0
July 12, 1995, Vol 274, No. 2 >
ARTICLE | July 12, 1995

Revascularization for Femoropopliteal Disease: Title and subTitle BreakA Decision and Cost-effectiveness Analysis FREE

Maria G. M. Hunink, MD, PhD; John B. Wong, MD; Magruder C. Donaldson, MD; Michael F. Meyerovitz, MD; Jelle de Vries; Donald P. Harrington, MD
[+] Author Affiliations

Reprint requests to the Department of Health Sciences, Medical Decision Making, Faculty of Medicine, University of Groningen, Ant Deusinglaan 1, 9713 AV Groningen, the Netherlands (Dr Hunink).


JAMA. 1995;274(2):165-171. doi:10.1001/jama.1995.03530020083037
Text Size: A A A
Published online
Article
References

Objective.  —To evaluate the relative benefits and cost-effectiveness of revascularization for femoropopliteal disease using percutaneous transluminal angioplasty or bypass surgery.

Design.  —Decision analysis using a multistate transition simulation model (Markov process) and cost-effectiveness analysis from the perspective of the health care system.

Setting.  —Based on mortality, morbidity, patency, and cost data from a literature review.

Patients.  —Hypothetical cohort of patients with chronic femoropopliteal disease who desire revascularization. Subgroup analysis for patients defined by age, sex, indication, lesion type, and graft type.

Interventions.  —Percutaneous transluminal angioplasty, bypass surgery, and a strategies combining the two treatments.

Main Outcome Measures.  —Five-year patency results, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios.

Results.  —For 65-year-old men with disabling claudication and a femoropopliteal stenosis or occlusion and for 65-year-old men with chronic critical ischemia and a femoropopliteal stenosis, initial angioplasty increased quality-adjusted life expectancy by 2 to 13 months and resulted in decreased lifetime expenditures compared with bypass surgery. For patients with chronic critical ischemia and a femoropopliteal occlusion, initial bypass surgery increased quality-adjusted life expectancy by 1 to 4 months and resulted in decreased lifetime expenditures compared with angioplasty. Sensitivity analysis demonstrated that angioplasty would always be the preferred initial treatment if the angioplasty 5-year patency rate exceeds 30%.

Conclusion.  —Angioplasty is the preferred initial treatment in patients with disabling claudication and a femoropopliteal stenosis or occlusion and in those with chronic critical ischemia and a stenosis. Bypass surgery is the preferred initial treatment in patients with chronic critical ischemia and a femoropopliteal occlusion.(JAMA. 1995;274:165-171)

