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)

[Electric brain activity in patients with simultaneous coronary artery bypass grafting and carotid endarterectomy]

AIM

To analyze the postoperative electroencephalography (EEG) power changes in patients after simultaneous coronary artery bypass grafting (CABG) and a left- or right-sided carotid endarterectomy (CEE).

MATERIAL AND METHODS

Forty-four patients with indications for surgical myocardial revascularization, including 24 patients with indications for CEE, were studied. Patients after simultaneous coronary and carotid surgery were divided into groups depending on the side of CEE: the left+CEE CABG group included 14 patients, the right CEE+CABG group included 10 patients. The group of isolated CABG consisted of 20 patients. The resting-state EEG with closed eyes was recorded before and at the 7-10th day after surgery. The changes of the spectral power (μV²/Hz), theta1 (4-6 Hz), theta2 (6-8 Hz), alpha1 (8-10 Hz), alpha2 (10-13 Hz) rhythms were analyzed, the hemispheric asymmetry (HA) coefficient of the rhythms was calculated.

RESULTS AND CONCLUSION

In the early postoperative period, the power of theta1 and theta2 rhythms increased compared to the preoperative level regardless of the type of cardiosurgical intervention. A local character of postoperative theta activity changes was revealed in the left+CEE CABG group, whereas the most pronounced decrease of the alpha-rhythm HA coefficient was observed in the right CEE+CABG group at the 7-10th day after surgery in comparison to the preoperative level. The results of the study suggest that the simultaneous coronary and carotid surgery does not significantly exacerbate the severity of brain damage compared to isolated CABG.

Vein Harvest Wound Healing after Bypass Surgery for Critical Limb Ischemia

BACKGROUND

Lower-limb revascularization surgery, especially when performed using the great saphenous vein, predisposes patients to major surgical trauma on initially ischemic tissue. Vein harvest wounds (VHWs) after infrainguinal revascularization heal slowly. This study's aim was to assess the factors associated with VHW healing after infrainquinal bypass surgery for critical limb ischemia (CLI).

METHODS

A retrospective patient record study was conducted. All patients with CLI who underwent infrainguinal bypass surgery with autologous vein graft between January 1, 2015, and December 31, 2017, in the Turku University Hospital, were included. Follow-up data were collected until February 28, 2018. The following data was collected from the patient files; risk factors, ankle-brachial indices (ABIs), systolic toe pressures (STPs), the presence of an ischemic ulcer, VHW dehiscence, and the time when the VHW was completely healed. Procedures with outflow vessels at either popliteal or tibial artery were analyzed separately. Descriptive and univariate statistical analyses were performed.

RESULTS

Altogether, 195 patients were operated on for CLI, of whom 133 (68.2%) patients had ischemic ulcers. The mean follow-up time was 535.0 days (range 3.0-1143.0 days). The mean ABI improvement was 0.49 (P = 0.00), and STP improvement, 39.9 mm Hg (P = 0.00). The median time taken when VHW was healed was 48.0 days (95% confidence interval [CI], 39.4-56.6) in patients without ischemic ulcers and 82.0 days (95% CI, 59.7-104.3) in patients with ischemic ulcers, P = 0.03. VHW in patients who underwent popliteal artery bypass (62 days, 95% CI, 12.9-93.0) healed faster than VHW in those who underwent tibial artery bypass (132 days, 95% CI, 48.0-93.0), P = 0.02. Risk factors and the preoperative or postoperative ABIs or STPs had no effect on VHW healing time.

CONCLUSIONS

VHW healing was remarkably slower after revascularization surgery in patients with an ischemic foot ulcer than in those without ischemic ulcers.

The Randomized Freeway Stent Study: Drug-Eluting Balloons Outperform Standard Balloon Angioplasty for Postdilatation of Nitinol Stents in the SFA and PI Segment

PURPOSE

The prospective randomized multicenter Freeway study evaluated the possible hemodynamic and clinical benefits of primary stent insertion followed by percutaneous transluminal angioplasty (PTA) with drug-eluting balloons (DEB) over post-stent insertion PTA with standard balloons in the treatment of symptomatic femoropopliteal arteriosclerotic lesions.

METHODS

In total, 204 patients in 13 centers in Germany and Austria were enrolled and randomized to primary stenting followed by either FREEWAY™ drug-eluting balloon or standard PTA balloon angioplasty. The primary endpoint was the rate of clinically driven target lesion revascularization (TLR) at 6 months; the secondary endpoints include TLR rate at 12 months and primary patency, shift in Rutherford classification, ankle-brachial index (ABI) and major adverse events (MAE) at 6 and 12 months. Lesion characteristics and vessel patency were analyzed by an independent and blinded corelab.

RESULTS

At 6-month and 12-month follow-up, TLR rate was lower in the DEB arm compared to standard PTA but did not reach statistical significance (4.1% vs. 9.0% p = 0.234 and 7.9% vs. 17.7% p = 0.064, respectively). Primary patency was significantly better for patients treated with the DEB at 6 months (90.3% vs. 69.8% p = 0.001) and 12 months (77.4% vs. 61.0% p = 0.027). Improvement in Rutherford classifications was likewise significantly better for patients in the DEB group at 6 (94.9% vs. 84.3% p = 0.027) and 12 months (95.5% vs. 79.9% p = 0.003). The percentage of patients with an improved ABI of 1.0-1.2 was significantly higher in the DEB group compared to the PTA group at 6 months (55.3% vs. 35.3%; p = 0.015) but without significant difference at 12 months (48.2% vs. 32.9%; p = 0.055). At 6 months, rate of major adverse events (MAE) was 1% in both arms, and at 12 months 2.2% for the DEB and 3.8% for the PTA group.

CONCLUSION

The Freeway Stent Study shows that the usage of DEB as a restenosis prophylaxis seems to be safe and feasible. The 12-month follow-up results give a clear sign in favor of the DEB group.

