Association of lower extremity arterial calcification with amputation and mortality in patients with symptomatic peripheral artery disease

Predictive value of lower extremity color doppler ultrasonography before knee arthroplasty on a postoperative cardiovascular event

BACKGROUND

The study intended to determine the presence of lower limb arterial calcification (LLAC) in lower extremity color Doppler ultrasonography (CDUS) before primary total knee arthroplasty (TKA) and its relation with cardiovascular events (CVE) during knee arthroplasty and the postoperative period, as well as to investigate its effect on surgical risk estimation.

METHODS

We designed this study as a retrospective cohort study. The study comprised 467 patients who met the inclusion criteria and had surgery for a primary gonarthrosis diagnosis between January 2005 and December 2015 were included. In the study group, patients with arterial calcification in the lower extremity CDUS were included; however, those reported not to have it were included in the control group. The research data were obtained from preoperative anesthesia records and patient medical records.

RESULTS

72% of the sample had preoperative cardiovascular comorbidity. There was no difference between the groups in terms of comorbidities, except for congestive heart failure (CHF) and peripheral artery disease (PAD). The groups did not differ in terms of ASA scores, either. Both pre- and post-operative CVEs, i.e., ischemic heart disease, dysrhythmia, and CHF, were statistically high in the study group. In terms of postoperative mortality, there was no statistical difference between the groups.

CONCLUSION

The study demonstrates that the presence of LLAC in CDUS is associated with increased risk of perioperative cardiovascular events (CVEs). Ultrasonographic detection of LLAC may give some idea the surgeon about the requirement for additional preoperative cardiac examinations.

Diagnostic Accuracy of Color Doppler and Calcium Scoring versus Dual-Energy Computed Tomography Angiography in the Assessment of Peripheral Arterial Diseases of Lower Limb

Objectives

Peripheral arterial disease (PAD) leads to narrowing and hardening of arteries which leads to increased risk of lower extremity amputation. Hence, the accuracy of non-invasive diagnostic methods such as calcium scoring and color Doppler needs to be assessed in comparison to the gold standard dual-energy computed tomography (DECT) angiography. This study aims to evaluate the accuracy of color Doppler and calcium scoring when compared to DECT angiography in the assessment of PAD of the lower limb. It is a cross- sectional retrospective study.

Material and Methods

The study included 55 patients aged between 40 and 70 years. All the patients with symptoms suggestive of PAD underwent color Doppler study of lower limb arterial system. Afterward, the patient underwent CT angiography. The first plain images were taken for calcium scoring following which contrast was given and further images were taken.

Results

As compared to CT angiography assessment, Doppler assessment was 88.1% sensitive but only 69.2% specific with diagnostic accuracy of 83.6%. For angiographically detected atheromatous changes, color Doppler had sensitivity and specificity of 86.2% and 76.9%. The derived cutoff value >149.1 of calcium score in lower limb arteries was in 100% agreement with CT angiography detected PAD, whereas, for atheromatous changes, total calcium score at a cutoff value of >842.2 had sensitivity and specificity of 75.9% and 80.8%.

Conclusion

Calcium scoring as compared to color Doppler has a higher diagnostic efficacy for the detection of DECT angiography confirmed PAD, whereas calcium score lacks adequate sensitivity at projected cutoff in the evaluation of atheromatous changes.

The use of activated vitamin D and risks of hospitalization for infection and amputation in incident hemodialysis patients in Taiwan: a nationwide population-based cohort study

BACKGROUND

Hemodialysis patients have a high risk of mortality. The most common causes of death are cardiovascular disease and infection. The potential hazard or benefit associated with vitamin D use and cardiovascular or infection outcome is poorly characterized.

