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