Screening of peripheral arterial disease in primary health care

Background and purpose

The screening tool for diagnosing lower extremity arterial disease is the assessment of the ankle-brachial index (ABI), which is widely used in general practice. However, resting ABI can easily produce a false negative result. In light of this, our goal was to determine the proportion of definitive diagnoses (peripheral arterial disease [PAD] confirmed or refuted) among patients screened in general practice, and the rate of cases in which the need for further specialized examination is necessary, with special attention to groups having non-compressible arteries and ABI negative symptomatic status. The aim of our work is to improve the efficiency of primary health care screening in PAD and reduce the extremely high domestic amputation ratio.

Patients and methods

Eight hundred and sixteen patients were screened. We used the Edinburgh Questionnaire and recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing.

Results

Thirty-three percent complained about lower extremity claudication; 23% had abnormal ABI values; 13% of the patients within the normal ABI range had complaints of dysbasia; and 12% were in the non-compressible artery group. The ABI-negative symptomatic group’s risk factor profile showed a close similarity to the clear PAD-positive and non-compressible artery groups.

Conclusion

The percentage of PAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups, together defined as the “murky zone”. When screening purposely for PAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is high clinical suspicion of PAD in spite of normal ABI values, further assessment may be considered.

Acute Limb Ischemia: An Update on Diagnosis and Management

This review presents an update on the diagnosis and management of acute limb ischemia (ALI), a severe condition associated with high mortality and amputation rates. A comprehensive spectrum of ALI etiology is presented, with highlights on embolism and in situ thrombosis. The steps for emergency diagnosis are described, emphasizing the role of clinical data and imaging, mainly duplex ultrasound, CT angiography and digital substraction angiography. The different therapeutic techniques are presented, ranging from pharmacological (thrombolysis) to interventional (thromboaspiration, mechanical thrombectomy, and stent implantation) techniques to established surgical revascularization (Fogarty thrombembolectomy, by-pass, endarterectomy, patch angioplasty or combinations) and minor or major amputation of necessity. Postprocedural management, reperfusion injury, compartment syndrome and long-term treatment are also updated.

[Differentiated approach to treatment of decompensated lower limb ischaemia with the use of the WIFI classification system]

In the present article, the authors substantiate the necessity of subdividing a heterogeneous cohort of patients presenting with Fontaine-Pokrovsky grade IV critical limb ischaemia into subgroups with the aim of making an appropriate therapeutic decision and predicting the outcome. We also translated into the Russian language the WIfI classification system developed by the Society for Vascular Surgery (2014) in order to predict limb loss and feasibility of performing revascularization. This is followed by comments on the classification, accompanied by examples of own clinical case studies. In order to check-up the ability of the SVS WIfI classification system to predict the one-year risk of major amputation in patients with decompensated ischaemia, we carried out a retrospective multicenter study, enrolling a total of 109 patients with unreconstructable stage IV chronic ischaemia. Our primary endpoint was the frequency of major amputation during the first year of follow up. The patients were divided into 4 subgroups based on a combination of the three WIfI domains, i. e., wound, ischaemia, and foot infection, respectively, as follows: 130 - 27% (n=29), 131 - 23% (n=25), 230 - 20% (n=22), and 231 - 30% (n=33). The frequency of amputation during the first year of follow-up with the natural course of the disease on the background of conventional therapy averagely amounted to 36%. By the WIfI component combinations, we revealed statistically significant differences between the subgroups (p=0.035): 130 - 21% (n=6), 131 - 28% (n=7), 230 - 36% (n=8), 231 - 55% (n=18). The WIfI classification makes it possible to predict the risk of major amputation in patients with limb-threatening ischaemia. The frequency of amputation during the first year of follow up in the natural course of the disease is associated not only with the WIfI clinical stage but also with the WIfI component combinations.

The association of four-limb blood pressure differences with cardiovascular risk factors and target organ changes in elderly Chinese: The Northern Shanghai Study

Background: The association of four-limb systolic blood pressure differences (SBPDs) including inter-arm (IASBPD), inter-leg (ILSBPD) and ankle-brachial index (ABI) with cardiovascular risk factors and target organ changes (TOCs) remains controversial. This study aims at investigating the association of those parameters with cardiovascular risk factors and TOCs in an elderly Chinese population.Methods: A total of 1528 subjects derived from the Northern Shanghai Study were studied. Four-limb BPs were simultaneously measured by VP-1000 device. Cardiovascular risk factors and TOCs including parameters of left ventricular structure and function, carotid intima-media thickness, carotid-femoral pulse-wave velocity (CF-PWV), estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio, were evaluated with standardized methods.Results: ABI significantly associated age (β = -0.004, p < .01), female gender (β = 0.02, p < .01), body mass index (β = -0.004, p < .01), smoking (β = -0.04, p < .01), high-density lipoprotein (β = 0.04, p < .01), low-density lipoprotein (β = -0.01, p = .01) and diabetes mellitus (β = -0.02, p < .01), while the fourth root of IASBPD significantly associated with body mass index (β = 0.03, p < .01), high-density lipoprotein (β = -0.10, p = .02) and brachial SBP (β = 0.003, p < .01); the fourth root of ILSBPD significantly associated with high-density lipoprotein (β = -0.12, p < .01) and diabetes mellitus (β = 0.09, p = .01). IASBPD, ILSBPD, and ABI all significantly associated with CF-PWV and eGFR (all p < .05) in either unadjusted or adjusted models, but not with other TOCs.Conclusion: Four-limb SBPDs, namely ABI, IASBPD, and ILSBPD, bore various burdens of cardiovascular risk factors and significantly and independently associated with CF-PWV and eGFR.

Comparison of three generic quality-of-life metrics in peripheral arterial disease patients undergoing conservative and invasive treatments

PURPOSE

To determine the effect of revascularisation for peripheral arterial disease (PAD) on QoL in the first and second year following diagnosis, to compare the effect depicted by Short Form Six Dimensions (SF-6D) and EuroQoL five Dimensions (EQ-5D) utilities, and Visual Analogue Scale (VAS) scores and to analyse heterogeneity in treatment response.

METHODS

Longitudinal data from 229 PAD patients were obtained in an observational study in southern Netherlands. Utility scores were calculated with the international (SF-6D) and Dutch (EQ-5D) tariffs. We analysed treatment effect at years 1 and 2 through propensity score-matched ANCOVAs. Thereby, we estimated the marginal means (EMMs) of revascularisation and conservative treatment, and identified covariates of revascularisation effect.

