A modern day perspective on smoking in peripheral artery disease

Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery Practice Guidelines for the endovascular management of claudication

OBJECTIVE

In 2015, Society for Vascular Surgery (SVS) guidelines on claudication management were released, spanning optimal medical management, procedural, and post-procedure recommendations. Uptake of guidelines and changes to clinical practice over time remain unknown. This study hypothesized that guideline-aligned practice increased after guideline release.

METHODS

The Vascular Quality Initiative Peripheral Vascular Intervention (VQI PVI) dataset was queried for years 2010 to 2021 for cases of claudication from occlusive disease. Only the initial procedure was considered, and subsequent interventions were excluded. The primary endpoint was care aligned with the 2015 SVS claudication treatment guidelines that were possible to evaluate in the VQI PVI dataset. Guideline-aligned practice before 2016 was compared with that after 2016. A hierarchical regression was used to control for hospital-level variation introduced by changing VQI membership during the study timeframe.

RESULTS

A majority of the 2015 SVS guideline GRADE 1-A recommendations can be assessed using the VQI PVI dataset. Overall, 93,654 cases were included, 30.9% before 2016 and 69.1% after guideline release. After controlling for hospital-level variation, guideline-aligned care improved for preoperative smoking cessation, aspirin, clopidogrel, and statin use, and postoperative medical therapy with antiplatelet, dual antiplatelet, and statin therapy. Guideline aligned care did not change over time for aorto-iliac stent use, covered stent use in calcified aortoiliac disease, or superficial femoral artery stenting for 5- to 15-cm lesions. Guideline-aligned care worsened for isolated infrapopliteal treatments and use of bare metal stents for 5- to 15-cm superficial femoral artery occlusions. Secondary analysis identified an association between area deprivation index and increased odds of smoking and decreased odds of meeting post-discharge optimal medical therapy.

CONCLUSIONS

Although guideline-aligned care improved after guideline release for medical management of claudication, procedural elements did not improve. Those with social deprivation were less likely to receive guideline-aligned care for medical management, representing a future area of study and improvement. High-grade recommendations can be tracked using the VQI PVI dataset and should be monitored to help improve care.

Evaluation of the utility of cardiac biomarkers for risk stratification in patients with lower extremity artery disease: A retrospective study

Critical limb threatening ischemia (CLTI) is associated with a one-year mortality rate of up to 25% making prompt diagnosis essentially. This study aims to investigate if cardiac biomarkers may serve as an effective tool for risk stratification in patients with lower extremity artery disease (LEAD). For this cross-sectional retrospective analysis, 21712 patients with LEAD were screened for eligibility from 2004 to 2020. Out of these patients, 367 were included and subdivided into those with CLTI and those without CLTI. Cardiac biomarkers, including N-terminal prohormone of brain natriuretic peptide (NT-proBNP), troponin, NT-proBNP/troponin ratio, creatin kinase myocardial band (CK-MB) and myoglobin, were retrospectively analyzed. Fifty-nine patients had CLTI (16.1%) with higher rates of NT-proBNP, NT-proBNP/troponin ratio, CK-MB and myoglobin (all p < 0.05) compared to non-CLTI patients. In univariate analysis, NT-proBNP, NT-proBNP/troponin ratio, CK-MB, myoglobin, age, C-reactive protein and non-insulin dependent diabetes mellitus (NIDDM) were associated with CLTI (all p < 0.05). In multivariate analysis, age and NIDDM remained significant predictors (all p < 0.05) while cardiac biomarkers were not independently associated with CLTI. Troponin, NT-proBNP and myoglobin were associated with mortality in univariate analysis (all p < 0.05). In multivariate analysis, troponin only remains to be associated with mortality (p = 0.001). Selected cardiac biomarkers failed to demonstrate statistically significant differentiation between CLTI and non-CLTI patients with LEAD, while troponin may be potentially associated with mortality.

