Effectiveness of Repetitive Hyperbaric Oxygen Therapy for Chronic Limb-Threatening Ischemia

BACKGROUND

Lower extremity artery disease is strongly associated with morbidity and is typically addressed through revascularization interventions. We assessed the clinical outcomes of patients with chronic limb-threatening ischemia (CLTI) without revascularization who did and did not undergo repetitive hyperbaric oxygen therapy (HBOT).

METHODS

Between April 2002 and March 2017, the records of 58 patients with CLTI (Rutherford classification 4 in 19% and 5 in 81%) were evaluated retrospectively. HBOT was performed at 2.8 atm of oxygen (HBOT group). The control group included those who could not continue HBOT and historical controls. Patients in poor general health or with an indication for revascularization therapy were excluded. We examined major adverse events (MAEs) and limb salvage rates. Independent predictors and risk stratification were analyzed using a multivariate regression analysis.

RESULTS

The mean age was 71±13 years. Of all patients, 67% had diabetes and 43% were undergoing hemodialysis. The mean follow-up period was 4.3±0.8 years. The overall survival rate was 84.5% and 81.0% at 1 and 3 years, respectively. The Cox regression analysis indicated that high body mass index (odds ratio [OR]: 0.86; 95% confidence interval [CI]: 0.76-0.97; p=0.01), well-nourished (OR: 1.21; 95% CI: 1.01-1.45), and HBOT (OR: 0.05; 95% CI: 0.01-0.26; p<0.001) independently predicted absence of MAEs. For major limb amputation, the ankle-brachial index (OR: 0.2; 95% CI: 0.05-0.86; p=0.03) and HBOT (OR: 0.04; 95% CI: 0.004-0.32; p=0.003) were independent predictors.

CONCLUSIONS

Repetitive, stand-alone HBOT was associated with MAE-free survival and limb salvage in patients with CLTI.

Incompressible ankle arteries predict increased morbidity and mortality in patients with an elevated ankle brachial index

OBJECTIVES

Patients with an elevated ankle brachial index (ABI) > 1.3 have a high burden of disease and poorer outcome compared to patients with a lower ABI. Previously differences between patients with ABI > 1.3 have not been studied in detail. The aim of this study was to analyze the morbidity and mortality of patients with ABI > 1.3.

METHODS

ABI measurements were performed in the vascular laboratory of Turku university hospital 2011-2013. Patients with ABI>1.3 in at least one lower limb were included in the study and divided into 3 groups: At least one lower limb ABI 1.3-2.5 but both limbs <2.5 (group 1), one limb ABI ≥2.5 (group 2), both limbs ABI ≥ 2.5 (group 3).

RESULTS

534 patients were included in the study. The patients in groups 2 and 3 were more often female (p < .001), older (p < .001), had more diabetes (p = .013), coronary artery disease (p = .001) and chronic heart (p = .010) and kidney failure (p = .013) compared to patients in group 1. The survival of patients in group 2 and 3 was significantly poorer compared to the patients in group 1 (HR1.6, 95% CI 1.2-2.2, p = .002 and 1.7, 95% CI 1.2-2.3, p < .001, respectively). Overall and cardiovascular mortality was higher in groups 2 and 3 than group 1.39.5% of patients with incompressible ankle arteries (ABI ≥ 2.5) in both lower limbs had toe pressure (TP) <50 mmHg and a poorer survival compared to patients with a higher TP.

CONCLUSIONS

Patients with incompressible ankle arteries have significantly higher overall and cardiovascular mortality and a greater burden of disease compared to the patients with a measurable yet abnormally high ABI. TP is a useful diagnostic tool when ABI is immeasurably high. All patients with ABI > 1.3 should be considered as high cardiovascular risk patients.

Outcomes of non-flow-limiting spiral dissection after drug-coated balloon angioplasty for de novo femoropopliteal lesions

BACKGROUND

Whether drug-coated balloon (DCB) angioplasty would be effective in spiral dissection (SD) lesions with no flow impairment has been thoroughly investigated.

AIMS

The present study sought to assess the clinical outcomes of non-flow-limiting SD after DCB angioplasty for de novo femoropopliteal lesions in patients with symptomatic lower extremity artery disease.

METHOD

This single-center retrospective study enrolled 497 patients with non-flow-limiting SD (n = 92) or non-SD (n = 405) without bailout stenting. The primary endpoint was 1-year primary patency, with the secondary endpoints including freedom from target lesion revascularization (TLR), major adverse limb event (MALE), all-cause death, and 30-day restenosis.

RESULTS

The 1-year primary patency and freedom from TLR were significantly lower in the SD group than in the non-SD group (69.8% vs. 83.3%, p = 0.004; 78.7% vs. 93.0%, p = 0.007, respectively). The SD group had a higher incidence of MALE and 30-day restenosis than the non-SD group (24.6% vs. 11.9%, p = 0.001; 4.3% vs. 0.5%, p = 0.002, respectively). All-cause death was comparable. One-year restenosis after SD was associated with chronic limb-threatening ischemia (CLTI) (hazard ratio, 3.36 [95% confidence interval, 1.21-9.36]; p = 0.020), TASC Ⅱ D (hazard ratio, 3.97 [95% confidence interval, 1.02-15.52]; p = 0.047), and residual stenosis ≥50% (hazard ratio, 4.92 [95% confidence interval, 1.01-23.94]; p = 0.048). The incidence of restenosis after SD increased with the number of these risk factors.

CONCLUSIONS

Despite normal antegrade flow, the 1-year primary patency rate after DCB angioplasty for de novo femoropopliteal lesions was significantly lower in lesions with SD than those without SD. CLTI, TASC II D, and residual stenosis ≥50% were risk factors associated with 1-year restenosis after DCB angioplasty for non-flow-limiting SD lesions.

Global Epidemiology of Lower Extremity Artery Disease in the 21st Century (2000-2021): a Systematic Review and Meta-analysis

BACKGROUND AND AIMS

The epidemiology of lower extremity artery disease (LEAD) is evolving. This meta-analysis of aggregate data aimed to (1) determine the global prevalence of LEAD and by regions in the 21st century and (2) update the associated risk factors in this period.

METHODS

A systematic literature review was performed through PubMed, Cochrane, Scopus, Science Direct and Google Scholar databases, restricted to general population studies between 01/2000 and 09/2021, with LEAD defined by a low (

RESULTS

Among 1418 references, 38 studies (127,961 participants) were retained. The global prevalence in adults, mostly ≥40 years, was estimated at 9.7% (95%CI: 7.1-12.4), higher in women (10.2%) than in men (8.8%), increasing sharply with age. The highest prevalence was found in South-Center Asia (14.5%) and the lowest in North America (5.6%). Significant associations were found between LEAD and current- (odds-ratio (OR) = 1.9, 95%CI: 1.4-2.5) and past-smoking (OR = 1.6, 95%CI: 1.3-1.9), and between LEAD and diabetes (OR = 2.3, 95%CI: 2.0-2.8). Hypertension was significantly associated with LEAD (OR = 2.3, 95%CI: 1.9-2.8) and in particular in South America (OR = 4.0). Obesity (OR = 1.5, 95%CI: 1.2-1.8) and hypercholesterolemia ≥200 mg/dL (OR = 1.9, 95%CI:1.3-2.8) were also significantly associated with LEAD. Conclusion: This meta-analysis highlights a currently high prevalence of LEAD worldwide, with substantial differences in global regions and between sexes. The strongest associations were found with metabolic risk factors.