REFERENCES

1 +
Becker GJ, Katzen BT, Dake MD.  Noncoronary angioplasty. Radiology . 1989;;170:921-940.
2 +
Johnston KW, Rae M, Hogg-Johnston SA, et al.  Five-year results of a prospective study of percutaneous transluminal angioplasty. Ann Surg . 1987;; 206:403-413.
3 +
Donaldson MC, Mannick JA, Whittemore AD.  Femoral-distal bypass with in situ greater saphenous vein: long-term results using the Mills valvulotome. Ann Surg . 1991;;213:457-465.
4 +
Gillum RF.  Peripheral arterial occlusive disease of the extremities in the United States: hospitalization and mortality. Am Heart J . 1990;;120:1414-1418.
5 +
US Dept of Health and Human Services.  Detailed diagnoses and procedures: National Hospital Discharge Survey, 1990. Vital Health Stat 13 .1992;;No. (113) .
6 +
Doubilet P, Abrams HL.  The cost of underutilization: percutaneous transluminal angioplasty for peripheral vascular disease. N Engl J Med . 1984;; 310:95-102.
7 +
Tunis SR, Bass EB, Steinberg EP.  The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease. N Engl J Med . 1991;;325:556-562.
8 +
Martin EC.  Transcatheter therapies in peripheral and noncoronary vascular disease: introduction. Circulation . 1991;;83( (suppl I) ):I-1-I-5.
9 +
Coffman JD.  Intermittent claudication: be conservative. N Engl J Med . 1991;;325:577-578.
10 +
Wolf GL, Wilson SE, Cross AP, Deupree RH, Stason WB.  Surgery or balloon angioplasty for peripheral vascular disease: a randomized clinical trial. J Vasc Intervent Radiol . 1993;;4:639-648.
11 +
Holm J, Arfvodsson B, Jivegard L, et al.  Chronic lower limb ischemia: a prospective randomized controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty (PTA). Eur J Vasc Surg . 1991;;5:517-522.
12 +
Donaldson MC, Whittemore AD, Mannick JA.  An argument in favor of all-autogenous tissue for vascular bypasses below the inguinal ligament.  In: Cameron JL, Balch CM, Langer B, et al, eds. Advances in Surgery . St Louis, Mo: Mosby-Year Book Co; 1991;;24:69-90.
13 +
Johnston KW.  Femoral and popliteal arteries: reanalysis of results of balloon angioplasty. Radiology . 1992;;183:767-771.
14 +
Hunink MGM, Donaldson MC, Meyerovitz MF, et al.  Risks and benefits of femoropopliteal percutaneous balloon angioplasty. J Vasc Surg . 1993;;17: 183-194.
15 +
Hunink MGM, Cullen KA, Donaldson MC.  Hospital costs of revascularization procedures for femoropopliteal arterial disease. J Vasc Surg . 1994;;19: 632-641.
16 +
Rutherford RB, Flanigan DP, Gupta SK, et al,  prepared by the Ad Hoc Committe on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery. Suggested standards for reports dealing with lower extremity ischaemia. J Vasc Surg . 1986;;4:80-94.
17 +
Rutherford RB, Becker GJ.  Standards for evaluating and reporting the results of surgical and percutaneous therapy for peripheral arterial disease. Radiology . 1991;;181:277-281.
18 +
Weinstein MC, Fineberg HV. Clinical Decision Analysis . Philadelphia, Pa: WB Saunders Co; 1980;.
19 +
Drummond MF, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes . Oxford, England: Oxford Medical Publications; 1987;.
20 +
BeckJR, Pauker SG.  The Markov process in medical prognosis. Med Decis Making . 1983;;3:419-458.
21 +
Sonnenberg FA, Beck JR.  Markov models in medical decision making: a practical guide. Med Decis Making . 1993;;13:322-338.
22 +
Sonnenberg FA, Wong JB.  Fine-tuning lifeexpectancy calculations using Markov processes. Med Decis Making . 1993;;13:170-172.
23 +
Goldman L, Gordon DJ, Rifkind BM, et al.  Cost and health implications of cholesterol lowering. Circulation . 1992;;85:1960-1968.
24 +
Morse MH, Jeans WD, Cole SEA, Grier D, Ndlovu D.  Complications in percutaneous transluminal angioplasty: relationships with patient age. Br J Radiol . 1991;;64:5-9.