Trends in lower extremity peripheral arterial disease incidence since 1990 and forecasting future statistics using Global Burden of Disease 2021: a time-series analysis

Background

Lower extremity peripheral arterial disease (LEPAD) significantly affects quality of life and is associated with severe cardiovascular risks. Studies on its long-term incidence trends are limited.

Objective

This study aims to analyze global trends in LEPAD incidence from 1990 to 2021 using the Global Burden of Disease (GBD) 2021 database and to forecast future trends between 2022 and 2030, providing insights for healthcare planning and resource allocation.

Methods

Data were extracted from the GBD 2021 database by genders, age groups, continents, and sociodemographic index (SDI) levels. Using Joinpoint regression analysis, annual percentage changes (APC) and average annual percentage changes (AAPC) were calculated to assess age-standardized incidence rates (ASIR) historical trends. Autoregressive integrated moving average (ARIMA) model was applied to predict ASIR between 2022 and 2030.

Results

The global ASIR of LEPAD showed a slight decrease from 1990 to 2021, though regional differences were notable. In 2021, the highest ASIR was in the Americas, while Africa had the lowest. Gender and age disparities were significant, and females and older populations were at higher risk. ARIMA predictions indicate a stable ASIR trend from 2025 onward.

Conclusion

This study provides a comprehensive analysis of LEPAD incidence trends and a forecast through 2030. While global incidence may stabilize, the rising burden in lower-income countries calls for prioritizing early intervention and health education in high-risk regions. These findings emphasize the importance of targeted resource allocation and strategic prevention efforts.

Cardiovascular Effects of Smoking and Smoking Cessation: A 2024 Update

Smoking is a significant risk factor for both acute and chronic cardiovascular diseases. These diseases contribute to approximately twenty percent of all-cause mortality. Research indicates that quitting smoking can substantially reduce or even reverse the harmful effects associated with smoking on cardiovascular health. Notably, these benefits can be observed in a relatively short period compared to the duration of smoking history. This article aims to provide data to understand the effects of smoking on the cardiovascular system locally as well as its effects as a pandemic globally and hence provide comprehensive strategies in the management of cardiovascular patients for smoking cessation.

Comparing arm-ergometry and treadmill exercise training on cardiovascular risk factors in peripheral artery disease: secondary analysis of the ARMEX trial

BACKGROUND

Peripheral artery disease (PAD), usually caused by atherosclerosis, is linked to high cardiovascular mortality. In this setting, a multidimensional cardiovascular rehabilitation program (CRP) comprising supervised exercise training can improve cardiovascular risk factors (CRF) control. This study compares the effects of an arm-ergometry supervised exercise training (AEx) with a standard treadmill protocol (TEx) on CRF.

METHODS

The ARMEX trial (ISRCTN54908548) was a single-center, single-blinded, parallel groups, noninferiority randomized clinical trial enrolling symptomatic PAD patients referred to a CRP. Participants were randomized (1:1) either to a 12-week AEx or TEx. Changes in blood pressure, lipid profile, glycated hemoglobin, body composition, physical activity levels, sedentary time and number of cigarettes smoked after the CRP were assessed.

RESULTS

Fifty-six patients (66±8.4 years; 87.5% male) were included: AEx (N.=28) and TEx (N.=28). Systolic and diastolic blood pressure decreased in both groups without significant between-group differences. Total cholesterol and low-density lipoprotein cholesterol decreased significantly only in the AEx group, without significant between-group differences. Weight, body mass index, waist circumference, waist/hip ratio and physical activity levels improved in both groups, without significant between-group differences. Smoking reduction was also similar between groups.

CONCLUSIONS

A multidimensional CRP, whether involving arm-ergometry or treadmill exercise, improved CRF control in symptomatic PAD patients. Both exercise modalities were equally effective, supporting their use as part of a comprehensive approach in this complex population.

