Mortality differences by race over 20 years in individuals with peripheral artery disease

INTRODUCTION

Racial disparities exist in patients with peripheral artery disease (PAD), with Black individuals having worse PAD-specific outcomes. However, mortality risk in this population has been mixed. As such, we sought to evaluate all-cause mortality by race among individuals with PAD.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (NHANES). Baseline data were obtained from 1999 to 2004. Patients with PAD were grouped according to self-reported race. Multivariable Cox proportional hazards regression was performed to calculate adjusted hazard ratios (HR) by race. A separate analysis was performed to study the effect of burden of social determinants of health (SDoH) on all-cause mortality.

RESULTS

Of 647 individuals identified, 130 were Black and 323 were White. Black individuals had more premature PAD (30% vs 20%, p < 0.001) and a higher burden of SDoH compared to White individuals. Crude mortality rates were higher in Black individuals in the 40-49-year and 50-69-year age groups compared to White individuals (6.7% vs 6.1% and 8.8% vs 7.8%, respectively). Multivariable analysis demonstrated that Black individuals with both PAD and coronary artery disease (CAD) had a 30% higher hazard of death over 20 years compared to White individuals (HR = 1.3, 95% CI: 1.0-2.1). The cumulative burden of SDoH marginally (10-20%) increased the risk of all-cause mortality.

CONCLUSIONS

In a nationally representative sample, Black individuals with PAD and CAD had higher rates of mortality compared to their White counterparts. These findings add further proof to the ongoing racial disparities among Black individuals with PAD and highlight the necessity to identify ways to mitigate these differences.

Clinical characteristics, treatment and outcomes of patients with spontaneous renal artery dissections

OBJECTIVES

The natural history and optimal management of spontaneous renal artery dissections (SRADs) are poorly understood. We compared baseline characteristics, presentation, management, and outcomes between patients with symptomatic versus asymptomatic SRADs.

METHODS

We performed a retrospective review of medical charts for patients diagnosed with SRAD at a single, tertiary care center. Patients were identified using billing codes. Patient demographics, medical history, clinical presentation, treatment, and follow up were recorded. We compared patients based on presence or absence of symptoms at the time of SRAD diagnosis.

RESULTS

A total of 125 patients were included; 73 (58.4%) patients had symptoms at the time of SRAD diagnosis. Symptomatic patients were younger at the time of diagnosis (47.4 vs. 54.3 years, p = 0.008) and more likely male (74.0% vs. 44.2%, p = 0.005). Most patients received medical therapy (93.2% vs. 82.6%, p = 0.32). Endovascular therapy utilization was low in both groups (8.2% vs. 7.7%, p = 0.9). Outcomes between the two groups were comparable; renal function remained stable, and mortality was rare.

CONCLUSION

Most patients who presented with SRAD were treated with medical therapy alone and usually experienced a benign course. Further studies are needed to understand the pathophysiology and natural history of renal artery dissections.

Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT: Results from the ATTRACT Multicenter Randomized Trial

Few studies have documented relationships between endovascular therapy, duplex ultrasonography (DUS), post-thrombotic syndrome (PTS), and quality of life (QOL). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial randomized 692 patients with acute proximal deep vein thrombosis (DVT) to receive anticoagulation or anticoagulation plus pharmacomechanical catheter-directed thrombolysis (PCDT). Compression DUS was obtained at baseline, 1 month and 12 months. Reflux DUS was obtained at 12 months in a subset of 126 patients. Clinical outcomes were collected over 24 months. At 1 month, patients who received PCDT had less residual thrombus compared to Control patients, evidenced by non-compressible common femoral vein (CFV) (21% vs 35%, p < 0.0001), femoral vein (51% vs 70%, p < 0.0001), and popliteal vein (61% vs 74%, p < 0.0001). At 12 months, in the ultrasound substudy, valvular reflux prevalence was similar between groups (85% vs 91%, p = 0.35). CFV non-compressibility at 1 month was associated with higher rates of any PTS (61% vs 46%, p < 0.001), a higher incidence of moderate-or-severe PTS (30% vs 19%, p = 0.003), and worse QOL (difference 8.2 VEINES-QOL (VEnous INsufficiency Epidemiological and Economic Study on Quality of Life) points; p = 0.004) at 24 months. Valvular reflux at 12 months was associated with moderate-or-severe PTS at 24 months (30% vs 0%, p = 0.01). In summary, PCDT results in less residual thrombus but does not reduce venous valvular reflux. CFV non-compressibility at 1 month is associated with more PTS, more severe PTS, and worse QOL at 24 months. Valvular reflux may predispose to moderate-or-severe PTS. ClinicalTrials.gov Identifier NCT00790335.