RESULTS

A year after diagnosis, 70 patients had been revascularised; the EMMs of revascularisation were 0.038, 0.077 and 0.019 for SF-6D, EQ-5D and VAS, respectively (always in this order). For conservative treatment these were - 0.017, 0.038 and 0.021. At 2-year follow-up, the EMMs of revascularisation were 0.015, 0.077 and 0.027, for conservative treatment these were - 0.020, 0.013 and - 0.004. Baseline QoL (and rest pain in year 2) were covariates of treatment effect.

CONCLUSIONS

We measured positive effects of revascularisation and conservative treatment on QoL a year after diagnosis, the effect of revascularisation was sustained over 2 years. The magnitude of effect varied between the metrics and was largest for the EQ-5D, which may be most suitable for QoL measurement in PAD patients. Baseline QoL influenced revascularisation effect, in clinical practice this may inform expected QoL gain in individual patients.

Effectiveness of the Pulsar-18 self-expanding stent with optional drug-coated balloon angioplasty in the treatment of femoropopliteal lesions – the BIOFLEX PEACE All-Comers Registry

Summary. Background: Previous studies showed favorable results after treatment of femoropopliteal lesions with the Pulsar-18 self-expanding (SE) nitinol stent. The objective of this registry was to evaluate whether these results will be confirmed in a real-world setting with varying stenting strategies. Patients and methods: In this prospective, observational trial, 160 patients with 186 femoropopliteal lesions were treated with the Pulsar-18 SE nitinol stent at 9 German sites. Mean lesion length was 116 ± 103 mm, and 41.9 % of the lesions were moderately or heavily calcified. Eighty lesions were concomitantly treated with drug-coated balloon (DCB). Main effectiveness outcome was primary patency at 12 months, and main safety outcome was freedom from the composite of device or procedure related death, major target limb amputation, and clinically driven target lesion revascularization (TLR) at 30 days and 6 months. Results: Kaplan-Meier estimate of primary patency was 89.1 %, 67.3 %, and 57.1 % at 6, 12, and 24 months. Freedom from TLR was 95.5 %, 91.4 %, and 85.2 % at 6, 12, and 24 months, respectively. Lesions, which were additionally treated with DCB (plus DCB-group), were longer (150 versus 82 mm on average, p < 0.0001), and associated with lower primary patency estimates than those without DCB angioplasty (stent-only-group) (log-rank p = 0.006). However, there was no difference in freedom from TLR between groups (log-rank p = 0.542). Improvement by ≥ 1 Rutherford category was achieved in 84.8 %, 81.0 %, and 81.7 % of patients at 6, 12, and 24 months, respectively. Walking distance and patient-reported pain improved persistently through 24 months (p < 0.001). Hemodynamic improvement was achieved in 68.2 %, 73.7 %, and 70.7 % of the patients at 6, 12, and 24 months, respectively. Conclusions: The Pulsar-18 self-expanding nitinol stent with optional drug-coated balloon angioplasty can be considered an efficacious and safe therapy option for endovascular treatment of femoropopliteal artery disease.

2018 Korean society of hypertension guidelines for the management of hypertension: part III-hypertension in special situations

Treatment of hypertension improves cardiovascular, renal, and cerebrovascular outcomes. However, the benefit of treatment may be different according to the patients' characteristics. Additionally, the target blood pressure or initial drug choice should be customized according to the special conditions of the hypertensive patients. In this part III, we reviewed previous data and presented recommendations for some special populations such as diabetes mellitus, chronic kidney disease, elderly people, and cardio-cerebrovascular disease.

Management of patients with concomitant coronary and carotid artery disease

Introduction: Ideal management of concomitant carotid and coronary artery occlusive disease remains under investigation. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines. With emerging data suggesting favorable outcome of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA) in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options. Areas covered: This review presents current evidence regarding the prevalence of carotid stenosis in patients with coronary artery disease, the common pathophysiologic links with an emphasis on the diverse mechanisms of stroke in the coronary artery bypass grafting (CABG) setting and discusses the contemporary registries and observational studies comparing outcomes of various revascularization strategies in high-risk patients. Authors conducted a literature search in two bibliographic databases including papers published from 1983 until 2018 (PubMed, Scopus). Expert opinion: Symptoms should drive the need to intervene on carotid stenosis in patients undergoing coronary revascularization. Carotid artery stenting has gained significant ground, especially among those individuals considered of high surgical risk. PCI may be considered as an alternative option for the management of severe concurrent coronary disease.

Red Blood Cell Distribution Width Predicts 1-month Complications after Percutaneous Transluminal Angioplasty

Background

The identification of patients at higher risk of developing percutaneous transluminal angioplasty (PTA)-related complications is pivotal for achieving better clinical outcomes. We carried out a single-center, observational, retrospective study to explore whether in-hospital changes of red blood cell distribution width (RDW) may help predicting early development of PTA-related complications.

Methods

The study population consisted of all consecutive patients who underwent PTA for severe peripheral artery occlusive disease (PAOD) during a 2-year period. RDW was measured at hospital admission and discharge, and the delta was calculated. Patient follow-up was routinely performed 1-month after hospital discharge, and was based on thoughtful medical assessment and arterial ultrasonography. The control population consisted of 352 ostensibly healthy subjects.

Results

The final PTA group consisted of 224 patients. Hemoglobin was lower, whilst mean corpuscular volume (MCV) and RDW were higher in PAOD cases than in controls. Overall, 11 PAOD patients (4.9%) developed clinically significant PTA-related complications 1-month after hospital discharge. Patients who developed 1-month PTA-related complications had lower hemoglobin concentration, but higher RDW and delta RDW than those who did not. Patients with delta RDW >1 had 60% higher risk of developing 1-month PTA-related complications and 88% higher risk of developing early reocclusion. Overall, RDW exhibited an area under the curve (AUC) of 0.68 and 0.74 for predicting 1-month PTA-related complications and early reocclusion, respectively.

