Femoral Plaque Echogenicity and Cardiovascular Risk in Claudicants

Arterial Adventitial Vasa Vasorum Density Reflects The Progression Of Unstable Plaques: A Retrospective Clinical Study

OBJECTIVE

Arterial adventitial vasa vasorum (AVV) plays an important role in the occurrence and development of atherosclerotic (AS) disease. AS is a systemic disease, and plaque is not only a local vascular event, but also occurs at multiple sites throughout the vascular bed. Currently, effective anti-AVV therapies are lacking. Therefore, we posed the following scientific questions: "does human carotid adventitial vasa vasorum density reflect plaque neovascularization and intimal-media hyperplasia in carotid?"; and "is it possible to reduce human AVV density by sonodynamic therapy (SDT)?"

METHODS

A retrospective study was conducted on 160 patients with carotid atherosclerosis. Duplex ultrasound scanning (DUS), contrast-enhanced ultrasound (CEUS), coronary angiography, and coronary CT angiography (CTA) were used for diagnosis and screening. Pearson correlation tests and Receiver operating characteristic (ROC) curve were used to analyze the relationships between AVV hyperplasia, vasa vasorum (VV) hyperplasia and the intima-media thickness (IMT). SDT was developed for the treatment of arterial AVV hyperplasia and AS plaques.

RESULTS

The presence of local AVV in carotid unstable plaques correlated with the echogenic properties of the carotid plaque and the extent of plaque progression; Furthermore local AVV hyperplasia in patients with carotid atherosclerotic plaques was associated with acute coronary syndrome (ACS) events; Local AVV hyperplasia in patients with carotid atherosclerotic plaques was associated with coronary artery stenosis. Notably, SDT reduced local AVV hyperplasia and shrank the plaques in human femoral and carotid atherosclerotic lesions.

CONCLUSIONS

The presence of AVV in human carotid arteries reflects the severity of carotid and coronary artery AS. Further, SDT can reduce the hyperplasia of local AVV in human femoral and carotid plaques.

Calcification patterns in femoral and carotid atheromatous plaques: A comparative morphometric study

This comparative study was designed to focus on the mineral patterns in human atherosclerotic plaques based on quantitative measurements of calcium deposits through the morphometric method. A total of 101 atherosclerotic plaques were harvested by conventional transluminal angioplasty from the carotid artery (CA) and different segments of the femoral-popliteal axis (FPA), fixed in formalin and sent for histological processing. The histological grade of the atherosclerotic plaque and the calcification pattern were evaluated, followed by a morphometric analysis of the mineral deposits. Regarding the localization, the advanced plaques (VII and VIII types) developed predominantly at the level of the superficial femoral artery (SFA) compared to the CA (P<0.001). This significant difference was maintained even if they were divided into low grade (IV and V) and high grade categories (VI, VII and VIII) (P<0.05). Compared with that in the carotid plaques, in the FPA plaques the mineralized surface increased in parallel with the narrowing of the vascular lumen diameter. The image analysis of the total pathological calcification score (pCS) showed a significant difference between the CA plaques and distal SFA (dSFA) plaques (P=0.038) and between the proximal SFA (pSFA) and dSFA plaques (P=0.013). In the case of the simple nodular pattern, calcification occupied significantly larger areas in the plaques developed in the dSFA and popliteal artery (PA) in comparison with the CA plaques (P=0.0007 and P=0.0009). pCSs calculated in plaques with extensive calcification pattern showed a lower value in the CA vs. the pSFA plaques (P=0.004). A less pronounced, but significant difference was observed between the pCS of pSFA and dSFA plaques (P=0.017). Femoral and carotid plaques exhibited different morphology and tendency for calcification. In parallel with the narrowing of the vascular lumen diameter, the mineralized surface increased at the level of different FPA segments. These results suggest that the mechanism is site-specific, and wall structure-dependent.

AST/ALT Ratio and Peripheral Artery Disease in a Chinese Hypertensive Population: A Cross-Sectional Study

Previous studies reported that the aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT) was a risk factor in cardiovascular disease. Peripheral artery disease (PAD) is an important risk factor for cardiovascular death. However, only a few studies investigated the correlations between the AST/ALT ratio and PAD. We analyzed data from 10 900 patients with hypertension from the Chinese Hypertension Registry Study; 350 patients had PAD (prevalence 3.2%). After adjusting for potential confounders, the AST/ALT ratio was independently and positively associated with risk of PAD (OR: 1.31, 95% CI, 1.13-1.59), and a significant increased risk of PAD for the third AST/ALT ratio tertile (T3) compared with the first tertile (T1; OR: 1.49, 95% CI, 1.09-2.04, P _trend = .005) was found. Moreover, when we combined T1 and T2 into one group and used it as a reference group, the risk of PAD increased with the increase in AST/ALT; the risk ratio was 1.52 (95% CI, 1.20-1.95). A higher AST/ALT ratio (≥1.65) was associated with PAD risk in Chinese adults with hypertension. Our results suggest that the AST/ALT ratio may help identify patients at high risk of vascular end points and might be a convenient, economical, and effective tool for evaluating the risk of atherosclerosis.

