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Mathlouthi A, Yei KS, Naazie I, Bertges DJ, Malas MB. Increased mortality with paclitaxel-eluting stents is driven by lesion length. J Vasc Surg 2020; 73:548-553.e2. [PMID: 32615286 DOI: 10.1016/j.jvs.2020.05.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endovascular stenting has become the first-line treatment of symptomatic peripheral artery disease of the femoropopliteal axis (FPA). Several randomized clinical trials have reported that paclitaxel-eluting stents (PESs) significantly reduce the rates of restenosis. However, a meta-analysis investigating paclitaxel-coated devices in the FPA showed a significant increase in all-cause mortality after the use of PES. The aim of this study was to compare the long-term, real-world outcomes of bare-metal stents (BMSs) and PESs for treating FPA occlusive disease. METHODS A retrospective review of the medical records of 296 patients who underwent FPA stenting between January 2011 and December 2017 was performed. Patients were grouped into BMS and PES groups. The primary end point was all-cause mortality. Secondary end points included limb salvage, primary patency, primary assisted patency, and secondary patency. A comparison between the two groups within TransAtlantic Inter-Society Consensus (TASC) II subgroups was also performed. RESULTS Of the study cohort, 101 patients (34%) received PES, whereas 195 patients (66%) underwent BMS placement. Median follow-up time was 23 months (interquartile range, 7-40 months). The 2-year all-cause mortality estimates were 12% for the PES group compared with 11.4% for the BMS group (P = .26). There were no differences in the 2-year limb salvage (90.7% vs 92%; P = .4), primary patency (78.8% vs 81.1%; P = .62), primary assisted patency (100% vs 96.5%; P = .4), and secondary patency (100% vs 98.6%; P = .26) between the PES and the BMS groups, respectively (all P > .05). These findings persisted when patients were stratified by TASC II lesions. Among patients with TASC C and D lesions, the use of PES was associated with significantly higher 2-year all-cause mortality (23.9% vs 5.1%; P = .05). After adjustment for age and other potential confounders, PES use was associated with significant increase in all-cause mortality (adjusted hazard ratio, 2.3; 95% confidence interval, 1.31-27 P = .02) in TASC C and D patients. CONCLUSIONS Consistent with the meta-analysis of several randomized clinical trials, the use of PES in a real-world setting was associated with a twofold increase in the risk of death. However, these findings were seen only among patients with TASC C and D lesions, who required multiple longer stents and potentially larger paclitaxel dose. There was no advantage in terms of patency in PES vs BMS in this population with extensive disease. Further studies of larger populations are required.
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Affiliation(s)
| | - Kevin S Yei
- University of California San Diego, San Diego, Calif
| | - Isaac Naazie
- University of California San Diego, San Diego, Calif
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102
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Gunnarsson T, Gottsäter A, Bergman S, Troëng T, Lindgren H. Eight-year outcome after invasive treatment of infrainguinal intermittent claudication: A population-based analysis from the Swedish vascular register (Swedvasc). SAGE Open Med 2020; 8:2050312120926782. [PMID: 32547751 PMCID: PMC7249589 DOI: 10.1177/2050312120926782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 04/03/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Invasive treatment of infrainguinal intermittent claudication is controversial, and long-term outcomes are scarce. The study aim was to evaluate 8 years results regarding new vascular interventions on index and contralateral limb, hospitalization, mortality, and amputation in 775 patients revascularized for infrainguinal intermittent claudication in 2009. METHODS Data on new vascular interventions retrieved from the Swedish vascular register (Swedvasc) were linked to the Inpatient Register and Cause of Death Register with information on hospitalizations, primary discharge diagnoses according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), deaths, causes of death, and amputations. RESULTS During 8 years of follow-up, 486 new vascular interventions were performed. Patients were admitted for a total of 4662 hospitalizations and spent 25,970 days in hospital. Between 79% and 99% of surviving subjects were hospitalized each year. During follow-up, 311 (40.1%) patients died. The most common causes of hospitalization and death were cerebrovascular disease, ischemic heart disease, or other diseases of the circulatory system, causing 47.5% of hospitalizations and 42.4% of deaths. Seventy-seven major lower limb amputations were performed in 52 patients. CONCLUSION As patients undergoing invasive treatment of infrainguinal intermittent claudication have high morbidity and mortality, during 8 years of follow-up, the indication for invasive treatment should be carefully weighed against concomitant comorbidities and the timing of this treatment optimized with regard to the patient's possibilities to enjoy positive treatment effects on quality of life.
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Affiliation(s)
- Thordur Gunnarsson
- Faculty of Medicine, Lund University, Lund, Sweden
- Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - Anders Gottsäter
- Faculty of Medicine, Lund University, Lund, Sweden
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Stefan Bergman
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Troëng
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Hans Lindgren
- Faculty of Medicine, Lund University, Lund, Sweden
- Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
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103
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Volumetric Carotid Flow Characteristics in Doppler Ultrasonography in Healthy Population Over 65 Years Old. J Clin Med 2020; 9:jcm9051375. [PMID: 32392788 PMCID: PMC7291321 DOI: 10.3390/jcm9051375] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Carotid flow velocity criteria are well established, with age being a factor influencing measurements. However, there are no volumetric standards for the flow in extracranial arteries. The aim of the study was related to volumetric flow assessment of extracranial arteries in a healthy population >65 years old. Methods: Doppler volumetric measurements of internal carotid (ICA), external carotid (ECA) and vertebral arteries (VA) were performed in 123 healthy volunteers >65 years old and compared with 56 healthy volunteers <65 years old. Results: The continuous decline in cerebral blood flow (CBF) volume was observed (p < 0.00001). Volumetric reference values were established in study groups: 1., 65–69 years: 898.5 ± 119.1; 2., 70–74 years: 838.5 ± 148.9; 3., 75–79 years: 805.1 ± 99.3; 4., >80 years: 685.7 ± 112.3 (mL/min). Significant differences were observed between groups: 1 and 3.4, as well as 3 and 4 (p = 0.0295, < 0.000001, 0.00446 respectively). CBF volume decreases gradually with age: 28–64 years—6.2 mL/year (p = 0.0019), 65–75 years—11.4 mL/year (p = 0.0121) and >75 years—14.3 mL/year (p = 0.0074). This is a consequence of flow volume decline in ICA (p = 0.00001) and to lesser extent ECA (p = 0.0011). The decrease of peak systolic (p = 0.002) and end diastolic (p = < 0.00001) velocities in ICA and peak systolic velocity in ECA (p = 0.0017) were observed. Conclusions: CBF decreases with ageing. Volumetric assessment of CBF may play an important additional role in diagnostics of patients with carotid stenosis. Doppler assessment of cerebral flow volume may create an interesting tool for identifying patients with diminished cerebrovascular reserve and higher risk of ischemic symptoms occurrence.
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104
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Djerf H, Hellman J, Baubeta Fridh E, Andersson M, Nordanstig J, Falkenberg M. Low Risk of Procedure Related Major Amputation Following Revascularisation for Intermittent Claudication: A Population Based Study. Eur J Vasc Endovasc Surg 2020; 59:817-822. [DOI: 10.1016/j.ejvs.2019.11.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 10/22/2019] [Accepted: 11/13/2019] [Indexed: 11/25/2022]
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105
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Perlander A, Jivegård L, Nordanstig J, Svensson M, Österberg K. Amputation-free survival, limb symptom alleviation, and reintervention rates after open and endovascular revascularization of femoropopliteal lesions in patients with chronic limb-threatening ischemia. J Vasc Surg 2020; 72:1987-1995. [PMID: 32276010 DOI: 10.1016/j.jvs.2020.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The optimal strategy for revascularization in chronic limb-threatening ischemia (CLTI) is not yet completely known and is still under debate. Endovascular treatment methods predominate despite limited evidence for their advantage. In this concurrent, prospective observational cohort study, we investigated outcomes after open and endovascular revascularization in the femoropopliteal segment for CLTI. METHODS Between March 2011 and January 2015, there were 190 patients presenting with CLTI with the principal target lesion in the superficial femoral or popliteal segment who underwent endovascular intervention (n = 117) or bypass surgery (n = 73) and were observed prospectively. The choice of revascularization technique was based on international and local guidelines. All patients were observed for 2 years. The primary end point was amputation-free survival (AFS) assessed with Kaplan-Meier estimates; secondary end points included CLTI symptom alleviation rates and reintervention rates. A Cox proportional hazards regression model was used to investigate risk factors for amputation and death. RESULTS AFS at 2 years was 59% in the endovascular group and 76% in the bypass group (P = .020). Kaplan-Meier survival analysis confirmed a significant difference in AFS, with mortality rate as the main driver for the observed intergroup AFS difference. In sequential multivariable regression analysis, the observed difference in AFS between the groups favored bypass surgery and remained significant after controlling for covariates of known prognostic importance (hazard ratio, 2.38; 95% confidence interval, 1.14-4.96). At 2 years, a higher proportion of patients subjected to bypass surgery remained free from ischemic rest pain, wounds, and gangrene (65% vs 45%; P = .009). The proportions of patients who underwent reintervention within 2 years were similar in the two groups (38% vs 39%; P = .90), but repeated reinterventions were more frequent in the bypass group. CONCLUSIONS At 2 years, bypass surgery was associated with higher AFS than endovascular intervention, a finding that could not be explained only by differences in case mix. More patients who had bypass surgery were free from CLTI symptoms at both 1 year and 2 years after revascularization. Reinterventions to maintain patency were equally common after bypass and endovascular intervention.
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Affiliation(s)
- Angelica Perlander
- Department of Vascular Surgery, Sahlgrenska University Hospital, and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Lennart Jivegård
- Health Technology Assessment Centre (HTA-centrum) Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital, and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Klas Österberg
- Department of Vascular Surgery, Sahlgrenska University Hospital, and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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106
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Risk factors for amputation are influenced by competing risk of death in patients with critical limb ischemia. J Vasc Surg 2020; 71:1305-1314.e5. [DOI: 10.1016/j.jvs.2019.07.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/15/2019] [Indexed: 12/22/2022]
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107
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Stanek F. Balloon catheters and stents with paclitaxel: are they really dangerous? A review and update. Minerva Cardiol Angiol 2020; 69:43-49. [PMID: 32163241 DOI: 10.23736/s2724-5683.20.05133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of this review is to summarize and update current research concerning the safety of drug-coated balloons (DCBs) and drug-eluting stents (DESs) with paclitaxel (PTX) in peripheral arteries. The data from the large randomized controlled trials showed evidence of the superiority of DCBs over plain balloon angioplasty concerning efficacy. Also, the safety parameters between the two groups did not differ. However, two meta-analyses identifying an increased late mortality risk after using PTX technologies were published only a short time ago. In contradiction, a lot of following studies (meta-analyses, real-world analysis, retrospective review) published in 2019 and 2020, did not confirm any significant difference in all-cause death between PTX and no-PTX cohorts. The safety of PTX technologies still represents the most serious and controversial issue in peripheral interventions. Until it is definitively solved further research must continue. In daily practice, recommendations for the use of PTX products include the treatment of restenosis after percutaneous transluminal angioplasty (PTA) (not of de novo lesions), the maintenance of patency of bypasses, and angioplasty for limb salvage. In heavily calcified lesions, a prior debulking with atherectomy is suitable. Generally, the risks and benefits of the application of PTX devices should be considered in every single patient.
