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)

A near-infrared spectroscopy-assisted test discriminates patients with peripheral arterial disease and venous insufficiency with changes of foot oxygenation following light elastic compression therapy

Background: Elastic compression therapy (CT) in patients with peripheral artery disease (PAD) and chronic venous insufficiency (CVI) may compromise arterial perfusion. We evaluated the feasibility of a toe-flexion test, which quantifies dynamic foot perfusion by near-infrared spectroscopy (NIRS), for the assessment of hemodynamic sustainability of CT in PAD patients with CVI. Patients and methods: In this prospective observational study, PAD patients aged 50-85 with combined CVI at CEAP stages II-IV were studied. The ankle-brachial index (ABI) was measured, and foot perfusion was determined after 10 consecutive toe-flexion movements with NIRS sensors placed on the dorsum of each foot. Knee-high open-toe compression stockings were applied, and the degree of compression was measured. Toflex-area was determined by calculating the area under the curve of the oxygenated hemoglobin track recorded by NIRS. A toflex-area reduction > 20 % following CT was arbitrarily defined to identify limbs of patients with improved foot perfusion. These subjects received CT to be worn and a diary to report adherence and symptoms. Results: Forty-seven PAD patients (74 ± 9 years; ABI 0.67 ± 0.24) with CVI were enrolled. For all legs, superimposable toflex-areas were observed for the first two attempts (ICC 0.92). Following application of CT (17 ± 2 mmHg), the toflex-area improved (from -162 ± 110 a.u. to -112 ± 104 a.u.; p < .001). Sixty-two limbs (n = 32 patients) exhibited improved foot perfusion after CT, with a mean variation of 80 ± 47 a.u., while 32 limbs (n = 23 patients) showed stable or worsened values. In a regression model, favorable variations in toflex-area after CT were linked to a worse baseline toflex-area (R² = 0.18; p < 0.001; r_partial = -0.42) while the percentage improvement directly correlated with CEAP class (p = 0.033). Conclusions: The NIRS-assisted test, which is feasible in a laboratory context, objectively discriminates the hemodynamic tolerability of the treatment and identifies subjects with combined PAD and CVI with improved perfusion after CT, in spite of the presence of PAD.

One-Year Clinical Outcomes following Implantation of InnovaTM Self-Expanding Nitinol Stents in Patients with Peripheral Artery Diseases Presenting Femoropopliteal Artery Lesions

Aim: Although the Innova™ self-expanding nitinol stent (Boston Scientific, Marlborough, MA) exhibits acceptable performance in long-term safety and efficacy when used for the treatment of femoropopliteal (FP) lesions, clinical outcomes following its implantation have not been systematically studied in real-world settings. We investigated the one-year clinical outcomes after implantation of Innova™ self-expanding nitinol stents for the treatment of FP lesions in real-world settings.

Methods: In this multicenter study, 481 lesions in 453 consecutive patients with peripheral artery disease (PAD) (74 ± 9 years; male, 70%; diabetes mellitus, 61%; dialysis, 27%; critical limb ischemia, 37%) who underwent endovascular therapy with the implantation of Innova™ self-expanding nitinol stents for FP lesions were analyzed from February 2016 to April 2017. The primary endpoint was one-year restenosis, whereas the secondary endpoints included one-year major adverse limb events and predictors for one-year restenosis.

Results: The mean lesion length was 18 ± 10 cm. One-year restenosis and major adverse limb event rates were 36% and 18%, respectively. Multivariate analysis revealed that the presence of diabetes mellitus (odds ratio [OR]: 1.83; 95% confidence interval [CI]: 1.07–3.13), distal reference vessel diameter (OR: 1.86; 95% CI: 1.09–3.16), spot stenting (OR: 2.27; 95% CI: 1.27–4.06), and lack of one-year cilostazol treatment (OR: 0.58; 95% CI: 0.33–1.00) were independent risk factors for one-year restenosis.

Conclusion: The current study demonstrated one-year clinical outcomes after Innova™ self-expanding nitinol stent placement for the treatment of FP lesions, including challenging cases in real-world settings.

CHA2DS2-VASc score predicts atrial fibrillation recurrence after cardioversion: Systematic review and individual patient pooled meta-analysis

BACKGROUND

Despite progresses in the treatment of the thromboembolic risk related to atrial fibrillation (AF), the management of recurrences remains a challenge.

HYPOTHESIS

To assess if congestive heart failure or left ventricular systolic dysfunction (CHA2 DS2 -VASc) score is predictive of early arrhythmia recurrence after AF cardioversion.

METHODS

Systematic review and individual patient pooled meta-analysis following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

INCLUSION CRITERIA

observational trials in patients with AF undergoing cardioversion, available data on recurrence of AF and available data on CHA2 DS2 -VASc score. Clinical studies of interest were retrieved by PubMed, Cochrane Library, and Biomed Central. Seven authors were contacted for joining the patient level meta-analysis, and three shared data regarding anthropometric measurements, risk factors, major comorbidities, and CHA2 DS2 -VASc score. The primary outcome was the recurrence of AF after cardioversion in patients free from antiarrhythmic prophylaxis. Univariate and multivariate logistic regression was performed.

RESULTS

Overall, we collect data of 2889 patients: 61% were male, 50% with hypertension, 12% with diabetes, and 23% with history of ischemic heart disease. The median CHA2DS2-VASc score was 2.. At the multivariate analysis, chronic kidney disease (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.12-3.27; P = 0.01), peripheral artery disease (OR 1.65; 95% CI 1.23-2.19; P < 0,0001), previous use of beta blockers (OR 1.5; 95% CI 1.19-1.88; P < 0.0001), and CHA2DS2-VASc score > 2 (OR 1.37; 95% CI 1.1-1.68; P = 0.002) were independent predictors of early recurrence of AF.

CONCLUSIONS

CHA2DS2-VASc score predicts early recurrence of AF in the first 30 days after electrical or pharmacological cardioversion. Protocol registration PROSPERO (CRD42017075107).

Carotid near-occlusion can be identified with ultrasound by low flow velocity distal to the stenosis

BACKGROUND

Most carotid near-occlusions are indistinguishable from conventional ≥ 50% stenosis on ultrasound, demonstrating high peak systolic velocity (PSV) in the stenosis.

PURPOSE

To study whether the velocity distal to the stenosis can separate high PSV near-occlusion from conventional ≥ 50% stenosis.

MATERIAL AND METHODS

We included patients with ≥ 50% carotid stenosis with high PSV (≥125 cm/s), examined with both computed tomography angiography (CTA) and ultrasound within 30 days, and a distal velocity measurement was performed. Based on CTA, cases were divided into three groups: conventional stenosis; near-occlusion without full collapse (NwoC; normal-appearing albeit small distal artery); and near-occlusion with full collapse (NwC; threadlike distal artery). Distal Doppler ultrasound flow velocities were compared between these groups.

