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Patel KS, Hamilton CA, Huntress LA, Rahimi SA, Beckerman WE. Nitinol overdose-rescue of acute limb ischemia caused by stenting of the common iliac, external iliac, common femoral, superficial femoral, and popliteal arteries in an actively smoking patient with claudication. J Vasc Surg Cases Innov Tech 2023; 9:101256. [PMID: 37799835 PMCID: PMC10547731 DOI: 10.1016/j.jvscit.2023.101256] [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: 02/01/2023] [Accepted: 06/01/2023] [Indexed: 10/07/2023] Open
Abstract
Intermittent claudication (IC) from peripheral arterial disease is typically managed with pharmacologic interventions and lifestyle changes. However, despite societal guidelines, initial endovascular interventions are being used more frequently with an increased incidence of complications, resulting in rapid disease progression to critical and acute limb-threatening ischemia (ALI). The present report describes the case of a patient who developed ALI after treatment of IC at another facility, with malpositioned bilateral common iliac stents, continuous stent extension into the popliteal artery, and acute occlusion of the entirety of the right lower extremity vasculature. This case illustrates how extensive endovascular intervention for IC can result in ALI requiring urgent revascularization.
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Affiliation(s)
| | - Charles A. Hamilton
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Lauren A. Huntress
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Saum A. Rahimi
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - William E. Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
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102
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Bierowski M, Galanis T, Majeed A, Mofid A. Peripheral Artery Disease: Overview of Diagnosis and Medical Therapy. Med Clin North Am 2023; 107:807-822. [PMID: 37541709 DOI: 10.1016/j.mcna.2023.05.007] [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: 08/06/2023]
Abstract
Peripheral artery disease (PAD) affects approximately 230 million people worldwide and is associated with an increased risk of major adverse cardiovascular and limb events. Even though this condition is considered a cardiovascular equivalent, it remains an underrecognized and undertreated entity. Antiplatelet and statin therapy, along with smoking cessation, are the foundations of therapy to reduce adverse events but are challenging to fully implement in this patient population. Race and socioeconomic status also have profound impacts on PAD outcomes.
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Affiliation(s)
- Matthew Bierowski
- Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Taki Galanis
- Division Vascular Medicine, Jefferson Vascular Center, Sidney Kimmel Medical College, Philadelphia, PA, USA.
| | - Amry Majeed
- Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Alireza Mofid
- Vascular Surgery, Thomas Jefferson University Hospital, 111 South 11th Street, Suite 6210 Gibbon, Philadelphia, PA 19107, USA
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103
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Li B, Zamzam A, Syed MH, Djahanpour N, Jain S, Abdin R, Qadura M. Fatty acid binding protein 4 has prognostic value in peripheral artery disease. J Vasc Surg 2023; 78:719-726. [PMID: 37318430 DOI: 10.1016/j.jvs.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Peripheral artery disease (PAD) remains undertreated, despite its association with major amputation and mortality. This is partly due to a lack of available disease biomarkers. The intracellular protein fatty acid binding protein 4 (FABP4) is implicated in diabetes, obesity, and metabolic syndrome. Given that these risk factors are strong contributors to vascular disease, we assessed the prognostic ability of FABP4 in predicting PAD-related adverse limb events. METHODS This was a prospective case-control study with 3 years of follow-up. Baseline serum FABP4 concentrations were measured in patients with PAD (n = 569) and without PAD (n = 279). The primary outcome was major adverse limb event (MALE; defined as a composite of vascular intervention or major amputation). The secondary outcome was worsening PAD status (drop in ankle-brachial index ≥0.15). Kaplan-Meier and Cox proportional hazards analyses adjusted for baseline characteristics were conducted to assess the ability of FABP4 to predict MALE and worsening PAD status. RESULTS Patients with PAD were older and more likely to have cardiovascular risk factors compared with those without PAD. Over the study period, MALE and worsening PAD status occurred in 162 (19%) and 92 (11%) patients, respectively. Higher FABP4 levels were significantly associated with 3-year MALE (unadjusted hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.04-1.27; adjusted HR, 1.18; 95% CI, 1.03-1.27; P = .022) and worsening PAD status (unadjusted HR, 1.18; 95% CI, 1.13-1.31; adjusted HR, 1.17; 95% CI, 1.12-1.28; P < .001). Three-year Kaplan-Meier survival analysis demonstrated that patients with high FABP4 levels had a decreased freedom from MALE (75% vs 88%; log rank = 22.6; P < .001), vascular intervention (77% vs 89%; log rank = 20.8; P < .001), and worsening PAD status (87% vs 91%; log rank = 6.16; P = .013). CONCLUSIONS Individuals with higher serum concentrations of FABP4 are more likely to develop PAD-related adverse limb events. FABP4 has prognostic value in risk-stratifying patients for further vascular evaluation and management.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Muzammil H Syed
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Niousha Djahanpour
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Shubha Jain
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Qadura
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
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Fujimura N, Obara H, Takahashi A, Miyata H, Hosaka A, Obitsu Y, Zempo N, Miyata T, Azuma N, Komori K. Surgical Treatment for Popliteal Artery Entrapment Syndrome in Japan: a Retrospective, Multicentre Study Using a National Clinical Registry. Eur J Vasc Endovasc Surg 2023; 66:381-388. [PMID: 37220801 DOI: 10.1016/j.ejvs.2023.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Surgical treatment is an established method for popliteal artery entrapment syndrome (PAES), which, however, mainly derives from single centre experiences where PAES cases are centralised and treated periodically. This study evaluated clinical outcomes of surgical treatment for PAES in a clinical setting where PAES cases were not centralised. METHODS Multicentre, retrospective cohort study using a national clinical registry. From a Japanese nationwide clinical registry, data for patients who underwent surgical treatment for PAES between 2013 and 2018, including 58 limbs from 41 institutes, were retrieved and evaluated. Patency was analysed using Kaplan-Meier curves. RESULTS The mean patient age was 36 ± 19 years, 78% were male, and the incidence of PAES was 0.24 limbs/centre/year, reflecting a clinical setting where PAES cases are not centralised. The most frequent arterial symptom was intermittent claudication (90%). Computed tomography was performed in 57 limbs (98%) for the diagnosis, however active manoeuvres such as dorsiflexion and plantarflexion during the examination was performed in only 13 limbs (22%), and occlusion of the popliteal artery was present in 38 limbs (66%) at diagnosis. Regarding surgical treatment, myotomy alone was performed in only seven limbs (12%), and other limbs were revascularised. Mean follow up was 26 ± 20 months, and surgical treatment was effective as it relieved symptoms in > 96% of limbs, with five year primary and secondary patency of the surgical treatment for PAES of 72% and 93%, respectively. CONCLUSION Results of surgical treatment were acceptable even in a clinical setting where PAES cases were not centralised. However, a low incidence of active manoeuvres performed during the examination and a high incidence of occlusion at diagnosis suggests there may be delayed or underdiagnosis of PAES in Japan, and increased awareness for PAES is warranted.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan; Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan.
| | - Arata Takahashi
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Akihiro Hosaka
- Department of Vascular Surgery, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan
| | - Yukio Obitsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Nobuya Zempo
- Division of Vascular Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Tetsuro Miyata
- Office of Medical Education, School of Medicine, International University of Health and Welfare, Otawara, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Imtiaz C, Farooqi MA, Bhatti T, Lee J, Moin R, Kang CU, Farooqi HMU. Focused Ultrasound, an Emerging Tool for Atherosclerosis Treatment: A Comprehensive Review. Life (Basel) 2023; 13:1783. [PMID: 37629640 PMCID: PMC10455721 DOI: 10.3390/life13081783] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
Focused ultrasound (FUS) has emerged as a promising noninvasive therapeutic modality for treating atherosclerotic arterial disease. High-intensity focused ultrasound (HIFU), a noninvasive and precise modality that generates high temperatures at specific target sites within tissues, has shown promising results in reducing plaque burden and improving vascular function. While low-intensity focused ultrasound (LIFU) operates at lower energy levels, promoting mild hyperthermia and stimulating tissue repair processes. This review article provides an overview of the current state of HIFU and LIFU in treating atherosclerosis. It focuses primarily on the therapeutic potential of HIFU due to its higher penetration and ability to achieve atheroma disruption. The review summarizes findings from animal models and human trials, covering the effects of FUS on arterial plaque and arterial wall thrombolysis in carotid, coronary and peripheral arteries. This review also highlights the potential benefits of focused ultrasound, including its noninvasiveness, precise targeting, and real-time monitoring capabilities, making it an attractive approach for the treatment of atherosclerosis and emphasizes the need for further investigations to optimize FUS parameters and advance its clinical application in managing atherosclerotic arterial disease.