Association between oxidative balance scores and peripheral artery disease in US adults: a cross-sectional study

Background

The Oxidative Balance Score (OBS) quantifies the overall oxidative stress burden, with higher scores indicating greater antioxidant (relative to prooxidant) activity. This study aimed to examine the association between peripheral arterial disease (PAD) and OBS.

Methods and materials

Data from the National Health and Nutrition Examination Survey (NHANES, 1999-2004) were analyzed for participants with ankle-brachial index (ABI) measurements. The total Oxidative Balance Score (OBS) comprised a lifestyle OBS (four lifestyle categories) and a dietary OBS (16 dietary factors). Logistic regression analyses evaluated associations between PAD and total OBS, lifestyle OBS, and dietary OBS. Restricted cubic spline (RCS) analyses assessed dose-response relationships between ABI, PAD, and OBS. Mediation analyses investigated the roles of glucolipid metabolism and renal function in the OBS-PAD association. Sensitivity and stratification analyses were conducted to ensure robustness.

Results

This study included 2,437 eligible adult participants. Logistic regression analysis, adjusted for multiple potential confounders, revealed negative associations between lifestyle OBS (OR = 0.88; 95% CI: 0.79, 1.00), total OBS (OR = 0.97; 95% CI: 0.94, 0.99), and the likelihood of PAD (all p < 0.05). Restricted cubic spline (RCS) analysis demonstrated a linear relationship between total OBS and PAD, with the likelihood of PAD decreasing as total OBS increased p for nonlinearity = 0.736. Dietary OBS, lifestyle OBS, and total OBS all showed positive linear correlations with ABI levels (all p < 0.05). Mediation analysis indicated that fasting plasma glucose (FPG) and creatinine (CREA) mediated 5.9 and 0.8% of the association between total OBS and PAD, respectively (all p < 0.05). Sensitivity analyses confirmed the negative association between total OBS and PAD p < 0.05, supporting the stability of the results. Stratified analyses highlighted the significant influence of Age, particularly in the younger population aged 20-44 years, a group warranting greater attention.

Conclusion

Our study demonstrated that higher total OBS is associated with a lower likelihood of PAD. Adopting an antioxidant-rich diet alongside a healthy lifestyle may help mitigate PAD risk. Additionally, modulating FPG and CREA levels could offer potential value in addressing the link between low OBS and PAD.

Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease

Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.

12. Vascular pain: Ischemic pain in the extremities and Raynaud's syndrome

INTRODUCTION

Peripheral artery diseases (PAD) and Raynaud's syndrome are associated with substantial morbidity. PAD, through the restriction of blood flow to the extremities, may lead to critical limb ischemia with symptoms of pain at rest which may eventually progress to severe limb ischemia with gangrene. This serious and painful clinical condition requires extensive medical care, is limb-threatening and, in case of delayed or unsuccessful treatment, is associated with a high mortality rate. In Raynaud's syndrome, the blood supply to certain parts of the body, usually the fingers and toes and less frequently the nose or ears, is restricted because of vasculopathy of the smaller vessels at acral sites. Under certain circumstances, with cold as the most well-known provoking factor, blood flow restriction occurs, leading to demarcated color changes and symptoms such as pain, paresthesia, and numbness. In severe cases of Raynaud syndrome tissue ischemia may lead to necrosis and the need for amputation of the affected area.

METHODS

In this narrative review, the literature on the diagnosis and interventional pain treatment of PAD and Raynaud's syndrome was updated and summarized.

OBJECTIVES

This review focused on interventional pain treatment. In PAD, the effects of the intervention on limb salvage, ulcer healing, and ischemic pain were summarized. Additionally, results with respect to skin microcirculation and quality of life were reported if available. In Raynaud's syndrome, we focused on the effect of the intervention on peripheral blood flow metrics and pain intensity during attacks.