Peripheral vascular manifestation in patients receiving an amphetamine analog: A case series

Amphetamine and its related derivatives and analogues (ADRA) are highly addictive central nervous system stimulants that are used commonly in the treatment of attention-deficit/hyperactivity disorder and narcolepsy. These medications are associated with many side effects but reports of peripheral arterial manifestations associated with ADRA usage are scarce. We retrospectively reviewed the records of 16 patients (median age 37 years (IQR 31–47), 13 females) referred to a single tertiary referral service while receiving ADRA. Follow-up was available for a median of 3 years (IQR 3–4.5). The most common presentation (62.5%) was mild vasospastic symptoms involving the upper, lower or both extremities. Six patients developed severe manifestations including tissue loss and the need for lower extremity amputation. Most patients (75%) refused to stop the medication during follow-up. Underlying rheumatologic disorders were found in 25% of the patients, and the presence of rheumatologic disease seemed to be associated with more severe vascular manifestations. In conclusion, it is important to search for ADRA usage as part of the differential diagnosis of digital ischemia.

Presentation, treatment, and outcomes in patients with spontaneous isolated celiac and superior mesenteric artery dissection

Spontaneous isolated celiac or superior mesenteric artery (SMA) dissection (SICMAD) is a rare clinical entity. Not much is known about the natural history and appropriate treatment. We retrospectively queried a prospectively collected institutional radiology database for all patients diagnosed with SICMAD from 1990 to 2017. We identified 42 arteries in 40 patients (83.3% male), mean age 54.8 ± 10.9 years, consisting of 24 celiac arteries and 18 SMA. SMA lesions were longer than celiac lesions (5.15 ± 3.81 vs 2.38 ± 1.40 cm, p = 0.008). Thirty-one patients had follow-up; mean follow-up was 4.9 ± 4.8 years. Morphologic improvement was seen in 20 (48%) arteries. Sakamoto IV lesions were more likely to remodel (OR: 11.26, 95% CI: 1.13, 588.26, p = 0.039), and Sakamoto II lesions less likely to remodel (OR: 0, 95% CI: 0.00, 0.93, p = 0.05). Patients received an average of 2.35 scans during follow-up. Symptom resolution occurred in all symptomatic patients, and 16% of patients had recurrence of symptoms. Follow-up CT scans revealed a stable arterial diameter for the majority of patients. In conclusion, the majority of patients with SICMAD improve with medical therapy alone. Aneurysmal dilatation is uncommon.

Radial Artery Pseudoaneurysm

PURPOSE

To review the causes, clinical course, and management of patients with catheter-associated radial artery pseudoaneurysm (PSA).

METHODS

We reviewed all patients diagnosed with radial artery PSA resulting from arterial line placement or radial artery access for cardiac procedures from 2010 to 2015.

RESULTS

We identified 11 cases: 5 caused by arterial lines and 6 by cardiac procedures. The diagnosis was confirmed by duplex ultrasound in all cases; PSA size ranged from less than 1 cm to 5 cm in diameter. Spontaneous thrombosis (over a mean of 27 days) occurred in 4 patients; each PSA was smaller than 3 cm. Surgery was performed in 7 patients with excision of the stalk and repair of the artery as the most common procedure. Only one case was performed emergently for acute carpal tunnel syndrome. Complications occurring owing to either the PSA or the treatment were recorded in 5 patients.