METHODS

We conducted a retrospective observational cohort study by recruiting 52,757 patients older than 20 years from Taiwan National Health Insurance Research Database (NHIRD) who initiated maintenance hemodialysis between 2001 and 2009. Patients who were prescribed activated vitamin D before the 360th day from hemodialysis initiation were defined as vitamin D users. The primary outcome of interest includes occurrence of acute myocardial infarction (AMI), ischemic stroke, lower limb amputation, and hospitalization for infection, respectively, while death events are treated as competing events. We conducted competing risk analysis using subdistribution hazard regression model to estimate subdistribution hazard ratios (SHRs) in relation to various outcomes.

RESULTS

During the median follow-up of 1019 days, the vitamin D users had a lower crude mortality rate, lower incidences of AMI, ischemic stroke, amputation, and hospitalization for infection compared with non-users. Taking into consideration competing events of death, vitamin D users were associated with a lower hazard of lower limb amputation (SHR 0.84 [95% CI, 0.74-0.96]) and hospitalization for infection (SHR 0.90 [95% CI, 0.87-0.94]), but not AMI or ischemic stroke, after adjustment for potential confounders. Subgroup analyses and dose response evaluation both showed a consistent association of activated vitamin D treatment with decreased risk of amputation and infection.

CONCLUSION

The findings suggest that therapeutic activated vitamin D use in hemodialysis patients may be beneficial for decreasing infection events and amputation, of which the latter is a complication of peripheral vascular disease, rather than reducing major atherosclerotic cardiovascular events such as AMI or ischemic stroke.

The risk factors for calcification vary among the different sections of the lower extremity artery in patients with symptomatic peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is associated with considerable mortality and morbidity worldwide. The present study explored the risk factors for arterial calcification among the different sections of the lower extremity in patients with PAD and analyzed their correlations with the extent of arterial stenosis at the corresponding section.

METHODS

This study enrolled symptomatic PAD patients from our hospital from March 2017 to March 2018. The lower extremity arterial calcification score (LEACS) and lower extremity arterial stenosis index (LEASI), representing the extent of arterial stenosis, were measured on computed tomography (CT) and the correlations between them were analyzed using Spearman's correlation analysis. The relationships between risk factors and calcification were analyzed among the different sections of the lower extremity artery.

RESULTS

In total, 209 patients were included. The LEACSs of the total lower extremity, aortoiliac artery, and femoropopliteal and infrapopliteal arteries were correlated with the LEASI (all P < 0.05), but their correlation was relatively weak in the aortoiliac artery. Univariate analysis showed that hypertension was associated with the total (P = 0.019) and aortoiliac (P = 0.012) LEACSs. Diabetes was related to both femoropopliteal (P = 0.001) and infrapopliteal (P = 0.002) LEACSs. The infrapopliteal LEACS was higher in male patients (P = 0.011). After adjustment for age, the above relationships were maintained among the different sections, but not in the total lower extremity artery.

CONCLUSIONS

The LEACS is associated with the LEASI in all arterial sections, but that of the aortoiliac artery was relatively weak. Different factors have different effects on calcification among the various sections of the lower extremity artery.

The Effect of Severe Femoropopliteal Arterial Calcification on the Treatment Outcome of Femoropopliteal Intervention in Patients with Ischemic Tissue Loss

Purpose

We investigated the effect of severe calcification of the femoropopliteal artery on intervention outcomes in patients with ischemic tissue loss.

Materials and Methods

A retrospective review of the first endovascular treatment of the femoropopliteal artery for ischemic tissue loss between May 2010 and February 2018 was performed. The calcification of femoropopliteal lesions was estimated by the Compliance 360° score, and lesions with a score of 4 were defined as severe calcification lesions.

