The Risk of Disease Progression in Peripheral Arterial Disease is Higher than Expected: A Meta-Analysis of Mortality and Disease Progression in Peripheral Arterial Disease

Urinary neutrophil gelatinase-associated lipocalin (NGAL) can potentially predict vascular complications and reliably risk stratify patients with peripheral arterial disease

Neutrophil gelatinase-associated lipocalin (NGAL) is expressed in atherosclerotic plaques and implicated in the development of cardiovascular diseases. Peripheral arterial disease (PAD) is an atherosclerotic disease that often results in major cardiovascular events. This study aimed to prospectively examine the potential of urine NGAL (uNGAL) in predicting worsening PAD status and major adverse limb events (MALE). Baseline urine NGAL (uNGAL) and urine creatinine (uCr) concentrations were measured in PAD (n = 121) and non-PAD (n = 77) patients. Levels of uNGAL were normalized for urine creatinine (uNGAL/uCr). Outcomes included worsening PAD status, which was defined as a drop in ankle brachial index (ABI) > 0.15, and major adverse limb events (MALE), which was defined as a need for surgical revascularization or amputations. PAD patients had 2.30-fold higher levels of uNGAL/uCr [median (IQR) 31.8 (17.0–62.5) μg/g] in comparison to non-PAD patients [median (IQR) 73.3 (37.5–154.7) μg/g] (P = 0.011). Multivariate cox analysis showed that uNGAL/uCr levels were independently associated with predicting worsening PAD status and MALE outcomes. Cumulative survival analysis, over follow up period, demonstrated a direct correlation between elevated uNGAL/uCr levels and PAD disease progression and MALE outcomes. These data demonstrate an association between elevated uNGAL/uCr levels and worsening PAD disease status and MALE outcomes, indicating its potential for risk-stratification of PAD patients.

Diagnostic Accuracy of Ankle-Brachial Pressure Index Compared with Doppler Arterial Waveforms for Detecting Peripheral Arterial Disease: A Systematic Review

GENERAL PURPOSE

To present the results of a research study evaluating the diagnostic accuracy of the ankle-brachial pressure index (ABPI) compared with that of Doppler arterial waveforms (DAWs) to detect peripheral arterial disease (PAD).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, the participant will:1. Summarize the evidence the authors considered when comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.2. Select the characteristics of the participants in the studies the authors analyzed.3. Identify the results of the authors' study comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.4. Distinguish the authors' conclusions about the advantages of using Doppler arterial waveforms to detect PAD.

Subunits of C1Q Are Associated With the Progression of Intermittent Claudication to Chronic Limb-Threatening Ischemia

Background

The pathophysiological mechanisms of intermittent claudication (IC) progression to chronic limb-threatening ischemia (CLTI) are still vague and which of patients with IC will become CLTI are unknown. This study aimed to investigate the key molecules and pathways mediating IC progression to CLTI by a quantitative bioinformatic analysis of a public RNA-sequencing database of patients with peripheral artery disease (PAD) to screen biomarkers discriminating IC and CLTI.

Methods

The GSE120642 dataset was downloaded from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) between IC and CLTI tissues were analyzed using the “edgeR” packages of R. The Gene Ontology and the Kyoto Encyclopedia of Genes and Genomes enrichment analyses were performed to explore the functions of DEGs. Protein–protein interaction (PPI) networks were established by the Search Tool for the Retrieval of Interacting Genes (STRING) database and visualized by Cytoscape software. Hub genes were selected by plugin cytoHubba. Gene set enrichment analysis was performed and the receiver operating characteristic curves were used to evaluate the predictive values of hub genes.

Results

A total of 137 upregulated and 21 downregulated DEGs were identified. Functional enrichment clustering analysis revealed a significant association between DEGs and the complement and coagulation cascade pathways. The PPI network was constructed with 155 nodes and 105 interactions. The most significantly enriched pathway was complement activation. C1QB, C1QA, C1QC, C4A, and C1R were identified and validated as hub genes due to the high degree of connectivity. The area under the curve values for the five hub genes were greater than 0.95, indicating high accuracy for discriminating IC and CLTI.

Conclusion

The complement activation pathway is associated with IC progression to CLTI. C1QB, C1QA, C1QC, C4A, and C1R might serve as potential early biomarkers of CLTI.

Joint associations of peripheral artery disease and accelerometry-based physical activity with mortality: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

BACKGROUND AND AIMS

Peripheral artery disease (PAD) and lower levels of physical activity are both associated with higher mortality. Yet, their joint prognostic impact has not been systematically examined, especially in Hispanics/Latinos, and with objective measures. We aimed to examine the joint associations of PAD and physical activity with mortality in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

METHODS

We studied 7,620 Hispanic/Latino adults aged 45-74 years at baseline (2008-2011) who underwent assessment of PAD with ankle-brachial index (ABI) and physical activity with hip-worn accelerometry. We calculated four physical activity measures: sedentary time, light activity, moderate/vigorous activity, and total activity counts. We quantified the relationship between ABI and mortality overall, and by tertiles of activity measures in restricted cubic splines, using multivariable Cox models accounting for sampling weights. We also assessed cross-categories of ABI and activity measures with mortality.

RESULTS

During a median follow up of 7.1 years, 314 participants died. We observed a U-shaped association of ABI with mortality overall (e.g., hazard ratio 1.80 [95%CI 1.20-2.80] at ABI 0.7 vs 1.2). This U-shaped association was generally consistent after stratifying by activity measures, but an elevated mortality risk for higher ABI was not evident in the most active tertile based on sedentary time, time in light activity, and total activity counts. In the cross-category analysis of ABI and physical activity, the highest mortality risk was consistently seen in abnormal ABI (≤0.9 or >1.4) plus the least active tertile (e.g., HR 5.61 [3.31-9.51] for light activity), compared to referent ABI (0.9-1.4) plus the other more active two tertiles, with no interactions between ABI and activity measure.

CONCLUSIONS

Abnormal ABI and lower accelerometry-based physical activity were independently and jointly associated with mortality in Hispanics, suggesting the importance of simultaneously evaluating leg vascular condition and physical activity.

Circulating Biomarkers in Lower Extremity Artery Disease

Lower extremity artery disease (LEAD), a chronic condition with disturbed lower extremity circulation due to narrowing of the arteries, is predominantly caused by atherosclerosis and is associated with the presence of cardiovascular risk factors and an increased risk of cardiovascular events. LEAD is prevalent among older individuals and predicted to rise with the ageing population. In progressive disease, the patient experiences symptoms of ischaemia when walking and, in advanced critical limb-threatening ischaemia, even at rest. However, LEAD is asymptomatic in most patients, delaying diagnosis and treatment. In this setting, circulating biomarkers may facilitate earlier diagnosis in selected individuals. This review provides a broad overview of the circulating biomarkers investigated to date in relation to LEAD and discusses their usefulness in clinical practice.

Sex Differences in Peripheral Artery Disease

Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.

Update on the pathophysiology and medical treatment of peripheral artery disease

Approximately 6% of adults worldwide have atherosclerosis and thrombosis of the lower limb arteries (peripheral artery disease (PAD)) and the prevalence is rising. PAD causes leg pain, impaired health-related quality of life, immobility, tissue loss and a high risk of major adverse events, including myocardial infarction, stroke, revascularization, amputation and death. In this Review, I describe the pathophysiology, presentation, outcome, preclinical research and medical management of PAD. Established treatments for PAD include antithrombotic drugs, such as aspirin and clopidogrel, and medications to treat dyslipidaemia, hypertension and diabetes mellitus. Randomized controlled trials have demonstrated that these treatments reduce the risk of major adverse events. The drug cilostazol, exercise therapy and revascularization are the current treatment options for the limb symptoms of PAD, but each has limitations. Novel therapies to promote collateral and new capillary growth and treat PAD-related myopathy are under investigation. Methods to improve the implementation of evidence-based medical management, novel drug therapies and rehabilitation programmes for PAD-related pain, functional impairment and ischaemic foot disease are important areas for future research.

