2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Advancements in Noncontrast Ultrasound Imaging for Low-Velocity Flow: A Technical Review and Clinical Applications in Vascular Medicine

Visualizing the arterial tree using ultrasound, from the aorta to the small vessels, has significantly improved over time due to advances in ultrasound imaging technology. Initially limited to exploring the major vessels, ultrasound analysis has made considerable progress with enhanced image quality. While injecting microbubbles as a contrast agent partially addresses this limitation, its use is constrained by the need for intravenous injection, making the examination more complex and time-consuming. To address these drawbacks, new commercial modes have emerged, distinct from conventional color- and power-Doppler modes, offering the ability to analyze slow flows and, consequently, microvascularization. These dedicated imaging modes include B-flowTM, E-flowTM, Superb Microvascular Imaging (SMITM), Micro Flow Imaging (MFITM), MV-FlowTM, Detective Flow Imaging (DFITM), Micro-VTM, and Angio PLUS imagingTM. Although these modes share similar objectives, they are based on different technologies, each with its own specific characteristics. The exact algorithms behind these modes vary and are proprietary but rely on a combination of approaches to reduce tissue clutter and electronic noise while improving sensitivity to slower-flow Doppler signals. This review aims to explain the technological basis of these "microvascular flow imaging modes" (MVFI) currently clinically available in vascular imaging to the physician and sonographer specialized in vascular ultrasound, discussing their current limitations and potential applications in vascular medicine.

Association between the Self-Reported like Engaging in Physical Activity and the Physical Activity Level in Patients with Peripheral Artery Disease

BACKGROUND

Patients with symptomatic peripheral artery disease (PAD) face numerous barriers to engaging in physical activity (PA), such as exercise-induced pain, so it is reasonable to hypothesize that these patients do not like engaging in PA. Therefore, this study aimed to analyze the prevalence of self-reported like engaging in PA, as well as whether this factor is associated with higher levels of PA and lower sedentary behavior (SB) in patients with symptomatic PAD.

METHODS

This cross-sectional study included 178 patients with symptomatic PAD who were submitted to a question related to self-reported like engaging in PA and a questionnaire related personal and environmental barriers to PA. PA level parameters (accelerometer) and 6-min walk test were also evaluated. The association between the like engaging in PA and PA level was analyzed using bivariate and multivariate logistic regression adjustments for sex, age, ankle-brachial index, and 6-min walk test. A significance was accepted at P < 0.05.

RESULTS

70.2% of our sample answered "totally agree" or "agree in part" with the statement "I like engaging in PA." Only lack of energy was the most prevalent barrier in patients who do not like engaging in PA. No significant associations between self-reported like to do PA and PA level and SB parameters were found (light PA: odds ratio [OR] = 1.000, confidence interval [CI] 95% = 0.999-1.000, P = 0.737; moderate-to-vigorous PA: OR = 1.000, CI 95% = 0.996; 1.003, P = 0.890; and SB: OR = 1.000, CI 95% = 1.000; 1.000, P = 0.836).

CONCLUSION

Although large proportion of patients with symptomatic PAD self-reported like engaging in PA, it was not associated with PA level and SB in patients with symptomatic PAD.

Warfarin and DOAC impact on cardiovascular and limb outcomes in patients with peripheral arterial disease

Background: Peripheral arterial disease (PAD) increases cardiovascular (CV) morbidity and mortality, but remains underdiagnosed and undertreated. Several trials support low-dose direct oral anticoagulant (DOAC) use in PAD treatment, although this has yet to be widely adopted in clinical practice. Patients and methods: We conducted a retrospective study of patients who underwent ankle-brachial index testing (ABI) from 1996 - 2020 at Mayo Clinic. We included patients with PAD defined by abnormal ABI (<1.0 or >/=1.4). Primary outcomes evaluated were myocardial infarcts (MI), ischemic strokes (IS), critical limb ischemia (CLI)/amputation, bleeding events and all-cause mortality. DOAC and warfarin use were each compared to no anticoagulant use for the outcomes using univariate analysis and multivariate analysis. Results: 22,162 patients had abnormal ABI readings; 1,266 were on warfarin and 269 were on DOAC for any indication. Both the DOAC and warfarin groups showed significant a decrease in all-cause mortality. The DOAC group showed superior mortality outcomes with HR 0.50 [95% CI 0.40-0.63], p-value <0.001 compared to warfarin with HR 0.88 [95% CI 0.81-0.96], p-value <0.004. There appeared to be a similar trend for MI and CLI/amputation however this was not statistically significant. IS was similar with only warfarin being statistically significant. The DOAC group had improved bleeding outcomes compared to the warfarin group, HR 0.53 (95% CI 0.24-0.85), p-value 0.007. Notably, the addition of ASA for both AC groups resulted in significant HR >1. Conclusions: Our study shows that anticoagulation use, particularly DOACs, is associated with decreased all-cause mortality in patients with PAD. There appears to be a favorable trend for DOACs in MI, IS and CLI/amputation. Lastly, DOACs were found to have superior outcomes with bleeding events.

Comparable clinical characteristics and outcomes of patients undergoing endovascular treatment for aorto-iliac or femoropopliteal lesions

Lower extremity peripheral arterial disease is usually a consequence of advanced atherosclerosis, leading to high mortality and morbidity. Although clinical characteristics and outcomes may differ among patients having peripheral disease in different arterial territories, contemporary data are scarce. From January 2019 to December 2022, this multicenter registry study included 712 patients undergoing endovascular treatment (EVT) for either aorto-iliac (AI) or femoropopliteal (FP) lesions. Patient characteristics and outcomes were compared between AI-EVT and FP-EVT groups. Clinical endpoints included major adverse cardiovascular events, major adverse limb events (MALE), and all-cause mortality, stratified by chronic limb-threatening ischemia (CLTI). Of the 712 patients, 217 (30.5%) and 495 (69.5%) underwent AI-EVT or FP-EVT. Patients undergoing AI-EVT were more likely to be men and current smokers, while diabetes was more frequent in the FP-EVT group. The prevalence of CLTI was significantly higher in the FP-EVT group. In the entire study population, the FP-EVT rather than the AI-EVT group had a significantly higher rate of MALE and mortality, but the incidence of major adverse cardiovascular events was similar between the two groups. When focusing only on patients without CLTI, the mortality risk was similar, while the MALE risk was still higher in the FP-EVT group. In conclusion, patients undergoing EVT for AI and FP lesions in contemporary settings were differently characterized by baseline factors. Although the worse clinical outcomes in the FP-EVT group were mainly driven by the higher prevalence of CLTI, the MALE risk was still increased in patients without CLTI.

Vascular and wound healing outcomes after puncture of small or stenotic inframalleolar arteries in patients with chronic limb-threatening ischemia

OBJECTIVE

This study evaluated the safety of below-the-ankle distal punctures, including stenotic or small-diameter inframalleolar arteries, on vessel integrity and wound healing in patients with chronic limb-threatening ischemia and infrapopliteal artery disease.

METHODS

This single-center, retrospective, nonrandomized, observational study analyzed 171 limbs from 155 patients (mean age: 76.1 ± 9.4 years; 74.2% with diabetes mellitus; 48.4% undergoing hemodialysis) with chronic limb-threatening ischemia (Rutherford classification 5-6) who underwent endovascular therapy using below-the-ankle distal punctures for de novo infrapopliteal disease (97.1% occlusion) between January 2014 and December 2024.