CONCLUSIONS

Spontaneous thrombosis may occur in smaller lesions over a few weeks. When required, surgery to evacuate the hematoma and repair the artery was effective in all cases.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Role of Sonographic Imaging to Assess the Pathophysiology of Cording in Patients Treated for Breast Cancer

The pathophysiology of cording (visible bands of tissue that can form in the ipsilateral axilla and arm following breast cancer surgery) remains equivocal. Cording can be a painful and functionally limiting condition. Our aim was to assess the role of duplex ultrasonographic imaging as a diagnostic tool for assessment of this condition. We evaluated five women who had undergone surgery for unilateral breast cancer. Cording was identified by self-report and confirmed by physical examination. Duplex ultrasonography was performed within one week of the clinical diagnosis of cording. Duplex ultrasonography failed to identify the cording structures and does not appear to be a useful diagnostic tool for determining the pathophysiology of cording following treatment for breast cancer. Research focusing on intervention strategies to facilitate the clinical resolution of cording following breast cancer surgery is needed.

What's past is prologue

Above knee and below knee patency for synthetic endografts are vastly different. Long-term data is encouragingly similar to synthetic bypass grafting. Optimize use of synthetic endografts in above knee femoropopliteal segments in non-critical limb ischemia patients.

Long-term experience and outcomes with transcatheter closure of patent foramen ovale

OBJECTIVES

This study sought to examine the frequency of indications for and the immediate and long-term clinical outcomes of transcatheter closure of patent foramen ovale (PFO).

BACKGROUND

Transcatheter PFO closure is commonly performed for several indications, including cryptogenic stroke, despite conflicting data regarding the efficacy of this intervention.

METHODS

We report the outcomes of 800 consecutive patients (52% male, 50 ± 14 years of age) who underwent PFO closure at our institution after multidisciplinary evaluation over a 16-year period.

RESULTS

Indications for closure included cryptogenic cerebrovascular event (94%), hypoxemia (2%), peripheral embolism (3%), and migraine headaches (2%). Procedural success was 99% with effective closure obtained in 93% of patients. At a mean follow-up of 42.7 ± 33.4 months, 21 patients suffered a recurrent ischemic neurologic event (12 strokes, and 9 transient ischemic attacks) for an incidence rate of 0.79 events per 100 person-years and freedom from recurrent events of 91.6% at 10 years. There was no device-based difference in the rate of recurrent ischemic neurologic events (p = 0.82). Only Eustachian valve prominence (hazard ratio: 9.04; 95% confidence interval: 2.07 to 39.44; p = 0.0034) was associated with recurrent neurologic events.

CONCLUSIONS

Transcatheter PFO closure is safe and feasible in patients with several clinical indications. The long-term efficacy of this intervention in patients with paradoxical embolism appears superb in this observational study. Carefully selected patients with features suggestive of paradoxical embolism are the most likely to benefit from PFO closure and should be the focus of future investigation.

Medical and interventional options to treat pulmonary embolism

Venous thromboembolism remains one of the most common conditions. Pulmonary embolism carries a mortality rate of over 15 % in the first 3 months after diagnosis. Venous thromboembolism is the fourth leading cause of death in the Western world, and the third leading cause of cardiovascular death trailing myocardial infarction and stroke. This section highlights the medical and interventional options presently available to treat this potentially lethal disease.

Upper Extremity Deep Vein Thrombosis: The Oft-forgotten Cousin of Venous Thromboembolic Disease

OPINION STATEMENT

Upper extremity deep venous thrombosis (UEDVT) accounts for between 4% and 10% of all deep venous thromboses, and may be due to primary or secondary causes. The incidence of UEDVT is increasing, partly due to the exponential growth in the use of central venous catheters and the increasing placement of permanent cardiac pacemaker or defibrillator devices. UEDVT not only compromises future vascular access but results in significant morbidity and mortality, with symptomatic pulmonary embolus occurring in approximately 12%, post-thrombotic syndrome in 13%, and mortality ranging from 15-50%. Treatment of UEDVT depends on the underlying cause, primary or secondary. In this review, we will evaluate the management options and present a proposed treatment algorithm for primary UEDVT, involving catheter-directed thrombolysis, selective use of mechanical thrombectomy, anticoagulation and antithrombotic therapy, expeditious early first rib resection to decompress the thoracic outlet, and the role of adjunctive endovascular balloon angioplasty and stenting in improving axillo-subclavian vein patency. With regard to secondary UEDVT, we will present a treatment algorithm for managing central venous catheter (CVC) thrombosis; review the options for antithrombotic and anticoagulant therapy; and discuss the role of endovascular therapy. Finally, we will review the data supporting the growing role of percutaneous transluminal angioplasty (PTA) or venoplasty and endovascular stenting as the modality of choice in managing SVC obstruction, whether due to benign or malignant causes, and provide a brief description of the role, benefits and potential complications of SVC filter placement.