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Affiliation(s)
- Cynthia Imtiaz
- Ocean and Biomedical Ultrasound Laboratory, Department of Ocean System Engineering, Jeju National University, Jeju-si 63243, Republic of Korea; (C.I.)
| | - Muhammad Awais Farooqi
- Department of Mechatronics Engineering, Jeju National University, Jeju-si 63243, Republic of Korea
| | - Theophilus Bhatti
- Interdisciplinary Department of Advanced Convergence Technology and Science, College of Pharmacy, Jeju National University, Jeju 63243, Republic of Korea
| | - Jooho Lee
- Ocean and Biomedical Ultrasound Laboratory, Department of Ocean System Engineering, Jeju National University, Jeju-si 63243, Republic of Korea; (C.I.)
| | - Ramsha Moin
- Department of Pediatrics, Elaj Hospital, Gujranwala 52250, Pakistan
| | - Chul Ung Kang
- Department of Mechatronics Engineering, Jeju National University, Jeju-si 63243, Republic of Korea
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Sidebottom DB, Huang C, Carradice D, Holt PJ, John-Pierre K, Roy IN. Antithrombotic drugs for cardiovascular risk reduction in patients with lower limb peripheral arterial disease: protocol for a systematic review and network meta-analysis of randomised controlled trials. BMJ Open 2023; 13:e072355. [PMID: 37562931 PMCID: PMC10423790 DOI: 10.1136/bmjopen-2023-072355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/23/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION The optimal antithrombotic regimen to reduce the risk of vascular events in patients with peripheral arterial disease (PAD) is contentious. This systematic review and network meta-analysis (NMA) aims to define the relative efficacy and risks of previously investigated antithrombotic medication regimens in preventing major cardiovascular events, vascular limb events and mortality in patients with PAD. METHODS AND ANALYSIS A peer-reviewed, systematic search will be executed in English on Medline, Embase, Cochrane (CENTRAL), Web of Science and Google Scholar databases in late 2022. The WHO International Clinical Trials Registry platform will also be searched for ongoing trials. Abstracts will be screened independently by two researchers for randomised controlled trials meeting the review criteria. All associated publications including the study protocol will be sought and evaluated together against prespecified inclusion/exclusion criteria. Two researchers will extract the data into a prepiloted extraction form. Risk-of-bias assessments will be performed using the Cochrane 'Risk-of-Bias V.2' criteria by individuals with domain expertise. All differences will be resolved by consensus or a third individual for ties.Included trials will be summarised. An NMA will be performed, subject to checks of assumptions. Both primary and secondary outcomes will be analysed on a whole network basis. Pairwise comparisons and league tables will be produced. Prespecified subgroup analyses will include sex, ethnicity, disease status, conservative versus interventional management and key comorbidities. The findings will be evaluated using the Grading of Recommendation Assessment, Development and Evaluation, informed by patient and public involvement work. ETHICS AND DISSEMINATION This is a systematic review of data in the public domain and does not require ethical approval. Dissemination will include presentations to key vascular and patient organisations, publication in a peer-reviewed journal and an open-access repository of the study data. PROSPERO REGISTRATION NUMBER CRD42023389262.
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Affiliation(s)
- David Brooke Sidebottom
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Daniel Carradice
- Hull York Medical School, Hull, UK
- Department of Vacular Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Peter J Holt
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Iain Nicholas Roy
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
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107
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Zou Y, Tong Q, Wang X, Jiang C, Qin Z, Zhao Y, Cheng J. Comparison of angiography and ultrasound for femoropopliteal angioplasty: decision-making and 12-month outcomes. INT ANGIOL 2023; 42:327-336. [PMID: 37347157 DOI: 10.23736/s0392-9590.23.05064-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND This study aimed to investigate whether intravascular ultrasound (IVUS) combined with angiography during percutaneous transluminal angioplasty impacts treatment strategies and the 12-month patency of the femoropopliteal artery, compared to angiography alone. METHODS This retrospective, single-center study enrolled 137 patients who underwent a femoropopliteal endovascular intervention between February 2020 and May 2021. Among these interventions, 43 were guided by IVUS combined with angiography and the remaining 94 were guided by angiography only. Treatment strategies and 12-month patency were analyzed in both groups. Multivariable analysis was performed to clarify the predictors of restenosis within 12 months. RESULTS Primary patency at 12 months was significantly higher in the IVUS group than in the angiography group (56.4% vs. 76.7%, P=0.047). The reference diameter on IVUS images was greater than that on angiography images. Therefore, the IVUS group presented a higher balloon-to-vessel ratio [1.0 (0.97, 1.01) vs. 1.06 (1.0.1.25)]. More adjunctive stents were required in the angiography group. However, more dissections were performed in the IVUS group, with no difference in flow-limiting dissections between groups. Target disease length (odds ratio 1.02, P=0.021) and balloon-to-vessel ratio (odds ratio 0.01, P=0.021) were independent predictors of restenosis. CONCLUSIONS Compared with angiography guidance alone, IVUS guidance for femoropopliteal artery-related treatment can significantly increase primary patency. This finding may be explained by the selection of larger balloons in IVUS and the resulting sufficient plaque compression and elastic membrane stretch. Moreover, IVUS was shown to detect more non-flow-limiting dissections than angiography.
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Affiliation(s)
- Yuchi Zou
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang Tong
- Department of Endocrinology, the Second Affiliated Hospital of Army Medical University, Choingqing, China
| | - Xuehu Wang
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chuli Jiang
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Qin
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Cheng
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China -
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Bose S, Hicks CW. Reply. J Vasc Surg 2023; 78:560-561. [PMID: 37481282 DOI: 10.1016/j.jvs.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Prouse G, Robaldo A, van den Berg JC, Ettorre L, Mongelli F, Giovannacci L. Impact of Multidisciplinary Team Meetings on Decision Making in Vascular Surgery: A Prospective Observational Study. Eur J Vasc Endovasc Surg 2023; 66:130-135. [PMID: 36972815 DOI: 10.1016/j.ejvs.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/20/2023] [Accepted: 03/21/2023] [Indexed: 03/28/2023]
Abstract
OBJECTIVE This cohort study aimed to prospectively determine the impact of multidisciplinary team meetings (MDTs) on treatment plans in vascular patients. METHODS The weekly MDT at the institution consisted of a structured discussion of vascular cases in the presence of at least one representative of each specialty from vascular surgery, angiology, and interventional radiology. Participants were asked to examine the cases entered on the digital MDT platform and to fill in forms with a detailed open text treatment recommendation for each patient. Individual recommendations were compared with the final MDT decision, which was based on a shared decision after discussion of clinical and radiological data. The primary endpoint was the agreement rate. The rate of decision implementation was determined to verify the adherence to MDT recommendations. RESULTS Four hundred consecutive case discussions in 367 patients between November 2019 and March 2021 were included, excluding patients needing urgent treatment, yielding MDT discussion in 88.5% of carotid artery cases, 83% of aorto-iliac cases, and 51.7% of peripheral arterial cases, which included 56.9% of the chronic limb threatening ischaemia cases. The overall average agreement rate was 71% ± 41%. Analysis according to the specialty of the attending physician showed agreement rates of 82% ± 30% for senior vascular surgeons, 62% ± 44% for junior vascular surgeons, 71% ± 43% for interventional radiologists, 58% ± 50% for angiologists (p < .001), and 75% ± 38% considering only senior practitioners. The inter-rater agreement, resulted in kappa coefficients of 0.60 - 0.68 for senior vascular surgeons, 0.29 - 0.31 for junior vascular surgeons, 0.39 - 0.52 for interventional radiologists, and 0.25 for angiologists. The MDT treatment decision was implemented in 353 (96.2%) cases. CONCLUSION The impact of MDT discussion on treatment recommendations and the adherence to MDT recommendations were significant and in line with results reported from other specialties.