RESULTS

Sixty patients were included: 33 patients with conventional stenosis; 20 patients with NwoC; and seven patients with NwC. Mean distal PSV was 93, 63, and 21 cm/s ( P < 0.001) and mean distal end-diastolic velocity was 30, 24, and 5 cm/s ( P < 0.001), respectively. A distal PSV < 50 cm/s was 63% sensitive and 94% specific for separating both types of near-occlusion from conventional stenosis.

CONCLUSION

In high PSV carotid stenoses, the distal velocity was lower in near-occlusions than conventional carotid stenosis. Distal velocities warrant further investigation in diagnostic studies.

Influence of smoking on physical function, physical activity, and cardiovascular health parameters in patients with symptomatic peripheral arterial disease: A cross-sectional study

The aim of this study was to analyze the impact of smoking on physical activity, walking capacity, and cardiovascular health in patients with symptomatic peripheral arterial disease (PAD). This cross-sectional study included 180 patients with symptomatic PAD. Patients were classified into 3 groups according to smoking history: smoker (n = 39), ex-smoker (n = 113), and never smoker (n = 28). Physical activity levels, physical function, walking capacity, and cardiovascular health parameters (clinical blood pressure, arterial stiffness, and heart rate variability) were assessed. Smoker patients presented higher sympathetic modulation to the heart (low frequency of heart rate variability: smokers, 71 ± 17 nu; ex-smokers, 53 ± 32 nu; never smokers, 49 ± 21 nu, P < .05) and sympathovagal balance (smokers: 2.44 ± 2.76, ex-smokers: 1.14 ± 1.74, never smokers: 1.04 ± 0.99, P < .05) and lower parasympathetic modulation to the heart (high frequency of heart rate variability: smokers, 29 ± 27 nu; ex-smokers, 47 ± 32 nu; never smokers, 51 ± 21 nu, P < .05) than other patients. In conclusion, nonsignificant differences were observed on physical activity levels, physical function, blood pressure, and arterial stiffness (P > .05). Smoking impairs cardiac autonomic modulation in patients with symptomatic PAD.

Patients’ radiation doses during percutaneous endovascular procedures in arteries of the lower limbs

Abstract. Background: Percutaneous endovascular revascularisation interventions are increasingly used in treatment of lower extremity artery disease and may expose patients to substantial radiation. Patients and methods: Dose-area product (DAP) was retrospectively analysed in 1063 consecutive interventions performed in adult patients with lower extremity artery disease in a single tertiary medical centre. Differences between procedure types, stratified according to anatomical region and arterial lesion complexity were evaluated. Results: Median DAP for diagnostic interventions was 35.6 (15.0–52.4) Gy cm2 in aorto-below-knee arteriography and 3.2 (2.0–4.5) Gy cm2 in ipsilateral femoral arteriography (p < 0.001). For angioplasty without stenting, median DAP was 53.4 (28.6–87.4) Gy cm2 for pelvic interventions vs. 5.9 (4.3–8.6) Gy cm2 for antegrade ipsilateral femoropopliteal interventions (p < 0.001). For stenting, median DAP was 54.9 (32.5–91.2) Gy cm2 for pelvic interventions vs. 8.3 (6.0–12.3) Gy cm2 for antegrade ipsilateral femoropopliteal interventions (p < 0.001). Inside the same anatomical region, diagnostic interventions were associated with significantly lower DAP than therapeutic interventions. Stenting vs no stenting increased DAP values only in antegrade ipsilateral femoropopliteal interventions (8.3 (6.0–12.3) vs 5.9 (4.3–8.6) Gy cm2 (p < 0.001). Arterial lesion complexity affected DAP values only in antegrade ipsilateral femoropopliteal therapeutic interventions. Conclusions: The most important factor influencing patients’ radiation doses was the anatomical region. Pelvic interventions were associated with 6–11-times higher DAP values than femoropopliteal interventions with antegrade ipsilateral approach. Stenting and complexity of lesions increased DAP only in antegrade ipsilateral femoropopliteal interventions.

Pharmacological profile of adenosine A2A receptors in patients with lower extremity peripheral artery disease and associated coronary artery disease: A pilot study

BACKGROUND

Altered blood flow occurs in patients with low extremity peripheral artery disease (LE-PAD). LE-PAD is mostly associated with coronary artery disease (CAD). Adenosine is an endogenous nucleoside that affects both coronary and limb artery blood flow, mostly via the adenosine A_2A receptor (A_2AR). We evaluated A_2AR expression and function in peripheral blood mononuclear cells (PBMCs) and the femoral artery tissues of patients with LE-PAD.

METHODS

Artery tissues and PBMCs were sampled in 24 patients with intermittent claudication, and compared with PBMCs in 24 healthy subjects. Expression and function of A_2AR was studied, using a A_2AR monoclonal antibody with agonist properties, allowing determination of A_2AR affinity (K_D) and cAMP production (ie.EC₅₀).

RESULTS

A_2AR expression on PBMCs was lower in patients than controls (median1.3 [range 0.6-1.8] vs 1.75 [1.45-2.1] arbitrary units; P < 0.01), and correlated with A_2AR expression in artery tissues (Pearson's r = 0.71; P < 0.01). Basal and maximally stimulated cAMP production of PBMCs was lower in patients vs controls: 172 [90-310] vs 244 [110-380] pg/10⁶ cells (P < 0.05) and 375 [160-659] vs 670 [410-980] pg/10⁶ cells (P < 0.05), respectively. A high K_D/EC₅₀ ratio, characteristic of spare receptors, was observed in CAD with inducible-myocardial-ischemia.

CONCLUSION

A_2AR expression in the arteries of patients, correlated with their expression in PBMCs. A_2AR expression was lower in patients than in controls. A single blood sample (for measurement of A_2AR expression on PBMCs) may help to screen patients with LE-PAD, whereas the presence of spare receptors may help with risk stratification before vascular surgery in CAD patients with high risk of myocardial ischemia.

Impact of Therapeutic Angiogenesis Using Autologous Bone Marrow-Derived Mononuclear Cells Implantation in Critical Limb Ischemia With Scleroderma - Subanalysis of the Long-Term Clinical Outcomes Survey

BACKGROUND

Many patients with collagen disease (CD), particularly scleroderma (SSc), develop critical limb ischemia (CLI), which leads to limb amputation. However, conventional therapies, including revascularization via surgical bypass, showed poor outcomes in CLI patients with CD. Many CLI patients with SSc showed poor responses to combination therapies including intravenous iloprost, PDE-5 inhibitors, and bosentan. Therefore, new methods of improving the peripheral circulation for limb salvage are required. This study was a subanalysis of the long-term clinical outcomes after autologous bone marrow-derived mononuclear cells (BM-MNC) in CLI patients with SSc.

METHODS AND RESULTS

We assessed no-option CLI patients with CD who underwent BM-MNC implantation at 10 institutes; 69 patients (39 with SSc-related diseases (SSc group) and 30 with other CDs (non-SSc group)), were included. The median follow-up duration was 36.5 months. The 10-year overall survival rate was 59.1% in the SSc group and 82.4% in the non-SSc group. The 10-year major amputation-free rates were 97.4% and 82.6%, respectively. The number of major or minor amputations in the SSc group trended to be less than that in the non-SSc group. Significant improvements in visual analog scale scores were observed in both groups.