Carotid Duplex Ultrasound Velocity Measurements Versus Intravascular Ultrasound in Detecting Carotid In-Stent Restenosis

Background— Duplex ultrasonography criteria for assessing the severity of carotid artery (CA) in-stent restenosis are not well established.

Methods and Results— We analyzed 39 patients (40 CAs) who underwent CA stenting with baseline and 6-month follow-up carotid duplex ultrasonography and intravascular ultrasound. Intravascular ultrasound measurements included minimum luminal diameter, percent diameter, and lumen area stenosis. Duplex ultrasonography measurements included peak systolic velocity (PSV), percentage change in PSV, end-diastolic velocity (EDV), and internal-to-common CA PSV ratio (ICA/CCA). Receiver operating characteristic curves assessed each duplex measurement to detect ≥50% diameter, ≥75% lumen area stenosis, and minimum luminal diameter <3 mm at follow-up. At 6-month intravascular ultrasound follow-up, ≥50% diameter and ≥75% lumen area CA in-stent restenosis occurred in 20% and 25%, respectively; minimum luminal diameter <3 cm occurred in 48%. Area under receiver operating characteristic curves for PSV, EDV, and ICA/CCA were 0.85, 0.96, and 0.89 for ≥50% diameter stenosis and 0.89, 0.93, and 0.88 for ≥75% lumen area stenosis, respectively. Optimal PSV, EDV, and ICA/CCA criteria to detect ≥50% diameter and ≥75% lumen area CA in-stent restenosis were greater compared with those for native CA. A >98% increase in PSV had the highest specificity, whereas the combination of EDV >41 cm/s and ICA/CCA >2 had the highest sensitivity in detecting ≥75% lumen area CA in-stent restenosis.

Conclusions— PSV, EDV, and ICA/CCA PSV ratio were good discriminators for detecting significant diameter and lumen area greater compared with those for native CA. The combination of duplex velocity criteria increases diagnostic accuracy.

Treatment of renal artery in-stent restenosis with sirolimus-eluting stents

The objective of this study was to analyze the use of sirolimus-eluting stent (SES) placement for the treatment of renal artery in-stent restenosis (RA-ISR). The optimal treatment of RA-ISR has not been fully elucidated to date. We retrospectively analyzed consecutive patients from our institution who underwent treatment of RA-ISR with a SES from May 2004 to June 2006. Using duplex ultrasound, RA-ISR (> 60% diameter) was determined by peak systolic velocity (PSV) > 300 cm/s and renal aortic ratio (RAR) > 4.0. Renal function (creatinine) and blood pressure were measured at baseline and follow-up. SESs were implanted in 16 patients (22 renal arteries) during the study period. The study cohort was predominantly female (75%) with a mean age of 68 +/- 12 years. RA-ISR was treated with SESs with a mean diameter of 3.5 mm and mean length of 17.9 +/- 3.8 mm. The mean post-dilation balloon diameter was 4.8 +/- 0.6. The baseline renal artery PSV was 445 +/- 131 cm/s with a mean RAR of 5.0 +/- 1.6. Follow-up information was available in 21 renal arteries. During a median follow-up of 12 months (range: 9-15 months), 15 renal arteries (71.4%) developed recurrence of ISR by ultrasonographic criteria. Univariate analysis revealed that female sex was an independent predictor of recurrence of ISR after SES implantation (p < 0.05). In conclusion, placement of a SES for the treatment of ISR in renal arteries is associated with high initial technical success but significant restenosis on duplex ultrasonography at follow-up.

Endovascular treatment of septic thrombophlebitis: a case report of a rare complication and review of the literature

We report a case of severe deep venous thrombosis (DVT) treated with multimodality therapy that was complicated by sepsis due to thrombus likely infected by Salmonella virchow. We review the current therapeutic options in the therapy of severe DVT and cardiovascular pathology associated with non-typhoid Salmonella.

