Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

Neixiao-ruanmai decoction No 2 improves carotid atherosclerosis by modulating gut microbiota and inhibiting TLR4/NF-κB pathway activation

BACKGROUND

Carotid atherosclerosis(CAs) plaques are challenging to reverse. Neixiao-Ruanmai Decoction No 2(NXRMT No 2), a Traditional Chinese Medicine (TCM) decoction, has shown potential in treating CAs. However, while preliminary clinical trials have confirmed the efficacy of NXRMT No 2 in improving CAs, the comparative effectiveness of long-term versus short-term treatment courses remains unclear, and the underlying mechanisms of this decoction are not yet fully understood.

METHODS

We conducted clinical trials, animal studies, 16S rRNA sequencing, metabolomics and fecal microbiota transplantation.

RESULT

Clinical research results indicate that NXRMT No 2(24 weeks of treatment) reduced total plaque area by 22.02%, maximum plaque thickness by 7.91%, and maximum plaque area by 21.29%. NXRMT No 2 improves patients'serum inflammatory levels, with a 24-week treatment course demonstrated superior efficacy compared to the 12-week treatment. Animal experiments demonstrated that NXRMT No 2 improved CAs progression, modulated the gut microbiota, inhibited the intestinal Toll-like receptor 4 (TLR4)/nuclear factor kappa-B (NF-κB) pathway and activated the expression of intestinal tight junction proteins.

CONCLUSION

NXRMT No 2 significantly attenuates CAs progression, with its primary mechanism likely related to modulating the gut microbiota to counteract the TLR4/NF-κB pathway and protect the intestinal barrier. This study provides evidence-based support for the use of NXRMT No 2 in treating CAs, offers guidance on optimal treatment duration for patients, and contributes to the development of traditional Chinese medicine formulations that improve CAs by modulating the gut microbiota-a significant advance in the prevention and treatment of CAs.

Outcomes of Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Procedure for the Treatment of Extensive Aortoiliac Occlusive Disease Using the BeGraft Balloon-Expandable Covered Stent: A Multicenter Observational Study

PURPOSE

The covered endovascular reconstruction of the aortic bifurcation (CERAB) technique offers an alternative for Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions involving the aortic bifurcation. The study aims to evaluate the outcomes of the CERAB technique for extensive aortoiliac occlusive disease (AIOD) using the BeGraft balloon-expandable covered stent (BECS).

MATERIALS AND METHODS

This is a physician-initiated, multicenter, retrospective, observational study. Between June 2017 and June 2021, all consecutive patients who underwent the CERAB procedure using the BeGraft stent (Bentley InnoMed, Hechingen, Germany) in 3 clinics were enrolled. Patients' demographics, lesion characteristics, and procedural results were collected and retrospectively analyzed. Follow-up was done at 1, 6, and 12 months and then annually with clinical examination, ankle-brachial index (ABI), and duplex ultrasound. The primary endpoint was the patency at 12 months. Secondary endpoints included procedural-related complications, secondary patency, freedom from target lesion revascularization (TLR), and clinical improvement.

RESULTS

In all, 120 patients (64 men) with a median age of 65 years (range: 34-84 years) were analyzed. Most patients had extensive AIOD classified as TASC II C (n=32; 26.7%) or TASC II D (n=81; 67.5%). The median duration of the procedure was 120 minutes (interquartile range [IQR]: 80-180 minutes). All 454 BeGraft stents (137 aortic and 317 peripheral) were successfully delivered and deployed. The overall procedural complication rate was 14 (11.7%). The median hospital length of stay was 5 days (IQR: 3-6 days). All patients improved clinically, and the ABI increased significantly (p<0.05). The median follow-up was 19 months (range: 6-56 months). The primary patency rate, secondary patency rate, and freedom from TLR at 12 months were 94.5%, 97.3%, and 93.5%, respectively.

CONCLUSIONS

The CERAB procedure with BeGraft BECSs has a high technical success rate, favorable patency outcomes, and low morbidity, even in relatively ill patients with extensive AIOD. Prospective randomized studies on the CERAB technique are definitely recommended.Clinical ImpactThis study evaluates the outcomes of BeGraft stents used during the covered endovascular reconstruction of the aortic bifurcation (CERAB) procedure. To date, several balloon-expandable covered stents have been used for this technique with satisfactory results. This study showed the safety and excellent patency of the CERAB technique in extensive AIOD using BeGraft balloon-expandable covered stents.

The phenomenon of drug-coating embolism during lower extremity endovascular interventions with paclitaxel-coated balloon

IntroductionThere is a risk of distal embolization lower extremity endovascular interventions. Possibly a drug-coating embolism caused by coating detachment from intravascular devices.MethodsThis review focuses on providing updated information on distal embolism in endovascular revascularization of lower extremity arteries, including the use of drug-coated balloons.ResultsDrug-coating embolism is a special case of distal embolization during recanalization of the arteries of the lower extremities. Preclinical studies have demonstrated embolization of drug-coated balloons during angioplasty of lower extremity arteries. However, the clinical role of drug-coating embolism is not completely clear. A 2020 meta-analysis found an increased risk of major lower extremity amputation after drug-coated balloon angioplasty in patients with critical limb ischemia. But long-term research is emerging to support the safety of using these devices. Perhaps a more thorough assessment of the quality of life and the degree of compensation of lower limb ischemia with an intraoperative assessment of the frequency of peripheral embolizations using ultrasound emboli detection, as well as microcirculation with transcutaneous oximetry and laser Doppler flowmetry of the operated lower limb will allow a more detailed study of the phenomenon of drug-coating embolism and its impact on long-term clinical outcomes.ConclusionAccording to the results of preclinical studies, the use of paclitaxel-coated balloons leads to an increase in the concentration of paclitaxel in distal skeletal muscles. However, paclitaxel concentration in skeletal muscle was significantly higher in first-generation DCBs. The non-target effects of drug-coating balloon are not fully understood and require further study. Understanding the phenomenon of drug-coating embolism can help physicians to better assess the patient risk and to minimize complications.

Comparative Evaluation of Two Paclitaxel-Coated Stents in an Experimental Setting

INTRODUCTION

Unlike paclitaxel-coated balloons, pre-clinical data comparing different paclitaxel-coated stents (PCSs) are weak. The study objective was to compare the features of the 2 main PCSs: Eluvia® (Boston Scientific, Marlborough, MA) versus ZilverPTX® (Cook Medical, Bloomington, IN).

METHOD

Analysis was carried out on 12 pigs divided into 2 groups: Eluvia® (n=6) and ZilverPTX® (n=6). The pigs received the PCS corresponding to their group in each external iliac artery and were paired one by one, to examine 6 different post-implantation timepoints: after 30 minutes, 6 hours, 24 hours, 3 days, 7 days, and 14 days. The paclitaxel concentration measurements and the histological analysis were carried out under blind testing on the plasma, arterial, lymph node, and muscle samples. A linear regression model and Wilcoxon Mann-Whitney test were used to study the variables.

RESULTS

The plasma paclitaxel rate decrease over 24 hours after PCS implantation was significantly different between the two groups, expressed by the correlation coefficient 0.19 (0.14-0.23; p<0.001) with an undetectable concentration at the 10th hour for Eluvia® versus 3 days for ZilverPTX®. Significantly higher paclitaxel concentrations with ZilverPTX® PCS were observed in muscle samples at each timepoint: extensor digitorum brevis 3.2 (1.17-5.23; p=0.005), biceps femoris 4.27 (2.27-6.26; p<0.001), semi-tendinosus 3.79 (1.85-5.73; p=0.001), tibialis anterior 3.0 (1.37-4.64; p=0.001), and in the femoral nodes 2.27±1.74 ng/g versus 0.14±0.13 ng/g (p<0.001). Histological analysis revealed a trend for more marked intimal inflammation in the arteries stented with ZilverPTX® (p=0.063), especially after the 7th and 14th days.

CONCLUSION

Such a difference in the concentration of paclitaxel in the plasma, muscles, and lymph nodes between the two stents was higher than expected based on differences in device design. The clinical consequences of these results remain to be elucidated, particularly regarding the concerning presence of paclitaxel in muscles and adjacent lymph nodes.Clinical ImpactThis experimental study compares 2 paclitaxel-coated stents. It demonstrates that differences in stent designs and drug features (coatings and concentrations) translate into differences in terms of concentrations of paclitaxel in the plasma, muscles, and lymph nodes. Our results favor the Eluvia® stent over the ZilverPTX® stent, although more studies are required to confirm this conclusion.

Interpretable machine learning prediction model for major adverse cardiovascular events in patients with peripheral artery disease

BACKGROUND

Major adverse cardiovascular events (MACE) are severe complications of peripheral arterial disease (PAD), associated with poor prognosis and disease burden. Therefore, the early identification of high-risk individuals is of paramount importance. This study aimed to develop and validate an interpretable machine learning-based prediction model for MACE risk in patients with PAD.

METHODS

This retrospective study included patients with PAD enrolled between January 2022 and December 2023, with follow-up completed in December 2024. The primary outcome was MACE, defined as a composite of myocardial infarction, stroke, and cardiovascular mortality, and patients were followed up for 12-24 months using data sourced from non-overlapping datasets of four centers: three for model training and internal validation; and one for external validation. Feature selection was performed using univariate analysis, LASSO logistic regression, and Random Forest algorithm. Ten different machine learning (ML) algorithms were employed to construct the risk prediction model. Model performance was evaluated based on discrimination and calibration. The SHapley Additive exPlanations (SHAP) method was used to visualize model features and individual case predictions. The final risk prediction model was presented as a web-based calculator.

RESULTS

This multicenter study involved both model development dataset (n = 1110) and external validation dataset (n = 448). Among the 1558 enrolled patients with PAD, 469 (30.1%) experienced MACE. The incidence of MACE was higher in the training cohort (32.0%, 249/777) compared to the internal validation cohort (30.6%, 102/333) and external validation cohort (26.3%, 118/448). The mean follow-up duration was 19.0 ± 11.3 months. Participants' mean age was 73.1 ± 10.8 years, with males comprising 70.0% (1091/1558). We developed ML models incorporating eight clinically significant variables, with Gradient Boosting (GraBoost) demonstrating comparatively better performance by achieving AUC values of 0.864 (95% confidence interval [CI]: 0.822-0.905) in internal validation cohort and 0.777 (95% CI: 0.720-0.833) in external validation cohort. The key predictors included: polyvascular disease, cerebrovascular disease, hemoglobin A1c, C-reactive protein, albumin, peripheral arterial surgery, coronary heart disease, and neutrophils.

CONCLUSION

The GraBoost algorithm outperformed other models in predicting MACE risk in patients with PAD, with external validation confirming its clinical applicability. The SHAP framework and web-based calculator enhanced the model's interpretability, enabling clinicians to better understand the factors contributing to MACE. This tool potentially helps clinicians identify MACE risk of patients with PAD and implement preventive measures more effectively.