Association between multi-site atherosclerotic plaques and systemic arteriosclerosis: results from the BEST study (Beijing Vascular Disease Patients Evaluation Study)

BACKGROUND

Arteriosclerosis can be reflected in various aspect of the artery, including atherosclerotic plaque formation or stiffening on the arterial wall. Both arteriosclerosis and atherosclerosis are important and closely associated with cardiovascular disease (CVD). The aim of the study was to evaluate the association between systemic arteriosclerosis and multi-site atherosclerotic plaques.

METHODS

The study was designed as an observational cross-sectional study. A total of 1178 participants (mean age 67.4 years; 52.2% male) enrolled into the observational study from 2010 to 2017. Systemic arteriosclerosis was assessed by carotid femoral artery pulse wave velocity (CF-PWV) and multi-site atherosclerotic plaques (MAP, > = 2 of the below sites) were reflected in the carotid or subclavian artery, abdominal aorta and lower extremities arteries using ultrasound equipment. The associations were assessed by multivariable logistic regression.

RESULTS

The prevalence of CF-PWV > 12 m/s and MAP were 40.2% and 74.4%. Atherosclerotic plaques in 3 sites were more common in male compared with that in female (48.9% versus 36.9%, p < 0.05). All CVD factors were worse in participants with MAP than that with <=1 site. Participants with CF-PWV > 12 m/s corresponded to a mean 82% probability of MAP with age and sex-adjusted. Patients with peripheral artery disease showed the highest odds ratio (OR) (3.88) for MAP, followed by smoking (2.485), CF-PWV > 12 m/s (2.25), dyslipidemia (1.89), male (1.84), stroke (1.64), hypoglycemic agents (1.56) and age (1.09) (all p < 0.001).

CONCLUSIONS

MAP was highly prevalent in this cohort, with male showing a higher prevalence than female. Higher systemic arteriosclerosis was independently associated with MAP, which indicating the supplementary value of arteriosclerosis for the earlier identification and intervention on MAP.

TRIAL REGISTRATION

Clinical Trial, URL: http://www.clinicaltrials.gov . Unique identifier: NCT02569268 .

Alcohol Consumption in Combination with an Atherogenic Diet Increased Indices of Atherosclerosis in Apolipoprotein E/Low-Density Lipoprotein Receptor Double-Knockout Mice

BACKGROUND

Alcohol abuse and adherence to atherogenic diet (AD; a low-carbohydrate-high-protein diet) have been positively associated with cardiovascular disease. In addition, it has been demonstrated clinically that dietary intake is increased on days when alcohol is consumed. Here, the additive effects of ethanol (EtOH) and AD on atherosclerosis, a major underlying cause of cardiovascular disease, were investigated in apolipoprotein E/low-density lipoprotein receptor double-knockout (KO) mice. The mechanisms, especially aortic oxidative stress damage, were highlighted.

METHODS

Twelve-week-old male KO mice on AD with or without EtOH treatment were bred for 4 months. Age-matched male C57BL/6J mice on a standard chow diet without EtOH treatment served as controls. Analyses were conducted using ultrasound biomicroscopy, histopathological and fluorescence immunohistochemical examinations, Western blots, and polymerase chain reaction.

RESULTS

KO mice on AD with EtOH treatment showed increases in aortic maximum intima media thickness, hypoechoic plaque formation, and mean Oil-Red-O content. These results were associated with enhanced ratio of aortic 8-hydroxy-2'-deoxyguanosine (8-OHdG)-immunopositive area to the metallothionein (MT) immunopositive area and suppression of AD-induced up-regulated aortic Mt1, Mt2, and upstream stimulatory factor 1 mRNA expressions. Moreover, 8-OHdG was expressed in the nuclei of CD31- and alpha smooth muscle actin-immunopositive cells, and the up-regulated mRNA expressions of aortic nitric oxide synthase 3 and platelet-derived growth factors were only observed in the KO mice on AD with EtOH treatment.