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Affiliation(s)
- Giorgio Prouse
- Service of Vascular Surgery, Ospedale Regionale di Lugano, Centro Vascolare Ticino, EOC, Lugano, Switzerland.
| | - Alessandro Robaldo
- Service of Vascular Surgery, Ospedale Regionale di Lugano, Centro Vascolare Ticino, EOC, Lugano, Switzerland
| | - Jos C van den Berg
- Service of Interventional Radiology, Ospedale Regionale di Lugano, Centro Vascolare Ticino, EOC, Lugano, Switzerland; Inselspital Bern, Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Bern, Switzerland
| | - Ludovica Ettorre
- Service of Vascular Surgery, Ospedale Regionale di Lugano, Centro Vascolare Ticino, EOC, Lugano, Switzerland
| | - Francesco Mongelli
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Luca Giovannacci
- Service of Vascular Surgery, Ospedale Regionale di Lugano, Centro Vascolare Ticino, EOC, Lugano, Switzerland
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Yeh CB, Yeh LT, Yang SF, Wang BY, Wang YH, Chan CH. Association between psoriasis and peripheral artery occlusive disease: a population-based retrospective cohort study. Front Cardiovasc Med 2023; 10:1136540. [PMID: 37378400 PMCID: PMC10291070 DOI: 10.3389/fcvm.2023.1136540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Psoriasis (PSO) is a chronic skin condition that affects a variety of disorders, especially the cardiovascular system. This study investigated the association between PSO and peripheral arterial disease (PAOD). Methods A retrospective cohort study design was carried out between 2000 and 2018. The exposure subject was a newly diagnosed PSO. The diagnosis of PSO was never elaborated as a comparison subject. Balanced heterogeneity of the two groups was used by propensity score matching. The cumulative incidence of PAOD between the two groups was performed using Kaplan-Meier analysis. The Cox proportional hazard model was used to measure the risk of PAOD risk hazard ratio. Results After matching the 1: 1 propensity score, 15,696 subjects with PSO and the same number of subjects without the diagnosis of PSO were recruited. The PSO subject had a higher risk of PAOD than the non-PSO subject (adjusted HR = 1.25; 95% CI = 1.03-1.50). In the 40-64-year-old subgroup, the subject of PSO exhibited an increased risk of PAOD than the subject without PSO. Conclusion Psoriasis is associated with an increased risk of peripheral arterial disease and curative care is necessary to reduce the risk of PAOD..
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Affiliation(s)
- Chao-Bin Yeh
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Liang-Tsai Yeh
- Department of Anesthesiology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Bo-Yuan Wang
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Ho Chan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
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Parwani D, Ahmed MA, Mahawar A, Gorantla VR. Peripheral Arterial Disease: A Narrative Review. Cureus 2023; 15:e40267. [PMID: 37448414 PMCID: PMC10336185 DOI: 10.7759/cureus.40267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Peripheral arterial disease (PAD) describes the partial or complete occlusion of blood flow in the distal arteries of the body. A decreased arterial patency may occur due to a reduction in the elasticity or diameter of the vessel. The goal of interventions is to decrease incidence and reduce complications by identifying and minimizing the primary causes. This paper discusses PAD affecting the aortoiliac, common femoral, and femoropopliteal arteries. In a significant portion of the population, PAD may lack usual symptoms such as limb pain, claudication, and diminished pulses. Imaging techniques become crucial to ensuring timely diagnosis, monitoring treatment effectiveness, and preventing recurrence. Duplex ultrasound (DUS) is a cheap and non-invasive preliminary technique to detect atherosclerotic plaques and grade arterial stenosis. Magnetic resonance angiography (MRA) provides the added advantage of minimizing artifacts. Digital subtraction angiography (DSA) remains the gold standard for grading the degree of stenosis but is only employed second-line to DUS or MRA due to the high dose of nephrotoxic contrast. Computed tomography angiography (CTA) is able to overcome the anatomical limitations of DUS and MRA and proves to be a suitable alternative to DSA in patients with renal disease. Preventative measures involve monitoring blood pressure, cholesterol levels, and tobacco usage. First-line treatment options include endovascular procedures as well as surgical interventions in cases of significant arterial involvement. Endovascular treatments involve the use of balloon angioplasty, drug-coated balloons, and drug-coated stents, to name a few, that serve as minimally invasive techniques to manage PAD. Surgical procedures, although more complex, are considered gold-standard treatment options for long and intricate lesions. Endovascular methods are generally preferred over surgical options as the complication risk is severely reduced and the rates of reintervention are comparable to surgical options.
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Affiliation(s)
- Divya Parwani
- Anatomical Sciences, St. George's University School of Medicine, St.George's, GRD
| | - Mohamed A Ahmed
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Anmol Mahawar
- Anatomical Sciences, St. George's University School of Medicine, St.George's, GRD
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Sorber R, Dun C, Kawaji Q, Abularrage CJ, Black JH, Makary MA, Hicks CW. Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023; 77:1720-1731.e3. [PMID: 37225352 PMCID: PMC10756146 DOI: 10.1016/j.jvs.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. METHODS We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. RESULTS A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). CONCLUSIONS Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Chen Dun
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qingwen Kawaji
- Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
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Ye J, Li Y, Lu Y, Wang Y, Liu B, Chang H. Homemade fenestration and chimney techniques for the left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair. Front Cardiovasc Med 2023; 10:1144751. [PMID: 37324627 PMCID: PMC10264814 DOI: 10.3389/fcvm.2023.1144751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/21/2023] [Indexed: 06/17/2023] Open
Abstract
Background To investigate the safety and efficacy of homemade fenestration and chimney techniques for the left subclavian artery (LSA) revascularization during zone 2 thoracic endovascular aortic repair (TEVAR). Methods From February 2017 to February 2021, 41 patients undergoing fenestration technique (group A) and 42 patients undergoing chimney technique (group B) to preserve the LSA during zone 2 TEVAR were enrolled in the present study. The procedure was indicated for dissections with unsuitable proximal landing zone with refractory pain and hypertension, rupture and malperfusion, and high-risk radiographic features. The baseline characteristics, peri-procedure, and follow-up clinical and radiographic data were recorded and analyzed. The primary endpoint was clinical success, and the secondary endpoints were rupture-free survival, LSA patency, and complications. Aortic remodeling, defined as patency, partial and complete thrombosis of the false lumen, was also analyzed. Results Technical success was achieved in 38 and 41 patients in groups A and B, respectively. Four intervention-related deaths were confirmed, two in each group. Immediate post-procedural endoleaks were detected in two and three patients in group A and B, respectively. No other major complications were found in either group, except for one retrograde type A dissection in group A. During follow-up, the initial clinical success rates were 90.24% and 92.86% in groups A and B, respectively. The primary and secondary mid-term clinical success rates were 87.5% and 90% in group A, and both of them were 92.68% in group B. Rupture-free survival and LSA patency were not significantly different between the two groups. The incidence of complete thrombosis in the aorta distal to the stent graft was 67.65% and 61.11% in groups A and B, respectively. Conclusions Apart from the lower clinical success rate of fenestration technique, both physician-modified techniques are available for LSA revascularization during zone 2 TEVAR and significantly promote favorable aortic remodeling.