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108
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Abstract
Peripheral artery disease of the lower limbs is a chronically progressive disorder characterised by the presence of occlusive lesions in the medium and large arteries that result in symptoms secondary to insufficient blood flow to the lower extremities. It is both a manifestation of systemic atherosclerosis and a marker of increased cardiovascular morbidity and mortality. Because of its highly heterogenous clinical picture, a detailed history and physical assessment, a high degree of suspicion for peripheral artery disease and the use of the ankle-brachial pressure index is essential to identify patients with peripheral artery disease. This will allow early administration of basic pharmacotherapy and lifestyle changes to reduce cardiovascular events, minimise claudication symptoms and enable optimal revascularisation to prevent loss of limb function.
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Affiliation(s)
- Keith A Chan
- Section of Adult Cardiology, Chong Hua Heart Institute, Cebu City, Philippines
| | - Alex Junia
- Section of Adult Cardiology, Chong Hua Heart Institute, Cebu City, Philippines
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Alves-Cabratosa L, Comas-Cufí M, Ponjoan A, Garcia-Gil M, Martí-Lluch R, Blanch J, Elosua-Bayes M, Parramon D, Camós L, Guzmán L, Ramos R. Levels of ankle-brachial index and the risk of diabetes mellitus complications. BMJ Open Diabetes Res Care 2020; 8:8/1/e000977. [PMID: 32144131 PMCID: PMC7059529 DOI: 10.1136/bmjdrc-2019-000977] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We sought to compare the association of categorized ankle-brachial index (ABI) with mortality and complications of diabetes in persons with no symptoms of peripheral arterial disease (PAD) and in primary cardiovascular disease prevention. RESEARCH DESIGN AND METHODS This is a retrospective cohort study of persons with type 2 diabetes aged 35-85 years, from 2006 to 2011. Data were obtained from the Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAPQ). Participants had an ABI measurement that was classified into six categories. For each category of ABI, we assessed the incidence of mortality; macrovascular complications of diabetes: acute myocardial infarction (AMI), ischemic stroke, and a composite of these two; and microvascular complications of this metabolic condition: nephropathy, retinopathy, and neuropathy. We also estimated the HRs for these outcomes by ABI category using Cox proportional hazards models. RESULTS Data from 34 689 persons with type 2 diabetes were included. The mean age was 66.2; 51.5% were men; and the median follow-up was 6.0 years. The outcome with the highest incidence was nephropathy, with 24.4 cases per 1000 person-years in the reference category of 1.1≤ABI≤1.3. The incidences in this category for mortality and AMI were 15.4 and 4.1, respectively. In the Cox models, low ABI was associated with increased risk and was significant from ABI lower than 0.9; below this level, the risk kept increasing steeply. High ABI (over 1.3) was also associated with significant increased risk for most outcomes. CONCLUSIONS The studied categories of ABI were associated with different risks of type 2 diabetes complications in persons asymptomatic for PAD, who were in primary cardiovascular prevention. These findings could be useful to optimize preventive interventions according to the ABI category in this population.
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Affiliation(s)
| | | | - Anna Ponjoan
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
- IDIBGI, Girona, Catalunya, Spain
| | | | - Ruth Martí-Lluch
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
- IDIBGI, Girona, Catalunya, Spain
| | - Jordi Blanch
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
| | | | - Dídac Parramon
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
- Primary Care Services, Catalan Institute of Health, Girona, Catalunya, Spain
| | - Lourdes Camós
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
- Primary Care Services, Catalan Institute of Health, Girona, Catalunya, Spain
| | - Lidia Guzmán
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
| | - Rafel Ramos
- ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
- Primary Care Services, Catalan Institute of Health, Girona, Catalunya, Spain
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110
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Lai YH, Lin YL, Wang CH, Kuo CH, Hsu BG. Negative correlation of serum adiponectin level with peripheral artery occlusive disease in hemodialysis patients. Tzu Chi Med J 2020; 32:70-74. [PMID: 32110524 PMCID: PMC7015003 DOI: 10.4103/tcmj.tcmj_19_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/24/2018] [Accepted: 01/14/2018] [Indexed: 01/23/2023] Open
Abstract
Objective: Adiponectin is a fat-derived hormone that secretes exclusively by adipocytes and has antiatherosclerotic effects. Peripheral arterial occlusive disease (PAOD) is associated with an increased risk of death in hemodialysis (HD) patients. The aim of this study was to evaluate the relationship between serum adiponectin levels and PAOD by ankle–brachial index (ABI) in HD patients. Materials and Methods: Blood samples were obtained from 100 HD patients. Serum adiponectin levels were measured using a commercial enzyme-linked immunosorbent assay kit. ABI values were measured using the automated oscillometric method (VaSera VS-1000). ABI values that <0.9 were included in the low ABI group. Results: Among the 100 HD patients, 18 of them (18.0%) were in the low ABI group. Compared with patients in the normal ABI group, the patients in the low ABI group had a higher prevalence of diabetes (P = 0.043), older age (P = 0.027), and lower serum adiponectin level (P = 0.003). In addition, the multivariable logistic regression analysis showed that adiponectin (Odds ratio [OR]: 0.927, 95% confidence interval [CI]: 0.867–0.990, P = 0.025) and age (OR: 1.054, 95% CI: 1.002–1.109, P = 0.043) were the independently associated with PAOD in HD patients. Conclusion: In this study, serum adiponectin level was found to be associated with PAOD in HD patients.
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Affiliation(s)
- Yu-Hsien Lai
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,PhD Program in Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Yu-Li Lin
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chih-Hsien Wang
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chiu-Huang Kuo
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Bang-Gee Hsu
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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111
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Saenz-Pipaon G, San Martín P, Planell N, Maillo A, Ravassa S, Vilas-Zornoza A, Martinez-Aguilar E, Rodriguez JA, Alameda D, Lara-Astiaso D, Prosper F, Paramo JA, Orbe J, Gomez-Cabrero D, Roncal C. Functional and transcriptomic analysis of extracellular vesicles identifies calprotectin as a new prognostic marker in peripheral arterial disease (PAD). J Extracell Vesicles 2020; 9:1729646. [PMID: 32158521 PMCID: PMC7048174 DOI: 10.1080/20013078.2020.1729646] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 02/07/2023] Open
Abstract
Peripheral arterial disease (PAD) is associated with a high risk of cardiovascular events and death and is postulated to be a critical socioeconomic cost in the future. Extracellular vesicles (EVs) have emerged as potential candidates for new biomarker discovery related to their protein and nucleic acid cargo. In search of new prognostic and therapeutic targets in PAD, we determined the prothrombotic activity, the cellular origin and the transcriptomic profile of circulating EVs. This prospective study included control and PAD patients. Coagulation time (Procoag-PPL kit), EVs cellular origin and phosphatidylserine exposure were determined by flow cytometry in platelet-free plasma (n = 45 PAD). Transcriptomic profiles of medium/large EVs were generated using the MARS-Seq RNA-Seq protocol (n = 12/group). The serum concentration of the differentially expressed gene S100A9, in serum calprotectin (S100A8/A9), was validated by ELISA in control (n = 100) and PAD patients (n = 317). S100A9 was also determined in EVs and tissues of human atherosclerotic plaques (n = 3). Circulating EVs of PAD patients were mainly of platelet origin, predominantly Annexin V positive and were associated with the procoagulant activity of platelet-free plasma. Transcriptomic analysis of EVs identified 15 differentially expressed genes. Among them, serum calprotectin was elevated in PAD patients (p < 0.05) and associated with increased amputation risk before and after covariate adjustment (mean follow-up 3.6 years, p < 0.01). The combination of calprotectin with hs-CRP in the multivariate analysis further improved risk stratification (p < 0.01). Furthermore, S100A9 was also expressed in femoral plaque derived EVs and tissues. In summary, we found that PAD patients release EVs, mainly of platelet origin, highly positive for AnnexinV and rich in transcripts related to platelet biology and immune responses. Amputation risk prediction improved with calprotectin and was significantly higher when combined with hs-CRP. Our results suggest that EVs can be a promising component of liquid biopsy to identify the molecular signature of PAD patients.
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Affiliation(s)
- Goren Saenz-Pipaon
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Patxi San Martín
- Oncohematology Program, Cima Universidad de Navarra, Pamplona, Spain
| | - Núria Planell
- Translational Bioinformatics Unit, Navarrabiomed, Pamplona, Spain
| | - Alberto Maillo
- Translational Bioinformatics Unit, Navarrabiomed, Pamplona, Spain
| | - Susana Ravassa
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,Laboratory of Heart Failure, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Pamplona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Amaia Vilas-Zornoza
- Oncohematology Program, Cima Universidad de Navarra, Pamplona, Spain.,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - Esther Martinez-Aguilar
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,Departamento de Angiología y Cirugía Vascular, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - José Antonio Rodriguez
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Daniel Alameda
- Oncohematology Program, Cima Universidad de Navarra, Pamplona, Spain
| | | | - Felipe Prosper
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,Oncohematology Program, Cima Universidad de Navarra, Pamplona, Spain.,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain.,Hematology Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - José Antonio Paramo
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain.,Hematology Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - Josune Orbe
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Carmen Roncal
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
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112
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Bevan GH, White Solaru KT. Evidence-Based Medical Management of Peripheral Artery Disease. Arterioscler Thromb Vasc Biol 2020; 40:541-553. [PMID: 31996023 DOI: 10.1161/atvbaha.119.312142] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Peripheral artery disease is an atherosclerotic disease of the lower extremities associated with high cardiovascular mortality. Management of this condition may include lifestyle modifications, medical management, endovascular repair, or surgery. The medical approach to peripheral artery disease is multifaceted and includes cholesterol reduction, antiplatelet therapy, anticoagulation, peripheral vasodilators, blood pressure management, exercise therapy, and smoking cessation. Adherence to this regimen can reduce limb-related complications like critical limb ischemia and amputation, as well as systemic complications of atherosclerosis like stroke and myocardial infarction. Relative to coronary artery disease, peripheral artery disease is an undertreated condition. In this article, we explore the evidence behind medical therapies for the management of peripheral artery disease.