Conclusions

The results of this study suggest that RDW may play a role for guiding the clinical decision making of PTA patients immediately after hospital discharge.

A systematic review of diagnostic techniques to determine tissue perfusion in patients with peripheral arterial disease

Introduction: Peripheral arterial disease (PAD) may cause symptoms due to impaired tissue perfusion of the lower extremity. So far, assessment of PAD is mainly performed by determination of stenosis or occlusion in the large arteries and does not focus on microcirculation. Several diagnostic techniques have been recently introduced that may enable tissue perfusion measurements in the lower limb; however, most have not yet been implemented in clinical daily practice. This systematic review provides an overview of these diagnostic techniques and their ability to accurately detect PAD by peripheral tissue perfusion. Areas covered: A literature search was performed for articles that described a diagnostic technique to determine tissue perfusion in patients with known PAD compared with healthy controls. Expert opinion: So far, transcutaneous oxygen measurements are most often used to measure tissue oxygenation in PAD patients, but evidence seems too low to define this technique as a gold standard, and implementing this technique for home monitoring is difficult. New potentially suitable diagnostic tests should be non-invasive, contact-free, and quick. Further research is needed for all of these techniques before broad implementation in clinical use is justified, in hospital, and for home monitoring.

The association of endothelin-1 gene polymorphism and its plasma levels with hypertension and coronary atherosclerosis

INTRODUCTION

Endothelin-1 (ET-1) is the most potent among all vasoconstrictors, and its association with cardiovascular diseases has been reported before. Our aim was to investigate the association of ET-1 plasma level and its gene polymorphisms (rs5370 and rs10478694) with hypertension and coronary atherosclerosis (CA).

MATERIAL AND METHODS

This study was carried out on 128 women and 132 men, who were divided into 4 groups: hypertensive without atherosclerosis (H+A-); hypertensive with atherosclerosis (H+A+); non-hypertensive with atherosclerosis (H-A+); and non-hypertensive without atherosclerosis (control group). Endothelin-1 plasma levels were measured by ELISA, and gene polymorphisms were detected by polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP) methods. Coronary artery diseases (CAD) were then defined based on angiography data.

RESULTS

The ET-1 plasma level was significantly higher in the H+A+ group in comparison with the other groups, especially H+A-. Comparing people with CA and those without it, the highest frequency level of the T allele of rs5370 was found in people with CA. Significantly higher frequencies of the 3A allele were detected in hypertensive patients in comparison with non-hypertensive individuals, when analyzing rs10478694.

CONCLUSIONS

Endothelin-1 plasma level shows a direct association with the risk of CA development. The T allele of rs5370 can be regarded as a risk factor for CA development. The 3A allele of rs10478694 can be associated with the risk of hypertension; therefore, it can be concluded that ET-1 and its gene polymorphisms play an important role in CA development and hypertension observed in the south-eastern populations of Iran.

[CEUS-application possibilities in the musculoskeletal system]

METHODICAL ISSUE

Contrast-enhanced ultrasound (CEUS) offers easily accessible visualization and quantification of the skeletal muscle microcirculation and other tissues in vivo and in real-time with almost no side effects.

AIM

The aim of this review is to present the increasing number of musculoskeletal CEUS applications.

METHODICAL INNOVATIONS/PERFORMANCE

CEUS applications regarding the musculoskeletal system include applications at bone and joints extending beyond the visualization of only the muscular microcirculation. Besides basic muscle physiology, impaired microcirculation in patients with peripheral artery disease or diabetes mellitus and the diagnosis of inflammatory myopathies have been the subject of previous CEUS studies. More recent studies in orthopedics and traumatology have focused on osseous and muscular perfusion characteristics, e. g., in differentiating infected and aseptic non-unions or the impact of different types of implants and prostheses on muscular microcirculation as a surrogate marker of clinical success.

PRACTICAL RECOMMENDATIONS

CEUS of the musculoskeletal system is used in clinical trials or off-label. Therefore, it is not well established in clinical routine. However, considering the increasing number of musculoskeletal CEUS applications, this could change in the future.

Copeptin, B-type natriuretic peptide and cystatin C are associated with incident symptomatic PAD

Purpose: The aim of this study is to evaluate plasma biomarkers as predictors for peripheral arterial disease (PAD). Materials and methods: Prospective longitudinal cohort study of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer study (MDCS) (n = 5550; 1991-94). Cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional proatrial natriuretic peptide (MR-proANP), mid-regional proadrenomedullin (MR-proADM), and conventional risk factors were measured at baseline. The diagnosis of symptomatic PAD was validated in 97% of the cases. Results: Cumulative incidence of PAD during median follow up of 23.4 years was 4.4% (men 5.9%, women 3.3%). Adjusted for age, sex, smoking, body mass index, hypertension, diabetes mellitus and total cholesterol, copeptin (hazard ratio [HR] 1.46; 95% confidence interval [CI] 1.19-1.80), N-BNP (HR 1.28; 95% CI 1.11-1.48), and cystatin C (HR 1.19; 95% CI 1.10-1.29) were independently associated with incident PAD. Subjects with the three biomarkers copeptin, N-BNP, and cystatin C in the highest quartiles, ran a high risk of incident PAD (HR 3.29; 95% CI 1.76-6.17) compared to those with no biomarker in the highest quartile. Conclusion: Copeptin, N-BNP, and cystatin C were associated with incident symptomatic PAD, implying that these biomarkers are sensitive indicators of early subclinical PAD. Clinical significance First prospective longitudinal cohort study evaluating Cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional proatrial natriuretic peptide (MR-proANP), and mid-regional proadrenomedullin (MR-proADM) as predictors for peripheral arterial disease (PAD). Copeptin, N-BNP, and Cystatin C where independently associated with incident symptomatic PAD after adjustment for conventional risk factors. Copeptin, N-BNP, and Cystatin C seem to be sensitive indicators of early subclinical PAD.

