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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Krittanawong C, Escobar J, Virk HUH, Alam M, Virani S, Lavie CJ, Narayan KMV, Sharma R. Lifestyle Approach and Medical Therapy of Lower Extremity Peripheral Artery Disease. Am J Med 2024; 137:202-209. [PMID: 37980970 DOI: 10.1016/j.amjmed.2023.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
Lower extremity peripheral artery disease (PAD) is common among patients with several risk factors, such as elderly, smoking, hypertension, and diabetes mellitus. Notably, PAD is associated with a higher risk of cardiovascular complications. Non-invasive interventions are beneficial to improve morbidity and mortality among patients with PAD. Traditional risk factors like smoking, diabetes mellitus, hypertension, and dyslipidemia play a significant role in the development of PAD. Still, additional factors such as mental health, glycemic control, diet, exercise, obesity management, lipid-lowering therapy, and antiplatelet therapy have emerged as important considerations. Managing these factors can help improve outcomes and reduce complications in PAD patients. Antiplatelet therapy with aspirin or clopidogrel is recommended in PAD patients, with clopidogrel showing more significant benefits in symptomatic PAD individuals. Managing several risk factors is crucial for improving outcomes and reducing complications in patients with PAD. Further research is also needed to explore the potential benefits of novel therapies. Ultimately, a comprehensive approach to PAD management is essential for improving morbidity and mortality among patients with this condition.
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Affiliation(s)
| | - Johao Escobar
- Division of Cardiology, Harlem Cardiology, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Salim Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; The Aga Khan University, Karachi, Pakistan; Baylor College of Medicine, Houston, Texas
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, La
| | - K M Venkat Narayan
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, Ga
| | - Raman Sharma
- Department of Medicine/Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY
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Vossen RJ, Fokkema TM, Vahl AC, Balm R. Systematic review and meta-analysis comparing the autogenous vein bypass versus a prosthetic graft for above-the-knee femoropopliteal bypass surgery in patients with intermittent claudication. Vascular 2024; 32:91-101. [PMID: 36066001 DOI: 10.1177/17085381221124701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES According to guidelines, the autogenous saphenous vein (ASV) is the preferred conduit for femoropopliteal bypass surgery in all patients with peripheral artery disease. However, in contrast to patients with critical limb ischemia (CLI), patients with intermittent claudication (IC) only, tend to have milder disease, and thus a prosthetic graft may be as good as a vein conduit. The objective of this study was to compare patency rates of the ASV and a prosthetic graft in femoropopliteal bypass surgery in patients with IC. METHODS A systematic literature search was performed in the PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing prosthetic graft versus ASV in patients with IC. Articles with a mixed IC and CLI study population were included if more than 50% of the study cohort was treated for IC. Primary analysis was performed on IC patients only. Secondary analysis was performed on the mixed group. The primary endpoint was short- and long-term patency and secondary endpoints were complications, limb salvage, and mortality. RESULTS In total, six studies with 524 patients were included. Only two studies reported solely on patients with IC. All these patients underwent above-the-knee bypasses and average patency rates at one and 5 years were 88% and 76% vs 81% and 68% in the ASV and the PTFE groups, respectively. One and five-year patency was not statistically different between the groups (OR 5.21; 95% CI 0.60-45.36 and OR 2.10; 95% CI 0.88-5.01). In a mixed population of patients with IC and CLI (84% IC patients), 1 year patency was comparable (OR 1.40; 95% CI 0.87-2.25). However, after a follow-up of over 3 years, this mixed group had significantly higher patency rates in favour of the ASV (OR 2.06; 95 % CI 1.30-3.26). Complication and amputation rates were comparable in both groups. CONCLUSIONS Limited data are available for patients receiving above-the-knee femoropopliteal bypass for intermittent claudication. The ASV remains the conduit of choice for femoropopliteal bypass surgery. However, the prosthetic conduit seems a feasible alternative for patients with intermittent claudication in whom the ASV is not present or unsuitable.
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Affiliation(s)
- R J Vossen
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Erasmus Medical Center, The Netherlands
| | - T M Fokkema
- Department of Vascular Surgery, Länssjukhuset Ryhov, Jönköping, Sweden
| | - A C Vahl
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
- Clinical Epidemiology, OLVG Amsterdam, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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Kharawala A, Nagraj S, Pargaonkar S, Seo J, Kokkinidis DG, Altin SE. Hypertension Management in Peripheral Artery Disease: A Mini Review. Curr Hypertens Rev 2024; 20:1-9. [PMID: 38083897 DOI: 10.2174/0115734021267004231122061712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 06/01/2024]
Abstract
Lower extremity peripheral artery disease (PAD) affects over 230 million adults globally, with hypertension being one of the major risk factors for the development of PAD. Despite the high prevalence, patients with hypertension who have concomitant PAD are less likely to receive adequate therapy. Through this review, we present the current evidence underlying hypertension management in PAD, guideline-directed therapies, and areas pending further investigation. Multiple studies have shown that both high and relatively lower blood pressure levels are associated with worse health outcomes, including increased morbidity and mortality. Hence, guideline-directed recommendation involves cautious management of hypertensive patients with PAD while ensuring hypotension does not occur. Although any antihypertensive medication can be used to treat these patients, the 2017 American Heart Association/American College of Cardiology (AHA/ACC), 2017 European Society of Cardiology (ESC), and 2022 Canadian guidelines favor the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) as the initial choice. Importantly, data on blood pressure targets and treatment of hypertension in PAD are limited and largely stem from sub-group studies and post-hoc analysis. Large randomized trials in patients with PAD are required in the future to delineate hypertension management in this complex patient population.
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Affiliation(s)
- A Kharawala
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - S Nagraj
- Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - S Pargaonkar
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - J Seo
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - D G Kokkinidis
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - S E Altin
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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Hallak AO, Hallak FZ, Hallak YO, Hallak OO, Hayson AW, Tanami SA, Bennett WL, Lavie CJ. Exercise Therapy in the Management of Peripheral Arterial Disease. Mayo Clin Proc Innov Qual Outcomes 2023; 7:476-489. [PMID: 37823000 PMCID: PMC10562863 DOI: 10.1016/j.mayocpiqo.2023.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Abstract
The incidence and prevalence of peripheral artery disease (PAD) are increasing globally and have a marked economic burden in the United States. The American Heart Association/American College of Cardiology guidelines recommend exercise therapy as a Class 1A, but its utilization remains suboptimal. This state-of-the-art review aims to provide a comprehensive review of the most updated information available on PAD, along with its risk factors, management options, outcomes, economic burden, and the role of exercise therapy in managing PAD.
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Affiliation(s)
- Ahmad O. Hallak
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA
| | | | - Yusuf O. Hallak
- School of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | | | - Aaron W. Hayson
- Department of Vascular Surgery, Ochsner Medical Center, New Orleans, LA
| | - Sadia A. Tanami
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo
| | | | - Carl J. Lavie
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA
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Abstract
PURPOSE OF REVIEW Hypertension (HTN) is a well known risk factor for atherosclerosis and peripheral arterial disease (PAD). PAD affects more than 250 million people globally and is associated with worse clinical outcomes. Although multiple studies have been performed to evaluate treatment of HTN in patients with PAD, blood pressure management in this high-risk cohort remains poor. RECENT FINDINGS There has been conflicting evidence regarding blood pressure goals in PAD with some recent studies showing adverse outcomes with low blood pressure in this patient population. Current guidelines, however, continue to recommend treatment goals in PAD patients similar to patients without PAD. To date, no single antihypertensive drug class has shown a clear benefit in PAD population over other antihypertensive drug classes. SUMMARY Prospective randomized trials enrolling PAD patients are required that can shed light on optimum blood pressure target and also distinguish between different antihypertensive drugs in terms of reducing adverse outcomes.
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Bearne LM, Delaney N, Nielsen M, Sheehan KJ. Inequity in exercise-based interventions for adults with intermittent claudication due to peripheral arterial disease: a systematic review. Disabil Rehabil 2022:1-10. [PMID: 35931094 DOI: 10.1080/09638288.2022.2102255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine the equity in access to trials of exercise interventions for adults with intermittent claudication due to peripheral arterial disease. METHODS Systematic electronic database searches of MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Clinical Trials, PEDRO, Opengrey, ISRCTN and ClinincalTrials.gov for randomised controlled trials of exercise interventions for adults with intermittent claudication were conducted. Data extraction was informed by Cochrane's PROGRESS-Plus framework. RESULTS Searches identified 6412 records. Following the screening of 262 full texts, 49 trials including 3695 participants were included. All trials excluded potential participants on at least one equity factor. This comprised place of residence, language, sex, personal characteristics (e.g., age and disability), features of relationships (e.g., familial risk factors) and time-dependent factors, (e.g., time since revascularisation). Overall, 1839 of 7567 potential participants (24.3%) were excluded based on equity factors. Disability was the most frequently reported factor for exclusions. CONCLUSION Trialists endeavour to enrol a representative sample in exercise trials whilst preserving the safety profile of the intervention. This review highlights that these efforts can inadvertently lead to inequities in access as all trials excluded potential participants on at least one equity factor. Future exercise trials should optimise participation to maximise generalisability of findings. PROSPERO registration no. CRD42020189965.Implications for rehabilitationEquity factors influence health opportunities and outcomes.All trials of exercise for people with intermittent claudication excluded adults on at least one equity factor.Disability was the predominant factor for exclusions from trials.Trials should optimise participation to maximise generalisability of results as these findings are used to inform treatment and service design.
