2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS)

Lipoprotein particle profile in the presence of peripheral artery disease among patients with coronary heart disease: Data from the CORDIOPREV study

BACKGROUND

Dyslipidemia is recognized as a contributing factor to peripheral artery disease (PAD). However, the influence of lipoprotein subfractions as compared to traditional serum lipid levels is not well-understood.

OBJECTIVE

This study explores the association between lipoprotein subfractions and the occurrence of PAD in patients with coronary heart disease (CHD).

METHODS

In the CORDIOPREV study, 981 patients were categorized based on PAD diagnosis, determined by an ankle-brachial index (ABI) ≤0.9. Those with ABI >0.9 and <1.4 were considered PAD-free, while patients with ABI ≥1.4 were excluded. We employed high-throughput nuclear magnetic resonance (NMR) spectroscopy to analyze the concentration and lipid content of lipoprotein subfractions.

RESULTS

PAD patients exhibited significantly lower levels of medium high-density lipoprotein (HDL) particles and reduced concentrations of associated lipids within these subfractions except for triglycerides. A higher concentration of large or medium HDL particles correlated with a lower PAD prevalence (odds ratio [OR]: 0.61, 95% CI, 0.44-0.84; OR: 0.59, 95% CI, 0.43-0.81, respectively). In multivariate logistic regression, medium HDL particle levels inversely associated with PAD presence (OR: 0.69, 95% CI, 0.48-0.99, P = .044) after adjustment for confounding factors.

CONCLUSIONS

The presence of PAD among CHD patients inversely correlates with medium HDL particle concentrations as determined by NMR. These insights could advance our understanding of PAD pathophysiology and HDL metabolism.

Cost-effectiveness and budget impact analysis of rivaroxaban with or without aspirin compared to aspirin alone in patients with coronary and peripheral artery diseases in Iran

BACKGROUND

Low-dose aspirin and rivaroxaban are the cornerstone treatment for cardiovascular prevention in patients with peripheral artery disease (PAD) and/or stable coronary artery disease (SCAD). The combination of rivaroxaban with aspirin imposes a synergistic effect on the inhibition of factor-induced platelet aggregation. The present work aimed at comparing the cost-utility and cost-effectiveness of rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban alone (5 mg twice daily) with aspirin alone in patients with peripheral artery disease (PAD) or coronary artery disease (CAD) and related subgroups.

METHODS

This pharmacoeconomic study was performed based on the insurance organization and utilized a state-transition decision Markov model. From the COMPASS trial, Clinical efficacy and Clinical events were collected. Health outcomes and cost were assessed over a 20-year time horizon (lifetime). The direct costs of medical services were included in the analysis. The results were stated based on Incremental Cost-Utility (ICUR) and Incremental Cost Effectiveness Ratio (ICER). Uncertainty was assessed utilizing deterministic and probabilistic sensitivity analyses. Discount rates of .058 and .03 were included for cost and effectiveness data, respectively. The budget impact based on the Markov model was estimated as the financial burden resulting from the insurance coverage of rivaroxaban.

RESULTS

In the total of CAD and PAD patients, treatment with rivaroxaban plus aspirin and rivaroxaban alone were more expensive than the aspirin alone, but also more effective, resulting in ICUR being $4594/QALY and $13601/QALY respectively, and for ICER being $3348/LYG and $9901/LYG. In PAD patients rivaroxaban plus aspirin had higher effectiveness than aspirin alone that ICUR and ICER being $11929/QALY and $9896/LYG respectively. In CAD patients, treatment with rivaroxaban plus aspirin was expensive and less effective than aspirin alone. The estimated annual budget impact was $28,253,135 for the rivaroxaban plus aspirin and $292,593,909 for the rivaroxaban alone in the total of CAD and PAD patients.

CONCLUSIONS

This study showed that rivaroxaban plus aspirin is a cost-effective alternative in PAD and total of CAD and PAD patients. In CAD patients, rivaroxaban plus aspirin and rivaroxaban alone were not cost-effective.

Aspirin and Hemocompatibility After LVAD Implantation in Patients With Atherosclerotic Vascular Disease: A Secondary Analysis From the ARIES-HM3 Randomized Clinical Trial

Importance

The Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure (ARIES-HM3) study demonstrated that aspirin may be safely eliminated from the antithrombotic regimen after HeartMate 3 (HM3 [Abbott Cardiovascular]) left ventricular assist device (LVAD) implantation. This prespecified analysis explored whether conditions requiring aspirin (prior percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG], stroke, or peripheral vascular disease [PVD]) would influence outcomes differentially with aspirin avoidance.

Objective

To analyze aspirin avoidance on hemocompatibility-related adverse events (HRAEs) at 1 year after implant in patients with a history of CABG, PCI, stroke, or PVD.

Design, Setting, and Participants

This was an international, multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial including patients implanted with a de novo HM3 LVAD across 51 centers. Data analysis was conducted from April to July 2024.

Interventions

Patients were randomized in a 1:1 ratio to receive aspirin (100 mg per day) or placebo, in addition to a vitamin K antagonist (VKA) targeted to an international normalized ratio of 2 to 3 in both groups.

Main Outcomes and Measures

Primary end point (assessed for noninferiority) was a composite of survival free of any nonsurgical (>14 days after implant) HRAEs including stroke, pump thrombosis, bleeding, and arterial peripheral thromboembolism at 12 months. Secondary end points included nonsurgical bleeding, stroke, and pump thrombosis events.

Results

Among 589 of 628 patients (mean [SD] age, 57.1 [13.7] years; 456 male [77.4%]) who contributed to the primary end point analysis, a history of PCI, CABG, stroke, or PVD was present in 41% (240 of 589 patients). There was no interaction between the presence of an atherosclerotic vascular condition and effect of aspirin compared with placebo (P for interaction= .23). The preset 10% noninferiority margin was not crossed for the studied subgroup of patients. Thrombotic events were rare, with no differences between aspirin and placebo in patients with and without vascular disease (P for interaction = .77). Aspirin treatment was associated with a higher rate of nonsurgical major bleeding events in the group with prior vascular condition history compared with those without aspirin (rate ratio for placebo compared with aspirin, 0.52; 95% CI, 0.35-0.79).

Conclusions and Relevance

Results of this prespecified analysis of the ARIES-HM3 randomized clinical trial demonstrate that in patients with advanced heart failure who have classical indications for antiplatelet therapy use at the time of LVAD implantation, aspirin avoidance was safe and not associated with increased thrombosis risk. Importantly, elimination of aspirin was associated with no increased thrombosis but a reduction in nonsurgical bleeding events in patients with a history of PCI, CABG, stroke, or PVD.

Trial registration

ClinicalTrials.gov Identifier: NCT04069156.

Nutritional habits in patients with peripheral arterial disease: Adherence to the mediterranean diet

INTRODUCTION

Adherence to the Mediterranean diet (Dietmed) exerts protective effects on cardiovascular disease (CVD). In the Lower Extremity Peripheral Arterial Disease (PAD) there are fewer studies that analyze these data.

OBJECTIVE

To determine adherence to Dietmed and dietary habits in patients with PAD, according to a history of CVD (coronary and/or cerebral ischaemic pathology) and according to the ankle-brachial index (ABI ≥ or <0,5).

MATERIAL AND METHODS

Cross-sectional analytical study carried out in a tertiary hospital. The sample was collected consecutively. Sociodemographic and clinical history, ankle-brachial index (ABI) and a 14-point Dietmed adherence dietary questionnaire were included. The analysis of categorical variables was carried out using the Pearson's Chi-Square test, the T-Student's statistic test for independent samples was used for parametric variables and the U. Mann-Whitney test for non-parametric variables.

RESULTS

Of the 97 patients, 87,6% had low adherence to Dietmed, with no differences according to the severity of PAD. However, when we analysed the data according to whether or not they had a history of CVD, we observed a high adherence to some items included in Dietmed, specifically, in the CVD group, the consumption of lean meat (95,5% vs 64%; P=.004). In addition, we observed a significant difference in the consumption in the group without a history of CVD (32% vs 9,1%; P=.033).

CONCLUSION

In our population, patients with PAD, regardless of the stage of the disease and whether they had associated coronary or cerebral ischaemic pathology, had low adherence to Dietmed. Therefore, it is important to implement nutritional education programmes in patients with PAD in all stages, as well as in those patients who have already suffered a vascular event, so that they maintain adherence to healthy dietary habits in the long term.

Pre-distance assessment from radial artery to lower extremity arterial lesion

Endovascular treatment (EVT) for patients with lower extremity artery disease is widely used as a less invasive alternative to surgical bypass. Recently, transradial artery intervention has gained popularity owing to its minimally invasive nature. The distance from the radial artery to the target vessel is critical for success; however, effective pre-assessment methods have not yet been established. This study aimed to evaluate the usefulness of predistance measurements from the left radial artery using simple computed tomography (CT) images. In this study, distance measurements were performed from the left radial artery to the left and right iliac artery bifurcations and from the left radial artery to the common femoral artery at the upper femoral border. These distances, measured using CT images before and after the lower-extremity contrast study, were compared with the distances identified during the lower-extremity contrast study. Distances measured using simple CT images showed a high correlation with the distances identified during the lower-extremity contrast examination (r = 0.9317, p < 0.0001; from the left radial artery to the left and right iliac artery bifurcation; r = 0.9402, p < 0.0001; and from the left radial artery to the right common femoral artery at the upper femoral border). Our results suggest that pre-distance measurement using simple CT images can be a useful tool for EVT using the left radial artery approach. Although future large-scale studies are required, this technique merits consideration owing to its widespread adoption in clinical practice.

Clinical Comparison of High- and Low-Dose Drug-Coated Balloons for De Novo Chronic Total Occlusive Femoropopliteal Lesions

BACKGROUND

Endovascular therapy (EVT) with a drug-coated balloon (DCB) is an established treatment for patients with atherosclerotic lesions in the femoropopliteal (FP) artery, including complex lesions. Currently, 3 types of DCBs are available, but the most effective DCB for FP chronic total occlusive (CTO) lesions is unknown.

METHODS AND RESULTS

In this retrospective, single-center study, we enrolled 539 consecutive patients (562 FP lesions) treated with EVT between January 2018 and December 2022. Of these patients, 161 with FP CTO lesions who underwent EVT with DCBs were included. Propensity-score matching was performed to compare the clinical outcomes of the high-dose (HD) and low-dose (LD) DCB groups, resulting in the analysis of 56 matched pairs. Primary patency and freedom from target lesion revascularization were significantly higher with HD-DCB than with LD-DCB (89.9% vs. 70.8%, respectively P=0.03; and 93.6% vs. 79.7%, respectively, P=0.046). Multivariate analysis showed that a larger minimum lumen area and the use of HD-DCB (vs. LD-DCB) were favorable predictors of primary patency at 1 year, while a small vessel diameter (≤4.5 mm) was an unfavorable predictor.

CONCLUSIONS

For FP CTO lesions, EVT performed with HD-DCB is superior to that with LD-DCB.