25 +
Henriksen LO, Jørgensen B, Holstein PE, Tonnesen KH, Karle A, Sager P.  Percutaneous transluminal angioplasty of infrarenal arteries in intermittent claudication. Acta Chir Scand . 1988;;154:573-576.
26 +
Capek P, McLean GK, Berkowitz HD.  Femoropopliteal angioplasty: factors influencing long-term success. Circulation . 1991;;83( (suppl I) ):I-70-I-80.
27 +
Belli AM, Cumberland DC, Knox AM, Procter AE, Wash CL.  The complication rate of percutaneous peripheral balloon angioplasty. Clin Radiol . 1990;;41:380-383.
28 +
Jeans WD, Armstrong S, Cole SEA, Horrocks M, Baird RN.  Fate of patients undergoing transluminal angioplasty for lower-limb ischemia. Radiology . 1990;;177:559-564.
29 +
Hasson JE, Acher CW, Wojtowycz M, McDermott J, Crummy A, Turnipseed WD.  Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality. Surgery . 1990;;108:748-754.
30 +
Weibull H, Bergqvist D, Jonsson K, Karlsson S, Takolander R.  Complications after percutaneous transluminal angioplasty in the iliac, femoral, and popliteal arteries. J Vasc Surg . 1987;;5:681-686.
31 +
Walden R, Siegel Y, Rubinstein ZJ, Morag B, Bass A, Adar R.  Percutaneous transluminal angioplasty: a suggested method for analysis of clinical, arteriographic, and hemodynamic factors affecting the results of treatment. J Vasc Surg . 1986;;3:583-590.
32 +
Milford MA, Weaver FA, Lundell CJ, Yellin AE.  Femoropopliteal percutaneous transluminal angioplasty for limb salvage. J Vasc Surg . 1988;;8:292-299.
33 +
Jørgensen B, Henriksen LO, Karle A, Sager P, Holstein PE, Tonnesen KH.  Percutaneous transluminal angioplasty of iliac and femoral arteries in severe lower-limb ischemia. Acta Chir Scand . 1988;; 154:647-652.
34 +
Jones BA, Maggisano R, Robb C, Saibil EA, Witchell SJ, Harrison AW.  Transluminal angioplasty: results in high-risk patients with advanced peripheral vascular disease. Can J Surg . 1985;;28: 150-152.
35 +
Kent KC, Donaldson MC, Attinger CE, Couch NP, Mannick JA, Whittemore AD.  Femoropopliteal reconstruction for claudication: the risk to life and limb. Arch Surg . 1988;;123:1196-1198.
36 +
Whittemore AD, Kent C, Donaldson MC, Couch NP, Mannick JA.  What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction? J Vase Surg . 1989;;10:299-305.
37 +
Quinones-Baldrich WJ, Busuttil RW, Baker JD, et al.  Is the preferential use of polytetrafluornethylene grafts for femoropopliteal bypass justified? J Vase Surg . 1988;;8:219-228.
38 +
Taylor LM, Edwards JM, Porter JM.  Present status of reversed vein bypass: five-year results of a modern series. J Vase Surg . 1990;;11:193-206.
39 +
Hobson RW, Lynch TG, Jamil Z, et al.  Results of revascularization and amputation in severe lower extremity ischaemia: a five-year clinical experience. J Vase Surg . 1985;;2:174-185.
40 +
Veith FJ, Gupta SK, Ascer E, et al.  Six-year prospective multicenter randomized comparison of autogenous saphenous vein and expanded polytetrafluorethylene grafts in infrainguinal arterial reconstructions. J Vase Surg . 1986;;3:104-114.
41 +
Leather RP, Shah DM, Chang BB, Kaufman JL.  Resurrection of the in situ saphenous vein bypass: 1000 cases later. Ann Surg . 1988;;208:435-442.
42 +
Bergamini TM, Towne JB, Bandyk DF, Seabrook GR, Schmitt DD.  Experience with in situ saphenous vein bypass during 1981 to 1989: determinant factors of long-term patency. J Vase Surg . 1991;;13:137-149.
43 +
Gupta SK, Veith FJ, Kram HB, Wengerter KR.  Prospective, randomized comparison of ringed and nonringed polytetrafluorethylene femoral popliteal bypass grafts: a preliminary report. J Vase Surg . 1991;;13:162-172.
44 +