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Key Words

• epidemiology
• general population
• lower extremity artery disease
• meta-analysis
• prevalence
• risk factors

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MESH Headings Collapse

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Affiliation(s)

Caroline Adou U1094 Inserm U270 IRD EpiMaCT Épidémiologie des maladies chroniques en zone tropicale, Limoges, France
Julien Magne U1094 Inserm U270 IRD EpiMaCT Épidémiologie des maladies chroniques en zone tropicale, Limoges, France
Nana Gazere U1094 Inserm U270 IRD EpiMaCT Épidémiologie des maladies chroniques en zone tropicale, Limoges, France
Maissa Aouida U1094 Inserm U270 IRD EpiMaCT Épidémiologie des maladies chroniques en zone tropicale, Limoges, France
Lucie Chastaingt U1094 Inserm U270 IRD EpiMaCT Épidémiologie des maladies chroniques en zone tropicale, Limoges, France Department of Vascular Surgery and Vascular Medicine, Dupuytren University Hospital, Limoges, France
Victor Aboyans U1094 Inserm U270 IRD EpiMaCT Épidémiologie des maladies chroniques en zone tropicale, Limoges, France Department of Cardiology, Dupuytren University Hospital, Limoges, France

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Paradox of the Relationship between Cardio-Ankle Vascular Index and Ankle-Brachial Index in Patients with Lower Extremity Artery Disease

Objectives: Measurements of ankle-brachial index (ABI) and toe-brachial index (TBI) are standard examinations for evaluating arterial blood flow in lower extremities and diagnosing lower extremity artery disease (LEAD). It remains to be clarified whether cardio-ankle vascular index (CAVI), a blood pressure-independent parameter of arterial stiffness, is associated with ABI and TBI in patients with LEAD. Methods: The subjects were 165 outpatients with LEAD. Arterial blood flow in lower extremities was evaluated by using ABI, TBI, and the degree of leg exercise-induced reduction of ABI (%). Results: CAVI showed significant positive correlations with ABI and TBI and showed significant inverse correlations with exercise-induced % decrease in ABI. CAVI was significantly higher in the 3rd tertile groups of ABI and TBI than that in the corresponding 1st tertile groups and was significantly lower in the 3rd tertile group of exercise-induced % decrease in ABI than that in the 1st tertile group. The above relationships remained significant after adjustment for age, body mass index, blood pressure, diabetes history, and habitual smoking. Conclusions: Although CAVI is a general parameter reflecting arterial stiffness, CAVI showed paradoxical associations, namely, positive associations with ABI and TBI and an inverse association with exercise-induced % decrease in ABI in patients with LEAD.

A Bayesian network meta-analysis for acute thrombosis after lower extremity artery endovascular treatment

BACKGROUND

Various endovascular treatment devices have been widely used in the lower extremity arterial disease (LEAD). Their patency efficiency for target lesions has been well studied and reported. Comparison of the risk of acute thrombosis events between the different endovascular treatment devices is unclear.

AIMS

To rank the risk of acute thrombosis events when bare metal stents (BMSs), covered stents (CSs), drug-eluting stents (DESs), drug-coated balloons (DCBs), and conventional percutaneous transluminal balloon angioplasty (PTA) are used to treat LEAD through Bayesian network meta-analysis.

METHODS

We performed a network meta-analysis of randomized controlled trials comparing the risk of 1-year postoperative acute thrombosis between BMSs, CSs, DESs, DCBs, and PTA for treating LEAD. Bayesian random models were used for pooled endovascular treatment modality comparisons. We ranked these treatment modalities via the Bayesian method according to their surface under the cumulative ranking curve (SUCRA) and estimated probabilities.

RESULTS

Nineteen studies (38 study arms; 2758 patients) were included. The Bayesian network ranking of treatments indicated that DCB had the lowest risk of acute thrombosis, PTA had the second-lowest risk of thrombosis, and CS, BMS, and DES had the highest risk of thrombosis. Regarding the treatment efficacy, the OR values of the loss of primary patency were significantly lower for DCB (OR = 0.44, 95% CI: 0.30-0.62), DES (OR = 0.36, 95% CI: 0.14-0.94), and CS (OR = 0.31, 95% CI: 0.18,0.56) than for PTA. When BMS was used as a reference, only the OR for CS was significantly lower (OR = 0.41, 95% CI = 0.21-0.82). Correspondingly, the Bayesian ranking of treatments from better to worse target lesion primary patency was CS, DES, DCB, BMS, and PTA.

CONCLUSION

With the available research evidence and according to the network analysis ranking, DES appears to have the highest risk of acute thrombosis and DCB appears to have the lowest risk.

Removal of Migrated Vascular Closure Device Plug Material From the Popliteal Artery Using the Bi-Directional Approach "Push Balloon Into Vessel and Close Embolus From Retrograde Site (PINCER)" Technique: A Case Report

Vascular closure devices (VCDs) are widely used to achieve rapid hemostasis after percutaneous intervention via the common femoral artery (CFA), with well-established efficacy and safety. Although VCD-related artery occlusion is rare, it can be critical. A 72-year-old female underwent endovascular therapy (EVT) for stent occlusion in the left superficial femoral artery through a 7-Fr guiding sheath from the right CFA. After the procedure, an acute right popliteal artery (POP-A) occlusion, associated with the EXOSEAL VCD plug, occurred. The plug material was successfully removed using a bidirectional approach. The migration plug was blocked to prevent distal vessel migration and pushed gently to close the antegrade system, using an over-the-wire balloon from the retrograde site. We named this the "Push balloon INto vessel and Close Embolus from Retrograde site" (PINCER) technique. Finally, the plug was successfully removed using biopsy forceps. Acute limb ischemia (ALI) caused by EXOSEAL is a rare condition. Removal of the emboli by EVT is clinically significant because it is minimally invasive. However, it is sometimes difficult to remove the embolus using only antegrade approach; thus, the bidirectional approach using the PINCER technique can be effective in these situations.

Limb and cardiovascular event risk in type 1 and 2 diabetic patients with peripheral artery disease

Background: Peripheral artery disease (PAD) is a risk factor for adverse limb events (LE) and cardiovascular events (CVE) that coexists with type 1 (T1) and 2 (T2) diabetes mellitus (DM). Little is known about comparative risk of LE and CVE in T1/T2 DM patients with PAD. Patients and methods: We queried our database of 40,144 patients ≥18 years old who underwent ankle brachial index (ABI) measurement from 01/1996-02/2020. We isolated T1/T2 DM patients with PAD diagnosed by ankle brachial index (ABI; low [<1.0] or elevated [>1.4]) and retrieved demographics including glycated hemoglobin (HbA1c). Primary outcomes were LE (critical limb ischemia/vascular amputation) and CVE (myocardial infarction/ischemic stroke). All-cause mortality was a secondary outcome. Multivariable Cox proportional regression yielded hazard ratios (HR) with 95% confidence intervals (CI) after adjusting for pertinent risk factors including age, hypertension, hyperlipidemia, smoking, and HbA1c. Results: Our study found 10,156 patients with PAD and DM (34% T1DM, 66% T2DM) with median follow-up time 34 mo (IQR 85 mo). T1DM patients were younger than T2DM (mean age 67 vs. 70 years), with higher median HbA1c (7.7 [IQR 1.9] vs. 6.7% [IQR 1.6]), and more prevalent hypertension, hyperlipidemia, CAD, and CKD. Antiplatelet and statin use was equivocal. Elevated ABI was more common in T1DM (47 vs. 28%). LE occurred in 23% and CVE in 12% patients. LE risk was higher in T1 than T2 DM patients (HR 1.58 [95% CI 1.44, 1.73], p<0.0001), but CVE and all-cause mortality were equivocal. These observations were preserved across ABI and HbA1c subgroup analyses. Conclusions: PAD patients with T1DM had a higher LE risk than those with T2DM, even after adjustment for glycemic control and pertinent risk factors, but CVE risk and all-cause mortality were equivocal. These data suggest a potential role for more intensive LE risk modification in PAD patients with T1DM, but further investigation is needed.

Examination of Lower Limb Microcirculation in Diabetic Patients with and without Intermittent Claudication

Intermittent claudication is a frequent complaint in lower extremity artery disease, but approximately two thirds of patients are asymptomatic, most of which are diabetic patients. Non-invasive angiological and microrheological tests on diabetic subjects with and without intermittent claudication were performed in the present study. In total, 98 diabetic patients were included and divided into two groups: 20 patients (63.5 ± 8.8 years, 55% men, 45% women) had intermittent claudication, 78 patients (65.5 ± 9.3 years, 61.5% men, 38.5% women) were asymptomatic. Hand-held Doppler ultrasound examination, transcutaneous tissue partial oxygen pressure (tcpO2) measurement, Rydel-Seiffer tuning fork tests, and 6-min walk tests were performed, and erythrocyte aggregation was investigated. Ankle-brachial index (p < 0.02) and tcpO2, measured during provocation tests (p < 0.003) and the 6-min walk test (p < 0.0001), significantly deteriorated in the symptomatic group. A higher erythrocyte aggregation index and faster aggregate formation was observed in claudication patients (p < 0.02). Despite the statistically better results of the asymptomatic group, 13% of these patients had severe limb ischemia based on the results of tcpO2 measurement. Claudication can be associated with worse hemodynamic and hemorheological conditions in diabetic patients; however, severe ischemia can also develop in asymptomatic subjects. Non-invasive vascular tests can detect ischemia, which highlights the importance of early instrumental screening of the lower limbs.