Embolic protection device use in renal artery stent placement

PURPOSE

The purpose of the present study was to report safety, efficacy, and renal function outcomes with use of the GuardWire embolic protection device (EPD) in renal artery stent placement for patients with renal artery stenosis (RAS) and chronic renal insufficiency (CRI).

MATERIALS AND METHODS

This was a retrospective study of all patients with RAS and CRI treated concomitantly with a GuardWire EPD and renal artery stents from December 2002 through June 2006. Renal function was determined by calculating the estimated glomerular filtration rate (eGFR) according to the Modification of Diet in Renal Disease formula, and subjects were divided into Kidney Disease Outcomes and Quality Initiative (K-DOQI) classes based on baseline eGFR. After revascularization, an improvement from baseline of at least one K-DOQI class was defined as improvement, unchanged K-DOQI class as stabilization, and worsening of at least one K-DOQI class as deterioration.

RESULTS

There were 63 patients (54% men) with a mean age of 75.2 years +/- 7.7. The mean baseline serum creatinine level and eGFR were 1.87 mg/dL +/- 0.6 (range, 1-3.8 mg/dL) and 36.63 mL/min per 1.73 m(2) +/- 11.42 (range, 13.85-59.99 mL/min per 1.73 m(2)), respectively, and at the last clinical follow-up, the respective measurements were 1.96 mg/dL +/- 0.72 and 38.75 mL/min per 1.73 m(2) +/- 13.25 (P = not significant). Over a mean follow-up period of 16 months +/- 12, 14 patients (25%) showed improvement, 33 (58%) had stable renal function, and 10 (18%) showed deterioration. There was one GuardWire-related dissection, which was successfully treated with a stent.

CONCLUSIONS

The GuardWire EPD, used during renal artery stent placement, is safe and was associated with stabilization or improvement in kidney function in 83% of patients with RAS and CRI.

May-Thurner syndrome in patients with cryptogenic stroke and patent foramen ovale: an important clinical association

BACKGROUND AND PURPOSE

We aimed to investigate the incidence of May-Thurner syndrome in patients with cryptogenic stroke with patent foramen ovale.

METHODS

This was a retrospective study. All consecutive patients with cryptogenic stroke having undergone patent foramen ovale closure from January 1, 2002, to December 31, 2007, at our institute were included in this study. Pelvic magnetic resonance venography studies of all patients were reviewed to determine if features of May-Thurner syndrome were present. Medical records and invasive venography studies of all patients were reviewed when available. All patients with May-Thurner syndrome features on magnetic resonance venography were reviewed by a vascular medicine specialist to define any previous incidence of deep vein thrombosis or any signs of chronic venous insufficiency. All patients also had lower limb venous duplex performed to rule out lower limb venous thrombosis.

RESULTS

A total of 470 patients from January 1, 2002, until December 31, 2007, with cryptogenic stroke underwent patent foramen ovale closure at our institute. Thirty patients (6.3%) had features consistent with May-Thurner syndrome on magnetic resonance venography. These patients were predominantly female (80%) with a mean age of 43.6+/-11.9 years. Twelve patients (40%) had abnormalities in their laboratory thrombophilia evaluation and 13 females (54.1%) were taking hormone-related birth control pills. Only 2 patients had a history and signs of chronic venous insufficiency. All patent foramen ovales demonstrated right-to-left shunting on transesophageal echocardiography. Atrial septal aneurysms/hypermobile atrial septa were present in 70% of patients with May-Thurner syndrome.

CONCLUSIONS

May-Thurner syndrome has an important clinical association with cryptogenic stroke and patent foramen ovale.