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Affiliation(s)
- Lindsay Mary Bearne
- School of Life Course and Population Sciences, King's College London, London, United Kingdom.,Centre for Applied Health and Social Care Research, Kingston University and St George's, University of London, London, United Kingdom
| | - Nancy Delaney
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Mae Nielsen
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Katie Jane Sheehan
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
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Yeung S, Perriman D, Chhabra M, Phillips C, Parkinson A, Glasgow N, Douglas KA, Cox D, Smith P, Desborough J. ACT Transition from Hospital to Home Orthopaedic Survey: a cross-sectional survey of unplanned 30-day readmissions for patients having total hip arthroplasty. BMJ Open 2022; 12:e055576. [PMID: 35636791 PMCID: PMC9152933 DOI: 10.1136/bmjopen-2021-055576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The aim of this study was to identify patient, hospital and transitional factors associated with unplanned 30-day readmissions in patients who had a total hip arthroplasty (THA). DESIGN A cross-sectional survey was performed. All patients attending a 6-week follow-up after a THA in the Australian Capital Territory (ACT) at four public and private clinics in the ACT from 1 February 2018 to 31 January 2019, were invited to complete an ACT Transition from Hospital to Home Orthopaedic Survey. PARTICIPANTS Within the ACT, 431 patients over the age of 16 attending their 6-week post-surgery consultation following a THA entered and completed the survey (response rate 77%). PRIMARY OUTCOME MEASURE The primary outcome measure was self-reported readmissions for any reason within 30 days of discharge after a THA. Multiple logistic regression was used to estimate ORs of factors associated with unplanned 30-day readmissions. RESULTS Of the 431 participants (representing 40% of all THAs conducted in the ACT during the study period), 27 (6%) were readmitted within 30 days of discharge. After controlling for age and sex, patients who did not feel rested on discharge were more likely to be readmitted within 30 days than those who felt rested on discharge (OR=5.75, 95% CI: (2.13 to 15.55), p=0.001). There was no association between post-hospital syndrome (ie, in-hospital experiences of pain, sleep and diet) overall and readmission. Patients who suffered peripheral vascular disease (PVD) were significantly more likely to have an unplanned 30-day readmission (OR=16.9, 95% CI: (3.06 to 93.53), p=0.001). There was no significant difference between private and public patient readmissions CONCLUSIONS: Hospitals should develop strategies that maximise rest and sleep during patients' hospital stay. Diagnosis and optimum treatment of pre-existing PVD prior to THA should also be a priority to minimise the odds of subsequent unplanned readmissions.
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Affiliation(s)
- Sybil Yeung
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Diana Perriman
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
- ACT Health, Canberra City, Australian Capital Territory, Australia
| | - Madhur Chhabra
- Department of Health Services Research and Policy, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Christine Phillips
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Anne Parkinson
- Australian Primary Health Care Research Institute, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas Glasgow
- Australian National University Research School of Population Health, Canberra, Australian Capital Territory, Australia
| | - Kirsty A Douglas
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Darlene Cox
- Health Care Consumer Association, Canberra, Australian Capital Territory, Australia
| | - Paul Smith
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
- The Trauma and Orthopaedic Resarch Unit, ACT Health, Canberra City, Australian Capital Territory, Australia
| | - Jane Desborough
- Department of Health Services Research and Policy, Australian National University, Canberra, Australian Capital Territory, Australia
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Ehrman JK, Salisbury D, Treat-Jacobson D. Decision Aids for Determining Facility Versus Non-Facility-Based Exercise in Those with Symptomatic Peripheral Artery Disease. Curr Cardiol Rep 2022; 24:1031-1039. [PMID: 35587854 PMCID: PMC9118189 DOI: 10.1007/s11886-022-01720-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 11/09/2022]
Abstract
Purpose of Review This paper sought to provide rationale for determining when a patient with symptomatic peripheral artery disease (PAD) might be referred for home-based versus facility-based exercise therapy. Recent Findings Multiple randomized controlled studies have embedded supervised, structured exercise therapy as a class IA recommended therapy for those with symptomatic PAD. More recently, there is interest in non-facility-based exercise training as an alternative. The current literature is mixed on the effectiveness of non-facility-based training and is influenced by the amount of contact with clinical staff providing some supervision (e.g., occasional facility-based exercise or coaching phone calls), and the intensity (e.g., performed intermittently by inducing pain or continually and not inducing pain) and frequency (e.g., 12-week common supervised exercise program or those longer than 24 weeks) of exercise. Certainly, the data suggests non-facility-based exercise, while possibly improving walking performance, is inferior to facility-based supervised exercise training. Comprehensive data is lacking on utilization of supervised exercise therapy in those with symptomatic PAD, but is likely <2% of those eligible who participate. This suggests a possible important role for alternatives including non-facility-based (e.g., home, fitness center). Summary Exercise training in the supervised, facility-based setting appears to be greatly underutilized. Non-facility-based exercise may help to overcome some of the most common barriers to participating in facility-based exercise including those related to motivation, transportation, and proximity. However, facility-based training is considered the gold standard so decisions about allowing a patient to exercise train at home must take into account issues including disease severity, patient motivation and available exercise resources, mobility and balance, cognitive function, and other medical concerns (e.g., symptomatic coronary artery disease or heart failure).
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Affiliation(s)
- Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Health System, 6525 2nd Avenue, Detroit, MI, 48202, USA.
| | - Derek Salisbury
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
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van den Houten MML, Jansen S, van der Laan L, Vriens PWHE, Willigendael EM, Koelemay MJW, Scheltinga MRM, Teijink JAW. The Effect of Arterial Disease Level on Outcomes of Supervised Exercise Therapy for Intermittent Claudication: A Prospective Cohort Study. Ann Surg 2022; 275:609-616. [PMID: 32740230 DOI: 10.1097/sla.0000000000004073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether level of arterial obstruction determines the effectiveness of SET in patients with IC. BACKGROUND DATA Guidelines advocate SET before invasive treatment for IC, but early revascularization remains widespread, especially in patients with aortoiliac disease. METHODS Patients were recruited from 10 Dutch centers between October 2017 and October 2018. Participants received SET first, followed by endovascular or open revascularization in case of insufficient effect. They were grouped according to level of stenosis (aortoiliac, femoropopliteal, multilevel, or rest group with no significant stenosis). Changes from baseline walking performance (maximal and functional walking distance on a treadmill test, 6-minute walk test) and vascular quality of life questionnaire-6 at 3 and 6 months were compared, after multivariate adjustment for possible confounders. Freedom from revascularization was estimated with Kaplan-Meier analysis. RESULTS Some 267 patients were eligible for analysis (aortoiliac n = 70, 26%; femoropopliteal n = 115, 43%; multilevel n = 69, 26%; rest n = 13, 5%). No between group differences in walking performance or vascular quality of life questionnaire-6 were found. Mean improvement in maximal walking distance after 6 months was 439 m [99% confidence interval (CI) 297-581], 466 m (99% CI 359-574), 353 m (99% CI 210-496), and 403 m (99% CI 58-749), respectively (P = 0.40). Freedom from intervention was 73.9% for aortoiliac disease and 88.6% for femoropopliteal disease (hazard ratio 2.46, 99% CI 0.96 - 6.30, P = 0.013). CONCLUSIONS Short-term effectiveness of SET for IC is not determined by the location of stenosis. Although aortoiliac disease patients improved walking performance and health-related quality of life similarly compared to other arterial disease level groups, they underwent revascularization more often.
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Affiliation(s)
- Marijn M L van den Houten
- Catharina Hospital, Department of Surgery, Eindhoven, The Netherlands
- Maastricht University, CAPHRI Research School, Maastricht, The Netherlands
| | - Sandra Jansen
- Catharina Hospital, Department of Surgery, Eindhoven, The Netherlands
- Maastricht University, CAPHRI Research School, Maastricht, The Netherlands
| | - Lijckle van der Laan
- Amphia Hospital, Department of Vascular Surgery, Breda, The Netherlands
- KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Patrick W H E Vriens
- Elisabeth Twee Steden Hospital, Department of Vascular Surgery, Tilburg, The Netherlands
| | - Edith M Willigendael
- Medical Spectrum Twente, Department of Vascular Surgery, Enschede, The Netherlands
| | - Mark J W Koelemay
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marc R M Scheltinga
- Maxima Medical Centre, Department of Vascular Surgery, Veldhoven, The Netherlands
| | - Joep A W Teijink
- Catharina Hospital, Department of Surgery, Eindhoven, The Netherlands
- Maastricht University, CAPHRI Research School, Maastricht, The Netherlands
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12
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Powell AC, Lugo CT, Dietrich CL, Lucas ER, Long JW, DeFrance A, Simmons JD. A Description of Outcomes Experienced by Patients Whose Orders for Peripheral Artery Revascularization Were Reviewed by a Nondenial Prior Authorization Program. Vasc Endovascular Surg 2022; 56:393-400. [DOI: 10.1177/15385744211055911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective After a nondenial prior authorization program evaluates orders for peripheral artery revascularization (PAR), ordering physicians sometimes withdraw their orders based upon program recommendations. Some patients with withdrawn orders receive PAR if claudication does not resolve. To characterize patient outcomes under this program, we evaluated whether associations existed between the withdrawal of patients’ initial PAR orders and the presence of claims for PAR and claims mentioning intermittent claudication (IC) in the following 16 weeks. Methods Orders for PAR placed from 1/1/19 to 9/30/19 for patients with Medicare Advantage health plans were extracted from a national healthcare organization’s database. Claims data from 0 to 16 weeks following the order were reviewed to determine if patients had downstream PAR claims, or if they had emergency department or hospital claims mentioning IC. Chi-square tests were used to assess the association between order withdrawal and downstream PAR, as well as claims mentioning IC. Multivariate logistic regressions were run to assess the same, controlling for patient age, sex, urbanicity, local median income, state obesity rate, type of PAR, ordering physician specialty, and whether PAR was ordered in a hospital setting. Results Of 1588 orders meeting inclusion criteria, 71.9% (1038/1444) of authorized orders and 61.1% (88/144) of withdrawn orders were followed by PAR within 16 weeks, a significant difference ( P < .01). Relatedly, 69.8% (1008/1444) of authorized orders and 70.8% (102/144) of withdrawn orders were followed by IC claims, an insignificant difference. Multivariate logistic regressions showed patients with withdrawn PAR orders had significantly lower adjusted odds of PAR (OR: 0.63; 95% CI: 0.44–0.91), but an insignificant difference in their adjusted odds of IC (OR: 1.10; CI: 0.76–1.64). Conclusions Although patients with withdrawn PAR orders were significantly less likely to receive PAR in the subsequent 16 weeks, no association was found between withdrawn PAR orders and subsequent claims mentioning IC.