CONCLUSIONS

The BM-MNC implantation may be feasible in no-option CLI patients with CD. In the SSc group, limb salvage rate tended to be higher than in the non-SSc group.

Modified calcium subtraction in dual-energy CT angiography of the lower extremity runoff: impact on diagnostic accuracy for stenosis detection

OBJECTIVES

To investigate the diagnostic accuracy of a modified three-material decomposition calcium subtraction (CS) algorithm for the detection of arterial stenosis in dual-energy CT angiography (DE-CTA) of the lower extremity runoff compared to standard image reconstruction, using digital subtraction angiography (DSA) as the reference standard.

METHODS

Eighty-eight patients (53 males; mean age, 65.9 ± 11 years) with suspected peripheral arterial disease (PAD) who had undergone a DE-CTA examination of the lower extremity runoff between May 2014 and May 2015 were included in this IRB-approved, HIPAA-compliant retrospective study. Standard linearly blended and CS images were reconstructed and vascular contrast-to-noise ratios (CNR) were calculated. Two independent observers assessed subjective image quality using a 5-point Likert scale. Diagnostic accuracy for ≥ 50% stenosis detection was analyzed in a subgroup of 45 patients who had undergone additional DSA. Diagnostic accuracy parameters were estimated with a random-effects logistic regression analysis and compared using generalized estimating equations.

RESULTS

CS datasets showed higher CNR (15.3 ± 7.3) compared to standard reconstructions (13.5 ± 6.5, p < 0.001). Both reconstructions showed comparable qualitative image quality scores (CS, 4.64; standard, 4.57; p = 0.220). Diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) for CS reconstructions was 96.5% (97.5%, 95.6%, 90.9%, 98.1) and 93.1% (98.8%, 90.4%, 82.3%, 99.1%) for standard images.

CONCLUSIONS

A modified three-material decomposition CS algorithm provides increased vascular CNR, equivalent qualitative image quality, and greater diagnostic accuracy for the detection of significant arterial stenosis of the lower extremity runoff on DE-CTA compared with standard image reconstruction.

KEY POINTS

• Calcified plaques may lead to overestimation of stenosis severity and false positive results, requiring additional invasive digital subtraction angiography (DSA). • A modified three-material decomposition algorithm for calcium subtraction provides greater diagnostic accuracy for the detection of significant arterial stenosis of the lower extremity runoff compared with standard image reconstruction. • The application of this algorithm in patients with heavily calcified vessels may be helpful to potentially reduce inconclusive CT angiography examinations and the need for subsequent invasive DSA.

Antithrombotics in stable peripheral artery disease

Patients with peripheral artery disease (PAD) are at high risk for ischemic cardiovascular complications. While single antiplatelet therapy (SAPT), predominantly aspirin, has long been the standard antithrombotic treatment in stable PAD, there have now been greater than 40,000 PAD patients randomized to varying antiplatelet and/or anticoagulant regimens. In this review, we provide a summary of the current evidence for antithrombotics in stable PAD, focusing on the rates of major adverse cardiovascular events (MACE), major adverse limb events (MALE), and major bleeding. SAPT has a limited role in the treatment of asymptomatic PAD, particularly in the absence of concomitant coronary artery disease. In symptomatic PAD, SAPT is effective in preventing MACE, though treatment with a thienopyridine appears marginally superior to aspirin. Dual antiplatelet therapy (DAPT) suggests benefit over SAPT in reducing MACE and MALE, though studies to date are not conclusive and/or are associated with excess major bleeding. Combining moderate to high intensity vitamin K antagonists with antiplatelet therapy does not reduce MACE or MALE and increases life-threatening bleeding. Rivaroxaban 2.5 mg BID in addition to aspirin reduces the incidence of both MACE and MALE as compared to aspirin alone, without increasing life-threatening bleeding. This regimen is associated with a reduced severity of MALE when it does occur. Comparisons across antithrombotic trials in PAD are challenging given the heterogeneity of patient populations and the differing assessment of outcomes. The vascular medicine practitioner can reduce ischemic cardiac and limb events, as well as minimize life-threatening bleeding, by choosing the optimal antithrombotic regimen in their PAD patients.

Supervised exercise therapy and revascularization: Single-center experience of intermittent claudication management

Guidelines recommend supervised exercise therapy (SET) as first-line treatment for intermittent claudication. However, the use of revascularization is widespread. We addressed the effectiveness of preventing (additional) invasive revascularization after primary SET or revascularization based on lesion and patient characteristics. In this single-center, retrospective, cohort study, 474 patients with intermittent claudication were included. Patients with occlusive disease of the aortoiliac tract and/or common femoral artery (inflow) were primarily considered for revascularization, while patients with more distal disease (outflow) were primarily considered for SET. In total, 232 patients were referred for SET and 242 patients received revascularization. The primary outcome was freedom from (additional) intervention, analyzed by Kaplan–Meier estimates. Secondary outcomes were survival, critical ischemia, freedom from target lesion revascularization (TLR), and an increase in maximum walking distance. In the SET-first strategy, 71% of patients had significant outflow lesions. Freedom from intervention was 0.90 ± 0.02 at 1-year and 0.82 ± 0.03 at 2-year follow-up. In the primary revascularization group, 90% of patients had inflow lesions. Freedom from additional intervention was 0.78 ± 0.03 at 1-year and only 0.65 ± 0.04 at 2-year follow-up, despite freedom from TLR of 0.91 ± 0.02 and 0.85 ± 0.03 at 1- and 2-year follow-up, respectively. In conclusion, SET was effective in preventing invasive treatment for patients with mainly outflow lesions. In contrast, secondary intervention rates following our strategy of primary revascularization for inflow lesions were unexpectedly high. These findings further support the guideline recommendations of SET as first-line treatment for all patients with intermittent claudication irrespective of level of disease.

Identifying asymptomatic patients at high-risk for stroke

Carotid endarterectomy and carotid artery stenting, in addition to good medical therapy, halve long-term stroke risk in asymptomatic patients with carotid artery stenosis. Since the absolute benefits following successful intervention are moderate, identification of asymptomatic patients at high-risk of future stroke could maximize the effectiveness of carotid interventions. The aim of this paper is to summarize the evidence for high-risk features associated with increased long-term stroke risk in asymptomatic patients. There is a paucity of reliable data describing the effect of clinical features, imaging findings and plaque characteristics on increased long-term stroke risk. Clinical and imaging features such as contralateral symptoms, silent brain infarcts/embolic signals, progression of stenosis and impaired cerebrovascular reactivity may be associated with increased future risk of stroke. Plaque characteristics such as echolucency, large plaque size (≥80 mm), intra-plaque hemorrhage, lipid-rich necrotic core and thinned/ruptured fibrous cap may also increase future risk of stroke. Whilst these form the basis for European guidelines targeting carotid intervention in asymptomatic patients with tight stenosis, conclusive evidence of their utility is lacking. Results from ongoing large, multicenter randomized clinical trials comparing carotid endarterectomy and carotid artery stenting with good medical therapy may be consistent with earlier trials, showing a halving of the long-term risk of stroke following successful carotid revascularization. However, they may well lack sufficient statistical power to identify higher-risk subgroups in whom the absolute gains of treatment are significantly higher. Large contemporary cohort studies are needed to provide further clarity regarding high-risk features associated with increased long-term stroke risk in asymptomatic patients with carotid artery stenosis.