CONCLUSIONS

Alcohol abuse and adherence to AD may promote the shift of aortic oxidative stress and antioxidative stress balance toward oxidative stress predominance and reduced antioxidative stress, which may be partly due to the decrease in MT at the cell biological level and down-regulation of Mt at the gene level, which in turn could play a role in the up-regulation of endothelial dysfunction-related and vascular smooth muscle cell proliferation-related gene expression and the progression of atherosclerosis in mice with hyperlipidemia.

Femoral Artery Ultrasound Examination

We compared intima–media thickness (IMT) and the prevalence of plaques in the common carotid artery (CCA) and common femoral artery (CFA) in apparently healthy participants. This multicenter study included 322 participants (59.9% female; age 20-78 years, mean 52.1 ± 15.3 years) who underwent Echo-color Doppler examination of the CCA and CFA bilaterally. Prevalence and composition of plaque were recorded. A significant ( P < .01) difference between mean CCA-IMT and mean CFA-IMT was detected (0.70 vs 0.73 mm). Plaque prevalence was significantly higher in the CFA compared to the CCA (40.7% vs 30.4%). Atherosclerotic plaques were found in both CFA and CCA in 46% of the cases, solely in CFA in 38%, and in CCA alone in 17%. The observed difference in plaque prevalence was even greater when only fibrolipid isolated plaques were considered (CFA 39.4% vs CCA 22.1%). In a healthy general population, atherosclerotic plaques were present in the CFA but not in the CCA in over one-third of the cases. Further studies must confirm whether ultrasonography of the CFA might be introduced in the screening protocols for cardiovascular risk assessment.

Non-invasive vulnerable plaque imaging: how do we know that treatment works?

Atherosclerosis is an inflammatory disorder that can evolve into an acute clinical event by plaque development, rupture, and thrombosis. Plaque vulnerability represents the susceptibility of a plaque to rupture and to result in an acute cardiovascular event. Nevertheless, plaque vulnerability is not an established medical diagnosis, but rather an evolving concept that has gained attention to improve risk prediction. The availability of high-resolution imaging modalities has significantly facilitated the possibility of performing in vivo regression studies and documenting serial changes in plaque stability. This review summarizes the currently available non-invasive methods to identify vulnerable plaques and to evaluate the effects of the current cardiovascular treatments on plaque evolution.

Physical activity in the prevention of peripheral artery disease in the elderly

Aging is a well-known cardiovascular risk factor and cardiovascular diseases (CVD) are estimated to be the most common cause of death in the elderly. Peripheral arterial disease (PAD) represents an important clinical manifestation of CVD leading to increase morbidity and mortality, especially in elderly population. The correct management of PAD population includes the prevention of cardiovascular events and relief of symptoms, most commonly intermittent claudication. Progressive physical activity is an effective treatment to improve walking distance and to reduce mortality and cardiovascular events in patients with PAD, however the ability to effectively engage in physical activity often declines with increasing age. The maintenance and increase of reserve functional capacity are important concepts in the elderly population. Ultimately, the goal in participation of physical activity in the healthy elderly population is maintenance and development of physical functional reserve capacity. Therefore, for individuals suffering of PAD, appropriate physical activity in the form of supervised exercise may serve as a primary therapy. Although there are few direct comparisons of therapeutic exercise programs vs. pharmacological or surgical interventions, these increases in walking distance are greater than those reported for the most widely used agents for claudication, pentoxyphylline, and cilostazol. Despite a reduction in mortality and improvement of quality of life caused by physical activity in the PAD population, the molecular, cellular, and functional changes that occur during physical activity are not completely understood. Therefore, this review article aims at presenting an overview of recent established clinical and molecular findings addressing the role of physical activity on PAD in the older population.

Quantitative imaging biomarkers for the evaluation of cardiovascular complications in type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a prevalent condition in aged populations. Cardiovascular diseases are leading causes of death and disability in patients with T2DM. Traditional strategies for controlling the cardiovascular complications of diabetes primarily target a cluster of well-defined risk factors, such as hyperglycemia, lipid disorders and hypertension. However, there is controversy over some recent clinical trials aimed at evaluating efficacy of intensive treatments for T2DM. As a powerful tool for quantitative cardiovascular risk estimation, multi-disciplinary cardiovascular imaging have been applied to detect and quantify morphological and functional abnormalities in the cardiovascular system. Quantitative imaging biomarkers acquired with advanced imaging procedures are expected to provide new insights to stratify absolute cardiovascular risks and reduce the overall costs of health care for people with T2DM by facilitating the selection of optimal therapies. This review discusses principles of state-of-the-art cardiovascular imaging techniques and compares applications of those techniques in various clinical circumstances. Individuals measurements of cardiovascular disease burdens from multiple aspects, which are closely related to existing biomarkers and clinical outcomes, are recommended as promising candidates for quantitative imaging biomarkers to assess the responses of the cardiovascular system during diabetic regimens.