Predictors of recurrence based on intravascular ultrasound findings after Eluvia placement in symptomatic peripheral arterial disease: A retrospective study

Background and Aims

Polymer-coated drug-eluting stents (Eluvia) have shown favorable clinical outcomes in real-world registries. There are no reports on recurrent predictors after Eluvia placement based on intravascular ultrasound (IVUS) findings.

Methods

We analyzed clinical data from the ASIGARU PAD registry, a retrospective, multicenter, observational study that enrolled patients who underwent endovascular therapy for superficial femoral and proximal popliteal arteries lesions using Eluvia or drug-coated balloon. The primary outcome was the identification of recurrent predictors, including IVUS parameters at 12 months. The rate of target lesion recurrence was also assessed.

Results

IVUS images were obtained in 54 of 65 cases. Seven recurrent cases (13.0%) were observed within 12 months. The random survival forest method presented eight predictive variables of recurrence: Clinical Frailty Scale (CFS), distal stent edge area, distal plaque burden, age, sex, distal external elastic membrane (EEM) area, minimum stent area (MSA), and distal lumen area. Furthermore, the partial dependence plot showed that frailty (CFS ≥ 6), smaller distal stent edge area, higher and lower distal plaque burden, older and younger age, female sex, smaller distal EEM area, smaller MSA, and smaller and larger distal lumen area predicted recurrence after Eluvia placement within 12 months.

Conclusion

CFS, distal stent edge area, distal plaque burden, age, sex, distal EEM area, MSA, and distal lumen area were significant recurrent predictors after Eluvia placement.

open surgical revascularization for patients with lower extremity artery disease: a systematic review and meta-analysis

BACKGROUND

Currently, the main treatment for lower extremity artery disease (LEAD) is revascularization, including endovascular revascularization (EVR) and open surgical revascularization (OSR), but the specific revascularization strategy for LEAD is controversial. This review provided the comprehensive and recent evidence for the treatment of LEAD.

METHODS

Medline, Embase, and the Cochrane Library databases were searched for relevant articles. Randomized controlled trials (RCTs) and cohort studies comparing the short-term or long-term outcomes between EVR and OSR of LEAD were identified. Short-term outcomes were 30-day mortality, major amputation, wound complication, major adverse cardiovascular events (MACEs), and length of hospital stay (LOS), while long-term outcomes included overall survival (OS), amputation-free survival (AFS), freedom from re-intervention (FFR), primary patency (PP), and secondary patency (SP).

RESULTS

11 RCTs and 105 cohorts involving 750,134 patients were included in this analysis. For the pooled results of cohort studies, EVR markedly decreased the risk of 30-day mortality, wound complication, MACEs, LOS, but increased the risk of OS, FFR, PP, and SP. For the pooled outcomes of RCTs, EVR was associated with obviously lower 30-day mortality, less wound complication and shorter LOS, but higher risk of PP, and SP. However, both RCTs and cohorts did not show obvious difference in 30-day major amputation and AFS.

CONCLUSIONS

Both the pooled results of cohorts and RCTs indicated that EVR was associated with a lower short-term risk for LEAD, while OSR was accompanied by a substantially lower long-term risk. Therefore, the life expectancy of LEAD should be strictly considered when choosing the revascularization modality. As the current findings mainly based on data of retrospective cohort studies, additional high-quality studies are essential to substantiate these results.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD42022317239.

Comparing the Safety and Feasibility of Endovascular Therapy via Transradial and Transfemoral Approaches in Patients with Aortoiliac Occlusive Disease: A Propensity Score-Matched Analysis of the Nationwide Registry

PURPOSE

Our objective was to evaluate the feasibility of performing endovascular therapy (EVT) for aortoiliac artery disease using transradial approach (TRA) as compared to transfemoral approach (TFA).

METHODS

We analyzed 9671 cases with symptomatic lower extremity artery disease due to aortoiliac occlusive disease (AIOD) treated using EVT from a Japanese Nationwide EVT Registry between January and December 2021. We compared the baseline characteristics, procedural information, and 30-day outcomes of patients who received EVT only via TRA (n=863 [16.9%]) and those only via TFA (n=4255 [83.1%]) by using propensity score (PS) matching, after excluding those who required regular dialysis, those who underwent hybrid surgeries, and those who received EVT through 2 or more approach sites.

RESULTS

After matching, the final study population consisted of 862 matched patients with similar baseline characteristics in each group. Technical success rate was comparable between the 2 groups (99.3% vs. 99.3%, p>0.99). No significant differences were observed with respect to the composite of all-cause death within 48 hours after EVT and post-procedural complications within 30 days, including severe bleeding that required transfusion, revascularization procedures, urgent surgeries, cerebral infarction, and major limb amputation (0.2% vs. 0.7%, p=0.29). Transradial approach was associated with shorter operation time (85 vs. 90 minutes, p=0.016), but longer fluoroscopy time (26 vs. 20 minutes, p<0.001) and higher contrast agent volume (80 vs. 75 mL, p<0.001).

CONCLUSION

After PS matching, TRA showed the comparable rates of successful EVT and 30-day complications in patients with AIOD compared to TFA. Transradial approach was found to be safe and be a viable alternative of TFA for the treatment of AIOD.

CLINICAL IMPACT

The efficacy of transradial approach (TRA) is established in percutaneous coronary intervention; however, its safety and feasibility are unclear in endovascular therapy (EVT). We analyzed 9,671 cases with symptomatic aortoiliac occlusive disease treated using EVT from a Nationwide Registry to compare the 30-day outcomes of those who received EVT only via TRA (n = 863 [16.9%]and those only via TFA (n=4,255 [83.1%]) by using propensity score matching. Technical success rate (99.3% vs. 99.3%, p > 0.99) and 30-day complications (0.2% vs. 0.7%, p = 0.29) were comparable between the two groups. EVT via TRA could be performed safely.

Preclinical atherosclerotic burden in carotid and lower extremity arteries in adults with congenital heart disease

Background: Over 90% of patients with congenital heart defects now reach adulthood, due to significant medical advances in recent decades. With advancing age, the risk of acquired cardiovascular diseases increases in addition to the already existing risk due to the congenital defect. The aim of this study was to evaluate the prevalence of atherosclerotic lesions in carotid and lower extremity arteries in adults with congenital heart disease (ACHD). Patients and methods: A total number of 108 ACHD patients (40.6±15.0 years, 50.0% male) and 22 healthy controls (39.3±16.6 years, 40.9% male) were included in this prospective study and underwent a comprehensive angiological examination that included vascular strain analysis on the common carotid artery. Results were stratified by the underlying ACHD lesion groups: shunt lesions (n=26), left-sided obstructive lesions (n=29), right-sided lesions (n=26) and complex lesions (n=27). Results: Colour-coded duplex sonography revealed atherosclerotic lesions in lower extremity arteries in 19 ACHD patients (17.6%). This prevalence did not significantly differ from the one assessed in controls (13.6%, p=0.77). All cases were asymptomatic and therefore classified as Fontaine stage I. 20.4% of ACHD patients presented atherosclerotic lesions in extracranial carotid arteries; amongst controls, the corresponding proportion was 18.4% (p=1.00). No significant differences were observed in atherosclerotic burden in extracranial carotid and lower limb arteries across the four ACHD patient groups (p=0.67 and p=0.89, respectively). Vascular strain analysis revealed no differences between patients and controls. Though circumferential strain varied over ACHD groups (p<0.05), comparison of strain measurements across all specific underlying defect subgroups revealed no significant difference for any of the studied strain parameters. Conclusions: ACHD patients present an atherosclerotic burden in extracranial carotid and lower limb arteries and a vascular stiffness that is comparable to healthy controls.

Quantitative Techniques of Ultrasonography in the Assessment of Femoropopliteal Atherosclerotic Lesions Using Peak Systolic Velocity Ratio: Results From the TURN-UP Study

PURPOSE

Duplex ultrasound (DUS)-measured peak systolic velocity ratios (PSVRs) are commonly used to evaluate arterial stenosis in lower extremity artery disease (LEAD). However, these measurement methods have not yet been standardized. This study aimed to reveal the influence of measuring methods on PSVR values.