Outcomes of Axillofemoral Bypass for Intermittent Claudication

OBJECTIVE

While endovascular therapy is often first-line treatment for medically refractory intermittent claudication (IC) caused by aorto-femoral disease, suprainguinal bypass is commonly performed. Although this is often aorto-femoral bypass (AoFB), axillo-femoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC.

METHODS

The Vascular Quality Initiative (2009-2019) was queried for suprainguinal bypass performed for IC. Univariable and multivariable analyses were used to compare perioperative and one-year outcomes between AxFB and a comparison cohort of AoFB.

RESULTS

We identified 3,261 suprainguinal bypasses performed for IC: 436 AxFB and 2,825 AoFB. Overall, mean age was 61.4 ± 9.1 years, 58.8% of patients were male sex, and 59.7% currently smoked. Patients undergoing AxFB, compared with AoFB, were more often older, male, never-smokers, and ambulated with assistance (all P<.001). They more often had hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, previous outflow peripheral endovascular interventions, and previous inflow or outflow bypass. AxFB, compared with AoFB, were more often uni-femoral (all P<.05). Patients undergoing AxFB, compared with AoFB, had shorter postoperative length of stay (median 4 vs. 6 days) and fewer perioperative pulmonary (3% vs. 7.9%) and renal complications (5.5% vs. 9.9%), but more perioperative ipsilateral major amputations (.9% vs. 0.04%) (all P<.05). There were no significant differences in perioperative myocardial infarction (2.8% vs. 2.7%), stroke (.7% vs. 1.1%), and death (1.8% vs. 1.7%) rates, respectively. At one year, Kaplan-Meier analysis demonstrated that the AxFB, compared with AoFB cohort, exhibited higher rates of death (7.3% vs. 3.6%, P=.002); graft occlusion or death (14.3% vs. 7.2%, P=.001); ipsilateral major amputation or death (12.5% vs. 5.6%, P<.001); and reintervention, amputation, or death (19% vs. 8.6%, P<.001). On multivariable analysis, AxFB was independently associated with increased risk of one-year reintervention, amputation, or death (HR 1.6, 95% CI 1.03-2.4, P=.04).

CONCLUSIONS

This retrospective analysis suggests that long-term complications were more frequent in patients who underwent AxFB as compared to AoFB, although patients treated with AxFB were at higher risk with more comorbidities. Since AxFB is associated with significant perioperative morbidity, mortality, and long-term complications, serious consideration should be given prior to its use for IC.

Objective Outcome Measures for Trials in Patients With Chronic Limb-Threatening Ischemia Across 2 Decades: Analysis and Recommendations

Chronic limb-threatening ischemia (CLTI) is prevalent and associated with morbidity and mortality. The published research concerning CLTI therapeutics is evolving. The goals of this review are to: 1) summarize the endpoints that are being used in trials assessing interventions for patients with CLTI; and 2) review gaps and discrepancies in current outcome definitions. A search was conducted of the PubMed database and ClinicalTrials.gov to identify studies published between January 2000 and March 2020 that evaluated treatment options for patients with CLTI. Meta-analyses, case series, case reports, abstracts, and expert opinion were excluded. Forty-nine studies (n = 11,667) were identified that fulfilled the inclusion criteria. Most trials reported clinical outcomes (mortality, 69.4%; limb events, 87.8%; target lesion revascularization, 83.7%). Mean follow-up duration was 23.7 months. In investigational device exemption trials, total follow-up and follow-up to primary outcomes were discordant (12 months vs 6 months; P = 0.0018). Hemodynamic testing was reported in 71.4%, usually ankle-brachial index. Patency was assessed in 89.8% of trials; ultrasound was used in 65.3% and invasive angiography in 85.7%, at baseline and/or during follow-up. Wound assessment was performed in 49.0% of studies, qualitative in 28.6% and quantitative in 20.4%. Finally, quality of life assessment was performed in 55% of studies. Definitions for many outcomes varied across studies. Consensus regarding which outcomes to study, uniform definitions, and optimal methods to measure some of these outcomes are yet to be established. A comprehensive effort by all stakeholders is needed to move the field of CLTI forward.

Evidence-Experience Gap and Future Perspective on the Treatment of Peripheral Artery Disease

Peripheral artery disease (PAD) is a systemic disease associated with impaired limb function, poor quality of life, and increased cardiovascular morbidity. Its incidence has been dramatically increasing over years because of the emergence of an aging society and the increase in the number of patients with atherosclerotic risk factors. The clustering of these risk factors promotes disease development, reportedly leading to the differential location of atherosclerotic lesions in lower extremity arteries. The clinical presentations of PAD include intermittent claudication and chronic limb-threatening ischemia (CLTI). PAD is associated with a high risk of mortality and morbidity from both cardiovascular and limb events. The therapeutic goals for patients with PAD include 1) relief from PAD-related limb symptoms, 2) the prevention of new-onset and the development and recurrence of PAD, and 3) the prevention of concomitant adverse events due to coronary artery disease (CAD) and cerebrovascular disease (CVD). There are several types of antithrombotic agents, and their main role in patients with PAD is to reduce systemic events mainly including cardiovascular and lower extremity-related events. Currently, the efficacy of direct oral anticoagulant (DOAC) is also suggested by recent clinical trials. Although endovascular therapy (EVT) has been a first-line revascularization strategy for symptomatic PAD, whether clinical outcomes after EVT are comparable to those after surgical bypass therapy remains inconclusive.

Mortality, Cardiovascular and Limb Events in Patients With Symptomatic Lower Extremity Artery Disease and Diabetes

The aim of this study was to compare the prognosis of patients according to diabetes status, during a 1-year follow-up after hospital admission for lower extremity artery disease, in the prospective COPART (COhorte de Patients ARTériopathes) registry. Inclusion criteria were intermittent claudication, ischemic rest pain, tissue loss, or acute limb ischemia, with radiological and hemodynamic confirmation. Among 2494 patients, 1235 (49.5%) had diabetes. Incidence rates for major adverse cardiovascular events (MACE) were 18.0/100 person-years (95% confidence interval [CI], 15.4-21.0) for the diabetes group and 11.1/100 person-years (95% CI, 9.2-13.4) for the non-diabetes group. Incidence rates of all-cause mortality were 29.8/100 person-years (95% CI, 26.5-33.4) for the diabetes group and 19.7/100 person-years (95% CI, 17.2-22.7) for the non-diabetes group. Incidence rates of major limb amputation were 24.2/100 person-years (95% CI, 21.1-27.8) for the diabetes group and 11.6/100 person-years (95% CI, 9.6-14.0) for the non-diabetes group. Diabetes was associated with MACE, adjusted hazard ratio 1.60 (95% CI, 1.16-2.22), and all-cause mortality, unadjusted HR 1.49 (95% CI, 1.24-1.78). In the multivariate analysis, diabetes was no longer associated with major amputation, adjusted HR 1.15 (95% CI, .87-1.51). Patients hospitalized for LEAD with diabetes had a higher risk of MACE than those without diabetes.

Statins and Peripheral Arterial Disease: A Narrative Review

Peripheral arterial disease (PAD) is a highly prevalent atherosclerotic condition. In patients with PAD, the presence of intermittent claudication leads to a deterioration in quality of life. In addition, even in asymptomatic cases, patients with PAD are at high risk of cardiac or cerebrovascular events. Treatment of PAD is based on lifestyle modifications; regular exercise; smoking cessation; and control of cardiovascular risk factors, including hypercholesterolemia. A growing number of studies have shown that statins reduce cardiovascular risk and improve symptoms associated with PAD. Current guidelines recommend the use of statins in all patients with PAD in order to decrease cardiovascular events and mortality. However, the prescribing of statins in patients with PAD is lower than in those with coronary heart disease. This review provides relevant information from the literature that supports the use of statins in patients with PAD and shows their potential benefit in decreasing lower limb complications as well as cardiovascular morbidity and mortality.