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Affiliation(s)
- Jiacheng Ye
- Department of Intervention Medicine, The First Hospital of Nanping Affiliated to Fujian Medical University, Nanping, China
| | - Yuliang Li
- Department of Intervention Medicine, The Second Hospital of Shandong University, Jinan, China
- Interventional Oncology Institute of Shandong University, Jinan, China
| | - Yue Lu
- Department of Intervention Medicine, The Second Hospital of Shandong University, Jinan, China
- Interventional Oncology Institute of Shandong University, Jinan, China
| | - Yongzheng Wang
- Department of Intervention Medicine, The Second Hospital of Shandong University, Jinan, China
- Interventional Oncology Institute of Shandong University, Jinan, China
| | - Bin Liu
- Department of Intervention Medicine, The Second Hospital of Shandong University, Jinan, China
- Interventional Oncology Institute of Shandong University, Jinan, China
| | - Haiyang Chang
- Department of Intervention Medicine, The Second Hospital of Shandong University, Jinan, China
- Interventional Oncology Institute of Shandong University, Jinan, China
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Giagtzidis I, Karkos C, Kadoglou FNPE, Spathis A, Papazoglou K. Serum levels of Matrix Metalloproteinases (MMPs) in patients undergoing endovascular intervention for peripheral arterial disease. Ann Vasc Surg 2023:S0890-5096(23)00250-9. [PMID: 37169253 DOI: 10.1016/j.avsg.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Matrix metalloproteinases (MMPs) play a significant role in the development and progression of atherosclerotic vascular disease. The purpose of this study was to measure and document the profile of plasma circulating MMPs in patients with peripheral arterial disease (PAD) undergoing endovascular revascularization. METHODS This was a single centre prospective observational study with 80 patients with PAD enrolled. They underwent percutaneous balloon angioplasty and/or angioplasty with stent. Exclusion criteria were acute limb ischemia, active inflammation, wet gangrene, liver disease, end stage renal failure and cancer. Patients that underwent open or hybrid (open and endovascular) approach, were also excluded from the study. Venous blood samples were taken preoperatively, 24 hours and 6 months postoperatively. The values of MMP-2, MMP-3, MMP-7, MMP-9 and their inhibitors (Tissue Inhibitor of metalloproteinases, TIMP), TIMP-1 and TIMP-2 were measured. RESULTS The mean age was 67.1 years and 66 of them (82.5%) were male. During the clinical follow up (mean 35.8% months), 12 patients died (16.4%), 15 (20.5%) of them had a major adverse limb event (MALE) and 14 (19.2%) of them had a major adverse cardiovascular event (MACE). There was a statistically significant raise in the values of MMP-2. MMP-3 and MMP-7 at 6 months postoperatively, when compared to the preoperative and 24 hours postoperative values. There was no correlation of MMP and TIMP values with mortality, MALE and MACE events. CONCLUSIONS The present single-centre prospective study documented increased circulating levels of MMPs post-operatively in PAD patients undergoing endovascular treatment. Vascular trauma caused by angioplasty, could trigger expression of MMPs and TIMPs, but the absence of any association with clinical complications requires further investigation.
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Affiliation(s)
- Ioakeim Giagtzidis
- Aristotle University of Thessaloniki, Ippokratio General Hospital, 5(th) Surgical Department, Thessaloniki, Greece.
| | - Christos Karkos
- Aristotle University of Thessaloniki, Ippokratio General Hospital, 5(th) Surgical Department, Thessaloniki, Greece
| | | | - Aris Spathis
- Department of Cytopathology, "Attikon" University Hospital, Athens, Greece
| | - Konstantinos Papazoglou
- Aristotle University of Thessaloniki, Ippokratio General Hospital, 5(th) Surgical Department, Thessaloniki, Greece
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Abstract
Peripheral artery disease (PAD) is a common type of atherosclerotic disease of the lower extremities associated with reduced quality of life and ambulatory capacity. Major adverse cardiovascular events and limb amputations are the leading cause of morbidity and mortality in this population. Optimal medical therapy is therefore critical in these patients to prevent adverse events. Risk factor modifications, including blood pressure control and smoking cessation, in addition to antithrombotic agents, peripheral vasodilators, and supervised exercise therapy are key pillars of medical therapy. Revascularization procedures represent key touch points between patients and health care providers and serve as opportunities to optimize medical therapy and improve long-term patency rates and outcomes. This review summarizes the aspects of medical therapy that all providers should be familiar with when caring for patients with PAD in the peri-revascularization period.
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Affiliation(s)
| | - Joshua A. Beckman
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Hope Weissler E, Stebbins A, Wruck L, Muñoz D, Gupta K, Girotra S, Whittle J, Benziger CP, Polonsky TS, Bradley SM, Hammill BG, Merritt JG, Zemon DN, Hernandez AF, Schuyler Jones W. Outcomes among patients with peripheral artery disease in the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study. Vasc Med 2023; 28:122-130. [PMID: 37025023 PMCID: PMC10795754 DOI: 10.1177/1358863x231154951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND We aimed to understand the effects of aspirin dose on outcomes in patients with peripheral artery disease (PAD) as well as their participation in a pragmatic randomized controlled trial. METHODS In a subanalysis of the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study, we compared aspirin doses (81 vs 325 mg) among participants with PAD and study participation metrics in patients with and without PAD. The primary outcome composite was all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. RESULTS Among 14,662 participants enrolled in ADAPTABLE with PAD status available, 3493 (23.8%) had PAD. Participants with PAD were more likely to experience the primary composite (13.76% vs 5.31%, p < 0.001), all-cause mortality (7.55% vs 3.01%, p < 0.001), myocardial infarction (5.71% vs 2.09%, p < 0.001), stroke (2.45% vs 0.86%, p < 0.001), and major bleeding (1.19% vs 0.44%, p < 0.001). A higher aspirin dose did not reduce the primary outcome in patients with PAD (13.68% vs 13.84% in 81 mg and 325 mg groups; OR 1.05, 95% CI 0.88-1.25). Participants with PAD were less likely to enroll via email (33.0% vs 41.9%, p < 0.0001), less likely to choose internet follow-up (79.2% vs 89.5%, p < 0.0001), and were more likely to change their aspirin doses (39.7% vs 30.7%, p < 0.0001). CONCLUSIONS ADAPTABLE participants with PAD did not benefit from a higher dose of aspirin and participated in the study differently from those without PAD. These results reinforce the need for additional PAD-specific research and suggest that different trial strategies may be needed for optimal engagement of patients with PAD. (ClinicalTrials.gov Identifier: NCT02697916).
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Affiliation(s)
| | | | - Lisa Wruck
- Duke Clinical Research Institute, Durham, NC
| | - Daniel Muñoz
- Vanderbilt University Medical Center, Nashville, TN
| | - Kamal Gupta
- University of Kansas Medical Center, Kansas City, KS
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Govsyeyev N, Nehler M, Conte MS, Debus S, Chung J, Dorigo W, Gudz I, Krievins D, Mills J, Moll F, Norgren L, Piffaretti G, Powell R, Szalay D, Sillesen H, Wohlauer M, Szarek M, Bauersachs RM, Anand SS, Patel MR, Capell WH, Jaeger N, Hess CN, Muehlhofer E, Haskell LP, Berkowitz SD, Bonaca MP. Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits. J Vasc Surg 2023; 77:1107-1118.e2. [PMID: 36470531 DOI: 10.1016/j.jvs.2022.11.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) have a high risk of adverse limb and cardiovascular events. The results from the VOYAGER PAD (efficacy and safety of rivaroxaban in reducing the risk of major thrombotic vascular events in subjects with symptomatic peripheral artery disease undergoing peripheral revascularization procedures of the lower extremities) trial have demonstrated that rivaroxaban significantly reduced this risk with an overall favorable net benefit for patients undergoing surgical revascularization. However, the efficacy and safety for those treated by surgical bypass, including stratification by bypass conduit (venous or prosthetic), has not yet been described. METHODS In the VOYAGER PAD trial, patients who had undergone surgical and endovascular infrainguinal LER to treat PAD were randomized to rivaroxaban 2.5 mg twice daily or placebo on top of background antiplatelet therapy (aspirin 100 mg to be used in all and clopidogrel in some at the treating physician's discretion) and followed up for a median of 28 months. The primary end point was a composite of acute limb ischemia, major amputation of vascular etiology, myocardial infarction, ischemic stroke, and cardiovascular death. The principal safety outcome was major bleeding using the TIMI (thrombolysis in myocardial infarction) scale. The index procedure details, including conduit type (venous vs prosthetic), were collected at baseline. RESULTS Among 6564 randomized patients, 2185 (33%) had undergone surgical LER. Of these 2185 patients, surgical bypass had been performed for 1448 (66%), using a prosthetic conduit for 773 patients (53%) and venous conduit for 646 patients (45%). Adjusting for the baseline differences and anatomic factors, the risk of unplanned limb revascularization in the placebo arm was 2.5-fold higher for those receiving a prosthetic conduit vs a venous conduit (adjusted hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.65-3.90; P < .001), and the risk of acute limb ischemia was three times greater (adjusted HR, 3.07; 95% CI, 1.84-5.11; P < .001). The use of rivaroxaban reduced the primary outcome for the patients treated with bypass surgery (HR, 0.78; 95% CI, 0.62-0.98), with consistent benefits for those receiving venous (HR, 0.66; 95% CI, 0.49-0.96) and prosthetic (HR, 0.87; 95% CI, 0.66-1.15) conduits (Pinteraction = .254). In the overall trial, major bleeding using the TIMI scale was increased with rivaroxaban. However, the numbers for those treated with bypass surgery were low (five with rivaroxaban vs nine with placebo; HR, 0.55; 95% CI, 0.18-1.65) and not powered to show statistical significance. CONCLUSIONS Surgical bypass with a prosthetic conduit was associated with significantly higher rates of major adverse limb events relative to venous conduits even after adjustment for patient and anatomic characteristics. Adding rivaroxaban 2.5 mg twice daily to aspirin or dual antiplatelet therapy significantly reduced this risk, with an increase in the bleeding risk, but had a favorable benefit risk for patients treated with bypass surgery, regardless of conduit type. Rivaroxaban should be considered after lower extremity bypass for symptomatic PAD to reduce ischemic complications of the heart, limb, and brain.