Results

Overall, 135 first femoropopliteal endovascular procedures on 135 limbs from 112 patients were included in this study. Among the 135 limbs that received treatement of the femoropopliteal arteries, 74 limbs had Trans-Atlantic Inter Society Consensus (TASC) A or B lesions and 61 limbs had TASC C or D lesions. Among 61 cases of TASC C or D lesions, 21 limbs (34.4%) had severe calcification; there was no statistically significant difference in limb salvage (P=0.75), and amputation-free survival (P=0.11) based on the degree of calcification. However, the survival rate in TASC C or D lesions was significantly different between the two groups (non-severe calcification group vs severe calcification group at 1-year, 2-years, and 3-years: 88.6%, 79.7%, and 61.0% vs 70.0%, 56.0%, and 28.0%, respectively, P=0.01). In multivariate analysis of influencing factors for poor survival in TASC C or D using the Cox proportional hazards model, severe calcification (hazard ratio, 2.362; 95% confidence interval, 1.035-5.391; P=0.041) was a statistically significant risk factor.

Conclusion

Severe femoropopliteal artery calcification was associated with poor survival, especially in TASC C or D lesions.

Low Iliofemoral Calcium Score May Predict Higher Survival after EVAR and FEVAR

BACKGROUND

Abdominal aortic aneurysm is associated with an increased mortality, mostly cardiovascular events. Moreover, aortoiliac calcification is associated with increased mortality in patients with peripheral occlusive disease. The aim of this study is to assess the potential association between iliofemoral calcification, assessed by calcium score, in patients undergoing infrarenal (endovascular aneurysm repair [EVAR]) or fenestrated endovascular aortic repair (FEVAR) and long-term mortality, particularly caused by cardiac events.

METHODS

All patients with preoperative noncontrast-enhanced computed tomographic scans who underwent infrarenal EVAR and FEVAR of nonruptured abdominal aortic aneurysm between 2004 and 2012 at a single tertiary center were screened for inclusion. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software. The values are presented as median and interquartile range.

RESULTS

About 404 (62.05%) of 651 patients who underwent EVAR and FEVAR had sufficient imaging quality to be included. There was no difference in survival between included and excluded patients (P = 0.33). Nine patients (2.2%) died within 30 days of the operation, whereas the remaining were followed up for 6.3 (4.7-8.4) years. The iliofemoral calcium score was 8348 (3830-14,179). Estimated overall survival at 5 years was 73 ± 2%. Patients within the lowest quartile of iliofemoral calcium score had significantly higher overall survival (5 years: 79 ± 4% vs. 71 ± 3%; P = 0.01) and cardiac event-free survival (5 years: 95 ± 2% vs. 91 ± 2%; P = 0.033) when compared with the remaining ones. Calcium score was associated with neither univariate regression analysis with survival (odds ratio, 1.016 [0.988-1.045]; P = 0.268) nor cardiac event-free survival (odds ratio, 1.024 [0.986-1.063]; P = 0.222).

CONCLUSIONS

Low iliofemoral calcium score may be associated with lower incidence of fatal cardiac events and all-cause long-term mortality after EVAR and FEVAR. This may be partially a reflection of aging and cardiovascular comorbidity but needs to be studied further.

Current developments in endovascular therapy of peripheral vascular disease

More than 200 million people worldwide have peripheral artery disease (PAD) or its most severe manifestation, critical limb ischemia (CLI). While endovascular treatment has become first line therapy in most cases, a number of challenges remain for optimal treatment of femoropopliteal (FP) or infrapopliteal (IP) disease, especially when these lesions are severely calcified, chronic total occlusions (CTOs) or in-stent restenosis (ISR). Continued evolution of technologies has significantly improved the outcomes for endovascular treatment. A number of new devices are in the pipeline right now, including new paclitaxel eluting stents and balloons, intravascular lithotripsy to treat severely calcified lesions, adventitial delivery of anti-restenotic agents to limit restenosis rates, and percutaneous femoro-popliteal bypass.

Percutaneous Impella Mechanical Circulatory Support Delivery Using Intravascular Lithotripsy

Intravascular lithotripsy (IVL) may be useful to deliver Impella devices in patients with peripheral arterial disease. Twelve patients were treated with peripheral IVL prior to Impella insertion. A total of 100% of patients underwent successful device implantation with no IVL complications. IVL can facilitate transfemoral access for Impella insertion. (Level of Difficulty: Advanced.).