Intake of α-linolenic acid is not consistently associated with a lower risk of peripheral artery disease: results from a Danish cohort study

Intake of the plant-derived n-3 fatty acid α-linolenic acid (ALA) has been associated with anti-atherosclerotic properties. However, information on the association between ALA intake and development of peripheral artery disease (PAD) is lacking. In this follow-up study, we investigated the association between dietary intake of ALA and the rate of PAD among middle-aged Danish men and women enrolled into the Danish Diet, Cancer and Health cohort between 1993 and 1997. Incident PAD cases were identified through the Danish National Patient Register. Intake of ALA was assessed using a validated FFQ. Statistical analyses were performed using Cox proportional hazard regression allowing for separate baseline hazards among sexes and adjusted for established risk factors for PAD. During a median of 13·6 years of follow-up, we identified 950 valid cases of PAD with complete information on covariates. The median energy-adjusted ALA intake within the cohort was 1·76 g/d (95 % central range: 0·94-3·28). In multivariable analyses, we found no statistically significant association between intake of ALA and the rate of PAD (P = 0·339). Also, no statistically significant associations were observed in analyses including additional adjustment for co-morbidities and in sex-specific analyses. In supplemental analyses with additional adjustment for potential dietary risk factors, we found a weak inverse association of PAD with ALA intake above the median, but the association was not statistically significant (P = 0·314). In conclusion, dietary intake of ALA was not consistently associated with decreased risk of PAD.

Use of statins in patients with peripheral artery disease

Atherosclerotic peripheral artery disease (PAD) is a growing health issue that affects more than 200 million individuals worldwide, conferring a high risk of cardiovascular events and death. In spite of its high prevalence, PAD has often been neglected in the past and the heightened cardiovascular risk of patients with PAD has been consistently under-recognized by practitioners. Considering that an integrated approach to reduce cardiovascular events and lower limb complications is necessary in this setting, statins represent the cornerstone of therapy as reported by current American and European guidelines. Literature has extensive data about the importance of lipid-lowering therapy in patients with PAD demonstrating that statins reduce symptoms, cardiovascular events and mortality. Despite data extrapolated from many studies on coronary artery diseases, moderate-dose statin therapy seems to be safe, and the minor risks posed in terms of myopathy-related symptoms are greatly outweighed by benefits. Other lipid-lowering drugs did not show the same results in terms of outcome and they should not be considered as first line therapy in these patients. The role of anti-PCSK9 inhibitors is emerging in the literature but further data are necessary to understand their superiority over statins.

Drug-Coated Balloon Angioplasty of Infrapopliteal Lesions in Patients with Critical Limb Ischaemia: 1-Year Results of the APOLLO Trial

PURPOSE

This study intended to assess effectiveness and safety of the drug-coated balloon (DCB) angioplasty of infrapopliteal atherosclerotic lesions in patients with critical limb ischaemia (CLI) in a real-world setting.

METHODS

Consecutive patients with critical limb ischaemia who underwent infrapopliteal drug-coated balloon angioplasty with the ELUTAX SV DCB were enrolled into the prospective, multicentre, single-arm observational registry. Primary outcome was clinical improvement at 6 and 12 months. Secondary outcomes were change in quality of life, primary patency, freedom from repeat revascularisation, and amputation-free survival at 6 and 12 months.

RESULTS

A total of 164 patients (74.7 ± 9.2 years) with CLI were included at nine German sites between November 2015 and September 2017. The majority (79.9%) of patients had diabetes mellitus, 57.3% had renal insufficiency, and 35.3% had coronary artery disease. Mean lesion length was 71.2 ± 76.5 mm. The Rutherford category improved by 3.0 ± 2.0 (p < 0.0001) within 12 months, resulting in a clinical improvement by at least one Rutherford category in 80.2% of the patients. Walking impairment questionnaire score, European Quality of Life index, and patient-reported pain improved significantly from baseline to 6 and 12 months. Primary patency was 68.5%, freedom from target lesion revascularisation 90.6%, and amputation-free survival 83.5% at 12 months.

CONCLUSION

Infrapopliteal drug-coated balloon angioplasty with the ELUTAX SV DCB in patients with critical limb ischaemia was efficacious and safe over the medium term. The study is registered with Clinical.Trials.gov (Identifier: NCT02539940).

Relationship between symptomatic lower limb peripheral artery disease and calcified carotid artery plaque detected on panoramic images of neurologically asymptomatic males

OBJECTIVE

Males with peripheral arterial disease (PAD) are at high risk of ischaemic stroke given that atherogenic risk factors for both diseases are similar. We hypothesized that neurologically asymptomatic males diagnosed with PAD would demonstrate calcified carotid artery plaques (CCAP) on panoramic images (PI) significantly more often than similarly aged males not having PAD.

METHODS

Investigators implemented a retrospective cross-sectional study. Subjects were male patients over age 50 diagnosed with PAD by ankle-brachial systolic pressure index results of ≤ 0.9. Controls negative for PAD had an ankle-brachial systolic pressure index > 0.9. Predictor variable was a diagnosis of PAD and outcome variable was presence of CCAP. Prevalence of CCAP amongst the PAD+ patients was compared to prevalence of CCAP among PAD- patients. Descriptive and bivariate statistics were computed and p-value was set at 0.05.

RESULTS

Final sample size consisted of 234 males (mean age 72.68 ± 9.09); 116 subjects and 118 controls. Among the PAD+ cohort, CCAP+ prevalence rate (57.76%) was significantly (p = 0.001) greater than the CCAP+ rate (36.44%) of the PAD- (control). There was no significant difference in atherogenic "risk factors" in the PAD+ cohort between CCAP+ and CCAP- subjects.

CONCLUSION

We demonstrated that CCAP, a "risk factor" for future stroke and "risk indicator" of future myocardial infarction is seen significantly more often detected on the PIs of older male patients with PAD than among those without. Dentists treating patients with PAD must be uniquely vigilant for the presence of CCAPs on their patients' PI.

Usefulness of Renal Autotransplantation for Radiotherapy-induced Renovascular Hypertension

We experienced a young woman with congestive heart failure (CHF) caused by renovascular hypertension (RVH) and subsequent hypertensive heart disease. She underwent tumor resection and intraoperative radiation therapy because of neuroblastoma at age 2. She was diagnosed with RVH and hypertensive heart disease due to radiation-induced renal artery stenosis at age 12. Thereafter, she was hospitalized with CHF caused by uncontrolled RVH at age 19, and renal autotransplantation with extraction of left kidney was performed after the recovery of CHF. Her blood pressure has been well controlled without CHF readmission during four years of follow-up after the operation.