Diagnostic limitations in advanced stage peripheral arterial disease in a cadaveric study comparing photon-counting and energy-integrating CT detectors

To evaluate the limits of 1st-generation dual-source photon-counting detector CT (PCD-CT) and 3rd-generation dual-source energy-integrating-detector (EID-CT) regarding imaging of advanced stage peripheral arterial disease (ASPAD) of the femoral runoff. One human cadaver with ASPAD of the superficial femoral arteries was surgically prepared to establish continuous extracorporeal perfusion of the right upper leg. In addition to one stent already in place, three more stents were deployed in positions with severe calcification and stenosis to create thirteen different scenarios of ASPAD. CT angiographies with different radiation dose (CTDIvol 10, 5, 3 mGy) and matching convolution kernels were performed with PCD-CT and EID-CT. In-stent lumen visibility, signal-to-noise ratio (SNR), and luminal attenuation were assessed quantitatively. Results were compared using analyses of variance with a PCD-CT maximum dose and resolution scan (96 mGy, BV89) serving as standard of reference. Highest and lowest stent lumen visibility was observed with PCD-CT BV76 (97 ± 2%) and EID BV40 (77 ± 5%), respectively. Severe stent underexpansion in conjunction with heavy calcification resulted in the worst lumen visibility. PCD-CT displayed superior dose efficiency, yielding comparable SNR at 3 mGy to EID-CT at 10 mGy (p = 0.27). Luminal attenuation was higher for PCD-CT regardless of dose and reconstruction settings (max. 369 ± 19 HU, BV76, 5 mGy vs. 329 ± 12 HU for EID, BV59, 5 mGy; p < 0.001). PCD-CT realises substantially higher image quality than EID-CT, thereby enhancing assessment of the femoral vasculature in ASPAD. Furthermore, this indicates substantial radiation dose and contrast agent volume saving potential. Both scanners show limitations in very low luminal diameters.

Diabetes in Peripheral Artery Disease: Prevalence, Complications, and Polypharmacy

Background: Patients with peripheral artery disease (PAD) and diabetes face high risks of comorbidities, tissue loss, and cardiovascular events. As global type 2 diabetes (T2DM) prevalence rises, so does its incidence in symptomatic patients with PAD, though this population is under-studied in Australia. This cross-sectional analysis sought to characterize PAD patients with diabetes regarding prevalence, major complications, medication use, and prescribing patterns, comparing them to non-diabetic PAD patients. We also examined PAD complications in relation to diabetic control. Methods: This cross-sectional study looked at the baseline data from 105 PAD participants in the TEAM-PAD randomized controlled trial that were analyzed using descriptive statistics, prevalence odds ratios and regression analysis. Participants were recruited between June 2023 and August 2024 from public clinics, private surgeons, and Concord Repatriation General Hospital, Sydney. Results: Diabetes prevalence was 52.83% (n = 56) with 29.5% (n = 31) of participants with T2DM having uncontrolled hyperglycemia (HbA1c ≥ 7%), which was weakly negatively correlated with age (r = -0.372, p = 0.039). Participants with T2DM were twice as likely to have a history of coronary artery disease (POR 2.43; 95% with a 95% confidence interval (CI) between 1.09-5.43, and over three times as likely to have tissue loss (POR 3.39; 95% CI 1.22-9.43). The odds of polypharmacy (≥5 medications) were 10 times greater in participants with T2DM (POR 10.8; 95% CI 2.31-50.4), affecting 96.4% of this group. Conclusions: Diabetes prevalence and associated complications were higher than previous estimates, underscoring the challenges in managing diabetes and polypharmacy in participants with PAD. A multidisciplinary approach may improve outcomes.

Clinical outcomes in patients with chronic limb-threatening ischemia after femoropopliteal intervention with a drug-coated balloon or stenting

OBJECTIVE

Endovascular treatment (EVT) for patients with an occlusive lesion of the femoropopliteal artery is performed worldwide due to its effectiveness. However, lesions in chronic limb-threatening ischemia (CLTI) are complex and a major concern in superficial femoral artery (SFA) EVT. Despite this, a detailed study of SFA EVT, and especially selection of the final device as a drug-coated balloon (DCB) or a stent, has not been performed in patients with CLTI. The aim of this stud was to compare the clinical outcomes of SFA EVT using a DCB or a stent in patients with CLTI.

METHODS

A multicenter retrospective observational study was performed at 21 Japanese centers. Comparisons were made between patients undergoing initial SFA EVT with a DCB or stenting after inverse probability of treatment weighting using the propensity score to control for potential confounding (patient demographics, comorbidities, medications, and procedural details). The primary outcome measure was major adverse limb events (MALE). We adopted cause-specific hazard models, using Fine and Gray's proportional hazards model in which death was treated as a competing risk. Secondary outcome measures were also evaluated: (1) technical success; (2) slow flow; (3) death within 30 days; (4) major adverse events within 30 days; (5) restenosis; (6) target lesion revascularization; (7) acute occlusion; (8) wound healing; (9) major amputation; and (10) all-cause mortality.

RESULTS

The study included 900 CLTI cases that underwent EVT with a DCB (n = 458) or stenting (n = 442) and had a median follow-up period of 17.5 months (interquartile range, 6.2-31.9 months). The DCB group had a lower risk of MALE than the stent group, with a hazard ratio of 0.68 (95% confidence interval, 0.52-0.89; P = .005). Subsequent analysis for the secondary outcome measures demonstrated that the DCB group had a higher prevalence of postprocedural slow flow and a lower incidence rate of acute occlusion (both P < .005 after Bonferroni correction).

CONCLUSIONSS

DCB angioplasty had a lower risk of MALE than stenting. These results suggest that a DCB might be more beneficial in initial SFA intervention in patients with CLTI.

The relationship between weight-adjusted waist index and peripheral artery disease

Background

Obesity is a significant risk factor for peripheral arterial disease (PAD). The weight-adjusted waist index (WWI) is a novel obesity metric that better reflects abdominal obesity than traditional body mass index (BMI). However, research on the relationship between WWI and PAD remains scarce.

Methods

Relevant data from the NHANES 1999-2004 were selected. Multiple logistic regression and restricted cubic spline (RCS) analyses were used to assess the relationship between WWI and the risk of PAD. Additionally, the area under the curve (AUC) of the receiver operating characteristic (ROC) was used to evaluate the predictive ability of WWI for PAD.

Results

A total of 5,686 participants were included in the study, of whom 476 had PAD and 5,210 did not. The results of multiple logistic regression showed that WWI was significantly positively associated with the risk of PAD after full adjustment for covariates (OR: 1.407, 95% CI: 1.100-1.799). Additionally, compared to the first quartile of WWI, the risk of PAD significantly increased in the second quartile (OR: 2.042, 95% CI: 1.333-3.129), third quartile (OR: 2.134, 95% CI: 1.354-3.364), and fourth quartile (OR: 2.491, 95% CI: 1.435-4.325). The ROC results showed that the AUC value for WWI was 0.697, while the AUC value for BMI was 0.520. Compared to BMI, WWI has a better predictive value for the risk of PAD.

Conclusion

There is a significant positive correlation between WWI and the risk of PAD. For individuals with high WWI, efforts should be made to reduce WWI to prevent the onset of PAD.

Systematic Review of Interleukin-35 in Endothelial Dysfunction: A New Target for Therapeutic Intervention

Endothelial dysfunction is a significant factor in the pathogenesis of various diseases. In pathological states, endothelial cells (ECs) undergo activation, resulting in dysfunction characterized by the stimulation of inflammatory responses, oxidative stress, cell proliferation, blood coagulation, and vascular adhesions. Interleukin-35 (IL-35), a novel member of the IL-12 family, is primarily secreted by regulatory T cells (Tregs) and regulatory B cells (Bregs). The role of IL-35 in immunomodulation, antioxidative stress, resistance to apoptosis, control of EC activation, adhesion, and angiogenesis in ECs remains incompletely understood, as the specific mechanisms of IL-35 action and its regulation have yet to be fully elucidated. Therefore, this systematic review aims to comprehensively investigate the impact of IL-35 on ECs and their physiological roles in a range of conditions, including cardiovascular diseases, tumors, sepsis, and rheumatoid arthritis (RA), with the objective of elucidating the potential of IL-35 as a therapeutic target for these ailments.

Prevalence, numbers and mortality risk of hypertensive patients with depressive symptom in China

BACKGROUND

China is currently grappling with the escalating burden of hypertension and depression. This study aimed to assess the prevalence and number of hypertensive patients with depressive symptom, and to evaluate their risk of all-cause mortality.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) were utilized to estimate the prevalence of individuals with both hypertension and depressive symptom, the recommendation rate for antihypertensive medications, the blood pressure control rate, and the corresponding population size. The Cox proportional hazard model was employed to estimate the risk of all-cause mortality associated with hypertension combined with depressive symptom.

RESULTS

Overall, 15.01% (95% CI: 13.80, 16.31) of adults, corresponding to 72.06 million (95% CI: 66.91, 77.23) individuals, were identified as having both hypertension and depressive symptom. Among these, 28.49 million (95% CI: 27.07, 29.92) were recommended to initiate blood pressure medications but did not comply. Furthermore, 19.53 million (95% CI: 18.01, 21.06) hypertensive patients with depressive symptom who were taking antihypertensive medications did not achieve their blood pressure control goals. Hypertension combined with depressive symptom was associated with an increased risk of all-cause mortality (hazard ratio = 2.21, 95% CI: 1.48, 3.31).

CONCLUSIONS

Our findings indicated a significant population of individuals with both hypertension and depressive symptom in China, with low treatment and control rates. The coexistence of hypertension and depression was linked to a heightened risk of all-cause mortality. Strategies for hypertension prevention and treatment should be integrated with considerations for depression.

CLINICAL TRIAL NUMBER

Not applicable.

Association of rs3798220 Polymorphism with Cardiovascular Incidents in Individuals with Elevated Lp(a)

Background/Objectives: Lipoprotein (a) [Lp(a)] plays a significant role in atherosclerosis and cardiovascular disease (CVD). Genetic regulation of Lp(a) involves variations in the apo(a) LPA gene, as specific polymorphisms like rs10455872 and rs3798220, both linked to higher Lp(a) levels and CVD. CVD remains the leading global cause of death, with high Lp(a) levels increasingly recognized as a significant factor in younger patients with no other CVD risk factors. We aimed to evaluate the association of LPA genetic variations with Lp(a) levels and its effect on cardiovascular risk as there are existing inconsistent findings. Methods: This case-control study included 251 subjects with a median age of 52 years (interquartile range, IQR = 17) and elevated Lp(a) levels. Cases were subjects who experienced early cardiovascular incidents (women < 65, men < 55 years old), and the control group included subjects without such history. Genotyping of LPA gene polymorphisms (rs10455872 and rs3798220) was performed, and demographic data with Lp(a) levels were collected. To evaluate the association between the LPA genotypes and the risk of cardiovascular incidents (CVI), several logistic regression models were performed. The cut-off points for Lp(a) levels were determined using diagnostic test accuracy measures. Results: The rs3798220-C allele was associated with higher Lp(a) levels (288 ± 166 nmol/L in cases vs. 189 ± 102 nmol/L in controls, p < 0.001) and myocardial infarction (53% in cases vs. 36% in controls, p = 0.036). Among cases, 28.9% carried the rs3798220-C allele, compared to 18.7% in controls. The rs10455872-G allele was slightly more prevalent in controls (34.15% vs. 29.69%) but without further significant associations. In this study, the cut-off Lp(a) value of 151 nmol/L, for patients with a positive family history of early CVD, is associated with a higher chance of developing CVI. Conclusions: This study demonstrates an association between the LPA rs3798220-C allele and higher Lp(a) levels, as well as an increased risk of early onset myocardial infarction. However, the obtained association should further be evaluated at a much larger scale.