Kram HB, Gupta SK, Veith FJ, Wengerter KR, Panetta TF, Nwosisi C.  Late results of two hundred seventeen femoropopliteal bypasses to isolated popliteal artery segments. J Vase Surg . 1991;; 14:386-390.
45 +
Hunink MGM, Wong JB, Donaldson MC, Meyerovitz MF, Harrington DP.  Patency results of percutaneous and surgical revascularization for femoropopliteal arterial disease. Med Decis Making . 1994;; 14:71-81.
46 +
Kinnison ML, White RI, Bowers WP, Dunlap ED.  Cost incentives for peripheral angioplasty. AJR Am J Roentgenol . 1985;;145:1241-1244.
47 +
Wolf GL, McLean G.  Comparison of the costs of bypass surgery and transluminal angioplasty for peripheral vascular disease. Semin Intervent Radiol . 1984;;1:237-239.
48 +
Gupta SK, Veith FJ.  Inadequacy of the diagnosis related group (DRG) reimbursements for limb salvage lower extremity arterial reconstructions. J Vase Surg . 1990;;11:348-357.
49 +
Mackey WC, McCullough JL, Conlon TP, et al.  The costs of surgery for limb-threatening ischaemia. Surgery . 1986;;99:26-35.
50 +
National Center for Health Statistics. Vital Statistics of the United States 1988: Volume II-Mortality, Part A . Hyattsville, Md: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control; 1991;.
51 +
Howell MA, Colgan MP, Seeger RW, Ramsey DE, Sumner DS.  Relationship of severity of lower limb peripheral vascular disease to mortality and morbidity: a six-year follow-up study. J Vase Surg . 1989;;9:691-697.
52 +
Fowkes FGR.  Epidemiology of atherosclerotic arterial disease in the lower limbs. Eur J Vase Surg . 1988;;2:283-291.
53 +
Criqui MH, Langer RD, Fronek A, et al.  Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med . 1992;;326:381-386.
54 +
Wong JB, Sonnenberg FA, Salem DN, Pauker SG.  Myocardial revascularization for chronic stable angina: analysis of the role of percutaneous transluminal coronary angioplasty based on data available in 1989. Ann Intern Med . 1990;;113:852-871.
55 +
McDaniel MD, Cronenwett JL.  Basic data related to the natural history of intermittent claudication. Ann Vase Surg . 1989;;3:273-277.
56 +
Plecha FR, Bertin VJ, Plech EJ, et al.  The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases. J Vase Surg . 1985;;2:769-774.
57 +
Miller N, Dardik H, Wolodiger F, et al.  Transmetatarsal amputation: the role of adjunctive revascularization. J Vase Surg . 1991;;13:705- 711.
58 +
Weiss GN, Gorton A, Read RC, Neal LA.  Outcomes of lower extremity amputations. J Am Geriatr Soc . 1990;;38:877-883.
59 +
Ravioli CA, Nichter LS, Baker JD, Busuttil RW, Machleder HI, Moore WS.  Cost of treating advanced leg ischemia. Arch Surg . 1988;;123:495-496.
60 +
Gupta SK, Veith FJ, Ascer E, White Flores SA, Gliedman ML.  Cost factors in limb-threatening ischaemia due to infrainguinal arteriosclerosis. Eur J Vase Surg . 1988;;2:151-154.
61 +
Callow AD, Mackey WC.  Costs and benefits of prosthetic vascular surgery. Int Surg . 1988;;73:237-240.
62 +
Cheshire NJW, Wolfe JHN, Noone MA, Davies L, Drummond M.  The economics of femorocrural reconstruction for critical leg ischaemia with and without autologous vein. J Vase Surg . 1992;;15:167-175.
63 +
Wittels EH, Hay JW, Gotto AM.  Medical costs of coronary artery disease in the United States. Am J Cardiol . 1990;;65:432-440.
64 +
Hunink MGM, Wong JB.  Meta-analysis of failure time data with adjustment for covariates. Med Decis Making . 1994;;14:59-70.
65 +
Pentecost MJ, Criqui MH, Dorros G, et al.  Guidelines for peripheral percutaneous transluminal angioplasty of the abdominal aorta and lower extremity vessels. Circulation . 1994;;89:511-531.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Becker GJ, Katzen BT, Dake MD.  Noncoronary angioplasty. Radiology . 1989;;170:921-940.