Impact of angiotensin receptor blockers on mortality after hospitalization for symptomatic lower extremity artery disease

AIMS

The objective was to assess the association between angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) prescription at discharge in patients hospitalized for symptomatic lower extremity artery disease (LEAD) and 1-year mortality.

METHODS AND RESULTS

The COPART registry is a multicentre, prospective, observational, cohort study which includes consecutive patients hospitalized for symptomatic LEAD in four French academic centres. All-cause mortality during a 1-year follow-up after hospital discharge was compared between patients with ARB, patients with ACEI and patients without ARB or ACEI. Analyses were performed using Cox models. As a sensitivity analysis, a propensity score (PS)-matching analysis was carried out. Among 1981 patients, 421 had ARB (21.3%), 766 ACEI (38.7%), and 794 no ACEI/ARB (40.1%) at discharge. During the 1-year follow-up, incidence rates for mortality were 12.6/100 person-years [95% confidence interval (CI) 9.7-16.1] for patients with ARB, 15.8/100 person-years (95% CI 13.4-18.6) for patients with ACEI and 19.8/100 person-years for patients without ACEI/ARB (95% CI 17.2-22.8). In a multivariate Cox model, ARB at discharge was associated with decreased mortality compared with no ACEI/ARB, hazard ratio (HR) 0.68 (95% CI 0.49-0.95), and with ACEI, HR 0.69 (95% CI 0.49-0.97). These results are consistent with those obtained by the Cox analyses in the PS-matched sample: HR 0.68 (95% CI 0.47-0.98) for patients with ARB compared with no ARB.

CONCLUSION

Angiotensin receptor blockers at discharge after hospitalization for symptomatic LEAD is associated with a better survival compared with ACEI or no ACEI/ARB.

Disparate effects of ankle-brachial index on mortality in the 'very old' and 'younger old' populations-the PolSenior survey

To assess the relationship between ankle-brachial index (ABI) and up to 10-year mortality in older individuals below and above the age of 80 years. In a multicenter survey of health status in the community dwelling subjects aged 55-59 and 65 + years in Poland, we assessed baseline medical history including risk-factors. We measured ABI, and serum creatinine, cholesterol, NT-proBNP, and interleukin-6 (IL-6) concentrations. We assessed mortality based on public registry. Between 2009 and 2019, 27.3% of 561 participants < 80 years, and 79.4% of 291 participants ≥ 80 years, died (p < 0.001); 67.8, 41.5, and 40.3% in the ABI groups < 0.9, 0.9-1.4, and > 1.4, respectively (p < 0.01). In the unadjusted Cox models, ABI was associated with mortality in the entire group, and < 80 years. In the entire group, analysis adjusted for age and sex showed mortality risk increased by 11% per year, and 50% with male sex. Mortality decreased by 37% per 1 unit ABI increase. In the group of people ≥ 80 years, only age was significantly associated with mortality (p < 0.001). In stepwise regression ABI < 0.9, male sex, active smoking, and NT-proBNP level were associated with risk of death < 80 years. In the ≥ 80 years old, mortality risk was associated with older age, and higher levels of IL-6, but not ABI. The ABI < 0.9 is associated with higher mortality in older people, but not among the oldest-old. In the oldest age group, age is the strongest predictor of death. In this age group, inflammageing is of importance.

Symptomatic human immunodeficiency virus infection is associated with advanced presentation and perioperative mortality in patients undergoing surgery for peripheral arterial disease

OBJECTIVE

Prior studies have demonstrated an increased risk of developing cardiovascular and peripheral arterial disease (PAD) in patients with human immunodeficiency virus (HIV). However, the effect of chronic HIV infection in patients with preexisting PAD and requiring vascular intervention is unclear. In the present study, we assessed the differences in clinical presentation and perioperative outcomes for patients with PAD who had undergone revascularization or amputation with and without HIV infection.

METHODS

International Classification of Diseases, 9th and 10th Revisions, Clinical Modification, codes were used to identify patients with a prior diagnosis of PAD who had undergone lower extremity revascularization or amputation in the National Inpatient Sample (2003-2017). From this group, the patients were divided for analysis into those with and without HIV infection. Of the patients with HIV infection (PWHs), we identified additional subsets of patients: those with any prior or current diagnosis of an HIV-related illness, including acquired immunodeficiency syndrome, designated as symptomatic HIV, and those without such a diagnosis, designated as asymptomatic HIV infection. Propensity score matching was performed to create matched cohorts. Population-based comparative analyses were performed of the clinical characteristics of the HIV-infected and HIV-uninfected groups. Univariate and multivariate logistic regression analyses of the perioperative in-hospital outcomes were performed on the matched cohorts.

RESULTS

A total of 224,912 patients aged 18 to 85 years were identified who had been admitted with an established diagnosis of PAD and had undergone a lower extremity procedure. Of these patients, 1264 (0.56%) also had a diagnosis of HIV infection. Symptomatic PWHs were more likely to present with critical limb ischemia than were the HIV-uninfected patients or asymptomatic PWHs (66.2% vs 46.3% and 43.6%; P < .01). However, both asymptomatic and symptomatic PWHs were more likely to have required minor (7.5% and 6.7% vs 2.6%; P < .01) and major (12.9% and 27.4% vs 7.0%; P < .01) amputations than were matched HIV-uninfected controls. Although adjusted multivariate logistic regression analysis demonstrated symptomatic HIV infection to be a significant, independent predictor of in-hospital mortality (odds ratio, 2.46; 95% confidence interval, 1.37-4.40; P = .003), the perioperative mortality for the asymptomatic PWH was comparable to that of matched HIV-uninfected controls.

CONCLUSIONS

Symptomatic PWHs, including patients living with acquired immunodeficiency syndrome, who had required a PAD-related procedure had presented with more advanced vascular disease and were most at risk of early perioperative mortality. However, the presentation and mortality between asymptomatic PWHs with well-controlled disease and HIV-uninfected patients were comparable. All PWHs with PAD were more likely to undergo lower extremity amputations than were HIV-uninfected matched controls. Asymptomatic, well-controlled HIV infection should not be a contraindication to elective PAD-related procedures because the mortality was similar to that of HIV-uninfected controls. However, the limb salvage rates might be lower for all PWHs with PAD, regardless of HIV disease severity. Taken together, these findings can improve perioperative risk stratification and surgical management of PAD in this high-risk population.

A single center's 15-year experience with palliative limb care for chronic limb threatening ischemia in frail patients

OBJECTIVE

Our institution's multidisciplinary Prevention of Amputation in Veterans Everywhere (PAVE) program allocates veterans with critical limb threatening ischemia (CLTI) to immediate revascularization, conservative, primary amputation or palliative limb care based on previously published criteria. These four groups align with the approaches outlined by the Global Guidelines for management of CLTI. The current study delineates the natural history of the palliative limb care group of patients and quantifies procedural risks and outcomes.

METHODS

Veterans prospectively enrolled into the palliative limb cohort of our PAVE program between January 2005 and January 2020 were analyzed. The primary outcome was mortality. Secondary outcomes included overall and limb-related readmissions, limb loss and wound healing. Clinical Frailty Score (CFS) was calculated and 5-year expected mortalities were estimated using the Veterans Administration Quality Enhancement Research Initiative (VA QUERI) tool. Regression analysis was performed to establish associations among the following variables: mortality, WIfI score, Clinical Frailty Score, overall admissions and limb-related admissions.

RESULTS

The PAVE program enrolled 1158 limbs over 15 years. 157 (13.5%) limbs in 145 patients were allocated to the palliative limb care group. The overall mortality of the group was 88.2% (median 3.5 months; range 0-91 months). Of the patients that expired, 50% (n=64) died within 3 months of enrollment. The predicted 5-year mortality for the group was 66%. The average frailty score of the group was 6.2, denoting someone who is moderately to severely frail. Based on CFS, 106 patients were considered frail while 39 were considered not frail. There was no difference in mortality between frail and non- frail patients, however there was a statistically significant difference in early mortality (<3 months), 56.2% vs 37.5% (p = 0.032), respectively. The 30-day limb-related readmission rate was 4.7%. Eventual major amputation was necessary in 18 (11.5%) limbs. Wound healing occurred in 30 patients (20.6%). Regression analysis demonstrated no association between frailty score and mortality (r = 0.55, p = 0.159) or between WIfI score and mortality (r = 0.0165, p = 0.98). There was a significant association between WIfI score and limb-related admissions (r = 0.97, p <0.001).

