scholarly journals Current practice of first-line treatment strategies in patients with critical limb ischemia

2015 ◽  
Vol 62 (4) ◽  
pp. 965-973.e3 ◽  
Author(s):  
Theodosios Bisdas ◽  
Matthias Borowski ◽  
Giovanni Torsello ◽  
Farzin Adili ◽  
Kai Balzer ◽  
...  
Keyword(s):  
Critical Limb Ischemia ◽  
Current Practice ◽  
Treatment Strategies ◽  
Limb Ischemia ◽  
Line Treatment ◽  
First Line ◽  
First Line Treatment

scholarly journals Endovascular Therapy Versus Bypass Surgery as First-Line Treatment Strategies for Critical Limb Ischemia

2016 ◽  
Vol 9 (24) ◽  
pp. 2557-2565 ◽  
Author(s):  
Theodosios Bisdas ◽  
Matthias Borowski ◽  
Konstantinos Stavroulakis ◽  
Giovanni Torsello ◽  
Farzin Adili ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Critical Limb Ischemia ◽  
Bypass Surgery ◽  
Treatment Strategies ◽  
Limb Ischemia ◽  
Line Treatment ◽  
First Line ◽  
First Line Treatment

One-Year Results of First-Line Treatment Strategies in Patients With Critical Limb Ischemia (CRITISCH Registry)

2018 ◽  
Vol 25 (3) ◽  
pp. 320-329 ◽  
Author(s):  
Konstantinos Stavroulakis ◽  
Matthias Borowski ◽  
Giovanni Torsello ◽  
Theodosios Bisdas ◽  
Farzin Adili ◽  
...  
Keyword(s):  
Conservative Treatment ◽  
Critical Limb Ischemia ◽  
Bypass Surgery ◽  
Treatment Strategies ◽  
Limb Ischemia ◽  
Treatment Choice ◽  
Line Treatment ◽  
First Line ◽  
Endovascular Revascularization ◽  
First Line Treatment

Purpose: To examine the outcomes of all first-line strategies for the treatment of critical limb ischemia (CLI), identify factors that influenced the treatment choice, and determine the risk of amputation or death after each treatment. Methods: CRITISCH ( ClinicalTrials.gov identifier NCT01877252) is a multicenter, national, prospective registry evaluating all available treatment strategies applied in 1200 consecutive CLI patients in 27 vascular centers in Germany. The recruitment started in January 2013 and was completed in September 2014. Treatment options were endovascular revascularization (642, 53.5%), bypass surgery (284, 23.7%), femoral artery patchplasty (126, 10.5%) with or without concomitant peripheral intervention, conservative treatment (118, 9.8%), and primary major amputation (30, 2.5%). The primary endpoint of this study was amputation-free survival (AFS). The Society of Vascular Surgery’s suggested objective performance goal (OPG) for AFS (71%) was used as the effectiveness criterion. Multivariable regression methods were employed to identify variables that influenced the treatment selection and AFS after each treatment; results are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results: The 12-month AFS estimates following endovascular therapy, bypass grafting, femoral patchplasty, and conservative treatment were 75%, 72%, 73%, and 72%, respectively. Factors influencing treatment choice were age, chronic kidney disease (CKD), diabetes, smoking, prior vascular procedures in the index leg, TransAtlantic Inter-Society Consensus II C/D lesions, and absence of runoff vessels. Cox regression analysis identified CKD (HR 2.07, 95% CI 1.26 to 3.41, p=0.004), the use of a prosthetic bypass conduit (HR 1.97, 95% CI 1.23 to 3.14, p=0.004), and previous vascular intervention in the index limb (HR 1.52, 95% CI 0.94 to 2.43, p=0.085) as independent risk factors for diminished AFS after bypass surgery. CKD (HR 1.47, 95% CI 1.09 to 1.99, p=0.012) and Rutherford category 6 (HR 1.81, 95% CI 1.30 to 2.52, p<0.001) compromised the performance of endovascular revascularization. Conclusion: CRITISCH registry data revealed that all first-line treatment strategies selected and indicated by the treating physicians met the suggested OPGs. CKD was an important determinant of patient prognosis after treatment regardless of the revascularization method.

scholarly journals Open Surgery as First-Line Treatment of Infrainguinal Multilevel TASC D Arterial Disease With Critical Limb Ischemia

2019 ◽  
Vol 58 (6) ◽  
pp. e53-e54
Author(s):  
Mohammad Abualhin ◽  
Mauro Gargiulo ◽  
Alessia Sonetto ◽  
Gianluca Faggioli ◽  
Rodolfo Pini ◽  
...  
Keyword(s):  
Critical Limb Ischemia ◽  
Open Surgery ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Line Treatment ◽  
First Line ◽  
First Line Treatment