Effects of sarpogrelate hydrochloride on peripheral arterial disease: A meta-analysis of randomized controlled trials

OBJECTIVE

The aim of our study was to assess the efficacy and safety of sarpogrelate hydrochloride by comparing the effects of sarpogrelate with conventional treatment on the improvement of symptoms in PAD patients.

METHODS

The search was conducted in PubMed, Embase, Cochrane library database, CNKI, CBM for relevant randomized controlled trials (RCTs) before January 1st, 2019. Inclusion and exclusion of studies, assessment of quality, outcome measures, data extraction and synthesis were completed by two reviewers independently. The meta-analysis was performed with RevMan 5.3.

RESULTS

Totally, 12 eligible RCTs were included in our analysis. Comparing the results of sarpogrelate group and control group, sarpogrelate significantly improved ankle-brachial index (ABI) levels (SMD = 0.05, [95%CI 0.20 to 0.74, P = .0005]), dorsalis pedis artery blood flow (MD = 0.16, [95%CI 0.09 to 0.23, P < .001]) and pain-free walking distance (PFWD) (MD = 201.86, [95%CI 9.34 to 394.38, P = .04]). The pooled analysis showed that a significant decrease in hsCRP (MD = -0.57, [95%CI -1.12 to -0.02, P = .04]) and IL-6 (MD = 1.48,[95%CI 0.39 to 2.56, P = .008]) was observed in the sarpogrelate treatment.

CONCLUSION

Sarpogrelate was effective for improving the symptoms of PAD and showed good tolerability without significant adverse events.

Intravascular lithotripsy-assisted Impella insertion: A case report

Coronary and peripheral arterial calcification increases the complexity of percutaneous treatment strategies in both coronary and peripheral interventions. The first use of intravascular lithotripsy (IVL) using the Shockwave IVL device (Shockwave Medical Inc) in femoropopliteal arteries for modification of calcified plaque was recently described. We present a case illustrating use of the device to deliver a 14 French sheath for delivery of an Impella mechanical circulatory device prior to high-risk percutaneous coronary intervention (PCI). This case illustrates that IVL may be used to facilitate a broadening array of procedures in the catheterization laboratory, including the delivery of large bore sheathes.

Cell-Matrix Interactions and Matricrine Signaling in the Pathogenesis of Vascular Calcification

Vascular calcification is a complex pathological process occurring in patients with atherosclerosis, type 2 diabetes, and chronic kidney disease. The extracellular matrix, via matricrine-receptor signaling plays important roles in the pathogenesis of calcification. Calcification is mediated by osteochondrocytic-like cells that arise from transdifferentiating vascular smooth muscle cells. Recent advances in our understanding of the plasticity of vascular smooth muscle cell and other cells of mesenchymal origin have furthered our understanding of how these cells transdifferentiate into osteochondrocytic-like cells in response to environmental cues. In the present review, we examine the role of the extracellular matrix in the regulation of cell behavior and differentiation in the context of vascular calcification. In pathological calcification, the extracellular matrix not only provides a scaffold for mineral deposition, but also acts as an active signaling entity. In recent years, extracellular matrix components have been shown to influence cellular signaling through matrix receptors such as the discoidin domain receptor family, integrins, and elastin receptors, all of which can modulate osteochondrocytic differentiation and calcification. Changes in extracellular matrix stiffness and composition are detected by these receptors which in turn modulate downstream signaling pathways and cytoskeletal dynamics, which are critical to osteogenic differentiation. This review will focus on recent literature that highlights the role of cell-matrix interactions and how they influence cellular behavior, and osteochondrocytic transdifferentiation in the pathogenesis of cardiovascular calcification.