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Affiliation(s)
- Graham H Bevan
- From the Department of Medicine (G.H.B., K.T.W.S.), University Hospitals Cleveland Medical Center, OH.,Case Western Reserve University School of Medicine, Cleveland, OH (G.H.B., K.T.W.S.)
| | - Khendi T White Solaru
- From the Department of Medicine (G.H.B., K.T.W.S.), University Hospitals Cleveland Medical Center, OH.,Harrington Heart and Vascular Institute (K.T.W.S.), University Hospitals Cleveland Medical Center, OH.,Case Western Reserve University School of Medicine, Cleveland, OH (G.H.B., K.T.W.S.)
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Frank U, Nikol S, Belch J, Boc V, Brodmann M, Carpentier PH, Chraim A, Canning C, Dimakakos E, Gottsäter A, Heiss C, Mazzolai L, Madaric J, Olinic DM, Pécsvárady Z, Poredoš P, Quéré I, Roztocil K, Stanek A, Vasic D, Visonà A, Wautrecht JC, Bulvas M, Colgan MP, Dorigo W, Houston G, Kahan T, Lawall H, Lindstedt I, Mahe G, Martini R, Pernod G, Przywara S, Righini M, Schlager O, Terlecki P. ESVM Guideline on peripheral arterial disease. VASA 2019; 48:1-79. [DOI: 10.1024/0301-1526/a000834] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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114
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 1965] [Impact Index Per Article: 393.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abdoli S, Katz S, Ochoa C. Long-Term Patency and Clinical Outcomes of Nitinol Stenting for Femoropopliteal Atherosclerotic Disease. Ann Vasc Surg 2019; 66:566-572. [PMID: 31705987 DOI: 10.1016/j.avsg.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of peripheral arterial disease (PAD) has become increasingly dominated by endovascular interventions. The short-term outcomes of endovascular therapy have been well studied, but late outcomes remain largely unpublished; in this series, we report the late outcomes of primary nitinol stenting. METHODS All patients undergoing primary nitinol stenting of the superficial femoral artery (SFA) and/or popliteal artery (PA) during a 10-year period by a single surgeon (S.K.) were reviewed. No attempts were made on patients with orificial or total occlusion of the SFA, PA, and proximal tibial arteries. Differences in primary patency, primary-assisted patency, secondary patency, and freedom from bypass were evaluated at 1, 5, and 9 years. RESULTS A total of 294 limbs in 240 patients were treated. One hundred and thirty additional endovascular procedures were observed during the study period averaging to 0.16 endovascular interventions per limb per year. Primary patency in TASC A/B limbs at 1, 5, and 9 years was 79%, 35%, and 19%, respectively, and in TASC C/D limbs was 62%, 11%, and 3%, respectively. Secondary patency in TASC A/B limbs at 1, 5, and 9 years was 96%, 81%, and 65%, respectively, and in TASC C/D limbs was 92%, 64%, and 41%, respectively. Freedom from bypass in TASC A/B limbs at 1, 5, and 9 years was 98%, 89%, and 85%, respectively, and in TASC C/D limbs was 95%, 78%, and 69%, respectively. Five below-the-knee amputations were observed during the study period. CONCLUSIONS An endovascular-first approach can be applied to the vast majority of femoropopliteal lesions. While the late outcomes of TASC C/D lesions are inferior to those of TASC A/B lesions, an endovascular-first approach still provides durable outcomes.
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Affiliation(s)
- Sherwin Abdoli
- Department of Surgery, Huntington Memorial Hospital, Pasadena, CA.
| | - Steven Katz
- Department of Surgery, Huntington Memorial Hospital, Pasadena, CA; Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA
| | - Christian Ochoa
- Department of Surgery, Huntington Memorial Hospital, Pasadena, CA; Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA
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Venermo M, Sprynger M, Desormais I, Björck M, Brodmann M, Cohnert T, De Carlo M, Espinola-Klein C, Kownator S, Mazzolai L, Naylor R, Vlachopoulos C, Ricco JB, Aboyans V. Editor's Choice – Follow-up of Patients After Revascularisation for Peripheral Arterial Diseases: A Consensus Document From the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2019; 58:641-653. [DOI: 10.1016/j.ejvs.2019.06.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/08/2019] [Indexed: 10/25/2022]
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Venermo M, Sprynger M, Desormais I, Björck M, Brodmann M, Cohnert T, De Carlo M, Espinola-Klein C, Kownator S, Mazzolai L, Naylor R, Vlachopoulos C, Ricco JB, Aboyans V. Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery. Eur J Prev Cardiol 2019; 26:1971-1984. [DOI: 10.1177/2047487319846999] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.
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Affiliation(s)
- Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Muriel Sprynger
- Department of Cardiology, University of Liege Hospital, Belgium
| | - Ileana Desormais
- Department of Thoracic and Vascular Surgery and Vascular Medicine, Dupuytren University Hospital, France
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Sweden
| | | | - Tina Cohnert
- Department of Vascular Surgery, Graz University Hospital, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Christine Espinola-Klein
- Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | | | - Lucia Mazzolai
- Division of Angiology, Lausanne University Hospital, Switzerland
| | - Ross Naylor
- Department of Vascular Surgery, Leicester Vascular Institute, UK
| | | | | | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital and Inserm 1098, France
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Brindisino F, Pennella D, Giovannico G, Rossettini G, Heick JD, Maselli F. Low back pain and calf pain in a recreational runner masking peripheral artery disease: A case report. Physiother Theory Pract 2019; 37:1146-1157. [PMID: 31661344 DOI: 10.1080/09593985.2019.1683922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Running is one of the most popular sports worldwide due to its low costs and its beneficial impact on health. Recent evidence suggests 11% to 85% of recreational runners experience at least one running-related injury each year and most of these are related to musculoskeletal conditions. The aim of this case report is to describe the clinical decision-making process that guided a physiotherapist to suspect a non-musculoskeletal cause in a recreational runner presenting with low back pain and calf pain secondary to Peripheral Artery Disease.Case Presentation: This case report describes the clinical history, clinical exam, laboratory and imaging tests, and surgical procedure of a 65 y.o. amateur runner suffering low back pain and left calf pain for 3 months. The patient's clinical findings suggested that referral to another health-care provider was required to explore potential non-musculoskeletal sources of pain. An angioplasty was necessary to solve the patient's clinical situation.Discussion and Conclusion: In this patient case, clinical findings along with a comprehensive family and personal history, ruled out a musculoskeletal condition and implicated a vascular condition.
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Affiliation(s)
- Fabrizio Brindisino
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise C/da Tappino c/o Cardarelli Hospital, Campobasso, Italy.,FTM, Physiotherapy and Manual Therapy, Physiotherapy Department, Lizzanello, Italy
| | - Denis Pennella
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise C/da Tappino c/o Cardarelli Hospital, Campobasso, Italy
| | - Giuseppe Giovannico
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise C/da Tappino c/o Cardarelli Hospital, Campobasso, Italy.,FTM, Physiotherapy and Manual Therapy, Physiotherapy Department, Lizzanello, Italy
| | - Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy
| | - John D Heick
- Northern Arizona University Flagstaff, Flagstaff, AZ, USA.,Department of Physical Therapy and Athletic Training, Flagstaff, AZ, USA
| | - Filippo Maselli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy
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Ruscica M, Macchi C, Fogacci F, Ferri N, Grandi E, Rizzoli E, D'Addato S, Borghi C, Cicero AF. Angiopoietin-like 3 and subclinical peripheral arterial disease: Evidence from the Brisighella Heart Study. Eur J Prev Cardiol 2019; 27:2251-2254. [PMID: 31648549 DOI: 10.1177/2047487319884378] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Massimiliano Ruscica
- Pharmacological and Biomolecular Sciences Department, University of Milan, Italy
| | - Chiara Macchi
- Pharmacological and Biomolecular Sciences Department, University of Milan, Italy
| | - Federica Fogacci
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Italy
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Italy
| | - Elisa Grandi
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Italy
| | - Elisabetta Rizzoli
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Italy
| | - Sergio D'Addato
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Italy
| | - Claudio Borghi
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Italy
| | - Arrigo Fg Cicero
- Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Italy
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Morbidity and mortality associated with atherosclerotic peripheral artery disease: A systematic review. Atherosclerosis 2019; 293:94-100. [PMID: 31606132 DOI: 10.1016/j.atherosclerosis.2019.09.012] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 07/23/2019] [Accepted: 09/20/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether improvements in the detection/treatment of peripheral artery disease (PAD) affect overall survival and morbidity. We undertook a systematic review to describe survival and morbidity in contemporary PAD cohorts. METHODS Electronic databases were searched for randomised and observational studies reporting mortality/morbidity events between 1 May 2003 and 31 December, 2017 in patients with PAD, diagnosed by intermittent claudication (IC), critical limb ischaemia (CLI), or an ankle brachial index (ABI) < 0.9. Pooled event rates for all-cause and cardiovascular (CV) mortality, non-fatal myocardial infarction (MI), non-fatal stroke, major CV events (MACE; non-fatal MI/stroke, CV death), and major amputation were calculated per 1000 person-years. RESULTS 124 eligible studies were identified (570,856 patients; 855,894 person-years of follow-up). Statin use was reported in 67% of the overall cohort and antiplatelet use in 79%. Pooled event rates for all-cause and CV mortality, MI, stroke, MACE, and major amputation were 113, 39, 20, 12, 71, and 70 per 1000 person-years, respectively. Compared with patients with an ABI <0.9, the presence of CLI was associated with increased rates of all-cause and CV mortality, MI, MACE, and major amputation. Event rates for stroke were similar between patients with an ABI <0.9 and CLI. CONCLUSIONS Our data show PAD patients have a high risk of all-cause and CV mortality, and imply the risk of stroke or MI is at least equivalent to the risk in patients with coronary artery disease. Moreover, our data underline the need for improved treatments to attenuate CV risk in PAD patients.