RESULTS

Stenosis at puncture sites were observed in 83.0% of the cases, with a median vessel diameter of 1.8 mm. During a median follow-up of 13.1 months, the Kaplan-Meier-estimated 1-year wound healing rate was 57.3%. Chronic occlusion at puncture sites, defined as vessel occlusion after initial revascularization, occurred in 32.2% of the cases. Multivariate analysis identified renal failure on hemodialysis (odds ratio [OR]: 2.76; 95% confidence interval [CI]: 1.12-6.81; p = 0.028), the Global Limb Anatomical Staging System P2 modifier (OR: 2.89; 95% CI: 1.15-7.28; p = 0.024), and smaller distal puncture vessel sizes (scored as 0 [>2.0 mm], 1 [1.5-2.0 mm], or 2 [<1.5 mm]; OR: 10.8; 95% CI: 4.11-28.3; p < 0.001) as independent predictors of chronic occlusion at the puncture sites. The area under the receiver operating characteristic curve for vessel diameter in predicting chronic occlusion at the puncture site was 0.88, with the Youden J statistic indicating a cutoff value of 1.7 mm. Multivariate analysis showed that an increased foot infection grade (hazard ratio [HR]: 0.71; 95% CI: 0.51-0.99; p = 0.043), a small artery disease score of 2 (HR: 0.54; 95% CI: 0.30-0.98; p = 0.042), and a chronic occlusion at the puncture site (HR: 0.51; 95% CI: 0.28-0.92; p = 0.025) were independent risk factors for impaired wound healing.

CONCLUSIONS

Below-the-ankle distal punctures in stenotic arteries may cause puncture site occlusions before wound healing. If distal vessels at the puncture site supply the wound, close monitoring with Doppler or other imaging is essential to detect occlusions until the wound heals. When distal puncture is needed, selecting a target vessel with a larger diameter and minimal disease burden may lower the risk of chronic occlusions and help prevent delays in wound healing.

Prompt Engineering for Large Language Models in Interventional Radiology

Prompt engineering plays a crucial role in optimizing artificial intelligence (AI) and large language model (LLM) outputs by refining input structure, a key factor in medical applications where precision and reliability are paramount. This Clinical Perspective provides an overview of prompt engineering techniques and their relevance to interventional radiology (IR). It explores key strategies, including zero-shot, one- or few-shot, chain-of-thought, tree-of-thought, self-consistency, and directional stimulus prompting, demonstrating their application in IR-specific contexts. Practical examples illustrate how these techniques can be effectively structured for workplace and clinical use. Additionally, the article discusses best practices for designing effective prompts and addresses challenges in the clinical use of generative AI, including data privacy and regulatory concerns. It concludes with an outlook on the future of generative AI in IR, highlighting advances including retrieval-augmented generation, domain-specific LLMs, and multimodal models.

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.

Peripheral arterial disease prevalence among sepsis hospitalizations and associated outcomes

OBJECTIVE

Sepsis is common, deadly, and exacerbated by comorbid conditions. Atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease (CAD) and peripheral artery disease (PAD), are risk factors for sepsis with minimal data on the association between PAD and outcomes. We aimed to evaluate the prevalence of ASCVD and the association between ASCVD and in-patient mortality and limb outcomes among sepsis hospitalizations.

METHODS

We generated ASCVD prevalence estimates among survey-weighted adult sepsis hospitalizations within the National Inpatient Sample (2016-2020). We included hospitalizations with a primary diagnosis of sepsis and excluded nonadult patients (<18 years), and those with missing outcome data (ie, in-hospital mortality) and demographic data (ie, age, sex, and race/ethnicity). Associations between ASCVD and in-hospital mortality and major or transmetatarsal amputation among sepsis hospitalizations were evaluated using Cox regression, adjusting for demographics (age, sex, race/ethnicity, and income) and comorbidities (diabetes mellitus, end-stage renal disease, cerebrovascular disease, and hypertension). Subgroup analyses were conducted to assess moderation of the association between ASCVD and outcomes by antithrombotic therapy.

RESULTS

Of 174,776,160 estimated hospitalizations (age, mean ± standard error, 50 ± 0.2 years; 44% male; 65% White), 5.5% (5.5%-5.6%) had a primary diagnosis of sepsis (age 69 ± 0.1; 51% male; 70% White); of which, 9.5% (9.3%-9.6%) had a secondary diagnosis of PAD (age 73 ± 0.05; 58% male; 73% White). PAD was associated with 18% higher adjusted risk of in-hospital mortality (95% confidence interval [CI], 1.17-1.20) and 4.36 times the risk of major or transmetatarsal amputation (95% CI, 4.18-4.56). Sepsis hospitalizations with joint ASCVD had the highest risk of in-hospital mortality (adjusted hazard ratio [aHR], 1.34; 95% CI, 1.31-1.36) compared with those with CAD alone (aHR, 1.25; 95% CI, 1.24-1.27) or PAD alone (aHR, 1.23; 95% CI, 1.21-1.26). Yet patients with PAD who were hospitalized for sepsis had a higher risk of in-hospital major or transmetatarsal amputation (aHR, 5.03; 95% CI, 4.76-5.32) compared with those with joint ASCVD (aHR, 3.89; 95% CI, 3.66-4.14); CAD was expectedly not associated with amputation (aHR, 1.05; 95% CI, 0.999-1.1). Subgroup analyses revealed significant interactions between ASCVD and antithrombotic therapy, such that, among those taking antithrombic therapy, the associations between ASCVD and in-hospital mortality (P < .001) and amputation (P < .05) were smaller when compared with the associations examined in the whole sample.

CONCLUSIONS

Sepsis and ASCVD are common and associated with a higher risk of adverse outcomes. PAD diagnosis occurred among 9.5% of sepsis hospitalizations and, mirroring CAD, increased the risk of in-hospital mortality by approximately 25%. Expectedly, PAD was associated with a higher risk of in-hospital amputation. Antithrombotic therapies, a staple of ASCVD medical optimization, reduced the risk of in-hospital amputation and mortality among patients with PAD hospitalized for sepsis. Medical optimization may improve outcomes in patients with sepsis and ASCVD.

Comparing the Clinical Performance of High-Dose and Low-Dose Drug-Coated Balloons for Long Femoropopliteal Artery Disease: Results of the SATELLITE Study

BACKGROUND

Previous studies have shown comparable outcomes between first-generation high-dose drug-coated balloon (HD-DCB) and second-generation low-dose drug-coated balloon (LD-DCB) for femoropopliteal artery disease. However, data about the clinical performances of these DCBs for longer lesions in real-world clinical settings are limited.

METHODS

In this multicenter, retrospective study, the clinical performances of the HD-DCB (IN.PACT, Medtronic, MN, USA) and the LD-DCB (Ranger, Boston, MA, USA) were assessed in cases of femoropopliteal artery disease with lesion length ≥ 150 mm. From the database, 288 lesions in 288 patients were assigned to the HD-DCB group, and 88 lesions in 88 patients were assigned to the LD-DCB group. Propensity score-matching analysis was performed to adjust for baseline patient and lesion characteristics. The primary outcome was the 2-year primary patency rate of the two types of DCBs.