Objective Evaluation With Noncontrast Computed Tomography Can Reveal Calcified Plaque Solidity in Peripheral Artery Diseases

PURPOSE

The presence of severely calcified plaque remains problematic in endovascular therapy, and no specific endovascular treatment strategy has been established. Estimating plaque solidity before the procedure may help operators penetrate calcified plaque with a guide wire. The aim of this study was to establish a method of measuring plaque solidity with noncontrast computed tomography (CT).

METHODS

This retrospective, single-center study included consecutive patients who, between October 2020 and July 2022, underwent noncontrast 5 mm and 1 mm CTs before endovascular therapy to penetrate calcified plaque with a wire in the common femoral, superficial femoral, and popliteal arteries. Three cross-sectional CT slices were selected. To target a calcified plaque lesion, the operator identified a region of interest, which corresponded to 24×24 pixels, and Hounsfield unit (HU) values of each pixel were displayed on the CT image. The average HU values and the ratio of number of pixels of lower values (130-599 HU) represented plaque solidity. We used the Mann-Whitney-Wilcoxon rank-sum test and the chi-square test to compare the solidity of plaques penetrated and not penetrated by the wire.

RESULTS

We evaluated 108 images of 36 calcified plaque lesions (in 19 patients). The wire penetrated 28 lesions (77.8%) successfully. The average HU value was significantly lower in the lesions that the wire penetrated than in the others, in both the 5 mm CT slices (434.7±86.8 HU vs 554.3±112.7 HU, p=0.0174) and 1 mm slices (497.8±103.1 HU vs 593.5±114.5 HU, p=0.0381). The receiver operating curve revealed that 529.9 and 533.9 HU in the 5 and 1 mm slices, respectively, were the highest values at which wires could penetrate. Moreover, at the lesions that were penetrates successfully, the ratio of number of lower HU value pixels was significantly higher both in 5 mm slice CTs (74.7±13.4 vs 61.7±13.1%, p=0.0347) and 1 mm (68.7±11.8 vs 57.1±11.4%, p=0.0174).

CONCLUSION

The use of noncontrast CT to evaluate plaque solidity was associated with successful wire penetration of calcified lesions in peripheral arteries.

CLINICAL IMPACT

This study revealed an association between the wire penetration inside calcified plaque and plaque solidity estimated using non-contrasted computed tomography. The mean Hounsfield unit values of three cross-sections in calcified plaques were associated with the successful wire penetration. This wire penetration difficulty is associated with extended procedure time, excessive radiation exposure, usage of extra contrast agents, and increased medical costs. Therefore, estimating calcified plaque solidity before procedure enables us to choose effective and lean procedures. In addition, to predict the success of dilating calcified plaque from the inside is also beneficial when the operator wants to avoid extra scaffold implantation for target lesions.

Comparison of Covered Stent versus Bare-Metal Stent Implantation in Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis

PURPOSE

This systematic review aimed to compare covered stent (CS) and bare-metal stent (BMS) implantation in treating aortoiliac occlusive disease.

MATERIALS AND METHODS

Comprehensive searches were conducted in the MEDLINE, Embase, and Cochrane Library databases for all pertinent studies. The end points included primary patency, secondary patency, freedom from target lesion revascularization (TLR), technical success, ankle-brachial index (ABI) improvement, periprocedural adverse events, major amputation, and mortality. Odds ratios (OR) or risk differences with 95% CIs were used to estimate the binary variables. The continuous variables were presented as mean difference (MD) with 95% CI.

RESULTS

Ten studies involving 1,861 limbs were included. For overall outcomes, compared with BMS, CS showed significantly superior in freedom from TLR (OR, 3.00; 95% CI, 1.05-8.51; P = .04) and ABI (MD, 0.03; 95% CI, -0.00 to 0.06; P = .04). No significant differences were found in technical success, primary patency (at 12, 24, 36, and 60 months), secondary patency, periprocedural adverse events, major amputation rates, and early mortality. Subgroup analyses favored CS in ABI improvement (MD, 0.06; 95% CI, 0.02-0.11; P = .01) after propensity score matching, and covered balloon-expandable stents demonstrated certain advantages in freedom from TLR (OR, 4.60; 95% CI, 1.79-11.81; P = .002). Additionally, no significant difference in primary patency at 36 months between the 2 groups with Trans-Atlantic Inter-Society Consensus D or severe calcification lesions.

CONCLUSIONS

Compared with BMS, CS presented advantages in reducing TLR and enhancing ABI improvement. Meanwhile, CS demonstrated comparable technical success, primary patency, secondary patency, periprocedural adverse events, major amputation rates, and early mortality.

[What is new in the management of peripheral arterial occlusive disease and diseases of the aorta? : Highlights of the ESC guidelines 2024]

The European Society of Cardiology (ESC) guidelines on peripheral arterial disease (PAD) and diseases of the aorta published in September 2024 for the first time combine recommendations for both diseases in a joint guideline document. The consolidation of PAD and aorta guidelines follows a holistic approach, which underlines the entirety of the arterial vascular system. This aim is underlined by a specifically introduced recommendation to take the entirety of the circulatory system into account in patients with vascular diseases. The focus in the current ESC guideline document is on a multidisciplinary, patient-centered management of PAD and diseases of the aorta, whereby the prevention and follow-up of patients after therapeutic interventions are emphasized. In PAD the document highlights exercise training and the procedure for patients with chronic wounds as well as risk stratification and hereditary diseases of the aorta.

Long-Term Outcomes of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique in Patients With Aorto-Iliac Occlusive Disease

BACKGROUND

The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) reconstruction is an endovascular technique, developed to reconstruct the aortic bifurcation in the most optimal anatomical and physiological manner. Short-term data were promising, but long-term data are still lacking. The objective was to report the long-term outcomes of CERAB for extensive aorto-iliac occlusive disease and to identify predictors for loss of primary patency.

METHODS

Consecutive electively treated patients with CERAB for aorto-iliac occlusive disease in a single hospital were identified and analyzed. Baseline and procedural data and follow-up were collected at 6-weeks, 6 months, 12 months, and annually thereafter. Technical success, procedural, and 30-day complications were evaluated, as well as overall survival. Patency and freedom from target lesion revascularization rates were analyzed using Kaplan Meier curves. Uni- and multivariate analysis were performed to identify possible predictors of failure.

RESULTS

One hundred and sixty patients were included (79 male). Indication for treatment was intermittent claudication for 121 patients (75.6%) and 133 patients (83.1%) had a TASC-II D lesion. Technical success was obtained in 95.6% of patients and the 30-day mortality rate was 1.3%. The 5-year primary, primary-assisted, and secondary patency rates were 77.5%, 88.1%, and 95.0%, respectively, with a freedom-from clinically driven target lesion revascularization (CD-TLR) rate of 84.4%. The strongest predictor of loss of primary patency of CERAB was a previous aorto-iliac intervention (odds ratio [OR]=5.36 (95% confidence interval [CI]: 1.30; 22.07), p=0.020). In patients not previously treated in the aorto-iliac tract, 5-year primary, primary assisted, and secondary patency rates were 85.1%, 94.4%, and 96.9%, respectively. At 5-year follow-up, an improved Rutherford was found in 97.9% of patients and the freedom from major amputation rate was 100%.

CONCLUSION

The CERAB technique is related to good long-term outcomes, particularly in primary cases. In patients that had prior treatment for aorto-iliac occlusive disease, there were more reinterventions and therefore surveillance should likely be more intense.

CLINICAL IMPACT

The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) reconstruction was designed to improve outcomes of endovascular treatment of extensive aorto-iliac occlusive disease. At 5-year follow-up clinical improvement was found in 97.9% of patients without major amputations. The 5-year overall primary, primary-assisted, and secondary patency rates were 77.5%, 88.1%, and 95.0%, respectively, with a freedom-from clinically driven target lesion revascularization rate of 84.4%. Significantly better patency rates were observed for patients that were never treated before in the target area. The data implicate that CERAB are a valid treatment option for patients with extensive aorto-iliac occlusive disease. For patients previously treated in the target area, other treatment options might be considered, or more intensive follow-up surveillance is warranted.

Impact of Below-the-Knee Runoff in Patients With Lower Extremity Artery Disease Who Underwent Endovascular Therapy Using Drug-Coated Balloons in Femoropopliteal Lesions

BACKGROUND

The impact of below-the-knee (BK) runoff after drug-coated balloon (DCB) treatment in femoropopliteal (FP) lesions has not been well investigated.

METHODS

This retrospective multicenter observational study enrolled 291 consecutive patients with lower extremity artery disease who underwent endovascular therapy with DCBs for FP lesions between January 2018 and December 2021. Patients were classified into four groups based on the BK runoff. Outcome measures included primary patency, freedom from clinically driven target lesion revascularization (CD-TLR) and amputation, and overall survival rates at 24 months. The predictors of restenosis at 24 months were also investigated.

RESULTS

In total, 43, 98, 117, and 33 patients were classified into three, two, one, and no BK runoff groups, respectively. In three, two, one, and no BK runoff groups, the primary patency rates were 72.1%, 67.3%, 61.4%, and 44.1% (p = 0.028); freedom from CD-TLR rates were 87.1%, 78.8%, 71.7%, and 47.1% (p < 0.001); freedom from amputation rates were 95.2%, 97.9%, 92.8%, and 91.5% (p = 0.499); and overall survival rates were 89.4%, 83.2%, 76.6%, and 61.2% (p = 0.007), respectively, at 24 months. Multivariate analysis showed that chronic limb-threatening ischemia, no BK runoff, Lutonix use, and residual stenosis > 30% were independent predictors of primary patency loss at 24 months. The risk score, calculated as the number of predictors, reflected the risk of restenosis.

CONCLUSION

No BK runoff was associated with worse midterm primary patency, freedom from CD-TLR, and overall survival rates than at least one BK runoff.

Employing magnetic resonance histology for precision chronic limb-threatening ischemia treatment planning

OBJECTIVE

Recent randomized controlled trials have demonstrated a notable prevalence of immediate technical failures in percutaneous vascular interventions (PVIs) for complex arterial lesions associated with chronic limb-threatening ischemia. Current imaging modalities present inherent limitations in identifying these lesions, making it challenging to determine the most suitable candidates for PVI. We present a novel preprocedural magnetic resonance imaging (MRI) histology protocol for identifying lesions that might present a higher rate of immediate and midterm PVI failure.

METHODS

We enrolled 22 patients (13 females, average age 65.8 ± 9.72 years) scheduled for PVI were prospectively and underwent 3T MRI using ultrashort echo time and steady-state free precession contrasts to characterize target lesions before PVI. Lesions were scored as hard if >50% of the lumen was occluded by hard components (calcium/dense collagen) on MRI in the hardest cross-section. Two readers evaluated MRI datasets. Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC)/Global Limb Anatomic Staging System (GLASS)/Wound, Ischemia and Foot infection scoring was performed based on intraprocedural angiograms and chart review. The relationship between MRI scoring, TASC/GLASS scoring, and procedural outcomes was investigated using univariate analysis. Midterm follow-up (revascularization and amputation rates) was recorded at 3 and 6 months after the intervention.

RESULTS

Our cohort of 22 patients yielded 40 target lesions. Five lesions were excluded (two for nondiagnostic image quality; three PVIs were ultimately diagnostic only). Six lesions (17%) were scored as hard. MRI-scored hard lesions had a higher proportion of immediate technical failure (hard vs soft 83% [5/6] vs 3% [1/29]; P < .001). Hard vs soft MRI scoring was the only factor significantly associated with immediate PVI technical success (P < .001), as opposed to TASC/GLASS scoring. Both at 3 months and 6 months after PVI, the reintervention rate was significantly higher among those lesions which were scored hard on MRI (3 months hard, 80% vs soft, 16% [P =.011]; 6 months hard, 80% vs soft, 27%; P = .047).