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Okuno K, Naito Y, Yasumura S, Sawada H, Asakura M, Masuyama T, Ishihara M. Haploinsufficiency of Transferrin Receptor 1 Impairs Angiogenesis with Reduced Mitochondrial Complex I in Mice with Limb Ischemia. Sci Rep 2019; 9:13658. [PMID: 31541184 PMCID: PMC6754437 DOI: 10.1038/s41598-019-49983-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/03/2019] [Indexed: 02/05/2023] Open
Abstract
Limb ischemia (LI) is a major consequence of peripheral artery disease (PAD) with a high mortality rate. Iron is an essential mineral to maintain physiological function of multiple organs. Intracellular iron transport is regulated by transferrin receptor 1 (TfR1). Although increase in serum ferritin levels has been reported in PAD patients, the mechanism of iron metabolism in LI is still unclear. The aim of this study is to investigate whether TfR1 deletion attenuates LI formation. To generate LI, the left femoral artery of 8-10 week-old C57BL6/J male mice was ligated. Adductor muscles were harvested at 28 days after surgery to investigate iron metabolism. The level of ferritin, intracellular iron storage protein, was higher in ischemic adductor muscles compared to non-ischemic adductor muscles. Level of intracellular iron transport protein, TfR1, was decreased in ischemic adductor muscles. LI was then generated in TfR1 heterozygous deleted mice (TfR1+/-) to examine whether TfR1 contributes to the pathophysiology of LI. Laser Doppler blood flowmetry revealed that blood flow recovery was attenuated in TfR1+/- mice compared to wild type (WT) littermates, along with decreased expression of ferritin and CD31 in ischemic adductor muscles. Since iron is used for energy production in mitochondria, we then assessed mitochondrial complexes in the ischemic adductor muscle. Of interest, expression of mitochondrial complex I, but not complexes II, III, and V in ischemic adductor muscles was significantly reduced in TfR1+/- mice compared to WT mice. Haploinsufficiency of TfR1 attenuated angiogenesis via reduction of mitochondrial complex I in LI in mice.
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Affiliation(s)
- Keisuke Okuno
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshiro Naito
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Seiki Yasumura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hisashi Sawada
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tohru Masuyama
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Baumgartner I, Norgren L, Fowkes FGR, Mulder H, Patel MR, Berger JS, Jones WS, Rockhold FW, Katona BG, Mahaffey K, Hiatt WR. Cardiovascular Outcomes After Lower Extremity Endovascular or Surgical Revascularization: The EUCLID Trial. J Am Coll Cardiol 2019; 72:1563-1572. [PMID: 30261955 DOI: 10.1016/j.jacc.2018.07.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 07/12/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Lower extremity revascularization (LER) is a common treatment in patients with peripheral artery disease (PAD), but long-term outcomes are poorly defined. OBJECTIVES The aim was to analyze LER in the EUCLID (Examining Use of tiCagreLor In paD) trial to determine predictors and cardiovascular outcomes. METHODS Patients were grouped according to whether they received a post-randomization LER (n = 1,738) or not (n = 12,147). All variables were assessed for significance in univariable and parsimonious multivariable models. The primary endpoint was myocardial infarction, ischemic stroke, or cardiovascular death; major adverse limb events (MALE) included acute limb ischemia or major amputation. RESULTS A post-randomization LER occurred in 12.5% of patients and was an endovascular LER in 74.7%. Endovascular LERs were performed more often in North America, whereas surgical procedures occurred more frequently in Europe. Independent factors predicting LER were prior and type of prior LER, geographic region, limb symptoms, diabetes, and smoking. A post-randomization LER was associated with an increased risk for the primary endpoint (hazard ratio: 1.60; 95% confidence interval: 1.35 to 1.90; p < 0.0001) and MALE (hazard ratio: 12.0; 95% confidence interval: 9.47 to 15.30; p < 0.0001). Event rates for the primary endpoint after LER were numerically higher in the surgical subgroup, but MALE were similar between surgical and endovascular LER. CONCLUSIONS In the EUCLID trial, LER was most often endovascular. Following LER, there was an increased hazard for the primary endpoint (with higher event rates in the surgical group) and a markedly increased risk for MALE events (with similar event rates between surgical and endovascular LER procedures). (A Study Comparing Cardiovascular Effects of Ticagrelor and Clopidogrel in Patients With Peripheral Artery Disease [EUCLID]; NCT01732822).
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Affiliation(s)
- Iris Baumgartner
- Swiss Cardiovascular Centre, Inselspital, Division of Angiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jeffrey S Berger
- Departments of Medicine and Surgery, New York University School of Medicine, New York, New York
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Frank W Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Kenneth Mahaffey
- Stanford Center for Clinical Research, Stanford University, School of Medicine, Stanford, California
| | - William R Hiatt
- Division of Cardiology and CPC Clinical Research, University of Colorado School of Medicine, Aurora, Colorado.
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Dake MD, Ansel GM, Bosiers M, Holden A, Iida O, Jaff MR, Lottes AE, O'Leary EE, Saunders AT, Schermerhorn M, Yokoi H, Zeller T. Paclitaxel-Coated Zilver PTX Drug-Eluting Stent Treatment Does Not Result in Increased Long-Term All-Cause Mortality Compared to Uncoated Devices. Cardiovasc Intervent Radiol 2019; 43:8-19. [PMID: 31502026 PMCID: PMC6940321 DOI: 10.1007/s00270-019-02324-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/21/2019] [Indexed: 12/24/2022]
Abstract
Purpose Patient-level data from two large studies of the Zilver PTX drug-eluting stent (DES) with long-term follow-up and concurrent non-drug comparator groups were analyzed to determine whether there was an increased mortality risk due to paclitaxel. Methods Data from the Zilver PTX randomized controlled trial (RCT) and Zilver PTX and bare metal stent (BMS) Japan post-market surveillance studies were analyzed. Five-year follow-up is complete in both DES studies; follow-up for the BMS study was limited to 3 years and is complete. Kaplan–Meier analyses assessed mortality. A Cox proportional hazards model identified significant factors related to mortality. Results In the RCT, there were 336 patients treated with the DES and 143 patients treated with percutaneous transluminal angioplasty (PTA) or BMS. In Japan, there were 904 DES patients and 190 BMS patients. There was no difference in all-cause mortality for the DES compared to PTA/BMS in the RCT (19.1% DES versus 17.1% PTA/BMS through 5 years, p = 0.60) or Japan (15.8% DES versus 15.3% BMS through 3 years, p = 0.89). Cox proportional hazard models revealed that age, tissue loss, and congestive heart failure were significantly associated with mortality in the RCT, and critical limb ischemia, age, renal failure, and gender were significantly associated with mortality in Japan (all p < 0.05). Neither treatment with Zilver PTX (p = 0.46 RCT, p = 0.49 Japan) nor paclitaxel dose (p = 0.86 RCT, p = 0.07 Japan) was associated with mortality. Conclusion Analyses of the Zilver PTX patient-level data demonstrated no increase in long-term all-cause mortality. Level of Evidence Zilver PTX RCT: Level 1, randomized controlled trial; Japan PMS studies: Level 3, post-market surveillance study. Electronic supplementary material The online version of this article (10.1007/s00270-019-02324-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael D Dake
- The University of Arizona, Roy P. Drachman Hall Building, B207, 1295 North Martin Avenue, P.O. Box 210202, Tucson, AZ, 85721-0202, USA.
| | - Gary M Ansel
- Department of Medicine, Ohio Health/Riverside Methodist Hospital, Columbus, OH, USA
| | - Marc Bosiers
- Foundation of Cardiovascular Research and Education, Münster, Germany
| | - Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | | | | | | | - Marc Schermerhorn
- Division of Vascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hiroyoshi Yokoi
- Department of Cardiovascular Medicine, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Thomas Zeller
- Universitaets-Herz-Zentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany
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Kolh P, Dick F, Sillesen H. EJVES, the Leading Journal in Vascular Surgery, is One of the Numerous Scientific Pillars of the ESVS. Eur J Vasc Endovasc Surg 2019; 58:311-314. [PMID: 31477217 DOI: 10.1016/j.ejvs.2019.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University of Liège, Belgium.
| | - Florian Dick
- Department of Vascular Surgery, Canton Hospital St Gallen, St Gallen, Switzerland; University of Bern, Bern, Switzerland
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Mizzi A, Cassar K, Bowen C, Formosa C. The progression rate of peripheral arterial disease in patients with intermittent claudication: a systematic review. J Foot Ankle Res 2019; 12:40. [PMID: 31404410 PMCID: PMC6683562 DOI: 10.1186/s13047-019-0351-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022] Open
Abstract
Background Intermittent claudication (IC) is the most common symptom of peripheral arterial disease and is generally treated conservatively due to limited prognostic evidence to support early revascularisation in the individual patient. This approach may lead to the possible loss of opportunity of early revascularisation in patients who are more likely to deteriorate to critical limb ischaemia. The aim of this review is to evaluate the available literature related to the progression rate of symptomatic peripheral arterial disease. Methods We conducted a systematic review of the literature in PubMed and MEDLINE, Cochrane library, Elsevier, Web of Science, CINAHL and Opengrey using relevant search terms to identify the progression rate of peripheral arterial disease in patients with claudication. Outcomes of interest were progression rate in terms of haemodynamic measurement and time to development of adverse outcomes. Two independent reviewers determined study eligibility and extracted descriptive, methodologic, and outcome data. Quality of evidence was evaluated using the Cochrane recommendations for assessing risk of bias and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Seven prospective cohort studies and one retrospective cohort study were identified and included in this review with the number of participants in each study ranging from 38 to 1244. Progression rate reports varied from a yearly decrease of 0.01 in ankle-brachial pressure index (ABPI) to a yearly decrease ABPI of 0.014 in 21% of participants. Quality of evidence ranged from low to moderate mostly due to limited allocation concealment at recruitment and survival selection bias. Conclusions Progression of PAD in IC patients is probably underestimated in the literature due to study design issues. Predicting which patients with claudication are likely to deteriorate to critical limb ischaemia is difficult since there is a lack of evidence related to lower limb prognosis. Further research is required to enable early identification of patients at high risk of progressing to critical ischaemia and appropriate early revascularisation to reduce lower limb morbidity.