CONCLUSION

Frail, chronic limb threatening ischemia patients have a high early mortality and a low risk of limb-related complications. They also have a low incidence of deferred primary amputation or limb-related readmissions. In our cohort, the vast majority of patients died within a few months of enrollment without needing an amputation. A comprehensive approach to the management of CLTI patients should include a palliative limb care option as a significant proportion of these patients have limited survival and can potentially avoid unnecessary surgery or major amputation.

Association of Smoking With Postprocedural Complications Following Open and Endovascular Interventions for Intermittent Claudication

Importance

Smoking is a key modifiable risk factor in the development and progression of peripheral artery disease, which often manifests as intermittent claudication (IC). Smoking cessation is a first-line therapy for IC, yet a minority of patients quit smoking prior to elective revascularization.

Objective

To assess if preprocedural smoking is associated with an increased risk of early postprocedural complications following elective open and endovascular revascularization.

Design, Setting, and Participants

This retrospective cohort study used nearest-neighbor (1:1) propensity score matching of 2011 to 2019 data from the Veterans Affairs Surgical Quality Improvement Program, including all cases with a primary diagnosis of IC and excluding emergent cases, primary procedures that were not lower extremity revascularization, and patients with chronic limb-threatening ischemia within 30 days of the intervention. All data were abstracted June 18, 2020, and analyzed from July 26, 2020, to June 30, 2021.

Exposures

Preprocedural cigarette smoking.

Main Outcomes and Measures

Any and organ system-specific (ie, wound, respiratory, thrombosis, kidney, cardiac, sepsis, and neurological) 30-day complications and mortality, overall and in prespecified subgroups.

Results

Of 14 350 included cases of revascularization, 14 090 patients (98.2%) were male, and the mean (SD) age was 65.7 (7.0) years. A total of 7820 patients (54.5%) were smoking within the preprocedural year. There were a total of 4417 endovascular revascularizations (30.8%), 4319 hybrid revascularizations (30.1%), and 5614 open revascularizations (39.1%). A total of 1594 patients (11.1%) had complications, and 57 (0.4%) died. Among 7710 propensity score-matched cases (including 3855 smokers and 3855 nonsmokers), 484 smokers (12.6%) and 34 nonsmokers (8.9%) experienced complications, an absolute risk difference (ARD) of 3.68% (95% CI, 2.31-5.06; P < .001). Compared with nonsmokers, any complication was higher for smokers following endovascular revascularization (26 [4.3%] vs 52 [2.1%]; ARD, 2.19%; 95% CI, 0.77-3.60; P = .003), hybrid revascularization (204 [17.3%] vs 163 [14.1%]; ARD, 3.18%; 95% CI, 0.23-6.13; P = .04), and open revascularization (228 [15.4%] vs 153 [10.3%]; ARD, 5.18%; 95% CI, 2.78-7.58; P < .001). Compared with nonsmokers, respiratory complications were higher for smokers following endovascular revascularization (20 [1.7%] vs 6 [0.5%]; ARD, 1.17%; 95% CI, 0.35-2.00; P = .009), hybrid revascularization (33 [2.8%] vs 10 [0.9%]; ARD, 1.93%; 95% CI, 0.85-3.02; P = .001), and open revascularization (32 [2.2%] vs 19 [1.3%]; ARD, 0.89%; 95% CI, 0-1.80; P = .06). Wound complications and graft failure were higher for smokers compared with nonsmokers following open interventions (wound complications: 146 [9.9%] vs 87 [5.8%]; ARD, 4.05%; 95% CI, 2.12-5.99; P < .001; graft failure: 33 [2.2%] vs 11 [0.7%]; ARD, 1.50%; 95% CI, 0.63-2.37; P = .001). In a sensitivity analysis, compared with active smokers (n = 5173; smoking within 2 weeks before the procedure), the risk of any complication was decreased by 65% for never smokers (n = 1197; adjusted odds ratio, 0.45; 95% CI, 0.34-0.59) and 29% for former smokers (n = 4755; cessation more than 1 year before the procedure; adjusted odds ratio, 0.71; 95% CI, 0.61-0.83; P = .001 for interaction).

Conclusions and Relevance

In this cohort study, more than half of patients with IC were smoking prior to elective revascularization, and complication risks were higher across all modalities of revascularization. These findings stress the importance of smoking cessation to optimize revascularization outcomes.

Contemporary outcomes of concomitant suprainguinal bypass with infrainguinal revascularization procedures in patients with chronic limb-threatening ischemia

OBJECTIVE

Combined suprainguinal and infrainguinal revascularization is sometimes necessary in the treatment of patients with chronic limb-threatening ischemia (CLTI). However, data on outcomes of concomitant revascularization procedures are lacking. We studied the outcomes of patients with CLTI who underwent suprainguinal bypass (SIB) alone, SIB with concomitant infrainguinal bypass (IIB), and SIB with concomitant infrainguinal peripheral endovascular intervention (IIPVI).

METHODS

We reviewed all patients in the Vascular Quality Initiative with CLTI who underwent SIB from January 2010 to June 2020. Logistic regression, Kaplan-Meier survival estimates, log-rank tests, and Cox regression were used to analyze outcomes. Outcomes were 30-day mortality, perioperative myocardial infarction, perioperative major amputation, 1-year amputation-free survival, and 5-year survival.

RESULTS

Of 8037 patients included, 81.3% (n = 6537) underwent SIB alone, 9.7% (n = 783) underwent SIB+IIB, and 8.9% (n = 717) underwent SIB+IIPVI. The indication for surgery was rest pain in 5040 (62.5%) and tissue loss in 3031 (37.6%). There were no significant differences in 30-day mortality and perioperative myocardial infarction rates. However, there was 2.8-fold increased odds of perioperative major amputation in both SIB+IIPVI (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.30-5.88; P = .008) and SIB+IIB (OR, 2.79; 95% CI, 1.38-5.54; P = .004) among patients with rest pain as compared with SIB alone. Comparing SIB+IIPVI with SIB alone, there were no significant differences in 1-year freedom from amputation and amputation-free survival. SIB+IIPVI was associated with a 27% increased risk of 5-year mortality (hazard ratio [HR], 1.27; 95% CI, 1.03-1.55; P = .035). Compared with SIB alone, SIB+IIB was associated with 97% increased risk of 1-year major amputation among patients with rest pain (HR, 1.97; 95% CI, 1.06-3.69; P = .033), but a 47% decreased risk of 1-year major amputation or death for patients with tissue loss (HR, 0.53; 95% CI, 0.37-0.78; P = .001). SIB+IIPVI, compared with SIB+IIB, was associated with a two-fold increased risk of 1-year major amputation or death (HR, 2.04; 95% CI, 1.04-2.23), P = .003) and a 52% increased risk of 5-year mortality (HR,1.52; 95% CI, 1.04-2.24; P = .032) among patients with tissue loss.

CONCLUSIONS

This study shows that SIB with concomitant infrainguinal revascularization in patients with rest pain is associated with an increased risk of amputation, whereas SIB+IIB in patients with tissue loss is associated with decreased risk of amputation or death. SIB+IIB outperformed SIB+IIPVI in patients with tissue loss. SIB with infrainguinal revascularization should be limited in patients with rest pain in line with current guidelines, but SIB+IIB may be preferred in patients with tissue loss.