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13
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Rimamskep SG, Favour M, Demilade SA, Charles AC, Olaseni BM, Bob-Manuel T. Peripheral Artery Disease: A comprehensive updated review. Curr Probl Cardiol 2021; 47:101082. [PMID: 34906615 DOI: 10.1016/j.cpcardiol.2021.101082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/03/2022]
Abstract
Peripheral arterial disease is estimated to affect more than 200 million people worldwide. Although more than 50% of those affected are asymptomatic, it accounts for 3-4% of amputations and a crude five-year death rate of 82.4 deaths per 1000 patient-years when adjusted for duration of follow-up. Additionally, peripheral artery disease is often an indicator of obstructive atherosclerotic disease involvement of cerebral and coronary vessels, consequently increasing the risk of stroke, cardiovascular death, and myocardial infarction in these patient populations. The management of peripheral arterial disease includes conservative therapies, pharmacological treatments, interventional and surgical revascularization of blood vessels. Percutaneous transluminal angioplasty with balloons and stents has improved clinical outcomes compared to medical treatment alone. Despite these advances, the prevalence of peripheral arterial disease remains high. This review article aims to provide focused, up-to-date information on the clinical course, diagnosis, medical and interventional approach of the management of peripheral artery disease.
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Affiliation(s)
| | - Markson Favour
- Department of Internal Medicine, Lincoln Medical Centre NY, USA
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Djerf H, Svensson M, Nordanstig J, Gottsäter A, Falkenberg M, Lindgren H. Editor's Choice - Cost Effectiveness of Primary Stenting in the Superficial Femoral Artery for Intermittent Claudication: Two Year Results of a Randomised Multicentre Trial. Eur J Vasc Endovasc Surg 2021; 62:576-582. [PMID: 34454817 DOI: 10.1016/j.ejvs.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/02/2021] [Accepted: 07/11/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Invasive treatment of intermittent claudication (IC) is commonly performed, despite limited evidence of its cost effectiveness. IC symptoms are mainly caused by atherosclerotic lesions in the superficial femoral artery (SFA), and endovascular treatment is performed frequently. The aim of this study was to investigate its cost effectiveness vs. non-invasive treatment. METHODS One hundred patients with IC due to lesions in the SFA were randomised to treatment with primary stenting, best medical treatment (BMT) and exercise advice (stent group), or to BMT and exercise advice alone (control group). Patients were recruited at seven hospitals in Sweden. For this analysis of cost effectiveness after 24 months, 84 patients with data on quality adjusted life years (QALY; based on the EuroQol Five Dimensions EQ-5D 3L™ questionnaire) were analysed. Patient registry and imputed cost data were used for accumulated costs regarding hospitalisation and outpatient visits. RESULTS The mean cost per patient was €11 060 in the stent group and €4 787 in the control group, resulting in a difference of €6 273 per patient between the groups. The difference in mean QALYs between the groups was 0.26, in favour of the stent group, which resulted in an incremental cost effectiveness ratio (ICER) of € 23 785 per QALY. CONCLUSION The costs associated with primary stenting in the SFA for the treatment of IC were higher than for exercise advice and BMT alone. With concurrent improvement in health related quality of life, primary stenting was a cost effective treatment option according to the Swedish national guidelines (ICER < €50 000 - €70 000) and approaching the UK's National Institute for Health and Care Excellence threshold for willingness to pay (ICER < £20 000 - £30 000). From a cost effectiveness standpoint, primary stenting of the SFA can, in many countries, be used as an adjunct to exercise training advice, but it must be considered that successful implementation of structured exercise programmes and longer follow up may alter these findings.
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Affiliation(s)
- Henrik Djerf
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department for Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Lindgren
- Vascular Centre, Skåne University Hospital, Malmö, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
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Abstract
Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.
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Affiliation(s)
- Joshua A Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN (J.A.B.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (P.A.S., M.S.C.)
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (P.A.S., M.S.C.)
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Ney B, Lanzi S, Calanca L, Mazzolai L. Multimodal Supervised Exercise Training Is Effective in Improving Long Term Walking Performance in Patients with Symptomatic Lower Extremity Peripheral Artery Disease. J Clin Med 2021; 10:jcm10102057. [PMID: 34064875 PMCID: PMC8151788 DOI: 10.3390/jcm10102057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 12/12/2022] Open
Abstract
This study aimed to evaluate the effect of a multimodal supervised exercise training (SET) program on walking performance for 12 months in patients with symptomatic lower extremity peripheral artery disease (PAD). Consecutive patients with Fontaine stage II PAD participating in the SET program of our hospital were retrospectively investigated. Walking performance, assessed using a treadmill with measures of the pain-free and maximal walking distance (PFWD, MWD, respectively), and 6 min walking distance (6MWD), were tested before and following SET, as well as at 6 and 12 months after SET completion. Ninety-three symptomatic patients with PAD (65.0 ± 1.1 y) were included in the study. Following SET, the walking performance significantly improved (PFWD: +145%, p ≤ 0.001; MWD: +97%, p ≤ 0.001; 6MWD: +15%, p ≤ 0.001). At 6 months, PFWD (+257%, p ≤ 0.001), MWD (+132%, p ≤ 0.001), and 6MWD (+11%, p ≤ 0.001) remained significantly improved compared with the pre-SET condition. At 12 months, PFWD (+272%, p ≤ 0.001), MWD (+130%, p ≤ 0.001), and 6MWD (+11%, p ≤ 0.001) remained significantly improved compared with the pre-training condition. The walking performance remained significantly improved in both women and men for up to 12 months (p ≤ 0.001). Multimodal SET is effective at improving walking performance in symptomatic patients with PAD, with improvements lasting up to 12 months.
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Manfredini F, Lamberti N, Traina L, Zenunaj G, Medini C, Piva G, Straudi S, Manfredini R, Gasbarro V. Effectiveness of Home-Based Pain-Free Exercise versus Walking Advice in Patients with Peripheral Artery Disease: A Randomized Controlled Trial. Methods Protoc 2021; 4:mps4020029. [PMID: 34068534 PMCID: PMC8163172 DOI: 10.3390/mps4020029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/24/2022] Open
Abstract
Exercise therapy in the intermediate stages of peripheral artery disease (PAD) represents an effective solution to improve mobility and quality of life (QoL). Home-based programs, although less effective than supervised programs, have been found to be successful when conducted at high intensity by walking near maximal pain. In this randomized trial, we aim to compare a low-intensity, pain-free structured home-based exercise (SHB) program to an active control group that will be advised to walk according to guidelines. Sixty PAD patients aged > 60 years with claudication will be randomized with a 1:1 ratio to SHB or Control. Patients in the training group will be prescribed an interval walking program at controlled speed to be performed at home; the speed will be increased weekly. At baseline and after 6 months, the following outcomes will be collected: pain-free walking distance and 6-min walking distance (primary outcome), ankle-brachial index, QoL by the VascuQoL-6 questionnaire, foot temperature by thermal camera, 5-time sit-to-stand test, and long-term clinical outcomes including revascularization rate and mortality. The home-based pain-free exercise program may represent a sustainable and cost effective option for patients and health services. The trial has been approved by the CE-AVEC Ethics Committee (898/20). Registration details: Clinicaltrials.gov NCT04751890 [Registered: 12 February 2021].
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Affiliation(s)
- Fabio Manfredini
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.L.); (G.P.)
- Unit of Rehabilitation Medicine, University Hospital of Ferrara, 44124 Ferrara, Italy;
| | - Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.L.); (G.P.)
| | - Luca Traina
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (L.T.); (G.Z.); (C.M.); (V.G.)
| | - Gladiol Zenunaj
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (L.T.); (G.Z.); (C.M.); (V.G.)
| | - Chiara Medini
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (L.T.); (G.Z.); (C.M.); (V.G.)
| | - Giovanni Piva
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.L.); (G.P.)
| | - Sofia Straudi
- Unit of Rehabilitation Medicine, University Hospital of Ferrara, 44124 Ferrara, Italy;
| | - Roberto Manfredini
- Department of Medical Sciences, University of Ferrara, via Fossato di Mortara 46, 44121 Ferrara, Italy
- Correspondence: ; Tel.: +39-0532237166
| | - Vincenzo Gasbarro
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (L.T.); (G.Z.); (C.M.); (V.G.)
- Department of Medical Sciences, University of Ferrara, via Fossato di Mortara 46, 44121 Ferrara, Italy
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Thanigaimani S, Phie J, Sharma C, Wong S, Ibrahim M, Huynh P, Moxon J, Jones R, Golledge J. Network Meta-Analysis Comparing the Outcomes of Treatments for Intermittent Claudication Tested in Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e019672. [PMID: 33890475 PMCID: PMC8200724 DOI: 10.1161/jaha.120.019672] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background No network meta-analysis has considered the relative efficacy of cilostazol, home exercise therapy, supervised exercise therapy (SET), endovascular revascularization (ER), and ER plus SET (ER+SET) in improving maximum walking distance (MWD) over short- (<1 year), moderate- (1 to <2 years), and long-term (≥2 years) follow-up in people with intermittent claudication. Methods and Results A systematic literature search was performed to identify randomized controlled trials testing 1 or more of these 5 treatments according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The primary outcome was improvement in MWD assessed by a standardized treadmill test. Secondary outcomes were adverse events and health-related quality of life. Network meta-analysis was performed using the gemtc R statistical package. The Cochrane collaborative tool was used to assess risk of bias. Forty-six trials involving 4256 patients were included. At short-term follow-up, home exercise therapy (mean difference [MD], 89.4 m; 95% credible interval [CrI], 20.9-157.7), SET (MD, 186.8 m; 95% CrI, 136.4-237.6), and ER+SET (MD, 326.3 m; 95% CrI, 222.6-430.6), but not ER (MD, 82.5 m; 95% CrI, -2.4 to 168.2) and cilostazol (MD, 71.1 m; 95% CrI, -24.6 to 167.9), significantly improved MWD (in meters) compared with controls. At moderate-term follow-up, SET (MD, 201.1; 95% CrI, 89.8-318.3) and ER+SET (MD, 368.5; 95% CrI, 195.3-546.9), but not home exercise therapy (MD, 99.4; 95% CrI, -174.0 to 374.9) or ER (MD, 84.2; 95% CrI, -35.3 to 206.4), significantly improved MWD (in meters) compared to controls. At long-term follow-up, none of the tested treatments significantly improved MWD compared to controls. Adverse events and quality of life were reported inconsistently and could not be meta-analyzed. Risk of bias was low, moderate, and high in 4, 24, and 18 trials respectively. Conclusions This network meta-analysis suggested that SET and ER+SET are effective at improving MWD over the moderate term (<2 year) but not beyond this. Durable treatments for intermittent claudication are needed.