First Line Treatment of Advanced Stage Hodgkin Lymphoma with Six Cycles of BEACOPPescalated Results in Superior Overall Survival Compared to ABVD: Results of a Network Meta-Analysis Including 10,011 Patients

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 551-551
Author(s):  
Peter Borchmann ◽  
Sven Trelle ◽  
Michaela Rancea ◽  
Heinz Haverkamp ◽  
Volker Diehl ◽  
...  
Keyword(s):  
Overall Survival ◽  
Initial Treatment ◽  
Meta Analysis ◽  
Treatment Strategies ◽  
Advanced Stage ◽  
Secondary Malignancies ◽  
Line Treatment ◽  
First Line ◽  
First Line Treatment

Abstract Abstract 551 Background: The best treatment strategy for advanced stage Hodgkin lymphoma (HL) is still a matter of debate. The German Hodgkin Study Group (GHSG) advocates aggressive treatment with BEACOPPescalated (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) to cure as many patients as possible with first-line therapy. However, BEACOPPescalated may expose patients to excessive toxicity. Treatment with ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) is supposed to be better tolerable. Proponents of primary ABVD therapy acknowledge a lower progression-free survival (PFS) compared to BEACOPPescalated. However, they argue that relapsing patients can subsequently be cured by high-dose chemotherapy resulting in comparable overall survival (OS). All trials evaluating these two strategies directly were either very small or included patient subgroups only. Although they congruently showed a significant PFS advantage for BEACOPPescalated, they were not powered to detect differences in OS, which obviously is the most important endpoint. Purpose: To assess the benefits and risks of different initial treatment strategies for adult patients with advanced stage HL and to provide patients and physicians with a high-level evidence for treatment decisions. Methods: Data Sources: We developed sensitive search strategies for CENTRAL, MEDLINE, and conference proceedings (searched from 01/1980 to 03/2012). Missing data was obtained from investigators. Study selection: Randomized trials that compared at least two out of twelve pre-defined chemotherapy regimens in adults with advanced stage HL. Two authors independently assessed studies for eligibility. Data extraction: We extracted data and assessed quality of trials in duplicate. The primary outcome was OS. Secondary outcomes included freedom-from-treatment failure (FFTF) and secondary malignancies. Data relates to four or five years of follow-up depending on the status of the trial. Data synthesis: We pooled data using network meta-analysis. Direct comparisons within trials were combined with indirect evidence from other trials by using a Bayesian random-effects model. Results are reported relative to ABVD with a hazard ratio (HR) >1 indicating superiority of ABVD. Results: 1,984 references were identified, of which 77 publications, reporting 14 trials, evaluating 11 different regimens were included. A total of 10,011 patients with 59,000 patient-years of follow-up were evaluable for the analyses of survival outcomes. Six cycles of BEACOPPescalated and 8 cycles of BEACOPP-14 were associated with the lowest risk for death of any cause (HR 0.38, 95%-CrI 0.20 to 0.75 and HR 0.43, 95%-CrI 0.22 to 0.86, respectively). Assuming a five-year survival rate of 89% for ABVD this would result in a 5-year survival benefit of 7% and 6% for 6 cycles of BEACOPPescalated and 8 cycles of BEACOPP-14, respectively (95%-CrI 3% to 9% and 2% to 9%, respectively). Eight cycles of BEACOPPescalated were also statistically significantly better as compared to ABVD but the effect was less pronounced. All other treatment strategies showed no statistically significant difference to ABVD. Similar results were obtained for FFTF. Between-trial heterogeneity was negligible in both analyses (tau-square 0.01 and 0.05, respectively). Overall, 327 secondary malignancy and 109 leukemia events accumulated over 57,529 patient-years of follow-up. Given the low number of events we were not able to accurately quantify the risk associated with each regimen; however, Stanford V might be associated with the lowest risk and C(M)OPP/EBV/CAD with the highest risk for secondary leukemias. Limitations: Some of the regimens were only evaluated in one trial. The number of secondary malignancies, especially leukemias, was low. Conclusions: The comparison of different first-line treatment strategies for advanced stage HL in this network meta-analysis shows a significant and relevant OS benefit for both, 6 cycles of BEACOPPescalated and 8 cycles of BEACOPP-14 over standard ABVD treatment. This analysis provides the currently best available evidence on OS of different initial treatment strategies for advanced stage HL patients and therefore adds valid and important information for both, patients and physicians. Disclosures: No relevant conflicts of interest to declare.