CONCLUSIONS

MRI histology could be a valuable tool for optimizing PVI patient selection and treatment strategies.

Stent Implantation and Thromboendarterectomy for the Common Femoral Artery in Real-World Practice

PURPOSE

To compare the outcomes of thromboendarterectomy (TEA) and endovascular therapy (EVT) with stenting for patients with atherosclerotic common femoral artery (CFA) occlusive disease.

MATERIALS AND METHODS

From a retrospective registry of 1193 consecutive patients with CFA treatment performed between 2018 and 2020 at 66 institutions in Japan, we identified patients who underwent TEA (n=432) or stent implantation (n=157). The primary outcome measures were the 1-year primary patency of TEA versus stenting with propensity score matching. The secondary outcome measures were perioperative complications, length of hospital stay, any reintervention, limb salvage, and overall survival. Interaction analysis for primary patency was performed with propensity score stratification to determine the appropriate target population for CFA stenting.

RESULTS

Propensity score matching extracted 101 pairs (101 patients in the EVT group and 253 patients in the TEA group). The 1-year primary patency rate was significantly higher in the TEA cohort (92.8% vs 84.6%, p=0.006). The freedom from reintervention rate was also significantly higher in the TEA cohort (94.0% vs 89.9%, p=0.030). However, the 1-year limb salvage (98.7% vs 100.0%, p=0.32), 1-year overall survival (90.8% vs 85.0%, p=0.14), and frequency of perioperative complications were not significantly different between the cohorts (6.9% vs 14.2%, p=0.10). Based on interaction analysis, the superiority of TEA over EVT in terms of patency was less apparent in patients with advanced age and chronic heart failure.

CONCLUSIONS

Thromboendarterectomy was superior to stenting in terms of primary patency and freedom from revascularization at 1 year. There was no significant difference in the incidence of perioperative complications between both groups. Thromboendarterectomy may be recommended as the standard treatment strategy for patients with atherosclerotic CFA disease, whereas stenting may be considered for patients with advanced age and chronic heart failure.

CLINICAL IMPACT

Thromboendarterectomy compared to stenting was the preferred revascularization strategy for patients with CFA disease in terms of primary patency and freedom from target lesion revascularization during the 1st year. The difference was attenuated in subgroups with advanced age (85 years or older) or chronic heart failure, thus stenting may be considered in patients with these backgrounds.

Elevated Iliac Calcium Score as a Marker of Coronary Calcification and Overall Atherosclerotic Risk

BACKGROUND

The initial assessment of cardiovascular risk in patients undergoing lower limb revascularization surgery is crucial to minimize complications and improve outcomes. This study aims to determine if the iliac calcium score (ICS) serves as a cardiologic risk marker by examining its correlation with the coronary calcium score (CCS) in these patients.

METHODS

This prospective observational single-center study included 248 patients with critical limb ischemia undergoing revascularization procedures from January 2022 to June 2023. Baseline characteristics such as age, gender, smoking status, comorbidities, and clinical status were recorded. CCS and ICS were calculated using preoperative computed tomography angiography. Multiple linear regression identified significant predictors of ICS, including CCS, iliac intima-media thickness (i-IMT), coronary artery disease, diabetes, chronic kidney disease, hypertension, dyslipidemia, and smoking.

RESULTS

The study population had a mean age of 74.4 years, 83.86% male. Significant correlations were found between ICS and CCS (Pearson r = 0.34, P < 0.001) and between ICS and i-IMT (Pearson r = 0.35, P < 0.001). Regression analysis revealed significant predictors for ICS, including CCS (coefficient = 1.808, P < 0.0001), i-IMT (coefficient = 3.11, P < 0.0001), coronary artery disease (coefficient = 11.94, P = 0.042), diabetes (coefficient = 19.59, P = 0.002), chronic kidney disease (coefficient = 11.79, P < 0.0001), and hypertension (coefficient = 22.10, P = 0.001). Dyslipidemia and smoking did not show significant associations with ICS.

CONCLUSIONS

The ICS shows a statistically significant association with the CCS and i-IMT in patients undergoing lower limb revascularization surgery. This correlation suggests that ICS reflects vascular calcification patterns like those observed in coronary arteries. Further studies are needed to explore this relationship in diverse patient populations and under varying clinical conditions.

Assessment of renal artery stenosis using renal fractional flow reserve and correlation with angiography and color Doppler ultrasonography: data from FAIR-pilot trial

Renal fractional flow reserve (rFFR), a hemodynamic evaluation indicator for functional measurement, could be used for the detection of significant renal artery stenosis (RAS). In this study, we evaluated the correlation between color Doppler ultrasonography (CDU), angiography and rFFR in assessing RAS and to validate cut-off points of ultrasound parameters for significant RAS with rFFR<0.8. A total of 77 renal artery lesions from 58 patients with at least unilateral RAS were included into this study. All patients were participated in Fractional Flow Reserve to Determine the Appropriateness of Percutaneous Renal Artery Intervention in Atherosclerosis Renal Hypertension Patients (FAIR)-pilot study (NCT05732077). The rFFR was measured through a pressure wire after renal hyperemia induced by dopamine. Peak systolic velocity (PSV), renal-to-aortic ratio (RAR), resistive index (RI) and side-to-side differences of the intrarenal resistive indices (ΔRI) were obtained by CDU. The rFFR showed good correlation with both CDU and angiography assessment methods. Among CDU parameters, the best correlation was observed in rFFR with PSV (rho = -0.668, P < 0.0001) and RAR (rho = -0.597, P < 0.001). With a rFFR<0.80 as cut-off value for significant RAS, we computed sensitivity, specificity, and area under the curve (AUC) of CDU parameters. The most predicting cut-off points of CDU parameters were calculated as PSV for 2.415 m/s, RAR for 4.495, RI for 0.605 and ΔRI for 0.04, respectively. A PSV > 2.415 m/s provided a sensitivity of 90%, specificity of 75%, accuracy of 81% and AUC of 0.84 for detecting RAS with rFFR<0.8.

Carotid Ultrasound Assessment Prior to Coronary Artery Bypass Grafting - An Irish Cardiac Surgery Center's Experience

BACKGROUND

Carotid stenosis is a risk factor for cerebrovascular accident (CVA) following coronary artery bypass grafting (CABG). Guidelines recommend selective preoperative screening with Doppler ultrasound (US) but nonselective application is commonplace. Recent data has questioned the efficacy of perioperative carotid intervention, challenging the value of this practice. We thus aimed to analyze the utility of carotid US assessment prior to CABG in our institution.

METHODS

This was a retrospective review of all patients over 18 that underwent a nonemergency CABG in a single Irish cardiac surgery center from January 2019 to December 2022.

RESULTS

1161 subjects were included. 1084/1161 (93.36%) underwent US assessment. 41/1084 (3.8%) had ≥70% stenosis and 189/1084 (17.5%) had ≥50% stenosis. 32/1084 (2.95%) underwent confirmatory imaging and 7/1084 (0.64%) underwent carotid intervention. Postoperative CVA occurred in 18/1161 (1.55%) and ≥70% (P = 0.024) and ≥50%(P < 0.001) carotid stenosis were associated with same. Chronic kidney disease (odds ratio [OR] = 1.66,P = 0.01), decreasing hemoglobin (OR = 1.13,P = 0.019), increasing age (OR = 1.03,P = 0.011) and being a current (OR = 3.21,P < 0.001) or ex-smoker (OR = 1.82,P = 0.004) were risk factors for ≥50% carotid stenosis on logistic regression. Multivessel coronary artery disease (CAD) was not associated with carotid stenosis (P = 0.563). Of those that underwent carotid intervention, 0/7 (0%) suffered a CVA, but this protective effect failed to reach statistical significance for those with ≥70% (P = 1) or ≥50% (P = 1) carotid stenosis.

CONCLUSIONS

Carotid US screening altered the management of only a small proportion of CABG patients despite near universal application, challenging the effectiveness of this practice. Multivessel CAD was not associated with carotid stenosis despite European guidelines listing it as screening criteria. Predictive models must be developed using identified risk factors to enable targeted preoperative screening.

Role of C-Reactive Protein as a Predictor of Early Revascularization and Mortality in Advanced Peripheral Arterial Disease

Background: Elevated high-sensitivity C-reactive protein (hsCRP) levels are associated with poor cardiovascular outcomes, particularly in patients with advanced peripheral arterial disease (PAD). This study aimed to assess the impact of hsCRP on clinical characteristics and long-term outcomes in a cohort of PAD patients. Methods: A total of 346 patients with advanced PAD were enrolled and stratified into two groups based on their median hsCRP level (Group 1: <0.32 mg/dL, Group 2: >0.32 mg/dL). The patients were followed for a mean of 102.70 ± 44.13 months. Their clinical characteristics, comorbidities, and long-term cardiovascular events, including myocardial and/or peripheral revascularization, ischemia, and death, were analyzed. This study evaluated two composite endpoints: major adverse cardiovascular events (MACEs) and major adverse peripheral events (MAPEs). MACEs comprised fatal cardiovascular events, cerebral ischemia, cardiac infarction, myocardial revascularization, acute peripheral arterial occlusion, and peripheral reperfusion. MAPEs included carotid reperfusion, acute peripheral arterial occlusion, and lower limb revascularization. Results: The patients in Group 2 had a higher body mass index, waist circumference, and waist-hip ratio compared to those in Group 1 (all p < 0.05). Inflammatory markers, including fibrinogen and the erythrocyte sedimentation rate, were significantly elevated in Group 2 (both p < 0.01). While the overall incidence of peripheral revascularization was similar between groups, these interventions occurred significantly earlier in Group 2 (28.24 ± 38.87 months vs. 67.04 ± 49.97 months, p = 0.004; HR: 2.015, 95% CI: 1.134-3.580, p = 0.017). The MAPEs were comparable in number, but occurred earlier in Group 2 (36.60 ± 37.35 months vs. 66.19 ± 48.18 months, p < 0.01; HR: 1.99, 95% CI: 1.238-3.181, p = 0.004). Similarly, the MACEs had an earlier onset in Group 2 (40.31 ± 38.95 months vs. 55.89 ± 46.33 months, p = 0.04; HR: 1.62, 95% CI: 0.983-1.987, p = 0.062). A total of 169 deaths were recorded during the follow-up. Group 2 exhibited a significantly higher mortality rate (56% vs. 42%, p < 0.01) and an earlier trend in mortality (76.58 ± 43.53 months vs. 84.86 ± 5.18 months), although this difference did not reach statistical significance (p = 0.22). Conclusions: Elevated hsCRP levels (>0.32 mg/dL) are associated with a worse clinical profile and earlier adverse events in patients with advanced PAD. Group 2 experienced significantly earlier peripheral revascularization, MACEs, and MAPEs. The mortality rates were also significantly higher, highlighting the prognostic value of hsCRP in this population.

Impact of duration of dual anti-platelet therapy on risk of complications after stent-assisted coiling of unruptured aneurysms

BACKGROUND

The optimal duration for dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC) of intracranial aneurysms is unclear. Longer-term therapy may reduce thrombotic complications but increase the risk of bleeding complications.