RESULTS

In PAD, prevention and treatment of risk factors are important. Initially, conservative treatment and pharmacological therapy are preferred first-line therapies. However, when disease progression occurs, interventional management may be considered. The literature search yielded conflicting evidence for sympathectomy as a treatment for PAD. Spinal cord stimulation (SCS) as a treatment modality for advanced PAD had high-quality evidence for limb salvage in subgroups of patients but conflicting evidence for other outcome measures such as pain, wound healing, and quality of life. The literature search for interventional pain management in Raynaud's syndrome was limited to only one randomized controlled trial (RCT) studying the effect of thoracic sympathectomy. This study had several limitations and hence the level of evidence for this interventional treatment is very low. No RCTs studying SCS in patients with Raynaud's syndrome were found.

CONCLUSIONS

In both PAD and Raynaud's syndrome, additional RCTs are needed to substantiate interventional (pain) management and bolster the evidence base for sympathectomy and SCS as treatment options.

Distinct biological signature and modifiable risk factors underlie the comorbidity between major depressive disorder and cardiovascular disease

Major depressive disorder (MDD) and cardiovascular disease (CVD) are often comorbid, resulting in excess morbidity and mortality. Here we show that CVDs share most of their genetic risk factors with MDD. Multivariate genome-wide association analysis of shared genetic liability between MDD and atherosclerotic CVD revealed seven loci and distinct patterns of tissue and brain cell-type enrichments, suggesting the involvement of the thalamus. Part of the genetic overlap was explained by shared inflammatory, metabolic and psychosocial or lifestyle risk factors. Our data indicated causal effects of genetic liability to MDD on CVD risk, but not from most CVDs to MDD, and showed that the causal effects were partly explained by metabolic and psychosocial or lifestyle factors. The distinct signature of MDD-atherosclerotic CVD comorbidity suggests an immunometabolic subtype of MDD that is more strongly associated with CVD than overall MDD. In summary, we identified biological mechanisms underlying MDD-CVD comorbidity and modifiable risk factors for prevention of CVD in individuals with MDD.

Mechanical, structural, and physiologic differences between above and below-knee human arteries

Peripheral Artery Disease (PAD) affects the lower extremities and frequently results in poor clinical outcomes, especially in the vessels below the knee. Understanding the biomechanical and structural characteristics of these arteries is important for improving treatment efficacy, but mechanical and structural data on tibial vessels remain limited. We compared the superficial femoral (SFA) and popliteal (PA) arteries that comprise the above-knee femoropopliteal (FPA) segment to the infrapopliteal (IPA) anterior tibial (AT), posterior tibial (PT), and fibular (FA) arteries from the same 15 human subjects (average age 52, range 42-67 years, 87 % male). Vessels were imaged using μCT, evaluated with biaxial mechanical testing and constitutive modeling, and assessed for elastin, collagen, smooth muscle cells (SMCs), and glycosaminoglycans (GAGs). IPAs were more often diseased or calcified compared to the FPAs. They were also twice smaller, 53 % thinner, and significantly stiffer than the FPA longitudinally, but not circumferentially. IPAs experienced 48 % higher physiologic longitudinal stresses (62 kPa) but 27 % lower circumferential stresses (24 kPa) and similar cardiac cycle stretch of <1.02 compared to the FPA. IPAs had lower longitudinal pre-stretch (1.12) than the FPAs (1.29), but there were no differences in the stored elastic energy during pulsation. The physiologic circumferential stiffness was similar in the above and below-knee arteries (718 kPa vs 754 kPa). Structurally, IPAs had less elastin, collagen, and GAGs than the FPA, but maintained similar SMC content. Our findings contribute to a better understanding of segment-specific human lower extremity artery biomechanics and may inform the development of better medical devices for PAD treatment. STATEMENT OF SIGNIFICANCE: Peripheral Artery Disease (PAD) in the lower extremity arteries exhibits distinct characteristics and results in different clinical outcomes when treating arteries above and below the knee. However, their mechanical, structural, and physiologic differences are poorly understood. Our study compared above- and below-knee arteries from the same middle-aged human subjects and demonstrated distinct differences in size, structure, and mechanical properties, leading to variations in their physiological behavior. These insights could pave the way for creating location-specific medical devices and treatments for PAD, offering a more effective approach to its management. Our findings provide new, important perspectives for clinicians, researchers, and medical device developers interested in treating PAD in both above- and below-knee locations.