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Affiliation(s)
- A Mizzi
- 1Faculty of Health Sciences, University of Malta, Msida, Malta
| | - K Cassar
- Mater Dei hospital, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - C Bowen
- 3School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - C Formosa
- 1Faculty of Health Sciences, University of Malta, Msida, Malta
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 721] [Impact Index Per Article: 144.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Alves-Cabratosa L, Garcia-Gil M, Comas-Cufí M, Blanch J, Ponjoan A, Martí-Lluch R, Elosua-Bayes M, Parramon D, Camós L, Ramos R. Role of Low Ankle-Brachial Index in Cardiovascular and Mortality Risk Compared with Major Risk Conditions. J Clin Med 2019; 8:E870. [PMID: 31216703 PMCID: PMC6617200 DOI: 10.3390/jcm8060870] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 12/24/2022] Open
Abstract
Cardiovascular prevention is of particular interest in persons with asymptomatic peripheral arterial disease. We aimed to quantify its association with mortality and cardiovascular outcomes, compared to other indicators of high risk. We performed a retrospective cohort study using the Database of the Catalan primary care system (SIDIAPQ), for 2006-2015, including 35-85-year-old patients with an ankle-brachial index (ABI) measurement, classified according to the presence of diabetes, cardiovascular disease, and low ABI (<0.9). We calculated the incidences and hazard ratios (HRs) for all-cause mortality, acute myocardial infarction, and ischemic stroke. During a median follow-up of 5.9 years, we analyzed 58,118 persons. The mean (SD) age was 66.6 (10.7) years and 53.4% were men. Compared to the reference group with no diabetes, no previous cardiovascular disease, and normal ankle-brachial index, the HR for all-cause mortality was 1.42 (1.25-1.63) in the group with low ABI, 1.35 (1.26-1.45) in those with diabetes, 1.50 (1.34-1.69) in those with previous cardiovascular disease, and 1.84 (1.68-2.01) in those with low ABI and diabetes. In conclusion, participants with low ABI showed increased mortality, acute myocardial infarction, and ischemic stroke incidence in all the subgroups. Patients with low ankle-brachial index plus diabetes presented increased mortality, acute myocardial infarction, and ischemic stroke risk, all at rates similar to those with previous cardiovascular disease.
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Affiliation(s)
- Lia Alves-Cabratosa
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
| | - Maria Garcia-Gil
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
| | - Marc Comas-Cufí
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
| | - Jordi Blanch
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
| | - Anna Ponjoan
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
- Institut d'Investigació Biomèdica de Girona (IDIBGI), 17190 Girona, Spain.
| | - Ruth Martí-Lluch
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
- Institut d'Investigació Biomèdica de Girona (IDIBGI), 17190 Girona, Spain.
| | - Marc Elosua-Bayes
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
| | - Dídac Parramon
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
- Primary Care Services, Girona, Catalan Institute of Health (ICS), 17001 Girona, Spain.
| | - Lourdes Camós
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
- Primary Care Services, Girona, Catalan Institute of Health (ICS), 17001 Girona, Spain.
| | - Rafel Ramos
- Vascular Health Research Group of Girona (ISV-Girona), Fundació Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 17002 Girona, Spain.
- Department of Medical Sciences, School of Medicine, University of Girona, 17003 Girona, Spain.
- Institut d'Investigació Biomèdica de Girona (IDIBGI), 17190 Girona, Spain.
- Primary Care Services, Girona, Catalan Institute of Health (ICS), 17001 Girona, Spain.
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 705] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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129
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Ueshima D, Barioli A, Nai Fovino L, D'Amico G, Fabris T, Brener SJ, Tarantini G. The impact of pre‐existing peripheral artery disease on transcatheter aortic valve implantation outcomes: A systematic review and meta‐analysis. Catheter Cardiovasc Interv 2019; 95:993-1000. [DOI: 10.1002/ccd.28335] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Daisuke Ueshima
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Medical School Padua Italy
| | - Alberto Barioli
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Medical School Padua Italy
| | - Luca Nai Fovino
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Medical School Padua Italy
| | - Gianpiero D'Amico
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Medical School Padua Italy
| | - Tommaso Fabris
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Medical School Padua Italy
| | - Sorin J. Brener
- Department of Medicine, Cardiac Catheterization LaboratoryNew York‐Presbyterian Brooklyn Methodist Hospital Brooklyn New York
| | - Giuseppe Tarantini
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Medical School Padua Italy
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130
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Stalling P, Engelbertz C, Lüders F, Meyborg M, Gebauer K, Waltenberger J, Reinecke H, Freisinger E. Unmet medical needs in intermittent Claudication with diabetes and coronary artery disease-A "real-world" analysis on 21 197 PAD patients. Clin Cardiol 2019; 42:629-636. [PMID: 31017298 PMCID: PMC6553564 DOI: 10.1002/clc.23186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/17/2019] [Accepted: 04/23/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is frequently co-prevalent with coronary artery disease (CAD) and diabetes (DM). The study aims to define the burden of CAD and/ or DM in PAD patients at moderate stages and further to evaluate its impact on therapy and outcome. METHODS Study is based on health insurance claims data of the BARMER reflecting an unselected "real-world" scenario. Retrospective analyses were based on 21 197 patients hospitalized for PAD Rutherford 1-3 between 1 January 2009 to 31 December 2011, including a 4-year follow-up (median 775 days). RESULTS In PAD patients, CAD is prevalent in 25.3% (n = 5355), DM in 23.5% (n = 4976), and both CAD and DM in 8.2% (n = 1741). Overall, in-hospital mortality was 0.4%, being increased if CAD was present (CAD alone: OR 1.849; 95%-CI 1.066-3.208; DM alone: OR 1.028; 95%-CI 0.520-2.033; CAD and DM: OR 3.115; 95%-CI 1.720-5.641). Both, CAD and DM increased long-term mortality (CAD alone: HR 1.234; 95%-CI 1.106-1.376; DM alone: HR 1.260; 95%-CI 1.125-1.412; CAD and DM: HR 1.76; 95%-CI 1.552-1.995). DM further increased long-term amputation risk (DM alone: HR 2.238; 95%-CI 1.849-2.710; DM and CAD: HR 2.199; 95%-CI 1.732-2.792), whereas CAD (alone) did not. CONCLUSIONS In a greater perspective, the data identify also mild to modest stage PAD patients at particular risk for adverse outcomes in presence of CAD and/or DM. CAD and DM both are related with a highly increased risk of long-term mortality even in intermittent claudication, and DM independently increased amputation risk.
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Affiliation(s)
- Philipp Stalling
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Christiane Engelbertz
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | | | - Matthias Meyborg
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | - Katrin Gebauer
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | - Johannes Waltenberger
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany.,Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | - Eva Freisinger
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
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131
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Jönelid B, Kragsterman B, Berglund L, Andrén B, Johnston N, Lindahl B, Oldgren J, Christersson C. Low Walking Impairment Questionnaire score after a recent myocardial infarction identifies patients with polyvascular disease. JRSM Cardiovasc Dis 2019; 8:2048004019841971. [PMID: 31019682 PMCID: PMC6469275 DOI: 10.1177/2048004019841971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 01/22/2023] Open
Abstract
Objectives To evaluate whether the Walking Impairment Questionnaire score could identify
patients with polyvascular disease in a population with recent myocardial
infarction and their association with cardiovascular events during two-year
follow-up. Design A prospective observational study. Setting Patients admitted to the acute coronary care unit, the Department of
Cardiology, Uppsala University Hospital. Participants Patients admitted with acute Non-STEMI- or STEMI-elevation myocardial
infarction. Main outcome measures The Walking Impairment Questionnaire, developed as a self-administered
instrument to assess walking distance,
speed, and stair climbing in patients
with peripheral artery disease, predicts future cardiovascular events and
mortality. Two hundred and sixty-three patients with recent myocardial
infarction answered Walking Impairment Questionnaire. Polyvascular disease
was defined as abnormal findings in the coronary- and carotid arteries and
an abnormal ankle–brachial index. The calculated score for each of all three
categories were divided into quartiles with the lowest score in first
quartile. Results The lowest (worst) quartile in all three Walking Impairment Questionnaire
categories was associated with polyvascular disease, fully adjusted;
distance, odds ratio (OR) 5.4 (95% confidence interval
(CI) 1.8–16.1); speed, OR 7.4 (95% CI 1.5–36.5);
stair climbing, OR 8.4 (95% CI 1.0–73.6). In
stair climbing score, patients with the lowest (worst)
score had a higher risk for the composite cardiovascular endpoint compared
to the highest (best) score; hazard ratio 5.3 (95% CI 1.5–19.0). The
adherence to medical treatment was high (between 81.7% and 99.2%). Conclusions The Walking Impairment Questionnaire is a simple tool to identify myocardial
infarction patients with more widespread atherosclerotic disease and
although well treated medically, stair climbing predicts cardiovascular
events.
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Affiliation(s)
- Birgitta Jönelid
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Björn Kragsterman
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Lars Berglund
- ³Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bertil Andrén
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Nina Johnston
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,³Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,³Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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132
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Abaraogu UO, Dall PM, Brittenden J, Stuart W, Tew GA, Godwin J, Seenan CA. Efficacy and Feasibility of Pain management and Patient Education for Physical Activity in Intermittent claudication (PrEPAID): protocol for a randomised controlled trial. Trials 2019; 20:222. [PMID: 30992033 PMCID: PMC6469131 DOI: 10.1186/s13063-019-3307-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/19/2019] [Indexed: 11/25/2022] Open
Abstract
Background Physical activity (PA) improves functional capacity and quality of life and provides secondary prevention benefits in individuals with peripheral arterial disease (PAD) and intermittent claudication (IC). However, pain and patient lack of knowledge are key barriers to the uptake of, and adherence to, PA recommendations. This trial will test the efficacy and feasibility of a non-invasive pain management intervention with and without patient education to improve PA in individuals with PAD and IC. Methods This is a randomised, controlled assessor-blinded feasibility trial with four parallel groups. Eighty adults with PAD and IC will be randomly assigned 1:1:1:1 to Active TENS (transcutaneous electrical nerve stimulation), Placebo TENS, Active TENS + Patient education or Placebo TENS + Patient education groups. All groups will continue to receive usual care over the intervention period. Participants randomised to Active TENS will receive a TENS device (preset at 120 Hz, 200 μs) and will be instructed to use the device daily at home or elsewhere for 6 weeks with a patient-determined intensity of “strong but comfortable”. Placebo TENS group participants will receive the same model of TENS device and instructions for use as those in the active group, except that the stimulation dose will be safely altered to produce non-therapeutic, ineffective stimulation. Participants randomised to patient education will receive a one-off 3-h workshop of structured group education (four to five persons in each group) and three sets of twice-weekly phone calls. Efficacy outcomes will be assessed at baseline, after 6 weeks of intervention and at 3 months follow-up. Absolute claudication distance using the Gardner treadmill protocol will be assessed as the primary outcome. Secondary outcomes will assess initial claudication distance, daily PA and patient-reported outcomes including quality of life, pain self-efficacy, depression, disease perception and walking impairment pain intensity and quality. Feasibility outcomes will assess rates of recruitment, retention and adherence. Focus groups with participants at the end of the trial will explore the acceptability of the interventions. Discussion This trial will determine the efficacy and feasibility of using a low-cost, CE-marked non-invasive pain management modality delivered with or without a patient-centred education intervention to improve PA in individuals with PAD and IC. Trial registration ClinicalTrials.gov, NCT03204825. Registered on 2 July 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3307-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ukachukwu O Abaraogu
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK. .,Department of Medical Rehabilitation, Faculty of Health Science and Technology, College of Medicine, University of Nigeria, Enugu, Nigeria.