Carotid Stump Syndrome: A Case That Highlights the Necessity of Digital Subtraction Angiography for the Prompt Management of the Syndrome

Background and Clinical Significance: Carotid stump syndrome (CSS) is a rare and unexpected cause of recurrent ischemic ipsilateral events in the carotid vascular territory despite the demonstrated occlusion of the internal carotid artery (ICA). It is believed to be caused by microemboli due to turbulent blood flow in the patent stump of the occluded ICA that passes through anastomotic channels and retrograde flow into the middle cerebral artery circulation. Case Presentation: We describe the case of a 65-year-old male patient who suffered multiple concurrent transient ischemic attacks (TIAs) with a totally occluded ipsilateral ICA revealed by computed tomography angiography (CTA). He was diagnosed with CSS, which required the safest therapeutic approach. A further investigation with digital subtraction angiography (DSA) was performed, and a trickle of blood flow was observed in the reportedly occluded ICA. The diagnosis of a true ICA occlusion was withdrawn, and a diagnosis of pseudo-occlusion was established, affecting the final treatment strategy. Therefore, the patient underwent an ipsilateral carotid endarterectomy (CEA), and he has remained asymptomatic since then. Conclusions: The differentiation between a pseudo-occlusion and a true ICA occlusion is essential in promptly managing acute recurrent ipsilateral ischemic strokes in the carotid vascular territory. A further investigation with DSA in cases with a totally occluded ICA using CTA is essential for excluding pseudo-occlusions in ipsilaterally symptomatic patients.

Feasibility Randomized Controlled Trial of Remotely Supervised Exercise versus Self-Directed Exercise for Intermittent Claudication

BACKGROUND

This trial examined the feasibility of a future trial of remotely supervised exercise (RSE) versus self-directed exercise (SDE) for stable claudication.

METHODS

Randomized, single center, assessor blind, feasibility trial. In the intervention arm patients received fortnightly video or telephone calls from a physiotherapist with a tailored exercise prescription and review of progress with the aim of a minimum of 120 min of leg exercise per week. In the comparator arm, patients were asked to do this themselves. Both groups had an electronic walking log which was inspected at 3 and 6 months. The primary endpoint was maximum walking distance recorded by a blinded assessor. As this was a feasibility study the randomization target was 40 patients.

RESULTS

44 patients were randomized over a 2 year period. The eligibility rate was 57% of those screened. The participation rate was 100% of those eligible. The withdrawal rate was 27% of those randomized. Maximum walking distance improved, on average, by +369m in the remotely supervised group and by +322m in the SDE group. Quality of life gains were similar in both arms.

CONCLUSION

A large randomized controlled trial comparing RSE with SDE would be difficult using this protocol, because of the high withdrawal rate and small treatment effect.

Interwoven Nitinol Stent Versus Laser-Cut-Type Nitinol Stent for Long Femoropopliteal Occlusive Disease: A Propensity Matched Analysis

PURPOSE

There are still limited data to determine the efficacy of interwoven nitinol stent (INS) compared with laser-cut nitinol stent (CNS) for the endovascular treatment of long femoropopliteal lesions. The aim of this study is to evaluate the short- and mid-term results of the effectiveness of CNS and INS in the revascularization of long femoropopliteal occlusions. We performed analyses of the primary and secondary outcome measures for subgroups of patients with below-the-knee and "above-the-knee" lesions.

MATERIALS AND METHODS

A retrospective propensity matched analysis was conducted on symptomatic patients (Rutherford category 3-6) with long occlusions of the femoropopliteal segment (> 15 cm) who underwent stenting with either INS or CNS from 2012 to 2020. The primary outcome measure was the primary patency in 2 years. Secondary outcome measures were secondary patency, major adverse cardiovascular events, major adverse limb events, sustained clinical improvement, and mortality.

RESULTS

After propensity score matching, 126 and 125 patients remained in the INS and CNS groups, respectively. There were no cases of major cardiovascular events (MACE) or major limb events in both groups during the perioperative period. There were no significant differences in primary and secondary patency during a 2-year follow-up. There were no stent fractures in the INS group, whereas in the CNS group the stent fractures rate reached 37 (29.6%) patients (p < 0.001). In the "above-the-knee" subgroup, INS and CNS showed comparable primary patency rates. However, the secondary patency rates were 82.0% and 96.9% in INS and CNS groups, respectively (p < 0.001). The secondary sustained clinical improvement rates were 79.8% and 93.9% in INS and CNS subgroups, respectively (p < 0.001). In the "below-the-knee subgroup," INS showed higher primary patency rate (INS: 64.9% CNS: 37.1%; p = 0.04). In the CNS group, the fractures rate "below the knee" was statistically significantly higher compared with stents "above the knee" (p = 0.03).

CONCLUSION

After propensity score matching, INS showed comparable results with CNS for the whole cohort. However, INS seems to achieve better outcomes for femoropopliteal lesion extended to the below-the-knee level.

Prevention of infection in aortic or aortoiliac peripheral arterial reconstruction

BACKGROUND

Peripheral arterial disease (PAD) results from the narrowing of arteries. Aortic aneurysms - abnormal dilatations in artery walls - are a related concern. For severe cases, arterial reconstruction surgery is the treatment option. Surgical site infections (SSIs) are a feared and common complication of vascular surgery. These infections have a significant global healthcare impact. Evaluating the effectiveness of preventive measures is essential.

OBJECTIVES

To assess the effects of pharmacological and non-pharmacological interventions, including antimicrobial therapy, antisepsis, and wound management, for the prevention of infection in people undergoing any open or hybrid aortic or aortoiliac peripheral arterial reconstruction.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform, LILACS, and ClinicalTrials.gov up to 11 November 2024.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a parallel (e.g. cluster or individual) or split-body design, and quasi-RCTs, which assessed any intervention to reduce or prevent infection following aortic or aortoiliac procedures for the treatment of aneurysm or PAD. There were no limitations regarding age and sex.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third review author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 21 RCTs with 4952 participants. Fifteen studies were assessed as having a high risk of bias in at least one domain, and 19 studies had an unclear risk of bias in at least one domain. We analysed 10 different comparisons for eight different outcomes. The comparisons were antibiotic versus placebo or no treatment; short-duration antibiotics (≤ 24 hours) versus long-duration antibiotics (> 24 hours); different types of systemic antibiotics (one versus another); antibiotic-bonded implant versus standard implant; Dacron graft versus stretch polytetrafluoroethylene graft; prophylactic closed suction drainage versus undrained wound; individualised goal-directed therapy (IGDT) versus fluid therapy based on losses, standard haemodynamic parameters and arterial blood gas values (standard care); comprehensive geriatric assessment versus standard preoperative care; percutaneous versus open-access technique; and negative pressure wound therapy (NPWT) versus standard dressing. The primary outcomes were graft infection rate and SSI rate. The secondary outcomes included all-cause mortality, arterial reconstruction failure rate, re-intervention rate, amputation rate, pain resulting from the intervention, and adverse events resulting from the interventions to prevent infection. We did not assess all the outcomes across the different comparisons. The main findings are presented below. Antibiotic versus placebo or no treatment (five studies) Very low-certainty evidence from five included studies suggests that antibiotic prophylaxis reduces SSI (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.71; 5 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNT) 9). With very low- to low-certainty evidence, there was little or no difference between the groups in the other assessed outcomes (graft infection rate, all-cause mortality, re-intervention rate, and amputation rate). We did not quantitatively assess other outcomes in this comparison. Short duration antibiotics (≤ 24 hours) versus long duration antibiotics (> 24 hours) (three studies) Very low-certainty evidence from three included studies suggests that there is little or no difference in graft infection rate (RR 2.74, 95% CI 0.11 to 65.59; 1 study, 88 participants) or SSI rate (RR 3.65, 95% CI 0.59 to 7.71; 1 study, 88 participants) between short- and long-duration antibiotic prophylaxis. We did not quantitatively assess other outcomes in this comparison. Different types of systemic antibiotics (one versus another) (seven studies) We grouped seven studies comparing one antibiotic to another into three subgroups that compared different classes of antibiotics amongst themselves. We found little or no difference between the groups analysed. Graft infection rate: beta-lactams versus cephalosporins (RR 0.36, 95% CI 0.02 to 8.71; 1 study, 88 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 5.00, 95% CI 0.24 to 103.05; 1 study, 238 participants; low-certainty evidence); one cephalosporin versus another (RR not estimable, CI not estimable; 1 study; 69 participants; very low-certainty evidence); SSI rate: beta-lactams and cephalosporins (RR 0.27, 95% CI 0.03 to 2.53; 2 studies, 229 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 2.17, 95% CI 0.65 to 7.23; 2 studies, 312 participants; very low-certainty evidence); and one cephalosporin versus another (RR 1.26, 95% CI 0.21 to 7.45; 3 studies, 625 participants; very low-certainty evidence). We could extract all-cause mortality data for the glycopeptide versus cephalosporin comparison; there was little or no difference between groups (RR 1.33, 95% CI 0.30 to 5.83; 1 study, 238 participants; low-certainty evidence). We did not quantitatively assess other outcomes in this comparison.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that the use of prophylactic antibiotics may prevent SSIs in aortic or aortoiliac peripheral arterial reconstruction. We found no superiority amongst specific antibiotics or differences in extended antibiotic use (over 24 hours) compared with shorter use (up to 24 hours), with low-certainty evidence. For other interventions, very low- to moderate-certainty evidence showed little or no difference across various outcomes. We advise interpreting these conclusions with caution due to the limited number of events in all groups and comparisons.

Great saphenous vein versus expanded polytetrafluoroethylene graft in patients undergoing elective treatment of popliteal artery aneurysm with posterior approach

BACKGROUND

Aim of this study is to compare 30-day and 5-year outcomes of great saphenous vein (GSV) vs. expanded polytetrafluoroethylene (ePTFE) graft in patients undergoing elective treatment of popliteal artery aneurysm (PAA) using a posterior approach.

METHODS

Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs who underwent open repair with posterior approach or endovascular repair in 40 centers was investigated. Out of of 971 cases, 525 patients were included in the present analysis. These were further divided into: posterior approach with GSV graft (252, GSV Group), and posterior approach with ePTFE graft (273, ePTFE Group). Thirty-day outcomes were assessed and compared. During follow-up, survival, primary patency, secondary patency, freedom from reintervention(s), and amputation-free survival were compared between the two groups using log-rank tests. Uni- and multivariate Cox regression analyses were performed in ePTFE Group to find predictive factors of poor outcomes.