Sex Differences in Trends and In-Hospital Outcomes Among Patients With Critical Limb Ischemia: A Nationwide Analysis

Background Critical limb ischemia (CLI) represents the most severe form of peripheral artery disease and is associated with significant mortality and morbidity. Contemporary data comparing the sex differences in trends, revascularization strategies, and in-hospital outcomes among patients with CLI are scarce. Methods and Results Using the National Inpatient Sample database years 2002 to 2015, we identified hospitalizations for CLI. Temporal trends for hospitalizations for CLI were evaluated. The differences in demographics, revascularization, and in-hospital outcomes between both sexes were compared. Among 2 400 778 CLI hospitalizations, 43.6% were women. Women were older and had a higher prevalence of obesity, hypertension, heart failure, and prior stroke. Women were also less likely to receive any revascularization (34.7% versus 35.4%, P<0.001), but the trends of revascularization have been increasing among both sexes. Revascularization was associated with lower in-hospital mortality among women (adjusted odds ratio [OR], 0.76; 95% CI, 0.71-0.81) and men (adjusted OR, 0.69; 95% CI, 0.65-0.73). On multivariable analysis adjusting for patient- and hospital-related characteristics as well as revascularization, women had a higher incidence of in-hospital mortality, postoperative hemorrhage, need for blood transfusion, postoperative infection, ischemic stroke, and discharge to facilities compared with men. Conclusions In this nationwide contemporary analysis of CLI hospitalizations, women were older and less likely to undergo revascularization. Women had a higher incidence of in-hospital mortality and bleeding complications compared with men. Sex-specific studies and interventions are needed to minimize these gaps among this high-risk population.

Early detection of macrovascular complications in type 2 diabetes mellitus in Medan, North Sumatera, Indonesia: A cross-sectional study

Background: Macrovascular complications occur very frequently in patients with type 2 diabetes mellitus (T2DM) with a high mortality rate, due to the development of cardiovascular disease (CVD), such as stroke, atherosclerosis acceleration, and atrial fibrillation. T2DM is a significant risk factor for CVD and has become the leading cause of death. The purpose of this study was to detect the early risk of macrovascular complications by using the ankle brachial index (ABI) as a marker. Methods: This study was an analytic study with a cross-sectional approach. The study population was patients with T2DM from several primary health care centers in Medan. In total, 89 subjects who met the inclusion and exclusion criteria were recruited with consecutive sampling. ABI was determined as the ratio of systolic blood pressure in the brachial artery to the posterior tibial artery after the subjects had been relaxed and felt comfortable in a supine position. Examination of vitamin D and lipid profile was derived from examination of venous blood.  Data were processed using SPSS and analyzed with one-way ANOVA. Results: The study found that there was a relationship between LDL-C, triglyceride, and vitamin D (25OH-D) based on the ABI (p > 0.05). Conclusions: ABI can be used for an early detection of macrovascular complications. Apart from being easy to perform, ABI was non-invasive. Some other risk factors that can also be used to assess complications and have relationships with ABI were LDL-C, triglyceride, and vitamin D (25OH-D). Complications in T2DM patients can be prevented with reasonable blood sugar control and lifestyle changes. Education and motivation need to be given to patients so that they become more independent in controlling their disease and improving their quality of life.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia

OBJECTIVE

The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI).

METHODS

This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan-Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement.

RESULTS

Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford's category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different (p = .006). Group 1 had significantly lower amputation rate at 36 months (p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40-36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02-0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07-16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02-0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015-29.95, p = .002) were the significant independent predictors of LCI.

CONCLUSION

The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

External Applicability of the COMPASS and VOYAGER-PAD Trials on Patients with Symptomatic Lower Extremity Artery Disease in France: The COPART Registry

OBJECTIVE

The aim of this study was to examine the external applicability of the COMPASS and the VOYAGER-PAD trials in patients with lower extremity artery disease (LEAD) in the real world.

METHODS

This was a multicentre retrospective analysis of prospectively collected COPART data, a French multicentre registry of patients hospitalised for symptomatic LEAD. The proportion of patients eligible for the combination of rivaroxaban 2.5 mg twice daily plus aspirin based on either COMPASS or VOYAGER-PAD criteria is reported. The one year cumulative incidence of outcomes between eligible and non-eligible patients, as well as eligible patients vs. control arms of the COMPASS (LEAD patient subgroup) and the VOYAGER-PAD trials were compared. Analyses were performed using Cox models.

RESULTS

Of 2 259 evaluable patients, only 679 (30.1%) were eligible for a low dose rivaroxaban plus aspirin regimen. Others were not eligible because of the need for anticoagulant (48.5% and 38.9% of patients meeting COMPASS and VOYAGER-PAD exclusion criteria, respectively) or dual antiplatelet therapy use (15.7% and 16.5%, respectively), high bleeding risk (14.4% and 11.6%, respectively), malignancy (26.1% and 21.0%, respectively), history of ischaemic/haemorrhagic stroke (21.1% and 19.8%, respectively), and severe renal failure (13.2% and 10.5%, respectively). COMPASS and VOYAGER-PAD eligible and ineligible patients were at higher risk of ischaemic events than participants in these trials. The one year cumulative incidences were 6.0% (95% CI 4.3 - 8.1) in the COMPASS eligible subset vs. 3.5% (95% CI 2.9 - 4.3) in the COMPASS control arm for major adverse cardiovascular events, and 27.9% (95% CI 19.9 - 38.3) in the VOYAGER-PAD eligible subset vs. 6.0% (95% CI 5.3 - 6.9) in the VOYAGER-PAD control arm for major adverse limb events.

CONCLUSION

Many patients hospitalised for symptomatic LEAD in France are not eligible for the low dose rivaroxaban plus aspirin combination. In turn, those eligible may potentially have greater absolute benefit because of higher risk than those enrolled in the trials.

Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication

Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes. This review focuses on the following issues: (1) definition, epidemiological data, diagnosis, risk factors, and pathogenic mechanisms in KT candidates and recipients; (2) adverse clinical consequences and outcomes; and (3) classical and new therapeutic approaches.

Infrared Thermography as a Diagnostic Tool for Peripheral Artery Disease

OBJECTIVE

The prevalence of peripheral arterial disease (PAD) is increasing worldwide. The ankle-brachial index (ABI) is considered the criterion standard of noninvasive screening, but it does have limitations. The present study aimed to clarify the clinical diagnostic potential of infrared thermography (IRT) compared with conventional noninvasive measurements for PAD.

METHODS

Patients were divided into two groups: the healthy control group (n = 93) and the PAD group (n = 164). Control participants had an ABI 0.9 to 1.4 and no former PAD diagnosis. The PAD group was divided into three subgroups based on ABI classifications and two subgroups based on toe pressure measurements. Investigators performed IRT using a standardized protocol with temperature measurements at five different foot sites.

MAIN RESULTS

Differences in skin temperatures between feet were greater (P < .001) in the PAD group than in healthy controls. In general, mean foot temperatures were lower in the PAD group than in controls but did not differ significantly among PAD subgroups based on ABI classifications or toe pressure measurements.

CONCLUSIONS

Infrared thermography effectively distinguished temperature differences between feet and thus might be diagnostically useful. However, because normal skin surface temperature varies among individuals, IRT alone cannot be recommended for evaluating PAD. However, it does have potential to provide additional information about circulation, subclinical infections, and the severity of vascular disease.

[Methods of decreasing the risk of repeat interventions in patients after arterial revascularization]

Discussed in the article are the main problems related to surgical treatment of patients with peripheral artery disease, particularly taking into consideration that in the world there are from 160 to 202 million people suffering from this disease, with two thirds of such patients having signs of lesions of coronary or cerebral arteries. Vascular reconstructive interventions cannot completely eliminate the problem, since in the postoperative period there may develop cardiovascular complications related to both the limb involved as either acute or progressing chronic ischaemia and arteries of other localization (coronary, cerebral). The risk of serious cardiovascular complications in patients with a history of endured adverse ischaemic events on the part of limbs is severalfold higher. To solve these problems and decrease complications, salicylic acid is used as basic therapy. Attempts at replacing it by another drug or combined therapy with an alternative antiaggregant showed no advantages in increased risk of massive haemorrhage. On the other hand, a combination of salicylic acid with an anticoagulant at a low dose, i. e., rivaroxaban 2.5 mg twice daily as compared with acetylsalicylic acid monotherapy made it possible to significantly decrease the incidence of various cardiovascular complications in the form of myocardial infarction, stroke, adverse ischaemic events on the part of the extremity, limb amputation.

Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study

BACKGROUND

Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown.

OBJECTIVE

The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program.

METHODS

This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up.

RESULTS

The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9% vs 3.5%; hazard ratio [HR] 0.24; 95% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4% vs 5.2%; HR 0.46; 95% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9% vs 3.5%; HR 0.52, 95% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs.

CONCLUSIONS

The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings.

Differentiating total from subtotal arterial occlusion in lower extremities by using reverse attenuation gradient sign in CT angiography

OBJECTIVES

To investigate the use of reverse attenuation gradient sign (RAGS) in CT angiography (CTA) to differentiate total from subtotal occlusion in lower extremities which poses different challenges for the procedure and carries different prognoses.

METHODS

Eighty patients with 91 lesions in the lower extremities were divided into total occlusion (TO) group and subtotal occlusion (SO) group confirmed by digital subtraction angiography. The CT numbers of vascular lumen at the end of lesion (proximal, P) and at the first entrance (distal, D) of the lateral branch were measured and their difference (CT(PD) = CT(P) - CT(D)) of each lesion was calculated. The CT number gradient (G(DP) = 2 * CT(PD)/[CT(P) + CT(D)]) was calculated by dividing the CT number difference by the average CT number of the two points. The existence of RAGS where the CT number at the distal point is higher than that at the proximal point (CT(PD) and G(PD) < 0) was determined and the diagnostic efficacy of using RAGS in CTA for differentiating total from subtotal occlusive lesions in lower extremities was calculated.

RESULTS

The SO group had higher CT numbers than the TO group (p < 0.001). More importantly, the SO group had positive CT number gradient (G(PD) > 0), while the gradient was negative (G(PD) < 0) in the TO group. The specificity and sensitivity of using RAGS (G(PD) < 0) in images for diagnosing TO of lower extremity were 97.6% and 92.0%, respectively, and 87.8% and 88.0% using the standard CTA images.

CONCLUSION

The use of RAGS in CTA images has high diagnostic accuracy to differentiate TO from SO in lower extremities.

KEY POINTS

• Total occlusions often exhibit higher CT number at distal point than at proximal point to the occlusion. • The reverse attenuation gradient sign (RAGS) may be determined using the CT number measurements between the proximal and distal points after occlusion. • RAGS can be used to improve the diagnostic efficiency in CTA to differentiate between total and subtotal occlusions of lower extremity arteries.

Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications

Objectives

Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications.

Methods

This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence.

Results

After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%.

Conclusion

To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Autologous Bone-Marrow vs. Peripheral Blood Mononuclear Cells Therapy for Peripheral Artery Disease in Diabetic Patients

Diabetes mellitus (DM) remains one of the most important risk factors for peripheral artery disease (PAD), with approximately 20% of DM patients older than 40 years old are affected with PAD. The current standard management for severe PAD is endovascular intervention with or without surgical bypass. Unfortunately, up to 40% of patients are unable to undergo these revascularization therapies due to excessive surgical risk or adverse vascular side effects. Stem cell therapy has emerged as a novel therapeutic strategy for these ‘no-option’ patients. Several types of stem cells are utilized for PAD therapy, including bone marrow mononuclear cells (BMMNC) and peripheral blood mononuclear cells (PBMNC). Many studies have reported the safety of BMMNC and PBMNC, as well as its efficacy in reducing ischemic pain, ulcer size, pain-free walking distance, ankle-brachial index (ABI), and transcutaneous oxygen pressure (TcPO2). However, the capacity to establish the efficacy of reducing major amputation rates, amputation free survival, and all-cause mortality is limited, as shown by several randomized placebo-controlled trials. The present literature review will focus on comparing safety and efficacy between BMMNC and PBMNC as cell-based management in diabetic patients with PAD who are not suitable for revascularization therapy.

[Key aspects of drug therapy in vascular surgery]

Peripheral arterial disease (PAD) is one of the most common manifestations of systemic atherosclerosis. PAD affects millions of people worldwide, thus greatly contributing to the structure of mortality and disability of the population of developed countries. Along with surgical revascularization, pharmacotherapy is becoming increasingly important in improving the prognosis in such patients. Modern clinical guidelines define optimal therapy for patients with PAD as simultaneous prescription of several classes of drugs (hypolipidemic, antithrombotic, antihypertensive and, probably, vasodilators), thus making it necessary for the surgeon to take into consideration possible drug interactions. This literature review presents the evolution of evidence-based approaches to drug therapy and an algorithm of choosing drugs, depending on initial risk for ischaemic events in patients with peripheral arterial disease.

Medical Therapy for Secondary Prevention of Atherothrombotic Events in Peripheral Artery Disease

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Histological Analysis of a Long Term Patent Subintimal Canal in the Superficial Femoral Artery

Introduction

Subintimal angioplasty (SIA) was introduced in the late 1980s and is a supplement to bypass surgery. Adaptation of the technique has been hampered by high rates of early intervention to maintain patency, but the long term assisted patency is good.

Report

The superficial femoral and popliteal artery containing a patent subintimal canal were explanted from a patient who died in the authors' ward. Histological analysis indicated that the lumen was created in the medial layer of the vessel wall. A collagen rich neointima and fragmented internal elastic lamina were observed, presumably as a result of activated smooth muscle cells. The luminal surface was partly covered by a single layer of CD31, von Willebrand factor, and partly CD144 positive cells. An early atherosclerotic lesion was observed distally in the subintimal canal.

Discussion

Remodelling and neo-cellularisation of the vascular wall after SIA are described. Notably, hallmarks of early and late stage atherosclerotic disease were evident throughout the subintimal canal. These observations require confirmation in a larger number of specimens but underscore the need for surveillance after SIA.

[Modern strategy to improve remote results of surgical treatment of peripheral artery disease]

Treatment of patients presenting with peripheral artery disease requires a comprehensive approach: correction of risk factors, drug therapy and, if necessary, an endovascular/hybrid/open intervention. Reconstructive operation may effectively improve a patient's quality of life in intermittent claudication, save the limb and life in case of severe ischaemia. Discussed in the article are advantages and disadvantages of various types of surgical interventions for peripheral artery disease, the concept PLAN (Patient risk, Limb severity, and ANatomic complexity) and the new Global Anatomic Staging System (GLASS). Good remote results may be ensured by adequate medicamentous therapy. Variations of antithrombotic therapy are versatile and debatable. Long-term dual antithrombotic or systemic anticoagulant therapy with administration of vitamin K antagonists are not indicated for peripheral artery disease. In this connection, the findings of the COMPASS and VOYAGER PAD studies are analysed. The VOYAGER PAD trial showed that in patients with peripheral artery disease who underwent revascularization of lower limbs, the addition of rivaroxaban at a dose of 2.5 mg twice daily to aspirin decreased the risk of lower-extremity unfavourable ischaemic events and major adverse cardiovascular events by 15%. The obtained findings open new possibilities of conservative therapy having a significant role in decreasing the risk for development of limb-threatening conditions.

Long-term clinical outcomes and cause of death after endovascular treatment for femoropopliteal artery lesions

BACKGROUND

Endovascular treatment (EVT) for femoropopliteal artery disease is common in clinical practice. However, little is known about its prognostic factors, causes of death, and long-term clinical outcomes.

METHODS

Two hundred eighty-five consecutive patients (mean age, 72±8 years, 73% men) undergoing their first EVT for de-novo femoropopliteal artery disease from 2009 to 2018 were studied. Patients were divided in two groups according to the presence of critical limb ischemia (CLI). We evaluated the incidence of major adverse limb events (MALE) including clinically driven target vessel revascularization and target limb major amputation, and all-cause death.