METHODS

A 132 femoropopliteal lesions with PSVR ranging from 1.5 to 3.5 evaluated using method A (angle correction 60°, the direction of blood flow, the no or few atherosclerotic changes closest to the lesion proximal side was defined as the nonstenotic area) were included. The following 4 different methods were then compared with method A: method B, angle correction 45°; method C, angle correction 60° measured along the vessel wall; D, angle correction 60°, with the nonstenotic area the lowest peak systolic velocity area; and E, angle correction 60°, with the reference point fixed at 2 cm proximal to the target lesion area. The difference in PSVR values was analyzed using the Bland-Altman method.

RESULTS

The mean PSVR value measured by method A was 2.27±0.51, those measured by methods B, C, D, and E were 2.21±0.55, 2.31±0.66, 2.34±0.63, and 2.11±0.63, respectively. The 95% prediction intervals of the differences in PSVR measurements versus A were -0.64 to +0.53 for method B, -0.59 to +0.68 for method C, -0.77 to +0.91 for method D, and -1.12 to +0.79 for method E.

CONCLUSION

PSVR values considerably differed between measuring methods. PSVR values by DUS are largely dependent on the measurement methods, which could considerably affect the judgment of LEAD.

CLINICAL IMPACT

Due to differences in several DUS measurement methods, the PSVR results could be changed. Therefore, to need further investigations and unification of measurement method.

The inpatient costs related to revascularization of lower extremity artery disease in terms of amputation and mortality rates

OBJECTIVE

With the initial utilization of endovascular treatment options in 1970s, the number of procedures performed for lower extremity artery disease (LEAD) both with open surgical (OS) and endovascular (EV) treatment increased, but this did not result in a decrease in the number of amputations. The burden of LEAD still constitutes a huge proportion among the health care costs over the world.

METHODS

The patients who admitted to our clinic between October 2014 and December 2019 with LEAD and required revascularization were enrolled. The total hospitalization costs related to LEAD were registered and divided into two groups as care costs and medical supplies costs.

RESULTS

181 procedures were performed to 133 patients. Mean age was 63.98 ± 11.65 and 115 (86.5%) patients were male. Mean follow-up period was 31.19 ± 17.99 months (95% CI). The most frequent comorbidities were diabetes mellitus (DM) (n = 86, 66.2%) and active smoking (n = 59, 44.4%). Total costs and medical supplies costs were increased in EV group when compared with OS group ($4347.26 ± 3352.96, $3339.28 ± 3459.53 p = .005 v.s. $3318.67 ± 2874.55,$904.42 ± 1209.97 p < .001, respectively). Care costs were increased in OS group when compared with EV group ($2434.85 ± 2641.89 v.s. $1028.56 ± 1397.77 p < .001). The highest total, medical supplies, and care costs were determined in EV + OS group ($13071.32 ± 13717; $6784.91 ± 8332.04; $6286.41 ± 7652.12, respectively).Graft/wound infection related and amputation related costs were 21% of all costs. Amputation-free survival was 71.42% (95% CI) with 21 total amputations. There were linear correlations between mortality and amputation (p = .002); also between mortality and cost (p = .001).

CONCLUSIONS

In mid-long-term period, the care costs are increased with OS; however, EV treatment significantly increases the medical supplies and total costs. The increase in cost is correlated with poor outcome. Although the comorbidities and risk factors of these patients lead the clinicians to perform more challenging endovascular approaches, in mid-long-term period, particularly failed endovascular procedures are not promising in terms of outcomes and costs. We consider that the best-fit therapy on time is cost-effective, life and extremity-saving either, by avoiding deleterious effects of severe ischemia, such as severe pain, tissue loss, and related major adverse cardiaovascular events.

Impact of Arterial Calcification of the Lower Limbs on Long-Term Clinical Outcomes in Patients on Hemodialysis

Lower limbs' arterial calcification is significantly associated with the clinical severity of lower extremity artery disease (LEAD) in patients undergoing hemodialysis (HD). However, the association between arterial calcification of the lower limbs and long-term clinical outcomes in patients on HD has not been elucidated. Calcification scores of the superficial femoral artery (SFACS) and below-knee arteries (BKACS) were quantitatively evaluated in 97 HD patients who were followed for 10 years. Clinical outcomes, including all-cause and cardiovascular mortality, cardiovascular events, and limb amputation were evaluated. Risk factors for clinical outcomes were evaluated using univariate and multivariate Cox proportional hazard analyses. Furthermore, SFACS and BKACS were divided into three groups (low, middle, and high), and their associations with clinical outcomes were evaluated using Kaplan-Meier analysis. SFACS, BKACS, C-reactive protein, serum albumin, age, diabetes, presence of ischemic heart disease, and critical limb-threatening ischemia were significantly associated with 3-year and 10-year clinical outcomes in the univariate analysis. Multivariate analysis showed that SFACS was an independent factor associated with 10-year cardiovascular events and limb amputations. Kaplan-Meier life table analysis showed that higher SFACS and BKACS levels were significantly associated with cardiovascular events and mortality. In conclusion, long-term clinical outcomes and the risk factors in patients undergoing HD were evaluated. Arterial calcification of the lower limbs was strongly associated with 10-year cardiovascular events and mortality in patients undergoing HD.

Diagnosis and Treatment of Lower Extremity Arterial Disease-A Survey among Family Medicine Trainees in Poland

Guidelines point to the ankle-brachial index (ABI) as a non-invasive tool for the initial diagnosis of lower extremity artery disease (LEAD). Questions have been raised whether primary practices should perform ABI. An online questionnaire was distributed among family medicine trainees in two academic centers in Poland. The questionnaire aimed to establish their knowledge about LEAD management and their opinion on the usefulness of ABI measurement and other LEAD diagnostic methods in primary care. ABI measurement was found either very or moderately useful in LEAD diagnosis by 94.5% of the respondents. Among the three most important elements of LEAD management, lifestyle changes, secondary prevention of atherosclerosis and exercise treatment were chosen, respectively, by 98.6%, 83.6% and 72.6% of them. ABI was seen as a useful diagnostic method at the primary care by 74% of the participants; however, 82.2% of them do not have access to ABI measurement in their workplace. The residents have good knowledge of the diagnostic methods of LEAD and consider ABI measurement as useful in LEAD diagnosis. However, most of them do not have access to ABI measurements in their clinical practices. Future discussion and potential financial changes will be needed for the introduction of ABI measurements into Polish primary care.

Use of the Walking Impairment Questionnaire and Walking Estimated-Limitation Calculated by History questionnaire to detect maximal walking distance equal to or lower than 250 m in patients with lower extremity arterial disease

Objective

The objective was to assess the accuracy and optimal threshold of the Walking Impairment Questionnaire (WIQ) and the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire in identifying patients with a maximal walking distance (MWD) below or equal to 250 m.

Methods

This retrospective study screened 388 consecutive patients with suspected symptomatic lower extremity arterial disease (LEAD). Collected data included the patient's history, resting ankle-brachial index, WIQ, and WELCH. MWD was assessed with a treadmill test at 2 mph (3.2 km/h) with a 10% grade. An optimized threshold for detection of MWD ≤ 250 m was determined for each questionnaire via receiver operating characteristic (ROC) curves. Subsequently, multivariate analysis was performed to build a new simple score to detect MWD ≤ 250 m.

Results

The study included 297 patients (63 ± 10 years old). With a threshold of ≤ 64%, the WIQ predicted MWD ≤ 250 m with an accuracy of 71.4% (66.2, 76.5%). With a threshold of ≤ 22, the WELCH predicted a treadmill walking distance of ≤ 250 m with an accuracy of 68.7% (63.4, 74.0%). A new score with only four "yes or no" questions had an accuracy of 71.4% (66.3, 76.6%). Items on this new score consisted of the level of difficulty of walking 1 block, declared maximum walking distance, usual walking speed, and maximum duration of slow walking.

Conclusion

A WIQ score ≤ 64% and a WELCH score ≤ 22 help to predict a walking distance of ≤ 250 m in a treadmill test at 2 mph (3.2 km/h) with a 10% grade. A 4-item score could be used for rapid evaluation of walking distance among patients with LEAD, but the validity of this 4-item score requires further confirmation studies.