RESULTS

Two groups were homogeneous in terms of preoperative risk factors and morphological data. Median follow-up duration was similar [24 months (IQR 10 - 36) GSV Group vs. 21 months (IQR 7-47) ePTFE Group; p = .123]. At 5 years, there were no differences between the two groups in terms of survival (84.7% GSV Group vs. 86.1% ePTFE Group; p = .097, log-rank = 2.756), secondary patency (94.9% GSV Group vs. 89.4% ePTFE Group; p = .068, log-rank = 3.336), and amputation-free survival (99.1% GSV Group vs. 99.6% ePTFE Group; p = .567, log-rank = .328). Five-year primary patency (89.5% GSV Group vs. 76.2% ePTFE Group; p = .007, log-rank = 7.239), and freedom from reintervention(s) (92.8% GSV Group vs. 80.6% ePTFE Group; p = .011, log-rank = 6.449) were significantly higher in GSV Group. Using multivariate analysis in ePTFE Group, factors compromising primary patency were patients on dialysis (p = .054, OR = 3.641), and patients that were not on any preoperative antiplatelet therapy or anticoagulation (p = .019, OR = 5.532), whilst none of the perioperative factors affected freedom from reintervention(s).

CONCLUSION

GSV as graft guaranteed better primary patency with less reinterventions rates at mid-term follow-up after treatment of PAAs via a posterior approach. Patients on dialysis and who were not on any preoperative antiplatelet therapy or anticoagulation had lower patency rates.

Incidence and Comparison of Postoperative Explained and Unexplained Fever in Open Aortic Repair

BACKGROUND

Fever is a classic symptom in postoperative period, but to our knowledge no study shows exclusively the occurrence of fever after open aortic repair (OAR) and explores the difference between explained and unexplained fever.

METHODS

Patients who underwent an OAR between March 2018 and April 2023 in Reims University Hospital were enrolled retrospectively. The primary end point was the rate of fever after OAR, which was classed in explained fever group (eFG) or unexplained fever group (uFG). Secondary outcomes were to compare fever characteristics, length of hospitalization, and mortality all causes at day 30 and day 90 between groups.

RESULTS

The occurrence of fever was 23.8% after OAR, and 52% of them were unexplained. Date of occurrence of fever was at mean 3.3 days in uFG versus 7.8 days in eFG (P = 0.051). Sixty-six percent of eFG had a diagnosis of pneumopathy. The duration of hospitalization was longer in eFG versus uFG (25 vs. 15 days) and no statistical difference was found for the mortality in both groups. After at mean 806 days of follow-up in uFG, there was no occurrence of vascular graft infection.

CONCLUSION

Fever after OAR occurred in a quarter of OAR patients and half of them were unexplained. Unexplained fever occurred earlier than eFG.

Digital ulcers in systemic sclerosis are strongly associated with digital arterial disease: a finger-by-finger analysis of finger brachial pressure index measurements

OBJECTIVES

The digital ulcers (DU) of SSc are disabling and frequent. Their pathogenesis involves a capillary microangiopathy and a digital arterial disease that few studies were able to quantify up to now. A multicentre observational study about the predictive value of capillaroscopy in SSc offered us the opportunity to evaluate further the complementary information provided by both capillary and arterial evaluations.

METHODS

During the SCLEROCAP study, five out of the nine centres performed a systematic evaluation of the finger brachial pressure index (FBPI) in the last four fingers of both hands at baseline, using the same laser-Doppler device. In the present work, FBPI measurements were compared between fingers with vs without DU or scars, before and after adjusting for the capillaroscopic pattern and systemic factors.

RESULTS

FBPI measurements were performed in 2537 fingers from 326 patients. Active ulcers or scars were found in 10.8% of those fingers, more often on the right hand, and in the second and third fingers. FBPI was lower than 0.70 in 26% of all fingers and in 57.5% of those with ulcers. A strong association was found between a low FBPI and the presence of DU, even after adjusting for capillaroscopic pattern, ulcer location and the patient himself.

CONCLUSION

These results confirm the importance of digital arterial disease in the pathogenesis of DU of SSc, which is independent from the microangiopathy. FBPI measurements complement the information provided by capillaroscopy and might have an important predictive value for subsequent DU.

Ischemia targeted coronary revascularization improves 5-year survival following carotid endarterectomy

OBJECTIVES

Long-term survival after carotid endarterectomy (CEA) is limited by adverse cardiac events with 5% annual mortality. We sought to determine whether diagnosis of silent coronary ischemia together with elective ischemia-targeted coronary revascularization can reduce death and myocardial infarction (MI) and improve long-term survival of patients after CEA.

METHODS

Observational cohort study of patients with no cardiac history or coronary symptoms undergoing elective CEA. Patients enrolled in a prospective study of preoperative cardiac evaluation using coronary computed tomography-derived fractional flow reserve (FFRCT) to detect silent (asymptomatic) coronary ischemia together with elective postoperative ischemia-targeted coronary revascularization were compared with matched controls with standard preoperative cardiac evaluation and no elective coronary revascularization. Lesion-specific coronary ischemia was defined as an FFRCT of ≤0.80 distal to >30% stenosis with severe ischemia defined as an FFRCT of ≤0.75. End points included all-cause death, cardiac death, MI, stroke, and major adverse cardiovascular events (MACE) (defined as cardiovascular death, MI, or stroke) during 5 years of follow-up.

RESULTS

FFRCT (n = 100) and control (n = 100) cohorts were well-matched with no significant differences in age, gender, comorbidities, or indications for CEA. Asymptomatic lesion-specific coronary ischemia (FFRCT of ≤0.80) was present in 57% of FFRCT patients, with severe ischemia in 44% and left main ischemia in 7%; 43% had no coronary ischemia (FFRCT of >0.80). The status of coronary ischemia was unknown in the controls. CEA was performed successfully in both cohorts with no deaths or neurological events, and all patients received optimal postoperative medical therapy. Elective ischemia-targeted coronary revascularization was performed in 33% of FFRCT patients within 3 months of CEA. Controls had no elective coronary revascularization. During 5 years of follow-up, compared with controls, the FFRCT group had fewer all-cause deaths (11% vs 24%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.17-0.77; P = .016); fewer cardiac deaths (3% vs 13%; HR, 0.15; 95% CI, 0.03-0.69; P = .009); fewer MIs (3% vs 21%; HR, 0.07; 95% CI, 0.02-0.31; P < .001), and fewer MACEs (10% vs 33%; HR, 0.21; 95% CI, 0.10-0.44; P < .001) with no differences in stroke. There were no cardiac deaths or MIs among patients with no coronary ischemia (FFRCT of >0.80). Annual mortality in FFRCT was 2.2% per year compared with 4.8% per year in controls.

CONCLUSIONS

Diagnosis of silent coronary ischemia together with elective ischemia-targeted coronary revascularization after CEA decrease the 5-year risk of all-cause death, cardiac death, MI, and MACE by >50% and improved survival (89%) compared with patients receiving standard cardiac evaluation and care (76%).

Outcomes of Revascularization for Peripheral Artery Disease in Aboriginal and Torres Strait Islander Peoples and Non-Indigenous Australians

BACKGROUND

Australia's Aboriginal and Torres Strait Islander Peoples are at high risk of peripheral arterial disease (PAD), but outcomes of revascularization are unknown. Revascularization outcomes were compared among Aboriginal and Torres Strait Islander and non-Indigenous Australians.

METHODS

A retrospective cohort study was conducted of patients who underwent lower limb revascularization between January 2015 and July 2023. PAD severity was defined using the Rutherford classification and angiographic scoring systems (ANGIO score, Global Limb Anatomic Staging System [GLASS], Trans-Atlantic Inter-Society Consensus). The primary outcome was major adverse limb events (MALE), that is, major amputation or repeat revascularization. The secondary outcomes were major adverse cardiovascular events (MACE), major amputation, and repeat revascularization alone.

RESULTS

A total of 504 patients were included. Fifty-seven (11.3%) were Aboriginal and Torres Strait Islander People, who were more likely to present with chronic limb-threatening ischemia (74% vs. 65%; P = 0.01) and have infrapopliteal disease (GLASS: odds ratio [OR] 1.93, 95% confidence interval 1.15-3.24; P = 0.013; ANGIO score: OR 1.97, 1.18-3.29; P = 0.01) compared to non-Indigenous Australians. Risk of MALE (rate ratio [RR] 1.39; 0.91-2.13; P = 0.126) and repeat revascularization (RR 1.18, 0.74-1.88; P = 0.493) were similar, but Aboriginal and Torres Strait Islander People had a higher risk of major amputation (RR 3.35; 1.66-6.75; P = 0.001) and MACE (RR 1.88, 1.17-3.03; P = 0.009) than non-Indigenous participants. Adjusted analyses suggested the increased risk of major amputation was due to Aboriginal and Torres Strait Islander People presenting with more severe PAD and tissue loss compared to non-Indigenous patients.

CONCLUSION

Aboriginal and Torres Strait Islander Peoples present with more severe PAD and have greater risk of major amputation. Culturally appropriate programs are needed to raise awareness and promote secondary prevention.

Derivation and validation of a non-invasive optoacoustic imaging biomarker for detection of patients with intermittent claudication

BACKGROUND

Peripheral arterial disease (PAD) affects more than 200 million people worldwide, with symptoms ranging from none to severe. Despite these different diagnostic options, patients with unclear leg pain remain challenging to diagnose. The primary objective of this study was to evaluate whether multispectral optoacoustic tomography (MSOT) can discriminate between healthy volunteers (HV) and patients with intermittent claudication (IC) by assessing hemoglobin-related biomarkers in calf muscle tissue.

METHOD

In this monocentric, cross-sectional, observational diagnostic trial (NCT05373927) n = 102 patients were included in two independent derivation (DC, n = 51) and validation cohorts (VC, n = 51). MSOT was performed before and after standardized heel raise provocation and was compared to standardized PAD diagnostics including pulse palpation, ankle brachial index (ABI), duplex sonography, 6-minute walk test (6MWT), assessment of health-related quality of life (VASCUQOL-6), and angiography (aggregated TransAtlantic Inter-Society Consensus classification, aTASC).

RESULTS

Here we show that MSOT is capable of differentiating IC and HV with an area under the receiver operator characteristics curve (AUROC) in DC by 0.99 (sensitivity: 100%, specificity: 95.8%) and in the VC by 0.95 (sensitivity: 96.2%, specificity: 96.0%). MSOT-derived oxygenation positively correlates with the ABI post-exercise (R = 0.83, P = 2.31 × 10-26), the absolute walking distance in the 6MWT (R = 0.77, P = 3.40 × 10-21), the VASCUQOL-6 (R = 0.79, P = 4.82 × 10-23) and negatively with aTASC classification (R = -0.80, P = 2.92 × 10-24).

CONCLUSIONS

Post-exercise MSOT-derived saturation in the calf muscle is validated as a non-invasive imaging biomarker to distinguish HV and IC patients yielding high sensitivity and specificity.

Effect of Nordic walking on walking ability in patients with peripheral arterial disease: a meta-analysis

BACKGROUND

Evaluating the effectiveness of Nordic walking in influencing walking ability in patients with peripheral arterial disease.