An unusual late complication of axillobifemoral bypass graft: a case report

Axillobifemoral bypass is a well-established surgical procedure performed in conditions that preclude direct arterial reconstruction due to aortic sepsis, aortoenteric fistula, or other hostile abdominal pathology or prohibitive surgical risk. The choice of prosthetic graft used is either knitted Dacron(R) or polytetrafluoroethylene, with equally good results. Although externally supported grafts reportedly yielded improvement in primary patency compared to historical controls, no consensus exists as to which demonstrates superiority over the other despite several retrospective studies. Complications are usually limited to the perioperative period, although late anastomotic disruption, graft thrombosis, axillary thromboembolism, pseudoaneurysm formation due to seat belt trauma, and hemorrhage or graft rupture have all been described. In addition to the above complications responsible for graft failure, perigraft infection, intimal hyperplasia, poor distal runoff, anastomotic fibrosis, and comorbid conditions may contribute to graft failure. We describe an unusual late complication of an axillobifemoral bypass graft whereby an organized thrombus within the layers of the bypass graft led to luminal compromise and, hence, attenuation of flow and resultant "failing graft."

Functional and clinical outcomes of nitinol stenting with and without abciximab for complex superficial femoral artery disease: A randomized trial

OBJECTIVE

To evaluate the effect of glycoprotein IIb/IIIa inhibition during nitinol stenting, of superficial femoral occlusive disease.

BACKGROUND

Stent implantation in the superficial femoral artery has been associated with suboptimal results while Glycoprotein IIb/IIIa inhibitors have shown improved procedural results during coronary intervention. We evaluated abciximab infusion during (Smart Stent) implantation in superficial femoral obstructions.

METHODS

We conducted a randomized placebo controlled trial. The two primary end points include: (1) 9-month restenosis defined as a decrease in ankle brachial index and in-stent duplex ultrasound restenosis: (2) adverse events defined as death (30 days) or repeat revascularization within 9 months.

RESULTS

Twenty-seven patients were randomized to abciximab and 24 patients to control (placebo). The primary end point of cumulative restenosis occurred in 15.4% of patients administered abciximab and in 12% administered placebo (P = 0.873). The primary restenosis endpoint in diabetics and total occlusions were similar at 14.3% and 15.4% respectively. The composite end point of 30-day mortality and 9-month revascularization occurred in 5.8% abciximab and 0% (P = 0.274) placebo with no 30-day deaths. Graded treadmill time and Rutherford class were all significantly improved in both groups, but the abciximab group did not appear to demonstrate any identifiable effect.

CONCLUSION

(Smart Stent) nitinol stenting of the superficial femoral artery was associated with favorable functional outcomes at 9 months. Adjunctive abciximab did not appear to demonstrate any identifiable effect.

Beta radiation in the treatment of in-stent restenosis of an in situ saphenous vein bypass graft A case report

We describe a case of instent restenosis in a femoral-distal saphenous vein bypass graft successfully treated with brachytherapy. A 45-year-old insulin-requiring diabetic woman underwent an in-situ femoral-anterior tibial bypass graft for a non-healing ischemic ulcer. Despite a technically successful percutaneous transluminal angioplasty and endovascular stenting of a retained valve within the threatened graft, the wound failed to heal. At the 1-month follow-up, instent restenosis was documented and successful cutting balloon angioplasty, complemented by adjunctive beta-irradiation was successfully performed. Clinical and hemodynamic success was achieved, with prompt ulcer healing and intermediate-term graft patency maintained on surveillance duplex ultrasound follow-up. We review the literature on radiation therapy in the management of peripheral arterial disease and discuss therapeutic options in the management of restenosis.

Duplex Ultrasonography of Vertebral and Subclavian Arteries

Duplex ultrasonography of the vertebral artery is an integral part of extracranial cerebrovascular screening and provides noninvasive diagnostic clues for subclavian or vertebral artery stenosis. This review describes technique for the ultrasound examination of the vertebral and subclavian arteries. Duplex images from various patients are used to illustrate a spectrum of hemodynamic changes that occur in the vertebral artery Doppler signal caused by subclavian artery stenosis and subclavian-vertebral steal.

Paget-Schroëtter syndrome: what to do?

Paget-Schroëtter syndrome, or primary thrombotic occlusion of the axillary-subclavian vein, is diagnosed in a 42-year-old man subsequently treated with thrombolysis and anticoagulation. Treatment strategies, including early and delayed surgical options, are discussed to determine the best risk/benefit ratio.