2 +
Johnston KW, Rae M, Hogg-Johnston SA, et al.  Five-year results of a prospective study of percutaneous transluminal angioplasty. Ann Surg . 1987;; 206:403-413.
3 +
Donaldson MC, Mannick JA, Whittemore AD.  Femoral-distal bypass with in situ greater saphenous vein: long-term results using the Mills valvulotome. Ann Surg . 1991;;213:457-465.
4 +
Gillum RF.  Peripheral arterial occlusive disease of the extremities in the United States: hospitalization and mortality. Am Heart J . 1990;;120:1414-1418.
5 +
US Dept of Health and Human Services.  Detailed diagnoses and procedures: National Hospital Discharge Survey, 1990. Vital Health Stat 13 .1992;;No. (113) .
6 +
Doubilet P, Abrams HL.  The cost of underutilization: percutaneous transluminal angioplasty for peripheral vascular disease. N Engl J Med . 1984;; 310:95-102.
7 +
Tunis SR, Bass EB, Steinberg EP.  The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease. N Engl J Med . 1991;;325:556-562.
8 +
Martin EC.  Transcatheter therapies in peripheral and noncoronary vascular disease: introduction. Circulation . 1991;;83( (suppl I) ):I-1-I-5.
9 +
Coffman JD.  Intermittent claudication: be conservative. N Engl J Med . 1991;;325:577-578.
10 +
Wolf GL, Wilson SE, Cross AP, Deupree RH, Stason WB.  Surgery or balloon angioplasty for peripheral vascular disease: a randomized clinical trial. J Vasc Intervent Radiol . 1993;;4:639-648.
11 +
Holm J, Arfvodsson B, Jivegard L, et al.  Chronic lower limb ischemia: a prospective randomized controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty (PTA). Eur J Vasc Surg . 1991;;5:517-522.
12 +
Donaldson MC, Whittemore AD, Mannick JA.  An argument in favor of all-autogenous tissue for vascular bypasses below the inguinal ligament.  In: Cameron JL, Balch CM, Langer B, et al, eds. Advances in Surgery . St Louis, Mo: Mosby-Year Book Co; 1991;;24:69-90.
13 +
Johnston KW.  Femoral and popliteal arteries: reanalysis of results of balloon angioplasty. Radiology . 1992;;183:767-771.
14 +
Hunink MGM, Donaldson MC, Meyerovitz MF, et al.  Risks and benefits of femoropopliteal percutaneous balloon angioplasty. J Vasc Surg . 1993;;17: 183-194.
15 +
Hunink MGM, Cullen KA, Donaldson MC.  Hospital costs of revascularization procedures for femoropopliteal arterial disease. J Vasc Surg . 1994;;19: 632-641.
16 +
Rutherford RB, Flanigan DP, Gupta SK, et al,  prepared by the Ad Hoc Committe on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery. Suggested standards for reports dealing with lower extremity ischaemia. J Vasc Surg . 1986;;4:80-94.
17 +
Rutherford RB, Becker GJ.  Standards for evaluating and reporting the results of surgical and percutaneous therapy for peripheral arterial disease. Radiology . 1991;;181:277-281.
18 +
Weinstein MC, Fineberg HV. Clinical Decision Analysis . Philadelphia, Pa: WB Saunders Co; 1980;.
19 +
Drummond MF, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes . Oxford, England: Oxford Medical Publications; 1987;.
20 +
BeckJR, Pauker SG.  The Markov process in medical prognosis. Med Decis Making . 1983;;3:419-458.
21 +
Sonnenberg FA, Beck JR.  Markov models in medical decision making: a practical guide. Med Decis Making . 1993;;13:322-338.
22 +
Sonnenberg FA, Wong JB.  Fine-tuning lifeexpectancy calculations using Markov processes. Med Decis Making . 1993;;13:170-172.
23 +
Goldman L, Gordon DJ, Rifkind BM, et al.  Cost and health implications of cholesterol lowering. Circulation . 1992;;85:1960-1968.
24 +
Morse MH, Jeans WD, Cole SEA, Grier D, Ndlovu D.  Complications in percutaneous transluminal angioplasty: relationships with patient age. Br J Radiol . 1991;;64:5-9.