METHODS

We searched 12 databases, including PubMed, Embase, Cochrane library, Web of Science, EBSCO host, Ovid, Scopus, ClinicalTrial.gov, and several top ranked Chinese databases, including China National Knowledge Infrastructure (CNKI), Wanfang Data, CBMdisc, VIP Database, ChiCTR. The search has no starting time limit and the deadline is April 9, 2024. Randomized controlled trials and pseudo-random controlled trials were included. The two authors independently screened the literature and evaluated the quality of the study using the Cochrane risk of bias tool. Meta analysis was conducted using Review Manager 5.4 and Stata 17.0 software.

RESULTS

A total of 8 studies involving 508 patients were included. Meta-analysis results showed that compared with supervised exercise therapy (SET), supervised NW was not associated with an increase in maximum walking distance (MWD) and claudication distance (CD) in PAD patients, whether during treadmill tests or 6-minute walk tests (6-MWT), and the results were not statistically significant. In terms of increasing exercise duration, SET was significantly higher than supervised NW and the results were statistically significant (SMD =  -0.41, 95% Cl: -0.72 to -0.09, Z =  2.54, P =  0.01 <  0.05). Among the 8 studies included, 2 studies had control groups that were not part of the supervised exercise program and were different, therefore no meta-analysis was conducted.

CONCLUSIONS

In PAD patients, supervised NW is no significant difference in walking ability compared to SET. NW presents a viable option when SET is not available.

PROSPERO REGISTRATION

PROSPERO registration number: CRD42024535828.

A Randomized Control Trial Investigating the Effect of Different Treatment Strategies on Mitochondrial Function in Peripheral Arterial Disease: A Study Protocol

Peripheral arterial disease encompasses different clinical symptoms, depending on the severity of the disease. In early stages, a walking-induced pain, known as intermittent claudication, is the leading clinical symptom. Repeating cycles of ischemia and reperfusion induce a typical myopathy, with mitochondria playing the key role within this pathophysiological condition. The aim of this study is to further evaluate the effects of different treatment strategies on mitochondrial function and overall cardiovascular outcomes within a randomized controlled trial. After inclusion, patients will be randomized into different study groups. Study group 1 will receive conservative treatment, while study group 2 will receive revascularization of underlying atherosclerotic lesions. Additionally, a healthy control group will be included. Muscle biopsies will be obtained from ischemic and nonischemic muscle regions, being defined by the anatomic localization of the atherosclerotic lesion, before initiation of treatment as well as after a time interval of 12 wk. Mitochondrial function and content will be evaluated using high-resolution respirometry and citrate synthase activity measurements. Cardiovascular outcomes will be determined by established protocols. This study is registered on ClinicalTrials.gov-NCT05644158. This study aims to gain further insights into the exact pathophysiological mechanism underlying mitochondrial dysfunction in peripheral arterial disease. The potential effects of mitochondrial regeneration within ischemic muscle regions following a conservative treatment approach will be compared to those reported after revascularization procedures. Additionally, correlation with cardiovascular outcome parameters and in vivo methods will provide a comprehensive approach to this research question.

Total Contact Cast after Sole Free Flap Reconstruction for Early Ambulation

Background  Free flap reconstruction can be performed in patients with chronic limb-threatening ischemia (CLTI). However, early walking training may increase the risk of wound dehiscence and prolong hospitalization. Total contact cast (TCC) treatment effectively addresses diabetic plantar ulcers by immobilizing the foot and distributing weight away from the ulcer area. This study aimed to assess the effect of postoperative TCC use on early limb loading and hospital stay in patients with CLTI with free flaps. Methods  Patients with CLTI who underwent free flap reconstruction between 2006 and 2023 were enrolled in this study. Postoperative time until weight-bearing initiation was compared between the TCC ( n  = 5) and non-TCC groups ( n  = 7). Results  The time to the initiation of weight-bearing on the affected limb was 52.3 ± 33.2 days in the non-TCC group and 19.8 ± 3.56 days in the TCC group ( p  = 0.105). The wound dissection rates were 42.9% (3/7) in the non-TCC group and 20% (1/5) in the TCC group ( p  = 0.408). At discharge, 28.6% (2/7) of the non-TCC group and 20% (1/5) of the TCC group had ulcers ( p  = 0.735). The average flap size was 149 ± 69.1 cm 2 in the non-TCC group and 95.6 ± 73.1 cm 2 in the TCC group ( p  = 0.268). Conclusion  Postoperative TCC use after free flap foot reconstruction may lead to early weight-bearing of the affected limb. Further studies with larger numbers of cases are needed.

Shared Decision-Making in Patients with an Abdominal Aortic Aneurysm or Peripheral Artery Disease: A Scoping Review

BACKGROUND

This review provides an overview of the literature on shared decision-making (SDM) in patients with abdominal aortic aneurysm (AAA) or peripheral artery disease (PAD) and identifies barriers and facilitators.

METHODS

A systematic scoping review was conducted, in which 4 databases were systematically searched for the period January 2007 to November 2024. All articles were reviewed by 2 independent authors and asses for quality using the mixed-methods appraisal tool (MMAT).

RESULTS

The literature search yielded 15,738 articles, of which 50 met the inclusion criteria. Quality assessment via MMAT showed good quality in 70% of the studies. Various influencing factors were revealed on SDM in patients, physicians, consult content, and the system or organization of care.

CONCLUSIONS

Despite increased attention, implementing SDM in AAA and PAD patients remains challenging due to healthcare professionals' limited understanding of SDM. Patients seek active involvement but often feel inadequately engaged. There is a notable lack of research focusing on health care professionals and systemic influences on SDM.

Pre-distance assessment from radial artery to lower extremity arterial lesion

Endovascular treatment (EVT) for patients with lower extremity artery disease is widely used as a less invasive alternative to surgical bypass. Recently, transradial artery intervention has gained popularity owing to its minimally invasive nature. The distance from the radial artery to the target vessel is critical for success; however, effective pre-assessment methods have not yet been established. This study aimed to evaluate the usefulness of predistance measurements from the left radial artery using simple computed tomography (CT) images. In this study, distance measurements were performed from the left radial artery to the left and right iliac artery bifurcations and from the left radial artery to the common femoral artery at the upper femoral border. These distances, measured using CT images before and after the lower-extremity contrast study, were compared with the distances identified during the lower-extremity contrast study. Distances measured using simple CT images showed a high correlation with the distances identified during the lower-extremity contrast examination (r = 0.9317, p < 0.0001; from the left radial artery to the left and right iliac artery bifurcation; r = 0.9402, p < 0.0001; and from the left radial artery to the right common femoral artery at the upper femoral border). Our results suggest that pre-distance measurement using simple CT images can be a useful tool for EVT using the left radial artery approach. Although future large-scale studies are required, this technique merits consideration owing to its widespread adoption in clinical practice.

Medication adherence of patients with peripheral arterial disease to antithrombotic therapy: a systematic review

OBJECTIVES

Antithrombotic therapy (ATT) prevents atherothrombotic events (AE) in patients with peripheral arterial disease (PAD). However, the benefit may be compromised by poor medication adherence (MA). Therefore, our primary objective was the proportion of patients with PAD with poor MA in literature following patient-reported, pharmacy-reported or laboratory-reported outcome measurements. Poor MA is a combined outcome of primary non-adherence (inability to initiate a prescription), secondary non-adherence (incorrect daily intake) and non-persistence (discontinuation of daily intake).

DESIGN

Systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

PubMed, EMBASE and Cochrane Library were searched from 2000 to June 2023.

ELIGIBILITY CRITERIA

Publications with a (sub)cohort of patients with PAD that reported on patients' MA to ATT were included.

DATA EXTRACTION AND SYNTHESIS

All articles were reviewed on eligibility and methodological quality by two independent researchers. The data were retrieved and collected in Review Manager Web and the percentages were calculated per subgroup. The risk of bias was assessed by using the Cochrane risk-of-bias tool for randomised controlled trials (RCT) and the methodological index for non-randomised studies score for non-RCTs.

RESULTS

We identified 274 potential records of which 10 studies (32 628 patients) were included. Six studies were RCTs and two prospective and two retrospective studies. Most studies scored a moderate risk of bias and had heterogeneous study designs. Poor MA rates ranged between 2% and 45%. Higher rates of poor MA were found in studies with longer follow-ups, pharmacy-reported outcome measurements and registry-based cohorts.

CONCLUSION

Heterogeneous study designs create a wide dispersion in the proportions. However, poor MA to ATT was found in approximately one-third of the patients with PAD and seemed to increase with longer therapy duration, which highlights the magnitude of this societal challenge. Enhancing patients' MA to ATT might be a key element in reducing the risk of AE, and therefore, more attention to MA in clinical and research settings is warranted.

PROSPERO REGISTRATION NUMBER

CRD42023431803.

Accuracy of duplex ultrasound in peripheral artery disease: a systematic review and meta-analysis

Lower limb peripheral artery disease (PAD) is highly prevalent. Current guidelines recommend duplex ultrasound (DUS) with spectral analysis for diagnosis. This systematic review and meta-analysis assessed the diagnostic accuracy of DUS in symptomatic PAD patients. We searched electronic databases for studies comparing DUS and arteriography. Arteries were analyzed individually and grouped into segments (aorto-common femoral, femoropopliteal, below the knee, and the entire lower limb). The meta-analysis estimated sensitivity, specificity, likelihood, and diagnostic odds ratios (DOR). Fifteen studies were included, analyzing 9,067 arteries. DUS accuracy for symptomatic PAD was 0.86 (95% CI 0.81-0.90) for sensitivity and 0.95 (95% CI 0.78-0.97) for specificity. The best results were observed for the femoropopliteal segment: sensitivity 0.86 (95% CI 0.80-0.90), specificity 0.95 (95% CI 0.93-0.97). The poorest performance was observed for the below-the-knee segment: sensitivity 0.78 (95% CI 0.60-0.89), specificity 0.92 (95% CI 0.78-0.97). Most studies had high and unclear risk of bias. There is significant heterogeneity in results, with a limited number of primary studies for each arterial segment, especially for the below-the-knee segment.

Clinical Characteristics of Inpatients with Diabetic Foot Ulcer Admitted with Non-Ulcer Complaints: A Retrospective Study

Background

Diabetic foot ulcer (DFU) inpatients admitted with non-ulcer complaints constitute a neglected group that might suffer from more non-standard treatments. This study intends to describe their clinical characteristics, and clarify the problems existing in the DFU management process.

Methods

In this retrospective study, admission complaints were determined by combining the final diagnosis and clinical documentation, and were categorized as: ulcer-related or non-ulcer complaints.

Results

A total of 264 DFU inpatients were included in the final analysis, of which, 80 (30.3%) were admitted with non-ulcer complaints. A total of 82.5% of the DFU inpatients with non-ulcer complaints were admitted to departments without DF specialists. IWGDF/IDSA grade, cerebrovascular diseases, chronic kidney disease, infection in other parts, glycosylated hemoglobin A1c and the source of hospitalization expenses were the independent influencing factors for admission with non-ulcer complaints (all P < 0.05). Before admission, only 11.3% of the patients with non-ulcer complaints had ever been treated by a DF specialist and/or in a clinical setting with DF specialists. After admission, 25.0% of the DFU inpatients with non-ulcer complaints did not receive any local wound care, and only 7.6% of the patients admitted to the departments without DF specialists obtained a referral.