Bing Neel Syndrome: The French Experience

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3068-3068
Author(s):  
Laurence Simon ◽  
Xavier Leleu ◽  
Jehan Dupuis ◽  
Therese Aurran ◽  
Lauris Gastaud ◽  
...  
Keyword(s):  
Median Time ◽  
Systemic Chemotherapy ◽  
Conflicts Of Interest ◽  
Cauda Equina ◽  
Treatment Strategies ◽  
High Dose ◽  
Line Treatment ◽  
First Line ◽  
Csf Analysis ◽  
First Line Treatment

Abstract Background: Bing-Neel syndrome (BNS) is a rare complication of Waldenström Macroglobulinemia (WM) defined as the direct involvement of central nervous system (CNS) by neoplastic cells. Because of its rarity, few data are currently available in the literature, which is mostly based on case-reports descriptions. The management of these patients is challenging with no consensus about the best treatment strategies to use. Patients and Methods: We retrospectively analyzed 37 patients out of 15 French centers databases, treated for a BNS between 1995 and 2014. Results: At the time of BNS diagnosis, the median age was 64 years. In 13 cases (35%), BNS was the first manifestation of WM. In others cases, median time between WM diagnosis and BNS was 96 months (range 2-300).BNS occurrence was correlated with a systemic progression of WM in 30% of cases. For the others patients with no systemic progression of WM, median time between the end of the last treatment of WM and BNS diagnosis was 30 months (range 10-72). The median IgM level was 11.25 g/L (range 0.35-60.8) at the time of BNS onset. Clinical manifestations: the most frequent symptoms at the time of BNS diagnosis were cognitive impairment (32%), motor or sensory deficits (30% and 16% respectively), pain (16%), cranial nerves involvement (30%), headache (21%), poor performance status (32%) and cauda equina syndrome (18%). The median interval between appearance of neurological symptoms and diagnosis of BNS was 4 months. Cerebrospinal fluid (CSF) analysis showed a lymphocytic meningitis in 81% of cases with a median of 33 cells/mm3 (range 7-3900), all with monoclonal B-cell population when phenotyping was available (except one case). Protein level was elevated in 94% (1,77 g/L in median, range 0,52-7,23). Magnetic resonance imaging (MRI) showed abnormalities in 83% (n=29/35) of cases. Meningeal enhancement was present in 52% of cases with conus medullaris infiltration in half of these patients. Cerebral enhancement was present in 45 % of cases and a normal pressure hydrocephalus in 3 cases. In 17% of cases, MRI was normal. Based on MRI results and CSF analysis, the majority of patients (81%, n=30/37) had an infiltrative form with only 7 patients presenting with a pseudotumoral involvement of brain parenchyma. The diagnosis was made on CSF analysis in the majority of cases (82%, n= 28/34). In four cases the diagnosis required a brain biopsy. First-line treatment comprised systemic chemotherapy in 89% (n=33/37) of cases. Treatment of CNS involvement was based on high-dose chemotherapy in 17 cases (methotrexate and/or aracytine). Intra-thecal chemotherapy was used in 70% of cases, and rituximab in 58% of cases. Autologous stem-cell transplantation (ASCT) in first-line was performed in 4 cases. 4 patients were treated up-front by whole-brain radiotherapy (in combination with systemic chemotherapy by fludarabine, cyclophosphamide and rituximab in 1 case). Outcome: 31 patients were assessable for first-line treatment response: overall response rate (ORR) was 68% (n=21/31) including 7 complete remissions; 7 patients had a progressive disease. 9 patients died. Median follow-up of alive patients was 23 months. At 5 years after BNS diagnosis, 79% of the patients were alive. Conclusion: Up to now, this is the most important retrospective cohort of patients presenting with Bing-Neel syndrome. In more than one third of the cases, BNS was the first manifestation of WM disease. Noteworthy is the late occurrence of some cases, up to 25 years. No correlation was observed between systemic progression of WM and BNS occurrence. BNS should be considered even in the context of a stable WM disease. In order to define the best treatment strategies, collection of additional cases is currently ongoing, and data will be up-dated at time of the meeting. Disclosures No relevant conflicts of interest to declare.

scholarly journals Percutaneous Mechanical Thrombectomy Using Rotarex® S Device in Acute Limb Ischemia in Infrainguinal Occlusions

2017 ◽  
Vol 2017 ◽  
pp. 1-8 ◽  
Author(s):  
Samuel Heller ◽  
Jean-Claude Lubanda ◽  
Petr Varejka ◽  
Miroslav Chochola ◽  
Pavel Prochazka ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Limb Ischemia ◽  
Performance Outcomes ◽  
Amputation Rate ◽  
Acute Limb Ischemia ◽  
Line Treatment ◽  
First Line ◽  
Invasive Treatment ◽  
Percutaneous Mechanical Thrombectomy ◽  
First Line Treatment