Media sclerosis drives and localizes atherosclerosis in peripheral arteries

Media sclerosis (MS) and peripheral artery disease (PAD) may coincide, particularly in type 2 diabetics (T2D) and in patients with chronic kidney disease (CKD). In contrast to non-diabetics, in T2D PAD is more severe and more distal. Although MS is suspected to play a role, the underlying pathophysiological reasons for the differences still remain elusive today. We tested the hypothesis that MS is a promoter of atherosclerosis as it occurs in T2D with PAD by interfering with arterial remodeling using an in-silico simulation. We confirmed that MS aggravates PAD by promoting negative remodeling. We found that the effect is more pronounced in smaller distal arteries compared to larger proximal ones. Our results suggest that the degree of this divergence depends on the ratio between the thickness of the intima relative to the thickness of the media/adventitia of the individually affected arteries.

Safety and Feasibility of Intravascular Lithotripsy for Treatment of Below-the-Knee Arterial Stenoses

Purpose: To evaluate the safety and feasibility of treating calcified infrapopliteal stenoses using an intravascular lithotripsy (IVL) system. Methods: The Disrupt BTK study was a prospective, nonrandomized, multicenter, feasibility, and safety trial that enrolled 20 patients (mean age 79.0±9.6 years; 14 men) at 3 participating sites (ClinicalTrials.gov identifier NCT02911623). Fifteen patients had Rutherford category 5 ischemia, and all patients had moderate to severe below-the-knee arterial calcification. Patients were treated with the Shockwave Medical Peripheral IVL System and followed for 30 days. The primary safety endpoint was a composite of major adverse events through 30 days defined as death, myocardial infarction, need for emergency surgical revascularization of the target limb, or amputation of the target limb. The primary effectiveness outcome was acute reduction in the percent diameter stenosis. Results: IVL catheter delivery was successful in 19 patients. The composite of major adverse events at 30 days was 0%. The acute reduction in percent diameter stenosis of target lesions was 46.5%. All patients achieved residual diameter stenosis ≤50%. Vascular complications were minimal with only 1 type B dissection reported and 2 stents placed. None of the subjects experienced thrombus formation, abrupt closure, distal embolization, or perforation. There were no device-related complications. Conclusion: The early results of this pilot study demonstrated that calcified, stenotic infrapopliteal arteries can be safely and successfully treated with intravascular lithotripsy.

Lower Extremity Arterial Calcification on Preoperative Knee Radiographs as a Predictor of Postoperative Cardiovascular Events After Primary Total Knee Arthroplasty

BACKGROUND

A cross-sectional study of total knee arthroplasty (TKA) patients was conducted to determine the association of lower-extremity arterial calcification (LEAC) with acute perioperative cardiovascular events (CVEs).

METHODS

Regression modeling was used to examine the association of radiographic presence of LEAC and acute myocardial infarction (MI), perioperative CVE, 30-day CVE readmit, and 30-day and 1-year mortality.

RESULTS

Of 900 TKA patients, LEAC was identified in 21.1%. Of LEAC cases, 1.6% had an acute MI vs 0.1% of non-LEAC cases (P = .031). Perioperative CVE rate was 5.8% for LEAC vs 1.5% for non-LEAC (P = .002). Having LEAC was identified as a significant risk factor for a perioperative CVE (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.09-7.35). Because of limited number of acute MI events, absence of 30-day CVE readmit, 30-day mortality, and few 1-year mortality events, computing OR for these was not possible. Likewise, because of small number of events (n = 3), estimates for the odds of LEAC cases having an acute MI are less reliable, yielding extremely large random errors (OR 11.37; 95% CI 0.09-597.93) and must be interpreted with caution. The OR for 1-year mortality was 1.88 (95% CI 0.17-13.20), but again with large random errors.

CONCLUSION

Our study shows that LEAC around the knee is associated with an increased risk of having a perioperative CVE. Crude radiographic detection of LEAC around the knee has the potential to improve risk stratification for TKA patients by informing the surgeon of the need for further preoperative cardiac workup.