[Platelet inhibition in patients with coronary, cerebral and peripheral macroangiopathy : What, when and how long?]

BACKGROUND

Inhibition of platelet aggregation can reduce the rate of vascular events in patients with coronary artery disease, carotid artery stenosis and symptomatic peripheral arterial disease. The choice of platelet inhibitors in monotherapy and combination therapy as well as the duration of dual platelet inhibition depend on the clinical situation and individual patient characteristics.

GOAL

The present review summarizes the latest data from clinical trials and recommendations regarding platelet inhibition in coronary, cerebral and peripheral arterial disease.

DATA

A large number of randomized trials on platelet inhibition in different clinical situations have been performed, allowing evidence-based recommendations on the choice of drugs and duration of treatment. Moreover, new guidelines of European professional societies on platelet inhibition in patients with coronary, cerebral and peripheral arterial disease have been recently published.

CONCLUSION

Based on latest randomized trials and major society guidelines, a number of recommendations on platelet inhibition in stable coronary artery disease, after stent implantation, after acute coronary syndromes and in cerebral and peripheral arterial disease can be made.

Feasibility and Clinical Relevance of a Mobile Intervention Using TrackPAD to Support Supervised Exercise Therapy in Patients With Peripheral Arterial Disease: Study Protocol for a Randomized Controlled Pilot Trial

Background

Peripheral arterial disease (PAD) is a common and severe disease with a highly increased cardiovascular morbidity and mortality. Through the circulatory disorder and the linked undersupply of oxygen carriers in the lower limbs, the ongoing decrease of the pain-free walking distance occurs with a significant reduction in patients’ quality of life. Studies including activity monitoring for patients with PAD are rare and digital support to increase activity via mobile health technologies is mainly targeted at patients with cardiovascular disease in general. The special requirement of patients with PAD is the need to reach a certain pain level to improve the pain-free walking distance. Unfortunately, both poor adherence and availability of institutional resources are major problems in patient-centered care.

Objective

The objective of this trackPAD pilot study is to evaluate the feasibility of a mobile phone–based self tracking app to promote physical activity and supervised exercise therapy (SET) in particular. We also aim for a subsequent patient centered adjustment of the app prototype based on the results of the app evaluation and process evaluation.

Methods

This study was designed as a closed user group trial, with assessors blinded, and parallel group study with face-to-face components for assessment with a follow-up of 3 months. Patients with symptomatic PAD (Fontaine stage IIa or IIb) and possession of a mobile phone were eligible. Eligible participants were randomly assigned into study and control group, stratified by their distance covered in the 6-min walk test, using the software TENALEA. Participants randomized to the study group received usual care and the mobile intervention (trackPAD) for the follow-up period of 3 months, whereas participants randomized to the control group received only usual care. TrackPAD records the frequency and duration of training sessions and pain level using manual user input. Clinical outcome data were collected at the baseline and after 3 months via validated tools (6-min walk test, ankle-brachial index, and duplex ultrasound at the lower arteries) and self-reported quality of life. Usability and quality of the app was determined using the user version of the Mobile Application Rating Scale.

Results

The study enrolled 45 participants with symptomatic PAD (44% male). Of these participants, 21 (47%) were randomized to the study group and 24 (53%) were randomized to the control group. The distance walked in the 6-min walk test was comparable in both groups at baseline (study group: mean 368.1m [SD 77.6] vs control group: mean 394.6m [SD 100.6]).

Conclusions

This is the first trial to test a mobile intervention called trackPAD that was designed especially for patients with PAD. Its results will provide important insights in terms of feasibility, effectiveness, and patient preferences of an app-based mobile intervention supporting SET for the conservative treatment of PAD.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13651

Multidisciplinary Treatment for Critical Limb Ischemia in Peripheral Arterial Disease

Critical limb ischemia (CLI) is a severe blockage of the arteries to the lower limbs characterized by poor prognoses for both salvage of the lower limb and patient survival. Accordingly, CLI must be diagnosed and treated appropriately from the earliest possible stage. To do so, multidisciplinary treatment not only by vascular surgeons but also by many other doctors and medical staff is necessary. Accurate diagnosis is indispensable to appropriate treatment of CLI; thus, the definitions in the recently issued new guidelines for CLI treatment are reviewed. The multidisciplinary treatment of CLI should be recognized as three elements: namely, multidisciplinary treatment to salvage the lower limb, to improve of survival prognosis, and to prevent CLI occurrence. In all of these events, team medicine administered by expert staff is indispensable. The specialist must have not only profound knowledge of his/her field of specialty but also professional skills and the ability to cooperate with other departments. A multidisciplinary treatment approach that combines the abilities of many specialists for treating severely ischemic limbs in patients with peripheral arterial disease is expected to improve both limb salvage and patient survival and should be promoted in daily clinical settings. (This is a translation of Jpn J Vasc Surg 2018; 27: 507–512.)

Blood pressure decreases after revascularization in atherosclerotic renal artery disease: A cohort study based on a multidisciplinary meeting

Background

In atherosclerotic renal artery disease, the benefit of revascularization is controversial. A clinical decision-making process based on a multidisciplinary meeting was formalized in the Lyon university hospital.

Objectives

To investigate whether this decisional process ensured a clinical benefit to patients assigned to renal revascularization.

Methods

Single-centre retrospective cohort study, including patients diagnosed from April 2013 to February 2015 with an atherosclerotic renal artery disease with a peak systolic velocity >180cm/s. For each patient, the decision taken in multidisciplinary meeting (medical treatment or revacularization) was compared to the one guided by international guidelines. Blood pressure values, number of antihypertensive medications, presence of an uncontrolled or resistant hypertension, and glomerular filtration rate at one-year follow-up were compared to baseline values. Safety data were collected.

