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    EBM Presentation EBM Presentation Presentation Transcript

    • 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
    • Scenario
    • Scenario 80 y/o male with diabetes for 20 years
    • Scenario 80 y/o male with diabetes for 20 years s/p right BK amputation 3 years ago
    • 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
    • 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 !!!
    • 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
    • Question
    • Question In patients with critical limb ischemia, is the amputation rate of endovascular stent less than of bypass surgery?
    • PICO
    • PICO P Patients with limb ischemia I Stents C Bypass surgery O Amputation rate
    • Background Knowledge
    • Background Knowledge Treatment of chronic critical limb ischemia Percutaneous transluminal angioplasty Bypass surgery Thrombolytic therapy
    • Background Knowledge Treatment of chronic critical limb ischemia Percutaneous transluminal angioplasty Bypass surgery Thrombolytic therapy Aortoiliac vs infrainguinal disease
    • Refined PICO
    • Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate
    • Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate Type: Therapy
    • 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
    • Database: PubMed
    • Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation
    • Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation Results: 175
    • Database: PubMed
    • Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH]
    • Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH] Limits Humans, Clinical Trial, Meta-analysis, Randomized Controlled Trial
    • Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH] Limits Humans, Clinical Trial, Meta-analysis, Randomized Controlled Trial Results: 8
    • Database: PubMed
    • Database: PubMed
    • Paper
    • Why?
    • Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy
    • Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy Infrainguinal disease
    • Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy Infrainguinal disease Primary Endpoint: Amputation-free survival
    • Critical Appraisal
    • Critical Appraisal Trial duration: 5.5 years
    • Critical Appraisal Trial duration: 5.5 years Eight individuals (1.7%) were lost to follow-up
    • Critical Appraisal Trial duration: 5.5 years Eight individuals (1.7%) were lost to follow-up Baseline data
    • Critical Appraisal
    • 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)
    • 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
    • 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
    • Validity of Critical Appraisal
    • Validity of Critical Appraisal Yes
    • Validity of Critical Appraisal Yes Yes
    • Validity of Critical Appraisal Yes Yes Yes
    • Validity of Critical Appraisal Yes Yes Yes blinded No
    • Validity of Critical Appraisal Yes Yes Yes blinded No Yes
    • Validity of Critical Appraisal Yes Yes Yes blinded No Yes baseline Yes
    • Level of Evidence
    • Level of Evidence
    • Application to our case
    • Application to our case Angioplasty = Stents ?
    • Application to our case Angioplasty = Stents ? : outcome costs
    • Application to our case Angioplasty = Stents ? : outcome costs : Yes
    • !anks! a