| | - Philippa M Dall
- Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonain University, Glasgow, UK
| | - Julie Brittenden
- Vascular Surgery NHS Greater Glasgow and Clyde Health Board, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Wesley Stuart
- Vascular Surgery NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - Garry A Tew
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle, UK
| | - Jon Godwin
- Institute of Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Christopher A Seenan
- Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonain University, Glasgow, UK
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Akioyamen LE, Tu JV, Genest J, Ko DT, Coutin AJS, Shan SD, Chu A. Risk of Ischemic Stroke and Peripheral Arterial Disease in Heterozygous Familial Hypercholesterolemia: A Meta-Analysis. Angiology 2019; 70:726-736. [PMID: 30871330 DOI: 10.1177/0003319719835433] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heterozygous familial hypercholesterolemia (HeFH) is a common genetic disorder predisposing affected individuals to lifelong low-density lipoprotein cholesterol (LDL-C) elevation and coronary heart disease. However, whether HeFH increases the risk of peripheral arterial disease (PAD) and ischemic stroke is undetermined. We examined associations between HeFH and these outcomes in a comprehensive systematic review and meta-analysis. We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, and PubMed (for ahead-of-print publications) for relevant English-language studies. Maximally adjusted risk estimates were pooled under random- and fixed-effects meta-analysis to derive odds ratios (ORs) and 95% confidence intervals (CIs). We included 6 studies representing 183 388 participants. Heterozygnous familial hypercholesterolemia was associated with a higher risk of PAD (OR: 3.59 [95% CI: 1.30-9.89]). This trend was nonsignificantly preserved (OR: 2.96 [95% CI: 0.68-12.88]) in sensitivity analyses of genetically defined HeFH. Genetic HeFH was not associated with increased ischemic stroke risk (OR: 0.76 [95% CI: 0.37-1.58]) although possessing an LDL-C >4.9 mmol/L (190 mg/dL) was (OR: 1.42 [95% CI: 1.06-1.89]). We found clinical and genetic diagnoses of HeFH to be associated with increased PAD risk. Genetically confirmed HeFH may not confer an increased risk of ischemic stroke. Modest associations may exist between LDL-C and ischemic stroke risk in HeFH.
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Affiliation(s)
- Leo E Akioyamen
- 1 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,2 ICES, Toronto, Ontario, Canada
| | - Jack V Tu
- 1 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,2 ICES, Toronto, Ontario, Canada.,3 Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jacques Genest
- 4 Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,5 McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Dennis T Ko
- 1 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,2 ICES, Toronto, Ontario, Canada.,3 Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Shubham D Shan
- 1 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,2 ICES, Toronto, Ontario, Canada
| | - Anna Chu
- 1 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,2 ICES, Toronto, Ontario, Canada
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Sadat U, Mariam NBG, Usman A, Chowdhury MM, El Nakhal T, DaCosta OF, Gillard JH, Hayes PD, Varty K. Association Between Abdominal Visceral Artery Calcification and All-Cause Mortality-A Computerized Tomography Imaging-Based Longitudinal Follow-Up Study. Angiology 2019; 70:237-243. [PMID: 30180770 DOI: 10.1177/0003319718796889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arterial calcification in different arterial beds has been observed to be an independent predictor of mortality. The association of abdominal visceral artery calcium with all-cause mortality remains unexplored. Patients who had undergone contrast-enhanced computerized tomography (CT) imaging for routine assessment of peripheral arterial disease (PAD) were considered for this study. A novel calcium score (abdominal visceral arteries calcium [AVAC]) for the abdominal visceral arteries (celiac axis, superior mesenteric, and renal arteries) was calculated using a modified Agatston score. Cumulative AVAC was defined as sum total of the calcium score of above individual arteries. The primary outcome was all-cause mortality. The association of AVAC with all-cause mortality was assessed. Of the 134 consecutive patients, 89 were included for analysis. Median follow-up duration was 72 (47-91) months since CT imaging; 35 (39%) patients died during this period. Hypertension and cumulative AVAC score had a significant association with all-cause mortality (P < .05). Cumulative visceral abdominal artery calcification is associated with all-cause mortality in patients with PAD. Future prospective studies are warranted to investigate this relationship in PAD and other patient cohorts.
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Affiliation(s)
- Umar Sadat
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.,University of Cambridge, Cambridge, United Kingdom
| | | | - Ammara Usman
- University of Cambridge, Cambridge, United Kingdom.,University Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Mohammed M Chowdhury
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.,University of Cambridge, Cambridge, United Kingdom
| | - Tamer El Nakhal
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Olga Fadeeva DaCosta
- Imaging Clinical Imaging Facility, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jonathan H Gillard
- University of Cambridge, Cambridge, United Kingdom.,University Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Paul D Hayes
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.,University of Cambridge, Cambridge, United Kingdom
| | - Kevin Varty
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
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Rehabilitative Exercise Reduced the Impact of Peripheral Artery Disease on Vascular Outcomes in Elderly Patients with Claudication: A Three-Year Single Center Retrospective Study. J Clin Med 2019; 8:jcm8020210. [PMID: 30736443 PMCID: PMC6406499 DOI: 10.3390/jcm8020210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 12/13/2022] Open
Abstract
The study retrospectively evaluated the association between rehabilitative outcomes and risk of peripheral revascularizations in elderly peripheral artery disease (PAD) patients with claudication. Eight-hundred thirty-five patients were enrolled. Ankle-brachial index (ABI) and maximal walking speed (Smax) were measured at baseline and at discharge from a structured home-based rehabilitation program. For the analysis, patients were divided according to a baseline ABI value (severe: ≤0.5; moderate: ≥0.5) and according to hemodynamic or functional rehabilitative response (responder: ABI ≥ 0.10 and/or Smax > 0.5 km/h). Three-year outcomes were collected from the regional registry. According to the inclusion criteria (age 60–80, ABI < 0.80; program completion) 457 patients, 146 severe and 311 moderate, were studied. The whole population showed significant functional and hemodynamic improvements at discharge, with 56 revascularizations and 69 deaths at follow-up. Compared to the moderate group, the severe group showed a higher rate of revascularizations (17% vs. 10%, p < 0.001) and deaths (29% and 8%, respectively; p < 0.001). However, patients with severe PAD who were ABI responders after rehabilitation showed less revascularizations than non-responders (13% vs. 21%; hazard ratio (HR): 0.52) and were not different from patients with moderate disease (9%). Superimposable rates were observed for Smax responders (13% vs. 21%; HR: 0.55; moderate 10%). In conclusion, elderly patients with severe PAD empowered by better rehabilitation outcomes showed lower rates of peripheral revascularizations and deaths that were comparable to patients with moderate PAD.
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137
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Lin PY, Sung PH, Chung SY, Hsu SL, Chung WJ, Sheu JJ, Hsueh SK, Chen KH, Wu RW, Yip HK. Hyperbaric Oxygen Therapy Enhanced Circulating Levels of Endothelial Progenitor Cells and Angiogenesis Biomarkers, Blood Flow, in Ischemic Areas in Patients with Peripheral Arterial Occlusive Disease. J Clin Med 2018; 7:jcm7120548. [PMID: 30558177 PMCID: PMC6306846 DOI: 10.3390/jcm7120548] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 01/06/2023] Open
Abstract
Background: This study tested the hypothesis that hyperbaric oxygen (HBO) therapy enhanced the circulating levels of endothelial progenitor cells (EPCs), soluble angiogenesis factors, and blood flow in ischemic areas in patients with peripheral arterial occlusive disease (PAOD). Methods: In total, 57 consecutive patients with PAOD undergoing the HBO therapy (3 atmospheres (atm) for 2 h each time) were prospectively enrolled into the present study. Venous blood sampling was performed to assess the circulating levels of EPCs and soluble angiogenesis factors prior to and during five sessions of HBO therapy. Additionally, skin perfusion pressure (SPP), an indicator of blood flow in ischemic areas, was measured by moorVMS-PRES. Results: The results demonstrated that the circulating levels of EPCs (cluster of differentiation (CD)34+/CD133+/CD45dim, CD31+/CD133+/CD45dim, CD34+) and soluble angiogenesis factors—vascular endothelial growth factor/stromal cell-derived factor 1/hepatocyte growth factor/fibroblast growth factor (VEGF/SDF-1α/HGF/FGF) were significantly increased post-HBO therapy as compared to pre-HBO therapy (all p < 0.01). Additionally, Matrigel assay showed that the angiogenesis was significantly increased in post-HBO therapy as compared to prior to therapy (p < 0.001). Furthermore, SPP was significantly increased in the ischemic area (i.e., plantar foot and mean SPP of the ischemic foot) in post-HBO therapy as compared to pre-HBO therapy (all p < 0.01). Importantly, the HBO therapy did appear to result in complications, and all the patients were uneventfully discharged without amputation. Conclusions: HBO therapy augmented circulating levels of EPCs and angiogenesis factors, and improved the blood flow in the ischemic area.
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Affiliation(s)
- Pao-Yuan Lin
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Sheng-Ying Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shan-Ling Hsu
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Jiunn-Jye Sheu
- Division of thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shu-Kai Hsueh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Re-Wen Wu
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan.
- Department of Nursing, Asia University, Taichung 41354, Taiwan.