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Affiliation(s)
- Nicholas Govsyeyev
- CPC Clinical Research & Community Health, Aurora, CO; Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Mark Nehler
- CPC Clinical Research & Community Health, Aurora, CO; Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO.
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | - Walter Dorigo
- Department of Vascular Surgery, Careggi Polyclinic Hospital, University of Florence, Florence, Italy
| | - Ivan Gudz
- Department of Surgery, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
| | - Dainis Krievins
- Pauls Stradinš University Hospital, University of Latvia, Riga, Latvia
| | - Joseph Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | - Frans Moll
- Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Rick Powell
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David Szalay
- Division of Vascular Surgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Henrik Sillesen
- Division of Cardiology, Department of Vascular Surgery, Rigshospitalet, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Max Wohlauer
- Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael Szarek
- CPC Clinical Research & Community Health, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; State University of New York, Downstate Health Sciences University, Brooklyn, NY
| | - Rupert M Bauersachs
- Cardioangiologic Center, Agaplesion Bethanien Hospital, Frankfurt am Main, Germany; Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC
| | - Warren H Capell
- CPC Clinical Research & Community Health, Aurora, CO; Division of Endocrinology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Nicole Jaeger
- CPC Clinical Research & Community Health, Aurora, CO
| | - Connie N Hess
- CPC Clinical Research & Community Health, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | | | - Scott D Berkowitz
- CPC Clinical Research & Community Health, Aurora, CO; Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Marc P Bonaca
- CPC Clinical Research & Community Health, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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Behrendt CA, Larena-Avellaneda A, Gombert A, Rother U. Evidenzbasierte antithrombotische Therapie der peripheren arteriellen Verschlusskrankheit (PAVK). GEFÄSSCHIRURGIE 2023. [DOI: 10.1007/s00772-023-00992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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119
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Koeckerling D, Raguindin PF, Kastrati L, Bernhard S, Barker J, Quiroga Centeno AC, Raeisi-Dehkordi H, Khatami F, Niehot C, Lejay A, Szeberin Z, Behrendt CA, Nordanstig J, Muka T, Baumgartner I. Endovascular revascularization strategies for aortoiliac and femoropopliteal artery disease: a meta-analysis. Eur Heart J 2023; 44:935-950. [PMID: 36721954 PMCID: PMC10011342 DOI: 10.1093/eurheartj/ehac722] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 10/24/2022] [Accepted: 11/22/2022] [Indexed: 02/02/2023] Open
Abstract
AIMS Optimal endovascular management of intermittent claudication (IC) remains disputed. This systematic review and meta-analysis compares efficacy and safety outcomes for balloon angioplasty (BA), bare-metal stents (BMS), drug-coated balloons (DCB), drug-eluting stents (DES), covered stents, and atherectomy. METHODS AND RESULTS Electronic databases were searched for randomized, controlled trials (RCT) from inception through November 2021. Efficacy outcomes were primary patency, target-lesion revascularization (TLR), and quality-of-life (QoL). Safety endpoints were all-cause mortality and major amputation. Outcomes were evaluated at short-term (<1 year), mid-term (1-2 years), and long-term (≥2 years) follow-up. The study was registered on PROSPERO (CRD42021292639). Fifty-one RCTs enrolling 8430 patients/lesions were included. In femoropopliteal disease of low-to-intermediate complexity, DCBs were associated with higher likelihood of primary patency [short-term: odds ratio (OR) 3.21, 95% confidence interval (CI) 2.44-4.24; long-term: OR 2.47, 95% CI 1.93-3.16], lower TLR (short-term: OR 0.33, 95% CI 0.22-0.49; long-term: OR 0.42, 95% CI 0.29-0.60) and similar all-cause mortality risk, compared with BA. Primary stenting using BMS was associated with improved short-to-mid-term patency and TLR, but similar long-term efficacy compared with provisional stenting. Mid-term patency (OR 1.64, 95% CI 0.89-3.03) and TLR (OR 0.50, 95% CI 0.22-1.11) estimates were comparable for DES vs. BMS. Atherectomy, used independently or adjunctively, was not associated with efficacy benefits compared with drug-coated and uncoated angioplasty, or stenting approaches. Paucity and heterogeneity of data precluded pooled analysis for aortoiliac disease and QoL endpoints. CONCLUSION Certain devices may provide benefits in femoropopliteal disease, but comparative data in aortoiliac arteries is lacking. Gaps in evidence quantity and quality impede identification of the optimal endovascular approach to IC.
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Affiliation(s)
- David Koeckerling
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Peter Francis Raguindin
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.,Swiss Paraplegic Research, Guido A. Zäch Str. 1, 6207 Nottwil, Switzerland.,Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse, 36002 Lucerne, Switzerland
| | - Lum Kastrati
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.,Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Sarah Bernhard
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Joseph Barker
- Department of Cardiovascular Sciences, University of Leicester, University Rd, Leicestershire LE1 7RH, UK
| | | | - Hamidreza Raeisi-Dehkordi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.,Community Medicine Department, Tehran University of Medical Sciences, PourSina St., Tehran 1417613151, Iran
| | - Christa Niehot
- Literature Searches Support, 3314SC Dordrecht, the Netherlands
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University of Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, XII. Városmajor u. 68., 1122 Budapest, Hungary
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Alphonsstraße 14, 22043 Hamburg, Germany
| | - Joakim Nordanstig
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - Taulant Muka
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.,Epistudia, 3011 Bern, Switzerland
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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Sorber R, Dun C, Kawaji Q, Abularrage CJ, Black JH, Makary MA, Hicks CW. Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023; 77:836-847.e3. [PMID: 37276171 PMCID: PMC10242207 DOI: 10.1016/j.jvs.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. METHODS We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. RESULTS A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). CONCLUSIONS Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Chen Dun
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qingwen Kawaji
- Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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Tsujimura T, Iida O, Ishihara T, Asai M, Masuda M, Okamoto S, Nanto K, Matsuda Y, Hata Y, Uematsu H, Toyoshima T, Higashino N, Nakao S, Mano T. Angioscopic Evaluation of Vascular Response After Fluoropolymer-Based Drug-Eluting Stent Implantation for Femoropopliteal Artery Lesions. Circ J 2023; 87:432-429. [PMID: 36624062 DOI: 10.1253/circj.cj-22-0635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although favorable clinical outcomes have been demonstrated for fluoropolymer-based paclitaxel-eluting stents (FP-DES) in the treatment of femoropopliteal lesions, the vascular response after implantation has not been systematically studied through intravascular imaging. METHODS AND RESULTS We angioscopically compared FP-DES: 24 in the early phase (mean [±SD] 3±1 months), 26 in the middle phase (12±3 months), and 20 in the late phase (≥18 months) after implantation. The dominant neointimal coverage grade, heterogeneity of neointimal coverage grade, and thrombus adhesion in the stent segment were evaluated. Neointimal coverage was graded as follows: Grade 0, stent struts exposed; Grade 1, struts bulging into the lumen, although covered; Grade 2, struts embedded in the neointima, but visible; Grade 3, struts fully embedded and invisible. Dominant neointimal coverage and heterogeneity grades were significantly higher in the middle and late phases than in the early phase (all P<0.05), but did not differ significantly between the middle and late phases. The incidence of thrombus adhesion was recorded for all stents in each of the 3 different phases. CONCLUSIONS The middle and late phases after FP-DES implantation were associated with significantly higher dominant neointimal coverage and heterogeneity grades than the early phase. However, thrombus adhesion was observed in all phases after FP-DES implantation. Arterial healing may not be completed even in the late phase after FP-DES implantation.