Role of triglyceride glucose index in long-term mortality of patients with lower extremity arterial disease

Aim: This work was designed to explore the role of the triglyceride-glucose (TyG) index in the prediction of long-term mortality in patients with lower extremity artery disease (LEAD) undergoing endovascular revascularization. Methods: The records of 723 patients with symptomatic LEAD undergoing endovascular revascularization between January 2016 and December 2021, with long-term follow-up until December 2021, were analyzed. Results: The rate of long-term mortality was significantly higher among patients with high TyG index than patients with low TyG index. Conclusion: The TyG index is an independent predictor of long-term mortality in patients with LEAD undergoing endovascular revascularization.

Secondary Prevention in Lower Extremity Artery Disease Patients: Lipid-Lowering Therapy and Long-Term Guideline Adherence

Lower extremity artery disease (LEAD) affects millions of elderly patients and is associated with elevated cardiovascular morbidity and mortality. Risk factor modification, including the therapy of dyslipidaemia, is mandatory to reduce cardiovascular event rates and to improve survival rates. However, only a minority achieve the recommended low-density lipoprotein cholesterol (LDL-C) target level < 55 mg/dL, according to the current ESC/EAS guidelines on the treatment of dyslipidaemia. This study elucidated the implementation of the lipid-lowering guideline recommendations of 400 LEAD patients with LDL-C > 100 mg/dL and their adherence to treatment adjustment during follow-up. Despite a sustained statin prescription in 93% of the patients, including 77% with high-intensity statins at follow-up, only 18% achieved the target level. Ezetimibe appeared in 21% and LDL-C goals were reached significantly more often with combination therapy. Recurrent revascularization appeared more often (28%) than coronary artery or cerebrovascular disease progression (14%) and 7% died. Despite the frequent use of high-intensity statins and expandable rates of ezetimibe, the progression of cardiovascular events remained inevitable. Only 18% of the patients had received recommendations on lifestyle modification, including dietary adaptations, which is key for a holistic approach to risk factor control. Thus, efforts for both pharmacological and behavioral strategies are needed to improve clinical outcomes and survival rates.

Clinical Characteristics and Current Practice of Endovascular Revascularization in Aorto-Iliac, Femoropopliteal and Infra-Popliteal Lower Extremity Artery Disease-Insights from the RECCORD Registry

BACKGROUND

Endovascular revascularization (EVR) is a pillar of therapeutic management in patients with symptomatic lower extremity artery disease (LEAD). Due to lack of scientific evidence, the approach of EVR type and the devices used at the different anatomic vascular segments of the lower limbs vary substantially between operators and centers. We analyzed data from the RECcording COurses of vasculaR Diseases (RECCORD) registry to assess the current real-world EVR treatment patterns in relation to anatomic vascular segments in symptomatic LEAD patients in Germany.

PATIENTS AND METHODS

RECCORD is an ongoing, prospective, multicenter, all-comers and entirely web-based registry platform. Baseline demographic and periprocedural data of patients undergoing EVR for symptomatic LEAD were assessed and performed EVRs were grouped according to the intervened anatomic vascular segment. We analyzed four EVR groups comprising either the aorto-iliac, femoropopliteal, or infrapopliteal segments (all these EVRs with or without a further intervention in another anatomic segment) or the infrapopliteal segment alone.

RESULTS

A total of 2210 EVR segments (in 1639 patients) were analyzed. Of those 616 (27.9%) were aorto-iliacal, 1346 (60.9%) femoropopliteal, 248 (11.2%) infrapopliteal and 104 (4.7%) only infrapopliteal segments. Aorto-iliac EVR was associated with younger age, smoking, claudication and simple lesions, while the distal infrapopliteal EVRs were related to advanced age, diabetes, multiple comorbidities, limb threatening ischemia and complex lesions. The use of different EVR devices at the aorto-iliac, femoropopliteal, infrapopliteal and only infrapopliteal segments were: only ballon-angioplasty: 8.3%, 12.9%, 58.1% and 63.5%; stenting: 82.3%, 45.3%, 16.9% and 12.5%; drug-coated balloon: 11.2%, 55.0%, 19.4% and 19.2%.

CONCLUSION

The RECCORD registry data demonstrate that in LEAD clinical and lesion characteristics are related to anatomic vascular segments. Despite the clear relationship between vascular segments and the current use of device types, prospective, segment-specific clinical studies are warranted to establish a consistent, evidence-based path for EVR in LEAD.

Lower Extremity Arterial Disease and Lumbar Spinal Stenosis: A Study of Exercise-Induced Arterial Ischemia in 5197 Patients Complaining of Claudication

Only few studies have analyzed the associations of lower extremity artery disease (LEAD) with lumbar spinal stenosis (LSS), although it is expected to be a frequent association. With exercise-oximetry, we determined the presence of exercise-induced regional blood flow impairment (ischemia) in 5197 different patients complaining of claudication and referred for treadmill testing. We recorded height, weight, age, sex, ongoing treatments, cardiovascular risk factor (diabetes, high blood pressure, current smoking habit), and history of suspected or treated LSS and/or lower limb revascularization. An ankle-brachial index at rest < 0.90 or >1.40 on at least one side was considered indicative of the presence of LEAD (ABI+). Ischemia was defined as a minimal DROP (Limb-changes minus chest-changes from rest) value < −15 mmHg during exercise oximetry. We analyzed the clinical factors associated to the presence of exercise-induced ischemia in patients without a history of LSS, using step-by-step linear regression, and defined a score from these factors. This score was then tested in patients with a history of LSS. In 4690 patients without a history of (suspected, diagnosed, or treated) LSS, we observed that ABI+, male sex, antiplatelet treatment, BMI< 26.5 kg//m2, age ≤ 64 years old, and a history of lower limb arterial revascularization, were associated to the presence of ischemia. The value of the score derived from these factors was associated with the probability of exercise-induced ischemia in the 507 patients with a history of LSS. This score may help to suspect the presence of ischemia as a factor of walking impairment in patients with a history of lumbar spinal stenosis.

The Impact of Chronic Kidney Disease on Mid-Term Outcomes after Revascularisation of Peripheral Arterial Occlusive Disease: Results from a Prospective Cohort Study

Objective: The current study aimed to determine the relationship between chronic kidney disease (CKD) and major 12-month outcomes for patients with in-hospital treatment for symptomatic peripheral arterial occlusive disease (PAOD). Methods: An analysis of the prospective longitudinal multicentric cohort study with 12-month follow-up was conducted including patients who underwent endovascular or open surgery for symptomatic PAOD at 35 German vascular centres (initial study protocol: NCT03098290). Severity of CKD was grouped into four stages combining information about the estimated glomerular filtration rate (eGFR) at baseline and dialysis dependency. Outcomes included overall mortality as well as the two composite endpoints of amputation or death, and of major cardiovascular events (MACE). 12-month incidences and adjusted hazard ratios were estimated using the Kaplan–Meier function and Cox proportional hazard models. Results: A total of 4354 patients (32% female, 69 years mean age, 68% intermittent claudication, 69% percutaneous endovascular revascularisation) were included and followed for 244 days in median. Thereof, 22% had any CKD and 5% had end stage kidney disease (ESKD) at baseline. The 12-month overall mortality rate was 3.6% (95% CI 2.3–4.9) with 96 events in the entire cohort: 147 were amputated or died (5.3%, 95% CI 5.2–5.3), and 277 had a MACE (9.5%, 95% CI 9.4–9.5). When compared with patients without kidney disease, ESKD was significantly associated with overall mortality (HR 1.9; 95% CI 1.1–3.5), amputation or death (HR 2.4; 95% CI 1.4–4.1), and MACE (HR 2.0; 95% CI 1.3–3.2). Conclusions: In the current study on mid-term outcomes after invasive revascularisation for symptomatic PAOD, one out of five patients suffered from any CKD while those few with ESKD had twice the odds of death, of amputation or death, and of major adverse cardiovascular events after twelve months. These results emphasise that concomitant CKD and its impact on outcomes should be considered by severity while mild and moderate grades should not lead to ineffectual treatment strategies.

miRNA Regulatory Networks Associated with Peripheral Vascular Diseases

A growing body of evidence indicates a crucial role of miRNA regulatory function in a variety of mechanisms that contribute to the development of diseases. In our previous work, alterations in miRNA expression levels and targeted genes were shown in peripheral blood mononuclear cells (PBMCs) from patients with lower extremity artery disease (LEAD), abdominal aortic aneurysm (AAA), and chronic venous disease (CVD) in comparison with healthy controls. In this paper, previously obtained miRNA expression profiles were compared between the LEAD, AAA, and CVD groups to find either similarities or differences within the studied diseases. Differentially expressed miRNAs were identified using the DESeq2 method implemented in the R programming software. Pairwise comparisons (LEAD vs. AAA, LEAD vs. CVD, and AAA vs. CVD) were performed and revealed 10, 8, and 17 differentially expressed miRNA transcripts, respectively. The functional analysis of the obtained miRNAs was conducted using the miRNet 2.0 online tool and disclosed associations with inflammation and cellular differentiation, motility, and death. The miRNet 2.0 tool was also used to identify regulatory interactions between dysregulated miRNAs and target genes in patients with LEAD, AAA, and CVD. The presented research provides new information about similarities and differences in the miRNA-dependent regulatory mechanisms involved in the pathogenesis of LEAD, AAA, and CVD.