METHODS

A retrospective review of prospectively maintained data at 12 institutions was conducted on patients with unruptured intracranial aneurysms who underwent SAC between January 1, 2016 and December 31, 2020, and were followed ≥6 months postprocedure. The type and duration of DAPT, stent(s) used, outcome, length of follow-up, complication rates, and incidence of significant in-stent stenosis (ISS) were collected.

RESULTS

Of 556 patients reviewed, 450 met all inclusion criteria. Nine patients treated with DAPT <29 days after SAC and 11 treated for 43-89 days were excluded from the final analysis as none completed their prescribed duration of treatment. Eighty patients received short-term DAPT. There were no significant differences in the rate of thrombotic complications during predefined periods of risk in the short, medium, or long-term treatment groups (1/80, 1.3%; 2/188, 1.1%; and 0/162, 0%, respectively). Similarly, no differences were found in the rate of hemorrhagic complications during period of risk in any group (0/80, 0%; 3/188, 1.6%; and 1/162, 0.6%, respectively). Longer duration DAPT did not reduce ISS risk in any group.

CONCLUSIONS

Continuing DAPT >42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis, although the risk of additional hemorrhagic complications remained low. It may be reasonable to discontinue DAPT after 42 days following non-flow diverting SAC of unruptured intracranial aneurysms.

Contribution of type 2 diabetes to major adverse cardiovascular events (MACE) in a long-term observational study with different stages of atherosclerosis

The impact of diabetes on incident cardiovascular disease in relation to the extent of atherosclerotic disease remains unclear. We aimed to investigate major adverse cardiovascular events (MACE) in patients with or without type 2 diabetes (T2DM) presenting with two extremes of atherosclerotic disease, those with angiographically documented minor coronary atherosclerotic lesions and those with symptomatic peripheral artery disease. We included 1238 patients from two prospective, long-term cohort studies. Patients underwent coronary angiography and/or sonography in order to assess the grade of atherosclerosis and were defined as having no signs of Atherosclerosis (n = 332; Group I), minor atherosclerosis (n = 425; Group II) and major atherosclerosis (n = 481; Group III). Cardiovascular events were recorded over a median follow-up period of 7.1 years (Q1 = 3.6 years, Q2 = 7.1 years, Q3 = 11.3 years), covering a total of 9533 patient years. We tested the hypothesis that T2DM infers the same relative risk increase irrespective of the atherosclerosis stage, considering 3-point MACE as the primary endpoint. Incident MACE was reported in 681 patients (51%). MACE occurred more frequently in patients with T2DM than in patients without T2DM (p < 0.001). Further, MACE occurred more frequently in group III (58.1%), than group II (34.1%) or group I (19.1%) (group I vs. group II vs. group III, p < 0.001). In a cox-regression-model, T2DM was a significant predictor of MACE in univariate analyses (HR = 2.43 [1.88-3.14], p < 0.001) and after multivariate adjustment for cardiovascular risk factors, as well as the different grades of atherosclerosis (HR = 1.37 [1.02-1.84], p = 0.034). Also, atherosclerosis grades predicted MACE (HR = 3.19 [2.75-3.70], p < 0.001) in univariate analyses, and also after multivariate adjustment for known cardiovascular risk factors, including T2DM (HR = 1.61 [1.31-1.98], p < 0.001). Finally, when testing for interactions between T2DM and stages of atherosclerosis on MACE we could not find any significant interaction (HR = 1.14 [0.86-1.52], p = 0.364). We conclude that T2DM infers an increased risk for MACE across anatomically and morphologically distinct stages of atherosclerosis.

Toe- Brachial Index: Utility, Futility, and Diagnostic Criteria

Ankle brachial index (ABI) can be unreliable in patients with non-compressible vessels. Our aim is to determine the feasibility of toe brachial index (TBI) and reporting criteria in a large population. We evaluated Doppler waveforms and segmental pressures in 26,719 limbs. TBI was obtained in 92.7%, mean TBI = 0.61 ± 0.25. TBI was obtained in 82%of limbs with unobtainable ABI. In hemodynamically normal subgroup (defined as those with normal ankle-brachial indices at rest and after exercise) the mean TBI was 0.84 ± 0.14. In severe PAD subgroup (defined as ABI < 0.5 and monophasic waveforms) the mean TBI was 0.16 ± 0.12. Limbs with a diagnosis of a PAD (ABI ≤ 0.9) had a TBI <0.8 in 99.5% of the cases, and <0.6 in 90% of the cases. A TBI of 0.8 had a negative predictive value for PAD of 0.99. A TBI cutoff of 0.6 had a positive predictive value for PAD of 0.95. Based on these results we propose defining normal TBI above 0.8, borderline between 0.8 and 0.61, abnormal TBI ≤ 0.6 and severe PAD as TBI ≤ 0.2. In conclusion TBI can be reliably measured in patients with PAD and offer valuable information when diagnosing PAD. We present our diagnostic criteria based on clinical data.

Platelet Membrane-Coated HGF-PLGA Nanoparticles Promote Therapeutic Angiogenesis and Tissue Perfusion Recovery in Ischemic Hindlimbs

Therapeutic angiogenesis has garnered significant attention as a potential treatment strategy for lower limb ischemic diseases. Although hepatocyte growth factor (HGF) has been identified as a key promoter of therapeutic angiogenesis, its clinical application is limited due to its short half-life. In this study, we successfully developed and characterized platelet membrane-coated HGF-poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NPs). These nanoparticles demonstrated enhanced capabilities to promote endothelial cell (EC) proliferation, migration, and tube formation in vitro. Additionally, their efficacy in improving tissue perfusion and promoting angiogenesis was confirmed in a hindlimb ischemia rat model. Our findings suggest that platelet membrane-coated HGF-PLGA-NPs could serve as a promising therapeutic approach for enhancing angiogenesis and restoring tissue perfusion in ischemic conditions.

Evaluation of the implementation of personalised outcomes forecasts to optimise supervised exercise therapy in patients with intermittent claudication: a multimethods process evaluation

BACKGROUND

Personalised outcomes forecasts (POFs) were introduced among physical and exercise therapists in the Netherlands to optimise supervised exercise therapy for patients with intermittent claudication. Yet, therapists' initial adoption and sustainable implementation of POFs can be influenced by various factors.

OBJECTIVES

The purpose of this study was to examine therapists' adoption of the POFs, their fidelity to the measurement protocol for supervised exercise therapy, and their perceived barriers and facilitators for using POFs in practice.

METHODS

A multimethod process evaluation was conducted, including quantitative descriptive and pre-post approaches, as well as a qualitative framework approach. To examine adoption, we evaluated the proportion of therapists who expressed interest in POFs by completing one of three provided e-learnings and the proportion of therapists who started using POFs in practice. To examine fidelity to the measurement protocol, we compared the per-episode proportion of follow-up measurements documented by therapists preimplementation and postimplementation. Qualitative data on barriers and facilitators were identified through semistructured interviews with therapists.

RESULTS

One year after the implementation, 89% of therapists eligible to use POFs (n=1727) completed at least one e-learning and 51% of therapists started using POFs. The per-episode proportion of documented follow-up measurements per therapist increased, from a mean rate of 37% (3 months) and 22% (6 months) during the preimplementation period to a mean rate of 53% (3 months) and 32% (6 months) during the postimplementation period (p<0.001). Among interviewed therapists (n=12), identified barriers included competing demands and a lack of skills or confidence. Identified facilitators included the potential to improve the quality of care and a positive user attitude.

CONCLUSIONS

Our findings suggest that although there is initial interest in and adoption of POFs, addressing barriers and leveraging facilitators through tailored implementation strategies could further increase their utilisation in practice.

The diagnosis and treatment of asymptomatic and symptomatic patients with carotid artery stenosis

Carotid artery atherosclerotic stenosis is an important annual cause of stroke in the United States. Moreover, the incidence of carotid artery stenosis is significantly increasing due to the widespread popularity of high fat and high salt diets, sedentary lifestyles, and the increasing age of the population. Of major importance to cardiovascular specialists is the fact that individuals with atherosclerotic carotid artery stenosis can have a prevalence of atherosclerotic coronary artery disease as high as 50 to 75%. Vascular screening for carotid artery stenosis with Doppler ultrasound should be considered for all symptomatic patients with possible carotid stenosis and also considered for asymptomatic patients with (1) symptomatic peripheral arterial disease, coronary artery disease, or atherosclerotic aortic aneurysm or, (2) multiple atherosclerotic risk factors. Carotid artery atherosclerotic plaques that are at high risk for rupture and thrombosis or cerebral embolization are characterized by large lipid cores, intraplaque hemorrhage, thin fibrous caps less than 165 μms that are infiltrated by macrophages and T cells or have surface ulcer(s) or fissures. Carotid artery plaque rupture with cerebral embolism can cause a stroke, transient ischemic attacks (TIA), or ipsilateral blindness (amaurosis fugax). Medical treatment based on the recommendations of the American and European Societies for Vascular Surgery and the American Heart Association for symptomatic patients with carotid stenosis and also asymptomatic patients with high risk carotid stenosis plaques include antiplatelet drugs, antihypertensive drugs for hypertension control and lipid lowering drugs. Management strategies and decisions about carotid revascularization in asymptomatic patients with high risk carotid stenosis should involve a multidisciplinary team and shared decision-making is recommended. The 30 day and five to 10 year outcomes in asymptomatic carotid stenosis patients who have undergone carotid endarterectomy, carotid stenting and/or optimal medical therapy are summarized from the Veterans Administration Cooperative Study, the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trials. The current Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) should help to resolve the debate regarding carotid artery revascularization versus primary medical treatment in asymptomatic patients with >70% carotid artery stenosis. Symptomatic patients who present within 4.5 hours of stroke onset require evaluation for acute intravenous pharmacologic thrombolysis and patients who present with large vessel occlusion within 24 hours of symptom onset should be considered for mechanical thrombectomy to reduce the neurologic deficit. Patients with carotid artery stenosis who present with a history of cerebral infarct in the preceding six months due to cerebral embolism require medical treatment and evaluation by a multidisciplinary team for carotid revascularization in order to prevent future strokes or TIAs. The outcomes of the North American Symptomatic Carotid Endarterectomy Trial, Carotid Revascularization Endarterectomy Versus Stent Trial, Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial, and the Safety and Efficacy Study for Reverse Flow Used during Carotid Artery Stenting Procedure trials for symptomatic patients with carotid stenosis are reviewed. A synopsis of treatment guidelines for symptomatic and asymptomatic carotid stenosis patients from the American and European Societies of Vascular Surgery and the American Heart Association/American Stroke Association are presented. Each patient with carotid artery stenosis must be carefully evaluated to determine the best treatment based on the clinical presentation, the imaging and laboratory diagnostic information, the treatment guidelines, and the patient needs and preferences as well as the patient's social and cultural factors.

Strategies to Improve Health Care Provider Prescription of and Patient Adherence to Guideline-Recommended Cardiovascular Medications for Atherosclerotic Occlusive Disease: Protocol for Two Systematic Reviews and Meta-Analyses of Randomized Controlled Trials

BACKGROUND

In patients with atherosclerotic occlusive diseases, systematic reviews and meta-analyses of randomized controlled trials (RCTs) report that antiplatelets, statins, and antihypertensives reduce the risk of major adverse cardiac events, need for revascularization procedures, mortality, and health care resource use. However, evidence suggests that these patients are not prescribed these medications adequately or do not adhere to them once prescribed.