Assessment of extracellular matrix-related biomarkers in patients with lower extremity artery disease

BACKGROUND

The prevalence of lower extremity artery disease (LEAD) is high (20%-25%) in the population older than 65 years, but patients are seldom identified until the disease is advanced. Circulating markers of disease activity might provide patients with a key opportunity for timely treatment. We tested the hypothesis that measuring blood-specific fragments generated during degradation of the extracellular matrix (ECM) could provide further insight into the pathophysiologic mechanism of arterial remodeling.

METHODS

The protein profile of diseased arteries from patients undergoing infrainguinal limb revascularization was assessed by a liquid chromatography and tandem mass spectrometry, nontargeted proteomic approach. The information retrieved was the basis for measurement of neoepitope fragments of ECM proteins in the blood of 195 consecutive patients with LEAD by specific enzyme-linked immunosorbent assays.

RESULTS

Histologic and proteomic analyses confirmed the structural disorganization of affected arteries. Fourteen of 81 proteins were identified as differentially expressed in diseased arteries with respect to healthy tissues. Most of them were related to ECM components, and the difference in expression was used in multivariate analyses to establish that severe arterial lesions in LEAD patients have a specific proteome. Analysis of neoepitope fragments in blood revealed that fragments of versican and collagen type IV, alone or in combination, segregated patients with mild to moderate symptoms (intermittent claudication, Fontaine I-II) from those with severe LEAD (critical limb ischemia, Fontaine III-IV).

CONCLUSIONS

We propose noninvasive candidate biomarkers with the ability to be clinically useful across the LEAD spectrum.

Prevalence of Calcification in Human Femoropopliteal Arteries and its Association with Demographics, Risk Factors, and Arterial Stiffness

OBJECTIVE

Arterial calcification and stiffening increase the risk of reconstruction failure, amputation, and mortality in patients with peripheral arterial disease, but underlying mechanisms and prevalence are unclear.

APPROACH AND RESULTS

Fresh human femoropopliteal arteries were obtained from n=431 tissue donors aged 13 to 82 years (mean age, 53±16 years) recording the in situ longitudinal prestretch. Arterial diameter, wall thickness, and opening angles were measured optically, and stiffness was assessed using planar biaxial extension and constitutive modeling. Histological features were determined using transverse and longitudinal Verhoeff-Van Gieson and Alizarin stains. Medial calcification was quantified using a 7-stage grading scale and was correlated with structural and mechanical properties and clinical characteristics. Almost half (46%) of the femoropopliteal arteries had identifiable medial calcification. Older arteries were more calcified, but small calcium deposits were observed in arteries as young as 18 years old. After controlling for age, positive correlations were observed between calcification, diabetes mellitus, dyslipidemia, and body mass index. Tobacco use demonstrated a negative correlation. Calcified arteries were larger in diameter but had smaller circumferential opening angles. They were also stiffer longitudinally and circumferentially and had thinner tunica media and external elastic lamina with more discontinuous elastic fibers.

CONCLUSIONS

Although aging is the dominant risk factor for femoropopliteal artery calcification and stiffening, these processes seem to be linked and can begin at a young age. Calcification is associated with the presence of certain risk factors and with elastic fiber degradation, suggesting overlapping molecular pathways that require further investigation.

Lower limb arterial calcification (LLAC) scores in patients with symptomatic peripheral arterial disease are associated with increased cardiac mortality and morbidity

AIMS

The association of coronary arterial calcification with cardiovascular morbidity and mortality is well-recognized. Lower limb arterial calcification (LLAC) is common in PAD but its impact on subsequent health is poorly described. We aimed to determine the association between a LLAC score and subsequent cardiovascular events in patients with symptomatic peripheral arterial disease (PAD).

METHODS

LLAC scoring, and the established Bollinger score, were derived from a database of unenhanced CT scans, from patients presenting with symptomatic PAD. We determined the association between these scores outcomes. The primary outcome was combined cardiac mortality and morbidity (CM/M) with a secondary outcome of all-cause mortality.