Relationships between Indicators of Lower Extremity Artery Disease and miRNA Expression in Peripheral Blood Mononuclear Cells

Lower extremity artery disease (LEAD) is an underdiagnosed and globally underestimated vascular disease caused by the progressive and chronic formation of atherosclerotic plaques in the arteries of the lower limbs. Much evidence indicates that the abnormal course of pathophysiological processes underlying LEAD development is associated with altered miRNA modulatory function. In the presented study, relationships between miRNA expression and clinical indicators of this disease (ABI, claudication distance, length of arterial occlusion, Rutherford category, and plaque localization) were identified. MiRNA expression profiles were obtained using next-generation sequencing in peripheral blood mononuclear cells (PBMCs) of 40 LEAD patients. Correlation analysis performed using the Spearman rank correlation test revealed miRNAs related to ABI, claudication distance, and length of arterial occlusion. In the DESeq2 analysis, five miRNAs were found to be dysregulated in patients with Rutherford category 3 compared to patients with Rutherford category 2. No miRNAs were found to be differentially expressed between patients with different plaque localizations. Functional analysis performed using the miRNet 2.0 website tool determined associations of selected miRNAs with processes underlying vascular pathology, such as vascular smooth muscle cell differentiation, endothelial cell apoptosis, response to hypoxia, inflammation, lipid metabolism, and circadian rhythm. The most enriched functional terms for genes targeted by associated miRNAs were linked to regulation of the cell cycle, regulation of the transcription process, and nuclear cellular compartment. In conclusion, dysregulations of miRNA expression in PBMCs of patients with LEAD are indicative of the disease and could potentially be used in the prediction of LEAD progression.

Automatic measurement of vascular calcifications in patients with aorto-iliac occlusive disease to predict the risk of re-intervention after endovascular repair

OBJECTIVE

There is currently a lack of consensus and tools to easily measure vascular calcification using computed tomography angiography (CTA). The aim of this study was to develop a fully automatic software to measure calcifications and to evaluate the interest as predictive factor in patients with aorto-iliac occlusive disease.

METHODS

This study retrospectively included 171 patients who had endovascular repair of an aorto-iliac occlusive lesion at the University Hospital of Nice between January 2011 and December 2019. Calcifications volumes were measured from CT-angiography (CTA) using an automatic method consisting in 3 sequential steps: image pre-processing, lumen segmentation using expert system and deep learning algorithms and segmentation of calcifications. Calcification volumes were measured in the infrarenal abdominal aorta and the iliac arterial segments, corresponding to the common and the external iliac arteries.

RESULTS

Among 171 patients included with a mean age of 65 years, the revascularization was performed on the native external and internal iliac arteries in respectively: 83 patients (48.5%); 107 (62.3%) and 7 (4.1%). The mean volumes of calcifications were 2759 mm³ in the infrarenal abdominal aorta, 1821 mm³ and 1795 mm³ in the right and left iliac arteries. For a mean follow up of 39 months, TLR was performed in 55 patients (32.2%). These patients had higher volume of calcifications in the right and left iliac arteries, compared with patients who did not have a re-intervention (2274 mm³ vs 1606 mm³, p=0.0319 and 2278 vs 1567 mm³, p=0.0213).

CONCLUSION

The development of a fully automatic software would be useful to facilitate the measurement of vascular calcifications and possibly better inform the prognosis of patients.

Application of Combined Superficial Femoral Artery Stenting and Deep Femoral Artery Profundoplasty in Chinese Patients With Lower Extremity Artery Disease

Objective: Lower extremity artery disease (LEAD) increases sharply with age and results in severe burden in individuals and in society. This study aimed to compare the efficiency of simple superficial femoral artery stenting (SFAS) and the hybrid operation, such as combined SFAS and deep femoral artery profundoplasty (DFAP), in the treatment of Chinese patients with LEAD, classified as Rutherford grades 3-5. Methods: There were 200 patients with LEAD classified as Rutherford grades 3-5 included in the simple SFAS group (n = 100) and the combined SFAS and DFAP group (n = 100). Results: All the patients had median age of 71 years, and there were 143 males (71.5%). Not only the increase rate of ankle brachial index (ABI), but also reduction rate of Rutherford grade, were significantly higher after surgery in the combined SFAS and DFAP group than in the simple SFAS group (P < 0.05 for all). The patency rate of patients in the combined SFAS and DFAP group was significantly higher than that of patients in the simple SFAS group during the follow-up (P < 0.05). Proportion of amputation and claudication distance <200 m had no significant difference between the two groups during the 2-year follow-up (P > 0.05 for all). Conclusion: This study demonstrated that, compared with SFAS, combined SFAS and DFAP improved not only the ABI and the Rutherford grade after surgery but also the patency rate during the follow-up in Chinese patients with LEAD. Hybrid operation has significant value in alleviating clinical symptoms after surgery, and, thereby, improving vascular prognosis in Chinese patients.

Sex-related differences in outcome after endovascular revascularization for lower extremity artery disease

Background: Sex-related differences may influence the outcome of endovascular revascularization (EVR) in patients with lower extremity arterial disease (LEAD) even under optimized healthcare supply. Patients and methods: LEAD patients who underwent EVR at the Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Germany between 2014 and 2016 were included into the retrospective study. Detailed information on risk factors and co-morbidities, medication, LEAD related measures, and interventional parameters were assessed. Outcome defined as technical success rate, complications, and mortality was analyzed up to 12 months follow-up. Results: In total, 165 female and 437 male LEAD patients were included. Women and men presented with comparable severity of LEAD in terms of critical limb threatening ischemia (46.2%), wound status (34.9%), and amputation rate (9.6%, all n.s.) at index. Intake of platelet inhibitors (65.8% female vs. 70.0% male), oral anticoagulants (21.3% vs. 25.4%), and statins (65.6% vs. 76.0%) was observed less frequently in female patients. Against the background of high technical success (85%), in-hospital death (0.8%), severe adverse cardiac (MCE; 1.7%), and limb events (MALE; 6.1%) occurred at low rates in either sex. Adjusted long-term mortality was not affected by patients' sex (female HR 0.755; p=0.312). Conclusions: Despite critical LEAD stages in every second patient, EVR was performed safe with high technical success rates in female and male patients. Long-term outcomes were observed at comparatively low rates in both sexes at the specialized vascular center. During aftercare, supply with statin therapy turned out improvable particularly in female LEAD patients.

Conversion From an Outpatient to an Inpatient Setting After an Endovascular Treatment for Lower Extremity Artery Disease

BACKGROUND

Outpatient endovascular treatment (EVT) for lower extremity artery disease (LEAD) is increasing. Some patients will, nonetheless, unexpectedly stay hospitalized for the night after the procedure. The purpose of this study was to identify the factors associated with a conversion from an outpatient setting (OS) to an inpatient setting (IS).

METHODS

From April 2017 to August 2019, we performed 745 EVT for LEAD. Patients scheduled for a same-day discharge procedure were retrospectively analyzed. The factors potentially associated with a conversion to an IS were assessed. Results are expressed as odds ratio (OR) with 95% confidence intervals.