Results

Forty-nine patients were included: 26 (53%) were assigned to a medical treatment and 23 (47%) to a renal revascularization. Therapeutic decision was in accordance with the 2013 American Health Association guidelines and with the 2017 European Society of Cardiology guidelines for 78% and 22% of patients who underwent revascularization, respectively. Patients assigned to revascularization presented a significant decrease in systolic blood pressure (-23±34mmHg, p = 0.007), diastolic blood pressure (-12±18mmHg, p = 0.007), number of antihypertensive medications (-1.00±1.03, p = 0.001), and number of uncontrolled or resistant hypertension (p = 0.022 and 0.031) at one-year follow-up. Those parameters were not modified among patients assigned to medical treatment alone. There was no grade 3 adverse event.

Conclusion

Based on a multidisciplinary selection of revascularization indications, patients on whom a renal revascularization was performed exhibited a significant improvement of blood pressure control parameters with no severe adverse events.

How to deal with calcium in the superficial femoral artery

Despite the continuous evolution of endovascular therapy, severe calcification remains a major issue for the minimally invasive treatment of superficial femoral artery (SFA) disease. The presence of calcium might negatively affect both the crossing of peripheral lesions and outcomes of all available treatment modalities and is therefore associated with unfavorable acute and long-term results. This manuscript summarizes the challenges raised from severe calcified atherosclerotic lesions and presents the outcomes of the various endovascular modalities in the treatment of calcified SFA disease.

Diagnostic criteria for the determination of clinically significant internal carotid artery stenosis using duplex ultrasound

BACKGROUND

Carotid endarterectomy is beneficial in symptomatic patients with ≥70% stenosis at the bifurcation of the internal carotid artery. The fact that the duplex ultrasound is widely used, inexpensive and non-invasive for examination of the carotid arteries underlines the importance of high accuracy of this method for grading internal artery stenosis.

PATIENTS AND METHODS

Duplex scans and arteriograms of carotid arteries of 142 patients were reviewed. Peak and end-diastolic velocities of the common and internal carotid arteries were recorded, and the percent stenosis of the internal carotid artery was determined by arteriogram. Receiver-operator characteristic curves of sensitivity, specificity, positive and negative predictive values and accuracy were determined.

RESULTS

The recommended criteria for the detection of ≥70% stenosis of the internal carotid artery were: peak systolic velocity in the internal carotid artery ≥215 cm/s, end-diastolic velocity in the internal carotid artery ≥65 cm/s, ratio of peak systolic velocities in the internal and common carotid arteries ≥2.7 and ratio of the end-diastolic velocities of the internal and common carotid arteries ≥3.7.

CONCLUSION

These criteria allow for reliable determination of internal carotid artery stenosis ≥70% by duplex ultrasound.

Long-Term Outcomes of Coronary and Carotid Artery Disease Revascularization in the FRIENDS Study

OBJECTIVES

The aim of this study is to assess long-term-outcomes of patients with concomitant CAD and COD treated with different revascularization strategies.

BACKGROUND

Multisite artery disease is common and patients with combined disease have poor prognosis. The best therapeutic strategy for patients with concomitant carotid obstructive disease (COD) and coronary artery disease (CAD) remains controversial.

METHODS

This observational registry enrolled, between January 2006 and December 2012, 1022 consecutive patients from high volume institutions with concomitant CAD and COD suitable for endovascular, surgical, or hybrid revascularization in both territories selected by consensus of a multidisciplinary team.

RESULTS

The cumulative incidence of 5-year major cardiovascular events (MACCE) including cardiovascular death, myocardial infarction (MI), or stroke in the overall population was 12%. The incidence of 5-year MACCE was not statistically different in the surgical, endovascular, or hybrid patients group (10.1% vs. 13.0% vs. 13.2%, P = .257, respectively). However, the hybrid group exhibited rates of myocardial infarction, chronic kidney disease, and cumulative incidence of all clinical events higher than the surgical group. After propensity score matching, the incidence of 5-year MACCE was similar in the three groups (13.0% vs. 15.0% vs. 16.0%, p = .947, respectively).

CONCLUSIONS

An individualized revascularization approach of patients with combined CAD and COD yields very good results at long-term follow-up, despite the high risk of this multilevel population even when the baseline clinical features are equalized.

Antiplatelet therapy for tibial balloon angioplasty: A clinical perspective

Percutaneous transluminal tibial balloon angioplasty has an important role in the therapeutic approach of critical limb ischaemia. Despite a growing number of patients with critical limb ischaemia, there are no trials to guide the pharmacologic approach post intervention. Guidelines pertaining to the antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty have not been developed. In addition, critical limb ischaemia patients have multiple comorbidities and a higher risk of bleeding. To examine the shortest duration of antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty, we reviewed the preclinical data used to develop the standards for the current angioplasty technique.

Significance of the combination of inter-limb blood pressure differences in the elderly: The Northern Shanghai Study

Whether the combination of inter-arm and inter-leg systolic blood pressure differences (BPDs) and ankle-brachial index is of clinical significance remains unclear. In this study, we aimed to investigate the association of the combination of inter-limb systolic BPDs with cardiovascular risk factors and hypertension-mediated organ damage (HMOD). A total of 2621 elderly subjects from the Northern Shanghai Study were divided into Group A, B, and C consisting of participants with 0, 1, and ≥2 abnormal inter-limb systolic BPDs, respectively. Comparisons of cardiovascular risk factors and parameters of cardiac, vascular, and renal damage between groups and logistic regression models were conducted. The proportions of subjects presenting 0, 1, and ≥2 abnormal inter-limb systolic BPDs were 60.9%, 25.1%, and 14.0%, respectively. Upward trends, from Group A, through Group B, to Group C, were observed for the level or prevalence of nearly all cardiovascular risk factors and HMOD (P for trend ≤0.007 for all). In multiple logistic regression, Group C showed significantly higher odds for carotid plaque (vs Group A: Odds ratio [OR] = 1.88, 95% confidence interval [CI] = 1.43-2.48; vs Group B: OR = 1.46, 95% CI = 1.08-1.97), arterial stiffness (vs Group A: OR = 1.26, 95% CI = 0.96-1.65; vs Group B: OR = 1.36, 95% CI = 1.01-1.83), and left ventricular hypertrophy (vs Group A: OR = 1.35, 95% CI = 1.04-1.76; vs Group B: OR = 1.25, 95% CI = 0.93-1.67), when compared with Group A and B. In conclusion, the combination of abnormal inter-limb systolic BPDs significantly associates with greater burden of cardiovascular risk factors and higher likelihood for HMOD, especially carotid plaque, arterial stiffness, and left ventricular hypertrophy.