Distinct genomic signatures and modifiable risk factors underly the comorbidity between major depressive disorder and cardiovascular disease

Major depressive disorder (MDD) and cardiovascular disease (CVD) are often comorbid, resulting in excess morbidity and mortality. Using genomic data, this study elucidates biological mechanisms, key risk factors, and causal pathways underlying their comorbidity. We show that CVDs share a large proportion of their genetic risk factors with MDD. Multivariate genome-wide association analysis of the shared genetic liability between MDD and atherosclerotic CVD (ASCVD) revealed seven novel loci and distinct patterns of tissue and brain cell-type enrichments, suggesting a role for the thalamus. Part of the genetic overlap was explained by shared inflammatory, metabolic, and psychosocial/lifestyle risk factors. Finally, we found support for causal effects of genetic liability to MDD on CVD risk, but not from most CVDs to MDD, and demonstrated that the causal effects were partly explained by metabolic and psychosocial/lifestyle factors. The distinct signature of MDD-ASCVD comorbidity aligns with the idea of an immunometabolic sub-type of MDD more strongly associated with CVD than overall MDD. In summary, we identify plausible biological mechanisms underlying MDD-CVD comorbidity, as well as key modifiable risk factors for prevention of CVD in individuals with MDD.

Lower limb arterial calcification and its clinical relevance with peripheral arterial disease

Lower limb arterial calcification (LLAC) is associated with an increased risk of mortality and it predicts poor outcomes after endovascular interventions in patients with peripheral artery disease (PAD). Detailed histological analysis of human lower artery specimens pinpointed the presence of LLAC in two distinct layers: the intima and the media. Intimal calcification has been assumed to be an atherosclerotic pathology and it is associated with smoking and obesity. It becomes instrumental in lumen stenosis, thereby playing a crucial role in disease progression. On the contrary, medial calcification is a separate process, systematically regulated and linked with age advancement, diabetes, and chronic kidney disease. It prominently interacts with vasodilation and arterial stiffness. Given that both types of calcifications frequently co-exist in PAD patients, it is vital to understand their respective mechanisms within the context of PAD. Calcification can be easily identifiable entity on imaging scans. Considering the highly improved abilities of novel imaging technologies in differentiating intimal and medial calcification within the lower limb arteries, this review aimed to describe the distinct histological and imaging features of the two types of LLAC. Additionally, it aims to provide in-depth insight into the risk factors, the effects on hemodynamics, and the clinical implications of LLAC, either occurring in the intimal or medial layers.

Multi-Modality Imaging of Atheromatous Plaques in Peripheral Arterial Disease: Integrating Molecular and Imaging Markers

Peripheral artery disease (PAD) is a common and debilitating condition characterized by the narrowing of the limb arteries, primarily due to atherosclerosis. Non-invasive multi-modality imaging approaches using computed tomography (CT), magnetic resonance imaging (MRI), and nuclear imaging have emerged as valuable tools for assessing PAD atheromatous plaques and vessel walls. This review provides an overview of these different imaging techniques, their advantages, limitations, and recent advancements. In addition, this review highlights the importance of molecular markers, including those related to inflammation, endothelial dysfunction, and oxidative stress, in PAD pathophysiology. The potential of integrating molecular and imaging markers for an improved understanding of PAD is also discussed. Despite the promise of this integrative approach, there remain several challenges, including technical limitations in imaging modalities and the need for novel molecular marker discovery and validation. Addressing these challenges and embracing future directions in the field will be essential for maximizing the potential of molecular and imaging markers for improving PAD patient outcomes.