Purpose. To evaluate the effectiveness of percutaneous mechanical thrombectomy using Rotarex S in the treatment of acute limb ischemia (ALI) in infrainguinal occlusions in a retrospective study of patients treated in our institution. Methods. In this study, we identified a total of 147 ALI patients that underwent mechanical thrombectomy using Rotarex S at our institution. In 82% of the cases, percutaneous thrombectomy was used as first-line treatment, and for the remainder of the cases, it was used as bailout after ineffective aspiration or thrombolysis. Additional fibrinolysis and adjunctive aspirational thrombectomy were utilized for outflow occlusion when required. Procedural outcomes, amputation rate, and mortality at 30 days were evaluated. Results. Of the 147 patients treated with mechanical thrombectomy, Rotarex S was used as first-line treatment in 120 cases and as second-line treatment in 27 cases. Overall, we achieved 90.5% procedural revascularization success rate when combining mechanical thrombectomy with limited thrombolysis for severe outflow obstruction, and 1 death and 3 amputations were observed. We achieved primary success in 68.7% of the patients with the mechanical thrombectomy only, and in 21.8% of the patients, we successfully used additional limited thrombolysis in the outflow. The overall mortality was 0.7% and amputation rate was 2% at 30 days. Conclusion. Percutaneous mechanical thrombectomy as first-line mini-invasive treatment in infrainguinal ALI is safe, quick, and effective, and the performance outcomes can be superior to that of traditional surgical embolectomy.

scholarly journals P635 Superior outcomes with early biologic-combination treatment in Crohn’s Disease: Data from an international inception cohort

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S527-S528
Author(s):  
M Matheeuwsen ◽  
K Vermeijden ◽  
P Bossuyt ◽  
L Pouillon ◽  
F Baert ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Treatment Strategies ◽  
Line Treatment ◽  
Newly Diagnosed ◽  
First Line ◽  
Time To Treatment ◽  
Group 4 ◽  
Time To Treatment Failure ◽  
Group 5 ◽  
First Line Treatment

Abstract Background Crohn’s disease (CD) is characterised by intestinal inflammation leading to progressive bowel damage. Over the past years, treatment goals have evolved from clinical remission to prevention of structural bowel damage. It is currently unknown which treatment options and sequences lead to superior outcomes in patients with newly diagnosed CD. Methods The aim of this study was to compare different treatment strategies and associated outcomes in newly CD. We performed a retrospective study in adult patients diagnosed with CD in Amsterdam (The Netherlands), Bonheiden or Roeselare (Belgium) between 2009 and 2019. Based on first-line treatment choice, patients were assigned to one of the five pre-defined treatment strategies. The primary outcome was time to treatment failure, defined as a switch to another CD treatment, escalating CD treatment, need for endoscopic balloon dilation or CD-related surgery, CD-related hospitalisation or a new perianal fistula. Time to treatment failure was compared between different treatment groups using Kaplan–Meier analysis and Cox proportional hazard models. Results In total, 188 newly diagnosed patients were included. Treatment with corticosteroids only as first-line treatment (group 1) was started in 35 patients, immunomodulators (azathioprine, 6-mercaptopurine or methotrexate; group 2) in 87 patients, biological therapy (infliximab, adalimumab or vedolizumab; group 3) in 26 patients, and biological therapy in combination with an immunomodulator (group 4) in 25 patients. Fifteen patients underwent direct surgery (group 5). Baseline characteristics (C-reactive protein, CD Endoscopic Index of Severity, Simple Endoscopic Score for CD, smoking status) were similar between the different treatment groups, although group 5 had significantly more patients with stricturing (Montreal B2) and penetrating (Montreal B3) disease subtypes [Table1]. Log-rank test revealed significantly longer median time to treatment failure in group 5 (573 days; 95% confidence interval (CI) 0, 1274; hazard ratio (HR) 0.37), group 4 (1077 days; 95% CI 436, 1717; HR 0.26) and group 3 (337 days; 95% CI 270, 403; HR 0.40) compared with group 2 (121 days; 95% CI 88, 153) (p ≤ 0.01). Median time to treatment failure in group 4 (1077 days; 95% CI 436, 1717; HR 0.35) was significantly longer compared with group 1 (195 days; 95% CI 141, 248) (p &lt; 0.01) (Table 2; Figure 1). CD Endoscopic Index of Severity (CDEIS), Simple Endoscopic Score for CD (SES-CD), *based on n = x patients. Conclusion These real-world data seem to show superior treatment survival in newly diagnosed CD patients receiving first-line treatment with biologicals (as mono- and combination therapy) and early surgery compared with patients receiving first-line treatment with immunomodulators alone.

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