Perioperative Outcomes are Adversely Affected by Poor Pretransfer Adherence to Acute Limb Ischemia Practice Guidelines

Wang, S. Keisin; Murphy, Michael P.; Gutwein, Ashley R.; Drucker, Natalie A.; Dalsing, Michael C.; Motaganahalli, Raghu L.; Lemmon, Gary W.; Akingba, A. George

doi:10.1016/j.avsg.2017.11.050

Cited by 14 publications

(7 citation statements)

References 19 publications

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“…A study of 87 patients in the USA who needed transfer to a vascular centre (36% with class IIb ischaemia), showed that although 76 received UFH before transfer, only 44 (58%) reached therapeutic levels, and those not achieving therapeutic levels had a higher re-intervention rate (47%). 62 In patients with confirmed or suspected heparin induced thrombocytopenia, non-heparin anticoagulants such as lepirudin, argatroban, or danaparoid are options. 63 Advice from a haematologist may be valuable.…”

Section: Initial Managementmentioning

confidence: 99%

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

Björck

Earnshaw

Acosta

et al. 2020

European Journal of Vascular and Endovascular Surgery

338

222

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Section: Initial Managementmentioning

confidence: 99%

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

Björck

Earnshaw

Acosta

et al. 2020

European Journal of Vascular and Endovascular Surgery

338

222

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“…[12][13] Acute limb ischemia is a complication that is combined with long hospital stays and high risk of amputation, disability, and death. [14][15][16][17] On the basis of COMPASS study, the Vascular Outcomes study of ASA along with rivaroxaban in endovascular or surgical limb revascularisation for peripheral artery disease (VOYAGER PAD) 3 was designed to assess the effectiveness and safety of 2.5 mg twice daily rivaroxaban plus aspirin in high risk PAD patients at high risk for lower extremity vascular reconstruction compared with aspirin alone. A low dose of rivaroxaban with added aspirin was associated with a significantly lower morbidity of ALI, major amputation for vascular causes, myocardial infarction, ischemic stroke, or death from cardiovascular causes compared to aspirin alone.…”

Section: Discussionmentioning

confidence: 99%

Oral Anticoagulant and Antiplatelet Therapy for Peripheral Arterial Disease: A Meta-analysis of Randomized Controlled Trials

Tang

Zhang

et al. 2021

Clin Appl Thromb Hemost

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Peripheral artery disease (PAD) is a common disease affecting over 200 million people worldwide. PAD is associated with significant limb and cardiovascular morbidity and mortality which is reduced by antiplatelet and antithrombotic therapy. However, the optimal type, dose, and time of antithrombotic therapy is still uncertain.We searched 4 electronic databases from January 1, 1990, to June 1, 2020, for randomized controlled trials of patients who received oral anticoagulant and antiplatelet therapy for PAD. The primary outcome was a composite of acute limb ischemia, major amputation, myocardial infarction, ischemic stroke, death from cardiovascular events, or death from any cause. Secondary outcomes included major bleeding, fatal bleeding, and intracranial hemorrhage events.We identified 3 studies that satisfied inclusion and exclusion criteria. Compared with antiplatelet alone, oral anticoagulant plus antiplatelet therapy improved acute limb ischemia (p < 0.00001), stroke (p = 0.005), and major amputation events (p = 0.11). However, oral anticoagulant plus antiplatelet therapy was not effective for prevention of myocardial infarction (p = 0.23), death from cardiovascular events (p = 0.65), or death from any cause (p = 0.66). Additionally, a significant increase in major bleeding events was demonstrated (p < 0.00001). There was no significant difference in fatal bleeding (p = 0.16) or intracranial hemorrhage events (p = 0.43). This meta-analysis showed that oral anticoagulant plus antiplatelet therapy for PAD may improve acute limb ischemia and major amputation or stroke risk compared with antiplatelet therapy alone, but could increase the risk of major bleeding events. On the other hand, measuring myocardial infarction, death, fatal bleeding, or intracranial hemorrhage risk remains controversial.