Transradial approach for the endovascular treatment of type I endoleak after aortic aneurysm repair: a case report

Background

Endovascular repair of aortic aneurysms (EVAR) is obtained through the positioning of an aortic stent-graft, which excludes the aneurysmatic dilation. Type I endoleak is the most common complication, and it is caused by an incompetent proximal or distal attachment site, causing the separation between the stent-graft and the native arterial wall, and in turn creating direct communication between the aneurysm sac and the systemic arterial circulation. Endoleak occurrence is associated with high intrasac pressures, and requires a quick repair to prevent abdominal aortic aneurysm rupture.

Case presentation

We report the first case of a 80-year-old man undergoing percutaneous closure of a peri-graft endoleak (type I) by transcatheter embolization through radial arterial access.

Conclusion

The transradial approach has been shown to be a safe and effective alternative to the traditional transfemoral approach. A decrease in vascular complications and improved patient comfort are the primary benefits of this technique in patients with previous EVAR.

The Norwegian Stroke in the Young Study (NOR-SYS): rationale and design

BACKGROUND

Ischemic stroke in young adults is a major health problem being associated with a higher vascular morbidity and mortality compared to controls, and a stroke recurrence rate of 25% during the first decade. The assumed cause of infarction and the detected risk factors determine the early- and long-term treatment. However, for many patients the cause of stroke remains unknown. Risk factor profile and etiology differ in young and elderly ischemic stroke patients, and atherosclerosis is the determined underlying condition in 10 to 15%. However, subclinical atherosclerosis is probably more prevalent and may go unrecognized.

METHODS/DESIGN

NOR-SYS is a prospective long-term research program. Standardized methods are used for anamnestic, clinical, laboratory, imaging, and ultrasound data collection in ischemic stroke patients aged ≤60 years, their partners and joint adult offspring. The ultrasound protocol includes the assessment of intracranial, carotid and femoral arteries, abdominal aorta, and the estimation of VAT. To date, the study is a single centre study with approximately 400 patients, 250 partners and 350 adult offspring expected to be recruited at our site.

DISCUSSION

NOR-SYS aims to increase our knowledge about heredity and the development of arterial vascular disease in young patients with ischemic stroke and their families. Moreover, optimization of diagnostics, prophylaxis and early intervention are major targets with the intention to reduce stroke recurrence and other clinical arterial events, physical disability, cognitive impairment and death.

Use of statins in lower extremity artery disease: a review

Background

Lower extremity artery disease (LE-PAD) is one of the most common manifestations of atherosclerosis, particularly in elderly patients, and it is related to a high cardiovascular risk.

Description

It is well established that statin therapy is characterized by crucial benefits on cardiovascular system by limiting atherosclerotic progression and reducing cardiovascular events and mortality. A growing body of evidence support efficacy of statins in LE-PAD due to the ability of both reducing cardiovascular risk and improving walking distance and, hence, quality of life. Consequently, statin therapy should be considered in all LE-PAD patients and new LDL-cholesterol targets should be reached.

Conclusions

Our opinion is that statin therapy remains still underutilized or with inadequate dosage, so therapy of LE-PAD patients should be improved to obtain all the demonstrated benefits of statins.

Ankle/brachial index to everyone

BACKGROUND

In the last years significant attention has been paid in identifying markers of subclinical atherosclerosis or of increased cardiovascular risk.

METHOD

An abnormal ankle/brachial index (ABI) identifies patients affected by lower extremity peripheral arterial disease, and even more important, represents a powerful predictor of the development of future ischemic cardiovascular events.

CONCLUSIONS

In our opinion, ABI is a cardiovascular risk prediction tool with very desirable properties that might become a routine measurement in clinical practice.

The role of atherectomy in the treatment of lower extremity peripheral artery disease

Background

The incidence of lower extremity peripheral artery disease (LE-PAD) continues to increase and associated morbidity remains high. Despite the significant development of percutaneous revascularization strategies, over the past decade, LE-PAD still represents a unique challenge for interventional cardiologists and vascular surgeons.