OBJECTIVE

We aim to systematically review and meta-analyze RCTs examining the effectiveness of implementation or adherence-supporting strategies for improving health care provider prescription of, or patient adherence to, guideline-recommended cardiovascular medications in patients with atherosclerotic occlusive disease.

METHODS

We designed and reported the protocol according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis-Protocols) statement. We will search MEDLINE, Embase, The Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL from their inception. RCTs examining implementation or adherence-supporting strategies for improving prescription of, or adherence to, guideline-recommended cardiovascular medications in adults with cerebrovascular disease, coronary artery disease, peripheral artery disease, or polyvascular disease (>1 of these diseases) will be included. Two investigators will independently review identified titles/abstracts and full-text studies, extract data, assess the risk of bias (using the Cochrane tool), and classify implementation or adherence-supporting strategies using the refined Cochrane Effective Practice and Organization of Care (EPOC) taxonomy (for strategies aimed at improving prescription) and Behavior Change Wheel (BCW; for adherence-supporting strategies). We will narratively synthesize data describing which implementation or adherence-supporting strategies have been evaluated across RCTs, and their reported effectiveness at improving prescription of, or adherence to, guideline-recommended cardiovascular medications (primary outcomes) and patient-important outcomes and health care resource use (secondary outcomes) within refined EPOC taxonomy levels and BCW interventions and policies. Where limited clinical heterogeneity exists between RCTs, estimates describing the effectiveness of implementation or adherence-supporting strategies within different refined EPOC taxonomy levels and BCW interventions and policies will be pooled using random-effects models. Stratified meta-analyses and meta-regressions will assess if strategy effectiveness varies by recruited patient populations, prescriber types, clinical practice settings, and study design characteristics. GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) will be used to communicate evidence certainty.

RESULTS

The search was completed on June 6, 2023. Database searches and the PubMed "related articles" feature identified 4319 unique citations for title/abstract screening. We are currently screening titles/abstracts.

CONCLUSIONS

These studies will identify which implementation and adherence-supporting strategies are being used (and in which combinations) across RCTs for improving the prescription of, or adherence to, guideline-recommended cardiovascular medications in adults with atherosclerotic occlusive diseases. They will also determine the effectiveness of currently trialed implementation and adherence-supporting strategies, and whether effectiveness varies by patient, prescriber, or clinical practice setting traits.

TRIAL REGISTRATION

PROSPERO CRD42023461317; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=461317; PROSPERO CRD42023461299; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=461299.

Approach to Endocrine Hypertension: A Case-Based Discussion

PURPOSE OF REVIEW

Hypertension remains a major chronic disease morbidity across the world, even in the twenty-first century, affecting ≈40% of the global population, adversely impacting the healthcare budgets in managing the high incidence of cardiovascular disease (CVD) complications and mortality because of elevated blood pressure (BP). However, evaluation and management of endocrine hypertension are not optimal in clinical practice. With three unique clinical case scenarios, we update the evidence base for diagnostic evaluation and management of endocrine hypertension in this review to inform appropriate day-to-day clinical practice decisions.

RECENT FINDINGS

Although most individuals with high BP suffer from essential hypertension (≈85%), some patients may have a clear underlying etiology (termed secondary hypertension), and a significant proportion of these patients have endocrine hypertension (≈10%) consequent to hormone excess from dysfunction of one or more endocrine glands. Even if a relatively common disease in the general population, the correct diagnosis and appropriate treatment of endocrine hypertension is often delayed because of poor awareness among clinicians, including primary care providers and physicians in the secondary care settings. An accurate and timely diagnosis of endocrine hypertension is crucial to potentially cure or at least properly manage these patients because the consequences of delays in diagnosis can be catastrophic, with markedly higher end-organ complications such as CVD, chronic kidney disease, and even premature mortality among sufferers.

Clinical reality and challenges with familial hypercholesterolemia patients' management. 2024 results from the Regional Center for Rare Diseases (RCRD) Registry in Poland

BACKGROUND

Despite advancements in early diagnosis and effective medications in last decade, most heterozygous familial hypercholesterolemia (heFH) patients still fail to achieve their low-density lipoprotein cholesterol (LDL-C) goals and remain at residual cardiovascular disease risk. We present recent data from the regional FH registry in Poland, highlighting the challenges and real-life clinical management of FH patients.

METHODS

The registry is held at the Regional Centre for Rare Diseases, founded in 2016, at the 2nd largest, supraregional hospital in Poland, where >80 different rare diseases in patients from all over Poland are diagnosed and treated, including phenotypically or genetically diagnosed FH patients. Our analysis focused on both children and adult FH patients, excluding those treated with inclisiran due to a small sample size (n = 5).

RESULTS

We studied 173 consecutive heFH patients, median age for adult population was 40 years (range: 27-57), of whom 56.14 % were women. Among the population, 82.1 % were adults (n = 142), and 31 were children (17.92 %; median age 9 (8-13), females 58.16 %). Children exhibited lower total cholesterol and triglyceride levels compared to adults, with no significant differences in LDL-C and high-density lipoprotein cholesterol (HDL-C) levels. Molecular diagnosis in the whole population revealed that 76.6 % had an LDL receptor (LDLR) mutation, while 23.4 % had an apolipoprotein B (APOB) mutation. Risk assessment categorized patients into high (70.7 %), very high (22.1 %), and extremely high (7.1 %) risk groups. Triple therapy achieved treatment goals in 61.76 % of adults and 70.97 % of children. At baseline, 36.62 % of adult patients were not using statins. High-intensity statin therapy combined with ezetimibe was initiated for the remaining patients. Only 3.33 % of patients avoided statins due to complete intolerance. Ezetimibe was used in 57.27 % of patients (mostly in combination therapy), and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were prescribed for 28.17 % FH patients. In adults receiving statin and ezetimibe therapy, median achieved LDL-C was 141 mg/dl (107-184). For triple therapy, median achieved LDL-C was 52.5 mg/dL (32-86.5). Overall median achieved LDL-C in the study population was 99.5 mg/dl (57.5-145.4). PCSK9 inhibitors reduced LDL-C by 165.6 mg/dl. Combination therapy did not significantly alter baseline lipoprotein(a) (Lp(a)) levels (p = 0.134), and PCSK9 inhibitors led to a mean Lp(a) reduction of 18.66 mg/dl (45 % reduction; p = 0.013). Multivariable regression analysis identified key factors for achieving LDL-C targets in FH patients: DLCN total score, DLCN category, ezetimibe use, and PCSK9 inhibitors.

CONCLUSIONS

In Poland, FH patients are often diagnosed too late (usually over 40 years of age), and many still do not reach their LDL-C goals. Combination LLT double or triple therapy significantly increases the likelihood of achieving LDL-C targets - even up to fivefold. Therefore, unrestricted access to PCSK9 inhibitors for all FH patients is crucial, without the current limitations imposed by drug reimbursement programs like B101.

Clopidogrel combined with rivaroxaban in peripheral artery disease after revascularization

Background

To evaluate the efficacy and safety of clopidogrel-rivaroxaban combination compared to aspirin-rivaroxaban combination in patients with symptomatic peripheral artery disease (PAD).

Methods

Consecutive patients with symptomatic PAD patients were analyzed from January, 2018 to June, 2022 at Nanjing Drum Tower Hospital. Patients were divided into two groups based on the antithrombotic therapy. The primary efficacy outcome was a composite of major adverse cardiovascular events (MACE) and major adverse limb events (MALE), and the primary safety outcome was major bleeding. Patients were followed until the first occurrence of any outcomes or the study end date (30 June 2024).

Results

A total of 695 patients were enrolled into this study. The clopidogrel-rivaroxaban combination significantly reduced the risk of composite outcome (HR: 0.59, 95%CI: 0.41-0.83) without increasing the risk of major bleeding (HR: 0.68, 95%CI: 0.27-1.69). When analyzed separately, clopidogrel-rivaroxaban combination was associated with a reduced risk of MALE (HR: 0.61, 95%CI: 0.41-0.91), although no significant differences were observed in terms of MACE (HR: 0.64, 95%CI: 0.34-1.20) or all bleeding events (HR: 1.00, 95%CI: 0.52-1.93). In the subgroup analysis, there were no significant interactions between the treatment groups and the subgroups of age, diabetes, lesion sites, Rutherford classifications and renal function for composite outcome, MACE and MALE.

Conclusion

The clopidogrel-rivaroxaban combination in PAD patients may offer enhanced cardiovascular protection without increasing the risk of bleeding complications. These findings suggested that clopidogrel could be a superior alternative to aspirin in dual antithrombotic therapy for PAD management.

Supervised exercise-based rehabilitation for people with intermittent claudication-Study protocol for a Danish implementation process (StRiDE)

INTRODUCTION

Intermittent claudication is a peripheral artery disease caused by arteriosclerosis. People with intermittent claudication experience leg cramping during walking, with relief of symptoms during rest. Evidence shows that by participating in supervised exercise therapy and smoking cessation programs, people with intermittent claudication can reduce those symptoms and improve health-related quality of life and maximal walking distance while minimizing the need for an operation. However, implementation of such health-promoting initiatives in clinical practice in Denmark and other countries is limited. This is a protocol presenting the implementation process of supervised exercise therapy and smoking cessation in a region of Denmark.

METHODS AND ANALYSIS

The implementation process is a collaboration between the municipalities in the Region of Zealand and the Department of Vascular Surgery at University Hospital Zealand. The study uses a convergent mixed-methods prospective clinical cohort design, and the theoretical frame of this implementation process follows the framework for Adapting an existing intervention to a new context (ADAPT). The process involves stakeholder engagement, ongoing evaluation through key performance indicators and relevant outcomes that will inform the implementation process across and within each municipality.

DISSEMINATION

Dissemination will happen throughout the process through continued meetings with stakeholders and dissemination of performance indicators and outcome results obtained through a database. All information about the study and material will be freely available. The project is registred on Clinicalgov (NCT06299956).

3D CT to 2D X-ray image registration for improved visualization of tibial vessels in endovascular procedures

PURPOSE

During endovascular revascularization interventions for peripheral arterial disease, the standard modality of X-ray fluoroscopy (XRF) used for image guidance is limited in visualizing distal segments of infrapopliteal vessels. To enhance visualization of arteries, an image registration technique was developed to align pre-acquired computed tomography (CT) angiography images and to create fusion images highlighting arteries of interest.

METHODS

X-ray image metadata capturing the position of the X-ray gantry initializes a multiscale iterative optimization process, which uses a local-variance masked normalized cross-correlation loss to rigidly align a digitally reconstructed radiograph (DRR) of the CT dataset with the target X-ray, using the edges of the fibula and tibia as the basis for alignment. A precomputed library of DRRs is used to improve run-time, and the six-degree-of-freedom optimization problem of rigid registration is divided into three smaller sub-problems to improve convergence. The method was tested on a dataset of paired cone-beam CT (CBCT) and XRF images of ex vivo limbs, and registration accuracy at the midline of the artery was evaluated.

RESULTS

On a dataset of CBCTs from 4 different limbs and a total of 17 XRF images, successful registration was achieved in 13 cases, with the remainder suffering from input image quality issues. The method produced average misalignments of less than 1 mm in horizontal projection distance along the artery midline, with an average run-time of 16 s.

CONCLUSION

The sub-mm spatial accuracy of artery overlays is sufficient for the clinical use case of identifying guidewire deviations from the path of the artery, for early detection of guidewire-induced perforations. The semiautomatic workflow and average run-time of the algorithm make it feasible for integration into clinical workflows.