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Affiliation(s)
- Shivshankar Thanigaimani
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - James Phie
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Chinmay Sharma
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Shannon Wong
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Muhammad Ibrahim
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Pacific Huynh
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Joseph Moxon
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Rhondda Jones
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Jonathan Golledge
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia.,The Department of Vascular and Endovascular Surgery Townsville University Hospital Townsville Queensland Australia
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Lortz J, Simanovski J, Kuether T, Kreitschmann-Andermahr I, Ullrich G, Steinmetz M, Rammos C, Jánosi RA, Moebus S, Rassaf T, Paldán K. Needs and Requirements in the Designing of Mobile Interventions for Patients With Peripheral Arterial Disease: Questionnaire Study. JMIR Form Res 2020; 4:e15669. [PMID: 32663154 PMCID: PMC7435621 DOI: 10.2196/15669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/11/2019] [Accepted: 03/29/2020] [Indexed: 12/24/2022] Open
Abstract
Background The development of mobile interventions for noncommunicable diseases has increased in recent years. However, there is a dearth of apps for patients with peripheral arterial disease (PAD), who frequently have an impaired ability to walk. Objective Using a patient-centered approach for the development of mobile interventions, we aim to describe the needs and requirements of patients with PAD regarding the overall care situation and the use of mobile interventions to perform supervised exercise therapy (SET). Methods A questionnaire survey was conducted in addition to a clinical examination at the vascular outpatient clinic of the West-German Heart and Vascular Center of the University Clinic Essen in Germany. Patients with diagnosed PAD were asked to answer questions on sociodemographic characteristics, PAD-related need for support, satisfaction with their health care situation, smartphone and app use, and requirements for the design of mobile interventions to support SET. Results Overall, a need for better support of patients with diagnosed PAD was identified. In total, 59.2% (n=180) expressed their desire for more support for their disease. Patients (n=304) had a mean age of 67 years and half of them (n=157, 51.6%) were smartphone users. We noted an interest in smartphone-supported SET, even for people who did not currently use a smartphone. “Information,” “feedback,” “choosing goals,” and “interaction with physicians and therapists” were rated the most relevant components of a potential app. Conclusions A need for the support of patients with PAD was determined. This was particularly evident with regard to disease literacy and the performance of SET. Based on a detailed description of patient characteristics, proposals for the design of mobile interventions adapted to the needs and requirements of patients can be derived.
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Affiliation(s)
- Julia Lortz
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Jan Simanovski
- Centre for Urban Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Tabea Kuether
- Centre of Competence Personal Analytics at the University of Duisburg-Essen, Department of Engineering Sciences, University of Duisburg-Essen, Duisburg, Germany
| | | | - Greta Ullrich
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Steinmetz
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Christos Rammos
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Susanne Moebus
- Centre for Urban Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Katrin Paldán
- Centre for Urban Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany.,Centre of Competence Personal Analytics at the University of Duisburg-Essen, Department of Engineering Sciences, University of Duisburg-Essen, Duisburg, Germany
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Abola MTB, Golledge J, Miyata T, Rha SW, Yan BP, Dy TC, Ganzon MSV, Handa PK, Harris S, Zhisheng J, Pinjala R, Robless PA, Yokoi H, Alajar EB, Bermudez-delos Santos AA, Llanes EJB, Obrado-Nabablit GM, Pestaño NS, Punzalan FE, Tumanan-Mendoza B. Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee. J Atheroscler Thromb 2020; 27:809-907. [PMID: 32624554 PMCID: PMC7458790 DOI: 10.5551/jat.53660] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD. OBJECTIVES The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD. METHODOLOGY A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique. RESULTS A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.
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Affiliation(s)
- Maria Teresa B Abola
- Department of Clinical Research, Philippine Heart Center and University of the Philippines College of Medicine, Metro Manila, Philippines
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, and Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Seung-Woon Rha
- Dept of Cardiology, Internal Medicine, College of Medicine, Korea University; Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Timothy C Dy
- The Heart Institute, Chinese General Hospital and Medical Center, Manila, Philippines
| | | | | | - Salim Harris
- Neurovascular and Neurosonology Division, Neurology Department, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital; International University of Health and Welfare, Fukuoka, Japan
| | - Elaine B Alajar
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital; University of the Philippines College of Medicine, Manila, Philippines
| | | | - Elmer Jasper B Llanes
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines Philippine General Hospital, Manila, Philippines
| | | | - Noemi S Pestaño
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital, Manila, Philippines
| | - Felix Eduardo Punzalan
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines; Philippine General Hospital, Manila, Philippines
| | - Bernadette Tumanan-Mendoza
- Department of Clinical Epidemiology, University of the Philippines College of Medicine, Manila, Philippines
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Rodrigues E, Silva I. Supervised exercise therapy in intermittent claudication: a systematic review of clinical impact and limitations. INT ANGIOL 2020; 39:60-75. [DOI: 10.23736/s0392-9590.19.04159-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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22
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Bevan GH, White Solaru KT. Evidence-Based Medical Management of Peripheral Artery Disease. Arterioscler Thromb Vasc Biol 2020; 40:541-553. [PMID: 31996023 DOI: 10.1161/atvbaha.119.312142] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Peripheral artery disease is an atherosclerotic disease of the lower extremities associated with high cardiovascular mortality. Management of this condition may include lifestyle modifications, medical management, endovascular repair, or surgery. The medical approach to peripheral artery disease is multifaceted and includes cholesterol reduction, antiplatelet therapy, anticoagulation, peripheral vasodilators, blood pressure management, exercise therapy, and smoking cessation. Adherence to this regimen can reduce limb-related complications like critical limb ischemia and amputation, as well as systemic complications of atherosclerosis like stroke and myocardial infarction. Relative to coronary artery disease, peripheral artery disease is an undertreated condition. In this article, we explore the evidence behind medical therapies for the management of peripheral artery disease.
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Affiliation(s)
- Graham H Bevan
- From the Department of Medicine (G.H.B., K.T.W.S.), University Hospitals Cleveland Medical Center, OH.,Case Western Reserve University School of Medicine, Cleveland, OH (G.H.B., K.T.W.S.)
| | - Khendi T White Solaru
- From the Department of Medicine (G.H.B., K.T.W.S.), University Hospitals Cleveland Medical Center, OH.,Harrington Heart and Vascular Institute (K.T.W.S.), University Hospitals Cleveland Medical Center, OH.,Case Western Reserve University School of Medicine, Cleveland, OH (G.H.B., K.T.W.S.)
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23
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Djerf H, Millinger J, Falkenberg M, Jivegård L, Svensson M, Nordanstig J. Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial. Circ Cardiovasc Interv 2020; 13:e008450. [PMID: 31937137 DOI: 10.1161/circinterventions.119.008450] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The long-term benefit of revascularization for intermittent claudication is poorly understood. The aim of this study was to investigate the long-term effectiveness and cost-effectiveness compared with a noninvasive approach. METHODS The IRONIC trial (Invasive Revascularization or Not in Intermittent Claudication) randomized patients with mild-to-severe intermittent claudication to either revascularization + best medical therapy + structured exercise therapy (the revascularization group) or best medical therapy + structured exercise therapy (the nonrevascularization group). The health-related quality of life short form 36 questionnaire was primary outcome and disease-specific health-related quality of life (vascular quality of life questionnaire) and treadmill walking distances were secondary end points. Health-related quality of life has previously been reported superior in the revascularization group at 1- and 2-year follow-up. In this study, the 5-year results were determined. The cost-effectiveness of the treatment options was analyzed from a payer/healthcare standpoint. RESULTS Altogether, 158 patients were randomized in a 1:1 ratio. Regarding the primary end point, no intergroup differences were observed for the short form 36 sum or domain scores from baseline to 5 years, except for the short form 36 role emotional domain score, with greater improvement in the nonrevascularization group (n=116, P=0.007). No intergroup differences were observed in the vascular quality of life questionnaire total and domain scores (n=116, NS) or in treadmill walking distances (n=91, NS). A revascularization strategy resulted in almost twice the cost per patient compared with a noninvasive treatment approach ($13 098 versus $6965, P=0.02). CONCLUSIONS After 5 years of follow-up, a revascularization strategy had lost its early benefit and did not result in any long-term improvement in health-related quality of life or walking capacity compared to a noninvasive treatment strategy. Revascularization was not a cost-effective treatment option from a payer/healthcare point of view. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01219842.
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Affiliation(s)
- Henrik Djerf
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Institute of Clinical Science (H.D., M.F.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Johan Millinger
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine (J.M., L.J., J.N.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Science (H.D., M.F.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Lennart Jivegård
- HTA Centrum (Health Technology Assessment Center) Västra Götaland (L.J.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine (J.M., L.J., J.N.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mikael Svensson
- Department of Public Health and Community Medicine (M.S.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine (J.M., L.J., J.N.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Bauersachs R, Debus S, Nehler M, Huelsebeck M, Balradj J, Bowrin K, Briere JB. A Targeted Literature Review of the Disease Burden in Patients With Symptomatic Peripheral Artery Disease. Angiology 2019; 71:303-314. [DOI: 10.1177/0003319719896477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients with peripheral artery disease (PAD) have an increased risk of cardiovascular (CV) and limb events, but the disease is frequently underdiagnosed and treatment options are limited. This review examines the disease burden of symptomatic PAD as well as key guideline recommendations. Publications were identified using the ProQuest portal to access the Medline, Medline In-Process, and Embase databases. Search terms for symptomatic PAD were combined with terms relevant to epidemiology, burden, treatment practice, and physiopathology. Articles in English published between January 2001 and September 2016 were screened according to the population, interventions, comparator, outcomes, and study design criteria. Relevant publications (n = 200) were identified. The reported incidence and prevalence of PAD varied depending on the definitions used and the study populations. Patients generally had a poor prognosis, with an increased risk of mortality, CV, and limb events and decreased quality of life. Guideline recommendations included ankle–brachial index measurements, exercise testing, and angiography for diagnosis and risk factor modification, antiplatelets, cilostazol, exercise therapy, or surgical interventions for treatment, depending on the patient profile. The clinical, humanistic, and economic burden of disease in patients with symptomatic PAD is substantial and needs to be reduced through improved PAD management.