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“…Pre-transfer management decisions by referring hospitals to an academic tertiary care facility for ALI patients occur less frequently than expected and are associated with an increased adverse event [13].…”

Section: Discussionmentioning

confidence: 99%

Delayed Treatment and Missed Opportunities for Limb Salvage in Patients with Peripheral Arterial Embolism

Nasto

Kavrakov

2020

Open Access Maced J Med Sci

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BACKGROUND: The peripheral arterial embolism (PAE) is a sudden decrease in limb perfusion due to acute occlusion of peripheral artery which leads to ischemic tissue damage, that can threaten the limb of a patient and requires immediate revascularization. It is estimated that the incidence of acute limb emoblism in the general population is around 14/100,000 inhabitants per year. Accurate and timely diagnosis is crucial to salvage the patient’s limb and sometimes the patient’s life. In cases of complete arterial occlusion and absence of collateral perfusion, irreversible damage can occur within 4 to 6 hours. The fundamental definition for treatment of acute peripheral arterial embolism is revascularisation. Revascularisation is either performed endovascularly or by an open surgical approach. A suspicion of acute ischemia based on history and physical examination warrants heparin administration and vascular surgery consultation. Delays in the management of acute peripheral arterial ischemia due to an embolism are common and associated with poor limb - salvage outcomes. AIM: Our study aims to identify medical consultations and cardiovascular assessments undergone by patients in the period prior to being hospitalised, in order to evaluate for missed or delayed opportunities for diagnosis. METHODS: Retrospective cohort study, utilising the medical documentation and previous outpatiently or inhospital consultations. Adult patients undergone treatment due to peripheral arterial embolism were identified and analyzed. Patients were identified through the administrative hospital database using the International Classification of Diseases. Hospitalised patients with those medcodes between 1st January 2010 - 1st March 2020 were recorded. RESULTS: Following exclusion, 424 patients (mean age 68.5 ± 5.85 years) were included. 159 patients (66.8%) had visited their family doctors or other medical specialist before admission and in all of the cases was initiated therapeutic approach. The rest of the cohort 79 patients (33.2%) presented lately due to other social reasons. The group of 159 patients that admitted lately due to medical indications - diagnostic, healthcare - administrative or treatment related problems are subject of our study. The largest group including 113 (71%) patients were treated outpatientley by vascular surgeons with preventative medications.17 patients (10.6%) were directed outpatientley to orthopaedic surgeon due to suspicion of trauma.15 patients (9.4%) were treated by their family doctors with pain relief medications. The rest of the 14 patients (8.8%) were treated by neurosurgeons or neurologists due to a suspicion of cauda eniqua and other neuropathies. The majority of the patients 108 (67.9%) were free of complains at the discharge, 11.3% of the studied cohort were with minimal post-treatment complains (numbness, coldness, absent peripheral pulsations, insignificant claudicatio). Amputation rate was 14.4%, incidence of rethrombosis 8.8% and recurrent embolism frequency around 3.7%. Death was registered in 21 cases (13.2%). CONCLUSION: The consequences of acute limb embolism such as prolonged hospitalization, major limb amputation, and/or death have a profound socioeconomic impact. Unrecognition of this vascular pathology and differential diagnosis difficulties are possibly leading factors for delayed or missed treatment.

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Perioperative Outcomes are Adversely Affected by Poor Pretransfer Adherence to Acute Limb Ischemia Practice Guidelines

Abstract: The practice of timely therapeutic anticoagulation of patients referred for ALI from community facilities occurs less frequently than expected and is associated with an increased perioperative reintervention rate.

Cited by 14 publications

References 19 publications

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

Oral Anticoagulant and Antiplatelet Therapy for Peripheral Arterial Disease: A Meta-analysis of Randomized Controlled Trials

Delayed Treatment and Missed Opportunities for Limb Salvage in Patients with Peripheral Arterial Embolism

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