RESULTS

The procedure was successful in 97.9% of cases. The non-CLI group comprised 205 patients (72%), and the CLI group comprised 80 patients (28%). The CLI group exhibited higher high-sensitivity C-reactive protein (hs-CRP) levels and a higher rate of hemodialysis than the non-CLI group. During the median follow-up period of 3.5 years, there were 62 deaths (21.8%) including cardiovascular (32.3%), infection (32,3%), and malignancy-related (22.6%) deaths. Kaplan-Meier analysis revealed that the CLI group had a significantly higher incidence of MALE and all-cause death (log-rank, both p<0.001, respectively). The leading causes of death in the CLI group were cardiovascular- and infection-related death; the leading cause of death in the non-CLI group was malignancy-related. On multivariate Cox hazard analysis, hemodialysis, TASC II classification C/D lesions, and CLI were significant predictors of MALE (p<0.001, p=0.005, and p=0.012, respectively). Hemodialysis, age, higher hs-CRP levels, and CLI were significant predictors of all-cause death (p<0.001, p=0.003, p=0.009, and p=0.021, respectively).

CONCLUSIONS

Although EVT for femoropopliteal artery disease appears feasible with a high rate of procedural success, a high incidence of MALE and all-cause death was observed. Further studies are needed to improve the outcomes in patients with CLI.

Antithrombotic therapy for postinterventional management of peripheral arterial disease

PURPOSE

Evidence on the use of antithrombotic pharmacotherapy in patients undergoing revascularization of lower extremities for symptomatic peripheral arterial disease (PAD) is reviewed.

SUMMARY

Individuals with PAD can experience leg pain, intermittent claudication, critical limb ischemia, and acute limb ischemia. In such patients, revascularization may be indicated to improve the quality of life and to prevent amputations. Antithrombotic therapy is often intensified in the postrevascularization period to prevent restenosis of the index artery and to counteract the prothrombotic state induced by the intervention. Therapeutic modalities include dual antiplatelet therapy (DAPT), anticoagulation, a combination of antiplatelet and anticoagulation therapy, and addition of cilostazol to single antiplatelet therapy. Subgroup analyses of data from randomized clinical trials provided low-quality evidence for the use of DAPT in patients with a below-knee prosthetic bypass graft and anticoagulation for those with a venous bypass graft. Cilostazol, when added to aspirin therapy, has been shown to prevent index vessel reocclusion after an endovascular intervention in patients at low risk for thrombosis in several small randomized trials.

CONCLUSION

There is a considerable paucity of high-quality evidence on the optimal antithrombotic regimen for patients undergoing lower extremity revascularization, with no particular therapy shown to consistently improve patient outcomes. The decision to initiate intensified antithrombotic therapy should include a close examination of its risk-benefit profile. The demonstrated benefit of such treatment is restricted to the prevention of index artery reocclusion, while an increased risk of bleeding may lead to significant morbidity and mortality.

Association of Disease Progression With Cardiovascular and Limb Outcomes in Patients With Peripheral Artery Disease: Insights From the EUCLID Trial

BACKGROUND

Patients with peripheral artery disease have a high risk of future cardiovascular disease events and mortality. Little is known about the changes in symptom classification over time in patients with peripheral artery disease and the association of changes in symptom classification with subsequent cardiovascular disease events.

METHODS

In this analysis of the EUCLID trial (Examining Use of Ticagrelor in Peripheral Artery Disease), we examined the changes in Rutherford classification (RC) of patients over 12 months. We examined the baseline characteristics of patients by change in symptom classification at 12 months (improved=decreased RC, no change, or worsened=increased RC), and the association between changes in symptom classification (RC) at 12 months and subsequent cardiovascular disease events.

RESULTS

Among 12 759 patients, 3240 (25%) were classified as improved by RC at 12 months, 8132 (64%) as no change, and 1387 (11%) as worsened. At 12 months, many patients who were asymptomatic or had mild/moderate claudication at enrollment had no change in symptom classification over 12 months (73.7% and 70.9%). Patients who worsened over 12 months were more likely to have comorbidities (diabetes mellitus and prior myocardial infarction) and more events (myocardial infarction, amputation, and major bleeding) by 12 months postrandomization, all P<0.001. Worsened symptom classification over 12 months was associated with increased risk of all-cause death (adjusted hazard ratio, 1.29 [95% CI, 1.03-1.62]), major amputation (adjusted hazard ratio, 4.12 [95% CI, 2.46-6.88]), and a composite of cardiovascular death, myocardial infarction, or stroke (adjusted hazard ratio, 1.30 [95% CI, 1.05-1.62]), all P<0.05 after 12 months postrandomization.

CONCLUSIONS

Patients with comorbidities and prior history of cardiovascular disease events at baseline and within the first 12 months of the trial were more likely to have worsened symptom classification at 12 months. Worsening symptom classification over 12 months was associated subsequently with an increased risk of all-cause death, amputation, and a composite of cardiovascular death, myocardial infarction, or stroke. Graphic Abstract: A graphic abstract is available for this article.

Volumetric Flow Changes in Extracranial Arteries in a Symptomatic Patient with Significant Bilateral Carotid Artery Stenosis: A Case Study and Literature Review

Patient: Male, 41-year-old

Final Diagnosis: Internal carotid artery stenosis

Symptoms: Transcient ischemic attacks

Medication: —

Clinical Procedure: Carotid artery stenting • endarterectomy

Specialty: Surgery

Internalization of HMGB1 (High Mobility Group Box 1) Promotes Angiogenesis in Endothelial Cells

OBJECTIVE

In patients with peripheral artery disease, blockages in arterioles <1 mm cannot be treated surgically, and there are currently few effective medicines. Studies have shown that inflammation in ischemic tissue is related to injury recovery and angiogenesis, but insufficient attention has been paid to this area. Studies have suggested that HMGB1 (high mobility group protein 1), which is released by ischemic tissue, promotes angiogenesis, but the mechanism is not entirely clear. In this study, we tested the internalization of HMGB1 in endothelial cells and investigated a novel proangiogenic pathway. Approach and Results: Using green fluorescent protein-tagged HMGB1 to stimulate endothelial cells, we demonstrated HMGB1 internalization via dynamin and RAGE (receptor for advanced glycation end products)-dependent signaling. Using a fluorescence assay, we detected internalized protein fusion to lysosomes, followed by activation of CatB (cathepsin B) and CatL (cathepsin L). The latter promoted the release of VEGF (vascular endothelial growth factor)-A and endoglin and upregulated the capacities of cell migration, proliferation, and tube formation in endothelial cells. We identified that the cytokine-induced fragment-a key functional domain in HMGB1-mediates the internalization and angiogenic function of HMGB1. We further confirmed that HMGB1 internalization also occurs in vivo in endothelial cells and promotes angiogenesis in mouse femoral artery ligation.

CONCLUSIONS

In this study, we identified a novel pathway of HMGB1 internalization-induced angiogenesis in endothelial cells. This finding sheds light on the regulatory role of inflammatory factors in angiogenesis through cell internalization and opens a new door to understand the relationship between inflammation and angiogenesis in ischemic diseases.

Presurgery exercise-based conditioning interventions (prehabilitation) in adults undergoing lower limb surgery for peripheral arterial disease

BACKGROUND

Lower limb peripheral arterial disease (PAD) is a type of cardiovascular disease where the blood vessels that carry the blood to the legs are hardened and narrowed. The most severe manifestation of PAD is critical limb ischaemia (CLI). This condition results in symptoms of intractable rest pain, non-healing wounds and ulceration, gangrene or both. PAD affects more than 200 million people worldwide and approximately 3% to 5% of people aged over 40 have PAD, rising to 18% in people over 70 years of age. Between 5% to 10% of symptomatic PAD patients will progress to CLI over a five-year period and the five year cumulative incidence rate for asymptomatic patients with PAD deteriorating to intermittent claudication is 7%, with 21% of these progressing to CLI. Treatment options include angioplasty, bypass or amputation of the limb, when life or limb is threatened. People with CLI have a high risk of mortality and morbidity. The mortality rates during a surgical admission are approximately 5%. Within one year of surgery, the mortality rate rises to 22%. Postoperative complications are as high as 30% and readmission rates vary between 7% to 18% in people with CLI. Despite recent advances in surgical technology, anaesthesia and perioperative care, a proportion of surgical patients have a suboptimal recovery. Presurgery conditioning (prehabilitation) is a multimodal conditioning intervention carried out prior to surgery using a combination of exercise, with or without nutritional or psychological interventions, or both. The use of prehabilitation is gaining momentum, particularly in elderly patients undergoing surgery and patients undergoing colorectal cancer surgery, as a means of optimising fitness to improve the prognosis for people undergoing the physiological stress of surgery. People with PAD are characterised by poor mobility and physical function and have a lower level of fitness as a result of disease progression. Therefore, prehabilitation may be an opportunity to improve their recovery following surgery. However, as multimodal prehabilitation requires considerable resources, it is important to assess whether it is superior to usual care. This review aimed to compare prehabilitation with usual care (defined as a preoperative assessment, including blood and urine tests). The key outcomes were postoperative complications, mortality and readmissions within 30 days of the surgical procedure, and one-year survival rates.