Conclusion

Approximately one-third of inpatients with DFU are admitted with non-ulcer complaints and most of them are admitted to departments without DF specialists. Inpatients with non-ulcer complaints have milder wounds but more severe and greater comorbidities and worse organ function. These patients do not receive standardized management for DFU either before or after admission. Targeted measures are needed to improve this situation.

Impact of Antithrombotic Therapy on Thrombotic and Bleeding Complications after Elective Endovascular Repair of Abdominal Aortic Aneurysms

PURPOSE

To investigate the influence of antithrombotic therapy on occurrence of thrombotic and bleeding complications after endovascular aneurysm repair (EVAR).

METHODS

In this retrospective single-center cohort study, patients who underwent elective endovascular aneurysm repair for abdominal aortic aneurysm were categorized into three antithrombotic groups: single antiplatelet therapy (SAPT), anticoagulants, or dual antiplatelet therapy (DAPT). Outcome measures were the incidence of major adverse cardiovascular events (MACE), prosthetic limb occlusions, and bleeding complications during follow-up.

RESULTS

Among 616 patients (SAPT: n = 450, anticoagulants: n = 84, and DAPT: n = 82), Kaplan-Meier analysis showed no significant difference (log-rank p = 0.37) in incidence of MACE between patients receiving SAPT (20.9%), anticoagulants (25.0%), and DAPT (14.6%) during a median follow-up of almost 4 years. In multivariable Cox regression analysis, only age (HR = 1.03; 95% CI 1.01-1.06, p = 0.01) and American Society of Anesthesiologists (ASA) classification (HR = 1.46; 95% CI 1.12-1.91; p = 0.01) were significant predictors for MACE. Prosthetic limb occlusion was observed in 38 patients during a median follow-up of 4 years; incidence between patients receiving SAPT (5.8%), anticoagulants (10.7%), and DAPT (3.7%) was not significantly different (log-rank p = 0.08). Age (HR = 0.96; 95% CI 0.92-1.00; p = 0.03) and use of anticoagulants (HR = 3.79, 95% CI 1.46-9.83; p < 0.01) were significant predictors for prosthetic limb occlusion. Bleeding complications occurred in 73 patients during median follow-up of almost 4 years, without significant difference (log rank p = 0.06) in incidence between patients receiving SAPT (10.7%), anticoagulants (19.0%), and DAPT (11.0%). ASA classification (HR = 1.74; 95% CI 1.23-2.46; p < 0.01) was a significant predictor for bleeding complications.

CONCLUSION

Use of anticoagulants after EVAR appears to be associated with a higher risk of prosthetic limb occlusion compared to the use of single or dual antiplatelet therapy.

Editor's Choice - Daily Remote Ischaemic Preconditioning for Intermittent Claudication: A Sham Controlled Randomised Trial

OBJECTIVE

Remote ischaemic preconditioning (RIPC) is a promising non-invasive strategy in which brief episodes of ischaemia and reperfusion can increase skeletal muscle resistance to ischaemia and improve mobility. This study aimed to determine whether 28 consecutive days of RIPC improved intermittent claudication (IC) symptoms compared with sham intervention.

METHODS

This single centre, parallel, randomised, sham controlled, double blind trial was conducted from January 2022 to April 2023 in outpatient settings. Forty two patients with stable IC Fontaine stage IIa or IIb were randomised to RIPC or sham for 28 days. The pre-specified primary outcome was a change in the maximum walking distance (MWD) after 28 days measured with a treadmill test. A > 10% change in MWD was considered clinically significant. Change in intermittent claudication distance (ICD), time to relief from claudication (TRC), and health related quality of life (HRQoL) measured with the VascuQoL-6 questionnaire were the secondary outcomes (ClinicalTrials.gov ID: NCT05084066).

RESULTS

Forty one men (RIPC = 23, sham = 18) aged 64.9 ± 7.4 years were analysed. A change of > 10% in MWD occurred in 14 patients in the RIPC group vs. eight patients in the sham group (relative risk 1.37, 95% confidence interval 0.74 - 2.25; p = .35). Changes in ICD, TRC, and HRQoL between the groups were not statistically significant.

CONCLUSION

In this trial, RIPC did not significantly improve MWD, ICD, or TRC compared with treatment with a sham device.

Pharmacomechanical thrombectomy with Angiojet in acute arterial occlusions: A prospective study among the results and outcomes

OBJECTIVE

The main objective of this present paper was to evaluate the results and outcomes of patients with acute limb ischemia (ALI) submitted to pharmacomechanical thrombectomy (PMT) endovascular surgery with Angiojet, regarding the number of cycles/pumps.

METHODS

Prospective, consecutive cohort study of ALI patients submitted to PMT endovascular intervention subdivided into two groups according to the number of cycles in the Angiojet technique: Group 1 higher than 150 cycles/second and Group 2 lesser than 150 cycles/second (cycles/s).

RESULTS

Overall, 92 patients with ALI submitted to PMT were evaluated. Two groups of patients were identified: Group 1 higher than 150 cycles/s with 60 patients and Group 2 lesser than 150 cycles/s with 32 patients. The overall mortality rate (OMR) was 15.1% (13 patients) in total cohort within the first 30 days. Group 1 had a higher OMR than Group 2 (16.1% vs 9.3%, p = 0.007). There were 4 cases of hematuria (4.3%), all of them in Group 1. We have performed a Kaplan-Meier regarding limb salvage rates: Group 1 had 85% and Group 2 had 95.7% at 1057 days. P = 0.081. Among the factors evaluated, the following were related to overall mortality rate: PMT with higher >150 cycles/s (HR = 7.17, p = 0.007, CI: 1.38-8.89), COVID-19 infection (HR = 2.75, p = 0.010, CI = 1.73-5.97), and post-operative acute kidney injury (HR = 2.97, p < 0.001, CI = 1.32-8.13). Among the factors evaluated, the following was related to limb loss: post-operative acute kidney injury (HR = 4.41, p = 0.036, CI: 1.771-7.132), probably because patients experiencing limb loss have a higher incidence of acute renal insufficiency due to higher circulating myoglobin higher hemolysis from the increased Angiojet cycles inducing rhabdomyolysis.

CONCLUSION

PMT with Angiojet is a safe and effective therapy in patients with ALI. However, patients receiving greater than 150 cycles/s were noted to have higher rates of acute kidney injury and mortality. This is likely reflective of increased thrombus burden and higher rates of hemolysis. Acute kidney injury, greater than 150 cycles/s, and COVID-19 infection were the variables with the strongest association to perioperative mortality.

Impact of open femoral endarterectomy on treating multilevel iliac and common femoral artery occlusive disease

Purpose

This study aimed to evaluate the impact of femoral endarterectomy (FE) on treating multilevel iliac and common femoral artery occlusive disease.

Materials and methods

From January 2013 to December 2022, 106 limbs in 103 patients with multilevel arterial occlusive disease underwent open FE and iliac angioplasty (FEIA) with or without infrainguinal revascularization. The primary outcome assessment was the changes in the TransAtlantic Inter-Society Consensus (TASC) II classification during the operation; the secondary outcomes included the primary patency (PP) and secondary patency (SP) of FEIA. The risk factors for PP loss were evaluated.

Results

Of the 103 patients, 91 were male. A total of 56 limbs were treated for chronic limb-threatening ischemia, and 61 limbs underwent infrainguinal revascularization. Preoperatively, aortoiliac occlusive disease (AIOD) was classified as TASC II C in 65 (61%) limbs and D in 41 limbs. During the operation, 19 limbs received additional thrombectomy for subacute or chronic thrombus components. Overall, FE and additional thrombectomy reduced the TASC II classification of AIOD from complex lesions (TASC II C/D) to simple lesions (B or lesser) in 101 (95%) of 106 limbs. Three early mortalities (2.8%, two from acute myocardial infarctions and one from pneumonia) were recorded. The PP and SP of FEIA were 89% and 96% at 1 year, 80% and 94% at 3 years, and 77% and 94% at 5 years, respectively. The severity of iliac and common femoral artery disease was not associated with PP loss of FEIA.

Conclusions

Despite the challenging nature of initially classified TASC II C/D lesions, our findings highlight the effectiveness of FE in reducing TASC II classification and the durable patency achieved with FEIA. Hybrid FEIA could be a viable primary treatment option, particularly for lesions featuring severe iliac and common femoral artery disease.

Artificial Intelligence Techniques for Prognostic and Diagnostic Assessments in Peripheral Artery Disease: A Scoping Review

Peripheral artery disease (PAD) is a major public health concern worldwide, associated with high risk of mortality and morbidity related to cardiovascular and adverse limb events. Despite significant advances in both medical and interventional therapies, PAD often remains under-diagnosed, and the prognosis of patients can be difficult to predict. Artificial intelligence (AI) has brought a wide range of opportunities to improve the management of cardiovascular diseases, from advanced imaging analysis to machine-learning (ML)-based predictive models, and medical data management using natural language processing (NLP). The aim of this review is to summarize and discuss current techniques based on AI that have been proposed for the diagnosis and the evaluation of the prognosis in patients with PAD. The review focused on clinical studies that proposed AI-methods for the detection and the classification of PAD as well as studies that used AI-models to predict outcomes of patients. Through evaluation of study design, we discuss model choices including variability in dataset inputs, model complexity, interpretability, and challenges linked to performance metrics used. In the light of the results, we discuss potential interest for clinical decision support and highlight future directions for research and clinical practice.

Atherosclerotic plaque instability in symptomatic non-significant carotid stenoses

Objective

Carotid endarterectomy for symptomatic carotid stenosis is recommended for patients with >70% stenosis, but not in those with <50%. Because non-significant, low-degree stenoses may still cause strokes, refined risk stratification is necessary, which could be improved by assessing biological features of plaque instability. To challenge risk-stratification based on luminal narrowing, we compared biological features of carotid plaques from symptomatic patients with low-degree (<50%) vs high-degree (>70%) stenosis and explored potential mechanisms behind plaque instability in low-degree stenoses.

Methods

Endarterectomy specimens were taken from symptomatic patients with high-degree (n = 204) and low-degree (n = 34) stenosis, all part of the Biobank of Karolinska Endarterectomies. Patient demographics, image-derived plaque morphology, and gene expression analyses of extracted lesions were used for comparisons. Plaque biology was assessed by transcriptomics using dimensionality reduction, differential gene expression, and gene-set enrichment analyses. Immunohistochemistry was used to study proteins corresponding to upregulated genes.