RESULTS

Among the 198 (26.6%) patients scheduled for outpatient EVT, mean age was 70.8±14.1 years old, 34.3% had an ASA score≥3 and 38.4% presented a chronic limb-threatening ischemia. Twenty-eight patients (14.1%) were converted from an OS to IS. Univariate analysis found that Rutherford stage≥4 (OR = 5.09 [2.11-12.27], P < 0.001), high blood pressure (OR = 3.19 [1.06-9.63], P = 0.040), ASA score≥3 (OR = 3.61 [1.58-8.24], P = 0.002), duration of procedure ≥90 min (OR = 2.36, [1.03-5.39], P = 0.042), anterograde puncture (OR = 2.94, [1.30-6.66], P = 0.009), arrival in the operating room ≥12:00 (OR = 13.05, [5.29-32.17], P < 0.001) and general anesthesia (OR = 3.89, [1.20-12.62], P = 0.024) were associated with a conversion. The multivariate analysis revealed that an arrival in the operative room ≥12:00 (OR = 11.71, [3.85-35.60], P < 0.001) and general anesthesia (OR = 6.76, [1.28-35.82], P = 0.009) were independent factors associated with a conversion.

CONCLUSION

Arrival in the operative room after 12:00 and general anesthesia represent two independent correctible factors associated with the risk of OS failure. No factor directly related to comorbidities or the LEAD severity was identified.

Association of skeletal muscle and cardiovascular risk factors in patients with lower extremity arterial disease

BACKGROUND

Sarcopenia is defined as low muscle mass, with low muscle strength or low physical performance. The skeletal muscle mass (or density) and strength are inversely associated with cardiovascular risk factors. We aim to determine the relationship between skeletal muscle characteristics (strength, mass, area), and cardiovascular risk factors in a population with lower extremity artery disease (LEAD) METHODS: : An observational, prospective study including patients with LEAD was conducted from January 2018 to December 2020. The cardiovascular risk factors and anthropometric measurements were prospectively registered. The skeletal muscle characteristics (area, density/mass and strength) were analysed. The skeletal muscle area and density were quantified with a CT scan. The strength was determined with a Jamar® hydraulic hand dynamometer.

RESULTS

96 patients with LEAD with 67.70± 10.11 years-old were enrolled in the study. The most prevalent cardiovascular risk factor was hypertension, followed by dyslipidemia and diabetes. Patients with diabetes had a lower handgrip strength and skeletal muscle density, when compared with patients without diabetes (strength: 19.67± 9.98 kgf versus 26.79 ± 11.80 kgf, p=0.002 and skeletal muscle density: 10.58 ± 17.61 HU versus 18.17 ± 15.33 HU, p=0.032). There was a trend for the association between the presence of cardiovascular risk factors (hypertension and dyslipidemia) and a decrease in skeletal muscle density and strength (density: hypertension: 13.46 ± 16.74 HU versus 20.38 ± 11.63 HU p=0.055; dyslipidemia: 13.57 ± 17.16 HU versus 17.74 ± 13.00 HU p=0.315; strength- hypertension: 22.55 ± 10.08 kgf versus 27.58 ± 15.11 p= 0.073; dyslipidemia: 22.80 ± 10.52 kgf versus 25.28 ± 13.14 kgf p=0.315). Interestingly, we found that smokers had a favorable skeletal muscle characteristic, which could be explained by the higher prevalence of diabetes in non-smokers.

CONCLUSIONS

The indicators of skeletal muscle dysfunction (strength and density) are associated to the presence of diabetes in patients with LEAD. Therapeutic strategies to improve the skeletal muscle characteristics could have a role in improving LEAD risk factors, particularly diabetes.

Are hypertensive patients with history of coronary artery disease at risk for silent lower extremity artery disease?

OBJECTIVES

We aimed to investigate the association between hypertension and asymptomatic lower extremity artery disease (LEAD) in outpatients with known history of coronary artery disease (CAD).

METHODS

Patients with known history of CAD who have been undergone coronary angiography and have significant coronary artery stenosis (more than 60%) were included. LEAD was defined as ankle-brachial index (ABI) < 0.9 in either leg. The risk of LEAD in hypertensive group was analyzed using chi-square test, and correlation between blood pressure (BP) and ABI was analyzed using Pearson correlation test in SPSS v.25.

RESULTS

One hundred and four patients were included. 82.7% of patients were male. Mean age was 57.05 ± 7.97. The prevalence of hypertension was 35.6%, and the prevalence of LEAD was 16.3%. A higher proportion of LEAD was found in hypertensive (18.9%) compared to non-hypertensive (14.9%), although not statistically significant (OR: 1.33; 95% CI: 0.46 to 3.85; p=0.598). There was an association between ABI and systolic BP (p=0.016), but not with diastolic BP (p=0.102).

CONCLUSIONS

Our study showed that the prevalence of LEAD in hypertension, especially in the CAD population, is relatively high. There was no association between hypertension and LEAD, but a higher prevalence of LEAD was found in hypertensive patients. Nevertheless, LEAD screening is still recommended in hypertensive patients, especially in the CAD population, given the fact that outcomes of health and mortality are worse for those with concomitants of these diseases.

Lower Lean Mass Is Associated with Greater Arterial Stiffness in Patients with Lower Extremity Artery Disease

Background: Arterial stiffness is independently associated with lower extremity artery disease (LEAD). Although obesity is already known as an independent cardiovascular risk factor, it was found that, paradoxically, in patients diagnosed with cardiovascular disease, an increase in body mass index (BMI) was associated with a decrease in mortality. However, the underlying mechanism of this paradoxical association remain uncertain. In this study, we firstly hypothesize that arterial stiffness correlates with body mass; secondly, the underlying mechanism of the association for patients with LEAD is individual body composition, in particular, lean mass. Methods: The present study was performed as a single-center, prospective, observational analysis. A total of 412 patients with current or previously diagnosed LEAD (Rutherford Classification 2–4) were included, the cfPWV and AIx were measured as indices of arterial stiffness, and a body composition assessment was performed. Results: In male patients, there was a significantly negative correlation between the AIx and lean mass coefficient (p = 0.004, 95% CI: −0.28 (−0.48–0.09)). Conclusion: For patients with peripheral arterial disease, our data show that lower lean mass in male patients is associated with increased arterial stiffness as measured by the AIx. Therefore, progressive resistance training may be beneficial for the reduction in arterial stiffness in PAD patients in secondary prevention.

Frequency of lower extremity artery disease in type 2 diabetic patients using pulse oximetry and the ankle-brachial index

Objectives: To determine the of undiagnosed lower extremity artery disease using the pulse oximetry in a type 2 diabetic population sample. Methods: Observational, cross-sectional, descriptive study that included 594 type 2 diabetic patients, with no previous history of lower extremity artery disease. Medical history, physical examination, determination of the ankle-brachial index (portable Doppler) and measurement of oxygen saturation in upper and lower extremities (pulse oximeter) were performed. Results: Frequency of lower extremity artery disease determined by ankle-brachial index was 18.4%. No significant correlations were detected between oxygen saturation and the ankle-brachial index except for the relationship between ankle-brachial index vs. oxygen saturation at 30 cm lower limb elevation vs. the supine position at no elevation (0 cm) in subjects under the age of 40. Pulse oximetry showed little diagnostic value in the screening of lower extremity artery disease. A relationship between lower extremity artery disease and age has been found. Its diagnosis was associated with a lower body mass index and lower systolic blood pressure in the lower extremities and higher in the upper extremities. Conclusions: We conclude that pulse oximetry is not useful in the screening for asymptomatic lower extremity artery disease in type 2 diabetics.

Long-term clinical outcome and mortality risks after paclitaxel-coated balloon angioplasty in patients with peripheral artery disease: An observational clinical study

BACKGROUND AND AIMS

Drug-eluting devices (DEDs) are usually used as a standard therapy for revascularization in femoropopliteal artery disease. Randomized controlled trails have found that DEDs with paclitaxel result in superior patency rates and decreased target lesion revascularization. A meta-analysis by Katsanos et al indicated an increased long-term mortality in patients treated with paclitaxel-coated devices. The aim of this observational clinical study was to assess the long-term clinical outcomes and mortality risk after paclitaxel-coated balloon angioplasty in patients with symptomatic peripheral artery disease.

METHODS

We retrospectively evaluated 287 patients with peripheral interventions, including 173 drug-coated balloon (DCB) angioplasties and 114 plain old balloon angioplasties (POBA), performed at our center between 2015 and 2018.

RESULTS

There were no significant differences in mortality rates between patients who received DCB angioplasty and those who received POBA. In the first year, the hazard ratio (HR) for DCB angioplasty was 0.59 (95% confidence interval [CI] 0.31 to 1.12, P = .104). After 2 years, this HR was 0.64 (95% CI 0.36-1.17, P = .145), while the 3-year and 4-year HR increased to 0.71 and 1.30 (3-year: 95% CI 0.37-1.33, P = ,283; 4-year: 95% CI 0.55-3.08, P = .546). No paclitaxel dose-response relationship with mortality rate was identified when adjusted for key predictors of mortality.