A multicenter randomized controlled study to evaluate whether neuromuscular electrical stimulation improves the absolute walking distance in patients with intermittent claudication compared with best available treatment

OBJECTIVE

To assess the clinical efficacy of a neuromuscular electrical stimulation (NMES) device to improve the absolute walking distance in patients with intermittent claudication as an adjunct to the local standard care available at the study sites compared with local standard care alone.

METHODS

This open, multicenter, randomized controlled trial included eight participating centers in England. Sites are equally distributed between those that provide supervised exercise therapy programs and those that do not. Patients with intermittent claudication meeting the eligibility criteria and providing consent will be randomized, depending on the center type, to either NMES and locally available standard care or standard care alone. The primary end point is change in absolute walking distance at 3 months (the end of the intervention period) by treadmill testing. Secondary outcomes include quality of life, compliance with the interventions, economic evaluation of the NMES device, and lower limb hemodynamic measures to further the understanding of underlying mechanisms. Recruitment commenced in March 2018 and will continue for a total of 15 months. The Neuromuscular Electrical Stimulation Improves the Absolute Walking Distance in Patients with Intermittent Claudication trial is funded by the UK Efficacy and Mechanism Evaluation Programme, Medical Research Council, and National Institute for Health Research partnership.

Safety and feasibility of simultaneous endovascular therapy for supra-arch multivessel stenosis in 256 Chinese patients

OBJECTIVES

To evaluate the safety and feasibility of simultaneous endovascular therapy for supra-arch multivessel stenosis.

BACKGROUND

Limited data are currently available on simultaneous intervention for supra-arch multivessel stenosis because of concerns regarding the high incidence of procedure-related complications.

METHODS

From January 2005 to December 2012, the clinical data of 256 consecutive inpatients who underwent simultaneous intervention for supra-arch multivessel stenosis were retrospectively analyzed. The primary end point was a composite of any type of stroke or neurological death within 30 days.

RESULTS

In total, 535 supra-arch vessels underwent endovascular therapy. In total, 234, 21, and 1 patient underwent simultaneous intervention of 2, 3, and 4 supra-arch vessels, respectively. The lesions involved only the anterior circulation in 40.2% (103/256), only the posterior circulation in 10.5% (27/256), and the combined circulations in 49.2% (126/256) patients. The overall procedural success rate was 99.6% (533/535). The incidence of the primary end point was 3.5%. According to the lesion location, the incidence of the primary end point was 3.9% (4/103), 0% (0/27), and 4.0% (5/126) in the patients who underwent endovascular treatment for the anterior circulation alone, posterior circulation alone, and combined circulations, respectively. According to the number of supra-arch lesions, the incidence of the primary end point was 3.4% (8/234), 4.8% (1/21), and 0% (0/1) in the patients who underwent simultaneous intervention of 2, 3, and 4 vessels, respectively.

CONCLUSIONS

The study showed that simultaneous intervention for supra-arch multivessel stenosis was safe and technically feasible.

A prescription support-tool for chronic management of oral antithrombotic combinations in adults based on a systematic review of international guidelines

BACKGROUND

Oral antithrombotic (AT) drugs, which include antiplatelet and anticoagulant therapies, are widely implicated in serious preventable bleeding events. Avoiding inappropriate oral AT combinations is a major concern. Numerous practical guidelines have been released; a document to enhance prescriptions of oral AT combinations for adults would be of great help.

OBJECTIVE

To synthesize guidelines on the prescription of oral AT combinations in adults and to create a prescription support-tool for clinicians about chronic management (≥ one month) of oral AT combinations.

METHODS

A systematic review of guidelines published between January 2012 and April 2017, in English or in French, from Trip database, Guideline International Network and PubMed, dealing with the prescription of oral ATs in adults was conducted. In-hospital management of ATs, bridging therapy and switches of ATs were not considered. Some specific topics requiring specialized follow-up (cancer, auto-immune disease, haemophilia, HIV, paediatrics and pregnancy) were excluded. Last update was made in November 2018.

RESULTS

A total of 885 guidelines were identified and 70 met the eligibility criteria. A prescription support-tool summarizing medical conditions requiring chronic management of oral AT combinations in adults with drug types, dosage and duration, on a double-sided page, was provided and tested by an external committee of physicians. The lack of specific guidelines for old people (age 75 years and older) is questioned considering the specific vulnerability of this age group to serious bleedings.

CONCLUSIONS

Recommendations on prescriptions about chronic management of oral AT combinations in adults were mainly consensual but dispersed in numerous guidelines according to the medical indication. We provide a prescription support-tool for clinicians. Further studies are needed to assess the impact of this tool on appropriate prescribing and the prevention of serious adverse drug events.

IN.PACT™ Admiral™ drug-coated balloons in peripheral artery disease: current perspectives

Endovascular therapy has evolved as a main treatment option especially in patients with short (<25 cm) femoropopliteal lesion. The latest guideline recommends the use of drug-eluting devices (both drug-coated balloons [DCBs] and drug-eluting stents) in short femoro-popliteal lesions as class IIb recommendation. DCB usage is also recommended for in-stent restenosis lesions (class IIb). DCBs are a more attractive treatment option because the lack of metal prosthesis allows for more flexibility in future treatment options including the option of treating nonstenting zones, previously DCB-treated zones with DCBs again. The IN.PACT™ Admiral™ DCB has shown promising clinical performance in several randomized control trials and global registries, and is currently the market DCB leader for the treatment of femoropopliteal lesions with more than 200,000 patients treated thus far. Currently, more than 10 DCBs have received Conformité Européene mark for the treatment of femoropopliteal atherosclerotic disease. Three of these (including IN.PACT Admiral DCBs) have also received Food and Drug Administration approval in the USA. However, some Conformité Européene-marked DCBs have failed to show consistent results in their clinical studies suggesting all DCBs are not created equal. Each DCB is unique (ie, drug type, drug dose, crystallinity, and excipient) with different clinical outcomes. In the current review, we will focus on the preclinical and clinical results of not only IN.PACT Admiral DCB, but also the other currently available DCBs.

Clinical Assessment of Peripheral Arterial Disease in the Office: What Do the Guidelines Say?