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Affiliation(s)
- Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmBH, Darmstadt, Germany
| | - Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery, Angiology, Endovascular Interventions, University of Hamburg-Eppendorf, Hamburg Germany
| | - Mark Nehler
- Vascular Surgery and Endovascular Therapy Faculty, University of Colorado and CPC Research, Denver, CO, USA
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Dua A, Gologorsky R, Savage D, Rens N, Gandhi N, Brooke B, Corriere M, Jackson E, Aalami O. National assessment of availability, awareness, and utilization of supervised exercise therapy for peripheral artery disease patients with intermittent claudication. J Vasc Surg 2019; 71:1702-1707. [PMID: 31699514 DOI: 10.1016/j.jvs.2019.08.238] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Supervised exercise therapy (SET) is an inexpensive, low-risk, and effective option when compared with invasive therapies for the treatment of patients with peripheral artery disease (PAD) and intermittent claudication. Randomized, controlled trials have demonstrated the benefits of SET in improving maximum walking distance in intermittent claudication patients, and society guidelines recommend SET as first-line therapy. In 2017, the Centers for Medicare & Medicaid Services (CMS) added coverage of SET. We aimed to evaluate the availability and use of SET programs, determine the awareness of SET CMS coverage in the United States, and gauge the academic interest in SET in the vascular community. METHODS An eight-question online survey regarding SET coverage, reimbursement, barriers to prescription, and SET use was sent to 900 vascular surgeons, cardiologists, and vascular medicine physicians across the United States. The most recent 2-year programs for the Vascular Annual Meeting, Midwestern Vascular Society, Eastern Vascular Society, and Western Vascular Society were reviewed to identify SET-related abstracts and gauge academic interest and awareness for SET within the vascular surgery community. RESULTS We received 135 physician responses (15%) to the survey. All 50 states were represented. The majority of responders (54%) stated that there was no SET program at their facility, and 5% did not know if there was a SET program available. Of those who did have a SET program available, 81% were associated with cardiac rehabilitation and 19% had a PAD-specific program. A significant number of physicians (49%) had never referred a patient for SET. Twenty-six percent were not aware that CMS covered SET sessions. Of the physicians who were aware of CMS reimbursement, 36% had never referred a patient to a SET program. Of all surveyed, 98% indicated they would refer patients to a SET program if one was available. Top barriers to use of a SET program included (1) no SET center availability and (2) significant cost or travel expense to the patient. A review of major vascular surgery meeting programs for the last 2 years yielded no identification of a SET-related abstract. CONCLUSIONS There is a lack of both availability and use of SET for patients with PAD with claudication, despite guideline recommendations and CMS reimbursement for SET sessions in the United States. When SET is offered, it is typically through cardiac rehabilitation programs which is not focused on PAD. Travel distance, lack of SET program availability, and low reimbursement rates are primary areas that could be addressed to improve use.
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Affiliation(s)
- Anahita Dua
- Division of Vascular Surgery, Massachusetts General Hospital, Boston
| | | | - Dasha Savage
- Division of Vascular Surgery, Stanford Hospital, Palo Alto, Calif
| | - Neil Rens
- Division of Vascular Surgery, Stanford Hospital, Palo Alto, Calif
| | - Neil Gandhi
- Division of Vascular Surgery, Stanford Hospital, Palo Alto, Calif
| | - Benjamin Brooke
- Division of Vascular Surgery, University of Utah, Salt Lake City, Utah
| | - Matthew Corriere
- Division of Vascular Surgery, University of Michigan, Ann Arbor Mich
| | | | - Oliver Aalami
- Division of Vascular Surgery, Stanford Hospital, Palo Alto, Calif.
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Brindisino F, Pennella D, Giovannico G, Rossettini G, Heick JD, Maselli F. Low back pain and calf pain in a recreational runner masking peripheral artery disease: A case report. Physiother Theory Pract 2019; 37:1146-1157. [PMID: 31661344 DOI: 10.1080/09593985.2019.1683922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Running is one of the most popular sports worldwide due to its low costs and its beneficial impact on health. Recent evidence suggests 11% to 85% of recreational runners experience at least one running-related injury each year and most of these are related to musculoskeletal conditions. The aim of this case report is to describe the clinical decision-making process that guided a physiotherapist to suspect a non-musculoskeletal cause in a recreational runner presenting with low back pain and calf pain secondary to Peripheral Artery Disease.Case Presentation: This case report describes the clinical history, clinical exam, laboratory and imaging tests, and surgical procedure of a 65 y.o. amateur runner suffering low back pain and left calf pain for 3 months. The patient's clinical findings suggested that referral to another health-care provider was required to explore potential non-musculoskeletal sources of pain. An angioplasty was necessary to solve the patient's clinical situation.Discussion and Conclusion: In this patient case, clinical findings along with a comprehensive family and personal history, ruled out a musculoskeletal condition and implicated a vascular condition.
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Affiliation(s)
- Fabrizio Brindisino
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise C/da Tappino c/o Cardarelli Hospital, Campobasso, Italy.,FTM, Physiotherapy and Manual Therapy, Physiotherapy Department, Lizzanello, Italy
| | - Denis Pennella
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise C/da Tappino c/o Cardarelli Hospital, Campobasso, Italy
| | - Giuseppe Giovannico
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise C/da Tappino c/o Cardarelli Hospital, Campobasso, Italy.,FTM, Physiotherapy and Manual Therapy, Physiotherapy Department, Lizzanello, Italy
| | - Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy
| | - John D Heick
- Northern Arizona University Flagstaff, Flagstaff, AZ, USA.,Department of Physical Therapy and Athletic Training, Flagstaff, AZ, USA
| | - Filippo Maselli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy
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Bolton L. Peripheral arterial disease: Scoping review of patient-centred outcomes. Int Wound J 2019; 16:1521-1532. [PMID: 31597226 DOI: 10.1111/iwj.13232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/04/2019] [Accepted: 09/13/2019] [Indexed: 01/13/2023] Open
Abstract
Peripheral arterial disease (PAD) impairs patients' quality of life (QOL), walking and ulcer healing, increasing patient pain, costs, and risks of amputation or mortality. A literature appraisal described PAD treatment capacity to improve validated patient-centred outcomes in controlled clinical studies. The PUBMED database was searched from 1 January 1970 to 21 June 2018, for original and derivative controlled clinical trial references addressing MeSH terms for 'ischemia' AND 'leg ulcer'. Non-ischemic ulcer treatment references were excluded. Frequencies of improved (P < .05) outcomes were reported. Eighty-eight studies on 4153 patients were summarized. Walking, pain or QOL improved mainly for interventions administered before PAD became severe. Amputation incidence, pain and ulcer healing were more frequently reported in those with severe PAD. Independent of PAD severity, patients experienced more likely improved walking, QOL, or pain reduction in response to structured walking interventions or those increasing calf muscle activity. Those with more severe PAD were more likely to report amputation reduction, mainly in response to invasive interventions. Those with PAD experienced more consistently improved patient-centred outcomes if they received multidisciplinary PAD management with supervised walking or calf muscle activity, with more likely amputation risk reduced for those with more severe PAD.
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Affiliation(s)
- Laura Bolton
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
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National survey of current practice and opinions on rehabilitation for intermittent claudication in the Danish Public Healthcare System. SCAND CARDIOVASC J 2019; 53:361-372. [PMID: 31394936 DOI: 10.1080/14017431.2019.1654614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective. International guidelines recommend rehabilitation including supervised exercise therapy in patients with Intermittent Claudication (IC), but knowledge of the implementation in clinical practice is limited. This study aims to investigate current practice and opinions on rehabilitation for patients with IC among vascular surgeons and rehabilitation departments in the municipalities and hospitals. Design. Three electronic cross-sectional surveys were distributed nationally to the Danish vascular surgeons (n = 131) and to rehabilitation departments in the municipalities (n = 92) and hospitals (n = 33). Results. The response rates were 70% among the vascular surgeons, 98% among the municipalities and 94% among the hospitals. Vascular surgeons utilize oral advice to exercise by self-administered walking, pharmacological treatment, and revascularization to improve walking distance in patients with IC. Currently, only 12% of the vascular surgeons referred to rehabilitation to improve walking distance, while almost all vascular surgeons (96%) would refer their patients to IC rehabilitation, if it was available. Only 14% of municipalities and none of the hospitals, who treat patients with IC, have a rehabilitation program designed specifically for patients with IC. However, 59% of the rehabilitation departments in the municipalities and 26% in the hospitals included patients with IC in rehabilitation program designed for other patient groups - mostly cardiac patients. There was consensus among the groups of respondents that future IC specific rehabilitation should include an initial conversation, supervised exercise therapy, smoking cessation, and patient education according to guidelines. Conclusion. Vascular surgeons support referral and participation in IC rehabilitation to improve walking distance in patients with IC. Despite some hospitals and municipalities included patients with IC in rehabilitation nearly all services fail to meet current guideline as specific services tailored to patient with IC is almost non-existent in Denmark. Our findings call for action for services to comply with current recommendations of structured, systematic rehabilitation for patients with IC.
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Beckman JA, White CJ. Paclitaxel-Coated Balloons and Eluting Stents: Is There a Mortality Risk in Patients With Peripheral Artery Disease? Circulation 2019; 140:1342-1351. [PMID: 31177820 DOI: 10.1161/circulationaha.119.041099] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paclitaxel drug-coated balloons and drug-eluting stents became commercially available for the treatment of intermittent claudication in 2015 and 2012, respectively. Both devices demonstrated superiority in limb revascularization compared with non-paclitaxel-coated devices and were rapidly accepted into clinical practice. In a recent systematic review and study-level meta-analysis, Katsanos et al reported a late all-cause mortality signal for patients in the drug-coated balloon and drug-eluting stent arms of randomized clinical trials for both devices. As a result of this safety signal, Vascular InterVentional Advances Physicians (VIVA), a not-for-profit 501c(3) organization, convened the Vascular Leaders Forum on March 1 and 2, 2019, in Washington, DC, to initiate an open and collaborative process of investigation into this finding. The Vascular Leaders Forum brought together 100 stakeholders, including an international group of representatives of cardiovascular medicine, interventional radiology, vascular medicine, and vascular surgery; oncologists; basic scientists; the Food and Drug Administration; the Centers for Medicare and Medicaid Services; and commercial manufacturers of these products. The Vascular Leaders Forum reviewed the natural history of peripheral arterial disease, the use of paclitaxel in peripheral arterial disease and other conditions, the harm signal noted by Katsanos et al, the impact of the methods chosen by Katsanos et al, possible mechanisms of harm, the role of the Food and Drug Administration in a setting like this one, and guidance for clinicians taking care of patients with symptomatic peripheral arterial disease. This document integrates the most current data to help establish an appropriate path forward to understand the risks and benefits associated with these technologies while ensuring the best treatment paradigm for patients.