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Affiliation(s)
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center
| | | | | | | | | | | | | | | | | | | | | | - Sho Nakao
- Kansai Rosai Hospital Cardiovascular Center
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Zil-E-Ali A, Aziz F, Goldfarb M, Radtka JF. The Implications of Surgeon Case Volume and Hospital Volume on Outcomes of Aortobifemoral Bypasses in Obese Patients. J Vasc Surg 2023; 77:1776-1787.e2. [PMID: 36796594 DOI: 10.1016/j.jvs.2023.01.208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Aortobifemoral (ABF) bypass is the gold standard for treating symptomatic aortoiliac occlusive disease. In the era of heightened interest in the length of stay (LOS) for surgical patients, this study aims to investigate the association of obesity with postoperative outcomes at the patient, hospital, and at surgeon levels. METHODS This study utilized the Society of Vascular Surgery (SVS) Vascular Quality Initiative (VQI) suprainguinal bypass database from 2003-2021. The selected study cohort was divided into obese patients (BMI ≥30) (Group I) and non-obese patients (BMI <30) (Group II). Primary outcomes of the study included mortality, operative time, and postoperative LOS. Univariate and multivariate logistic regression analyses were performed to study the outcomes of ABF bypass in Group I. Operative time, and postoperative LOS were transformed into binary values by median split for regression analysis. A p-value of ≤ 0.05 was deemed statistically significant in all the analyses of this study. RESULTS The study cohort consisted of 5,392 patients. In this population, 1,093 were obese (Group I), and 4,299 were non-obese (Group II). Group I was found to have more females with higher rates of comorbid conditions, including hypertension, diabetes mellitus, and congestive heart failure. Patients in Group I had increased odds of prolonged operative time (≥ 250 mins) and an increased LOS (≥6 days). Patients in this Group also had a higher chance of intraoperative blood loss, prolonged intubation, and required vasopressors postoperatively. There was also an increased odds of postoperative decline in renal function in the obese population. Patients with prior history of CAD, hypertension, diabetes mellitus, and urgent or emergent procedures were found to be risk factors for LOS>6 days in obese patients. An increase in the surgeons' case volume was associated with lesser odds of operative time ≥ 250 mins; however, no significant impact was found on postoperative LOS. Hospitals where ≥ 25% ABF bypasses were performed on obese patients were also more likely to have LOS <6 days after ABF operations, compared to hospitals where <25% of ABF bypasses were performed on obese patients. Patients undergoing ABF for CLTI or acute limb ischemia had longer LOS and increased operative time. CONCLUSION ABF bypass in obese patients is associated with prolonged operative times and longer LOS than in non-obese patients. Obese patients operated by surgeons with more cases of ABF bypasses have shorter operative times. An increasing hospital's obese patient proportion was related to decreased LOS. These findings support the known volume-outcome relationship that with a higher surgeon case volume and increased proportion of obese patients in a hospital, there is an improvement in outcomes of obese patients undergoing ABF bypass.
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Affiliation(s)
- Ahsan Zil-E-Ali
- Division of Vascular Surgery, Heart & Vascular Institute, The Pennsylvania State University, Hershey, PA 17033
| | - Faisal Aziz
- Division of Vascular Surgery, Heart & Vascular Institute, The Pennsylvania State University, Hershey, PA 17033.
| | - Matthew Goldfarb
- Department of General Surgery, Sinai Hospital of Baltimore, Baltimore, MD 21215
| | - John F Radtka
- Division of Vascular Surgery, Heart & Vascular Institute, The Pennsylvania State University, Hershey, PA 17033
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Tsujimura T, Iida O, Takahara M, Tomoi Y, Okazaki J, Yamaoka T, Ichihashi S, Hirose T, Kitano I, Suzuki K, Fujimura N, Mano T. Assessment of 3-Year Patency after Endoluminal versus Surgical Bypass Therapy for Complex Femoropopliteal Artery Disease. J Vasc Interv Radiol 2023; 34:1045-1053.e3. [PMID: 36775016 DOI: 10.1016/j.jvir.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 01/16/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
PURPOSE To compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass for complex femoropopliteal (FP) arterial lesions. MATERIALS AND METHODS In this retrospective multicenter study, 530 patients with symptomatic peripheral artery disease (Rutherford classification 1-3, 66.0%; 4-6, 34.0%) who underwent either endoluminal bypass with Viabahn stent grafts (n = 276) or surgical bypass (n = 254) (with saphenous vein grafts, 74.4%; prosthetic grafts, 25.6%) for FP arterial lesions between 2010 and 2018 were analyzed. The propensity score-matched analysis was performed to compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass. The primary end point was primary patency (freedom from restenosis). The secondary end points were secondary patency, freedom from target lesion revascularization (TLR), limb salvage, and overall survival. The interaction effect of baseline characteristics on the association of the revascularization strategy with the risk of restenosis was analyzed using the Poisson mixed-effect model. RESULTS The propensity score-matched analysis extracted 107 pairs. After propensity score matching, the primary patency rate at 1, 2, and 3 years was 84.5%, 75.1%, and 70.9%, respectively, for the endoluminal bypass group versus 78.6%, 73.3%, and 72.0%, respectively, for the surgical bypass group (P = .65). There was no significant difference in secondary patency, freedom from TLR, limb salvage, and overall survival (all P > .05). The subsequent interaction analysis revealed that the involvement of popliteal lesions, small distal reference vessel diameters, and long lesions favored surgical bypass over endoluminal bypass because of improved primary patency (all P for interaction < .05). CONCLUSIONS The 3-year clinical outcomes after endoluminal bypass or surgical bypass for FP arterial lesions were similar.
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Affiliation(s)
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Suita, Japan; Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Tomoi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Jin Okazaki
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shigeo Ichihashi
- Department of Radiology, Nara Medical University, Kashihara, Japan
| | - Tomoaki Hirose
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ikuro Kitano
- Department of Vascular Surgery, Shinsuma General Hospital, Kobe, Japan
| | - Kenji Suzuki
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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Cetlin MD, Polonsky T, Ho K, Zhang D, Tian L, Zhao L, Greenland P, Treat-Jacobson D, Kibbe MR, Criqui MH, Guralnik JM, McDermott MM. Barriers to participation in supervised exercise therapy reported by people with peripheral artery disease. J Vasc Surg 2023; 77:506-514. [PMID: 36150636 DOI: 10.1016/j.jvs.2022.09.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE This study identified barriers to participation in supervised exercise therapy covered by the Centers for Medicare and Medicaid Services (CMS), reported by people with lower extremity peripheral artery disease (PAD). METHODS People with PAD participating in research studies of walking impairment due to PAD in the Chicagoland area were asked to complete a questionnaire between March 15, 2019, and July 12, 2022, assessing their experience and attitudes about supervised exercise therapy. Participants were identified using mailed postcards to people aged 50 and older in Chicagoland, from medical centers in Chicago, and using bus and train advertisements. The questionnaire was developed based on focus group feedback from people with PAD. RESULTS Of 516 participants with PAD approached, 489 (94.8%) completed the questionnaire (mean age: 71.0 years [standard deviation: 8.7], mean ankle-brachial index: 0.71 [standard deviation: 0.25]; 204 [41.7%] women and 261 [53.4%] Black). Of the 489 participants, 416 (85.1%) reported that their physician had never prescribed or recommended supervised exercise therapy. Overall, 357 (73.2%) reported willingness to travel three times weekly to the medical center for supervised exercise participation. However, of these, 214 (59.9%) reported that they were unwilling or unable to pay the $11 per exercise session copay required for supervised exercise covered by CMS. Of 51 people with PAD who reported prior participation in supervised exercise, only 5 (9.8%) completed the 12 weeks of supervised exercise therapy covered by CMS and 29 (56.9%) completed 6 or fewer weeks. Of 131 (26.8%) unwilling to travel three times weekly to a center for supervised exercise, the most common reasons for unwillingness to participate were "too time-consuming" (55.0%), "too inconvenient" (45.8%), and "lack of interest in treadmill exercise" (28.2%). CONCLUSIONS Approximately 2 to 4 years after CMS began covering supervised exercise for PAD, most people with PAD in this study from a large urban area had not participated in supervised exercise therapy. Of those who participated, most completed fewer than half of the sessions covered by CMS. The required CMS copayment was a common barrier to supervised exercise participation by people with PAD.