Lower extremity peripheral arterial disease (PAD) is the manifestation of atherosclerotic disease within the lower extremities. The presentation of PAD is diverse ranging from asymptomatic disease to claudication or to debilitating rest pain, nonhealing ulcers, and gangrene. PAD is associated with significant morbidity, mortality, and healthcare costs. Proper diagnosis and management of PAD is important so as to maintain quality of life and reduce the risk of cardiovascular disease and adverse limb events such as amputation. This document provides a comprehensive outpatient approach to the clinical assessment of PAD that includes risk factors, diagnosis, treatment, and follow-up options.

One-Year Results of the LIBERTY 360 Study: Evaluation of Acute and Midterm Clinical Outcomes of Peripheral Endovascular Device Interventions

Purpose: To report the 1-year results of a multicenter study of peripheral artery disease (PAD) treatment with a variety of endovascular treatment strategies employed in routine practice. Materials and Methods: The LIBERTY trial (ClinicalTrials.gov identifier NCT01855412) is a prospective, observational, core laboratory–assessed, multicenter study of endovascular device intervention in 1204 subjects (mean age 69.8±10.7 years; 770 men) stratified by Rutherford category (RC): claudicants (RC2,3; n=501) and critical limb ischemia (CLI) with no/minimal tissue loss (RC4,5; n=603) or significant tissue loss (RC6; n=100). Key outcomes included quality of life (QoL) measures (VascuQol and EuroQol) and freedom from major adverse events (MAE), defined as death (within 30 days), major amputation, and target vessel revascularization based on Kaplan-Meier analysis. Results: Successful revascularization was beneficial, with RC improvement noted across all groups. Thirty-day freedom from MAE estimates were high across all groups: 99.2% in RC2,3, 96.1% in RC4,5, and 90.8% in RC6. At 12 months, the freedom from MAE was 82.6% in RC2,3, 73.2% in RC4,5, and 59.3% in RC6 patients. Estimates for freedom from major amputation at 12 months were 99.3%, 96.0%, and 81.7%, respectively. QoL scores improved significantly across all domains in all groups with 12-month VascuQol total scores of 5.3, 5.0, and 4.8 for RC2,3, RC4,5, and RC6, respectively. Conclusion: The results indicate that peripheral endovascular intervention is a viable treatment option for RC2,3, RC4,5, and RC6 patients as evidenced by the high freedom from major amputation, as well as the improvement in QoL and the RC at 12 months. Furthermore, primary unplanned amputation is often not necessary in RC6.

Multidisciplinary Approach to PAD: Who's on Your Team?

The complexity of peripheral arterial disease (PAD) and its multiorgan involvement requires the utilization of a multispecialty team approach. Members of this team include a vascular specialty (interventional radiology, cardiology, and vascular surgery), podiatry, orthopedic surgery, primary care, infectious disease, endocrinology, plastic surgery, wound care nursing, and dietetics. A team approach has been proven to significantly improve patient outcomes as well as decreasing amputation rates. In order to promote collaboration and avoid duplication of care, the team can be broken down into three main pillars: medical management, wound care, and revascularization. A complete team approach is vital for this population, with an overall goal to treat all manifestations of the disease and prevent further progression and risk of major sequelae of the disease.

Current Medical and Surgical Stroke Prevention Therapies for Patients with Carotid Artery Stenosis

Carotid Artery Stenosis (CAS) is a marker of systemic atherosclerosis and patients with CAS are at high risk of vascular events in multiple vascular locations, including ipsilateral ischemic stroke. Both medical and surgical therapies have been demonstrated effective in reducing this risk. The optimal management for patients with asymptomatic carotid artery stenosis remains controversial. In patients with symptomatic CAS ≥70%, CEA has been demonstrated to reduce the risk of stroke. With the risk of recurrent stroke being particularly high in the first 2 weeks after the first event, Carotid Endarterectomy (CEA) or carotid angioplasty with stenting provides maximal benefits to patients with symptomatic CAS ≥70% if performed within this «2-week» target. Several large ongoing trials are currently comparing the risks and benefits of carotid revascularization versus medical therapy alone.

The peripheral atherosclerotic profile in patients with type 1 diabetes warrants a thorough vascular assessment of asymptomatic patients

AIMS

Epidemiological data on subclinical atherosclerotic disease in type 1 diabetes mellitus (DM1) are scarce. We aimed to estimate the subclinical atherosclerosis profile of asymptomatic patients with DM1 and an abnormal ankle-brachial index (ABI).

MATERIAL AND METHODS

In a cross-sectional design (ClinicalTrials.gov Identifier: NCT02910271), we estimated ABI in 289 consecutive asymptomatic patients with DM1. An abnormal ABI led to measurements of toe-brachial index (TBI) and peripheral doppler ultrasound (DUS) to diagnose peripheral artery disease (PAD) and/or atherosclerotic carotid plaques (ACP).

RESULTS

A reduced (≤0.9) or increased (>1.2) ABI was detected in 17 (6%) and 75 (26%) patients, respectively. PAD was confirmed by TBI and DUS in 9 (53%) patients with a reduced ABI and 28 (37%) patients with an increased ABI, resulting in a 12.8% (9.4-17.2) prevalence of asymptomatic PAD. Fourteen patients with an abnormal ABI also exhibited ACP [4.8% (2.9-7.9)], with 64% of these patients showing bilateral disease. Artery stenosis was mild or moderate in 21% and 29% of patients, respectively. Thus, 46 [16% (12-21)] patients showed asymptomatic PAD, ACP, or both. According to our data, we would have to explore three asymptomatic patients with DM1 and normal pulses to unmask one case of PAD, and seven asymptomatic patients showing abnormal ABI values to detect one carotid disease.

CONCLUSIONS

Peripheral artery disease is often undiagnosed in asymptomatic patients with DM1. However, its presence may change medical management in a substantial percentage of cases, highlighting the potential benefit of a thorough vascular assessment on these patients.

Self-Expanding Nitinol Stent vs Percutaneous Transluminal Angioplasty in the Treatment of Femoropopliteal Lesions: 3-Year Data From the SM-01 Trial

Purpose: To report the midterm outcomes of a trial comparing self-expanding nitinol stents to percutaneous transluminal angioplasty (PTA) with provisional stenting in the treatment of obstructive disease in the superficial femoral and popliteal arteries. Materials and Methods: The SM-01 study ( ClinicalTrials.gov identifier NCT01183117), a single-blinded, multicenter, randomized controlled trial in Japan, enrolled 105 consecutive patients with de novo or postangioplasty restenotic femoropopliteal lesions; after removing protocol violations (1 from each group), 51 patients (mean age 74±8 years; 36 men) in the stent group and 52 patients (mean age 73±8 years; 35 men) in the PTA group were included in the intention-to-treat analysis. The groups were well-matched at baseline. Patients were followed to 36 months with duplex imaging. Three-year primary patency was assessed based on a duplex-derived peak systolic velocity ratio <2.5. Freedom from clinically-driven target vessel revascularization (TVR) and target lesions revascularization (TLR) were estimated using the Kaplan-Meier method. Results: The technical success rate was higher (100% vs 48%, p<0.001) and the frequency of vascular dissection was lower (4% vs 31%, p<0.001) in the stent group. The S.M.A.R.T stent group had a higher 3-year primary patency rate (73% vs 51%, p=0.033). Freedom from clinically-driven TVR and TLR were not significantly different between the groups. Conclusion: The S.M.A.R.T. stent maintained a higher primary patency rate than PTA at 3 years in this randomized trial; the need for clinically-driven revascularization was similar for both therapies.