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Saratzis A, Paraskevopoulos I, Patel S, Donati T, Biasi L, Diamantopoulos A, Zayed H, Katsanos K. Supervised Exercise Therapy and Revascularization for Intermittent Claudication: Network Meta-Analysis of Randomized Controlled Trials. JACC Cardiovasc Interv 2019; 12:1125-1136. [PMID: 31153838 DOI: 10.1016/j.jcin.2019.02.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/05/2019] [Accepted: 02/12/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to perform a comprehensive meta-analysis comparing all therapeutic modalities for intermittent claudication (IC), including best medical therapy (BMT) alone, percutaneous angioplasty (PTA), supervised exercise therapy (SET), and PTA combined with SET, to establish the optimal first-line treatment for IC. BACKGROUND IC is a common health problem that limits physical activity, results in decreased quality of life (QoL) and is associated with poor cardiovascular outcomes. Previous meta-analyses have attempted to combine data from randomized trials; however, none have combined data from all possible treatment combinations or synthesized QoL outcomes. METHODS Following a systematic review of the published research (conducted in December 2018) that identified 37 published randomized trials, a network meta-analysis was performed combining all possible IC treatment strategies. RESULTS Overall, 2,983 patients with IC were included (mean weighted age 68 years, 54.5% men). Comparisons were performed between BMT (n = 688, 28 arms) versus SET (n = 1,189, 35 arms) versus PTA (n = 511, 12 arms) versus PTA plus SET (n = 395, 8 arms). Mean weighted follow-up was 12 months (95% confidence interval: 9 to 23 months). Compared with BMT alone, PTA plus SET outperformed other treatment strategies, with a maximum walking distance gain of 290 m (95% credible interval: 180 to 390 m; p < 0.001). A variety of QoL assessments using validated tools were reported in 15 trials; PTA plus SET was superior to other treatments (Cohen's D = 1.8; 95% credible interval: 0.21 to 3.4). CONCLUSIONS In addition to BMT, PTA combined with SET seems to be the optimal first-line treatment strategy for IC in terms of maximum walking distance and QoL improvement.
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Affiliation(s)
- Athanasios Saratzis
- Department of Vascular Surgery, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom.
| | | | - Sanjay Patel
- Department of Vascular Surgery, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Tommaso Donati
- Department of Vascular Surgery, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Lukla Biasi
- Department of Vascular Surgery, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Athanasios Diamantopoulos
- Department of Vascular Surgery, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 69:e71-e126. [PMID: 27851992 DOI: 10.1016/j.jacc.2016.11.007] [Citation(s) in RCA: 428] [Impact Index Per Article: 85.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
PURPOSE OF REVIEW This paper provides a concise update on the management of peripheral artery disease (PAD). RECENT FINDINGS PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group. Structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs will improve. Finally, ensuring more patients with PAD receive aspirin therapy and statins may improve long-term survival, while further research will help determine if adding newer antiplatelet or anticoagulant medications may reduce leg amputations in selected patients. Clinicians should have a low threshold to obtain an angiogram and to pursue revascularization in patients with foot ulcers, gangrene, or foot infections. In patients with claudication, clinicians should maximize the benefits derived from exercise therapy and medical management before offering percutaneous or surgical revascularization.
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Affiliation(s)
- Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112),, Houston, TX, 77030, USA.
| | - Courtney L Grant
- Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112),, Houston, TX, 77030, USA
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Sapienza P, Mingoli A, Sterpetti AV, Rubino P, Crocetti D, Grande R, Ferrer C, Serra R, Tartaglia E. External Iliac Artery to Tibial Arteries Vein Graft for Inaccessible Femoral Artery. Ann Vasc Surg 2019; 60:293-300. [PMID: 31075456 DOI: 10.1016/j.avsg.2019.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND An endovascular-first approach to limb salvage and relief from lifestyle-limiting claudication is widely accepted. Stenosis or short occlusion of common, superficial femoral, and popliteal arteries can be corrected with percutaneous transluminal angioplasty (PTA) with stent positioning. Patency rates of these procedures are limited. We report our experience with external iliac artery to the infrapopliteal vessels vein grafts when the endovascular treatment fails. METHODS Between January 2013 and January 2019, 16 patients (16 limbs) were operated on for limb-threatening ischemia after the occlusion of PTA with stent positioning of the common, superficial femoral, and popliteal arteries. Three patients were treated at our hospital by interventional radiologists; the remaining were operated on elsewhere. An external iliac artery to the infrapopliteal vessels vein bypass graft was anatomically interposed to restore blood flow. End points of the study were death-related events, vein graft failure, and major (above- or below-knee amputation) or minor (foot or toe amputation) limb loss. RESULTS There were 12 men and 4 women. Mean age of patients was 68 years. Indication for the initial PTA with stent positioning of the common and superficial femoral artery was according to the Rutherford classification Grade I: Category 1, 11 patients (69%) and Category 2, 5 (31%) patients (Stage IIa and IIb according to Fontaine classification, respectively). Great saphenous vein was used in 14 (87%) cases and in 2 (13%) cases a composite graft with a segment of cephalic vein was required. The distal anastomoses were performed on the posterior tibial artery in 6 (37%) cases, anterior tibial artery in 4 (26%), and peroneal artery in 6 (37%). Four-year survival and primary patency rates were 71% (standard error [SE] = 0.15) and 73% (SE = 0.14), respectively. One graft occlusion required an above-knee amputation. Four-year limb salvage rate was 86% (SE = 0.13). DISCUSSION We recommend the external iliac artery as source of inflow in patients in whom the vein bypass cannot originate from the common femoral or from a more distal inflow source because of previous PTA with stent positioning or it is deemed hazardous.
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Affiliation(s)
- Paolo Sapienza
- Department of General and Plastic Surgery "Pietro Valdoni", "Sapienza" University of Rome, Rome, Italy.
| | - Andrea Mingoli
- Emergency Department, "Sapienza" University of Rome, Rome, Italy
| | - Antonio V Sterpetti
- Department of General and Plastic Surgery "Pietro Valdoni", "Sapienza" University of Rome, Rome, Italy
| | - Paolo Rubino
- Department of Vascular Surgery, Civil Hospital, Catanzaro, Italy
| | - Daniele Crocetti
- Department of General and Plastic Surgery "Pietro Valdoni", "Sapienza" University of Rome, Rome, Italy
| | - Raffaele Grande
- Department of General and Plastic Surgery "Pietro Valdoni", "Sapienza" University of Rome, Rome, Italy
| | - Ciro Ferrer
- Department of General and Plastic Surgery "Pietro Valdoni", "Sapienza" University of Rome, Rome, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University "Magna Graecia", Catanzaro, Italy
| | - Elvira Tartaglia
- Department of Vascular and Endovascular Surgery, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, Paris, France
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Bouwens E, Klaphake S, Weststrate KJ, Teijink JA, Verhagen HJ, Hoeks SE, Rouwet EV. Supervised exercise therapy and revascularization: Single-center experience of intermittent claudication management. Vasc Med 2019; 24:208-215. [PMID: 30795714 PMCID: PMC6535809 DOI: 10.1177/1358863x18821175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Elke Bouwens
- 1 Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sanne Klaphake
- 2 Department of Vascular Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karin J Weststrate
- 2 Department of Vascular Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joep Aw Teijink
- 3 Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands.,4 Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Hence Jm Verhagen
- 2 Department of Vascular Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- 5 Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ellen V Rouwet
- 2 Department of Vascular Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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van den Houten MM, Jansen SC, Sinnige A, van der Laan L, Vriens PW, Willigendael EM, Lardenoije JWH, Elshof JWM, van Hattum ES, Lijkwan MA, Nyklíček I, Rouwet EV, Koelemay MJ, Scheltinga MR, Teijink JA. Protocol for a prospective, longitudinal cohort study on the effect of arterial disease level on the outcomes of supervised exercise in intermittent claudication: the ELECT Registry. BMJ Open 2019; 9:e025419. [PMID: 30782932 PMCID: PMC6367988 DOI: 10.1136/bmjopen-2018-025419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Despite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease. METHODS AND ANALYSIS This multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1-3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6 min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves. ETHICS AND DISSEMINATION This study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United 'MEC-U' (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally. TRIAL REGISTRATION NUMBER NTR7332; Pre-results.
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Affiliation(s)
- Marijn Ml van den Houten
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
- CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sandra Cp Jansen
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
- CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anneroos Sinnige
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Patrick Whe Vriens
- Department of Vascular Surgery, Elisabeth Twee Steden Hospital, Tilburg, The Netherlands
| | - Edith M Willigendael
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Jan-Willem M Elshof
- Department of Vascular Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - Eline S van Hattum
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maarten A Lijkwan
- Department of Vascular Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Ivan Nyklíček
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disorders (CoRPS), Tilburg, The Netherlands
| | - Ellen V Rouwet
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mark Jw Koelemay
- Department of Vascular Surgery, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Marc Rm Scheltinga
- Department of Vascular Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Joep Aw Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
- CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
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Tummala S, Scherbel D. Clinical Assessment of Peripheral Arterial Disease in the Office: What Do the Guidelines Say? Semin Intervent Radiol 2019; 35:365-377. [PMID: 30728652 DOI: 10.1055/s-0038-1676453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Srini Tummala
- Limb Preservation Program, Department of Interventional Radiology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Derek Scherbel
- University of Miami, Miller School of Medicine, Miami, Florida
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Abstract
Peripheral arterial disease (PAD) is a prevalent, morbid, and mortal disease. Claudication represents an early, yet common manifestation of PAD. A clinical history and physical examination combined with an ankle-brachial index can help make a diagnosis of claudication. Due to the polyvascular nature of the underlying atherosclerosis, PAD is often associated with heart disease and stroke. Although health implications of PAD derive from both its limb and cardiovascular manifestations, claudication is life-threatening, less limb-threatening. Medical modification of cardiovascular risk factors and exercise are the cornerstone in the treatment of claudication. Revascularization in claudication is focused at improvement in claudication symptoms and functional status, rather than aggressive attempts at limb salvage. The aim of this article is to summarize the strategies in the treatment of claudication, to serve as a concise and informative reference for physicians who are managing these patients. A framework of the decision-making process in the management of patients with claudication is shown, which can be applied in clinical practice.