25 +
Henriksen LO, Jørgensen B, Holstein PE, Tonnesen KH, Karle A, Sager P.  Percutaneous transluminal angioplasty of infrarenal arteries in intermittent claudication. Acta Chir Scand . 1988;;154:573-576.
26 +
Capek P, McLean GK, Berkowitz HD.  Femoropopliteal angioplasty: factors influencing long-term success. Circulation . 1991;;83( (suppl I) ):I-70-I-80.
27 +
Belli AM, Cumberland DC, Knox AM, Procter AE, Wash CL.  The complication rate of percutaneous peripheral balloon angioplasty. Clin Radiol . 1990;;41:380-383.
28 +
Jeans WD, Armstrong S, Cole SEA, Horrocks M, Baird RN.  Fate of patients undergoing transluminal angioplasty for lower-limb ischemia. Radiology . 1990;;177:559-564.
29 +
Hasson JE, Acher CW, Wojtowycz M, McDermott J, Crummy A, Turnipseed WD.  Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality. Surgery . 1990;;108:748-754.
30 +
Weibull H, Bergqvist D, Jonsson K, Karlsson S, Takolander R.  Complications after percutaneous transluminal angioplasty in the iliac, femoral, and popliteal arteries. J Vasc Surg . 1987;;5:681-686.
31 +
Walden R, Siegel Y, Rubinstein ZJ, Morag B, Bass A, Adar R.  Percutaneous transluminal angioplasty: a suggested method for analysis of clinical, arteriographic, and hemodynamic factors affecting the results of treatment. J Vasc Surg . 1986;;3:583-590.
32 +
Milford MA, Weaver FA, Lundell CJ, Yellin AE.  Femoropopliteal percutaneous transluminal angioplasty for limb salvage. J Vasc Surg . 1988;;8:292-299.
33 +
Jørgensen B, Henriksen LO, Karle A, Sager P, Holstein PE, Tonnesen KH.  Percutaneous transluminal angioplasty of iliac and femoral arteries in severe lower-limb ischemia. Acta Chir Scand . 1988;; 154:647-652.
34 +
Jones BA, Maggisano R, Robb C, Saibil EA, Witchell SJ, Harrison AW.  Transluminal angioplasty: results in high-risk patients with advanced peripheral vascular disease. Can J Surg . 1985;;28: 150-152.
35 +
Kent KC, Donaldson MC, Attinger CE, Couch NP, Mannick JA, Whittemore AD.  Femoropopliteal reconstruction for claudication: the risk to life and limb. Arch Surg . 1988;;123:1196-1198.
36 +
Whittemore AD, Kent C, Donaldson MC, Couch NP, Mannick JA.  What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction? J Vase Surg . 1989;;10:299-305.
37 +
Quinones-Baldrich WJ, Busuttil RW, Baker JD, et al.  Is the preferential use of polytetrafluornethylene grafts for femoropopliteal bypass justified? J Vase Surg . 1988;;8:219-228.
38 +
Taylor LM, Edwards JM, Porter JM.  Present status of reversed vein bypass: five-year results of a modern series. J Vase Surg . 1990;;11:193-206.
39 +
Hobson RW, Lynch TG, Jamil Z, et al.  Results of revascularization and amputation in severe lower extremity ischaemia: a five-year clinical experience. J Vase Surg . 1985;;2:174-185.
40 +
Veith FJ, Gupta SK, Ascer E, et al.  Six-year prospective multicenter randomized comparison of autogenous saphenous vein and expanded polytetrafluorethylene grafts in infrainguinal arterial reconstructions. J Vase Surg . 1986;;3:104-114.
41 +
Leather RP, Shah DM, Chang BB, Kaufman JL.  Resurrection of the in situ saphenous vein bypass: 1000 cases later. Ann Surg . 1988;;208:435-442.
42 +
Bergamini TM, Towne JB, Bandyk DF, Seabrook GR, Schmitt DD.  Experience with in situ saphenous vein bypass during 1981 to 1989: determinant factors of long-term patency. J Vase Surg . 1991;;13:137-149.
43 +
Gupta SK, Veith FJ, Kram HB, Wengerter KR.  Prospective, randomized comparison of ringed and nonringed polytetrafluorethylene femoral popliteal bypass grafts: a preliminary report. J Vase Surg . 1991;;13:162-172.
44 +