OBJECTIVES

To assess the effectiveness of prehabilitation (preoperative exercise, either alone or in combination with nutritional or psychological interventions, or both) on postoperative outcomes in adults with PAD undergoing open lower limb surgery.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 25 September 2019.

SELECTION CRITERIA

We considered all published and unpublished randomised controlled trials (RCTs) comparing presurgery interventions and usual care. Primary outcomes were postoperative complications, mortality and readmission to hospital within 30 days of the surgical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed all records identified by the searches conducted by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We found no RCTs that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We found no RCTs conducted to determine the effects of prehabilitation on mortality or other postoperative outcomes when compared to usual care for patients with PAD. As a consequence, we were unable to provide any evidence to guide the treatment of patients with PAD undergoing surgery. To perform a randomised controlled trial of presurgery conditioning would be challenging but trials are warranted to provide solid evidence on this topic.

Adherence and exercise mode in supervised exercise therapy for peripheral artery disease

Supervised exercise therapy (SET) is a first-line treatment for people with peripheral artery disease (PAD). However, data on patient adherence to SET are limited. In addition, while intermittent treadmill exercise has been widely tested, no studies have investigated recumbent total body stepping (step-ex). We examined whether exercise mode (treadmill walking [n = 17], step-ex [n = 18], or a multimodal approach [n = 18]) affected adherence to a 12-week SET program. We also investigated the potential safety and viability of step-ex for people with PAD by looking at change in exercise training capacity (highest metabolic equivalent of tasks [METs] achieved and highest total MET-minutes achieved per session). The 53 participants comprised 50% female candidates (n = 26) and were (mean [SD]) 74.2 (8.3) years old, with an ankle-brachial index of 0.70 (0.19). Overall adherence to SET was 62%. There was a difference in adherence between groups (P = .022), with the multimodal group (73.6% [21.5%]) higher than the treadmill group (50.2% [28.8%], P = .010). Treadmill participants (n [%]) (8 [47.1%]) dropped out at a higher rate than the multimodal group (3 [16.7%], P = .053). All groups increased the exercise training capacity. The multimodal group achieved greater improvement in total MET-minutes achieved per session (61.5 [45.1]) than the treadmill group (14.7 [44.3]) (P = .008).A multimodal approach to PAD exercise therapy resulted in higher adherence and greater change in exercise training capacity. Step-ex was safe for people with PAD. While further study is warranted, it is appropriate for SET programs to consider a multimodal approach using step-ex, especially given the varied health and physical ability of the PAD population.

Sex-Specific Risks of Major Cardiovascular and Limb Events in Patients With Symptomatic Peripheral Artery Disease

BACKGROUND

Patients with peripheral artery disease (PAD) have a higher risk of major adverse cardiovascular events (MACE) compared with those without PAD.

OBJECTIVES

The aim of this post hoc analysis was to evaluate sex-specific differences in MACE and limb events in the EUCLID (Examining Use of Ticagrelor in PAD) trial.

METHODS

Cox proportional hazards models were used to compare time-to-event outcomes stratified by sex. Covariates were introduced after adjusted model selection.

RESULTS

EUCLID enrolled 13,885 patients with PAD (28% women [n = 3,888]). PAD severity and medical treatment were comparable between sexes, whereas prior lower extremity revascularization was reported less frequently in women (54.8% vs. 57.3%; p = 0.006). Women were older (mean ± SD age: 67.8 ± 8.9 vs. 66.1 ± 8.2 years; p < 0.001) and more likely to have diabetes mellitus (p = 0.004), hypertension, hyperlipidemia, and chronic kidney disease (all p < 0.001). Over a mean follow-up of 30 months, women had a lower risk of MACE (9.5% vs. 11.2%; adjusted hazard ratio: 0.77; 95% confidence interval: 0.68 to 0.88; p < 0.001) and all-cause-mortality (7.6% vs. 9.7%; adjusted hazard ratio: 0.61; 95% confidence interval: 0.53 to 0.71; p < 0.001). In contrast, risk for major adverse limb events (2.6% vs. 3.0%) and hospitalization for acute limb ischemia (1.6% vs. 1.7%) were not different by sex.

CONCLUSIONS

Although women with PAD are at lower risk for MACE and all-cause mortality, risk for limb events was similar between sexes over a mean follow-up of 30 months. Understanding sex-specific differences and dissociation between baseline cardiovascular risk and subsequent cardiovascular events requires further investigation. (A Study Comparing Cardiovascular Effects of Ticagrelor and Clopidogrel in Patients With Peripheral Artery Disease [EUCLID]; NCT01732822).

Prevention, Diagnosis, and Management of Chronic Wounds in Older Adults

Chronic wounds are common, disproportionately affect older adults, and are likely to be encountered by providers across all specialties and care settings. All providers should be familiar with basic wound prevention, identification, classification, and treatment approach, all of which are outlined in this article.

A meta-analysis of mortality after minor amputation among patients with diabetes and/or peripheral vascular disease

OBJECTIVE

Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed.

METHODS

A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality.

RESULTS

A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and "diabetic" results.

CONCLUSIONS

Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients.

Illness perceptions in patients with peripheral arterial disease: A systematic review of qualitative studies

BACKGROUND

Patients with chronic diseases create their own subjective beliefs about their conditions based on their illness perceptions. In the common-sense model, illness perceptions constitute personal beliefs about illness with regard to five components: identity, timeline, cause, control/cure, and consequences. Patients' illness perceptions affect both their management of their disease and their adherence to treatment. Since patients with peripheral arterial disease need life-long treatment for secondary prevention, generating knowledge about illness perceptions in patients with peripheral arterial disease is essential.

OBJECTIVES

To systematically review and synthesise the literature on illness perceptions in patients with peripheral arterial disease.

DESIGN

A systematic review DATA SOURCES: PubMed, CINAHL, and PsycINFO.

REVIEW METHODS

A systematic search strategy was conducted in December 2017, with an update in July 2019. Two team members independently screened all titles and abstracts. A relevance and quality appraisal of the studies was performed. The references from the included studies were evaluated for additional studies. The data from 14 studies were extracted and synthesised using a "best-fit" approach to framework analysis. A deductive analysis was conducted using the common-sense model. The data not suitable for the framework were analysed separately using inductive conventional content analysis, yielding an additional component representing the retrospective consequences of peripheral arterial disease.

FINDINGS

The findings showed diversity in illness perceptions in each of the five components of the framework as well as in the additional component. The findings showed participants' lack of understanding of the chronic nature of the disease, i.e., about the timeline, the identity of the symptoms and the cause of the disease. The patients' beliefs about control and cures varied from having high motivation to engage in physical activity to thinking that walking could make their situations worse. There was fear about the future, as patients perceived disease progression and decreasing control to be consequences of their illness. Living with the disease, the emphasis in the additional component, was a process for regaining control and adapting to their situations.

CONCLUSIONS

Patients with peripheral arterial disease shape their own understandings of their conditions. These beliefs may influence their management of their disease and adherence to treatment. Therefore, the current study suggests that illness perceptions should be addressed when planning secondary prevention for patients with peripheral arterial disease.