Results

The demographics of the two groups were statistically similar. Calcification, lipid-rich necrotic core, intraplaque hemorrhage, plaque burden, and fibrous cap thickness were similar in both groups, whereas the sum of lipid-rich necrotic core and intraplaque hemorrhage was higher (P = .033) in the high-degree stenosis group. Dimensionality reduction analysis indicated poor clustering separation of plaque gene expression in low-compared with high-degree stenosis lesions, whereas differential gene expression showed upregulation of hypoxia-inducible factor 3A (log2 fold change, 0.7212; P = .0003), and gene-set enrichment analyses identified pathways related to tissue hypoxia and angiogenesis in low-degree stenoses. Hypoxia-inducible factor 3-alpha protein was associated with smooth muscle cells in neo-vascularized plaque regions.

Conclusions

Plaques from symptomatic patients with non-significant low-degree carotid stenoses showed morphologic and biological features of atherosclerotic plaque instability that were comparable to plaques from patients with high-degree stenoses, emphasizing the need for improved stroke risk stratification for intervention in all patients with symptomatic carotid stenosis irrespective of luminal narrowing. An increased expression of hypoxia-inducible factor 3A in low-degree stenotic lesions suggested mechanisms of plaque instability associated with tissue hypoxia and plaque angiogenesis, but the exact role of hypoxia-inducible factor 3A in this process remains to be determined.

Clinical relevance

Carotid plaques from symptomatic patients with <50% stenosis show morphologic and biological features of plaque instability, comparable to high-degree stenosis, which emphasizes the need for improved stroke risk stratification beyond stenosis severity.

Novel Endovascular Technique for Thrombus Removal: The "Super Grab a Clot and Hold ON (Super GACHON)" Technique

We present a case of a 60-year-old man with claudication in his right foot; the patient had received stent-graft implantation for the right superficial femoral artery (SFA) 1 year ago. Computed tomography angiography suggested stent occlusion of the right SFA, and a thrombus was considered to cause occlusion. To avoid distal embolization, we performed lesion recanalization via a trans-ankle intervention. First, we performed aspiration for the lesion; however, the thrombus persisted. Second, we performed the "Super Grab a Clot and Hold ON" technique and removed several thrombi. Finally, we used drug-coated balloons as a final device for the lesion. Two years later, the right SFA was found open upon an ultrasonography.

Preoperative Neutrophil-to-Lymphocyte Ratio as a Predictor of Clinical Outcomes in Patients Undergoing Femoral Endarterectomy

Background/Objectives: This study aimed to evaluate the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) in patients with peripheral arterial disease (PAD) undergoing femoral endarterectomy. Methods: We performed a retrospective analysis of our institutional data, evaluating consecutive patients with PAD who underwent femoral endarterectomy between January 2013 and March 2023. The main objective was to assess the prognostic value of preoperative NLR for 5-year mortality. Additionally, we examined its relationship with perioperative clinicopathological features and 5-year major adverse limb events (MALEs). Results: During the study period, 200 consecutive patients underwent femoral endarterectomy. Of these, 128 patients with available NLR values within 30 days prior to surgery were analyzed. According to the receiver operating characteristic curve, the cut-off value of NLR was 4.0. Eighty-seven patients (68.0%) were assigned to the low-NLR group, and 41 patients (32.0%) to the high-NLR group. The frequency of postoperative complications did not differ significantly between the two groups. Freedom from MALEs up to five years was significantly lower in the high-NLR group (66.0% vs. 46.5%, p = 0.006). The overall survival rates were significantly lower in the high-NLR group (p < 0.001). At 1, 3, and 5 years, the survival rates in the low-NLR group were 96.4%, 91.6%, and 84.5%, respectively, while those in the high-NLR group were 84.2%, 59.5%, and 42.5%. Univariate analysis showed that cerebrovascular disease, end-stage renal disease, Rutherford category ≥ 4, a low albumin concentration (<3.5 g/dL), and a high NLR were significantly associated with 5-year mortality. Multivariate analysis indicated that a high NLR was the only independent factor associated with 5-year mortality. Conclusions: Preoperative NLR > 4.0 was significantly associated with 5-year rates of MALE and mortality in patients with symptomatic CFA occlusive disease who underwent femoral endarterectomy.

Predictive Ability of the Pedal Medial Arterial Calcification Score for Major Adverse Limb Events Among Patients with Chronic Limb-Threatening Ischemia

BACKGROUND

Pedal medial arterial calcification (pMAC) is a potential predictor of major adverse limb events (MALEs) among patients with critical limb-threatening ischemia (CLTI). This study aims to validate the prognostic value of the pMAC score in predicting major lower-limb amputation (MLLA) and need for redo revascularisation.

METHODS

A single-center study involving 196 patients diagnosed with CLTI, reviewed between 2012 and 2022. Patients' pMAC scores were obtained through X-ray assessments. Correlations between pMAC scores and the incidence of MALE and redo revascularization, were analyzed. A power analysis using G∗ Power 3 software determined a needed sample size of 157 participants. Statistical analysis employed SPSS 26, utilizing descriptive statistics, Chi Square, Mann-Whitney, Kaplan-Meier with log-rank test, and Cox regression for predictor identification.

RESULTS

The cohort was predominantly male (79.1%) and diabetic (59.2%). Redo revascularization need was 15.3%, increasing with pMAC scores: 3.3% (low), 24.5% (medium), and 50% (high) (P < 0.001). MLLA frequency also rose with pMAC scores: 6.7%, 27.5%, and 50% respectively (P < 0.001). Higher pMAC scores correlated with a higher incidence of MALE (P = 0.029). Multivariate analysis showed medium pMAC (hazard ratio (HR) 4.159, P = 0.002), high pMAC (HR 7.366, P = 0.015), and Global Limb Anatomic Staging System (GLASS) stage 3 (HR 3.529, P = 0.011) as independent MLLA predictors. Redo revascularization predictors included female sex (HR 2.106, P = 0.063), Black race (HR 64.498, P = 0.001), medium pMAC (HR 6.812, P = 0.002), high pMAC (HR 11.455, P = 0.008), and GLASS stage 3 (HR 2.899, P = 0.037).

CONCLUSIONS

The pMAC score effectively predicts MALE in CLTI patients and enhances risk stratification. Using both, pMAC scores and GLASS stages enhances predictive accuracy, identifying patients at higher risk for MLLA, informing clinical decision-making and therapeutic strategies.

Elective Surgical Repair of Popliteal Artery Aneurysms with Posterior Approach vs. Endovascular Exclusion: Early and Long Term Outcomes of Multicentre PARADE Study

OBJECTIVE

The aim of this study was compare elective surgical repair of popliteal artery aneurysms (PAAs) via a posterior approach vs. endovascular exclusion, analysing early and five year outcomes in a multicentre retrospective study.

METHODS

Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs that underwent open repair with posterior approach or endovascular repair in 37 centres was investigated. An aneurysm length of ≤ 60 mm was considered the only inclusion criterion. A total of 605 patients were included; 440 PAAs (72.7%) were treated via a posterior approach (open group) and the remaining 165 PAAs (27.3%) were treated using covered stents (endo group). Continuous data were expressed as median with interquartile range. Thirty day outcomes were assessed and compared. At follow up, primary outcomes were freedom from re-intervention, secondary patency, and amputation free survival. Secondary outcomes were survival and primary patency. Estimated five year outcomes were compared using log rank test.

RESULTS

At 30 days, no differences were found in major morbidity, mortality, graft occlusion, or re-interventions. Three patients (0.7%) in the open group experienced nerve injury. The overall median duration of follow up was 32.1 months. At five year follow up, freedom from re-intervention was higher in the open group (82.2% vs. 68.4%; p = .021). No differences were observed in secondary patency (open group 90.7% vs. endo group 85.2%; p = .25) or amputation free survival (open group 99.0% vs. endo group 98.4%; p = .73). A posterior approach was associated with better survival outcomes (84.4% vs. 79.4%; p = .050), and primary patency (79.8% vs. 63.8%; p = .012).

CONCLUSION

Early and long term outcomes following elective repair of PAAs measuring ≤ 60 mm via a posterior approach or endovascular exclusion seem comparable. Nerve injury might be a rare but potential complication for those undergoing open surgery. Endovascular repair is associated with more re-interventions.

Mid-Term Results of Popliteal-Pedal Inframalleolar Vein Bypasses in Chronic Limb-Threatening Ischemia Patients After Previous Failed Tibial Endovascular Recanalization

BACKGROUND

Inframalleolar bypass still preserves its role in the modern endovascular era. Aim of this study was to evaluate the mid-term outcomes of "short" inframalleolar vein bypasses in patients with chronic limb-threatening ischemia (CLTI) after the previously failed tibial endovascular recanalization.

METHODS

Between January 2015 and December 2021,107 CLTI patients in 3 Italian Departments of Vascular Surgery underwent "short" inframalleolar vein bypass after failed tibial endovascular recanalization. Early (30-day) and 3-year outcomes were evaluated in terms of survival, primary patency, primary assisted patency, secondary patency, and amputation-free survival. Univariate analysis of the perioperative factors affecting outcomes were performed by the means of log-rank test. The associations of procedure variables were sought based on a multivariate Cox regression analysis.

RESULTS

Distal anastomosis (inframalleolar) was mostly performed on dorsal pedis (64, 59.8%). At 30 days, bypass occlusion was recorded in 5 cases (4.6%). The mean follow-up period was 20.5 ± 17.9 months. The estimated 3-year overall survival was 66.7%. Three-year estimates of primary patency, primary assisted patency, secondary patency, and amputation-free survival were 68.5%, 70.1%, 70.2%, and 76.7%, respectively. Multivariate analysis showed a negative association of insulin treatment with primary patency (HR 4.3, P = 0.04), primary assisted patency (HR 5.1, P = 0.02), and secondary patency (HR 5.1, P = 0.02). The negative association of long-term corticosteroid use was also found with primary patency (HR 7.8, P = 0.005), primary assisted patency (HR 8.7, P = 0.003), secondary patency (HR 8.7, P = 0.003), and amputation-free survival (HR 3.9, P = 0.05).

CONCLUSIONS

Short" vein bypasses to the foot arteries in CLTI patients yielded good mid-term overall patency and limb salvage rates after a failed tibial endovascular recanalization. Insulin-dependent diabetes mellitus and long-term corticosteroid use seemed to affect the outcomes.

Impact of co-presence of malnutrition-inflammation-atherosclerosis factors on prognosis in lower extremity artery disease patients after endovascular therapy

Malnutrition and inflammation are common problems of adverse outcomes in various diseases as atherosclerosis. Recently, the concept of malnutrition-inflammation-atherosclerosis (MIA) syndrome is known to a crucial prognostic factor in patients with end-stage renal disease. We investigated the prognostic impact of the co-presence of MIA factors in patients with lower-extremity artery disease (LEAD) after endovascular therapy (EVT). This retrospective study included 284 patients with LEAD who underwent EVT. MIA factors were defined in patients with: low geriatric nutritional risk index (< 92) as "malnourished"; greater high-sensitivity C-reactive protein levels (≥ 0.1 mg/dL) as "inflamed"; a history of coronary artery revascularization, lacunar or atherothrombotic brain infarction as "atherosclerotic". We examined the relationship between baseline characteristics and major adverse cardiovascular and cerebrovascular events (MACCE) including all-cause mortality. Sixty-two patients (22%) died and 72 patients (25%) had MACCE, including all-cause death. Forty-four (16%) patients had every 3 of MIA (3-MIA) factors. The mean follow-up period was 737 days. Multivariate Cox proportional hazards regression analysis models revealed that 3-MIA factors correlated significantly with all-cause death [hazard ratio (HR) 3.46, 95% confidence interval (CI) 1.89-6.34; p < 0.001] and MACCE (HR 2.91, 95% CI 1.62-5.22; p < 0.001), after adjusting for relevant factors. Kaplan-Meier analysis revealed that the rates of all-cause death (p < 0.001) and MACCE (p < 0.001) were significantly higher when the MIA factors overlapped and are observed in patients with chronic limb-threatening ischemia. Among patients with LEAD after EVT, the co-presence of MIA factors was an independent risk factor for all-cause death and MACCE.

DIAMACC: protocol of a prospective diagnostic accuracy study of the maximal systolic acceleration to detect peripheral arterial disease in patients with diabetes-related foot ulceration in the Netherlands

INTRODUCTION

Foot ulcers are one of the most serious complications of diabetes, leading to significant risks on amputation and mortality. Peripheral arterial disease (PAD) is an important factor for the development and the outcome of diabetic foot ulcers (DFU). Although prompt and accurate detection of PAD is critical to reduce complications, its diagnosis can be challenging with currently used bedside tests (such as ankle-brachial index and toe pressure) due to medial arterial calcification. A new and promising bedside test for the detection of PAD is the maximal systolic acceleration (ACCmax), measured by duplex ultrasonography (DUS). The primary aim of this study is to assess the diagnostic performance of the ACCmax to detect PAD in patients with DFU, in comparison with commonly used bedside tests. Secondary aims include the correlation between diagnostic test accuracy and patient comorbidities. Tertiary objectives focus on collecting (follow-up) data for prognostic evaluation, such as ulcer healing, revascularisation feasibility, amputation risk, cardiovascular events and mortality.

METHODS AND ANALYSIS

A multicentre prospective diagnostic accuracy study with 198 patients will be conducted to assess the diagnostic performance of multiple index tests to detect PAD in patients with DFU, with special emphasis on ACCmax. A full lower limb arterial DUS will serve as reference test.

ETHICS AND DISSEMINATION

Study protocol approval was gained from the Medical Ethical Committee Leiden/Den Haag/Delft and registered at ClinicalTrials.gov. The findings of this study will be reported through peer-reviewed publications and (inter)national conferences.

TRIAL REGISTRATION NUMBER

NCT05646147.

Apolipoprotein and peripheral artery disease: Mendelian randomization analysis

BACKGROUND

The prevalence of peripheral arterial disease (PAD) is on the rise globally, leading to adverse clinical outcomes. Our aim was to investigate the causal relationship between apolipoprotein and PAD, as well as the potential mediating role of smoking, diabetes, hypertension, myocardial infarction, and ischemic stroke.

METHODS

We employed two-sample Mendelian randomization (TSMR) to assess the causal effect of apoB/A1 on the risk of PAD and potential mediators (smoking, diabetes mellitus, hypertension, myocardial infarction, and ischemic stroke), as well as the causal effect of those mediators on PAD. The use of multivariate MR (MVMR) allowed us to explore and quantify the mediating role of these factors in the causal association between apoB/A1 and the risk of PAD.

RESULTS

Our MR analysis showed that each standard deviation increase in apoB/A1 increased the risk of PAD by 46% (OR = 1.460, 95% CI: 1.255-1.697, P = 8.74E-07). Hypertension, myocardial infarction, and ischemic stroke were ultimately recognized as the mediators of the causal relationship between apoB/A1 and PAD, explaining 7.5%, 19.7%, and 62.5% of the causal effect, respectively, and the proportion combined of the three together was 81%.

CONCLUSIONS

These studies demonstrated that elevated apoB/A1 increases the risk of developing PAD and that this association may be mediated by hypertension, myocardial infarction, and ischemic stroke.

High on-treatment platelet reactivity in peripheral arterial disease: A systematic review

OBJECTIVES

To highlight current evidence pertaining to the measurement methods and prevalence of high on-treatment platelet reactivity (HTPR) in patients with PAD, as well as to evaluate the relationship between HTPR and recurrent adverse cardiovascular and limb events in PAD patients.

METHODS

A systematic review of English-language literature on HTPR in patients with PAD. An electronic literature search of PubMed and Medline was performed in May 2021.

RESULTS

A total of 29 studies with a total number of 11,201 patients with PAD were identified. HTPR during clopidogrel treatment ranges from 9.8 to 77%, and during aspirin treatment ranges from 4.1 to 50% of PAD patients. HTPR was associated with adverse clinical outcomes. The need for limb revascularisation was higher in patients with HTPR during clopidogrel use. Similarly, HTPR during aspirin use in the PAD population was predictive of adverse cardiovascular events (HR 3.73; 95% CI, 1.43-9.81; p = .007). A wide range of techniques were applied to measure platelet resistance, without consensus on cut-off values. Furthermore, differing patient populations, a variety of antiplatelet regimens, and differing clinical endpoints highlight the high degree of heterogeneity in the studies included in this review.

CONCLUSION

No consensus on technique or cut-off values for HTPR testing has been reached. Patients with HTPR are potentially at a greater risk of adverse limb-related and cardiovascular events than patients sensitive to antiplatelet therapy illustrating the need for clinical implementation of HTPR testing. Future research must aim for consistent methodology. Adaptation of antiplatelet therapy based on HTPR results requires further exploration.

Role of Multistate Models to Predict Patency, Limb Salvage, and Survival: New Concepts to Analyse Data in Peripheral Arterial Disease

OBJECTIVE

In peripheral arterial disease, patency, limb salvage, and survival rates are mostly reported using Kaplan-Meier analyses. When comparing different revascularisation techniques, these methods have limitations in analysing complex patient flows over time. This study aimed to present, illustrate, and discuss new concepts based on multistate models of analysing outcome parameters in peripheral arterial disease.

METHODS

Previously published data from a single centre, randomised controlled trial (RCT) with 218 cases that underwent either vein bypass surgery (bypass group, n = 109) or nitinol stent angioplasty (stent group, n = 109) of long femoropopliteal lesions were re-analysed using non-homogeneous Markov models. A step by step description of the concepts of states, state space, definitions, and illustration of transition probability curves as well as the benefits of multistate models is given. The RCT was registered at ISRCTN.com (ISRCTN18315574).

RESULTS

Transition probability curves over time showed similar patterns in the bypass and stent groups. Significant differences in the transition probabilities were found for transitions from primary patency as well as secondary patency to end of patency. The transition probability for patients with preserved primary patency at 24 months who moved to end of patency at 48 months was 19.9% in the stent group vs. 6.4% in the bypass group (p < .001).

CONCLUSION

The proposed method can answer important questions, such as: Did patients after femoropopliteal stenting with preserved primary patency at two years lose their patency more quickly within the following years compared with bypass surgery? And did stent patients after a re-intervention to maintain patency at one year lose their patency more quickly compared with bypass surgery within the following years? Completely new research questions can now be raised and answered to optimise treatment and follow up strategies; this might lead to better identification of subgroups at higher risk of clinical deterioration following revascularisation procedures.

Impact of Tourniquet Use in Major Lower Limb Amputation: A Systematic Review and Meta-analysis

OBJECTIVE

Intra-operative blood loss is a significant complication of major lower limb amputation (MLLA). This systematic review and meta-analysis assessed the effect of tourniquet use on patients undergoing amputation.

DATA SOURCES

Embase, MEDLINE, and Cochrane databases were searched from inception to April 2024.

REVIEW METHODS

Inclusion criteria were any study design assessing MLLA with and without tourniquet use. Primary outcomes were peri-operative blood loss and transfusion requirements. Secondary outcomes were operative duration, surgical site infection, stump revision, and mortality. Articles were screened and data extracted independently by two reviewers, then pooled using random effects meta-analysis, and presented with their GRADE certainty. Risk of bias was assessed using ROBINS-I and Cochrane RoB 2 tools.

RESULTS

Seven studies (one randomised controlled trial [RCT] and six cohort studies) were included, totalling 1 018 limbs (412 tourniquet, 606 non-tourniquet). Intra-operative blood loss was lower with tourniquet use (mean difference [MD] -192.09 mL; 95% confidence interval [CI] -291.67 - -92.52; p < .001); however, there was no significant difference in total blood loss measured over the first three to four post-operative days (MD -254.66 mL; 95% CI -568.12 - 58.80; p = .11). Post-operative haemoglobin drop was lower for tourniquet patients (MD -0.55 g/dL; 95% CI -0.80 - -0.31; p < .001). The odds ratio (OR) for requiring blood transfusion was 0.65 (95% CI 0.38 - 1.11; p = .11) for tourniquet vs. non-tourniquet patients, with no significant difference in the number of units transfused per patient (MD -0.35, 95% CI -0.72 - 0.03; p = .070). Operation duration was shorter with tourniquet use (MD -8.69 minutes, 95% CI -15.95 - -1.42; p = .020). There was no significant difference in rates of surgical site infection (OR 1.07, 95% CI 0.60 - 1.90; p = .82), stump revision (OR 0.71, 95% CI 0.43 - 1.16; p = .17), or death (OR 0.80, 95% CI 0.49 - 1.30; p = .36). GRADE certainty was low or very low for all outcomes.

CONCLUSION

Tourniquet use may be associated with reduced post-operative haemoglobin drop and operative duration, without negative consequences on stump infection, revision, and mortality. However, most data are observational. Further RCTs are needed to generate higher quality evidence.

Endovascular revascularization vs open surgical revascularization as the first strategy for arterial acute mesenteric ischemia: A systematic review and meta-analysis

OBJECTIVE

This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI).

METHODS

This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence.

RESULTS

A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031).

CONCLUSIONS

Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.

Catheter-Directed Arterial Thrombolysis with a Low-Dose Recombinant Tissue Plasminogen Activator Regimen for Acute Lower Limb Ischemia-Results of the First Regional Registry of Acute Limb Ischemia in Romania

Acute limb ischemia is a limb-threatening condition that is associated with a high degree of mortality and morbidity, with the latter related to acute kidney injury and rhabdomyolysis that can rapidly lead to multiple organ failure. The aim of this study was to assess the efficacy and safety of catheter-directed arterial thrombolysis in acute lower limb ischemia in the Department of Vascular Surgery, Timișoara, Romania. A total of 158 patients (114 males-72.15% and 44 females-27.85%) with symptoms of acute lower limb ischemia were admitted and treated with catheter-directed arterial thrombolysis following our protocol. The amputation-free survival rate at 1 month after the thrombolysis was 82.3%, and at 6 months it was 77.85%. The performance of additional procedures to obtain distal perfusion was predictive of an improved outcome at 30 days. The estimated survival rate at 6 months was 84.81% (SE 0.02). The mean survival time was 158.74 days. We recommend the usage of a thrombolytic regimen in patients with a life expectancy of more than 6 months, even in Rutherford stage IIb patients, if there is no major impairment in the sensorial and mobility function of the ischemic leg.

Editor's Choice - Impact of Infrapopliteal Revascularisation Establishing In Line Flow to the Wound in Patients with Chronic Limb Threatening Ischaemia

OBJECTIVE

This study aimed to determine the impact of infrapopliteal (IP) revascularisation establishing in line flow to the wound (IFW) on wound healing in chronic limb threatening ischaemia (CLTI), using a core laboratory assessment for wounds and in line flow.

METHODS

The Wound directed Angiosome RevasculaRIsation apprOach to patients with cRitical limb iSchaemia (WARRIORS) multicentre observational study enrolled patients with CLTI with tissue loss undergoing IP revascularisation in Japan, with scheduled two year follow up. The primary outcome measure was complete wound healing, defined as achievement of complete epithelialisation of all wounds without major amputation. IP revascularisation establishing IFW was defined as revascularisation after which a tibiopedal artery that actually fed an injured pedal unit was patent. The incidence of wound healing was compared between the IFW and non-IFW groups using inverse probability of treatment weighting based on the propensity score.

RESULTS

A total of 440 patients with CLTI (median age, 75 years; male, 64.1%; diabetes mellitus, 72.0%; dialysis, 57.7%) with tissue loss (Wound, Ischaemia, and foot Infection stage 4, 66.4%) who underwent IP revascularisation (endovascular procedure, n = 304; bypass grafting, n = 136) between October 2017 and June 2020 were registered. During a median follow up of 23.6 months, 51.1% achieved wound healing. Successful IP revascularisation with IFW was achieved in 68.2%. After analysis, the IFW group had a higher rate of wound healing than the non-IFW group (34.5 vs. 16.1 per 100 person years; p = .030). The association between IFW and wound healing was not statistically different between patients undergoing bypass grafting and those undergoing an endovascular procedure (p for interaction = .38). There was no statistically significant interaction effect between IFW and direct revascularisation for wound healing (p for interaction = .51).

CONCLUSION

IP revascularisation establishing IFW was statistically significantly associated with a higher wound healing rate in patients with CLTI.

Counseling Intervention and Cardiovascular Events in People With Peripheral Artery Disease: A Post Hoc Analysis of the BIP Randomized Clinical Trial

Importance

It is unclear whether counseling to promote walking reduces the risk of major adverse cardiovascular events (MACE) in people with peripheral artery disease (PAD).

Objective

To test whether a counseling intervention designed to increase walking reduced the risk of MACE in patients with PAD.

Design, Setting, and Participants

The BIP trial was a randomized clinical trial, with recruitment performed between January 2015 and July 2018 and follow-up concluded in August 2023. Participants with walking impairment due to PAD from vascular departments in the Australian cities of Brisbane, Sydney, and Townsville were randomly allocated 1:1 to the intervention or control group. Data were originally analyzed in March 2024.

Intervention

Four brief counseling sessions aimed to help patients with the challenges of increasing physical activity.

Main Outcomes and Measures

The primary outcome was the between-group difference in risk of MACE, which included myocardial infarction (MI), stroke, and cardiovascular death. The relationship between Intermittent Claudication Questionnaire (ICQ) scores, PAD Quality of Life (PADQOL) scores, and MACE was examined with Cox proportional hazard regression analyses.

Results

A total of 200 participants were included, with 102 allocated to the counseling intervention (51.0%) and 98 to the control group (49.0%).Participants were followed up for a mean (SD) duration of 3.5 (2.6) years. Median (IQR) participant age was 70 (63-76) years, and 56 of 200 participants (28.0%) were female. A total of 31 individuals had a MACE (composed of 19 MIs, 4 strokes, and 8 cardiovascular deaths). Participants allocated to the intervention were significantly less likely to have a MACE than participants in the control group (10 of 102 participants [9.8%] vs 21 of 98 [21.4%]; hazard ratio [HR], 0.43; 95% CI, 0.20-0.91; P = .03). Greater disease-specific quality of life (QOL) scores at 4 months (ICQ: HR per 1-percentage point increase, 0.97; 95% CI, 0.95-0.99; P < .001; PADQOL factor 3 [symptoms and limitations in physical functioning]: HR per 1-unit increase, 0.91; 95% CI, 0.84-0.98; P = .01) and at 12 months (ICQ: HR per 1-percentage point increase, 0.97; 95% CI, 0.95-0.99; P = .003; PADQOL factor 3: HR per 1-unit increase, 0.91; 95% CI, 0.84-0.98; P = .02) were associated with a lower risk of MACE. In analyses adjusted for ICQ or PADQOL factor 3 scores at either 4 or 12 months, allocation to the counseling intervention was no longer significantly associated with a lower risk of MACE.

Conclusions and Relevance

This post hoc exploratory analysis of the BIP randomized clinical trial suggested that the brief counseling intervention designed to increase walking may reduce the risk of MACE, possibly due to improvement in QOL.

Trial Registration

anzctr.org.au Identifier: ACTRN12614000592640.

Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest Score is a Long-Term Cardiovascular Risk Predictor After Aortoiliac Revascularization

BACKGROUND

Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) is a validated self-explanatory score applied in cardiac or noncardiac surgeries. This study aims to assess the predictive value of the MICA score for cardiovascular events after aortoiliac revascularization.

METHODS

This prospective cohort underwent elective aortoiliac revascularization between 2013 and 2021. Patients' demographic, clinical characteristics, and outcomes were registered. The patients were divided into 2 groups according to the MICA score using optimal binning. Survival analysis to test for time-dependent variables and multivariate Cox regression analysis for independent predictors were performed.

RESULTS

This study included 130 patients with a median follow-up of 55 months. Preoperative MICA score was ≥6.5 in 41 patients. MICA ≥6.5 presented a statistically significant association, with long-term occurrence of acute heart failure (HR = 1.695, 95% CI 1.208-2.379, P = 0.002), major adverse cardiovascular events (HR = 1.222, 95% CI 1.086-1.376, P < 0.001), and all-cause mortality (HR = 1.256, 95% CI 1.107-1.425, P < 0.001). Multivariable Cox regression confirmed MICA as a significant independent predictor of long-term major adverse cardiovascular events (aHR = 1.145 95% CI 1.010-1.298, P = 0.034) and all-cause mortality (aHR = 1.172 95% CI 1.026-1.339, P = 0.020).

CONCLUSIONS

The MICA score is a quick, easy-to-obtain, predictive tool in identifying patients with a higher risk of postaortoiliac revascularization cardiovascular events, such as acute heart failure, major adverse cardiovascular events, and all-cause mortality. Additional research for the validation of the MICA score in the context of aortoiliac revascularization and specific interventions is necessary.

Dual Antithrombotic Therapy versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis

OBJECTIVE

Patients with symptomatic lower extremity arterial disease (LEAD) are recommended to receive antiplatelet therapy, while direct oral anticoagulants (DOACs) are standard for stroke prevention in patients with atrial fibrillation (AF). For patients with concomitant LEAD and AF, data comparing dual antithrombotic therapy (an antiplatelet agent used in conjunction with a DOAC) vs. DOAC monotherapy are scarce. This retrospective cohort study, based on data from the Taiwan National Health Insurance Research Database, aimed to compare the efficacy and safety of these antithrombotic strategies.

METHODS

Patients with AF who underwent revascularisation for LEAD between 2012 - 2020 and received any DOAC within 30 days of discharge were included. Patients were grouped by antiplatelet agent exposure into the dual antithrombotic therapy and DOAC monotherapy groups. Inverse probability of treatment weighting was used to mitigate selection bias. Major adverse limb events (MALEs), ischaemic stroke or systemic embolism, and bleeding outcomes were compared. Patients were followed until the occurrence of any study outcome, death, or up to two years.

RESULTS

A total of 1 470 patients were identified, with 736 in the dual antithrombotic therapy group and 734 in the DOAC monotherapy group. Among them, 1 346 patients received endovascular therapy as the index revascularisation procedure and 124 underwent bypass surgery. At two years, dual antithrombotic therapy was associated with a higher risk of MALEs than DOAC monotherapy (subdistribution hazard ratio [SHR] 1.34, 95% confidence interval [CI] 1.15 - 1.56), primarily driven by increased repeat revascularisation. Dual antithrombotic therapy was also associated with a higher risk of major bleeding (SHR 1.43, 95% CI 1.05 - 1.94) and gastrointestinal bleeding (SHR 2.17, 95% CI 1.42 - 3.33) than DOAC monotherapy.

CONCLUSION

In patients with concomitant LEAD and AF who underwent peripheral revascularisation, DOAC monotherapy was associated with a lower risk of MALEs and bleeding events than dual antithrombotic therapy.

One-year limb salvage and quality of life following mechanical aspiration thrombectomy in patients with acute lower extremity ischemia

OBJECTIVE

Lower extremity acute limb ischemia (LE-ALI) is associated with high morbidity and mortality rates, and a burden on patient quality of life (QoL). There is limited medium- to long-term evidence on mechanical aspiration thrombectomy (MT) in patients with LE-ALI. The STRIDE study was designed to assess safety and efficacy of MT using the Indigo Aspiration System in patients with LE-ALI. Thirty-day primary and secondary endpoints and additional outcomes were previously published. Here, we report 365-day secondary endpoints and QoL data from STRIDE.

METHODS

STRIDE was a multicenter, prospective, single-arm, observational cohort study that enrolled 119 patients across 16 sites in the United States and Europe. Patients were treated first-line with MT using the Indigo Aspiration System (Penumbra, Inc). The study completed follow-up in October 2023. Secondary endpoints at 365 days included target limb salvage and mortality. Additionally, the VascuQoL-6 questionnaire, developed for evaluating patient-centered QoL outcomes for peripheral arterial disease, was assessed at baseline and follow-up through 365 days.

RESULTS

Seventy-three percent of patients (87/119) were available for 365-day follow-up. Mean age of these patients was 65.0 ± 13.3 years, and 44.8% were female. Baseline ischemic severity was classified as Rutherford I in 12.6%, Rutherford IIa in 51.7%, and Rutherford IIb in 35.6%. In general, baseline and disease characteristics (demographics, medical history, comorbidities, target thrombus) of these patients are similar to the enrolled cohort of 119 patients. The secondary endpoints at 365 days for target limb salvage was 88.5% (77/87) and mortality rate was 12.0% (12/100). VascuQoL-6 improved across all domains, with a median total score improvement from 12.0 (interquartile range, 9.0-15.0) at baseline to 19.0 (interquartile range, 16.0-22.0) at 365 days.

CONCLUSIONS

These 365-day results from STRIDE demonstrate that first-line MT with the Indigo Aspiration System for LE-ALI portray continued high target limb salvage rates and improved patient-reported QoL. These findings indicate Indigo as a safe and effective therapeutic option for LE-ALI.