EBM Presentation

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EBM Presentation

  1. 1. EBM Presentation Group No. 3 1 2 3 1. Department of surgery, VGHTC 2. Department of internal medicine, TAFGH 3. Department of family medicine, LSH
  2. 2. Scenario
  3. 3. Scenario 80 y/o male with diabetes for 20 years
  4. 4. Scenario 80 y/o male with diabetes for 20 years s/p right BK amputation 3 years ago
  5. 5. Scenario 80 y/o male with diabetes for 20 years s/p right BK amputation 3 years ago Left foot chronic ulcer, ABI: 0.6, angio: femoral a. stenosis
  6. 6. Scenario 80 y/o male with diabetes for 20 years s/p right BK amputation 3 years ago Left foot chronic ulcer, ABI: 0.6, angio: femoral a. stenosis Afraid of amputation !!!
  7. 7. Scenario 80 y/o male with diabetes for 20 years s/p right BK amputation 3 years ago Left foot chronic ulcer, ABI: 0.6, angio: femoral a. stenosis Afraid of amputation !!! Femoral popliteal a. bypass VS stents
  8. 8. Question
  9. 9. Question In patients with critical limb ischemia, is the amputation rate of endovascular stent less than of bypass surgery?
  10. 10. PICO
  11. 11. PICO P Patients with limb ischemia I Stents C Bypass surgery O Amputation rate
  12. 12. Background Knowledge
  13. 13. Background Knowledge Treatment of chronic critical limb ischemia Percutaneous transluminal angioplasty Bypass surgery Thrombolytic therapy
  14. 14. Background Knowledge Treatment of chronic critical limb ischemia Percutaneous transluminal angioplasty Bypass surgery Thrombolytic therapy Aortoiliac vs infrainguinal disease
  15. 15. Refined PICO
  16. 16. Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate
  17. 17. Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate Type: Therapy
  18. 18. Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate Type: Therapy Level of evidence Level 1 Level 2 Level 3 Level 4 RCT Cohort Case-control Case series
  19. 19. Database: PubMed
  20. 20. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation
  21. 21. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation Results: 175
  22. 22. Database: PubMed
  23. 23. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH]
  24. 24. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH] Limits Humans, Clinical Trial, Meta-analysis, Randomized Controlled Trial
  25. 25. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH] Limits Humans, Clinical Trial, Meta-analysis, Randomized Controlled Trial Results: 8
  26. 26. Database: PubMed
  27. 27. Database: PubMed
  28. 28. Paper
  29. 29. Why?
  30. 30. Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy
  31. 31. Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy Infrainguinal disease
  32. 32. Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy Infrainguinal disease Primary Endpoint: Amputation-free survival
  33. 33. Critical Appraisal
  34. 34. Critical Appraisal Trial duration: 5.5 years
  35. 35. Critical Appraisal Trial duration: 5.5 years Eight individuals (1.7%) were lost to follow-up
  36. 36. Critical Appraisal Trial duration: 5.5 years Eight individuals (1.7%) were lost to follow-up Baseline data
  37. 37. Critical Appraisal
  38. 38. Critical Appraisal After 6 months, no significant difference in amputation-free survival (48 vs 60 p’t; hazard ratio: 0.73; 95% CI: 0.49-1.07)
  39. 39. Critical Appraisal After 6 months, no significant difference in amputation-free survival (48 vs 60 p’t; hazard ratio: 0.73; 95% CI: 0.49-1.07) No difference in health- related quality of life
  40. 40. Critical Appraisal After 6 months, no significant difference in amputation-free survival (48 vs 60 p’t; hazard ratio: 0.73; 95% CI: 0.49-1.07) No difference in health- related quality of life One third higher hospital costs in surgery-first strategy for the first year
  41. 41. Validity of Critical Appraisal
  42. 42. Validity of Critical Appraisal Yes
  43. 43. Validity of Critical Appraisal Yes Yes
  44. 44. Validity of Critical Appraisal Yes Yes Yes
  45. 45. Validity of Critical Appraisal Yes Yes Yes blinded No
  46. 46. Validity of Critical Appraisal Yes Yes Yes blinded No Yes
  47. 47. Validity of Critical Appraisal Yes Yes Yes blinded No Yes baseline Yes
  48. 48. Level of Evidence
  49. 49. Level of Evidence
  50. 50. Application to our case
  51. 51. Application to our case Angioplasty = Stents ?
  52. 52. Application to our case Angioplasty = Stents ? : outcome costs
  53. 53. Application to our case Angioplasty = Stents ? : outcome costs : Yes
  54. 54. !anks! a

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