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Affiliation(s)
- Keith Pereira
- Division of Vascular and Interventional Radiology, Saint Louis University, St. Louis, Missouri
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Sharath SE, Lee M, Kougias P, Taylor WC, Zamani N, Barshes NR. Successful Smoking Cessation Associated with Walking Behavior in Patients with Claudication. Ann Vasc Surg 2018; 56:287-293. [PMID: 30500660 DOI: 10.1016/j.avsg.2018.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/16/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Behavioral economics theories suggest that a preference for delayed benefits promotes positive behavioral change, a concept relevant to both smoking cessation and community-based exercise regimens for claudication. Given the high rate of smoking among older veterans, we were interested in examining the association between smoking cessation, exercise regimen adherence, and preferences for delayed versus immediate benefits. METHODS Between April 2017 and March 2018, patients with claudication at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, received questionnaires collecting information on social, behavioral, and psychological characteristics. A dual validation system, via the electronic medical record and survey data, measured the primary outcome-smoking cessation versus current smoking. Self-reported physical activity was measured through the validated Ainsworth's compendium of Physical Activities and binary survey questions. The Walking Impairment and Barratt's Impulsivity Questionnaires measured subjective symptom severity and behavioral economics factors, respectively. Multivariable, logistic regression models identified significant associations. RESULTS The survey was mailed to 500 patients who met the eligibility criteria. We received responses from 148 individuals (30%), and 67 of 141 (48%) indicated that they had successfully quit smoking. In unadjusted comparisons, the median cognitive complexity score in the smoking cessation group was higher than that in the current smoking group. A greater proportion of patients who reported walking for exercise (n = 46) also reported successful smoking cessation (28/46, 61%). Among those who were not walking for exercise (n = 88), more individuals reported current smoking (49/88, 56%). In the multivariable model, individuals who had successfully stopped smoking were older (odds ratio [OR]: 7.59, P < 0.001), more likely to walk for exercise (OR: 3.94, P = 0.009), more interested in the future than in the present (OR: 1.73, P = 0.030), and more likely to regularly save money (OR: 3.49, P = 0.046). CONCLUSIONS We found that participants who reported successful smoking cessation were more likely to report walking for exercise. Our findings suggest that adherence to walking may be less challenging for patients who have already successfully implemented and continue to implement another beneficial health behavior (smoking cessation). Patients with claudication who are current smokers may be less likely to adopt exercise recommendations.
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Affiliation(s)
- Sherene E Sharath
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - MinJae Lee
- Division of Clinical and Translational Sciences, Department of Internal Medicine, The University of Texas McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Panos Kougias
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Wendell C Taylor
- Department of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX
| | - Nader Zamani
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME, Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis J, Joglar J, Pressler SJ, Wijeysundera DN. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary. Vasc Med 2018; 22:NP1-NP43. [PMID: 28494710 DOI: 10.1177/1358863x17701592] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
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- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | | | - Heather L Gornik
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | | | | | | | - Douglas E Drachman
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,5 Society for Cardiovascular Angiography and Interventions Representative
| | - Lee A Fleisher
- 6 ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Francis Gerry R Fowkes
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,7 Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative
| | | | - Scott Kinlay
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,8 Society for Vascular Medicine Representative
| | - Robert Lookstein
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Sanjay Misra
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,9 Society of Interventional Radiology Representative
| | - Leila Mureebe
- 10 Society for Clinical Vascular Surgery Representative
| | - Jeffrey W Olin
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Rajan A G Patel
- 7 Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative
| | | | - Andres Schanzer
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,11 Society for Vascular Surgery Representative
| | - Mehdi H Shishehbor
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Kerry J Stewart
- 3 ACC/AHA Representative.,12 American Association of Cardiovascular and Pulmonary Rehabilitation Representative
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Green JL, Harwood AE, Smith GE, Das T, Raza A, Cayton T, Wallace T, Carradice D, Chetter IC. Extracorporeal shockwave therapy for intermittent claudication: Medium-term outcomes from a double-blind randomised placebo-controlled pilot trial. Vascular 2018; 26:531-539. [PMID: 29722640 DOI: 10.1177/1708538118773618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Peripheral arterial disease most commonly presents as intermittent claudication (IC). Early evidence has suggested that extracorporeal shockwave therapy is efficacious in the short term for the management of intermittent claudication. The objective of this pilot trial was to evaluate the medium-term efficacy of this treatment. Methods This double-blind randomised placebo-controlled pilot trial randomised patients with unilateral intermittent claudication in a 1:1 fashion to receive extracorporeal shockwave therapy or a sham treatment for three sessions per week over three weeks. Primary outcomes were maximum walking distance and intermittent claudication distance using a fixed-load treadmill test. Secondary outcomes included pre- and post-exertional ankle-brachial pressure indices, safety and quality of life assessed using generic (SF36, EQ-5D-3L) and disease-specific (vascular quality of life) measures. All outcome measures were assessed at 12 months post-treatment. Results Thirty participants were included in the study (extracorporeal shockwave therapy, n = 15; sham, n = 15), with 26 followed up and analysed at 12 months (extracorporeal shockwave therapy, n = 13; sham, n = 13). Intragroup analysis demonstrated significant improvements in maximum walking distance, intermittent claudication distance and post-exertional ankle-brachial pressure indices ( p < 0.05) in the active treatment group, with no improvements in pre-exertional ankle-brachial pressure indices. Significant improvements in quality of life were observed in 3 out of 19 domains assessed in the active group. A re-intervention rate of 26.7% was seen in both groups. Conclusions These findings suggest that extracorporeal shockwave therapy is effective in improving walking distances at 12 months. Although this study provides important pilot data, a larger study is needed to corroborate these findings and to investigate the actions of this treatment. ISRCTN NCT02652078.
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Affiliation(s)
- Jordan Luke Green
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Amy Elizabeth Harwood
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - George Edward Smith
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Tushar Das
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Ali Raza
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Thomas Cayton
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Tom Wallace
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
| | - Ian Clifford Chetter
- Academic Vascular Surgical Unit, Hull York Medical School/University of Hull, Hull, UK
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Fakhry F, Fokkenrood HJP, Spronk S, Teijink JAW, Rouwet EV, Hunink MGM. Endovascular revascularisation versus conservative management for intermittent claudication. Cochrane Database Syst Rev 2018; 2018:CD010512. [PMID: 29518253 PMCID: PMC6494207 DOI: 10.1002/14651858.cd010512.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intermittent claudication (IC) is the classic symptomatic form of peripheral arterial disease affecting an estimated 4.5% of the general population aged 40 years and older. Patients with IC experience limitations in their ambulatory function resulting in functional disability and impaired quality of life (QoL). Endovascular revascularisation has been proposed as an effective treatment for patients with IC and is increasingly performed. OBJECTIVES The main objective of this systematic review is to summarise the (added) effects of endovascular revascularisation on functional performance and QoL in the management of IC. SEARCH METHODS For this review the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). The CIS also searched trials registries for details of ongoing and unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing endovascular revascularisation (± conservative therapy consisting of supervised exercise or pharmacotherapy) versus no therapy (except advice to exercise) or versus conservative therapy (i.e. supervised exercise or pharmacotherapy) for IC. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data, and assessed the methodological quality of studies. Given large variation in the intensity of treadmill protocols to assess walking distances and use of different instruments to assess QoL, we used standardised mean difference (SMD) as treatment effect for continuous outcome measures to allow standardisation of results and calculated the pooled SMD as treatment effect size in meta-analyses. We interpreted pooled SMDs using rules of thumb (< 0.40 = small, 0.40 to 0.70 = moderate, > 0.70 = large effect) according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated the pooled treatment effect size for dichotomous outcome measures as odds ratio (OR). MAIN RESULTS We identified ten RCTs (1087 participants) assessing the value of endovascular revascularisation in the management of IC. These RCTs compared endovascular revascularisation versus no specific treatment for IC or conservative therapy or a combination therapy of endovascular revascularisation plus conservative therapy versus conservative therapy alone. In the included studies, conservative treatment consisted of supervised exercise or pharmacotherapy with cilostazol 100 mg twice daily. The quality of the evidence ranged from low to high and was downgraded mainly owing to substantial heterogeneity and small sample size.Comparing endovascular revascularisation versus no specific treatment for IC (except advice to exercise) showed a moderate effect on maximum walking distance (MWD) (SMD 0.70, 95% confidence interval (CI) 0.31 to 1.08; 3 studies; 125 participants; moderate-quality evidence) and a large effect on pain-free walking distance (PFWD) (SMD 1.29, 95% CI 0.90 to 1.68; 3 studies; 125 participants; moderate-quality evidence) in favour of endovascular revascularisation. Long-term follow-up in two studies (103 participants) showed no clear differences between groups for MWD (SMD 0.67, 95% CI -0.30 to 1.63; low-quality evidence) and PFWD (SMD 0.69, 95% CI -0.45 to 1.82; low-quality evidence). The number of secondary invasive interventions (OR 0.81, 95% CI 0.12 to 5.28; 2 studies; 118 participants; moderate-quality evidence) was also not different between groups. One study reported no differences in disease-specific QoL after two years.Data from five studies (n = 345) comparing endovascular revascularisation versus supervised exercise showed no clear differences between groups for MWD (SMD -0.42, 95% CI -0.87 to 0.04; moderate-quality evidence) and PFWD (SMD -0.05, 95% CI -0.38 to 0.29; moderate-quality evidence). Similarliy, long-term follow-up in three studies (184 participants) revealed no differences between groups for MWD (SMD -0.02, 95% CI -0.36 to 0.32; moderate-quality evidence) and PFWD (SMD 0.11, 95% CI -0.26 to 0.48; moderate-quality evidence). In addition, high-quality evidence showed no difference between groups in the number of secondary invasive interventions (OR 1.40, 95% CI 0.70 to 2.80; 4 studies; 395 participants) and in disease-specific QoL (SMD 0.18, 95% CI -0.04 to 0.41; 3 studies; 301 participants).Comparing endovascular revascularisation plus supervised exercise versus supervised exercise alone showed no clear differences between groups for MWD (SMD 0.26, 95% CI -0.13 to 0.64; 3 studies; 432 participants; moderate-quality evidence) and PFWD (SMD 0.33, 95% CI -0.26 to 0.93; 2 studies; 305 participants; moderate-quality evidence). Long-term follow-up in one study (106 participants) revealed a large effect on MWD (SMD 1.18, 95% CI 0.65 to 1.70; low-quality evidence) in favour of the combination therapy. Reports indicate that disease-specific QoL was comparable between groups (SMD 0.25, 95% CI -0.05 to 0.56; 2 studies; 330 participants; moderate-quality evidence) and that the number of secondary invasive interventions (OR 0.27, 95% CI 0.13 to 0.55; 3 studies; 457 participants; high-quality evidence) was lower following combination therapy.Two studies comparing endovascular revascularisation plus pharmacotherapy (cilostazol) versus pharmacotherapy alone provided data showing a small effect on MWD (SMD 0.38, 95% CI 0.08 to 0.68; 186 participants; high-quality evidence), a moderate effect on PFWD (SMD 0.63, 95% CI 0.33 to 0.94; 186 participants; high-quality evidence), and a moderate effect on disease-specific QoL (SMD 0.59, 95% CI 0.27 to 0.91; 170 participants; high-quality evidence) in favour of combination therapy. Long-term follow-up in one study (47 participants) revealed a moderate effect on MWD (SMD 0.72, 95% CI 0.09 to 1.36; P = 0.02) in favour of combination therapy and no clear differences in PFWD between groups (SMD 0.54, 95% CI -0.08 to 1.17; P = 0.09). The number of secondary invasive interventions was comparable between groups (OR 1.83, 95% CI 0.49 to 6.83; 199 participants; high-quality evidence). AUTHORS' CONCLUSIONS In the management of patients with IC, endovascular revascularisation does not provide significant benefits compared with supervised exercise alone in terms of improvement in functional performance or QoL. Although the number of studies is small and clinical heterogeneity underlines the need for more homogenous and larger studies, evidence suggests that a synergetic effect may occur when endovascular revascularisation is combined with a conservative therapy of supervised exercise or pharmacotherapy with cilostazol: the combination therapy seems to result in greater improvements in functional performance and in QoL scores than are seen with conservative therapy alone.
