Advances in the Management of Peripheral Artery Disease

Review new concepts in pharmacotherapy for peripheral arterial disease

PURPOSE OF REVIEW

To provide an overview of new concepts in the pharmacotherapy of patients with peripheral artery disease (PAD).

RECENT FINDINGS

Modern therapeutic strategies for patients with PAD include specific symptom management and multidisciplinary prevention of cardiovascular events. Low-dose rivaroxaban in combination with aspirin improves outcomes compared with aspirin monotherapy among patients with PAD. Other novel concepts include the use of bosentan, vorapaxar or sildenafil among symptomatic patients with PAD. Likewise, lipid-lowering therapy reduces the risk of major cardiovascular and limb events.

SUMMARY

Personalized management, identification of risk factors and shared-decision making are crucial in improving the best medical therapy for patients with PAD. Further studies are needed to assess the long-term safety and efficacy of novel strategies in real-world patients.

Insulin-Dependent Status Influences Post-Procedural Outcomes in Diabetic Patients Following Lower Extremity Endovascular Intervention for Peripheral Arterial Disease

PURPOSE

Diabetic patients are at increased risk of developing lower extremity peripheral arterial disease (PAD) requiring revascularization. This study assessed the effect of insulin dependence in diabetics on post-procedural outcomes following infra-inguinal endovascular intervention.

MATERIALS AND METHODS

The American College of Surgeon's National Surgical Quality Improvement Program database was used to identify 8022 patients undergoing infra-inguinal endovascular interventions between 2014 and 2017. Thirty-day post-procedural outcomes for patients without diabetes, with non-insulin-dependent diabetes mellitus (NIDDM), and with insulin-dependent diabetes mellitus (IDDM) were compared.

RESULTS

At presentation, IDDM patients were more likely to present with critical limb ischemia compared to NIDDM and non-diabetic patients. In propensity score-weighted logistic regression analysis, IDDM status was an independent predictor for increased renal complication (odds ratio [OR] = 3.08, confidence interval [CI] = 1.44-6.65), sepsis (OR = 1.68, CI = 1.13-2.48), wound complication (OR = 1.57, CI = 1.09-2.25, p = 0.006), UTI (OR = 2.07, CI = 1.09-3.94, p = 0.03), and readmission (OR = 1.21, CI = 1.03-1.42). NIDDM status was an independent predictor for increased risk of renal complications (OR = 2.80, CI = 1.18-6.63).

CONCLUSIONS

IDDM status is an independent predictor for increased risk of 30-day post-procedural complications and readmission compared to both NIDDM and non-diabetic status in patients undergoing lower extremity endovascular interventions for PAD.

Downregulation of miRNA‑328 promotes the angiogenesis of HUVECs by regulating the PIM1 and AKT/mTOR signaling pathway under high glucose and low serum condition

Vascular complications are the primary reason for disability and mortality associated with diabetes mellitus (DM), and numerous microRNAs (miRNAs/miRs) are involved in the process, such as miR‑122, miR‑24 and miR‑423. It has been reported that miR‑328 regulates DM and cardiovascular disease; however, the role and mechanism of action underlying miR‑328 in HUVECs is not completely understood. The present study aimed to investigate the role and mechanism of action underlying the effects of miR‑328 on the functions of HUVECs. To simulate hyperglycemia combined with ischemia‑induced tissue starvation, HUVECs were cultured in endothelial cell medium with 25 mmol/l D‑glucose and 2% FBS for 24 h [high glucose (HG) + 2% FBS group]. HUVEC miR‑328 expression levels were detected by reverse transcription‑quantitative PCR. Cell migration, cytotoxicity and tube‑like structure formation were analyzed using wound healing, Cell Counting Kit‑8 and tube formation assays, respectively. Following transfection with miR‑328 inhibitor, miR‑328 expression was downregulated in HUVECs. Protein expression levels were determined by western blotting. Compared with the control group, the migration and tube‑like structure formation of HUVECs were decreased, and cell cytotoxicity was increased in the HG + 2% FBS group. The protein expression levels of vascular endothelial growth factor were also decreased, and the expression levels of miRNA‑328 in the HG + 2% FBS group were increased compared with the control group. However, miRNA‑328 downregulation reversed the aforementioned effects. Further experiments indicated that the AKT signaling pathway was inhibited in the HG + 2% FBS group; however, miR‑328 downregulation activated the AKT/mTOR signaling pathway, which was blocked by the AKT signaling pathway inhibitor, perifosine. Gene prediction and western blotting demonstrated that miR‑328 displayed a regulatory role via Pim‑1 proto‑oncogene, serine/threonine kinase (PIM1). In conclusion, miR‑328 expression was upregulated and angiogenesis was inhibited when HUVECs were subjected to high glucose and low serum conditions. miR‑328 downregulation enhanced angiogenesis by increasing PIM1 expression and activating the AKT/mTOR signaling pathway in HUVECs under high glucose and low serum conditions.

The Frequency and Risk Factors of Diabetic Foot Ulcer Recurrence Among Jordanian Patients with Diabetes

BACKGROUND

Diabetic foot is a major public health problem and their complications are an imperative cause of morbidity and mortality in diabetes.

OBJECTIVE

To evaluate the rate of recurrence of foot ulcers post two years of follow-up, including the associated risk factors in the patients attending the diabetic foot clinic at the National Center for Diabetes, Endocrinology, and Genetics (NCDEG), Amman, Jordan.

METHODS

A historical cohort design was adopted for the patients who presented for the first time to the diabetic foot clinic at the NCDEG. Every patient who came to the clinic was reviewed by using his or her medical files with respect to diabetic foot-related complaints. Patients were classified under four categories: (1) Recurrent foot ulcers (2) chronic foot ulcer (3) free of recurrence, and (4) no foot ulcers. Among the four groups, group 1 (recurrent foot ulcers, n=76) and group 3 (free of recurrence, n=54) were included for the analysis.

RESULTS

Among the 141 patients who presented to the diabetic foot clinic during the two-year study period, 76 (53.9%) of them experienced ulcer recurrences, 54 (38.3%) were recurrence-free, and 11 (7.8%) had chronic ulceration. The two-year recurrence rate was 58.5%. The presence of deformity and osteomyelitis were the statistically significant independent risk factors for recurrent foot ulceration.

CONCLUSION

This study of recurrences was clearly related to the type and complications of the ulcers rather than to the other variables. Recurrent foot ulceration is linked to the presence of osteomyelitis and/or deformities.