CONCLUSIONS

Analyses of patient level data identified no significant mortality differences between DCB angioplasty and POBA after 4 years of follow-up. Furthermore, there was no dose-response relationship between paclitaxel and mortality. These findings demonstrate that paclitaxel DCB is safe. Further long-term multicenter studies are needed to determine the risk of late mortality.

Efficacy and Safety of Antiplatelet Therapies in Symptomatic Peripheral Artery Disease: A Systematic Review and Network Meta-Analysis

BACKGROUND

Clopidogrel monotherapy is guideline-recommended in symptomatic peripheral artery disease (PAD). The advent of new antithrombotic strategies prompts an updated analysis of available evidence on antiplatelet therapy for PAD.

METHODS

We searched MEDLINE, Embase and CENTRAL through January 2019 for randomised controlled trials and observational studies comparing antiplatelet therapies as monotherapy, dual therapy, or combination with anticoagulants. Efficacy (major adverse cardiovascular events, acute or chronic limb ischaemia, vascular amputation, peripheral revascularisation) and safety (all-cause mortality and overall bleeding) outcomes were evaluated via Bayesian network meta-analyses.

RESULTS

We analysed 26 randomised controlled trials. Clopidogrel (hazard ratio, HR, 0.78; 95% credible interval [CrI] 0.65-0.93) and ticagrelor (HR 0.80; 95% CrI 0.65-0.98) significantly reduced major adverse cardiovascular events risk compared with aspirin. No significant difference was observed for dual antiplatelet therapy with clopidogrel and aspirin. Vorapaxar significantly reduced limb ischaemia and revascularisation compared with placebo, while dual antiplatelet therapy with clopidogrel and aspirin showed a trend for reduced risk of amputation compared with aspirin (risk ratio 0.68; 95% CrI 0.43-1.04). For all-cause mortality, picotamide, vorapaxar, dipyridamole with aspirin, and ticlopidine showed a significantly lower risk of all-cause mortality vs aspirin. Clopidogrel and ticagrelor showed similar overall bleeding risk vs aspirin, while dual antiplatelet therapy with clopidogrel and aspirin significantly increased bleeding risk.

CONCLUSION

This updated network meta-analysis confirms that clopidogrel significantly decreases the risk of major adverse cardiovascular events compared with aspirin, without increasing bleeding risk. Clopidogrel should remain a mainstay of PAD treatment, at least in patients at higher bleeding risk.

The efficacy and safety of Chinese herbal medicine Shen-Qi Hua-Yu formula in patients with diabetic lower extremity artery disease: Study protocol of a multi-center, randomized, double-blind, placebo-controlled trial

BACKGROUND

Lower extremity artery disease (LEAD) is greatly harmful to Type 2 Diabetes Mellitus patients. Traditional Chinese Medicine (TCM) is an alternative therapy to delay the development of macrovascular diseases, but the existing evidence of its efficacy, safety and mechanism of action is insufficient. We report a study protocol of a multi-center, randomized, double-blind, placebo-controlled trial that aims to use well-designed clinical trial to evaluate the efficacy and safety of Chinese herbal medicine (CHM) Shen-Qi Hua-Yu formula, and to explore efficacy mechanism of the TCM granules and the biomarkers of TCM syndrome.

METHODS

This is a multi-center, double-blind, randomized, and placebo-controlled study that randomized 120 participants into 2 groups. The treatment group will receive TCM granules and conventional medicine, while the control group will receive placebo in addition to conventional medicine. Two groups will receive 12-week treatment and 48-week follow-up, with a total of 13 visits. Primary efficacy outcomes included ankle brachial index. Secondary efficacy outcomes included fasting plasma glucose, blood lipid, hemorheology indexes, advanced glycation end products, the inner diameter, peak systolic velocity, end diastolic velocity and mean average velocity of the anterior tibial artery, posterior tibial artery and dorsalis pedis artery, and TCM syndrome score. The safety and endpoint outcomes will be evaluated in this trial. The study will explain the biological therapeutic mechanism of Shen-Qi Hua-Yu formula for diabetic LEAD, and try to use Isobaric tags for Relative and Absolute Quantitation (iTRAQ) and Western blot to screen biomarkers of characteristic diagnosis and clinical efficiency evaluation of the TCM syndrome.

DISCUSSION

This study is a multi-center, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of CHM in patients with diabetic LEAD, and to interpret the therapeutic mechanism of Shen-Qi Hua-Yu formula in treatment of diabetic LEAD through proteomics technology, and to screen biomarkers with characteristics of TCM diagnosis and clinical efficacy evaluation. On the other hand, to our knowledge, this study may be the first trial of CHM formulas to observe cardiovascular outcomes through long-term follow-up for the treatment of diabetic LEAD, which is of great value.

TRIAL REGISTRATION

This study is registered on the Chinese Clinical Trial Registry: ChiCTR1900026372.

The White Blood Cell Count to Mean Platelet Volume Ratio for the Prediction of Chronic Limb-Threatening Ischemia in Lower Extremity Artery Disease

Background: The white blood cell count to mean platelet volume ratio (WMR) is increasingly gaining importance as a promising prognostic marker in atherosclerotic disease, but data on lower extremity artery disease (LEAD) are not yet available. The principle aim of this study was to assess the association of the WMR with the occurrence of CLTI (chronic limb-threatening ischemia) as the most advanced stage of disease. Methods: This study was performed as a retrospective analysis on 2121 patients with a diagnosis of LEAD. Patients were admitted to the hospital for the reason of LEAD and received conservative or endovascular treatment. Blood sampling, in order to obtain the required values for this analysis, was implemented at admission. Statistical analysis was conducted by univariate regression in a first step and, in case of significance, by multivariate regression additionally. Results: Multivariate regression revealed an increased WMR (p < 0.001, OR (95%CI) 2.258 (1.460–3.492)), but also advanced age (p < 0.001, OR (95%CI) 1.050 (1.040–1.061)), increased CRP (p < 0.001, OR (95%CI) 1.010 (1.007–1.014)), and diabetes (p < 0.001, OR (95%CI) 2.386 (1.933–2.946)) as independent predictors for CLTI. Conclusions: The WMR presents an easily obtainable and cost-effective parameter to identify LEAD patients at high risk for CLTI.

[Effects of neural therapy on quality of live in patients with inoperable lower extremity artery disease]

Background and purpose

Our aim was to evaluate the effects of percutaneous neurolysis of lumbal sympathetic ganglions on pain and the resulting changes in quality of life with validated objective and subjective methods. To follow the adverse effects and complications of the procedure.

Methods

A prospective, non-randomized, interventional, clinical cohort study under real life conditons was conducted. The time of the observation was 6 months. Palliative neural therapy was performed to reduce the ischemic pain of the affected leg of the patients involved in the study. Prior to treatment and after 35 days, Visual Analogue Scale (VAS) was used to measure the intensity of lower limb pain. The related changes in the quality of life were followed by a general 36-Item Short-Form Health Survey (SF-36) questionnaire. We measured the changes of the patients' skin temperature and ankle/arm index. The post-treatment results were compared to the pre-treatment results. We compared the results of objective and subjective measures. We followed the side effects and complications of the pain therapy. Each of the examined subjects had obliterative (Fontaine II/b stage) arterial disease of the lower limbs, in which no revascularization intervention was feasible and their ischemic pain was of VAS≥7.

Results

Data of 124 patients (69 male, 55 female) could be evaluated. The decrease in intensity of limb pain in the post-treatment period was significant (p=0.001). Quality of life also indicated a significant improvement (p=0.004). Changes in skin temperature and ankle/arm index demonstrated significant improvement (p≤0.005): skin temperature increased from 27.6°C to 31.2°C, the ankle/arm index inceased from 0.67 to 0.83 on average. Changes in objective and subjective measures correlated with each other. No worthening of symptoms, serious adverse events or complications were observed.

Conclusion

The chemical denervation of the lumbar sympathetic ganglions with percutaneous application is a minimally invasive intervention, useful in outpatient care, which can be well tolerated by the patient without any significant side effect or complication. Its hyperaemic effect and the pain reduction of the leg can improve the quality of life of the patients.