[Interventional angiology : Endovascular treatment of chronic and acute limb ischemia]

The development of new technologies and techniques has significantly advanced the field of endovascular peripheral interventions for chronic and acute limb ischemia over the last 20 years. Nowadays, the majority of patients with symptomatic peripheral arterial occlusive disease can be treated percutaneously using an endovascular first approach as a minimally invasive alternative to classical bypass surgery. Balloon angioplasty and stent implantation are the mainstays of endovascular interventions. For reconstruction of complex aortoiliac occlusions covered stents are frequently used. Patency rates after femoropopliteal interventions have been improved by the introduction of drug-eluting balloon and stent technologies. Advances in material and access techniques now enable the successful endovascular treatment of more complex infrapopliteal stenoses and occlusions.

Current evidence of drug-elution therapy for infrapopliteal arterial disease

New and sophisticated endovascular devices, such as drug-eluting stents (DES) and drug-coated balloons (DCB), provide targeted drug delivery to affected vessels. The invention of these devices has made it possible to address the reparative cascade of arterial wall injury following balloon angioplasty that results in restenosis. DESs were first used for the treatment of infrapopliteal lesions almost 20 years ago. More recently, however, DCB technology is being investigated to improve outcomes of endovascular below-the-knee arterial procedures, avoiding the need for a metallic scaffold. Today, level IA evidence supports the use of infrapopliteal DES for short to medium length lesions, although robust evidence that justifies the use of DCBs in this anatomical area is missing. This review summarizes and discusses all available data on infrapopliteal drug-elution devices and highlights the most promising future perspectives.

Oxysterols as a biomarker in diseases

Cholesterol is one of the most important chemical substances as a structural element in human cells, and it is very susceptible to oxidation reactions that form oxysterol. Oxysterols exhibit almost the exact structure as cholesterol and a cholesterol precursor (7-dehydrocholesterol) with an additional hydroxyl, epoxy or ketone moiety. The oxidation reaction is performed via an enzymatic or non-enzymatic mechanism. The wide array of enzymatic oxysterols encountered in the human body varies in origin and function. Oxysterols establish a concentration equilibrium in human body fluids. Disease may alter the equilibrium, and oxysterols may be used as a diagnostic tool. The current review presents the possibility of using non-enzymatic oxysterols and disturbances in enzymatic oxysterol equilibrium in the human body as a potential biomarker for diagnosing and/or monitoring of the progression of various diseases.

Critical appraisal of international guidelines for the screening and treatment of asymptomatic peripheral artery disease: a systematic review

Background

Peripheral artery disease (PAD) is often asymptomatic but increases the risk of developing cardiovascular events. Due to the uncertainties regarding the quality of related guidelines and a lack of clear-cut evidence, we performed a systematic review and critical appraisal of these guidelines to evaluate their consistency of the recommendations in asymptomatic PAD population.

Methods

Guidelines in English between January 1st, 2000 to December 31th, 2017 were screened in databases including Medline via PubMed, EMBASE, the G-I-N International Guideline Library, the National Guidelines Clearinghouse, the Canadian Medication Association Infobase and the National Library for Health. Those guidelines containing recommendations on screening and treatment for asymptomatic PAD were included, and three reviewers evaluated the quality of the guidelines using Appraisal of Guidelines Research and Evaluation (AGREE) II instrument. Related recommendations were then fully extracted and compared by two reviewers.

Results

Fourteen guidelines were included finally and the AGREE scores ranged from 39 to 73%. Most of included guidelines scored low in Rigor of development and Editorial independence, and only two guidelines (ACCF/AHA, AHA/ACC) reached the standard on Conflict of Interest from Institute of Medicine (IOM). Eight guidelines recommended screening at different strength while the others found insufficient evidence or were against screening. Conflicting recommendations on treatment were found in the target value of the lipid lowering and antiplatelet therapy. The treatment policies in three guidelines (BWG, CEVF, ESC) appeared more aggressive, but they had low transparency between guideline developer and industry or did not reach the standard of IOM.

Conclusions

Current guidelines on asymptomatic PAD varied in the methodological quality and fell short of the standard in the rigor of development and editorial independence. Conflicting recommendations were found both on the screening and treatment. More effort is needed to provide clear-cut evidences with high quality and transparency among guideline developer and industry.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0960-8) contains supplementary material, which is available to authorized users.

Guidelines adherence or chronic total occlusion recanalization of the superficial femoral artery with a stentless approach: The next frontier?

In patients with intermittent claudication and long chronic total occlusions of the superficial femoral artery, a primary surgical bypass or stenting is recommended. However, due to the invasive nature, high complication rates and patient-related comorbidities, surgery is currently not the preferred method and full lesion stenting for long chronic total occlusions has the obvious consequences of permanent metallic implants. We report a case of a patient with a long chronic total occlusion of the superficial femoral artery with intermittent claudication. Endorsing an endovascular-first strategy, he was treated via an antegrade and retrograde approach with a complete recanalization and a stentless treatment with rotational atherectomy and drug-coated balloons. We believe this is a feasible endovascular strategy for the treatment of long chronic total occlusions of the superficial femoral artery for patients refusing open surgery. Further investigations are needed to evaluate long-term clinical outcomes of these novel techniques.

[Peripheral arterial occlusive disease as predictor of high atherosclerotic burden]

Atherosclerosis is a disease which affects the whole arterial vascular tree. In particular patients with peripheral arterial occlusive disease (PAOD) often suffer from additional atherosclerotic manifestations in other vascular territories. This has a direct impact on cardiovascular prognosis. Atherosclerosis is an inflammatory disease. A high inflammatory burden is associated with polyvascular atherosclerosis and also with the occurrence of cardiovascular events. Control of cardiovascular risk factors is crucial for the treatment of patients with polyvascular atherosclerosis. In addition, anticoagulation treatment is very important in patients with atherosclerosis. Moreover, exercise training is an important treatment option in PAOD patients not only to improve walking distance but also for multiple additional positive effects. So far the role of anti-inflammatory treatment is not clear and must be further elaborated by future clinical research.

Sortilin levels are associated with peripheral arterial disease in type 2 diabetic subjects

BACKGROUND

Sortilin is a 95-kDa protein which has recently been linked to circulating cholesterol concentration and lifetime risk of developing significant atherosclerotic disease. Sortilin is found inside different cell types and circulating in blood. Higher circulating sortilin concentration has been found in patients with coronary atherosclerosis compared to control subjects. Sortilin concentration is influenced by statin therapy.