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Affiliation(s)
- Farzin Fakhry
- Erasmus MCDepartments of Epidemiology & RadiologyDr Molewaterplein 40PO Box 2040RotterdamNetherlands3015 GD
| | | | - Sandra Spronk
- Erasmus MCDepartments of Epidemiology & RadiologyDr Molewaterplein 40PO Box 2040RotterdamNetherlands3015 GD
- Dutch Health Care InspectorateDepartment of Research and InnovationUtrechtNetherlands
| | - Joep AW Teijink
- Catharina HospitalDepartment of Vascular Surgeryvisiting address: Michelangelolaan 2, 5623 EJ, Eindhovenpostal address: P.O. Box 1350EindhovenNetherlands5602 ZA
| | - Ellen V Rouwet
- Erasmus MCDepartment of Vascular SurgeryRotterdamNetherlands
| | - M G Myriam Hunink
- Erasmus MCDepartment of EpidemiologyPO Box 2040RotterdamNetherlands3000 CA
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Data, guidelines, and practice of revascularization for claudication. J Vasc Surg 2017; 66:911-915. [PMID: 28842076 DOI: 10.1016/j.jvs.2017.05.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/12/2017] [Indexed: 01/20/2023]
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Larsen ASF, Jacobsen MB, Wesche J, Kløw NE. Additional functional outcomes after endovascular treatment for intermittent claudication. Acta Radiol 2017; 58:944-951. [PMID: 27872352 DOI: 10.1177/0284185116679459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Endovascular treatment (EVT) for intermittent claudication (IC) is performed in selected patients where conservative treatment and training fail. Treatment outcomes reported in vascular registries (survival, limb-survival, and re-intervention rate) are inadequate for low-risk patients with IC. Additional measurements of blood flow reduction and functional impairment clarify the indication for treatment and facilitate outcome evaluation. Purpose To analyze the additional outcome information on peripheral arterial pressures and walking capacity obtained from a local registry of EVT. Material and Methods Patients with IC treated with endovascular technique (angioplasty or stent) were prospectively entered into a local registry in addition to the national registry (NORKAR), with information on arterial pressures (ankle brachial index [ABI]) and treadmill performance (maximum walking distance [MWD]). Results A total of 242 consecutive patients (41% women; median age, 70 years) receiving the first treatment between July 2010 and December 2012 were included, 61% with aorto-iliac lesions. After 3 months, mean ABI increased from 0.62 (0.59-0.64) to 0.85 (0.83-0.87). The median MWD increased from 160 m to 410 m. Sixty-two percent reached the test maximum of 10 min. The improvement in ABI and MWD persisted after 1 year. When preoperative ABI was moderately reduced (0.5-0.9), ABI was normal in 61% after 3 months and in 55% after 1 year. When preoperative ABI was low (<0.5), ABI was normal in 43% both after 3 months and 1 year. Conclusion ABI and walking capacity were important outcome variables and improved after EVT. ABI improvement was better for patients with moderately reduced preoperative ABI than with low ABI.
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Affiliation(s)
- Anne Sofie F Larsen
- Department of Radiology, Ostfold Hospital Trust, Sarpsborg, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Morten B. Jacobsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Internal Medicine, Ostfold Hospital Trust, Sarpsborg, Norway
- Norwegian University of Life Sciences, Aas, Norway
| | - Jarlis Wesche
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Vascular and Thoracic Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Nils Einar Kløw
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Radiology, Oslo University Hospital, Oslo, Norway
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Hageman D, Fokkenrood H, Essers P, Koelemay M, Breek J, Vahl A, Scheltinga M, Teijink J. Improved Adherence to a Stepped-care Model Reduces Costs of Intermittent Claudication Treatment in The Netherlands. Eur J Vasc Endovasc Surg 2017; 54:51-57. [DOI: 10.1016/j.ejvs.2017.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 04/15/2017] [Indexed: 02/05/2023]
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Sharath SE, Kougias P, Barshes NR. The influence of pain-related beliefs on physical activity and health attitudes in patients with claudication: A pilot study. Vasc Med 2017; 22:378-384. [DOI: 10.1177/1358863x17709944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We examined how pain beliefs are related to symptom severity, expectations of risk/benefits, and baseline physical activity among claudicants. Eligible patients at the Michael E DeBakey Veterans Affairs Medical Center were administered questionnaires that measured: fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire [FABQ]), walking impairment, baseline physical activity, claudication type, and risk/benefit attitudes. Among 20 participants, the median age was 69 years (IQR: 66–75). In our efforts to understand how fear-avoidance beliefs influenced physical activity among people with claudication, we found that 12 out of 19 participants (63%) thought that the primary etiology of their pain was walking, while 18 (out of 20) (90%) people thought that walking would exacerbate their leg symptoms – suggesting that there was some confusion regarding the effects of walking on claudication. Those who expected that walking would benefit their symptoms more than surgery reported fewer fear-avoidance beliefs ( p=0.01), but those who believed that walking would make their leg pain worse expected greater benefit from surgery ( p=0.02). As symptom severity increased, fear-avoidance beliefs also increased ( p=0.001). The association between symptom severity and fear-avoidance beliefs indicates that as pain or impairment increases, the likelihood of avoiding behaviors that are thought to cause pain might also increase. Accounting for pain-related beliefs when recommending physical activity for claudication should be considered.
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Affiliation(s)
- Sherene E Sharath
- Research Service Line, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Panos Kougias
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Operative Care Line, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Operative Care Line, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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46
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Valentine EA, Ochroch EA. 2016 American College of Cardiology/American Heart Association Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Perioperative Implications. J Cardiothorac Vasc Anesth 2017; 31:1543-1553. [PMID: 28826846 DOI: 10.1053/j.jvca.2017.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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47
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135:e686-e725. [PMID: 27840332 PMCID: PMC5479414 DOI: 10.1161/cir.0000000000000470] [Citation(s) in RCA: 371] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care. In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5
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Affiliation(s)
| | - Heather L Gornik
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Coletta Barrett
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Neal R Barshes
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Matthew A Corriere
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Douglas E Drachman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Lee A Fleisher
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Francis Gerry R Fowkes
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Naomi M Hamburg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Scott Kinlay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Robert Lookstein
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Sanjay Misra
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Leila Mureebe
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Jeffrey W Olin
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Rajan A G Patel
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Judith G Regensteiner
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Andres Schanzer
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Mehdi H Shishehbor
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Kerry J Stewart
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Diane Treat-Jacobson
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - M Eileen Walsh
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
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48
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135:e726-e779. [PMID: 27840333 PMCID: PMC5477786 DOI: 10.1161/cir.0000000000000471] [Citation(s) in RCA: 373] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care. In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5
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Affiliation(s)
| | - Heather L Gornik
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Coletta Barrett
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Neal R Barshes
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Matthew A Corriere
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Douglas E Drachman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Lee A Fleisher
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Francis Gerry R Fowkes
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Naomi M Hamburg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Scott Kinlay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Robert Lookstein
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Sanjay Misra
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Leila Mureebe
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Jeffrey W Olin
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Rajan A G Patel
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Judith G Regensteiner
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Andres Schanzer
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Mehdi H Shishehbor
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Kerry J Stewart
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - Diane Treat-Jacobson
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
| | - M Eileen Walsh
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Functioning as the lay volunteer/patient representative. ACC/AHA Representative. Vascular and Endovascular Surgery Society Representative. Society for Cardiovascular Angiography and Interventions Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative. Society for Vascular Medicine Representative. Society of Interventional Radiology Representative. Society for Clinical Vascular Surgery Representative. Society for Vascular Surgery Representative. American Association of Cardiovascular and Pulmonary Rehabilitation Representative. Society for Vascular Nursing Representative
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Patterson RB. A modest proposal. J Vasc Surg 2017; 65:594-602. [PMID: 28236913 DOI: 10.1016/j.jvs.2016.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/07/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Robert B Patterson
- Department of Surgery, Division of Vascular Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 69:1465-1508. [PMID: 27851991 DOI: 10.1016/j.jacc.2016.11.008] [Citation(s) in RCA: 411] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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