Clinical and economic implications of focal dissection treatment following percutaneous transluminal angioplasty of the superficial femoral artery: an exploratory analysis based on the TOBA II Study

Aim: Percutaneous transluminal angioplasty (PTA) for peripheral artery disease (PAD) commonly leads to dissections which are associated with higher target lesion revascularization (TLR) rates. Clinical and economic consequences of dissection management in the femoropopliteal artery following PTA, and specifically the potential economic benefit of focal dissection repair using the novel Tack Endovascular System, remain unknown. Methods: A decision-analytic model was used to estimate 24-month clinical events, costs and quality-adjusted life year (QALY) gain for a Tack-supported versus status-quo PTA strategy. Patient and lesion characteristics and TLR rates were derived from the PTA cohort of the TOBA II clinical trial, an observational cohort, and literature. Cost-effectiveness was determined from a US payer and provider perspective separately for the non-severe (grade A or B), severe (grade C and higher) and the entire dissection cohort. Results: TLR rates were lower for the Tack-supported strategy compared with PTA (7.7 vs 27.4% in the non-severe, 13.9 vs 25.8% in the severe and 12.0 vs 26.3% in the entire dissection cohort). Cost and QALY differences were +$297/ + 0.0110 in the non-severe dissection cohort and -$1602/ + 0.0067 in the severe dissection cohort, resulting in an incremental cost-effectiveness ratio (ICER) of $25,622 in the non-severe cohort and dominance in the severe cohort and the entire cohort. Conclusion: Compared with a 'status-quo' approach, proactive focal stenting may lead to fewer reinterventions and improved quality of life. There appears to be a graded economic benefit of focal dissection treatment, being cost-effective in non-severe dissections and even cost saving in severe dissections.

Risk factors of incident acute limb ischemia after contemporary femoropopliteal endovascular revascularization from a multicenter registry: A retrospective observational study

Purpose

To investigate the incidence of acute limb ischemia (ALI) among patients with femoropopliteal (FP) lesions treated with contemporary endovascular therapy (EVT) and to identify risk factors for ALI after FP-EVT.

Methods

In this retrospective multicenter registry, we analyzed patients with lower extremity artery disease having FP lesions who underwent EVT between 2017 and 2021. We investigated the incident ALI related to the index EVT and its risk factors. We also assessed the prognosis after the incident ALI.

Results

During a median follow-up of 35.3 months, incident ALI was observed in 72 of 3102 patients (2.3%). The Rutherford classification I/IIa/IIb/III was 50.0%, 30.5%, 18.1%, and 1.4%, respectively. Variables independently associated with the incident ALI were chronic limb-threatening ischemia (CLTI; hazard ratio, 1.83; p = 0.015), reference vessel diameter < 6 mm (2.39; p = 0.011), lesion length >25 cm (3.35; p = 0.005) with its time interaction (0.72 per 1 year; p = 0.042), P2/3 segment involvement (2.73; p < 0.001), chronic total occlusion (CTO; 3.40; p < 0.001), and in-stent restenosis/occlusion (3.21; p < 0.001). During a median follow-up of 12.8 months after the ALI event, all-cause mortality was 27.8% and the rate of major amputation was 6.9%.

Conclusions

The FP-EVT showed that the occurrence of ALI was 2.3% during a median follow-up of 35.3 months. The independent predictors of the ALI event were CLTI, small vessels, long lesions, CTO, and in-stent restenosis; however, the impact of lesion length was attenuated over time after the index EVT.

Sarcopenia is associated with lower step count in patients with peripheral artery disease following endovascular treatment

INTRODUCTION

Patients with peripheral artery disease (PAD) often complain of reduced physical activity (PA) despite improvements in intermittent claudication after successful endovascular treatment (EVT). Sarcopenia resulting from chronic ischemia can affect post-EVT PA levels.

OBJECTIVE

This study aims to assess the association between sarcopenia and post-EVT PA levels.

METHODS

One hundred five patients with PAD were consecutively enrolled in this study. PA was assessed using the post-EVT step count and the pre-EVT International Physical Activity Questionnaire. Sarcopenia was diagnosed based on the Asia Working Group for Sarcopenia and defined as low muscle mass and strength, and/or slow walking speed. The patients were categorized into three groups: 1) patients with sarcopenia (Sarcopenia Group); 2) patients with only low muscle mass or strength, and/or slow walking speed (Suspected-Sarcopenia Group); and 3) patients who did not fulfill all the sarcopenia criteria (No-Sarcopenia Group).

RESULTS

Proportions of patients in the Sarcopenia, Suspected-Sarcopenia, and No-Sarcopenia Groups were 31.4, 38.1, and 30.5%, respectively. After controlling for potential confounders, the Sarcopenia Group demonstrated significantly lower step counts than the Suspected-Sarcopenia Group (p = .016) and No-Sarcopenia Group (p = .009).

CONCLUSIONS

Our findings indicate that patients with PAD and sarcopenia require rehabilitation strategies to enhance physical performance.

Importance of Successful Revascularization in Acute Limb Ischemia: Sub-Analysis From the RESCUE ALI Trial

BACKGROUND

This study aimed to assess the 1-year clinical outcomes and predictors of technical success in acute limb ischemia (ALI) treatment.

METHODS

A sub-analysis of the REtroSpective multiCenter study of endovascUlar or surgical intErvention for ALI (RESCUE ALI) study involved 185 patients with ALI and technical success (n = 131) or failure (n = 54) treated via surgical, endovascular, or hybrid revascularization between January 2015 and August 2021. The primary endpoint was 1-year amputation-free survival (AFS), and the secondary endpoints included preoperative complications and 1-year reintervention.

RESULTS

The technical success group had a significantly higher 1-year AFS rate than the technical failure group (79% vs. 44%, p < 0.001). Perioperative complications rate showed no significant difference between the two groups. The incidence of reintervention was lower in the technical success group (17% vs. 30%, p = 0.049). Age ≥ 80 years, time from onset ≥ 24 h, no below-the-knee artery runoff, and preoperative c-reactive protein ≥ 5 mg/dL were negatively associated with technical success across all procedures. In surgical revascularization, no below-the-knee artery runoff was negatively associated with technical success. For endovascular revascularization, onset-to-treatment time ≥ 48 h was negatively related and thromboembolism in atrial fibrillation was positively related to technical success. In hybrid revascularization, supra- to infrapopliteal lesions were negatively associated with technical success.

CONCLUSIONS

Technical success in ALI treatment significantly enhances 1-year AFS rates. Thus, choosing the appropriate revascularization procedure based on predictors of technical success is crucial for improving patient outcomes.

Diabetes mellitus and peripheral artery disease

Atherosclerotic peripheral artery disease (PAD), that is, arteriosclerosis obliterans, is pathologically rooted in atherosclerosis, similar to other cardiovascular diseases. In addition to smoking, hypertension, and dyslipidemia, diabetes mellitus is a major risk factor. People with diabetes mellitus have an elevated risk of developing PAD. PAD in turn increases the risk of diabetic foot ulcers and gangrene in the population. Rest pain, nonhealing ulcers, and gangrene associated with chronic ischemia are known as chronic limb-threatening ischemia (CLTI). This article gives an overview of the link between atherosclerotic PAD, particularly CLTI, and diabetes mellitus. First, the clinical impact of CLTI among patients with diabetes mellitus is presented. Second, its clinical features, including prognosis, comorbidity, occurrence, and seasonality, are mentioned. The clinical management of CLTI is also discussed. Diabetes mellitus has notable clinical impact on CLTI and vice versa. CLTI has different clinical features from those of other atherosclerotic cardiovascular diseases. Its clinical profile also differs between individuals with both diabetes mellitus and CLTI and general people with diabetes mellitus. There is considerable room for improvement in CLTI treatment and management. Clinical measures taken before revascularization, including CLTI risk assessment, prompt diagnosis, and expedited referral to vascular specialists, may enhance CLTI outcomes. Further research is warranted to obtain more evidence.

Clinical Outcomes following Invasive Treatment of Femoropopliteal Artery Disease: A Retrospective Single-Center Cohort Study

PURPOSE

To identify predictors of clinical success in invasive treatment for femoropopliteal arterial disease aiding clinical decision-making.

MATERIALS AND METHODS

A retrospective analysis was performed on 676 consecutive patients who underwent a first episode of invasive treatment for femoropopliteal disease, either endovascular therapy (EVT) or femoropopliteal bypass (FPB), between 2004 and 2015. Primary end points were primary and secondary clinical patency and amputation rate. Kaplan-Meier curves were used to evaluate clinical patency. A Cox proportional hazard model explored predictors of primary end points.

RESULTS

Most patients (58%) underwent EVT as primary intervention, while 42% underwent FPB. Median follow-up was 43 months. The only independent predictor for loss of primary clinical patency was critical limb-threatening ischemia (CLTI) (P = .008; hazard ratio [HR], 1.25; 95% CI, 1.07-1.47). Secondary clinical patency was positively associated with FPB surgery (P = .037; HR, 0.66; 95% CI, 0.44-0.97), a higher pre-interventional ankle-brachial index (P = .029; HR, 0.43; 95% CI, 0.20-0.92), more distal runoff vessels (P = .036; HR, 0.77; 95% CI, 0.60-0.98), and the absence of ischemic heart disease (P = .006; HR, 1.69; 95% CI, 1.16-2.47). In patients with CLTI, chronic renal failure predicted loss of primary and secondary clinical patency and increased amputation risk.

CONCLUSIONS

In this cohort, CLTI was independently associated with decreased primary clinical patency in invasive treatment for femoropopliteal disease. Secondary clinical patency was positively associated with FPB, higher ankle-brachial index, more runoff vessels, and the absence of ischemic heart disease.

In-Stent Restenosis in Peripheral Arterial Disease: Ultra-High-Resolution Photon-Counting Versus Third-Generation Dual-Source Energy-Integrating Detector CT Phantom Study in Seven Different Stent Types

PURPOSE

The visualization of peripheral in-stent restenosis using energy-integrating detector CT is challenging due to deficient spatial resolution and artifact formation. This study compares the first clinically available photon-counting detector CT to third-generation dual-source energy-integrating detector CT.

MATERIALS AND METHODS

Nylon cylinders with central bores (4 mm, 2 mm), mimicking 75% and 95% stenoses, were placed inside seven different 8-mm diameter stents and filled with diluted contrast medium. Phantoms were scanned with photon-counting detector CT at slice thicknesses of 0.2 mm (available only in this scanner type), 0.5 mm, and 1.0 mm versus 0.5 mm and 1.0 mm in energy-integrating detector CT at matched CT dose indices. Contrast-to-noise ratios were calculated from attenuation rates. Residual lumen size was measured as full width at half-maximum. Subjective image quality was assessed by two independent blinded raters.

RESULTS

Mean contrast-to-noise ratio was lowest in photon-counting detector CT at 0.2 mm slice thickness (0%, 75%, and 95% in-stent restenosis: 6.11 ± 0.6, 5.27 ± 0.54, and 5.02 ± 0.66) and highest at 1.0 mm slice thicknesses with similar measurements in photon-counting detector CT and energy-integrating detector CT (11.46 ± 1.08, 9.94 ± 1.01, 8.26 ± 1.0 vs. 3.34 ± 1.0, 9.92 ± 0.38, 7.94 ± 1.07). Mean full width at half-maximum measurements in photon-counting detector CT at 0.2 mm slice thickness for 0%, 75%, and 95% in-stent restenosis were 8.00 ± 0.37, 3.98 ± 0.34, and 1.92 ± 0.16 mm. Full width at half-maximum was least precise in 95% in-stent restenosis at 1.0 mm slice thickness with similar measurements between scanners (1.57 ± 0.33 vs. 1.71 ± 0.15 mm). Interrater correlation coefficient was 0.75 [95% CI: [0.53; 0.86]; subjective scores were best at 0.2 mm slice thickness in photon-counting detector CT (19.43 ± 0.51 and 19.00 ± 0.68).

CONCLUSION

In phantom in-stent restenosis in 8 mm stents, we observed similar full width at half-maximum for photon-counting detector CT and energy-integrating detector CT in 0% and 75% in-stent restenosis, but at 95% in-stent restenosis, FWHM tended to be more accurate in smaller slice thicknesses in both scanners. Subjective image assessment yielded best results at 0.2 mm slice thickness in photon-counting detector CT despite lower contrast-to-noise ratio.

CYP2C19 Genotype-Guided Antiplatelet Therapy and Clinical Outcomes in Patients Undergoing a Neurointerventional Procedure

In neurovascular settings, including treatment and prevention of ischemic stroke and prevention of thromboembolic complications after percutaneous neurointerventional procedures, dual antiplatelet therapy with a P2Y12 inhibitor and aspirin is the standard of care. Clopidogrel remains the most commonly prescribed P2Y12 inhibitor for neurovascular indications. However, patients carrying CYP2C19 no-function alleles have diminished capacity for inhibition of platelet reactivity due to reduced formation of clopidogrel's active metabolite. In patients with cardiovascular disease undergoing a percutaneous coronary intervention, CYP2C19 no-function allele carriers treated with clopidogrel experience a higher risk of major adverse cardiovascular outcomes, and multiple large prospective outcomes studies have shown an improvement in clinical outcomes when antiplatelet therapy selection was guided by CYP2C19 genotype. Similarly, accumulating evidence has associated CYP2C19 no-function alleles with poor clinical outcomes in clopidogrel-treated patients in neurovascular settings. However, the utility of implementing a genotype-guided antiplatelet therapy selection strategy in the setting of neurovascular disease and the clinical outcomes evidence in neurointerventional procedures remains unclear. In this review, we will (1) summarize existing evidence and guideline recommendations related to CYP2C19 genotype-guided antiplatelet therapy in the setting of neurovascular disease, (2) evaluate and synthesize the existing evidence on the relationship of clinical outcomes to CYP2C19 genotype and clopidogrel treatment in patients undergoing a percutaneous neurointerventional procedure, and (3) identify knowledge gaps and discuss future research directions.

Spontaneous walking characteristics of patients with peripheral arterial disease

Background: Walking rehabilitation is the cornerstone of patients with peripheral arterial disease (PAD) treatment. In order to propose a personalised walking rehabilitation program to each patient, it is important to know the PAD-patients walking characteristics. Such data are lacking in the literature. The aim of this study was to analyse the spontaneous walking characteristics of PAD patients. Patients and methods: This study was conducted between May 2016 and March 2018. Walking characteristics (cadence, stride, number of daily walking episodes, duration of an episode, distance covered during an episode, daily total walking duration and distance, walking speed) were recorded by Withings Pulse O2® activity trackers for one week in patients with asymptomatic or symptomatic PAD. Walking intensity was classified as ambling pace (<2 METs), slow walking (2-3 METs) and active walking (>3 METs). Study protocol has been approved by an independent ethics committee. Results: Eighty-seven patients were included (males 87%, mean age 66 ± 9 years, intermittent claudication 86%, right ankle brachial index (ABI) = 0.80 ± 0.19 and left ABI = 0.79 ± 0.15). The mean recording duration was 8 ± 1.2 days. Most of the steps were shuffling pace (shuffling pace 55.7%, active walking 32.8%, slow walking 11.5%). There was no significant difference between weekdays and weekend days nor for cadence, stride, episode duration, distance covered during an episode, number of daily walking episodes, daily total walking duration and distance. The average duration of active walking episodes was 3 minutes. Duration of active walking was less than 3 minutes in 66% of patients with a mean duration of 1 minute and 55 seconds. Conclusion: Analysis of PAD patients spontaneous walking characteristics with an activity tracker can get the maximum active walking duration achieved by each patient and be useful to offer a personalised walking rehabilitation program.

Relationship between hyoid-carotid distance, hyoid position and morphology and degree of stenosis and associated stroke: Hyoid-carotid relationship

BACKGROUND

Pressure on carotid artery by hyoid bone may influence plaque formation. We studied CTA-based hyoid-carotid anatomical interaction and its relationship with carotid stenosis degree and stenosis-related stroke.

METHODS

We retrospectively analysed pre-operative CTA of 205 consecutive adults having undergone carotid endarterectomy (CEA) for asymptomatic or symptomatic stenosis. Radiological measurements were: degree stenosis, hyoid-carotid distance, carotid position in regard to hyoid, and hyoid morphology.

RESULTS

In total, 410 carotids (including 114 symptomatic and 296 asymptomatic stenotic and non-stenotic carotids) from 205 CEA patients (median age 74, 72% men) were analysed. Median carotid stenosis was 61% (70% for symptomatic and 51% for asymptomatic carotids, p<0.0001; 70% for CEA and 30.5% for non-CEA carotids, p<0.0001). None of the other radiological parameters differed between asymptomatic/symptomatic carotids, between non-CEA/CEA carotids, or between asymptomatic/symptomatic patients. Median hyoid-carotid distance was 4.3mm, with 82% of carotids in posterolateral quadrant position in regard to the hyoid. There was no correlation between stenosis degree and hyoid-carotid distance (rho=-0.039), hyoid width (rho=-0.079), length (rho=0.007) or circumferential length (rho=-0.005), and stenosis degree was comparable between different carotid position quadrants (p=0.51).

CONCLUSIONS

Hyoid-carotid distance, hyoid position and morphology are not correlated with the degree of carotid stenosis or symptomatic carotid stenosis.

CLINICAL TRIAL REGISTRATION-URL

http://www.

CLINICALTRIALS

gov: Unique identifier: NCT05349526.

Clinical Outcomes of Patients With Cholesterol Crystal Embolism Accompanied by Lower Extremity Wound

Cholesterol crystal embolism (CCE) accompanied by a lower extremity wound is occasionally difficult to differentiate from chronic limb-threatening ischemia (CLTI) and treat. The present multi-center retrospective observational study investigated the clinical characteristics and prognosis of CCE with lower extremity wounds. Consecutive patients (n = 58) clinically diagnosed as CCE with lower extremity wounds between April 2010 and December 2019 were studied. CCE was diagnosed using histological findings, foot condition, renal impairment, and eosinophilia. The primary outcome was 1-year wound healing rate. Patients with CCE were compared with 1309 patients diagnosed with CLTI with tissue loss during the same study period. The CCE group had a significantly more severe Wound, Ischemia, and foot Infection (WIfI) classification compared with the CLTI group. After Kaplan-Meier analysis, the CCE group had a similar 1-year wound healing (55.1 vs 58.3%, P = .096) as the CLTI group. In multivariate stratified Cox regression analysis by WIfI stages, CCE was significantly associated with poor wound healing compared with CLTI [hazard ratio .36 (95% confidence interval .21-.62)]. In conclusion, among the similar WIfI clinical stages, wound healing was significantly worse in the CCE group than in the CLTI group.

External validation of the OAC3-PAD risk score after endovascular revascularisation

Background: The OAC3-PAD bleeding risk score was developed to assess the bleeding risk in patients with peripheral arterial disease (PAD), however its performance in patients treated exclusively with endovascular revascularisation has not yet been tested. We aimed to externally validate the bleeding risk score for this patient cohort. Patients and methods: A retrospective observational study, analysing the data of all PAD patients successfully treated with endovascular revascularisation in a single centre within a five-year period. The performance of the Cox proportional hazards (CPH) model, upon which the OAC3-PAD bleeding risk score is based, was tested using calibration methods, discrimination, and a scaled Brier score for overall performance. The OAC3-PAD bleeding risk score was calculated for all patients, classifying them into the four respective risk groups. Kaplan-Meier curves were plotted for all risk groups and discrimination was tested using log-rank tests. Results: While discrimination of the CPH model was adequate, calibration of the model was poor and the scaled Brier score was 3.27% (95% CI 0.65%-4.40%). Of the 1,434 patients, 33 (2.3%) experienced a major bleeding event. The frequency of bleeding was 0.4% in the low risk group (3/736 patients), 0.8% in the low-to-moderate risk group (2/243 patients), 5.8% in the moderate-to-high risk group (15/258 patients), and 6.6% in the high risk group (13/197 patients). The OAC3-PAD score successfully discriminated each of the two lower bleeding risk groups from one of the two higher risk groups, but failed to discriminate among the two lower risk groups and the two higher risk groups, respectively. Conclusions: Although the OAC3-PAD score did not stratify patients into the four respective risk groups, it allowed discrimination between the low risk patients and the high risk patients. It could therefore become a useful tool for predicting major bleeding events in patients with PAD after endovascular revascularisation.

Comparison of Early Outcomes in Patients Who Underwent Common Femoral Thromboendarterectomy with Vein versus Bovine Pericardial Patches

BACKGROUND

The treatment outcomes of vein and bovine pericardial patches in thromboendarterectomy (TEA) for common femoral artery (CFA) lesions in patients with peripheral arterial disease (PAD) remain unclear. The purpose of this study was to evaluate the efficacy and safety of the bovine pericardial patch by comparing it with vein patch angioplasty.

METHODS

This was a multicenter retrospective study. We reviewed the data of patients who underwent TEA with patch angioplasty (vein versus bovine pericardial patch angioplasty) for PAD between January 2018 and December 2022. Indication for revascularization is patients with PAD with claudication symptoms to rest pain and foot ulcers that interfere with daily life, with lesions in the CFA region. The primary end point was 2-year patency. The secondary end points were postoperative wound complications, including patch rupture, and safety of remote-phase puncture of the patch area after patch angioplasty.

RESULTS

Within the observation period, TEA was performed on 157 limbs in 136 patients using vein patches and on 86 limbs in 79 patients using bovine pericardial patches. The number of claudication/rest pain/tissue loss was 110/13/34 cases in the vein patch group and 57/14/15 cases in the bovine pericardial patch group, respectively. No significant differences were observed in patient characteristics. No significant between group differences were observed in operative time, blood loss, or percentage of patients who underwent concomitant revascularization during the procedure. The 2-year primary patency rates of the vein and bovine pericardial patch were 95.6% and 92.8%, respectively (P = 0.49). The rate of surgical site infection in this study was 2.5% in the vein patch group and 5.8% in the bovine pericardial patch group, respectively (P = 0.29). Rupture of the patch occurred in 4 (2.5%) and 4 (4.7%) patients in the vein and bovine pericardial patch groups, respectively (P = 0.46), and the percentage of cases requiring revision of the patch site was 7 (4.5%) and 5 (5.8%) in the vein and bovine pericardial patch groups, respectively (P = 0.76). Postoperatively, 23 patients in the vein and 13 patients in the bovine pericardial patch groups underwent patch puncture during the remote period. The median follow-up duration from the date of the surgery to the date of the puncture was 544 days and 374 days in the vein and bovine pericardial patch groups, respectively. No patch-related complications were observed during remote stage puncture.

CONCLUSIONS

Compared with vein patches, TEA with bovine pericardial patches had acceptable outcomes in terms of patency and postoperative complications.