Kram HB, Gupta SK, Veith FJ, Wengerter KR, Panetta TF, Nwosisi C.  Late results of two hundred seventeen femoropopliteal bypasses to isolated popliteal artery segments. J Vase Surg . 1991;; 14:386-390.
45 +
Hunink MGM, Wong JB, Donaldson MC, Meyerovitz MF, Harrington DP.  Patency results of percutaneous and surgical revascularization for femoropopliteal arterial disease. Med Decis Making . 1994;; 14:71-81.
46 +
Kinnison ML, White RI, Bowers WP, Dunlap ED.  Cost incentives for peripheral angioplasty. AJR Am J Roentgenol . 1985;;145:1241-1244.
47 +
Wolf GL, McLean G.  Comparison of the costs of bypass surgery and transluminal angioplasty for peripheral vascular disease. Semin Intervent Radiol . 1984;;1:237-239.
48 +
Gupta SK, Veith FJ.  Inadequacy of the diagnosis related group (DRG) reimbursements for limb salvage lower extremity arterial reconstructions. J Vase Surg . 1990;;11:348-357.
49 +
Mackey WC, McCullough JL, Conlon TP, et al.  The costs of surgery for limb-threatening ischaemia. Surgery . 1986;;99:26-35.
50 +
National Center for Health Statistics. Vital Statistics of the United States 1988: Volume II-Mortality, Part A . Hyattsville, Md: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control; 1991;.
51 +
Howell MA, Colgan MP, Seeger RW, Ramsey DE, Sumner DS.  Relationship of severity of lower limb peripheral vascular disease to mortality and morbidity: a six-year follow-up study. J Vase Surg . 1989;;9:691-697.
52 +
Fowkes FGR.  Epidemiology of atherosclerotic arterial disease in the lower limbs. Eur J Vase Surg . 1988;;2:283-291.
53 +
Criqui MH, Langer RD, Fronek A, et al.  Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med . 1992;;326:381-386.
54 +
Wong JB, Sonnenberg FA, Salem DN, Pauker SG.  Myocardial revascularization for chronic stable angina: analysis of the role of percutaneous transluminal coronary angioplasty based on data available in 1989. Ann Intern Med . 1990;;113:852-871.
55 +
McDaniel MD, Cronenwett JL.  Basic data related to the natural history of intermittent claudication. Ann Vase Surg . 1989;;3:273-277.
56 +
Plecha FR, Bertin VJ, Plech EJ, et al.  The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases. J Vase Surg . 1985;;2:769-774.
57 +
Miller N, Dardik H, Wolodiger F, et al.  Transmetatarsal amputation: the role of adjunctive revascularization. J Vase Surg . 1991;;13:705- 711.
58 +
Weiss GN, Gorton A, Read RC, Neal LA.  Outcomes of lower extremity amputations. J Am Geriatr Soc . 1990;;38:877-883.
59 +
Ravioli CA, Nichter LS, Baker JD, Busuttil RW, Machleder HI, Moore WS.  Cost of treating advanced leg ischemia. Arch Surg . 1988;;123:495-496.
60 +
Gupta SK, Veith FJ, Ascer E, White Flores SA, Gliedman ML.  Cost factors in limb-threatening ischaemia due to infrainguinal arteriosclerosis. Eur J Vase Surg . 1988;;2:151-154.
61 +
Callow AD, Mackey WC.  Costs and benefits of prosthetic vascular surgery. Int Surg . 1988;;73:237-240.
62 +
Cheshire NJW, Wolfe JHN, Noone MA, Davies L, Drummond M.  The economics of femorocrural reconstruction for critical leg ischaemia with and without autologous vein. J Vase Surg . 1992;;15:167-175.
63 +
Wittels EH, Hay JW, Gotto AM.  Medical costs of coronary artery disease in the United States. Am J Cardiol . 1990;;65:432-440.
64 +
Hunink MGM, Wong JB.  Meta-analysis of failure time data with adjustment for covariates. Med Decis Making . 1994;;14:59-70.
65 +
Pentecost MJ, Criqui MH, Dorros G, et al.  Guidelines for peripheral percutaneous transluminal angioplasty of the abdominal aorta and lower extremity vessels. Circulation . 1994;;89:511-531.

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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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