METHODS

We enrolled statin-naïve subjects with type 2 diabetes mellitus and we performed a cross-sectional study to evaluate the association between sortilin levels and the presence of clinically significant lower limb peripheral artery disease (PAD) in a population of statin-free diabetic subjects.

RESULTS

Out of the 154 patients enrolled in our study, 80 patients were free from PAD, while 74 had clinically significant PAD. Sortilin concentration was significantly higher in the latter group compared to the former (1.61 ± 0.54 ng/mL versus 0.67 ± 0.30 ng/mL, P < 0.01) and there was a trend toward increased sortilin levels as disease severity increased. The association of sortilin levels with PAD remained after adjusting for major risk factors in a multivariate analysis.

CONCLUSIONS

We showed that sortilin is significantly and independently associated with the presence of lower limb PAD in a statin-free diabetic population and it may be a promising marker for clinically significant atherosclerosis of the lower limbs. Further studies are needed to confirm this finding and to evaluate its clinical usefulness.

Cardiac function response to stenting in atherosclerotic renal artery disease with and without heart failure: results from the Carmel study

Aims

Consensus‐derived guidelines recommend renal stenting for patients with atherosclerotic renal artery disease (ARAD) and heart failure (HF). The aim of this prospective multi‐centre observational study was to verify our hypothesis that changes in E/e′, an echocardiographic correlate of left ventricular (LV) filling pressure, following renal stenting may differ between ARAD patients with and without HF.

Methods and results

This study enrolled de novo ARAD patients undergoing renal stenting at 14 institutions. The primary endpoint was the difference in E/e′ change between ARAD patients with and without HF. Clinical and echocardiographic data were prospectively collected at baseline, the day following renal stenting, and 1 month and 6 months afterwards. ARAD patients with HF were defined as patients with New York Heart Association (NYHA) Class 2 and more, or a history of HF hospitalization. A total of 76 patients were included, and 39% were ARAD patients with HF. ARAD patients with HF had significantly lower estimated glomerular filtration rate (P = 0.028) and higher NYHA functional class (P < 0.001) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (P = 0.001) than ARAD patients without HF. Also, ARAD patients with HF had significantly lower LV ejection fraction (P = 0.003) and e′‐velocity (P = 0.003) and higher E/e′ ratio (P = 0.001), left atrial volume index (LAVI) (P = 0.046), LV end‐diastolic volume (LVEDV) (P = 0.001), LV end‐systolic volume (LVESV) (P = 0.001), and LV mass index (P = 0.009) than ARAD patients without HF. All procedures were successful. In contrast to blood pressure and renal function, there was a significant interaction in E/e′ (P_interaction < 0.001) between time and HF, and ARAD patients with HF showed a significant (P < 0.001) decrease in E/e′ albeit those without HF. By the same token, there was a significant interaction in NYHA class (P_interaction < 0.001), MLHFQ score (P_interaction = 0.018), E‐velocity (P_interaction = 0.002), LAVI (P_interaction = 0.001), LVEDV (P_interaction = 0.003), and LVESV (P_interaction = 0.001) between time and HF with a significant improvement in all these variables in ARAD patients with HF (NYHA class, P = 0.001; MLHFQ score, P = 0.002; E‐velocity, P = 0.005; LAVI, P = 0.001; LVEDV, P = 0.017; and LVESV, P = 0.011).

Conclusions

Change in LV filling pressure after renal stenting differed between ARAD patients with and without HF, with a significant improvement in LV filling pressure in patients with HF‐ARAD. These unique findings might support clinical cardiac benefits of renal stenting in ARAD patients with HF.

Association between Peripheral Artery Disease and Major Adverse Cardiovascular Events in Patients with Acute Coronary Syndrome: Findings from the Gulf COAST Registry

OBJECTIVE

To evaluate the association between peripheral artery disease (PAD) and major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) in the Arabian Gulf.

METHODS

Data from 4,044 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013 were analyzed. PAD was defined as any of the following: claudication, amputation for arterial vascular insufficiency, vascular reconstruction, bypass surgery, or percutaneous intervention in the extremities, documented aortic aneurysm or an ankle brachial index of <0.8 in any of the legs. MACE included stroke/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and readmissions for cardiac reasons diagnosed between hospital admission and at 1-year post discharge. Analyses were performed using univariate and multivariate statistical techniques.

RESULTS

The overall mean age of the cohort was 60 ± 13 years and 66% (n = 2,686) were males. A total of 3.3% (n = 132) of the patients had PAD. Patients with PAD were more likely to be associated with smoking, prior MI, hypertension, diabetes mellitus, and stroke/TIA. At the 1-year follow-up, patients with PAD were significantly more likely to have MACE (adjusted OR [aOR], 2.07; 95% confidence interval [CI]: 1.41-3.06; p< 0.001). The higher rates of events were also observed across all MACE components; stroke/TIA (aOR, 3.22; 95% CI: 1.80-5.75; p< 0.001), MI (aOR, 2.15; 95% CI: 1.29-3.59; p =0.003), all-cause mortality (aOR, 2.21; 95% CI: 1.33-3.69; p =0.002), and readmissions for cardiac reasons (aOR, 1.83; 95% CI: 1.24-2.70; p =0.003).

CONCLUSIONS

PAD was significantly associated with MACE in ACS patients in the Arabian Gulf.

Prevalence of peripheral arterial disease in patients with heart failure with preserved ejection fraction

OBJECTIVES

To describe the prevalence of the reduced ankle-brachial index (ABI) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) attended at a HF clinic in the metropolitan region of Porto Alegre, and to compar the patients to those with reduced ejection fraction (HFrEF).

METHODS

A descriptive observational study, included patients referred to the heart failure clinic in HU-Ulbra with HFpEF or HFrEF and diastolic dysfunction, and measurements of ABIs using vascular Doppler equipment were performed in both groups.

RESULTS

The sample consisted of 106 patients with HF, 53.9% of the patients had HFpEF, and 19.4% had a diagnosis of peripheral arterial disease (PAD) (ABI less than 0.9). PAD was identified in 24.1% of the patients with HFpEF, while15.8% of patients in the HFrEF group were diagnosed with PAD.

CONCLUSION

Our results did not identify a significantly different prevalence of altered and compatible PAD values in patients with HFpEF. However, we showed a prevalence of 19.4%, a high value if we consider similar populations.

[Subclavian artery stenosis combined with vertebral artery stenosis may lead to compensatory blood flow changes in the contralateral vertebral artery]

OBJECTIVE

To investigate the severity of blood steal and the hemodynamic profiles in patients with subclavian artery stenosis combined with vertebral artery stenosis.

METHODS

A retrospective analysis was performed of transcranial Doppler (TCD) data from patients with subclavian artery stenosis (SAS) and concomitant unilateral/bilateral vertebral artery stenosis (VAS, &gt;50%) or occlusion in our institution between February, 2014 and July, 2018.Thirty-seven patients with SAS combined with VAS (SAS+VAS) were reviewed for types of blood steal, peak systolic velocities of blood flow in affected subclavian artery and the contralateral vertebral artery, and the findings of hyperemia testing.These data were also reviewed for 39 SAS patients without VAS (control group) for comparison of blood steal and hemodynamic profiles.

RESULTS

In SAS+VAS group, 5 patients showed no blood steal; blood steal in stage Ⅰ was found in 22 patients, stage Ⅱ in 7, and stage Ⅲ in 3, as compared to the numbers of 17, 12 and 10 in the control group, respectively (H=9.431, P=0.002).The peak systolic velocity of the contralateral vertebral artery was 43.91±17.43 cm/s in SAS+VAS group, significantly lower than that in the control group (53.56±17.45 cm/s; t= 629.5, P=0.006).Hyperemia testing showed a significant difference in the negative rate between SAS+VAS group and the control group[35.1%(13/37) vs 7.7%(3/39);χ²=8.603, P=0.003).

CONCLUSIONS

SAS combined with VAS may lead to reduced compensatory blood flow in the contralateral vertebral artery to lessen the severity of subclavian steal syndrome.

The Association of Lipoprotein(a), Apolipoprotein(a) Phenotypes and Autoantibodies to Lipoprotein(a) With Lower Extremity Artery Disease

AIM

Lipoprotein(a) [Lp(a)] and low molecular weight (LMW) apolipoprotein(a) [apo(a)] phenotype are risk factors of сoronary heart disease and stroke. Data about the role of Lp(a) and phenotypes apo(a) in the development of lower extremity artery disease (LEAD) is scarce. The aim of our study was to assess the association of Lp(a), apo(a) phenotypes and autoantibodies to apolipoprotein B100 (apoB100) lipoproteins with LEAD.

MATERIALS AND METHODS

The study included 622 patients (386 male and 236 female, average age 61±12 years), examined in the Department of Atherosclerosis of National Medical Research Center of Cardiology. Patients were divided into 2 groups: the main group included 284 patients with LEAD, 338 patients without significant atherosclerosis of coronary, carotid and lower limbs arteries formed the control group. LEAD was diagnosed as atherosclerotic lesions with at least one stenosis of low limb artery ≥50 % and ankle-brachial index ≤0.9. The concentration of Lp(a), lipids was measured in blood serum of all the patients, level of autoantibodies to apoB100 lipoproteins was measured in 247 patients, and apo(a) phenotypes were determined in 389 patients.

RESULTS

Patients with LEAD were older, were more frequently male, and had a greater prevalence of risk factors including hypertension, type 2 diabetes, smoking than the control group patients (p&lt;0.001 in all the cases). The level of Lp(a) was significantly higher in the main group compared to control group: 35 [14; 67] mg / dl vs. 14 [5; 32] mg / dl, p&lt;0,001. ROC analysis demonstrated that the level of Lp(a) ≥26 mg / dl was associated with LEAD (sensitivity 61 %, specificity 70 %). The prevalence of Lp(a) ≥26 mg / dl and LMW apo(a) phenotype were higher in the main group in comparison with the control group: 61 % vs. 30 % and 48 % vs. 26 % respectively (p&lt;0.001 in the both cases). The odds ratio of LEAD in the presence of Lp(a) ≥26 mg / dl was 3.7 (95 % confidence interval (CI), 2.6-5.1, p&lt;0.001) and in the presence of LMW apo(a) phenotype was 2.6 (95 % CI, 1.7-4.0, p&lt;0.001). In logistic regression analysis adjusted for age, sex, hypertension, smoking, diabetes, both Lp(a) and LMW apo(a) phenotype were independent predictors of LEAD when included separately. The level of IgM autoantibodies to Lp(a) was significantly higher in the control group compared to the patients with LEAD (p=0.01). Concentration of IgG autoantobodies to Lp(a) and LDL in the plasma did not differ essentially in the both groups.

CONCLUSION

The level of Lp(a) ≥26 mg / dl and LMW apo(a) phenotype are independent predictors of LEAD, whereas the contribution of autoantobodies to Lp(a) in LEAD development is controversial.

Anti-platelet and anti-coagulant therapy in peripheral arterial disease prior to surgical intervention

OBJECTIVE

Peripheral artery disease is a major clinical co-morbidity that can significantly affect quality of life, especially in the presence of diabetes mellitus and older age. The focus of this literature review is on medical management, through anti-platelet and anti-coagulation, of peripheral artery disease prior to undergoing surgical or endovascular management.

METHOD

Extensive electronic literature search performed in four major databases (PubMed, SCOPUD, Embase and Ovid) to identify the published randomized and non-randomized studies that compared and discussed the management of peripheral artery disease with different anti-thrombotic agents.

RESULTS

A total of 17 studies were identified to meet the inclusion criteria of this review. Among them, 4 were systematic review and meta-analyses, 1 was observational study and 12 were randomized controlled trials. The reported outcomes in each study are summarized and reported separately within this review.

CONCLUSION

Peripheral artery disease is a complex and multifactorial clinical condition. The use of dual anti-platelets, such as aspirin and clopidogrel, are the key in preventing major cardiovascular events as well as stroke and death. Utilization of anti-coagulation such as direct oral anti-coagulants' as additional parameters for the prevention of disease progression, is paramount. Eventually, the choice of either dual-antiplatelet therapy or combined anti-coagulation with anti-platelets should be carefully considered, particularly following the most recent published debatable studies.

Multidisciplinary team decision is rare and decreasing in percutaneous vascular interventions despite positive impact on in-hospital outcomes

Background: Worldwide prevalence of peripheral artery disease (PAD) is increasing and peripheral vascular intervention (PVI) has become the primary invasive treatment. There is evidence that multidisciplinary team decision-making (MTD) has an impact on in-hospital outcomes. This study aims to depict practice patterns and time changes regarding MTD of different medical specialties. Methods: This is a retrospective cross-sectional study design. 20,748 invasive, percutaneous PVI of PAD conducted in the metropolitan area of Hamburg (Germany) were consecutively collected between January 2004 and December 2014. Results: MTD prior to PVI was associated with lower odds of early unsuccessful termination of the procedures (Odds Ratio 0.662, p < 0.001). The proportion of MTD decreased over the study period (30.9 % until 2009 vs. 16.6 % from 2010, p < 0.001) while rates of critical limb-threatening ischemia (34.5 % vs. 42.1 %), patients´ age (70 vs. 72 years), PVI below-the-knee (BTK) (13.2 % vs. 22.4 %), and rates of severe TASC C/D lesions BTK (43.2 % vs. 54.2 %) increased (all p < 0.001). Utilization of MTD was different between medical specialties with lowest frequency in procedures performed by internists when compared to other medical specialties (7.1 % vs. 25.7 %, p < 0.001). Conclusions: MTD prior to PVI is associated with technical success of the procedure. Nonetheless, rates of MTD prior to PVI are decreasing during the study period. Future studies should address the impact of multidisciplinary vascular teams on long-term outcomes.