Role of Low Ankle-Brachial Index in Cardiovascular and Mortality Risk Compared with Major Risk Conditions

Cardiovascular prevention is of particular interest in persons with asymptomatic peripheral arterial disease. We aimed to quantify its association with mortality and cardiovascular outcomes, compared to other indicators of high risk. We performed a retrospective cohort study using the Database of the Catalan primary care system (SIDIAPQ), for 2006-2015, including 35-85-year-old patients with an ankle-brachial index (ABI) measurement, classified according to the presence of diabetes, cardiovascular disease, and low ABI (<0.9). We calculated the incidences and hazard ratios (HRs) for all-cause mortality, acute myocardial infarction, and ischemic stroke. During a median follow-up of 5.9 years, we analyzed 58,118 persons. The mean (SD) age was 66.6 (10.7) years and 53.4% were men. Compared to the reference group with no diabetes, no previous cardiovascular disease, and normal ankle-brachial index, the HR for all-cause mortality was 1.42 (1.25-1.63) in the group with low ABI, 1.35 (1.26-1.45) in those with diabetes, 1.50 (1.34-1.69) in those with previous cardiovascular disease, and 1.84 (1.68-2.01) in those with low ABI and diabetes. In conclusion, participants with low ABI showed increased mortality, acute myocardial infarction, and ischemic stroke incidence in all the subgroups. Patients with low ankle-brachial index plus diabetes presented increased mortality, acute myocardial infarction, and ischemic stroke risk, all at rates similar to those with previous cardiovascular disease.

Prospective study on clinical characteristics of Japanese diabetic patients with chronic limb-threatening ischemia presenting Fontaine stage IV

The aim of this prospective cross-sectional study was to reveal clinical characteristics of Japanese diabetic patients with chronic limb-threatening ischemia (CLTI) presenting ischemic unhealed ulcer/gangrene (Fontaine stage IV) in the real-world settings. The present study included 132 Japanese diabetic patients who underwent endovascular therapy for CLTI presenting Fontaine stage IV. The prevalence of diabetes-related complications, as well as prior history of ankle-brachial index (ABI) measurement before CLTI onset, was evaluated adopting multiple imputation (50 times). Duration of diabetes was referred to as time from diagnosis. The patients were aged 70 ± 10 years, with duration of diabetes 23 ± 12 years. The diabetes-related complications were so common that only 17% (95% confidence interval: 11-24%) and 25% (17-33%) of the population were free from advanced micro- and macroangiopathies, respectively. The clustering of advanced macroangiopathies was not significantly associated with duration of diabetes (P = 0.62). On the other hand, that of advanced microangiopathies was significantly positively associated with duration of diabetes (P = 0.004). However, even in patients with duration of diabetes < 10 years, as many as 63% (38-87%) of patients had at least one advanced microangiopathy. Only 31% (22-39%) of the patients had prior history of ABI measurement before CLTI onset. The history was inversely associated with age (P = 0.005). In conclusion, the advanced diabetes-related complications were highly prevalent, even in those whose diabetes was diagnosed less than a decade before. In addition, only a few patients had ever undergone ABI measurement before CLTI onset.

A Novel, Individualized Exercise Program for Patients with Peripheral Arterial Disease Recovering from Bypass Surgery

The effectiveness of an individual six-month-long physical exercise program in improving health-related quality of life (HRQOL) is unclear. There is some evidence that an individual exercise program can be effective for this aim. The goal of this study was to compare an individual six-month-long physical exercise program for patients with PAD (Peripheral Arterial Disease) with a traditional exercise program and find the effect of these programs on HRQOL and PAD risk factors. The study included patients who underwent femoral–popliteal artery bypass grafting surgery. Patients were divided into three groups: patients participating in an individual six-month-long physical exercise program (group I), in the standard physical activity program (group II), and in a control group (group III), with no subjects participating in rehabilitation II. Results: group I patients had a significantly (p < 0.001) higher HRQOL at 6 months after their surgery compared with groups II and III. The HRQOL scores were significantly (p < 0.05) lower after surgery among older (≥ 65), overweight participants, as well as among patients with diabetes mellitus and cardiovascular diseases when comparing study results with patients without these risk factors.

The Association of Periodontitis and Peripheral Arterial Occlusive Disease-A Systematic Review

Background: Observational studies support an association between periodontitis (PD) and atherosclerotic vascular disease, but little is known specifically about peripheral arterial occlusive disease (PAOD).

OBJECTIVES

To systematically review the evidence for an association between PD and PAOD.

DATA SOURCES

Medline via PubMed.

REVIEW METHODS

We searched the Pubmed database for original studies, case reports, case series, meta-analyses and systematic reviews that assessed whether there is an association between PD (all degrees of severity) and PAOD (all degrees of severity). The reporting of this systematic review was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement following the Population, Intervention, Control, and Outcome (PICO) format.

RESULTS

17 out of 755 detected studies were included in the qualitative synthesis. Nine studies demonstrated associations between PD and PAOD, and two studies reported associations between tooth loss and PAOD. Six studies addressed the pathomechanism regarding PD as a possible trigger for PAOD. No study that dismissed an association could be detected. Odds ratios or hazard ratios ranged from 1.3 to 3.9 in four large cohort studies after adjusting for established cardiovascular risk factors.

CONCLUSIONS

The presented evidence supports a link between PD and PAOD. Further studies which address the temporality of PD and PAOD and randomized controlled intervention trials examining the causal impact of PD on PAOD are needed. Although our results cannot confirm a causal role of PD in the development of PAOD, it is likely that PD is associated with PAOD and plays a contributing role.