RESULTS

220 patients (66% male; median age 69 years) were included with follow-up for a median 46 [IQR 31-64] months. Median total LLAC scores were higher in those patients suffering a primary outcome (6831 vs. 1652; p = 0.012). Diabetes mellitus (p = 0.039), ischaemic heart disease (p = 0.028), chronic kidney disease (p = 0.026) and all-cause mortality (p = 0.012) were more common in patients in the highest quartile of LLAC scores. The area under the curve of the receiver operator curve for the LLAC score was greater (0.929: 95% CI [0.884-0.974]) than for the Bollinger score (0.824: 95% CI [0.758-0.890]) for the primary outcome. A LLAC score ≥ 4400 had the best diagnostic accuracy to determine the outcome measure.

CONCLUSION

This is the largest study to investigate links between lower limb arterial calcification and cardiovascular events in symptomatic PAD. We describe a straightforward, reproducible, CT-derived measure of calcification-the LLAC score.

Association of arterial calcification with chronic limb ischemia in patients with peripheral artery disease

OBJECTIVE

Arterial calcification is associated with an increased risk of limb events, including amputation. The association between calcification in lower extremity arteries and the severity of ischemia, however, has not been assessed. We thus sought to determine whether the extent of peripheral artery calcification (PAC) was correlated with Rutherford chronic ischemia categories and hypothesized that it could independently contribute to worsening limb status.

METHODS

We retrospectively reviewed all patients presenting with symptomatic peripheral artery disease who underwent evaluation by contrast and noncontrast computed tomography scan of the lower extremities as part of their assessment. Demographic and cardiovascular risk factors were recorded. Rutherford ischemia categories were determined based on history, physical examination, and noninvasive testing. PAC scores and the extent of occlusive disease were measured on noncontrast and contrast computed tomography scans, respectively. Spearman's correlation testing was used to assess the relationship between occlusive disease and calcification scores. Multivariable logistic regression was used to identify factors associated with increasing Rutherford ischemia categories.

RESULTS

There were 116 patients identified, including 75 with claudication and 41 with critical limb ischemia. In univariate regression, there was a significant association between increasing Rutherford ischemia category and age, diabetes duration, hypertension, the occlusion score, and PAC. There was a moderate correlation between the extent of occlusive disease and PAC scores (Spearman's R = 0.6). In multivariable analysis, only tobacco use (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-8.3), diabetes duration (OR, 1.04; 95% CI, 1.01-1.08), and the calcification score (OR, 2.1; 95% CI, 1.4-3.2) maintained an association with increasing ischemia categories after adjusting for relevant cardiovascular risk factors and the extent of occlusive disease.

CONCLUSIONS

PAC is independently associated with increased ischemia categories in patients with peripheral artery disease. Further research aimed at understanding the relationship between arterial calcification and worsening limb ischemia is warranted.

Emerging and Future Therapeutic Options for Femoropopliteal and Infrapopliteal Endovascular Intervention

Despite recent advances in endovascular therapy for peripheral artery disease, current technologies remain limited by rates of long-term restenosis and application to complex lesion subsets. This article presents data on upcoming therapies, including novel drug-coated balloons, drug-eluting stents, bioresorbable scaffolds, novel drug delivery therapies to target arteries, techniques to limit postangioplasty dissection, and treatment of severely calcified lesions.

Calcification of the splenic, iliac, and breast arteries and risk of all-cause and cardiovascular mortality

BACKGROUND AND AIMS

CVD risks associated with coronary artery calcification (CAC) and aortic calcification (AC) are well known, but less is known about other calcified arteries. We aimed to assess the associations of arterial calcification in the breast, splenic, and internal and external iliac arteries with CVD risk factors and mortality.

