time lower extremity revascularization at our institution., Methods: We retrospectively reviewed all consecutive patients undergoing first-time lower extremity revascularization, both endovascular and open, for CLTI from 2005 to 2014. Patients were stratified into 2 groups based on travel distance from home to hospital greater than or less than 30 miles. Outcomes included reintervention, major amputation, restenosis, primary patency, wound healing, length of stay, length of follow-up and mortality. Kaplan-Meier estimates were used to determine event rates. Logistic and cox regression was used to evaluate for an independent association between travel distance and these outcomes., Results: Of the 1293 patients were identified, 38% traveled >30 miles. Patients with longer travel distances were younger (70 years vs 73 years; P = .001), more likely to undergo open revascularization (65% vs 41%; P < .001), and had similar Wound, Ischemia, foot Infection stages (P = .404). Longer distance travelled was associated with an increase in total hospital length of stay (9.6 days vs 8.6 days; P = .031) and shorter total duration of postoperative follow-up (2.1 years vs 3.0 years; P = .001). At 5 years, there was no definitive difference in the rate of restenosis (hzard ratio [HR], 1.3; 95% confidence interval [CI], 0.91-1.9; P = .155) or reintervention (HR, 1.4; 95% CI, 0.96-2.1; P = .065), but longer travel distance was associated with an increased rate of major amputation (HR, 2.1; 95% CI, 1.2-3.7; P = .011), and death (HR, 1.6; 95% CI, 1.2-2.2; P = .002). Longer travel distance was also associated with higher rate of nonhealing wounds (HR, 2.3; 95% CI, 1.5-3.5; P = .001)., Conclusions: Longer patient travel distance was found to be associated with a lower likelihood of limb salvage and survival in patients undergoing first-time lower extremity revascularization for CLTI. Understanding and addressing the barriers to discharge, need for multidisciplinary follow-up, and appropriate postoperative wound care management will be key in improving outcomes at tertiary care regional specialty centers., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Clinical Impact: After percutaneous deep venous arterialization (pDVA), the created arteriovenous circuit needs time to develop. Postprocedural care in patients after pDVA is essential in order to create optimal conditions for maturation of the circuit, and thus save the limb. However, current literature mainly focusses on the procedure itself, making postprocedural care an underexposed topic. Therefore, this study presents an overview of the available literature of postprocedural care of pDVA patients and provides recommendations based on expert opinion when current knowledge is limited., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Steven Kum is a paid consultant to LimFlow.