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EBM Presentation

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  • 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. Scenario
  • 3. Scenario 80 y/o male with diabetes for 20 years
  • 4. Scenario 80 y/o male with diabetes for 20 years s/p right BK amputation 3 years ago
  • 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. 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. 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. Question
  • 9. Question In patients with critical limb ischemia, is the amputation rate of endovascular stent less than of bypass surgery?
  • 10. PICO
  • 11. PICO P Patients with limb ischemia I Stents C Bypass surgery O Amputation rate
  • 12. Background Knowledge
  • 13. Background Knowledge Treatment of chronic critical limb ischemia Percutaneous transluminal angioplasty Bypass surgery Thrombolytic therapy
  • 14. Background Knowledge Treatment of chronic critical limb ischemia Percutaneous transluminal angioplasty Bypass surgery Thrombolytic therapy Aortoiliac vs infrainguinal disease
  • 15. Refined PICO
  • 16. Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate
  • 17. Refined PICO P Patients with limb ischemia I Angioplasty C Bypass surgery O Amputation rate Type: Therapy
  • 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. Database: PubMed
  • 20. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation
  • 21. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation Results: 175
  • 22. Database: PubMed
  • 23. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH]
  • 24. Database: PubMed Keywords (limb ischemia) AND bypass AND angioplasty AND amputation*[MeSH] Limits Humans, Clinical Trial, Meta-analysis, Randomized Controlled Trial
  • 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. Database: PubMed
  • 27. Database: PubMed
  • 28. Paper
  • 29. Why?
  • 30. Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy
  • 31. Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy Infrainguinal disease
  • 32. Why? Multicentric randomized trial surgery-first (n=228) or angioplasty-first (n=224) strategy Infrainguinal disease Primary Endpoint: Amputation-free survival
  • 33. Critical Appraisal
  • 34. Critical Appraisal Trial duration: 5.5 years
  • 35. Critical Appraisal Trial duration: 5.5 years Eight individuals (1.7%) were lost to follow-up
  • 36. Critical Appraisal Trial duration: 5.5 years Eight individuals (1.7%) were lost to follow-up Baseline data
  • 37. Critical Appraisal
  • 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. 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. 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. Validity of Critical Appraisal
  • 42. Validity of Critical Appraisal Yes
  • 43. Validity of Critical Appraisal Yes Yes
  • 44. Validity of Critical Appraisal Yes Yes Yes
  • 45. Validity of Critical Appraisal Yes Yes Yes blinded No
  • 46. Validity of Critical Appraisal Yes Yes Yes blinded No Yes
  • 47. Validity of Critical Appraisal Yes Yes Yes blinded No Yes baseline Yes
  • 48. Level of Evidence
  • 49. Level of Evidence
  • 50. Application to our case
  • 51. Application to our case Angioplasty = Stents ?
  • 52. Application to our case Angioplasty = Stents ? : outcome costs
  • 53. Application to our case Angioplasty = Stents ? : outcome costs : Yes
  • 54. !anks! a