RESULTS

Propensity score matching was used to extract 76 pairs with no significant intergroup differences in baseline patient and lesion characteristics. The average lesion length was 257.5 and 255.7 mm in the HD and LD-DCB groups, respectively. The 2-year primary patency rates between the HD and LD-DCB groups were comparable (68.5% vs. 60.4%; p = 0.33). There were also no significant differences in clinically driven target lesion revascularization, acute limb ischemia, major amputation, or overall survival between the two types of DCBs.

CONCLUSION

The clinical outcomes between the HD and LD-DCBs did not significantly differ in real-world populations with severely complex lesions.

Association of monocyte-to-high-density lipoprotein cholesterol ratio with peripheral artery disease and long-term mortality

BackgroundThis study aims to investigate the association of monocyte-to-high-density lipoprotein cholesterol ratio (MHR) with peripheral artery disease (PAD) and long-term mortality.MethodsData from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004 were analyzed, with mortality follow-up tracked via the National Death Index until December 31, 2019. Logistic regression was used to examine the relationship between MHR and PAD, while Cox proportional hazards regression assessed the association of MHR with mortality in individuals with PAD.ResultsA total of 6319 participants were included, among whom 550 were identified as having PAD. In weighted multivariate logistic regression analysis, participants in the third (odds ratio [OR]: 1.031, 95% confidence interval [CI]: 1.009-1.053, p = 0.007) and fourth (OR: 1.034, 95% CI: 1.011-1.057, p = 0.006) quartiles of MHR demonstrated significantly higher risks of PAD compared to those in the first quartile. Among PAD individuals, during a median follow-up period of 136 (71, 197) months, 422 deaths occurred. Higher MHR was associated with an increased risk of long-term mortality in females (hazard ratio [HR]: 1.695, 95% CI: 1.222-2.350, p = 0.002) but not in males (HR: 0.761, 95% CI: 0.554-1.044 p = 0.090).ConclusionsElevated MHR is independently associated with PAD among U.S. population. The association between MHR and long-term prognosis of PAD exhibits gender differences, with a significant relationship observed between elevated MHR and long-term mortality risk in females, but not in males.

Skin perfusion pressure in lower extremities at haemodialysis initiation is associated with 1-year mortality and cardiovascular disease

BACKGROUND

Skin perfusion pressure (SPP) is a noninvasively obtained and useful measurement for assessing peripheral arterial disease (PAD). Decreased SPP in lower extremities is associated with poor survival in maintenance haemodialysis (HD) patients. Nevertheless, the prognostic significance of SPP at HD initiation has not been determined. We investigated the relation between SPP and death or cardiovascular disease (CVD) in incident HD patients.

METHODS

Data were collected retrospectively from patients with SPP measurements taken by dialysis nurses at HD initiation during 2020-2023. Then we assessed the association between the minimum value of SPP in the bilateral dorsal/plantar portions of each patient (SPPmin) and outcomes, consisting of mortality and CVDs within 1 year after HD initiation.

RESULTS

This study examined 104 incident HD patients with a median age of 74 (79% male). Based on the suggested cut-off value from receiver operating characteristic analysis, patients were divided into two groups: patients with SPPmin ≥ 60 mmHg (higher SPPmin) and those with SPPmin < 60 mmHg (lower SPPmin). Kaplan-Meier analysis indicated the 1-year survival and CVD-free rate as significantly lower in the lower SPPmin group than in the higher SPPmin group (p < .001). Cox proportional hazards analyses showed lower SPPmin as associated with the composite outcome. The relation between lower SPPmin and outcome held true in each subgroup with cardiovascular risk such as older age and history of CVD.

CONCLUSION

SPP measured by dialysis nurses at HD initiation is associated with 1-year adverse outcomes in incident HD patients.

Distribution of lipoprotein (a) levels in patients with lower extremity artery disease and their impact on amputation and survival: a retrospective study

BACKGROUND

Elevated lipoprotein (a) (Lp(a)) is an independent risk factor for lower extremity artery disease (LEAD) with equivocal effect on amputation and mortality. Results regarding aggressive lipid-lowering therapies (LLT) are missing. We examined LEAD patients with Lp(a) measurement and the impact of intensive LLT on amputation and survival.

METHODS

Baseline characteristics of 263 LEAD patients with Lp(a) measurement treated in a tertiary hospital from 01/2017 until 01/2022 were recorded. Patients were categorized into three groups according to their Lp(a) values (< 30 mg/dL, 30-90 mg/dL and > 90 mg/dL). Lipid values and LLT were recorded at baseline and during follow-up (median 750 days). Peripheral endovascular revascularizations (EVR), amputations and death during follow-up were analysed.

RESULTS

Of 263 patients, 75% were male, mean age was 67 ± 10 years. Elevated Lp(a) values ≥ 30 mg/dL were found in 32%, 16% had values > 90 mg/dL. Baseline low-density lipoprotein cholesterol (LDL-C) was 89 ± 38 mg/dL, decreasing to 61 ± 30 mg/dL at follow-up, with no difference between Lp(a) groups (63 ± 32 mg/dL vs. 52 ± 23 mg/dL vs. 60 ± 25 mg/dL, p = 0.273). Statin dose was intensified more frequently in those with elevated Lp(a) (16% vs. 35% vs. 33%, p = 0.005), who also received significantly more often ezetimibe (50% vs. 58% vs. 73%, p = 0.028) and proprotein convertase subtilisin/kexin type 9 inhibitors (2% vs. 3% vs. 8%, p = 0.043). No difference was seen regarding EVR (91% vs. 95% vs. 90%, p = 0.729), amputations (4% vs. 7% vs. 0%, p = 0.245) and death (8% vs. 5% vs. 3%, p = 0.436).

CONCLUSIONS

Aggressive LLT in high-risk LEAD patients with elevated Lp(a) levels enabled LDL-C target achievement in a majority by combination of established lipid-lowering agents. An increase in EVR, amputation or death could not be observed in patients with high Lp(a) levels.

Optimal Medical Therapy in Peripheral Artery Disease

Peripheral artery disease (PAD) is a highly prevalent subset of cardiovascular disease associated with significant limb-related and concomitant atherosclerotic complications, resulting in high morbidity and mortality. Consequently, appropriate identification and timely initiation of guideline-directed medical therapy is crucial. Despite its widespread prevalence, PAD remains underdiagnosed and undertreated, posing a substantial public health challenge. This review delves into the evidence-based nonpharmacological and pharmacologic treatment strategies for PAD, underscoring the necessity of a multidisciplinary approach.

Iliac Arterial Intervention

Peripheral arterial disease affects a large patient population, and a large percentage of these patients have evidence of aortoiliac occlusive disease. This review discusses the evaluation and characterization of iliac lesions as well as the associated interventional procedures focusing on techniques, device choice, potential complications, and postprocedural care. We discuss stent choice and studies aimed at analyzing the outcomes associated with each type as well as a brief discussion of intravascular lithotripsy which is quickly becoming a popular plaque modifier in endovascular procedures.

Systematic review of tracking-based technology for patients with claudication

INTRODUCTION

Peripheral artery disease (PAD) typically presents with claudication. Although supervised exercise therapy is recommended, many hospitals do not have a program and therefore patients are unable to receive optimal therapy. Tracking-based technology (TBT), including activity monitors and mhealth applications, have stimulated the expansion into PAD management. This systematic review evaluates the effectiveness of TBT for claudication based on walking performance, perceived walking impairment, and quality of life (QoL).

METHODS

A multidatabase search was undertaken using the terms PAD OR intermittent claudication AND wearable devices OR mobile health applications. This systematic review was conducted according to PRISMA guidelines.ResultsA literature search identified 586 studies, of which 18 were eligible for inclusion. This totaled 1055 patients, with 15 randomized controlled trials and three cohort studies. Patients in the TBT group showed improvements in all walking ability parameters (including 6-minute walking distance, claudication onset time, maximum walking time, maximum walking distance, and claudication distance), QoL, and in the self-reported walking impairment questionnaires.

CONCLUSION

There is evidence for supporting the introduction of TBT into the management of PAD as TBT improves walking performance, functional status, and QoL in patients with PAD. However, further information regarding adherence and compliance rates, as well as long-term outcomes, are imperative in assessing the effectiveness of TBT due to limited existing studies. PROSPERO Registration No.: CRD42022307731.

Validation of High Ischemic and Bleeding Risk Criteria of European Guidelines in Peripheral Arterial Disease

BACKGROUND

The 2024 European Society of Cardiology (ESC) guidelines for peripheral arterial disease (PAD) propose the dedicated high ischemic risk (HIR) and high bleeding risk (HBR) criteria.

OBJECTIVES

The purpose of this study was to validate the ESC-HIR and HBR criteria using real-world data.

METHODS

From January 2019 to December 2022, this multicenter retrospective registry included 824 patients undergoing endovascular treatment for aortoiliac and femoropopliteal PAD. The ESC-HIR criteria include previous amputation, critical limb-threatening ischemia, previous revascularization, high-risk comorbidities (heart failure, diabetes, polyvascular disease), and estimated glomerular filtration rate <60 mL/min/1.73 m2, while the ESC-HBR criteria include dialysis or renal impairment (estimated glomerular filtration rate <15 mL/min/1.73 m2), acute coronary syndrome <30 days, history of stroke or transient ischemic attack, and active or clinically significant bleeding. Although patients were initially divided into 4 groups according to the presence or absence of HIR and HBR, patients with HBR and no HIR were excluded caused by the small sample size (n = 2). Major adverse cardiovascular and limb events and bleedings were evaluated.

RESULTS

Of the 822 patients, 62 (7.5%), 467 (56.8%), and 293 (35.6%) were grouped in the HIR (-)/HBR (-), HIR (+)/HBR (-), and HIR (+)/HBR (+). During the median follow-up period of 726 days, major adverse cardiovascular and limb events occurred in 0%, 9.5%, and 16.4% among the 3 groups (P = 0.005). The incidence of major bleeding events was 4.8%, 2.4%, and 6.8%, respectively (P = 0.009).

CONCLUSIONS

The ESC-HIR and HBR criteria successfully stratified ischemic and bleeding risks in patients with PAD undergoing endovascular treatment.

The role of the HALP score in determining the severity of lower extremity peripheral arterial disease

ObjectivePeripheral artery disease (PAD) is a chronic circulatory disorder characterized by atherosclerotic plaque buildup in the peripheral vascular system, restricting blood flow to the lower extremities and carrying a significant risk of morbidity and mortality. This study investigates the role of the hemoglobin, albumin, lymphocyte, and platelet (HALP) score as a prognostic marker for assessing the severity of lower extremity peripheral artery disease (LEAD). The HALP score integrates hematologic and nutritional markers, providing a composite index that may reflect both the inflammatory and nutritional states impacting LEAD progression.MethodsA cross-sectional retrospective study was conducted, analyzing 186 patients diagnosed with LEAD through peripheral angiography. Participants were classified according to the TransAtlantic Inter-Society Consensus (TASC) II criteria, with mild to moderate disease (TASC A-B) and severe disease (TASC C-D). Laboratory data were collected within the first week of diagnosis, and HALP scores were calculated. The association between HALP scores and LEAD severity was evaluated through correlation and logistic regression analyses. Inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) were also analyzed.ResultsSignificant differences were observed between TASC A-B and TASC C-D groups in demographic and clinical variables. Patients in the severe LEAD group were older, had a higher prevalence of diabetes and hyperlipidemia, and exhibited lower hemoglobin and albumin levels with higher platelet counts (p < .001). A significant inverse correlation was found between HALP score and LEAD severity (R = -0.607, p < .001), indicating that lower HALP scores are associated with more advanced disease. The HALP score displayed strong discriminatory performance in ROC analysis (AUC = 0.889), with an optimal cut-off of 3.14 providing 81% sensitivity and 80% specificity for predicting severe LEAD.ConclusionThe HALP score is a valuable, non-invasive predictor of LEAD severity and may serve as a practical tool for clinical risk assessment. Incorporating the HALP score into routine evaluation protocols could support more personalized management approaches for patients with LEAD, guiding both therapeutic decisions and long-term monitoring.

Algorithm for the Revascularization of Infrainguinal Arterial Disease

Peripheral artery disease (PAD) is a common vascular condition affecting over 200 million people worldwide. It is primarily characterized by stenosis or occlusion of peripheral arteries due to atherosclerosis. The infrainguinal segment is frequently involved in PAD, making revascularization decisions for infrainguinal arterial disease (IAD) complex. Multiple factors, including the patient's condition and anatomical characteristics, must be carefully considered when determining the optimal treatment approach. Once these factors are evaluated, the first revascularization strategy is selected from among open, endovascular, or hybrid modalities, based on high-level evidence. Endovascular therapy is widely accepted as the standard treatment for simple IAD, with balloon angioplasty and stenting being the commonly used techniques. However, advancements in endovascular techniques have enabled the treatment of increasingly complex lesions. Additionally, drug-based technologies have enhanced the durability of treatment outcomes, including improvements in primary patency rates and freedom from target lesion revascularization. Similar to surgical endarterectomy, percutaneous atherectomy has been developed to remove atherosclerotic plaques and mitigate intimal calcification. The purpose of this paper is to present an algorithm for revascularization of IAD through a comprehensive review of studies comparing the outcomes of various treatment modalities.

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.

Updates in Arterial Ulcers

Arterial ulcers are a clinical symptom of a complex array of underlying comorbid factors, namely peripheral artery disease (PAD). Chronic limb-threatening ischemia is representative of end-stage PAD. Ulcers of other etiologies can carry an arterial component, mandating recognition of risk factors, a comprehensive history and physical examination, and appropriate diagnostic testing in lower extremity ulcers. The primary therapy for arterial ulcers is re-establishment of in-line arterial flow, achieved by endovascular therapy or open revascularization. Medical management is essential to slow disease progression, and topical therapies are crucial to promote rapid ulcer closure and reduce infection risk.

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.

TCF7L2 as a target of peripheral artery disease in patients with type 2 diabetes: A 2-sample Mendelian randomization and bioinformatics study

This study examines the causal relationship between type 2 diabetes (T2D) and peripheral artery disease (PAD) and their potential mechanisms based on the analysis of the Gene Expression Omnibus database and 2-sample Mendelian randomization (MR). The first part involved a 2-sample MR study and a comprehensive meta-analysis. Differences in the results were assessed using inverse-variance weighting. Heterogeneity was examined using the Cochrane Q statistical test. The leave-one-out method was applied for sensitivity analysis. The potential horizontal pleiotropic effect was assessed using the MR-Egger intercept technique. The second part involved differential gene analysis and weighted gene coexpression network analysis. Subsequently, we overlapped and consolidated the results from the 2 parts to identify the key genes between them. MR analysis results suggested a statistically significant correlation between the incidence of PAD and T2D (odds ratio: 1.22, 95% confidence interval: 1.13-1.32, P = 3.74e-07). We anticipated a pivotal role for TCF7L2 in PAD and T2D. T2D was significantly associated with PAD risk. Simultaneously, the study deepened our understanding of the underlying mechanisms of both diseases, proposing TCF7L2 as a promising target.

Association of age on thromboelastography coagulation profiles among elderly patients with peripheral arterial disease

OBJECTIVE

This study aimed to determine whether age affects thromboelastography (TEG) coagulation profiles among elderly patients with peripheral arterial disease. We hypothesized that TEG parameters would not significantly differ between age groups when controlled for anticoagulation regimen.

METHODS

This was a prospective, single-institution, observational study that included patients aged 65 years and older who underwent open or endovascular lower extremity revascularization for peripheral arterial disease from December 2020 through December 2023. A total of 158 patients were grouped into categories: by age (65 to 74 years and 75+ years) and anticoagulation regimen (single antiplatelet [50%], dual antiplatelet [15%], therapeutic anticoagulation [27%], none [8%]). Objective TEG coagulation profiles were collected preoperatively and were compared among patient groups. One-way analysis of variance was used to compare three or more groups of continuous data, and χ2 analysis or Fisher exact test were used to compare categorical data.

RESULTS

Among 158 patients (36.4% female; median age, 74.5 ± 6.6 years), there were no significant differences in TEG parameters (reaction time, maximum amplitude, lysis at 30 minutes, angle, adenosine diphosphate % aggregation, adenosine diphosphate % inhibition) between age groups when stratified by anticoagulation regimen (all P > .05). Thrombosis rates were similar between age groups (21.1% vs 20.6%; P = .936), but mortality was significantly higher in the 75+ group (20.6% vs 5.6%; P = .005).

CONCLUSIONS

Objective coagulation parameters do not appear to vary significantly among age groups within the elderly population when controlled for antiplatelet/anticoagulant regimen. TEG profiles may be used to guide anticoagulation management among elderly patients. Further studies can help elucidate the full utility of TEG profiles for coagulation surveillance among elderly patients.

Safety and efficacy of home-based walking exercise for peripheral artery disease

OBJECTIVE

Home-based walking exercise is first-line therapy for peripheral artery disease (PAD), but benefits of home-based walking exercise are variable. This study evaluated whether specific clinical characteristics were associated with greater improvement after home-based walking exercise or with higher rates of serious adverse events (SAEs).

METHODS

Data were combined from two randomized clinical trials comparing home-based walking exercise with control in PAD. The home-based exercise interventions used behavioral interventions to help participants adhere to exercise. The primary outcome was the proportion of PAD participants who improved 6-minute walk (6MW) by at least 20 meters. Serious adverse events consisted of overnight hospitalizations or death that occurred during the randomized clinical trial.

RESULTS

Of 376 participants with PAD (69.6 years; 54.5% Black; 49.5% women), 217 were randomized to exercise and 159 to control. Home-based exercise improved 6MW by at least 20 meters in 100 participants (54.9%), compared with 37 (28.0%) in control (odds ratio, 3.13; 95% confidence interval, 1.94-5.06; P < .001). Age, sex, race, comorbidities, baseline 6MW, and income did not significantly alter the effect of home-based exercise on improved 6MW. SAEs occurred in 28.1% and 23.3% of participants randomized to exercise and control, respectively (P = .29). There were statistically significant interactions, indicating that home-based exercise increased SAE rates, compared with control, in Black compared with non-Black participants (P interaction < .001), in those with vs without coronary artery disease (CAD) (P interaction < .001), and in people with vs without history of heart failure (P interaction = .005).

CONCLUSIONS

Among people with PAD, home-based exercise improved 6MW by at least 20 meters in 54.9% of people. Older age, female sex, Black race, and specific comorbidities were not associated with lower rates of attaining meaningful improvement in 6MW following home-based exercise. Further study is needed to establish whether certain patient characteristics, such as history of coronary artery disease, may affect SAE rates in patients with PAD participating in home-based exercise.

Impact of Below-the-Knee Runoff in Patients With Lower Extremity Artery Disease Who Underwent Endovascular Therapy Using Drug-Coated Balloons in Femoropopliteal Lesions

BACKGROUND

The impact of below-the-knee (BK) runoff after drug-coated balloon (DCB) treatment in femoropopliteal (FP) lesions has not been well investigated.

METHODS

This retrospective multicenter observational study enrolled 291 consecutive patients with lower extremity artery disease who underwent endovascular therapy with DCBs for FP lesions between January 2018 and December 2021. Patients were classified into four groups based on the BK runoff. Outcome measures included primary patency, freedom from clinically driven target lesion revascularization (CD-TLR) and amputation, and overall survival rates at 24 months. The predictors of restenosis at 24 months were also investigated.

RESULTS

In total, 43, 98, 117, and 33 patients were classified into three, two, one, and no BK runoff groups, respectively. In three, two, one, and no BK runoff groups, the primary patency rates were 72.1%, 67.3%, 61.4%, and 44.1% (p = 0.028); freedom from CD-TLR rates were 87.1%, 78.8%, 71.7%, and 47.1% (p < 0.001); freedom from amputation rates were 95.2%, 97.9%, 92.8%, and 91.5% (p = 0.499); and overall survival rates were 89.4%, 83.2%, 76.6%, and 61.2% (p = 0.007), respectively, at 24 months. Multivariate analysis showed that chronic limb-threatening ischemia, no BK runoff, Lutonix use, and residual stenosis > 30% were independent predictors of primary patency loss at 24 months. The risk score, calculated as the number of predictors, reflected the risk of restenosis.

CONCLUSION

No BK runoff was associated with worse midterm primary patency, freedom from CD-TLR, and overall survival rates than at least one BK runoff.

Magnetic resonance angiography in diagnostic long-term follow-up of primary patency of the MOTIV drug-eluting bioresorbable vascular scaffold in the region below the knee: 5 years of experience

PURPOSE

Treatment of peripheral artery disease (PAD) in the region below the knee (BTK) is dissatisfying as failure of treated target lesions (TLF) is frequent and diagnostic imaging is often challenging. In the BTK-region metallic drug-eluting stents (mDES) yielded best results concerning primary patency (PP), but also annihilate signal in magnetic resonance angiography (MR-A). A recently introduced non-metallic drug eluting bioresorbable Tyrocore® vascular scaffold (deBVS), that offers an option for re-treatment of lesions due to its full degradation within 3-4 years after placement, was investigated with respect to its compatibility with MR-A to unimpededly depict previously treated target lesions.

METHODS

Patency of the deBVS in the BTK-region was assessed retrospectively using contrast enhanced MR-A of the lower limbs in patients with PAD of Lafontaine-grades II-IV (n = 19). Clinically driven MR-A censoring was triggered by an assumed target lesion failure (CD-TLF), which served to compute the probability of PP during the observation period of 5 years. Compatibility of this particular deBVS with MRI was additionally proven via in-vitro experiments.

RESULTS

The scaffold was found to be fully compatible with MRI. The normalised intra-luminal signal measured in MR-A increased significantly after successful deBVS-placement. The retrospective 5-years PP-probability was 0.87 (CI95%: [0.71,1.0]) with 2 stent-occlusions observed after 90 days. No major adverse events occurred.

CONCLUSION

Assessment of PAD in the BTK-region after placement of the Tyrocore®-deBVS using MRA is feasible. The promising high PP-probability after 5-years and the persistent full interpretability of treated target lesions by MR-A after stent-placement encourage further prospective assessment of this deBVS in treatment of PAD in the BTK-region.

Design and baseline characteristics of the STRIDE trial: evaluating semaglutide in people with symptomatic peripheral artery disease and type 2 diabetes

BACKGROUND

People with lower extremity peripheral artery disease (PAD) suffer from a high burden of symptoms and significant functional impairment. There are few therapies that improve function and reduce symptoms in this population. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been shown to improve glycaemic control, reduce body weight, and reduce the risk of major adverse cardiovascular events in people with atherosclerotic cardiovascular disease and type 2 diabetes (T2D).

METHODS AND RESULTS

STRIDE (NCT04560998) is a randomized, placebo-controlled, double-blind phase 3b trial evaluating 1 mg once-weekly subcutaneous semaglutide (GLP-1 RA) vs. placebo, in people with symptomatic PAD (Fontaine IIa claudication) and T2D. Eligible participants were ≥18 years, had haemodynamically stable PAD, had no planned intervention, and were not receiving a GLP-1 RA. The primary endpoint is change in maximum walking distance on a constant-load treadmill (CLT). Secondary endpoints include quality of life and cardiometabolic assessments. A total of 792 participants were randomized in 20 countries. Participants' median age was 68 and median T2D duration 12 years. Risk factors included 25.6% current smokers, 87.9% with hypertension, and 42.7% with coronary heart disease. The mean BMI was 29.6 kg/m2 and the mean HbA1C was 7.3%. Participants exhibited baseline functional impairment with a median maximum walking distance of 186 m on a CLT.

CONCLUSION

STRIDE has enrolled participants with symptomatic PAD and T2D, frequent risk factors and comorbidities, and functional impairment. The trial will provide evidence for the functional outcomes with semaglutide in people with PAD and T2D.

Cangrelor Use for Viabahn Stent Graft Patency as Bridge to Coronary Artery Bypass Graft Surgery

Utilization of cangrelor following coronary artery stent placement as a bridge to cardiac surgery has been previously described in the literature. However, the use of cangrelor as bridge therapy to cardiac surgery for endovascular revascularization is lacking. We describe a case involving a 47-year-old female who developed a left lower extremity tibioperoneal trunk non-obstructing arterial dissection following extracorporeal membrane oxygenation decannulation, requiring repair with a Viabahn endoprosthesis. To maintain stent patency, as well as treat the patient's multi-vessel coronary disease and left ventricular thrombus, triple therapy with cangrelor, aspirin, and bivalirudin was utilized as the patient was optimized for a coronary artery bypass procedure. Our case describes a unique antiplatelet and anticoagulation strategy in a complex patient involving a multi-disciplinary team.

Risk factors of incident acute limb ischemia after contemporary femoropopliteal endovascular revascularization from a multicenter registry: A retrospective observational study

Purpose

To investigate the incidence of acute limb ischemia (ALI) among patients with femoropopliteal (FP) lesions treated with contemporary endovascular therapy (EVT) and to identify risk factors for ALI after FP-EVT.

Methods

In this retrospective multicenter registry, we analyzed patients with lower extremity artery disease having FP lesions who underwent EVT between 2017 and 2021. We investigated the incident ALI related to the index EVT and its risk factors. We also assessed the prognosis after the incident ALI.

Results

During a median follow-up of 35.3 months, incident ALI was observed in 72 of 3102 patients (2.3%). The Rutherford classification I/IIa/IIb/III was 50.0%, 30.5%, 18.1%, and 1.4%, respectively. Variables independently associated with the incident ALI were chronic limb-threatening ischemia (CLTI; hazard ratio, 1.83; p = 0.015), reference vessel diameter < 6 mm (2.39; p = 0.011), lesion length >25 cm (3.35; p = 0.005) with its time interaction (0.72 per 1 year; p = 0.042), P2/3 segment involvement (2.73; p < 0.001), chronic total occlusion (CTO; 3.40; p < 0.001), and in-stent restenosis/occlusion (3.21; p < 0.001). During a median follow-up of 12.8 months after the ALI event, all-cause mortality was 27.8% and the rate of major amputation was 6.9%.

Conclusions

The FP-EVT showed that the occurrence of ALI was 2.3% during a median follow-up of 35.3 months. The independent predictors of the ALI event were CLTI, small vessels, long lesions, CTO, and in-stent restenosis; however, the impact of lesion length was attenuated over time after the index EVT.

Comparison of Endovascular Interventions for the Treatment of Superficial Femoral Artery Disease: A Network Meta-analysis

Background

To understand the relative safety and efficacy of endovascular treatment modalities used for superficial femoral artery (SFA) disease, we performed a network meta-analysis to compare outcomes between percutaneous transluminal angioplasty (PTA), atherectomy (A), bare metal stent (BMS), brachytherapy/radiotherapy, covered stent graft (CSG), cutting balloon angioplasty (CBA), drug-coated balloon (DCB), drug-eluting stent (DES), and intravascular lithotripsy (L).

Methods

We performed a systematic literature search of PubMed from January 2000 to January 2023 to identify randomized trials comparing endovascular interventions for the treatment of SFA disease. The primary end points were technical success and 12-month primary patency.

Results

In total, 57 studies (9089 patients) were included. The mean age of the included patients was 68.4 years, 41.4% had diabetes, 18.3% had critical limb ischemia, and 81.3% had de novo lesions. A mean of 1.2 lesions were treated per patient. Technical success was superior for CSG, BMS, and A+DCB compared with PTA, while A+DCB and CSG were superior to DCB. All interventions except brachytherapy alone had superior primary patency compared with PTA. There were no significant differences in 12-month mortality or major amputation. All interventions except L+DCB, PTA+A, and CBA were superior to PTA regarding target lesion revascularization, while only DCB, DES, and BMS were better than PTA at improving Rutherford classification.

Conclusions

In SFA disease, PTA alone is mostly inferior to other endovascular techniques. This comparison of other endovascular techniques will be valuable for endovascular device selection in the treatment of SFA disease.

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.

Effects of incentivising dialysis facilities on peripheral arterial disease care in patients undergoing haemodialysis: a claims-based cohort study

Background

Peripheral arterial disease (PAD) occurs frequently in patients undergoing dialysis, but early intervention for PAD may not be fully implemented. We evaluated the effects of financially incentivising dialysis facilities that provided early detection and management of PAD on outcomes of PAD care.

Methods

This retrospective cohort study identified patients aged 18-74 years who received maintenance haemodialysis between April 2016 and March 2021 from the JMDC Claims Database. The (time-dependent) exposure was claim for incentives for early detection and management of PAD. The outcomes were PAD screening tests (process indicator) and infections, revascularisation procedures, and amputations in the lower extremities (outcome indicators). We used Poisson regression models with generalised estimation equations for the number of screening tests and Cox proportional hazards models for the first incidence of the outcome indicator.

Results

Overall, 5850 patients on haemodialysis were identified: 5183 and 667 with and without claims for the incentive, respectively; the numbers of screening tests were 9070 and 776, respectively (adjusted ratio of the frequency, 1.89 [95% confidence interval 1.70-2.10]). Among patients with and without claims for the incentive, infections occurred in 479 and 109 (adjusted hazard ratio [HR], 0.99 [0.80-1.23]), revascularisations were performed in 192 and 29 (adjusted HR, 1.11 [0.75-1.66]), and amputations were conducted in 72 and 9 patients, respectively (adjusted HR, 1.35 [0.66-2.75]).

Conclusion

The financial incentive for early detection and management of PAD was associated with a higher frequency of PAD screening tests, but not with improved outcome indicators.

Acute Arterial Ischemia Secondary to Intrapelvic Acetabular Migration: A Multidisciplinary Approach

This case report evaluates current diagnostic and treatment approaches for intrapelvic acetabular migration, focusing on the rare but serious complication of acute limb ischemia following hip arthroplasty. A 67-year-old female with a history of total hip arthroplasty 10 years ago presented with acute limb ischemia after experiencing a traumatic event 72 hours prior, which had caused displacement of her hip prosthesis. Notably, she had a history of a traumatic event two years earlier for which she had been advised to undergo surgical correction, which she had refused. A multidisciplinary team assessed her preoperatively. She was diagnosed with SVS III irreversible acute limb ischemia due to compression of the external iliac artery from the prosthesis migration, prompting an emergency hip disarticulation. The patient successfully underwent hip disarticulation and mechanical thrombectomy of the external iliac artery using a Fogarty catheter. Postoperative recovery was notable, with significant pain relief, improved mental status, and restoration of the iliac pulse. Early diagnosis and management of acute arterial injury are crucial to preventing severe outcomes. This report highlights the importance of timely intervention to mitigate limb-threatening and life-threatening complications. It underscores the need for vigilant monitoring during hip replacements and the effectiveness of a multidisciplinary approach in complex cases. Continued research is essential to enhance diagnostic and therapeutic strategies for this rare yet critical complication and to improve overall patient outcomes.

Epidemiology of aortic and peripheral arterial diseases in France

BACKGROUND

Peripheral arterial diseases (PADs) account for much of the morbidity and hospitalizations experienced by patients with cardiovascular disease. Epidemiological data on these diseases are lacking in France.

AIMS

To describe the epidemiology of aortic diseases (aneurysm and dissection) and PADs in France in 2022.

METHODS

This study was carried out using the National Health Data System. Patients hospitalized with these diseases in 2022 and patients who died from these diseases in 2021 were selected. The prevalence of aortic diseases and PADs among people alive on 1 January 2023 was estimated from previous hospitalizations and registered long-term disease. Mortality and secondary treatment were examined in the year following hospitalization.

RESULTS

In 2022, there were 68,702 patients hospitalized in France for a lower extremity artery disease (LEAD), 9083 for abdominal aortic aneurysm and 9027 for dissection or aneurysm of a medium-sized artery (standardized rates: 112.6, 15.0 and 15.5 per 100,000, respectively). The standardized prevalences of these diseases were 1.23%, 0.17% and 0.22% of adults, respectively. Regional and social disparities in the age-standardized rates of hospitalized patients were observed. One-year mortality ranged from approximately 11% for patients hospitalized for thoracic aortic aneurysm or medium-sized artery dissection/aneurysm to 27.0% for aortic dissection. The proportions of patients hospitalized due to LEAD who were being treated with antiplatelet or lipid-lowering drugs 1 year after the index hospitalization were 86.6% and 75.9%, respectively.

CONCLUSION

The burden of aortic diseases and PADs is considerable in France and mortality remains high for ruptured aortic aneurysm and aortic dissection.

Antithrombotic therapy following lower extremity endovascular revascularization: The results of a survey of vascular specialists

Objective

Antithrombotic therapy improves endovascular intervention outcomes for peripheral artery disease. However, there are limited data guiding the choice and duration of these adjuvant therapies. Thus, we explored current antithrombotic prescribing preferences among vascular interventionalists, hypothesizing that there are varied and inconsistent treatment practices among providers.

Methods

We developed and distributed a de-identified RedCap survey via Twitter and email to Vascular Quality Initiative members (February 2023). Multiple-choice questions queried antithrombotic agents and treatment durations for a clinical vignette (a claudicant on 81 mg aspirin and statin) with different arterial disease locations (iliac, femoropopliteal, or tibial vessels) and different revascularization strategies (angioplasty or stenting, with and without drug-coating). Antithrombotic options included monotherapies with antiplatelet agents or low-dose rivaroxaban; dual therapies with aspirin combined with a P2Y12 inhibitor (dual antiplatelet therapy, DAPT) or low-dose rivaroxaban (dual pathway inhibition or DPI); or triple therapy with aspirin, a P2Y12 inhibitor, and low-dose rivaroxaban. Options for therapy duration included 30, 90, 180, and 365 days, or indefinitely.

Results

There were 199 respondents (17% female, 68% White race, 63% academic, 88% vascular surgery). Across all treatment scenarios, respondents selected DAPT (n = 171/199; 86%) in at least one revascularization scenario, followed by aspirin monotherapy (n = 83/199; 42%) and DPI (n = 49/199; 25%). Therapy choice did differ by both anatomic location and revascularization strategy (P < .05). DAPT was most selected following femoropopliteal revascularization (n = 165/199, 83%) and bare metal stenting (n = 162/198, 82%). However, aspirin monotherapy was most selected following iliac level revascularization (n = 52/197; 26%) and following percutaneous transluminal angioplasty at any level (n = 51/182; 28%). DPI was most selected following tibial revascularization (n = 39/184; 21%) and following percutaneous transluminal angioplasty (n = 38/182; 21%). Among those who selected DAPT, the 90-day (n = 99/171; 58%) duration was preferred. Those who selected DPI favored indefinite treatment durations (n = 34/49; 69%). Indefinite DAPT and DPI therapy were more commonly selected for distal level revascularization (P < .05). Rivaroxaban utilization was limited secondary to cost (n = 108/178; 61%), lack of demonstrated effectiveness (n = 75/178; 42%), and concern for safety and bleeding (n = 27/178; 15%).

Conclusions

Following lower extremity endovascular treatment of peripheral artery disease, a 90-day duration of DAPT remains the most commonly selected antithrombotic regimen despite the emergence of DPI as an evidence-based antithrombotic therapy. The variability in provider preferred antithrombotic agent and treatment duration emphasizes the need for high-quality evidence for the medical optimization of revascularization outcomes.

Clinical Outcomes of Non-Stent-Based Interventions for Symptomatic Below-the-Knee Peripheral Artery Disease in the Excellence in Peripheral Artery Disease (XLPAD) Registry

For endovascular treatment of below-the-knee (BTK) peripheral artery disease (PAD), independently adjudicated real-world outcomes comparing non-stent-based balloon angioplasty (percutaneous transluminal angioplasty) and adjunctive treatments with or without a concomitant ipsilateral femoropopliteal (FP) artery intervention are scarce. A total of 1,060 patients from the multicenter XLPAD registry who underwent non-stent-based BTK PAD intervention between 2006 and 2021 were included. The primary outcome was the 1-year incidence of major adverse limb events (MALEs), a composite of all-cause death, any amputation, or clinically driven repeat revascularization. A total of 566 patients underwent BTK and 494 BTK + FP interventions; 72% were men, with a mean age of 68.4 ± 10.9 years. Diabetes mellitus was more prevalent in the BTK-only group (76.5% vs 69%, p = 0.006). Mean Rutherford class was 4.2 ± 1.18; chronic limb-threatening ischemia was more frequent in the BTK group (55.3% vs 49%, p = 0.040). Moderate to severe calcification was more frequent in the BTK + FP group (21.2% vs 27.1%, p = 0.024), as was lesion length (110.6 ± 77.3 vs 135.4 ± 86.3 mm, p <0.001). Nearly 81% of lesions were treated with percutaneous transluminal angioplasty. Drug-coated balloon (1.6% vs 14%, p <0.001) and atherectomy (38% vs 58.5%, p <0.001) use was more frequent in the BTK + FP group. The rate of procedural success was higher in the BTK + FP group (86% vs 91%, p = 0.009), with amputation being the most common complication at 3.3% within 30 days after the procedure. The rates of 1-year MALE (21.2% vs 22.3%, p = 0.675) and mortality (4.6% vs 3.4%, p = 0.3) were similar between the BTK and BTK + FP groups. Nonstent treatment for BTK PAD with concomitant FP intervention leads to high procedural success and similar rates of 1-year MALE compared with isolated BTK intervention. Condensed Abstract: The vast majority of below-the-knee (BTK) peripheral artery disease (PAD) interventions are performed with balloon angioplasty. Presence of inflow femoropopliteal PAD in patients who undergo BTK interventions can affect the outcome of the procedure. This report explores immediate procedural success and major adverse limb events at 1 year after balloon angioplasty treatment for isolated BTK PAD and in patients who underwent an additional femoropopliteal PAD intervention.

Evaluation of properties for Carbothane™ 3575A-based electrospun vascular graftsin vitroandin vivo

Bioengineered vascular grafts (VGs) have emerged as a promising alternative to the treatment of damaged or occlusive vessels. It is thought that polyurethane (PU)-based scaffolds possess suitable hemocompatibility and biomechanics comparable to those of normal blood vessels. In this study, we investigated the properties of electrospun scaffolds comprising various blends of biostable polycarbonate-based PU (Carbothane™ 3575A) and gelatin. Scaffolds were characterized by scanning electron microscopy, infra-red spectroscopy, small-angle x-ray scattering, stress-loading tests, and interactions with primary human cells and blood. Data fromin vitroexperiments demonstrated that a scaffold produced from a blend of 5% Carbothane™ 3575A and 10% gelatin has proven to be a suitable material for fabricating a small-diameter VG. A comparativein vivostudy of such VGs and expanded polytetrafluoroethylene (ePTFE) grafts implanted in the abdominal aorta of Wistar rats was performed. The data of intravital study and histological examination indicated that Carbothane-based electrospun grafts outclass ePTFE grafts and represent a promising device for preclinical studies to satisfy vascular surgery needs.

Antithrombotic Strategies for Patients With Peripheral Artery Disease: JACC Scientific Statement

Patients with peripheral artery disease (PAD) experience major cardiovascular and limb events. Antithrombotic strategies including antiplatelets and anticoagulants remain a cornerstone of treatment and prevention. Recent trials have shown heterogeneity in the response to antithrombotic therapies in patients presenting primarily with PAD when compared to those presenting primarily with coronary artery disease. In addition, there is observed heterogeneity with regards to the effects of antiplatelets and anticoagulants with respect to different outcomes including cardiovascular and major adverse limb events. This, coupled with risks of bleeding, requires a patient-centered and holistic assessment of benefit-risk when selecting antithrombotic strategies for patients with PAD. A global multidisciplinary work group was convened to evaluate antithrombotic strategies in PAD and to summarize the current state of the art. Common clinical scenarios around antithrombotic decision making were provided. Finally, insights with regard to implementation future investigation were described.

Management of Pain in People Living With Chronic Limb Threatening Ischemia: Highlights From a Rapid Umbrella Review

Peripheral artery disease is a complex health condition. It is associated with atherosclerotic occlusive lesions in the arteries limiting normal blood flow, mostly involving the lower extremities, leading to chronic limb-threatening ischemia (CLTI). Chronic unrelenting ischemic leg pain can be debilitating and distressing, contributing to poor health-related quality of life. Comprehensive management of pain associated with CLTI requires multimodal approaches that draw on a range of strategies and specialist treatments delivered by an interdisciplinary team across various health care settings. We recognized a significant gap in evidence-based strategies that are accessible, appropriate, acceptable, effective, and safe for the elderly with CLTI-associated pain. We therefore conducted an umbrella review or overview of multiple existing reviews that employ a rigorous and transparent method to comprehensively identify and synthesize relevant literature including systematic, scoping, and narrative reviews. The purpose of this umbrella review was to aggregate and compare various management options to inform best practices and quality indicators for the management of ischemic pain in older patients with peripheral artery disease.

Diet and exercise in relation to lower extremity artery disease

Adherence to the Mediterranean diet (MeD) has been associated with a reduced incidence of peripheral arterial disease (PAD)/lower extremity arterial disease (LEAD) in observational trials and in a randomized trial. In secondary prevention, a lower hazard ratio for composite major adverse cardiovascular events has been associated with better adherence to MeD in a relatively small, randomized trial. This has not been confirmed in a sub-analysis of a large interventional trial of dual antithrombotic treatment. The effects of vegetarian, vegan or low carbohydrate/ketogenic diets on the incidence and outcomes of PAD/LEAD are not known. While abdominal obesity is associated with diabetes mellitus and PAD/LEAD, the lowest incidence of PAD/LEAD has been found in subjects with a body mass index 25-29.9 kg/m2. Malnutrition is a negative prognostic factor for survival of patients with chronic limb threatening ischemia. Physical activity (PA) is an acute stressor, but habitual recreational PA results in beneficial adaptations and improved health. In observational studies, lower levels of exercise and lower physical fitness have been associated with more prevalent PAD/LEAD. In contrast to coronary artery disease, that shows a reverse J-shaped relationship between long-term endurance exercise and coronary atherosclerosis, such a relationship is not known for PAD/LEAD. A general recommendation for maintaining cardiovascular health is performing regular moderate-intensity exercise with some vigorous-intensity aerobic PA, and resistance exercise at least twice a week. Combinations of healthy behaviors are more effective in preventing PAD/LEAD than a single behavioral component. In treatment of PAD/LEAD causing intermittent claudication, supervised walking training is recommended among measures of first-line treatment, while unsupervised walking training should be considered as an alternative.

Hypertension in Patients With Peripheral Artery Disease: An Updated Literature Review

Peripheral artery disease (PAD), a condition where there is reduced blood flow due to narrowing or blockage of the arteries of the peripheral vasculature, is an epidemic that currently affects eight million people in the United States alone and is a major risk equivalent to having active coronary artery disease (CAD). However, it is commonly underdiagnosed in the general population. Hypertension is a common cardiovascular condition characterized by elevated blood pressure levels. There are several mitigating risk factors that can reduce the risk of complications of PAD, with hypertension playing a major role. This literature review aims to explore the relationship between hypertension and PAD, including their shared risk factors, pathophysiological mechanisms, and management strategies. In addition, we will analyze how this impacts major cardiovascular outcomes, such as critical limb ischemia, vascular amputation, myocardial infarction (MI), ischemic stroke, and cardiovascular-related death by examining relevant studies, current guidelines, and evidence. This literature review is intended to guide practitioners on ideal blood pressure parameters and evidence-based anti-hypertensives that provide overall cardiovascular benefit in both the primary care and hospital-based setting. By understanding the association between hypertension and PAD and the underlying pathophysiological mechanisms, healthcare professionals can improve diagnosis, treatment, and management strategies for affected individuals.