Method

Typical features of atherosclerosis that affects peripheral vascular bed (diffuse nature, poor distal runoff, critical limb ischemia, chronic total occlusion) contribute to the disappointing results of traditional percutaneous transluminal angioplasty (PTA). New technologies have been developed in attempt to improve the safety and effectiveness of percutaneous revascularization. Among these, atherectomy, debulking and removing atherosclerotic plaque, offers the potential advantage of eliminating stretch on arterial walls and reducing rates of restenosis.

Conclusions

This review summarizes the features and the current applications of new debulking devices.

Endovascular treatment of lower extremity arteries is associated with an improved outcome in diabetic patients affected by intermittent claudication

BACKGROUND

Lower extremity peripheral arterial disease (LE-PAD) is a highly prevalent condition among diabetic patients, associated with reduced walking capacity and a high incidence of cardiovascular events. Endovascular revascularization of lower extremities arteries improves walking performance and quality of life of diabetic patients affected by intermittent claudication, but few studies evaluated the impact of revascularization on cardiovascular outcome in this high-risk population. Accordingly, in the present study we evaluated if leg-ischemia resolution by effective lower limbs percutaneous revascularization can also impact cardiovascular outcome in a homogeneous group of diabetic patients affected by intermittent claudication.

METHODS

236 diabetic patients affected by LE-PAD at stage II of Fontaine's classification, with ankle/brachial index ≤ 0.90 and one or more hemodynamically significant stenosis in at least one artery of the ileo-femoro-popliteal axis were enrolled in the study. According to the Trans-Atlantic Inter Society Consensus II recommendations, 123 (52.1%) underwent percutaneous transluminal angioplasty (PTA group), while 113 (47.9%) underwent conservative medical therapy only (MT group). The incidence of major cardiovascular events (cardiovascular death, myocardial infarction, ischemic stroke, coronary or carotid revascularization) was prospectively analyzed with Kaplan-Meier curves and the risk of developing a cardiovascular event calculated by Cox analyses.

RESULTS

No baseline difference in cardiovascular risk factors were observed between the PTA and MT groups, except for a lower prevalence of males in PTA group (74.8% vs. 85.8%, p=0.034). Furthermore, patients in the PTA group showed a worse walking capacity as expressed by maximum walking distance (108.7 ± 300.9 vs 378.4 ± 552.3 meters, p<0.001). During a median follow-up of 20 months (12.0-29.0), the incidence of cardiovascular events was markedly lower in patients in the PTA group with respect to patients in the MT group (7.3% vs. 22.1%, p=0.001), and patients of the MT group had at Cox analysis a 3.9 increased risk with respect to PTA group, after adjustment for potential confounding factors (95% CI 1.1-15.3, p=0.049).

CONCLUSIONS

The present study shows that lower limbs revascularization of diabetic patients affected by intermittent claudication, in addition to improve walking performance, is associated with a reduction in the incidence of future major cardiovascular events.

Abdominal aortic aneurysm in patients affected by intermittent claudication: prevalence and clinical predictors

Background

Abdominal aortic aneurysm (AAA) is a frequent cause of death among elderly. Patients affected by lower extremity peripheral arterial disease (LE-PAD) seem to be particularly at high risk for AAA. We aimed this study at assessing the prevalence and the clinical predictors of the presence of AAA in a homogeneous cohort of LE-PAD patients affected by intermittent claudication.

Methods

We performed an abdominal ultrasound in 213 consecutive patients with documented LE-PAD (ankle/brachial index ≤0.90) attending our outpatient clinic for intermittent claudication. For each patient we registered cardiovascular risk factors and comorbidities, and measured neutrophil count.

Results

The ultrasound was inconclusive in 3 patients (1.4%), thus 210 patients (169 males, 41 females, mean age 65.9 ± 9.8 yr) entered the study. Overall, AAA was present in 19 patients (9.0%), with a not significant higher prevalence in men than in women (10.1% vs 4.9%, p = 0.300). Patients with AAA were older (71.2 ± 7.0 vs 65.4 ± 9.9 years, p = 0.015), were more likely to have hypertension (94.7% vs 71.2%, p = 0.027), and greater neutrophil count (5.5 [4.5 – 6.2] vs 4.1 [3.2 – 5.5] x10³/μL, p = 0.010). Importantly, the c-statistic for neutrophil count (0.73, 95% CI 0.60 – 0.86, p =0.010) was higher than that for age (0.67, CI 0.56–0.78, p = 0.017). The prevalence of AAA in claudicant patients with a neutrophil count ≥ 5.1 x10³/μL (cut-off identified at ROC analysis) was as high as 29.0%.

Conclusions

Prevalence of AAA in claudicant patients is much higher than that reported in the general population. Ultrasound screening should be considered in these patients, especially in those with an elevated neutrophil count.