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138
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Ryan TE, Yamaguchi DJ, Schmidt CA, Zeczycki TN, Shaikh SR, Brophy P, Green TD, Tarpey MD, Karnekar R, Goldberg EJ, Sparagna GC, Torres MJ, Annex BH, Neufer PD, Spangenburg EE, McClung JM. Extensive skeletal muscle cell mitochondriopathy distinguishes critical limb ischemia patients from claudicants. JCI Insight 2018; 3:123235. [PMID: 30385731 DOI: 10.1172/jci.insight.123235] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/02/2018] [Indexed: 12/31/2022] Open
Abstract
The most severe manifestation of peripheral arterial disease (PAD) is critical limb ischemia (CLI). CLI patients suffer high rates of amputation and mortality; accordingly, there remains a clear need both to better understand CLI and to develop more effective treatments. Gastrocnemius muscle was obtained from 32 older (51-84 years) non-PAD controls, 27 claudicating PAD patients (ankle-brachial index [ABI] 0.65 ± 0.21 SD), and 19 CLI patients (ABI 0.35 ± 0.30 SD) for whole transcriptome sequencing and comprehensive mitochondrial phenotyping. Comparable permeabilized myofiber mitochondrial function was paralleled by both similar mitochondrial content and related mRNA expression profiles in non-PAD control and claudicating patient tissues. Tissues from CLI patients, despite being histologically intact and harboring equivalent mitochondrial content, presented a unique bioenergetic signature. This signature was defined by deficits in permeabilized myofiber mitochondrial function and a unique pattern of both nuclear and mitochondrial encoded gene suppression. Moreover, isolated muscle progenitor cells retained both mitochondrial functional deficits and gene suppression observed in the tissue. These findings indicate that muscle tissues from claudicating patients and non-PAD controls were similar in both their bioenergetics profile and mitochondrial phenotypes. In contrast, CLI patient limb skeletal muscles harbor a unique skeletal muscle mitochondriopathy that represents a potentially novel therapeutic site for intervention.
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Affiliation(s)
- Terence E Ryan
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | | | - Cameron A Schmidt
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | - Tonya N Zeczycki
- East Carolina Diabetes and Obesity Institute.,Department of Biochemistry and Molecular Biology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Saame Raza Shaikh
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Thomas D Green
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | - Michael D Tarpey
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | - Reema Karnekar
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | - Emma J Goldberg
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | | | | | - Brian H Annex
- Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - P Darrell Neufer
- Department of Physiology.,East Carolina Diabetes and Obesity Institute
| | | | - Joseph M McClung
- Department of Physiology.,East Carolina Diabetes and Obesity Institute.,Department of Cardiovascular Sciences
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139
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van Haelst ST, Teraa M, Moll FL, de Borst GJ, Verhaar MC, Conte MS. Prognostic value of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification in patients with no-option chronic limb-threatening ischemia. J Vasc Surg 2018; 68:1104-1113.e1. [DOI: 10.1016/j.jvs.2018.02.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/11/2018] [Indexed: 01/26/2023]
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140
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Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-Brachial Index: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 320:177-183. [PMID: 29998344 DOI: 10.1001/jama.2018.8357] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Peripheral artery disease (PAD) is a manifestation of atherosclerosis in the lower limbs. It can impair walking and, in severe cases, can lead to tissue loss, infection, and amputation. In addition to morbidity directly caused by PAD, patients with PAD are at increased risk for cardiovascular disease (CVD) events, because atherosclerosis is a systemic disease that also causes coronary and cerebrovascular events. OBJECTIVE To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on screening for PAD and CVD risk with the ankle-brachial index (ABI). EVIDENCE REVIEW The USPSTF reviewed the evidence on whether screening for PAD with the ABI in generally asymptomatic adults reduces morbidity or mortality from PAD or CVD. The current review expanded on the previous review to include individuals with diabetes and interventions that include supervised exercise and physical therapy intended to improve outcomes in the lower limbs. FINDINGS The USPSTF found few data on the accuracy of the ABI for identifying asymptomatic persons who can benefit from treatment of PAD or CVD. There are few studies addressing the benefits of treating screen-detected patients with PAD; 2 good-quality studies showed no benefit of using the ABI to manage daily aspirin therapy in unselected populations, and 2 studies showed no benefit from exercise therapy. No studies addressed the harms of screening, although the potential exists for overdiagnosis, labeling, and opportunity costs. Studies that addressed the harms of treatment showed nonsignificant results. Therefore, the USPSTF concludes that the current evidence is insufficient and that the balance of benefits and harms of screening for PAD with the ABI in asymptomatic adults cannot be determined. CONCLUSIONS AND RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk with the ABI in asymptomatic adults. (I statement).
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Affiliation(s)
| | | | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
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141
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Yu W, Wang B, Zhan B, Li Q, Li Y, Zhu Z, Yan Z. Statin therapy improved long-term prognosis in patients with major non-cardiac vascular surgeries: a systematic review and meta-analysis. Vascul Pharmacol 2018; 109:1-16. [PMID: 29953967 DOI: 10.1016/j.vph.2018.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/08/2018] [Accepted: 06/21/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate whether statin intervention will improve the long-term prognosis of patients undergoing major non-cardiac vascular surgeries. METHODS Major database searches for clinical trials enrolling patients undergoing major non-cardiac vascular surgeries, including lower limb revascularization, carotid artery surgeries, arteriovenous fistula, and aortic surgeries, were performed. Subgroup analyses, stratified by surgical types or study types, were employed to obtain statistical results regarding survival, patency rates, amputation, and cardiovascular and stroke events. Odds ratio (ORs) and 95% confidence intervals (CIs) were calculated by Review Manager 5.3. Sensitivity analysis, publication bias and meta-regression were conducted by Stata 14.0. RESULTS In total, 34 observational studies, 8 prospective cohort studies and 4 randomized controlled clinical trials (RCTs) were enrolled in the present analysis. It was demonstrated that statin usage improved all-cause mortality in lower limb, carotid, aortic and mixed types of vascular surgery subgroups compared with those in which statins were not used. Additionally, the employment of statins efficiently enhanced the primary and secondary patency rates and significantly decreased the amputation rates in the lower limb revascularization subgroup. Furthermore, for other complications, statin intervention decreased cardiovascular events in mixed types of vascular surgeries and stroke incidence in the carotid surgery subgroup. No significant publication bias was observed. The meta-regression results showed that the morbidity of cardiovascular disease or the use of aspirin might affect the overall estimates in several subgroups. CONCLUSIONS This meta-analysis demonstrated that statin therapy was associated with improved survival rates and patency rates and with reduced cardiovascular or stroke morbidities in patients who underwent non-cardiac vascular surgeries.
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Affiliation(s)
- Wenpei Yu
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China; The Thirteenth People's Hospital of Chongqing, The Chongqing Geriatric Hospital, Chongqing 400053, China
| | - Bin Wang
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China; Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, Beijing Key Laboratory of Kidney Disease, National Clinical Research Center for Kidney Diseases, Fuxing Road 28, Beijing 100853, China
| | - Bin Zhan
- The Thirteenth People's Hospital of Chongqing, The Chongqing Geriatric Hospital, Chongqing 400053, China
| | - Qiang Li
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Yingsha Li
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Zhiming Zhu
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Zhencheng Yan
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China.
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Müller-Hülsbeck S, Hopf-Jensen S, Keirse K, Zeller T, Schroë H, Diaz-Cartelle J, Gray WA. Eluvia drug-eluting vascular stent system for the treatment of symptomatic femoropopliteal lesions. Future Cardiol 2018; 14:207-213. [PMID: 29631434 DOI: 10.2217/fca-2017-0105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Endovascular options are increasingly recognized as primary treatments for lower extremity peripheral arterial disease inadequately responsive to noninvasive therapy. Options include balloon angioplasty and stent implantation, and newer technologies incorporate drug coatings to prevent restenosis and reduce the need for reintervention. The Eluvia drug-eluting vascular stent system (Boston Scientific, MA, USA) was designed with a biocompatible fluoropolymer coating to allow for drug elution over time. Initial clinical results demonstrate promising efficacy in terms of sustained femoropopliteal artery patency along with a good safety profile. This review summarizes the existing clinical literature on treatment of femoropopliteal artery lesions with Eluvia, and outlines the continuing research program.
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Affiliation(s)
| | | | - Koen Keirse
- Vascular Surgery, Regional Hospital Heilig Hart Tienen, Tienen, Belgium
| | - Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Herman Schroë
- Thoracic and Vascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
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143
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Mukherjee D, Contos B, Emery E, Collins DT, Black JH. High Reintervention and Amputation Rates After Outpatient Atherectomy for Claudication. Vasc Endovascular Surg 2018; 52:427-433. [DOI: 10.1177/1538574418772459] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Outpatient use of atherectomy for peripheral arterial disease has grown rapidly and outcomes are poorly understood. We analyzed outcomes of atherectomy done for claudication, comparing office and hospital outpatient settings. Analysis of Medicare Part B claims data was performed for incident femoral–popliteal or tibial–peroneal atherectomy from 2012 to 2014. Longitudinal analysis assessed services 18 months before, during, and up to 18 months after the incident peripheral vascular intervention (PVI). Differences between office-based and hospital outpatient-based settings were assessed using χ2 and Fisher exact tests. Comparing procedure settings, significant differences in race (femoral–popliteal: P = .04, tibial–peroneal: P = .001), chronic renal failure (femoral–popliteal: P = .002), and hypertension (femoral–popliteal: P = .01, tibial–peroneal: P = .006) were found. Nine hundred twenty-four patients undergoing femoral–popliteal atherectomy were analyzed (262 office based, 662 hospital outpatient based); 42.7% of office-based and 36.9% of hospital outpatient-based femoral–popliteal atherectomy patients had repeat PVI within 18 months ( P = .10). Major amputation was performed in 2.3% and 3.2% of patients in office and hospital outpatient settings, respectively ( P = .47). Four hundred twenty-three patients undergoing tibial–peroneal atherectomy were analyzed (202 office based, 221 hospital outpatient based); 46.5% of office-based and 38.9% of hospital outpatient-based tibial–peroneal atherectomy patients had repeat PVI within 1 year ( P = .11). Major amputation was performed in 5.0% and 8.1% of patients in office and hospital outpatient settings, respectively ( P = .19). Our study demonstrates higher than expected rates of major amputation for patients undergoing peripheral arterial atherectomy with regard to previously reported rates. Further studies may be required to prove the efficacy and safety of atherectomy for occlusive disease in the femoral–popliteal and tibial–peroneal segments to ensure outcomes are not worse than the natural history of medically managed claudicants.