METHODS

We conducted a case-cohort study nested in a cohort of 5196 individuals who self-referred or were referred by a health care provider for whole body computed tomography (CT), including a random subcohort (n = 395) and total and CVD mortality cases (n = 298 and n = 90), who died during a median follow-up of 9.4 years. Arterial calcification in the breast, splenic, and internal and external iliac arteries on CT was scored using a simple visual score. AC and CAC were previously measured using the Agatston technique. Logistic regression models were made to study associations of CVD risk factors with calcification in the different vascular beds. Prentice-weighted Cox proportional hazards models adjusted for CVD risk factors, and calcification in other vascular beds, were used to study associations with mortality.

RESULTS

In the subcohort, the mean age was 56.6 years (SD 11.1) and 41.3% were female. The prevalence of calcification on CT, was 11.6% in the splenic, 47.9% in the internal iliac and 9.5% in the external iliac arteries, while 3.7% of women had breast artery calcification (BAC). Calcification in the splenic and iliac arteries was associated with calcification in the abdominal aorta but differentially associated with other CVD risk factors in logistic regression models. The prevalence of BAC was too low to fit these multivariable models. Calcification of the external iliac arteries was significantly associated with both all-cause and CVD mortality, but no longer significant when adjusted for CVD risk factors. Breast artery calcification was associated with both all-cause and CVD mortality independent of CVD risk factors and AAC and CAC (all-cause HR 5.67 [95% CI 1.50-21.41]).

CONCLUSIONS

Risk factors associated with calcification, and the association of calcification with risk of mortality differ across vascular beds, possibly reflecting different pathophysiology.

Semiquantitative assessment of tibial artery calcification by computed tomography angiography and its ability to predict infrapopliteal angioplasty outcomes

OBJECTIVE

Tibial artery calcification (TAC) is associated with increased risk of amputation and mortality in peripheral artery disease. We sought to investigate whether the severity of TAC based on semiquantitative analysis of computed tomography angiography (CTA) can predict outcomes of endovascular therapy in patients with critical limb ischemia.

METHODS

We reviewed medical records of 124 patients who underwent lower extremity CTA before intervention. Based on CTA, TAC severity was categorized into three groups: minimal calcification (MC; n = 43), intermediate calcification (IC; n = 36), or extensive calcification (EC; n = 45). Immediate and late outcomes of infrapopliteal interventions were compared, and predictors of the outcomes were investigated.

RESULTS

The categorized severity of target TAC correlated with the log-transformed TAC score (r = 0.873; P < .001). The EC group was younger and had more diabetes and chronic kidney disease compared with the MC or IC group (all P < .001). The technical success was lower in the EC group (71.1%) than in the MC (95.3%) or IC (91.7%) group (P = .001). The survival free of unplanned amputations at 2 years was significantly lower in the EC group (58.9%) than in the MC (79.0%) or IC (95.3%) group (P < .001). Extensive TAC was an independent predictor of technical success (hazard ratio, 0.02; 95% confidence interval, 0.00-0.45; P = .014) and unplanned amputation (hazard ratio, 9.90; 95% confidence interval, 2.05-47.75; P = .004).

CONCLUSIONS

The categorized severity of TAC by semiquantitative analysis of CTA correlated with TAC score, and extensive TAC was associated with a lower technical success rate of angioplasty and an increased incidence of unplanned amputation.

Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical Considerations

Cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure. Unfortunately, these mechanisms are not adequately modulated by therapeutic strategies focusing solely on optimal glycemic control with currently available drugs or approaches. In the setting of multifactorial risk reduction with statins and other lipid-lowering agents, antihypertensive therapies, and antihyperglycemic treatment strategies, cardiovascular complication rates are falling, yet remain higher for patients with diabetes mellitus than for those without. This review considers the mechanisms, history, controversies, new pharmacological agents, and recent evidence for current guidelines for cardiovascular management in the patient with diabetes mellitus to support evidence-based care in the patient with diabetes mellitus and heart disease outside of the acute care setting.

Peripheral arterial disease and revascularization of the diabetic foot

Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised--treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches.