Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication

Evaluating the between-day reliability and likelihood of change of a test battery incorporating vastus lateralis muscle thickness, ankle-brachial pressure index, maximal voluntary torque, and six-minute walk test in patients with claudication

ObjectiveThe study aims to evaluate the between-day reliability of a proposed test battery for patients with claudication that can be used for monitoring the effectiveness of exercise interventions and other therapeutic strategies tailored to this patient population.MethodsTwenty-five men with claudication were recruited. The test battery consisted of the Vastus Lateralis muscle thickness (VL-MT), ankle-brachial pressure index (ABI), unilateral isometric knee extension maximal voluntary torque (MVT) and 6-minute walk test (6MWT). A single investigator conducted the tests for each patient on two separate testing sessions (T1 and T2) 5-7 days apart.ResultsGood to excellent reliability was observed for VL-MT (ICC = 0.95, 95% LOA = ±3.10 mm, SEM = 0.81 mm), ABI (ICC = 0.97, 95% LOA = ±0.10, SEM = 0.02), MVT (ICC = 0.97, 95% LOA = ±24.0 N·m, SEM = 6.31 N·m), 6MWT distance (ICC = 0.99, 95% LOA = ±39.6 m, SEM = 11.0 m), 6MWT time to claudication (ICC = 0.99, 95% LOA = ±30.8 s, SEM = 7.8 s), and 6MWT ratings of pain (ICC = 0.87, 95% LOA = ±2.4 CR-10+, SEM = 0.7 CR-10+ ). Analysis derived from reliability data indicates a change of 1.4 mm for VL-MT, 0.14 for ABI, 12 N·m for MVT, 25 m for 6MWT distance, 15 s for 6MWT time to claudication and 1 CR-10+ for 6MWT ratings of pain is required to be interpreted as the minimum 'likely' change (76% chance).ConclusionsThe test battery provides a reliable assessment of patients with claudication and can be widely used to evaluate the effects of exercise programmes and other therapeutic interventions. For the individual, changes in VL-MT, ABI, MVT, and 6MWT greater than the minimum likely change as a result of an exercise programme or an intervention are likely changes and less influenced by error associated with the test.

Association of cognitive impairment and peripheral artery disease (PAD): A systematic review

This systematic review aimed to describe the association between peripheral artery disease (PAD) and cognitive impairment or dementia. We included studies reporting on the association between PAD (defined by ankle-brachial index ⩽ 0.9) and cognitive function in adult populations. MEDLINE, Embase, CINAHL, PsycINFO, and CENTRAL were systematically searched from inception to January 2025. Study quality was assessed using the Risk of Bias In Nonrandomized Studies of Exposure effects (ROBINS-E) tool. A narrative synthesis was undertaken structured by cognitive outcome and study design. Thirty-eight studies were included in the review (58,586 participants). The results provide evidence that PAD is associated with cognitive impairment. Seventeen (81%) cross-sectional studies and four (67%) longitudinal studies reported associations of PAD with poorer cognitive performance or increased risk of cognitive impairment. Impaired memory and processing speed were most frequently associated with PAD. PAD was also associated with increased dementia risk in cross-sectional (odds ratios = 1.50-2.41) and longitudinal studies (hazard ratios = 1.03-2.40), although proportionally fewer longitudinal studies reported significant association of PAD with dementia. Results suggest increased prevalence of cognitive impairment, independent of cardiovascular risk factors and cerebrovascular disease. Awareness of the prevalence of cognitive impairment and its potential impact on treatment adherence and engagement in a healthy lifestyle is important for clinicians treating patients with PAD. Screening for cognitive impairment in those with PAD may aid early diagnosis and management of cognitive impairment in this high-risk population. Further research is required to determine whether screening for and optimal management of PAD has cognitive benefits. (PROSPERO Registration No.: CRD42023399608).

The Role of Profunda Femoral Artery Retrograde Puncture in Complex Revascularization of Ileo-Femoral Chronic Total Occlusions

INTRODUCTION

The profunda femoral artery (PFA) puncture is generally fraught with risk of bleeding and iatrogenic damage, leading to possible impaired flow in such a valuable artery. However, the PFA represents a potential retrograde path to the common femoral artery (CFA) due to its usual good size and convenient location. Since endovascular treatment of the CFA and its bifurcation is gaining popularity, this study intends to report the use of PFA access in complex revascularizations.

MATERIALS AND METHODS

This is a retrospective multicenter registry on PFA retrograde approaches, including 15 cases in which this access was used during challenging recanalizations of iliac and femoral chronic total occlusions (CTO). This access was performed as a bailout in 11 cases (73.3%). The puncture's technical success and the diseased segments' recanalization were achieved in all cases. Hemostasis was done by intraluminal balloon inflation (9/15, 60%), external manual compression (4/15, 26.7%), or closure device deployment (2/15, 13.3%). No complications related to the access were noted.

CONCLUSION

This series represents the largest cohort of patients who underwent retrograde PFA puncture for iliac and femoral CTO crossing. It shows how different clinical and anatomical settings may suit this endovascular approach, making it a safe alternative that vascular specialists should be aware of.Clinical ImpactRetrograde puncture of the profunda femoral artery (PFA) could represent a strategic approach during complex iliac and femoral endovascular revascularizations and total endovascular femoral reconstruction. This article presents 15 cases of PFA retrograde puncture and conveys technical tips for performing this maneuver correctly and avoiding potential risks at the level of this vessel. Surgeons and interventionalists should be aware of this possibility, especially with the increasing number of total endovascular treatments of the femoral bifurcation.

Exercise oximetry in clinical practice: A single-centre perspective on procedure and techniques

In moderate lower extremity artery disease (LEAD), when tissue ischaemia due to impaired inflow occurs at exercise but not during rest, exercise oximetry may be evaluated as a part of the diagnosis process. Initially used when assessing critical limb ischaemia at rest, transcutaneous oximetry (TcpO2) has also been used in the last two decades during exercise assessment as a non-invasive method to measure oxygen pressure at the skin's surface, offering insights into loco-regional oxygen delivery-requirement mismatch. The introduction of decrease from rest of oxygen pressure (DROP) analysis in the TcpO2 technique, which corresponds to the difference between limb oxygen pressure changes and chest oxygen pressure changes from rest, provides new information about the severity of the local ischaemia during exercise. In this paper, we elucidate the utilization of TcpO2 during exercises (Ex-TcpO2) over the years and provide information about how the technique has evolved and how the changes in the testing procedures have provided the opportunity for detecting abnormalities in both vascular and non-vascular clinical practice. We discuss the importance of Ex-TcpO2 in the diagnosis of peripheral artery disease and its valuable contribution as a differential diagnostic tool for patients with co-morbid conditions such as lumbar spinal stenosis. We also provide recommendations about the utilization of Ex-TcpO2 and contribute to a better understanding of the techniques in terms of efficacy, limitations and clinical applications. However, clarifications about its role in the diagnostic algorithm are needed, to ensure a better integration of the technique in clinical practice.

Semaglutide and walking capacity in people with symptomatic peripheral artery disease and type 2 diabetes (STRIDE): a phase 3b, double-blind, randomised, placebo-controlled trial

BACKGROUND

Peripheral artery disease is a highly morbid type of atherosclerotic vascular disease involving the legs and is estimated to affect over 230 million individuals globally. Few therapies improve functional capacity and health-related quality of life in people with lower limb peripheral artery disease. We aimed to evaluate whether semaglutide improves function as measured by walking ability as well as symptoms, quality of life, and outcomes in people with peripheral artery disease and type 2 diabetes.

METHODS

STRIDE was a double-blind, randomised, placebo-controlled trial done at 112 outpatient clinical trial sites in 20 countries in North America, Asia, and Europe. Participants were aged 18 years and older, with type 2 diabetes and peripheral artery disease with intermittent claudication (Fontaine stage IIa, able to walk >200 m) and an ankle-brachial index of less than or equal to 0·90 or toe-brachial index of less than or equal to 0·70. Participants were randomly assigned (1:1) using an interactive web response system to receive subcutaneous semaglutide 1·0 mg once per week for 52 weeks or placebo. The primary endpoint was the ratio to baseline of the maximum walking distance at week 52 measured on a constant load treadmill in the full analysis set. Safety was evaluated in the safety analysis set. This trial is registered with ClinicalTrials.gov, NCT04560998 and is now completed.

FINDINGS

From Oct 1, 2020, to July 12, 2024, 1363 patients were screened for eligibility, of whom 792 were randomly assigned to semaglutide (n=396) or placebo (n=396). 195 (25%) participants were female and 597 (75%) were male. Median age was 68·0 years (IQR 61·0-73·0). The estimated median ratio to baseline in maximum walking distance at week 52 was significantly greater in the semaglutide group than the placebo group (1·21 [IQR 0·95-1·55] vs 1·08 [0·86-1·36]; estimated treatment ratio 1·13 [95% CI 1·06-1·21]; p=0·0004). Six serious adverse events in five (1%) participants in the semaglutide group and nine serious adverse events in six (2%) participants in the placebo group were possibly or probably treatment related, with the most frequent being serious gastrointestinal events (two events reports by two [1%] in the semaglutide group and five events reported by three [1%] in the placebo group). There were no treatment-related deaths.

INTERPRETATION

Semaglutide increased walking distance in patients with symptomatic peripheral artery disease and type 2 diabetes. Research implications include the need for future studies to further elucidate mechanisms of benefit and to assess the efficacy and safety in patients with peripheral artery disease who do not have type 2 diabetes.

FUNDING

Novo Nordisk.

10 Years' Experience of Endovascular Reconstruction of Aortoiliac Occlusive Lesions: HERAB Technique

BACKGROUND

Hybrid endovascular reconstruction of the aortic bifurcation (HERAB) is an alternative technique to covered endovascular reconstruction of aortic bifurcation (CERAB) developed in our tertiary center for complex (TransAtlantic Inter-Society Consensus C-D) aortoiliac occlusive disease (AIOD). The purpose of this study was to report our results at 10 years and try to identify factors influencing patency.

METHODS

From 2012 to 2023, all consecutive cases requiring endovascular aortic bifurcation reconstruction with HERAB technique for AIOD were collected at our tertiary center. Baseline data, procedural data, their 30-days complications, and overall survival were recorded. Patency and freedom from target lesion revascularisation were analyzed. Univariate analysis was performed to identify predictors of patency loss.

RESULTS

A total of 92 patients were included in the study. The AIOD was classified as TASC II D in 97% of cases, and indication for revascularisation was intermittent claudication in 63 cases (68.5%). Technical success rate was 93.5% and the 30-day mortality rate was 1.1%. Respective 5-year primary, primary assisted, and secondary patency rates were 68.8%, 80.7%, and 89.5%, with freedom from target lesion revascularisation rate of 83.7%. The collateral network patent before the surgery was preserved in 97% of cases. Only the use of a LifeStream stent for iliac kissing stent was associated with the loss of patency. In the case of patency loss, clinical presentation was the same as the onset event in 52% of cases. Overall, the limb salvage rate was 98%.

CONCLUSION

HERAB represents a safe and effective long-term alternative to CERAB. This procedure offers an advantage of preserving the collateral network, allowing the use of low-profile devices, and less expensive procedure.

A systematic review supporting the Society for Vascular Surgery guideline update on the management of intermittent claudication

OBJECTIVE

This systematic review and meta-analysis evaluates the current evidence on the management of intermittent claudication (IC), a prevalent manifestation of peripheral arterial disease (PAD).

METHODS

We conducted comprehensive searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. We addressed six questions developed by a guideline committee from the Society for Vascular Surgery, addressing pharmacological treatments, exercise regimens, endovascular interventions, and predictors of major adverse cardiovascular, limb-related events, and mortality.

RESULTS

The search resulted in 5333 citations, from which we included 73 studies (46 randomized trials). In patients with PAD and IC who had one or more high-risk comorbidities, low-dose rivaroxaban and aspirin were associated with lower risk of major adverse limb events and major adverse cardiovascular events than aspirin alone. In patients who have undergone surgical or endovascular interventions for PAD, the addition of low-dose rivaroxaban to aspirin may improve limb outcomes. Of note, rivaroxaban trials excluded patients at high risk of bleeding. Single antiplatelet agents showed no significant efficacy differences head-to-head in ambulatory patients with IC and had a lower bleeding risk compared with combination therapy or anticoagulation. Home exercise programs were feasible and may be an alternative to supervised exercise in ambulatory patients with IC and in those who had revascularization. Several comorbidities increased the risk of adverse outcomes after revascularization for IC, such as advanced age, diabetes, coronary artery disease, chronic obstructive pulmonary disease, previous interventions, congestive heart failure, infrapopliteal artery involvement, and longer lesion lengths. In patients with IC undergoing endovascular intervention for superficial femoral artery disease, plain balloon angioplasty was associated with worse outcomes than drug elution or stent implantation for intermediate or longer lesions (ie, >5 cm).

CONCLUSIONS

This systematic review summarizes the current evidence base for the management of IC, offering insights into the relative benefits and risks of various therapeutic strategies. The findings underscore the need for individualized patient care, considering both the potential benefits and risks associated with different interventions.

Patterns and Timings of Recurrence After Fluoropolymer-Coated Drug-Eluting Stent Use for Femoropopliteal Artery Diseases - Results of the PLANET Study

BACKGROUND

Fluoropolymer-coated drug-eluting stents (FP-DESs) are widely used to treat femoropopliteal artery (FPA) disease. However, data on the pattern and timing of recurrence after FP-DES implantation are limited. This study aimed to address this knowledge gap.

METHODS AND RESULTS

This multicenter retrospective study analyzed 439 limbs of 398 patients treated with FP-DESs for de novo FPA lesions. The outcome measures were clinical outcomes in cases of recurrence, defined as a composite of restenosis and reocclusion. The timing of recurrence was categorized into early (within 1 year of treatment) and late (after 1 year). The factors associated with recurrence were analyzed by comparing cases of early and late recurrence. The early recurrence group showed a significantly higher frequency of reocclusion, particularly stent thrombosis. In addition, in this group, patients with reocclusion tended to exhibit significantly more severe clinical symptoms than those with restenosis. Deployment of FP-DES beyond the P1 segment was independently associated with early recurrence. Chronic total occlusion was independently associated with early reocclusion. Female sex, diabetes, not using statins, and long lesions were independently associated with late recurrence. Not using statins, warfarin use, and long lesions were independent predictive factors for late reocclusion.

CONCLUSIONS

The patterns and clinical symptoms of recurrence after FP-DES implantation for FPA differed according to the timing of recurrence, as did the factors associated with recurrence.

One-Year Results of Endovascular Treatment of Long Femoropopliteal Lesions With Viabahn® Stent Graft

PURPOSE

The performance of self-expanding stent graft (Gore® Viabahn®) in femoropopliteal interventions has been proven through trials with long lesions. However, there are limited data on the incorporation of additional edge-protection to reduce focal edge stenosis. The aim of this study was to assess the clinical safety and efficiency of Viabahn® stent graft incorporating additional edge-protection in the treatment of long femoropopliteal lesions [TransAtlantic Inter-Society Consensus (TASC) C/D] in patients with symptomatic peripheral arterial disease.

METHODS

This is 2 centers, retrospective, observational, single-arm study. Patients with symptomatic (Rutherford category 2-6) de novo and restenosis TASC C/D lesions of the femoropopliteal segment were treated with Viabahn® stent graft. Additional edge-protection bare metal stent (BMS), drug-coated balloon (DCB), or drug-eluting stent (DES) were allowed at the proximal and distal edges of the Viabahn® stent graft. The primary endpoint was the primary patency.

RESULTS

Between October 2019 and October 2022, 188 symptomatic patients with 198 limbs were treated (TASC D=68, 34%). The mean lesion length was 256±118 mm, and 88% were total occlusion. Additional BMS, DCB, or DES were used at Viabahn® edges in 24%, 16%, and 13% of cases, respectively. The mean follow-up was 12 months. The primary patency rate at 12 months was 70.8%. A significantly lower rate of primary patency was reported in the Viabahn® + BMS group (54.3%) compared to Viabahn® group (76.5%), Viabahn® + DCB group (81.4%), and Viabahn® + DES group (72.5%; p=0.01). The primary sustained clinical improvement rate was 85%. The Rutherford category assessment was significantly improved at last follow-up compared to baseline (p<0.0001). There were 2 cases of acute ischemia.

CONCLUSION

The use of Viabahn® stent graft in long lesions (TASC C/D) with drug-coated devices as additional edge-protection seems to improve the results in the treatment of long and complex femoropopliteal lesions. These results reinforce the need for randomized clinical trials to assess the value of self-expanding stent graft for long femoropopliteal lesions.Clinical ImpactThis study evaluates the clinical impact of the performance of a self-expanding stent graft (Gore® Viabahn®) in femoropopliteal lesions and demonstrates its safety and efficacy in the treatment of long and complex lesions. The results indicate that the combination of the Viabahn® with paclitaxel-eluting devices on its proximal and distal edges increases clinical improvement and decreases the incidence of restenosis. Overall, this study highlights the benefit of active therapy in the Viabahn® edges and supports its increased use in clinical practice to optimise long-term outcomes in long and complex femoropopliteal lesions.

Sex Disparities in Medical Management: Influence on Morbidity in Peripheral Arterial Disease

BACKGROUND

Peripheral artery disease (PAD) has traditionally been identified as a male-dominant disease; however, current literature suggests that female patients may be at increased risk of adverse outcomes. Given the key differences between sexes, we conducted a retrospective review to identify presurgery risk predictors that may increase morbidity within the female PAD population.

METHODS

Data were extracted from the Vascular Quality Initiative database for patients who underwent suprainguinal or infrainguinal bypass surgery for PAD between 2009 and 2020. Binary logistic regression was used to assess for sex differences in risk predictors, drug administration characteristics, and postoperative outcomes; analysis was adjusted for potential covariates.

RESULTS

A total of 79,981 patients were included based on our eligibility criteria, 34% of which were female. Female patients typically presented at an older age, were more frequently hypertensive and diabetic, and were significantly less likely to be prescribed angiotensin-converting enzyme inhibitors, anticoagulants, and statin preoperatively. Women had a significantly higher postoperative risk of all-cause morbidity (1.06 [1.03, 1.09];P = 0.004), mortality (1.09 [1.05, 1.13];P < 0.001), stroke (1.48 [1.35, 1.62];P < 0.001), and major adverse cardiovascular events (1.19 [1.10, 1.28];P < 0.001) when compared to male patients. No preoperative statin use was a significantly greater predictor for all-cause morbidity in women.

CONCLUSION

Following surgery for PAD, our results suggest that female patients have a significantly greater risk of adverse outcomes as compared to male patients. Reduced administration of key medication including statin and angiotensin-converting enzyme inhibitors along with a greater comorbidity burden in female patients may be major contributors to this greater morbidity risk.

Mid-term outcomes of Shockwave intravascular lithotripsy in the IVLIAC Registry for the treatment of calcified iliac occlusive disease

OBJECTIVE

The aim of this study was to evaluate safety and efficacy of intravascular lithotripsy (IVL) treatment in calcified iliac arteries and explore a new approach to determining whether to stent or not to stent calcific iliac vessels.

METHODS

All consecutive patients who underwent IVL (Shockwave Medical) for calcified iliac arteries from February 2021 to May 2024 at four centers were included. Indication for IVL was Rutherford category ≥3 in iliac lesions with moderate-to-severe calcification and was based on a new algorithm: IVL as stand-alone therapy ± provisional stenting in case of stenosis, or IVL as vessel preparation for planned stenting in cases of chronic total occlusion. The primary endpoint was primary patency; assisted primary patency, secondary patency, and freedom from iliac complications were also analyzed. Clinical and procedural data were compared between two groups: IVL stand-alone therapy (IVL ONLY) vs IVL with adjunctive stenting (IVL + STENT). Indication for IVL ONLY was based on adjunctive completion assessments (extravascular ultrasound and translesional gradient pressure). A Cox regression univariate analysis between cases with or without target lesion revascularization was performed.

RESULTS

In total, 100 iliac arteries were treated in 86 patients (52 male; mean age, 74 ± 9 years). Median follow-up was 20 months (range, 1-45 months). Critical limb ischemia was present in 55% of the patients, the majority of whom (75%) had severe calcifications (180°-360°). The mean target lesion length was 40.95 ± 29.25 mm with a mean stenosis of 84% ± 10% (12 chronic total occlusions). Technical success was 99%. The target lesions were treated with IVL ONLY in 77% of cases, whereas IVL + STENT was employed in the remaining 23% of the cases (provisional stenting, 11%; planned stenting, 12%). Mean residual stenosis was 14.95% ± 14% at final angiogram. Extravascular ultrasound with improved imaging (bi-triphasic in place of monophasic/blunted ipsilateral common femoral artery waveform), and/or decreased translesional gradient pressure (mean, -71%) were detected in all IVL ONLY cases. Primary patency and assisted primary patency at 24 months were 95% (95% confidence interval, 85.1%-98.1%) and 98% (95% confidence interval, 92%-99.5%), respectively, whereas secondary patency was 100%. Primary patency showed no statistically significant difference (P = 24) between the IVL ONLY and IVL + STENT groups. There was one iliac rupture and no distal embolization. Longer target lesions (P = 24) were significantly related to target lesion revascularization.

CONCLUSIONS

IVL is a safe and effective treatment option for calcific iliac occlusive disease. This multicenter experience shows promising mid-term results in terms of primary patency despite the very low stenting rate, preserving future treatment options. Further studies are needed to confirm these findings.

Dual Antiplatelet Therapy After Iliac Artery Stenting Improves Limb Salvage and Freedom from Major Adverse Limb Events Compared to Single Antiplatelet Therapy

BACKGROUND

Antiplatelet therapy is recommended by the Society for Vascular Surgery guidelines for patients following peripheral arterial intervention. However, there are no guidelines regarding the role of dual antiplatelet therapy (DAPT) following iliac interventions. The goal of this study was to assess whether there was clinical benefit to DAPT compared to single antiplatelet therapy following isolated iliac stenting.

METHODS

A retrospective study was conducted utilizing patients from the Vascular Quality Initiative database who underwent isolated iliac stenting from 2010 to 2022. Patients were separated into 4 cohorts based upon antiplatelet therapy at discharge: no APT, aspirin, clopidogrel, and DAPT. Those on DAPT or anticoagulation prior to the procedure were excluded. Univariable Kaplan-Meier and multivariable Cox regression analyses at 1 year postprocedure were conducted to evaluate overall survival, amputation-free survival, and major adverse limb event (MALE)-free survival.

RESULTS

A total of 1,375 (6.0%) patients were discharged on no APT, 6,045 (26.6%) on aspirin, 3,076 (13.5%) on clopidogrel, and 12,243 (53.8%) on DAPT. Patients discharged on any medication had improved 1-year survival (95.5% DAPT, 94.0% ASA, 94.8% clopidogrel, 82.5% no APT; P < 0.001), amputation-free survival (90.5% DAPT, 87.3% ASA, 89.1% clopidogrel, 73.4% no APT; P < 0.001), and MALE-free survival (87.3% DAPT, 84.0% ASA, 85.1% clopidogrel, 70.1% no APT; P < 0.001). DAPT had improved protection over aspirin with decreased risk of amputation (hazard ratio: 0.78, confidence interval: 0.69-0.87, P < 0.001) and risk of MALE (hazard ratio: 0.79, confidence interval: 0.71-0.87, P < 0.001). Hematoma rate was equivocal between all 4 cohorts within 30 days of the index procedure (3.05% no APT, 2.93% aspirin, 2.44% clopidogrel, 3.10% DAPT; P = 0.271).

CONCLUSION

Antiplatelet therapy following isolated iliac stenting for PAD may be associated with increased survival, limb salvage, and freedom from MALE. DAPT over aspirin may be further associated with improved outcomes.

Can Common Femoral Artery Doppler Waveform Analysis Reliably Predict Hemodynamically Significant Disease of the Aortoiliac Arteries? A Systematic Review and Meta-Analysis

BACKGROUND

Many guidelines recommend duplex scanning as the first-line investigation for peripheral arterial disease. Qualitative evaluation of the common femoral artery (CFA) waveform provides information regarding the likely presence of significant aortoiliac disease. Certain centers use a "triphasic-and-down" policy, proceeding directly to antegrade endovascular intervention of infra-inguinal disease if the CFA waveform is triphasic. Others mandate cross-sectional imaging regardless of CFA waveform to exclude occult aortoiliac disease. This review aims to analyze the reliability of CFA waveform in excluding significant aortoiliac disease.

METHODS

MEDLINE, Embase, Cochrane library, and reference lists were searched for studies comparing CFA waveform analysis with reference tests assessing aortoiliac disease. Triphasic waveforms were considered "normal", while biphasic/monophasic were considered "abnormal." Meta-analyses using a bivariate model produced pooled diagnostic accuracy metrics, including negative and positive predictive values, sensitivity, and specificity.

RESULTS

Eight studies with 1,139 limbs were included. Where reported, the mean age was 67, 64.4% had claudication and 35.6% had critical limb ischemia, 42.3% were smokers, and 33.3% were diabetic. Reference investigations were catheter or cross-sectional angiography(n = 5), aortoiliac duplex(n = 2), and intra-arterial pressures(n = 1). The pooled negative predictive value was 84.7% (95% confidence interval [CI]: 59.3%-97.0%), meaning a triphasic waveform correctly excludes significant aortoiliac disease 84.7% of the time, and positive predictive value was 71.3% (95% CI: 36.1%-93.1%). Sensitivity was 0.86 (95% CI: 0.78-0.92), indicating 14% of patients with significant aortoiliac disease had triphasic waveforms, and specificity was 0.78 (95% CI: 0.61-0.89).

CONCLUSION

The best data available suggests Doppler waveform analysis lacks precision in identifying and excluding significant aortoiliac disease compared to heterogenous reference tests. A low threshold for cross-sectional imaging before antegrade endovascular intervention may be appropriate.

Planning of lipid-lowering treatment in atherosclerotic vascular disease. Consensus SEC/SEA/SEEN/SEMFYC/SEMERGEN/SEMG/SEN/SEACV/S.E.N

In recent years we have been experiencing an advance in lipid-lowering therapies, with the appearance of new drugs that act on the different metabolic pathways, reducing both the levels of cholesterol associated with low-density lipoproteins (LDL-C) containing apoproteinB (ApoB), and vascular risk. However, the results in achieving goals are still scarce, as well as the use of the different therapies that help us to achieve them. Among the reasons that justify this situation are: the inadequate identification of vascular risk, the underuse of therapies, poor adherence to the recommended treatment, the lack of organization in terms of the assignment of roles and algorithms of action in the follow-up of patients and the need for improved education and psychosocial interventions that influence both adherence and consolidation of Healthy lifestyle habits. This consensus document aims to improve the approach and follow-up of dyslipidemia in a comprehensive way, defining the planning of lipid-lowering therapies as a control strategy (SEC/SEA/SEEN/SEMFYC/SEMERGEN/SEMG/SEN/SEACV/S.E.N.).

Support of Home-Based Structured Walking Training and Prediction of the 6-Minute Walk Test Distance in Patients With Peripheral Arterial Disease Based on Telehealth Data: Prospective Cohort Study

Background

Telehealth has been effective in managing cardiovascular diseases like stroke and heart failure and has shown promising results in managing patients with peripheral arterial disease. However, more work is needed to fully understand the effect of telehealth-based predictive modeling on the physical fitness of patients with peripheral arterial disease.

Objective

For this work, data from the Keep Pace study were analyzed in depth to gain insights on temporal developments of patients' conditions and to develop models to predict the patients' total walking distance at the study end. This could help to determine patients who are likely to benefit from the telehealth program and to continuously provide estimations to the patients as a motivating factor.

Methods

This work analyzes continuous patient-reported telehealth data, in combination with in-clinic data from 19 Fontaine stage II patients with peripheral arterial disease who underwent a 12-week telehealth-based walking program. This analysis granted insights into the increase of the total walking distance of the 6-minute walk tests (6MWT) as a measure for physical fitness, the steady decrease in the patients' pain, and the positive correlation between well-being and the total walking distance measured by the 6MWT.

Results

This work analyzed trends of and correlations between continuous patient-generated data. Findings of this study include a significant decrease of the patients' pain sensation over time (P=.006), a low but highly significant correlation between pain sensation and steps taken on the same day (r=-0.11; P<.001) and the walking distance of the independently performed 6MWTs (r=-0.39; P<.001). Despite the reported pain, adherence to the 6MWT measurement protocol was high (85.53%). Additionally, patients significantly improved their timed-up-and-go test times during the study (P=.002). Predicting the total walking distance at the study end measured by the 6MWT worked well at study baseline (root mean squared error of 30 meters; 7.04% of the mean total walking distance at the study end of 425 meters) and continuously improved by adding further telehealth data. Future work should validate these findings in a larger cohort and in a prospective setting based on a clinical outcome.

Conclusions

We conclude that the prototypical trend estimation has great potential for an integration in the telehealth system to be used in future work to provide tailored patient-specific advice based on these predictions. Continuous data from the telehealth system grant a deeper insight and a better understanding of the patients' status concerning well-being and level of pain as well as their current physical fitness level and the progress toward reaching set goals.

Long Term Outcomes of Non-operative Treatment for Popliteal Artery Entrapment Syndrome: A Multicentre Study

OBJECTIVE

Surgical decompression is generally recommended for popliteal artery entrapment syndrome (PAES); however, many young patients are reluctant to undergo surgery. Additionally, there is no consensus on the management of asymptomatic or mildly symptomatic cases. This multicentre study investigated the prognosis of non-operated limbs with PAES and analysed outcomes in limbs undergoing delayed surgical intervention in order to refine management strategies.

METHODS

Patients diagnosed with PAES and treated in three hospitals between January 1994 and October 2022 were included. Medical records and imaging data were reviewed retrospectively. Symptoms were classified into Rutherford categories, and the anatomical abnormality was classified after image review. Data analysis was performed using R software.

RESULTS

Among 96 limbs diagnosed with PAES, 64 underwent surgery, while 32 received conservative treatment. There were no statistically significant differences in demographics or ankle brachial index between the surgery and no surgery groups; however, smoking and alcohol consumption rates were statistically significantly higher in the surgery group. Additionally, Rutherford classification and extent of arterial occlusion were statistically significantly more severe in the surgery group compared with the no surgery group (p < .001 and p = .015, respectively). Of the 32 limbs treated conservatively, 30 remained stable (94%), and two limbs (6%) underwent delayed surgery during a mean follow up of 68.9 months. None experienced severe complications of amputation, death, or distal embolism.

CONCLUSION

Patients with PAES with no or mild symptoms who are reluctant to undergo surgery can be safely managed with regular follow up and conservative treatment. Monitoring symptoms through outpatient visits and imaging enables effective management. Surgical intervention can be safely performed if symptoms worsen over time.

Lifetime risk of lower extremity peripheral arterial disease: a Danish nationwide longitudinal study

BACKGROUND AND AIMS

Lower extremity peripheral arterial disease (PAD) presents a substantial disease burden, yet lifetime estimates remain scant. This nationwide study quantified the lifetime risk of PAD and its clinical outcomes in Denmark.

METHODS

This cohort study included 4 275 631 individuals in Denmark aged 40-99 years between 1998 and 2018. We estimated the lifetime risk using a modified survival analysis method, considering death as a competing risk event.

RESULTS

Over a median 15.5-year follow-up, 151 846 individuals were diagnosed with PAD (median age at diagnosis 71.5 years, interquartile range 63.1-79.2). The overall lifetime risk of PAD from age 40 was 11.6% (95% confidence interval 11.6%-11.7%), decreasing from 12.9% in 1998-2002 to 10.7% in 2013-18. Males had a higher lifetime risk than females (12.8% vs. 10.5%). Socioeconomic disparities were evident, with higher risks for those with lower educational levels (risk difference 3.4%, 95% confidence interval 3.2%-3.6%) and lower income (risk difference 0.4%, 95% confidence interval 0.2%-0.5%). One year after PAD diagnosis, 21.4% had undergone lower limb revascularization, 8.0% had experienced a major amputation, and 16.2% had died. At 5 years, the corresponding proportions were 26.4%, 10.8%, and 40.8%, respectively. The risk of lower limb revascularization showed little variation by sex and socioeconomic status, whereas there was a strong socioeconomic gradient for major amputation and all-cause death.

CONCLUSIONS

More than one in 10 Danish individuals are diagnosed with symptomatic PAD during their lifetime. Peripheral arterial disease diagnosis is associated with high morbidity and mortality at 1 and 5 years.

Lipidomic insights on abdominal aortic aneurysm and peripheral arterial disease

Abdominal aortic aneurysm (AAA) and peripheral arterial disease (PAD) are two cardiovascular diseases associated with considerable morbidity, mortality and quality of life impairment. As they are multifactorial diseases, several factors contribute to their pathogenesis, including oxidative stress and lipid peroxidation, and these may have key roles in the development of these pathologies. Alterations of the lipid metabolism and lipid profile have been reported in cardiovascular diseases but to a lesser extent in AAA and PAD. Modifications in the profile of some molecular lipid species, in particular, native phospholipid and triglyceride species were mainly reported for AAA, while alterations in the fatty acid profile were noticed in the case of PAD. Oxidized phospholipids were also reported for AAA. Although AAA and PAD have a common atherosclerotic root, lipidomics demonstrates the existence of distinct lipid. Lipidomic research regarding AAA and PAD is still scarce and should be set in motion to increase the knowledge on the lipid changes that occur in these diseases, contributing not only to the discovery of new biomarkers for diagnosis and prognosis assessment but also to tailor precision medicine in the clinical field.

Benefits of Duplex Ultrasound Surveillance of Infrainguinal Bypass Grafts and Institutional Costs of Graft Failure: A Retrospective Single-Center Study

BACKGROUND

The Achilles' heel of infrainguinal bypass grafts (IIBGs) is restenosis. Duplex ultrasound (DUS) surveillance is commonly undertaken to identify restenosis allowing intervention for graft salvage. We report the impact of DUS surveillance on patient outcomes alongside healthcare-associated costs.

METHODS

Consecutive patients undergoing IIBG at our institution were included (January 2017-December 2020). Data on DUS surveillance (1-, 6-, and 12-month scans) were collated. Primary outcome was lower limb salvage rates at 2 years. Graft failure was defined by radiological evidence of significant graft stenosis ("at risk") or occlusion (with or without symptoms). Institutional costs for treatment associated with at-risk grafts were quantified. Follow-up was 100% complete at 2 years.

RESULTS

Briefly, 254 patients had IIBG (196 men, median age 70 years). Of those, 192 patients (76%) entered DUS surveillance, and 109 (43%) completed it. In patients who completed surveillance (versus incomplete versus none) major lower limb amputation rates were 6.4% (vs. 12% and vs. 30%, P = 0.174 and P < 0.001, respectively). Enrolling in DUS surveillance was associated with improved limb salvage and survival rates compared to having no surveillance at all (Log rank P < 0.001). Managing graft failure led to 372 additional cross-sectional imaging studies, 302 outpatient reviews, 1,538 hospital admission days and 226 open and endovascular reinterventions, with a total additional National Health Service cost of £ 1,436,085/€1,683,912. Enrollment into a surveillance program was associated with higher costs.

CONCLUSION

Enrolling in DUS surveillance following IIBG is associated with improved outcomes. Graft failure and its subsequent management confer additional costs. DUS surveillance is costly, but may be justified by improved limb-salvage rates and the associated reduction in amputation-associated costs.

Clinical improvement after arterial revascularization is associated with exercise oximetry results

Introduction: Exercise transcutaneous oximetry (Ex-TcpO2) is used to support the vascular origin of lower-limb pain, or to assess walking impairment. The aim of this study was to describe the association between Ex-TcpO2 measurement and the perioperative clinical and morphological outcomes after revascularization in patients with intermittent claudication (IC). Methods: From January to December 2022, a single-center prospective observational study was conducted among patients with IC. Patients were referred by vascular surgeons for Ex-TcpO2 for doubtful arterial origin. Perioperative clinical and morphological outcomes were assessed by the Rutherford-Becker classification and duplex ultrasound examination. The primary patency rate and primary sustained clinical improvement were evaluated at 1 month after revascularization. Results: Eighty-two patients (64% men) underwent Ex-TcpO2 and were enrolled in the study, of whom 65% were category III of the Rutherford classification. Indications for Ex-TcpO2 were to assess the origin of the IC symptoms in 65%. Sixty-seven (81%) patients had positive Ex-TcpO2, and 15 (18%) had negative Ex-TcpO2. Patients with positive Ex-TcpO2 were older (65 ± 13 vs 58 ± 20, p = 0.43), and had a significantly lower ankle-brachial index (ABI) compared to the negative group (0.65 ± 0.22 vs 0.92 ± 0.22, p < 0.001) as well as a lower maximum walking distance (MWD) (200 m [150, 300] vs 525 m [500, 872], p < 0.001). Forty-two patients underwent revascularization (Ex-TcpO2 positive [n = 35/67]; Ex-TcpO2 negative [n = 7/15]). Revascularization technical success and primary patency rate were 100% in both groups. Clinical improvement was significantly greater in the Ex-TcpO2 positive group (97% [n = 34/35] vs 0% [n = 0/7], p < 0.001). Multivariate analysis shows a positive association between pain at the buttock and the decrease from rest of oxygen pressure (DROP) ≤ -15 mmHg at the level of the buttock with the presence of iliac lesions. Conclusion: On a routine basis, Ex-TcpO2 is a tool of interest to assess patients with claudication for doubtful arterial origin or walking distance, especially in proximal IC, and to predict favorable clinical outcomes after revascularization.

Quantitative correlation between carotid or lower limb atherosclerosis and coronary heart disease: a retrospective observational study

Background

Early diagnosis and intervention are key for the treatment of coronary heart disease (CHD). Ultrasound is used to assess risk stratification in patients with coronary artery disease. However, few studies quantify the relationship between carotid or lower limb atherosclerosis and coronary revascularization. The purpose of this study is to demonstrate that the semi-quantitative degree of atherosclerosis in the neck or lower extremity vessels can predict the need for coronary revascularization, thereby establishing a predictive model for coronary revascularization based on peripheral vascular disease.

Methods

Patients who underwent coronary angiography and peripheral vascular ultrasound were randomly selected for semi-quantitative analysis of the degree of coronary artery and peripheral vascular stenosis. Data from 306 patients were collected.

Results

The semiquantitative score, grade score and lower limb score from vascular ultrasound were positively correlated with the Gensini score of coronary artery lesions. The semi-quantitative score (score = 2) predicted the sensitivity and specificity for coronary revascularization at 83.74% and 61.72%, respectively. The graded score (score = 2) predicted the sensitivity and specificity for coronary revascularization at 77.24% and 72.13%, respectively. The lower extremity score (score = 3) predicted the sensitivity and specificity for coronary revascularization at 90.24% and 54.55%, respectively.

Conclusions

Carotid semiquantitative scores, grade scores, and lower limb scores are predictive factors for the need for coronary revascularization and can serve as auxiliary examinations for the early diagnosis of coronary artery disease.

Differences in Pharmacokinetic and Histopathological Effects of Five Drug-Coated Balloons: An Experimental Study in Rabbit

BACKGROUND

The optimal design concept and the safety of drug-coated balloons (DCBs) have not been completely determined yet. Also, the optimal approach for DCB-based revascularization of peripheral artery diseases still remains undefined. This study was designed to explore the in vivo pharmacokinetic and histopathological effects of DCBs using Ranger and 4 Chinese DCBs after implantation and administration in New Zealand rabbits.

MATERIALS AND METHODS

Fifty New Zealand rabbits were divided into 5 groups with 10 rabbits in each group according to the DCB used: Ranger (Boston Scientific), Orchid (Acotec), Reewarm (Endovastec), Ultrafree (Zylox), and Yaohang (Polyrey). After being guided to the lower segment of the abdominal aorta, the DCB was inflated for 3 minutes. Plasma, inflated infrarenal aorta, vastus lateralis muscle, anterior tibial muscle, and right toes were harvested for histological and paclitaxel concentration analyses 4 hours or 28 days after the angioplasty.

RESULTS

At 4 hours after aortic angioplasty, the overall paclitaxel concentrations in aortic wall were not statistically different (p = 0.050), but the paclitaxel concentrations in vastus lateralis muscle (p = 0.002), anterior tibial muscle (p = 0.006) and toe (p < 0.001) were not totally same according to the results of Kruskal-Wallis test. In toe, concentrations of paclitaxel were significantly lower for the Ranger (120.8 ng/g) DCB than for the Orchid (1880 ng/g; p = 0.008), Reewarm (347 ng/g; p = 0.016), and Ultrafree (261 ng/g; p = 0.016) DCBs. Concentrations of paclitaxel in the toe were not statistically different between Ranger and Yaohang DCBs (p = 0.421). Neointimal area (p < 0.001), neointimal thickness (p < 0.001), and percentage of luminal stenosis (p < 0.001) were less for Ranger DCB than for other DCBs 28 days after aortic angioplasty. The differences in paclitaxel concentrations in tissues 28 days after aortic angioplasty were not statistically significant.

CONCLUSION

Different design concepts will make a difference in the in vivo pharmacokinetic and histopathological effects of DCBs. The Ranger DCB can achieve similar drug delivery efficiency as other higher-dose DCBs and fewer neointimal hyperplasia. Although clinical implications remain to be further investigated, the present results may provide implications for the design and use of DCBs.Clinical ImpactThe current preclinical study suggested that different design concepts would make a difference in the pharmacokinetic and histopathological effects of drug-coated balloons (DCBs). Though Ranger DCB had the lowest paclitaxel loading in this study, it still achieved similar drug delivery efficiency with other higher-dose DCBs. Also, neointimal hyperplasia was less for the Ranger DCB than for the other DCBs 28 days after aortic angioplasty. Although clinical implications remain to be further investigated, the present results may provide implications for the design and use of DCBs.

Comparative Analysis of Three Year Results of Two Paclitaxel Related Stents for the Management of Femoropopliteal Disease in a Real World Setting

OBJECTIVE

Randomised clinical trials have demonstrated superiority of the Eluvia stent over Zilver PTX for femoropopliteal artery disease in terms of one and two year clinical outcomes, but comparative real world data beyond two years are not available. This study aimed to compare Zilver PTX and Eluvia stents and to report three year primary patency, patient outcomes, and safety results from the REALDES study.

METHODS

The REALDES study was a prospective, multicentre, observational study that enrolled adult patients with symptomatic femoropopliteal disease scheduled for treatment with either Zilver PTX or Eluvia. The study included patients with native femoropopliteal artery disease treated with Zilver PTX (n = 96 limbs) or Eluvia (n = 104 limbs). The primary outcome was three year primary patency, and secondary outcomes included freedom from clinically driven target lesion revascularisation (TLR) and Tosaka classification.

RESULTS

The baseline characteristics were comparable between the Zilver PTX and Eluvia groups, apart for greater lesion lengths in the Zilver PTX group. At three years, the primary patency rates were 70.0% for Zilver PTX and 65.2% for Eluvia, with no statistically significant difference (p = .74). Furthermore, there were no statistically significant differences between the two stents at one and two years. Freedom from TLR rates were 79.4% for Zilver PTX and 76.3% for Eluvia, with no statistically significant difference (p = .27). The incidence of Tosaka class III was 7.3% in the Zilver PTX group and 14.4% in the Eluvia group at three years (p = .10). Among patients with re-stenosis, the incidence of in stent occlusion was statistically significantly higher with Eluvia (57.7%) than with Zilver PTX (29.2%) (p = .041). No baseline characteristics were associated with the three year re-stenosis risk.

CONCLUSION

The Zilver PTX and Eluvia stents demonstrated comparable primary patency and freedom from clinically driven TLR after three years in real world femoropopliteal artery interventions. In routine clinical practice, Eluvia should be used judiciously in backgrounds with a high risk of re-stenosis.

Diagnostic Test Accuracy of Pedal Acceleration Time to Identify Peripheral Artery Disease

OBJECTIVE

Pedal acceleration time (PAT) is a novel method of using diagnostic ultrasound to evaluate the haemodynamic characteristics of pedal arteries and has potential as an adjunctive vascular testing method. The primary objective of this study was to assess the diagnostic accuracy of PAT in identifying peripheral artery disease (PAD) in a population with clinically suspected PAD.

METHODS

This was a multicentre cross sectional study to estimate the diagnostic test accuracy. Participants with clinically suspected PAD were recruited via consecutive sampling at four centres. Colour duplex ultrasound (reference standard) and toe brachial index (TBI) were measured by a vascular sonographer. A second vascular sonographer, blinded to all other measures, conducted the PAT measurements on the same limb. PAD was defined as a > 50% stenosis in any vessel from the distal aorta to the foot. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were estimated for all PAT values. Receiver operating characteristic curves were also generated.

RESULTS

One hundred and eighty-eight participants (227 limbs) were recruited, with a mean age of 71 years (standard deviation 10, range 43 - 93) with 56 women (29.8%) including 133 (70.7) limbs having PAD (59%) and 61 (32.4%) claudicants. Area under the curve for PAT: lateral plantar artery 0.72 (0.65 - 0.79), medial plantar artery 0.72 (0.65 - 0.79), dorsal metatarsal artery 0.77 (0.70 - 0.84), arcuate artery 0.71 (0.64 - 0.78), and deep plantar artery 0.73 (0.67 - 0.80). Utilising the worst case PAT measure for the limb for identifying PAD had an AUC of 0.79 (0.74 - 0.85) and positive and negative predictive values of 0.81 (0.57 - 0.89) and 0.66 (0.57 - 0.75), respectively. Area under the curve for the toe brachial index was 0.78 (0.71 - 0.85) and that of ankle brachial index was 0.70 (0.62 - 0.77).

CONCLUSION

PAT had an acceptable diagnostic test accuracy as an assessment tool to identify PAD in a population with clinically suspected PAD. All five measures yielded similar accuracy to toe pressure and TBI; however, using the worst case PAT value yielded the highest diagnostic test accuracy of all PAT measures. The PAT diagnostic threshold for the presence of PAD may be revised to > 85 ms to optimise the performance of the test for the identification of PAD.

Multicomponent interventions designed to support adherence to guideline-recommended therapy in patients with peripheral artery disease: A scoping review

Adherence to guideline-recommended therapies for peripheral artery disease (PAD), including pharmacotherapy (antiplatelet, lipid-lowering, and antihypertensive agents) and lifestyle modifications (smoking cessation, diet, weight management, and physical activity) remains low. Though single-component interventions targeting smoking cessation, exercise, or medication adherence show some efficacy, comprehensive multicomponent interventions are vital for addressing the complexity of PAD management. This review systematically synthesized multicomponent interventions for patients with PAD. A systematic search was conducted in Embase, MEDLINE, Cochrane Library, APA PsycINFO, CINAHL, Web of Science Core Collection, ProQuest, and Google Scholar to identify primary research describing multicomponent interventions supporting PAD treatment adherence, published between 2007 and 2024. A narrative synthesis was reported using the Template for Intervention Description and Replication (TIDieR) checklist and the behavioral change techniques (BCT) taxonomy. Out of 15 studies (2462 patients, 60.4% men) included in this review, only two addressed all guideline-recommended treatment aspects. Key intervention components included structured exercise (12/15) and education programs (10/15). Most interventions were delivered by multidisciplinary teams in hospital settings over 3 months. Only one study employed behavioral theory in its development, and most interventions (13/15) focused on the BCT 'instructions on how to perform a behavior' rather than diverse BCTs. No interventions significantly increased adherence to all PAD therapies. Few studies measured the intervention's impact on adherence, making it difficult to determine effective intervention characteristics. Most interventions lacked behavioral science approaches and were not designed to address specific adherence determinants. Future interventions should incorporate these elements to effectively address patients' needs. Open Science Framework Registry ID: osf.io/7xqzj.

Prognostic Value of Toe Pressure Measurements in Patients with Diabetic Foot Ulcers and Medial Arterial Calcification

BACKGROUND

Diabetic foot ulcers (DFUs) are one of the most serious chronic diabetes-related complications. Since medial arterial calcification (MAC) can be present in patients with a DFU, toe pressure (TP) measurements are advised to grade potential ischemia. However, the value of TP to predict clinical outcomes in this group of patients is poorly understood. Therefore, the primary aim of this study was to investigate the relationship between TP values and ulcer healing in patients with DFU and concomitant MAC.

METHODS

A single-center retrospective cohort study was conducted. Patients were included if they were 18 years or older, presented with a DFU, had a TP measurement and concomitant MAC in the same limb. MAC was defined as an ankle-brachial index (ABI) above 1.30, or incompressible arteries during ABI measurement. Multistate models were fitted to analyze the outcomes of interest (ulcer healing, revascularization, amputation, and mortality).

RESULTS

In total, 148 patients were included. During the 180 days follow-up, the cumulative incidence of a healed ulcer was 34% (95% confidence interval [CI]: 27-42%), whereas 32% (95% CI: 26-41%) of patients had a persisting open wound. An approximately positive linear correlation was observed between TP values and the probability of ulcer healing, regardless of whether patients had undergone a revascularization procedure. However, the absolute healing rate was low, and no clear distinction could be made for intermediate TP values (between 30 and 80 mm Hg).

CONCLUSION

Lower TP values are correlated with nonhealing of a DFU in patients with MAC, but clear absolute differences in healing are only seen between very low (below 30 mm Hg) and high (above 80 mm Hg) measurements. For intermediate TP values, the predictive strength of ulcer healing is weak. This should be of particular importance when grading ischemia in this subgroup of patients in wound classification systems.

Transitions of frailty after lower extremity interventions for chronic limb-threatening ischemia

BACKGROUND

Frailty is common among surgical patients and predicts poor surgical outcomes. This study aimed to analyze transitions in frailty state among patients undergoing lower extremity care for chronic limb-threatening ischemia (CLTI).

METHODS

Between 2018 and 2022, all patients undergoing a primary intervention for CLTI (endovascular intervention [EV], bypass [BYP], major amputation [AMP]) or wound care were analyzed. Frailty was assessed by Vascular Quality Initiative-derived Risk Analysis Index. Frailty was defined as a Vascular Quality Initiative-derived Risk Analysis Index score of ≥35. Transition in frailty state between preoperative and follow-up measurement at 1 month and 1 year were analyzed. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis. Amputation-free survival (survival without AMP) and freedom from major adverse limb events (above-ankle amputation of the index limb or major re-intervention (new BYP graft, jump/interposition graft revision) were evaluated.

RESULTS

We included 1859 patients (56% male; mean age, 65 ± 11 years) who underwent either EV (52%), a BYP (29%), AMP (13%), or wound care (6%). Amon them, 25% were considered frail on initial evaluation (28%, 16%, 32%, and 30% EV, BYP, AMP, and wound care, respectively). At 30 days, overall frailty increased to 34%: 13% of patients moved from nonfrail to frail (9%, 18%, 22%, and 5% for EV, BYP, AMP, and wound care, respectively), and 4% of patients moved from frail to nonfrail (6%, 2%, 1%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, overall frailty increased to 40%: an additional 13% of patients shifted from nonfrail to frail (15%, 6%, 23%, and 8% for EV, BYP, AMP, and wound care, respectively), and 5% of patients shifted from frail to nonfrail (4%, 8%, 2%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, frailty increased by 28% in EV, 16% for BYP, 32% in AMP, and 43% in wound care. Frailty at baseline, 30 days, and 1 year was associated with a high Charlson's Comorbidity Index. Shifting to a frail state postoperatively was associated with decreased survival and a lower amputation-free survival at 1 year.

CONCLUSIONS

After major interventions for CLTI at 1 year, 27% of patients shift from a nonfrail to a frail state, and 9% of patients shift from a frail to a nonfrail state with differences across modalities in comparison to wound care, where 13% of patients moved from a nonfrail to a frail state, and none shifted from a frail to a nonfrail state. Shifting to a frail state after intervention is associated with poor outcomes and should be considered when evaluating and intervention in a patient with CLTI.

Rate and Predictors of Disease Progression in Patients with Conservatively Managed Intermittent Claudication: A Systematic Review

BACKGROUND

Intermittent claudication (IC) is a common pathology, affecting 4.5% of the United Kingdom population, and is associated with significant health burden if disease progresses to chronic limb-threatening ischemia (CLTI). The natural history of conservatively managed IC remains poorly described, and this study aimed to examine the rate and predictors of progression from IC to CLTI.

METHODS

Systematic review (PROSPERO ID: CRD42023401259) in accordance with Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines of available literature using Scopus, World of Science, Medline, Embase, and CINAHL databases. Adult patients with IC managed conservatively were included. Progression rate was defined as percentage of IC patients developing CLTI at follow-up. Predictors identified from univariate and multivariate analyses were included. A quantitative synthesis was planned if studies depicted homogeneity.

RESULTS

Search terms yielded 6,404 unique reports. Nine studies (7 retrospective and 2 prospective cohorts) on a total of 4,115 patients were included in the primary synthesis. Women constituted 22.7% on average (0-30.1%) of patients included within studies. All included studies were nonrandomized cohort designs with expected limitations in terms of determining causal effect. The risk of bias was assessed as "moderate" in 5, and "serious" in 4 of the 9 included studies. 1.1-36.7% of claudicants from studies included developed CLTI by end of follow-up (mean 5.4 ± 2.72 years). A pooled progression rate of 15.26% at maximal (10 years) follow-up did not reach significance (P = 0.67) in meta-analysis and is likely unreliable, demonstrating 99% heterogeneity (P < 0.01). Predictors of progression were advanced age, diabetes, hemodialysis, smoking, serum low-density lipoprotein, HbA1c, and baseline severity of ischemia (Ankle-brachial index, Toe-brachial index and claudication distance) in univariate analysis. Diabetes, smoking and hemodialysis were predictors of progression in multivariate analysis. Only three studies investigating biomarkers of peripheral arterial disease (PAD) progression were found.

CONCLUSIONS

Diabetes, renal failure, and smoking are significant predictors of PAD progression. Poor quality evidence and data heterogeneity preclude conclusive estimates of progression rates. Women are underrepresented among studies. Future structured, prospective prognostic studies addressing the progression of conservatively managed IC are needed to inform personalized management strategies.

Streamlined Clinical Management Pathways May Reduce Major Amputations in Patients with Chronic Limb Threatening Ischaemia: A Prospective Cohort Study with Historical Controls

OBJECTIVE

Patient characteristics and patterns of disease in chronic limb threatening ischaemia (CLTI) have markedly changed in recent years. Urgent specialist referral and timely revascularisation are recommended in international guidelines. UK guidelines now recommend revascularisation within five days of referral for inpatients and two weeks in outpatients. This study compared the contemporary one year major amputation incidence in patients with CLTI with a historical cohort at a single UK centre.

METHODS

This was a single centre, observational cohort study with historical controls. A prospective cohort was recruited between May 2019 and March 2022. A historical cohort presenting between 2013 and 2015 inclusive was retrospectively identified. Significant changes in management pathways, including establishing a rapid access limb salvage clinic, occurred between these periods, aiming to expedite time from referral to revascularisation. The one year primary outcome was major amputation, and the secondary outcome was death. Major amputation was analysed by Fine-Gray competing risks models (death as the competing risk), presented as subdistribution hazard ratios (SHRs). One year mortality was analysed by Cox regression, presented as hazard ratios. Analyses were adjusted for propensity score.

RESULTS

A total of 928 patients were included (432 prospective and 496 historical). Proportions of patients presenting with tissue loss (72.2% vs. 71.6%; p = .090) were similar in both cohorts. At one year, 48 patients (11.1%) in the prospective cohort and 124 patients (25.0%) in the historical cohort had undergone a major amputation (p < .001). Risk of major amputation was 57.0% lower in the prospective cohort compared with the historical cohort after adjustment for propensity score (SHR 0.43, 95% confidence interval 0.29 - 0.63; p < .001).

CONCLUSION

An encouraging reduction in major amputation incidence was observed after improvements to CLTI management pathways, but residual confounding is likely. The generalisability of these results is uncertain.

Fundamentals of wound care for amputation prevention

The initial skin breakdown and subsequent healing processes are complex and influenced by various parameters, including systemic factors, infectious bioburden, and perfusion. Vascular wounds comprise inadequate inflow (due to peripheral artery disease), microvascular damage (result of diabetes mellitus), or vasoconstriction. Normal healing of acute wounds occurs in a sequence of defined stages; however, if a dysregulated inflammatory state ensues, it is classified as chronic. Both chronic and vascular wounds carry an increased risk of amputation. Therefore, holistic wound care is crucial in preventing limb loss. This review outlines a systematic approach to wound assessment and examines the latest recommendations for managing vascular wounds, focusing on strategies for preventing amputations.

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.

Editor's Choice - Results of SurVeil Versus IN.PACT Admiral Paclitaxel Coated Balloons in Femoropopliteal Arteries: 24 Month Outcomes of the Randomised TRANSCEND Study

OBJECTIVE

The aim of the TRANSCEND study was to compare the safety and efficacy of the next generation SurVeil PCB with the IN.PACT Admiral PCB in patients with femoropopliteal arterial disease. SurVeil is a lower dose PCB (2.0 μg/mm2vs. 3.5 μg/mm2 for IN.PACT Admiral) with a uniform microcrystalline coating intending to enhance durability and maximise drug delivery.

METHODS

TRANSCEND is a prospective, single blind, randomised controlled, multicentre, non-inferiority clinical study. Patients with femoropopliteal artery disease in Rutherford stages 2 - 4 were randomised 1:1 to the SurVeil or the IN.PACT Admiral PCB. A sample size of 446 patients was calculated to prove non-inferiority of the SurVeil compared with the IN.PACT Admiral PCB for primary safety and efficacy endpoints at twelve months. Primary safety was defined as a composite of freedom from device and procedure related death through 30 days, and freedom from major target limb amputation and clinically driven (CD) target vessel revascularisation at twelve months. Primary efficacy was defined as primary patency at twelve months as a composite of freedom from binary re-stenosis and freedom from CD target lesion revascularisation. Secondary outcomes were reported up to twenty four months.

RESULTS

A total of 446 subjects were randomised, 222 to the SurVeil and 224 to the IN.PACT Admiral PCB. Primary safety was 91.8% for the SurVeil vs. 89.8% for the IN.PACT Admiral PCB (pnon-inferiority < .001), and primary efficacy was 82.2% vs. 85.9% (pnon-inferiority = .003). Primary patency through twenty four months was 65.4% with the SurVeil and 66.9% with the IN.PACT Admiral PCB (pnon-inferiority = .005).

CONCLUSION

The next generation low dose SurVeil PCB demonstrated excellent safety and efficacy up to twenty four months and was non-inferior to the IN.PACT Admiral PCB. (ClinicalTrials registration ID: NCT03241459).

Nutritional habits in patients with peripheral arterial disease: Adherence to the mediterranean diet

INTRODUCTION

Adherence to the Mediterranean diet (Dietmed) exerts protective effects on cardiovascular disease (CVD). In the Lower Extremity Peripheral Arterial Disease (PAD) there are fewer studies that analyze these data.

OBJECTIVE

To determine adherence to Dietmed and dietary habits in patients with PAD, according to a history of CVD (coronary and/or cerebral ischaemic pathology) and according to the ankle-brachial index (ABI ≥ or <0,5).

MATERIAL AND METHODS

Cross-sectional analytical study carried out in a tertiary hospital. The sample was collected consecutively. Sociodemographic and clinical history, ankle-brachial index (ABI) and a 14-point Dietmed adherence dietary questionnaire were included. The analysis of categorical variables was carried out using the Pearson's Chi-Square test, the T-Student's statistic test for independent samples was used for parametric variables and the U. Mann-Whitney test for non-parametric variables.

RESULTS

Of the 97 patients, 87,6% had low adherence to Dietmed, with no differences according to the severity of PAD. However, when we analysed the data according to whether or not they had a history of CVD, we observed a high adherence to some items included in Dietmed, specifically, in the CVD group, the consumption of lean meat (95,5% vs 64%; P=.004). In addition, we observed a significant difference in the consumption in the group without a history of CVD (32% vs 9,1%; P=.033).

CONCLUSION

In our population, patients with PAD, regardless of the stage of the disease and whether they had associated coronary or cerebral ischaemic pathology, had low adherence to Dietmed. Therefore, it is important to implement nutritional education programmes in patients with PAD in all stages, as well as in those patients who have already suffered a vascular event, so that they maintain adherence to healthy dietary habits in the long term.

Misdiagnosis of Acute Limb Ischemia from Non-Vascular Specialists Results in a Delayed Presentation and Negatively Affects Patients' Outcomes

BACKGROUND/OBJECTIVES

Acute Limb Ischemia (ALI) is a vascular emergency which is accompanied by a significant risk of limb loss or even death. Rapid restoration of arterial perfusion using surgical and/or endovascular techniques is crucial for limb salvage. Undeniably, an accurate and prompt diagnosis is the first step to improve patient prognosis. The typical clinical presentation is not always present and the variety of symptoms may result in non-vascular specialists missing the diagnosis.

METHODS

In this single-center retrospective descriptive study, we reviewed all patients hospitalized between January 2018 and January 2024 for ALI. Patients who were initially misdiagnosed, causing a delayed diagnosis > 24 h, and who therefore did not receive timely treatment, were identified. Moreover, patients with a timely diagnosis of ALI who were treated in our institution during the same time period were collected.

RESULTS

Among 280 ALI patients, 14 were initially misdiagnosed. The median time from initial symptoms to definite diagnosis was 38.8 days (range 1.5-365). Several specialties such as orthopedic surgeons, neurologists, and general practitioners were involved in patients' initial assessment. Three patients underwent primary amputation due to irreversible ALI, while nine underwent revascularization and one conservative treatment. Thirty-day limb salvage rate was 9/14 and thirty-day mortality was observed in one patient. Secondary interventions were needed in 65% of these cases. Patients with a delayed ALI diagnosis, when compared to those with a timely diagnosis, presented a significantly lower limb salvage rate (65% vs. 89%, p-value = 0.02) and a significantly higher rate of reinterventions (65% vs. 18%, p-value < 0.001).

CONCLUSIONS

Many patients with ALI are primarily referred to non-vascular specialties. Misdiagnosed and mistreated ALI negatively affects outcomes.

Practices of low value or unnecessary practices in vascular prevention

BACKGROUND

Low-value practices are avoidable interventions that provide no health benefits. The objective of this study was to conduct a narrative review of the recommendations for practices of low value-care in vascular prevention.

METHODS

A narrative review of all low value-care recommendations for vascular prevention published in the main European and North American scientific societies for clinical practice guidelines between 2014 and 2024 was carried out.

RESULTS

A total of 38 clinical practice guidelines and consensus documents from international organizations in the United States, Canada, the United Kingdom, and Europe were reviewed, 28 of which included between 1 and 20 recommendations on practices of low value-care in vascular prevention. The total number of recommendations was 141. The American Heart Association is the society that offers the largest number of recommendations of low value-care, with 39 recommendations (27.7%) in 5 clinical practice guidelines (13.2% of the total guidelines with recommendations). The guideline for the management of arterial hypertension of the European Society of Hypertension is the guideline that concentrates the largest number of recommendations of low value-care in a single guideline, with 20 recommendations (14.2% of the total guidelines with recommendations).

CONCLUSIONS

There are more and more guidelines that explicitly describe diagnostic or pharmacological activities of low value-care or Do Not Do Class III or recommendation D. Some guidelines agree, but others show clear discrepancies, which can illustrate the uncertainty of the scientific evidence and the differences in its interpretation.

Effect of arm-ergometry versus treadmill supervised exercise on health-related quality of life and mental health in patients with peripheral artery disease: secondary outcomes from the ARMEX trial

BACKGROUND

Peripheral artery disease (PAD) negatively affects walking performance, health-related quality of life (HRQoL) and mental health. Exercise training is recommended as a first-line treatment for PAD, with potential impact on all these outcomes, but the optimal program design is not completely ascertained. The aim of this study was to compare arm-ergometry (AEx) and treadmill supervised exercise training (TEx) on HRQoL and mental health in patients with PAD.

METHODS

This was an ancillary study of the ARMEX trial, a single-center, single-blinded, parallel group, randomized clinical trial, enrolling symptomatic PAD patients referred to a cardiovascular rehabilitation program (CRP). Participants were randomized (1:1) to a 12-week AEx or TEx, along with the core components of a CRP (nutritional and psychological support). Participants completed the short form 36 Health Survey and the Hospital Anxiety and Depression scale before and after the intervention. Differences between groups in the change from baseline to the end of the study were analyzed using ANCOVA, adjusted for baseline values, or the Mann-Whitney U test.

RESULTS

Fifty-six patients (66 ± 8.4 years; 87.5% male) were included: AEx (n = 28) and TEx (n = 28). Physical functioning, role-physical, bodily-pain, general health, mental health and physical component summary (PCS) significantly improved in AEx group. In the TEx group, physical functioning, role-physical, bodily-pain, vitality, social functioning, role-emotional and PCS significantly improved. Role-physical and role-emotional improved more in TEx, with no between-group differences in the other domains. Changes in PCS were significantly associated with changes in walking distances. Hospital Anxiety and Depression scale scores improved in both groups, without between-group differences. This improvement was associated with self-reported walking distance.

CONCLUSION

Both exercise protocols improved HRQoL and mental health in patients with symptomatic PAD, highlighting exercise-based programs as important treatment strategies for this population.

TRIAL REGISTRATION NUMBER

ISRCTN54908548 (retrospectively registered).

Long-Term Results of Treatment of Aortoiliac Occlusive Disease With the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique: A UK Multicenter Study

OBJECTIVE

This updated UK multicenter study aims to report long-term results following use of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD) in patients with chronic limb-threatening ischemia (CLTI) or intermittent claudication (IC).

METHODS

A retrospective analysis was conducted including 85 patients who underwent CERAB between November 1, 2012, and March 31, 2020, till March 2024. Anatomical data were assessed using pre-operative imaging. Outcome measures included freedom from target lesion reintervention (fTLR), freedom from major limb amputation (fMLA), and overall survival.

RESULTS

The median age was 65 years, with 62.4% males. Over a median follow-up of 58.2 months (IQR 55.7-67.1 months), 2 patients were lost to follow-up. There were 16 deaths (18.8%) and 2 major amputations (2.4%) in the entire study period. Target lesion reintervention was required in 14 patients (16.5%) at the last follow-up. The Kaplan-Meier fTLR at 1, 3, and 5 years was 89.2%, 83.0%, and 83.0%, respectively. fMLA at 1, 3, and 5 years was 98% at all intervals, and survival rates at 1, 3, and 5 years were 94.1%, 89.4%, and 80.1%, respectively. Subintimal iliac access was associated with worse fTLR (HR 4.33 (95% CI 1.30-14.37, p=0.017)), which remained significant when adjusted to patient and anatomical characteristics (HR 5.88 (95% CI 1.02-33.95, p=0.047)). There was no significant association between fTLR and the need for common femoral endarterectomy (HR 3.57 (95% CI 0.42-30.5, p=0.244)] or external iliac artery stenting (HR 0.47 (95% CI 0.07-3.05, p=0.427)) during the index procedure.

CONCLUSION

The long-term outcomes of CERAB for treating AIOD demonstrate its viability as a durable revascularization option, with acceptable morbidity, mortality, and patency rates. Factors reflecting more complex lesions are associated with poorer outcomes. Findings support the need for randomized controlled trials on CERAB and a focus on the pre- and intra-operative decision-making based on the complexity of TASC C and D lesions.

CLINICAL IMPACT

The findings of this study reinforce the long-term durability of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD), demonstrating favourable reintervention and limb salvage rates. These results support CERAB as a viable alternative to open surgery, particularly in patients with complex anatomies or significant comorbidities. This data enables clinicians to make more informed decisions regarding patient selection and procedural strategies, such as minimising the use of subintimal iliac access to improve long-term outcomes. The study underscores the need for further randomised trials to establish CERAB's role in evidence-based clinical guidelines for AIOD management.

A Diagnostic Comparison Study between Maximal Systolic Acceleration and Acceleration Time to Detect Peripheral Arterial Disease

BACKGROUND

Detecting peripheral arterial disease (PAD) can be particularly challenging in patients with diabetes mellitus (DM) or chronic kidney disease (CKD) due to medial arterial calcification (MAC). Current bedside tests, such as the ankle-brachial index, are less accurate in these patient groups. The primary aim of this study is to evaluate the diagnostic accuracy of point-of-care duplex ultrasound parameters maximal systolic acceleration (ACCmax) and acceleration time (AT) to detect PAD, including a comparison of both metrics.

METHODS

Patients suspected of having PAD, who underwent point-of-care duplex ultrasound measurements (ACCmax and AT) of the posterior tibial artery (PTA) and/or anterior tibial artery (ATA) at ankle level along with computed tomography angiography were eligible for inclusion. PAD was defined as a stenosis >50% on computed tomography angiography. Diagnostic accuracy of AT was evaluated at calculated (Youden index) and prespecified cut-off values (121 ms), using the sensitivity, specificity, positive likelihood ratio, negative likelihood ratios, and area under the curve. The McNemar test compared ACCmax with AT at prespecified and calculated cut-off values. Subgroup analyses of patients prone to MAC (i.e., those with DM and/or CKD) were also performed.

RESULTS

This study included 184 patients (267 legs) with a high prevalence of DM (53%) and CKD (36%). The diagnostic accuracy of AT to identify PAD for PTA showed a sensitivity of 84%, specificity of 98%, positive likelihood ratio of 42.00, negative likelihood ratio of 0.16 and area under the curve of 0.96. Regarding the ATA, the results were 81%, 93%, 11.57, 0.20, and 0.92, respectively. Statistical comparisons favored ACCmax over AT in detecting PAD at prespecified and calculated cut-off values for both the PTA and ATA (P < 0.001). Additionally, in patients prone to MAC, ACCmax also outperformed AT in detecting PAD (P values ranging from <0.001 to 0.039). For patients without PAD, no significant differences were observed in the ability to rule out the disease.

CONCLUSIONS

ACCmax proved to be more accurate than AT in detecting PAD, also in patients prone to MAC. While no significant difference was found between ACCmax and AT in their diagnostic accuracy to exclude PAD, ACCmax should be favored in the diagnostic work-up in patients suspected of PAD due to its superior ability to detect an arterial stenosis.

Evaluation of balloon and self-expandable stents for common femoral artery stenosis

BACKGROUND

Endovascular treatment of the common femoral artery (CFA) and its bifurcation is currently recommended for patients with hostile groin (prior femoral bifurcation open surgery, history of radiotherapy) or severe comorbidities (advanced age, frailty, obesity). Preliminary results have shown favorable outcomes. Among the different endovascular techniques (atherectomy, intravascular lithotripsy, plain balloon angioplasty, drug-coated balloon angioplasty, stenting), stents are mainly used but the best type of stent to use is still debated. The aim of this study was to assess the value of balloon-expandable stents (BES) and self-expandable stents (SES) for stenosis of the femoral bifurcation.

METHODS

Consecutive patients with stenosis of the CFA and its bifurcation were included from 2016 to 2022. Demographic data, the type of stent used, procedural data, and angiographic variables were collected. Groups were defined according to the type of stent implanted. Primary patency was defined as a binary end point based on a duplex ultrasound peak systolic velocity ratio of ≤2.4 as assessed by duplex ultrasound examination, in the absence of clinically driven target lesion revascularization (TLR) or bypass of the target lesion. Secondary outcomes were clinical sustained improvement, freedom from TLR at 12 months, mean ankle-brachial index improvement, primary-assisted patency, and secondary patency.

RESULTS

A total of 90 procedures conducted in 77 patients were included in this study, 26 in the SES group and 64 in the BES group. The most common symptomatology according to the Rutherford classification was class 2, 3, and 4 (28%, 48%, and 8%, respectively). The type of lesions in the CFA, assessed using the Azema classification, were comparable between both groups (SES/BES group type 2: 31%/27%; type 3: 54%/62%). At 12 months, the primary patency rates for SES and BES were 88% (26/26 patients) and 72% (58/64 patients) (P = .10). At 12 months, freedom from TLR rates for SES and BES were 97% vs 81%, respectively (P = .13).

CONCLUSIONS

SES for CFA stenosis show a trend toward better patency and freedom from TLR rates at 12 months. However, controlled studies are warranted to further investigate the significance of this trend.

Editor's Choice - Role of Antiplatelet Therapy in Patients Managed for Complex Aortic Aneurysms using Fenestrated or Branched Endovascular Repair

OBJECTIVE

Despite the increasing number of fenestrated and branched endovascular aortic repair (F/B-EVAR) procedures, evidence on post-operative antiplatelet therapy is very limited. This study aimed to investigate the role of single antiplatelet therapy (SAPT) vs. double antiplatelet therapy (DAPT) after F/B-EVAR in 30 day and follow up outcomes.

METHODS

A multicentre retrospective analysis was conducted, including F/B-EVAR patients managed from 1 January 2018 to 31 December 2022. Comparative outcomes were assessed according to post-operative antiplatelet therapy. The cohort was divided into the SAPT group (acetylsalicylic acid [ASA] or clopidogrel) and DAPT group (ASA and clopidogrel). The duration of SAPT or DAPT was one to six months. Primary outcomes were 30 day death, and cardiovascular ischaemic and major haemorrhagic events. Secondary outcomes were survival and target vessel (TV) patency during follow up.

RESULTS

A total of 1 430 patients were included: 955 under SAPT and 475 under DAPT. The 30 day mortality rate was similar (SAPT 2.1% vs. DAPT 1.5%; p = .42). Cardiovascular ischaemic events were lower in the DAPT group (SAPT 11.9% vs. DAPT 8.2%; p = .040), with DAPT being an independent protector for acute mesenteric (p = .009) and lower limb ischaemia (p = .020). No difference was found in 30 day major haemorrhagic events (SAPT 7.5% vs. DAPT 6.3%; p = .40). The mean follow up was 21.8 ± 2.9 months. Cox regression showed no survival confounders, with similar rates between groups (log rank p = .71). DAPT patients enjoyed higher TV patency (SAPT 93.4%, standard error [SE] 0.7% vs. DAPT 97.0%, SE 0.6%; log rank p = .007) at thirty six months. Cox regression revealed B-EVAR as a predictor of worse TV patency (hazard ratio 2.03, 95% confidence interval 1.36 - 3.03; p < .001). DAPT was related to higher patency within B-EVAR patients (SAPT 87.2%, SE 2.1% vs. DAPT 94.9%, SE 1.9%; p < .001).

CONCLUSION

DAPT after F/B-EVAR was associated with lower risk of cardiovascular ischaemic events and higher TV patency, especially in B-EVAR cases. No difference in major haemorrhagic events was observed at 30 days.