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Affiliation(s)
| | | | - Erica Emery
- Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Devon T. Collins
- Inova Fairfax Medical Campus, Falls Church, VA, USA
- George Mason University, Fairfax, VA, USA
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145
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Baviera M, Bertelè V, Avanzini F, Vannini T, Tettamanti M, Fortino I, Bortolotti A, Merlino L, Roncaglioni MC. Peripheral arterial disease: Changes in clinical outcomes and therapeutic strategies in two cohorts, from 2002 to 2008 and from 2008 to 2014. A population-based study. Eur J Prev Cardiol 2018; 25:1735-1743. [DOI: 10.1177/2047487318770299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The aim of our study was to evaluate whether treatments for peripheral artery disease changed in two different cohorts identified in 2002 and 2008, and whether this had an impact on mortality and major clinical outcomes after six years of follow-up. Methods Using administrative health databases of the largest region in Northern Italy, we identified patients admitted to hospital for peripheral artery disease in 2002 and 2008. Both cohorts were followed for six years. All cause death, acute coronary syndrome, stroke and major amputations, cardiovascular prevention drugs and revascularization procedures were collected. Incidence of events was plotted using adjusted cumulative incidence function estimates. The risk, for each outcome, was compared between 2002–2008 and 2008–2014 using a multivariable Fine and Gray’s semiparametric proportional subdistribution hazards model. Results In 2002 and 2008, 2885 and 2848 patients were identified. Adjusting for age, sex, Charlson comorbidity index and severity of peripheral artery disease we observed a significant reduction (in 2008 vs. 2002) in the risk of acute coronary syndrome (28%), stroke (27%) and major amputation (17%). No change was observed in the risk of death. The percentages of patients with peripheral artery revascularizations, during the hospital stay, increased: 43.8% in 2002 vs. 49.0% in 2008, p < 0.001. From 2002 to 2008 there was a significant absolute increase in the prescription of lipid-lowering drugs (+18%), antiplatelets (+7.2%) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (+11.8%), p < 0.001. Conclusions In six years of follow-up we observed a reduction in risk of major cardiovascular events in 2008–2014 in comparison with the 2002–2008 cohort. Increasing use of revascularization interventions and cardiovascular prevention drugs could have contributed to the better prognosis.
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Affiliation(s)
- Marta Baviera
- Laboratory of Cardiovascular Prevention, IRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Italy
| | - Vittorio Bertelè
- Drug Regulatory Policies Lab IRCCS – Istituto di Ricerche Farmacologiche ‘Mario Negri’, Italy
| | - Fausto Avanzini
- Laboratory of Cardiovascular Prevention, IRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Italy
| | - Tommaso Vannini
- Laboratory of Cardiovascular Prevention, IRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Italy
| | - Mauro Tettamanti
- Laboratory of Geriatric Neuropsychiatry, IRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Italy
| | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Italy
| | | | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Italy
| | - Maria Carla Roncaglioni
- Laboratory of Cardiovascular Prevention, IRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Italy
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146
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Kalbaugh CA, Loehr L, Wruck L, Lund JL, Matsushita K, Bengtson LGS, Heiss G, Kucharska-Newton A. Frequency of Care and Mortality Following an Incident Diagnosis of Peripheral Artery Disease in the Inpatient or Outpatient Setting: The ARIC (Atherosclerosis Risk in Communities) Study. J Am Heart Assoc 2018; 7:JAHA.117.007332. [PMID: 29654201 PMCID: PMC6015432 DOI: 10.1161/jaha.117.007332] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Available health services data for individuals with peripheral artery disease (PAD) are often from studies of those eligible for or undergoing intervention. Knowledge of the frequency of care and mortality following an initial PAD diagnosis by setting (outpatient versus inpatient) is limited and represents an opportunity to provide new benchmark information. Methods and Results The purpose of this study was to characterize the frequency of care and mortality following an incident PAD diagnosis in the outpatient or inpatient setting using data from the ARIC (Atherosclerosis Risk in Communities) study cohort linked with Centers for Medicare and Medicaid Services fee‐for‐service claims data (2002–2012). Direct standardization was used to estimate age‐standardized rates of encounters and mortality. PAD was defined by billing code in any claim position. We observed 1086 incident PAD cases (873 outpatient, 213 inpatient). At 1 year after diagnosis, participants diagnosed in the outpatient setting had 2.15 (95% confidence interval [CI], 2.10–2.21) PAD‐related outpatient encounters per person‐year, and 6.4% (95% CI, 4.8–8.1) had a PAD‐related hospitalization. Conversely, participants diagnosed in the inpatient setting had 1.02 (95% CI, 0.94–1.10) PAD‐related outpatient encounters per person‐year, and 14.2% (95% CI, 9.3–18.7) had a PAD‐related rehospitalization. One‐year mortality was 7.1% (95% CI, 5.4–8.7) and 16.0% (95% CI, 11.0–21.1) among those diagnosed in outpatient and inpatient settings, respectively. Conclusions This study provides important data estimating frequency of care and mortality by the setting of initial PAD diagnosis. Individuals with PAD are frequent users of health care, and those diagnosed in the inpatient setting have high rates of rehospitalization and mortality.
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Affiliation(s)
- Corey A Kalbaugh
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, NC .,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, NC
| | - Laura Loehr
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC
| | - Lisa Wruck
- Center for Preventive Medicine, Duke Clinical Research Institute, Durham, NC
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC
| | - Kunihiro Matsushita
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Gerardo Heiss
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC
| | - Anna Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, NC.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, NC
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147
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Itoga NK, Minami HR, Chelvakumar M, Pearson K, Mell MM, Bendavid E, Owens DK. Cost-effectiveness analysis of asymptomatic peripheral artery disease screening with the ABI test. Vasc Med 2018; 23:97-106. [PMID: 29345540 PMCID: PMC5893367 DOI: 10.1177/1358863x17745371] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Screening for asymptomatic peripheral artery disease (aPAD) with the ankle-brachial index (ABI) test is hypothesized to reduce disease progression and cardiovascular (CV) events by identifying individuals who may benefit from early initiation of medical therapy. Using a Markov model, we evaluated the cost effectiveness of initiating medical therapy (e.g. statin and ACE-inhibitor) after a positive ankle-brachial index (ABI) screen in 65-year-old patients. We modeled progression to symptomatic PAD (sPAD) and CV events with and without ABI screening, evaluating differences in costs and quality-adjusted life years (QALYs). The cost of the ABI test, physician visit, new medication, CV events, and interventions for sPAD were incorporated in the model. We performed sensitivity analysis on model variables with uncertainty. Our model found an incremental cost of US $338 and an incremental QALY of 0.00380 with one-time ABI screening, resulting in an incremental cost-effectiveness ratio (ICER) of $88,758/QALY over a 35-year period. The variables with the largest effects in the ICER were aPAD disease prevalence, cost of monthly medication after a positive screen and 2-year medication adherence rates. Screening high-risk populations, such as tobacco users, where the prevalence of PAD may be 2.5 times higher, decreases the ICER to $24,092/QALY. Our analysis indicates the cost effectiveness of one-time screening for aPAD depends on prevalence, medication costs, and adherence to therapies for CV disease risk reduction. Screening in higher-risk populations under favorable assumptions about medication adherence results in the most favorable cost effectiveness, but limitations in the primary data preclude definitive assessment of cost effectiveness.
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Affiliation(s)
- Nathan K. Itoga
- Stanford University; Department of Surgery, Division of Vascular Surgery
| | | | - Meena Chelvakumar
- Stanford University; Center for Health Policy and Primary Care and Outcomes Research
| | - Keon Pearson
- Stanford University; Department of Surgery, Division of Vascular Surgery
| | - Matthew M. Mell
- Stanford University; Department of Surgery, Division of Vascular Surgery
| | - Eran Bendavid
- Stanford University; Center for Health Policy and Primary Care and Outcomes Research
| | - Douglas K. Owens
- Stanford University; Center for Health Policy and Primary Care and Outcomes Research
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148
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Ten Year Mortality in Different Peripheral Arterial Disease Stages: A Population Based Observational Study on Outcome. Eur J Vasc Endovasc Surg 2018; 55:529-536. [DOI: 10.1016/j.ejvs.2018.01.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/23/2018] [Indexed: 11/21/2022]
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149
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Katsiki N, Giannoukas AD, Athyros VG, Mikhailidis DP. Lipid-lowering treatment in peripheral artery disease. Curr Opin Pharmacol 2018; 39:19-26. [DOI: 10.1016/j.coph.2018.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/14/2018] [Accepted: 01/19/2018] [Indexed: 12/19/2022]
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150
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Schaller MS, Ramirez JL, Gasper WJ, Zahner GJ, Hills NK, Grenon SM. Frailty Is Associated with an Increased Risk of Major Adverse Cardiac Events in Patients with Stable Claudication. Ann Vasc Surg 2018; 50:38-45. [PMID: 29477684 DOI: 10.1016/j.avsg.2017.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty, a syndrome characterized by decreased physiologic reserves and resistance to stressors, is associated with disability, poor surgical outcomes, and mortality. We evaluated the impact of frailty on cardiovascular disease (CVD) events in peripheral arterial disease (PAD) patients with intermittent claudication. METHODS We conducted a retrospective review of patients with stable intermittent claudication enrolled in the OMEGA-PAD study between 2010 and 2015. The modified frailty index (mFI) is a retrospectively validated index of frailty derived from the Canadian Study of Health and Aging and was used in this study to categorize frailty as low, medium, or high. Our outcome was time to occurrence of a major adverse cardiac event (MACE), defined as a composite endpoint of myocardial infarction, coronary revascularization, stroke, or CVD-related death. Cox proportional hazards models were used to calculate relative hazards ratio. RESULTS There were 129 subjects with a mean age of 67 years, 97% were men, 36% were diabetic, and 33% had known coronary heart disease. When the mFI criteria were applied, 38 subjects were "low" frailty, 72 were "medium" frailty, and 19 were "high" frailty. During the median follow-up period of 34 months (interquartile range: 25-43), 29 subjects experienced a MACE. When compared to the lowest mFI, patients with medium frailty were 2.8 times more likely to have an event (95% confidence interval [CI]: 0.95-8.46, P = 0.06), whereas patients with a high mFI were 4.8 times as likely (95% CI: 1.43-15.8, P = 0.01). In a model adjusted for age, smoking status, and presence of diabetes, those with a medium mFI were 4.3 times more likely to have an event (95% CI: 1.37-13.7, P = 0.01) and those with a high mFI were 9.2 times as likely (95% CI: 2.6-32.4, P = 0.001). CONCLUSIONS Higher mFI category is associated with a significantly increased risk of MACE in PAD patients with stable claudication. Frailty may serve as a useful adjunct for assessment of overall cardiac risk, particularly as treatment options are being contemplated.
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Affiliation(s)
- Melinda S Schaller
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA; Vascular Surgery Section, Veterans Affairs Medical Center, San Francisco, CA
| | - Greg J Zahner
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, San Francisco, CA; Vascular Surgery Section, Veterans Affairs Medical Center, San Francisco, CA.
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