Chronic Venous Insufficiency

Patients with chronic venous insufficiency arguably have been relegated to a standard of care that is lower than that for those with the more appealing entity of peripheral arterial disease. Fortunately, the collaboration of an expanding group of clinicians (including cardiologists and vascular medicine specialists) with vascular surgeons is stimulating a renewed interest in the management of patients afflicted with venous disease. With the increased level of awareness of venous disease, technologic advances undoubtedly will augment the armamentarium available for the treatment of patients with chronic venous insufficiency. The focus on the prevention of venous thromboembolic complications has been advanced greatly, as witnessed by the growth of new pharmacologic agents, such as heparinoids, antiplatelet agents, direct thrombin inhibitors, thrombolytics, and pentasaccharides. In addition, the more aggressive strategy of intervening in acute deep venous obstruction by using thrombolytic agents and adjunctive mechanical thrombectomy devices potentially may obviate the future sequelae of chronic venous insufficiency. The tremendous growth of endovascular techniques in recent years has revolutionized the management of problems due to acute and chronic arterial obstructive disease. The application of these techniques in the future may have a similar impact in improving the clinical outcomes of patients with chronic venous disease and potentially, if proven safe and efficacious in clinical trials, may lower the threshold for intervention to an earlier disease stage. Similarly, with the advent of endovascular and endoscopic techniques, surgical procedures will also continue to evolve, with these procedures complementing one another, as opposed to serving as surrogates, which traditionally has been the case.

Potential emerging therapeutic strategies to prevent restenosis in the peripheral vasculature

Despite the availability of antiplatelet and antithrombotic therapies, recent advances in catheter and stent technology and improved operator skill, restenosis remains the most frequent problem associated with percutaneous and surgical revascularization interventions for both coronary and peripheral arterial disease. Prevention of restenosis in the coronary vasculature has been demonstrated with cilostazol, trapidil, probucol, tranilast, nitric oxide donors, and clopidogrel. Given the similarities in revascularization procedures and in the pathophysiology of restenosis, it is possible that these results may be extrapolated to the setting of restenosis in the peripheral vasculature, making trials with these agents imperative. Several new agents have shown promising preliminary results for the prevention of restenosis in the peripheral vasculature, including cilostazol, low-molecular-weight heparins, and elastase. Several nonpharmacologic treatment modalities are also under study to prevent peripheral and coronary restenosis and have shown favorable initial results. These include endovascular radiation brachytherapy, arterial gene therapy, photoangioplasty, and several novel treatment delivery systems.

Management of peripheral arterial disease and intermittent claudication

BACKGROUND

Peripheral arterial disease (PAD) is the chronic obstruction of the arteries supplying the lower extremities. The most common symptom is intermittent claudication resulting in aching pain, numbness, weakness, or fatigue in the muscle groups of the lower extremities.

METHODS

Using the key words "peripheral arterial disease," "intermittent claudication," "atherosclerosis," and "cardiovascular disease," MEDLINE databases were searched from 1970 to the present. The most recent articles pertinent to current treatment recommendations for PAD and intermittent claudication were selected to document this review.

RESULTS AND CONCLUSIONS

Symptoms of intermittent claudication are induced by walking or exercise and usually resolve with rest. Disease severity varies from patients who are asymptomatic to those who have unremitting symptoms. A high overlap exists between PAD and coronary artery and cerebrovascular disease. Risks for long-term morbidity and mortality are identical for PAD, intermittent claudication, and coronary artery disease. Treatment of PAD is aimed at maintaining or improving functional status, reducing or eliminating ischemic symptoms, and preventing disease progression. Exercise and aggressive risk factor modification represent the cornerstones of treatment. Risk factors include smoking, diabetes, lipid abnormalities, hypertension, C-reactive protein, lipoprotein(a), and hyperhomocystinemia. Antiplatelet and lipid-altering therapies decrease risk of atherosclerotic vascular complications and are being studied to improve intermittent claudication. Cilostazol, a new antiplatelet, antithrombotic agent, reduces claudication symptoms. Angiogenic growth factors have shown preliminary success in patients with rest pain and ischemic ulcers and are being investigated for use in patients with intermittent claudication. Invasive revascularization procedures can be considered for patients with critical limb ischemia or when medical therapy fails.