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Affiliation(s)
| | - Tamar Polonsky
- Department of Medicine, University of Chicago Medical School, Chicago, IL
| | - Karen Ho
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Dongxue Zhang
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lu Tian
- Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Lihui Zhao
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Philip Greenland
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Melina R Kibbe
- University of Virginia School of Medicine, Charlottesville, VA
| | - Michael H Criqui
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
| | - Jack M Guralnik
- Department of Epidemiology, University of Maryland, College Park, MD
| | - Mary M McDermott
- Northwestern University Feinberg School of Medicine, Chicago, IL.
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Bose S, Dun C, Sorber R, Stonko DP, Solomon AJ, Black JH, Lum YW, Conte MS, Makary MA, Hicks CW. Practice patterns surrounding the use of tibial interventions for claudication in the Medicare population. J Vasc Surg 2023; 77:454-462.e1. [PMID: 36058433 PMCID: PMC9868091 DOI: 10.1016/j.jvs.2022.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE At present, no data are available to support the use of tibial interventions in the treatment of claudication. We characterized the practice patterns surrounding tibial peripheral vascular interventions (PVIs) for patients with claudication in the United States. METHODS Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients who underwent an index PVI for claudication. Patients with any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during an index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and multivariable hierarchical logistic regression were used to assess the patient and physician characteristics associated with the use of tibial PVI for claudication. RESULTS Of 59,930 Medicare patients who underwent an index PVI for claudication between 2017 and 2019, 16,594 (27.7%) underwent a tibial PVI (isolated tibial PVI, 38.5%; tibial PVI with concomitant femoropopliteal PVI, 61.5%). Of the 1542 physicians included in our analysis, the median physician-level tibial PVI rate was 20.0% (interquartile range, 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR], 1.23), increasing age (aOR, 1.30-1.96), Black race (aOR, 1.47), Hispanic ethnicity (aOR, 1.86), diabetes (aOR, 1.36), no history of hypertension (aOR, 1.12), and never-smoking status (aOR, 1.64; P < .05 for all). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR, 2.97), practice location in the West (aOR, 1.75), high-volume PVI practice (aOR, 1.87), majority of practice in an ambulatory surgery center or office-based laboratory setting (aOR, 2.37), and physician specialty. The odds of vascular surgeons performing tibial PVI were significantly lower compared with radiologists (aOR, 2.98) and cardiologists (aOR, 1.67; P < .05 for all). The average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs quartile 1-3, $12,023.96 vs $692.31 per patient; P < .001). CONCLUSIONS Tibial PVI for claudication was performed more often by nonvascular surgeons in high-volume practices and high-reimbursement settings. Thus, a critical need exists to reevaluate the indications, education, and reimbursement policies surrounding these procedures.
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Affiliation(s)
- Sanuja Bose
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Chen Dun
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Rebecca Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Alex J. Solomon
- Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
| | - James H. Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Ying-Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Michael S. Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Martin A. Makary
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
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Sanders KM, Nacario JH, Smith EJT, Jaramillo EA, Lancaster EM, Hiramoto JS, Conte MS, Iannuzzi JC. Structured discharge documentation reduces sex-based disparities in statin prescription in vascular surgery patients. J Vasc Surg 2023; 77:1504-1511. [PMID: 36682597 DOI: 10.1016/j.jvs.2023.01.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Perioperative statin use has been shown to improve survival in vascular surgery patients. In 2018, the Northern California Vascular Study Group implemented a quality initiative focused on the use of a SmartText in the discharge summary. We hypothesized that structured discharge documentation would decrease sex-based disparities in evidence-based medical therapy. METHODS A retrospective analysis was conducted using Vascular Quality Initiative eligible cases at a single institution. Open or endovascular procedures in the abdominal aorta or lower extremity arteries from 2016 to 2021 were included. Bivariate analysis identified factors associated with statin use and sex. Multivariate logistic regression was performed with the end point of statin prescription at discharge and aspirin prescription at discharge. An interaction term assessed the differential impact of the initiative on both sexes. Analysis was then stratified by prior aspirin or statin prescription. An interrupted time series analysis was used to evaluate the trend in statin prescription over time. RESULTS Overall, 866 patients were included, including 292 (34%) female and 574 (66%) male patients. Before implementation, statins were prescribed in 77% of male and 62% of female patients (P < .01). After implementation, there was no statistically significant difference in statin prescription (91% in male vs 92% in female patients, P = .68). Female patients saw a larger improvement in the adjusted odds of statin prescription compared with male patients (odds ratio: 3.1, 95% confidence interval: 1.1-8.6, P = .04). For patients not prescribed a statin preoperatively, female patients again saw an even larger improvement in the odds of being prescribed a statin at discharge (odds ratio: 6.4, 95% confidence interval: 1.8-22.7, P < .01). Interrupted time series analysis demonstrated a sustained improvement in the frequency of prescription for both sexes over time. The unadjusted frequency of aspirin prescription also improved by 3.5% in male patients vs 5.5% in female patients. For patients not prescribed an aspirin preoperatively, we found that the frequency of aspirin prescription significantly improved for both male (19% increase, P = .006) and female (31% increase, P = .001) patients. There was no significant difference in the perioperative outcomes between male and female patients before and after standardized discharge documentation. CONCLUSIONS A simple, low-cost regional quality improvement initiative eliminated sex-based disparities in statin prescription at a single institution. These findings highlight the meaningful impact of regional quality improvement projects. Future studies should examine the potential for structured discharge documentation to improve patient outcomes and reduce disparities.
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Affiliation(s)
- Katherine M Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Joyce H Nacario
- Heart and Vascular Services, Department of Quality & Patient Safety, University of California, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Emanuel A Jaramillo
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Elizabeth M Lancaster
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA.
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Zhang Q, Liu X, Li Q, Liu Y, He H, Wang K, Yan Z. Quantitative model for assessment of lower-extremity perfusion in patients with diabetes. Med Phys 2023; 50:3019-3026. [PMID: 36617729 DOI: 10.1002/mp.16214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/12/2022] [Accepted: 12/28/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Although diabetic and atherosclerotic vascular diseases have different pathophysiological mechanisms, the screening methods currently used for diabetic lower-extremity vascular diseases are mainly based on the evaluation methods used for atherosclerotic vascular diseases. Thus, assessment of microvascular perfusion is of great importance in early detection of lower-extremity ischemia in diabetes. PURPOSE This cross-sectional study aimed to develop a quantitative model for evaluating lower-extremity perfusion. METHODS We recruited 57 participants (14 healthy participants and 43 diabetes patients, of which 16 had lower-extremity arterial disease [LEAD]). All participants underwent technetium-99 m sestamibi (99mTc-MIBI) scintigraphy and ankle-brachial index (ABI) examination. We derived two key perfusion kinetics indices named activity perfusion index (API) and basal perfusion index (BPI). This study was registered in ClinicalTrials.gov (URL: https://www. CLINICALTRIALS gov, NCT02752100). RESULTS The estimated limb perfusion values in our lower-extremity perfusion assessment (LEPA) model showed excellent consistency with the actual measured data. Diabetes patients showed reduced lower-extremity perfusion in comparison with the control group (BPI: 106.21 ± 11.99 vs. 141.56 ± 17.38, p < 0.05; API: 12.34 ± 3.27 vs. 14.56 ± 3.12, p < 0.05). Using our model, the reductions in lower-extremity perfusion could be detected early in approximately 96.30% of diabetes patients. Patients with LEAD showed more severe reductions in lower-extremity perfusion than diabetes patients without LEAD (BPI: 47.85 ± 20.30 vs. 106.21 ± 11.99, p < 0.05; API: 7.06 ± 1.70 vs. 12.34 ± 3.27, p < 0.05). Discriminant analysis using API and BPI could successfully screen all diabetes patients with LEAD with a sensitivity of 100% and specificity of 80.77%. CONCLUSIONS We established a LEPA model that could successfully assess lower-extremity microvascular perfusion in diabetes patients. This model has important application value for the recognition of early-stage LEAD in patients with diabetes.
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Affiliation(s)
- Qian Zhang
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China
| | - Xiaoxiao Liu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China
| | - Qiang Li
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China
| | - Yushuang Liu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China
| | - Hongbo He
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China
| | - Kaifa Wang
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China.,School of Mathematics and Statistics, Southwest University, Chongqing, PR China
| | - Zhencheng Yan
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Chongqing Institute of Hypertension, Daping Hospital, Army Medical University, Chongqing, PR China
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129
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Yang B, Xiaping Z. The clinical significance of serum HMGB1 in patients with lower extremity arteriosclerosis obliterans after interventional vascular restenosis. Front Surg 2023; 9:1031108. [PMID: 36704514 PMCID: PMC9872960 DOI: 10.3389/fsurg.2022.1031108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/28/2022] [Indexed: 01/08/2023] Open
Abstract
Objective This study explored the correlation between serum HMGB1 levels and postoperative vascular restenosis in patients with lower extremity arteriosclerosis obliterans (LEASO). Methods A total of 362 patients LEASO who received vascular intervention were recruited in this study. Serum HMGB1 levels were measured by enzyme-linked immunosorbent assay. Logistic regression analysis was used to identify the influencing factors associated with vascular restenosis. The R procedure was used to create nomogram model. Receiver operating characteristic (ROC) analysis was used to determine the predictive value of serum HMGB1 and nomogram model for vascular restenosis. Results Of the 362 LEASO patients included, 103 (28.45%) developed restenosis within 6 months of postoperative follow-up. Postoperative HMGB1 levels were significantly higher in patients with restenosis compared to those with non-restenosis. Postoperative HMGB1 levels were significantly and positively correlated with the severity of postoperative restenosis (r = 0.819). The AUC of postoperative HMGB1 for the diagnosis of postoperative restenosis was 0.758 (95% CI: 0.703-0.812), with a sensitivity and specificity of 56.31% and 82.24%, respectively. Multivariate logistic regression analysis showed that diabetes, smoking, regular postoperative medication, increased fibrinogen, decreased red blood cells, increased hs-CRP, and increased postoperative HMGB1 were independently associated with postoperative restenosis in patients with LEASO. The C-index of the nomogram prediction model constructed based on the seven influencing factors mentioned above was 0.918. The nomogram model was significantly more predictive of postoperative restenosis in LEASO patients compared with a single postoperative HMGB1 (AUC: 0.918, 95% CI: 0.757-0.934). Conclusion Postoperative serum HMGB1 is an independent risk factor associated with postoperative vascular restenosis in patients with LEASO, and a novel nomogram model based on postoperative serum HMGB1 combined with clinical characteristics may help to accurately predict the risk of postoperative restenosis in patients with LEASO.
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Affiliation(s)
- Bo Yang
- Department of Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhang Xiaping
- Department of Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China,Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China,Correspondence: Zhang XiaPing
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Kim SY, Lee YM, Son YJ. Factors associated with self-management after hybrid revascularization in patients with peripheral artery disease: A structural equations model. J Adv Nurs 2023; 79:170-181. [PMID: 36082905 DOI: 10.1111/jan.15440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/14/2022] [Accepted: 08/30/2022] [Indexed: 12/15/2022]
Abstract
AIM To investigate the factors associated with self-management after hybrid revascularization in patients with lower extremity peripheral artery disease using a structural equation modelling approach. DESIGN A cross-sectional study was adopted. METHODS A total of 221 patients who underwent hybrid revascularization for peripheral artery disease of the lower limbs were included from outpatient clinics at a 1200-bed tertiary care hospital in Korea. Data were collected using a self-reported questionnaire between December 1, 2019, and August 31, 2020. Structural equation modelling was applied to test the hypothetical model. RESULTS The item mean score of participants' self-management was 6.28 (standard deviation, 0.83) out of 8. The structural equation modelling had a good fit index. Autonomy support from healthcare providers was directly associated with self-management (β = 0.20, p = 0.041). Illness perception directly (β = -0.33, p = 0.031) and indirectly (β = -0.19, p = 0.032) influenced self-management through competence and relatedness in patients with peripheral artery disease. The construct of autonomy support from healthcare providers, illness perception, competence and relatedness accounted for 49% of the variance in self-management. The Sobel test confirmed the statistically significant mediating effects of competence (z = -4.52, p < 0.001) and relatedness (z = -2.12, p < 0.001) on the relationship between illness perception and self-management. CONCLUSION Our findings revealed that autonomy support from healthcare providers and patients' illness perception directly influenced patients' self-management. Additionally, patients' illness perception can indirectly influence self-management through their perceived competence and relatedness. IMPACT Healthcare providers' autonomy support to patients may promote self-care behaviours, leading to greater autonomous motivation. Assessment of patients' illness perception before patient education is vital to designing effective self-management strategies which can improve patients' perceived competency and meaningful relatedness with healthcare providers.
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Affiliation(s)
- So-Young Kim
- Department of Nursing, Pusan National University Yangsan Hospital, Busan, South Korea
| | - Yun Mi Lee
- College of Nursing, Institute of Health Science Research, Inje University, Busan, South Korea
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul, South Korea
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Majumdar M, Waller D, Poyant J, McElroy I, Lella S, Feldman ZM, Levine E, Kim Y, Nuzzolo K, Kirshkaln A, DeCarlo C, Dua A. Variability of antiplatelet response in patients with peripheral artery disease. J Vasc Surg 2023; 77:208-215.e3. [PMID: 36028157 DOI: 10.1016/j.jvs.2022.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Antiplatelet therapy has been a pillar of management for peripheral artery disease (PAD). However, a significant subset of patients with PAD will be resistant to certain antiplatelet medications and, therefore, have an increased risk of graft and/or stent thrombosis unknown to the surgeon. At present, no point-of-care testing to identity which patients will experience benefit from these medications has been incorporated into the treatment guidelines. Thromboelastography with platelet mapping affords an opportunity to evaluate real-time coagulation dynamics and platelet function. In the present prospective, observational study, we aimed to delineate the variation in response to antiplatelet therapy in patients with PAD undergoing revascularization. METHODS All patients who were undergoing named vessel revascularization during December 2020 through April 2022 were prospectively enrolled. Platelet mapping assays were performed in three clinical phases: preoperative, postoperative inpatient, and postoperative outpatient. The distribution of platelet reactivity within patients receiving mono- vs dual antiplatelet therapy was assessed, and a between-group inferential analysis was performed. The effect of comorbidities and intervention subtype on platelet inhibition was also analyzed. RESULTS A total of 521 platelet mapping samples from 143 individual patients were analyzed using thromboelastography with platelet mapping. We found wide variability in the distribution of platelet inhibition, with a range of 0 to 100 and an interquartile range of 37.6. Although platelet inhibition with clopidogrel 75 mg was higher on average (44.8 ± 30.2) than that with aspirin 81 mg (24.6 ± 23.7) or aspirin 325 mg (27.1 ± 26.4; P = .001), clopidogrel at 75 mg demonstrated the highest variability in response. CONCLUSIONS These data have demonstrated significant variability in the response to both mono- and dual antiplatelet therapy in PAD patients undergoing lower extremity revascularization. Future research on the effect of this variability in response on the clinical outcomes could provide invaluable understanding of the perioperative thrombotic risk.
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Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Davis Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA
| | - Imani McElroy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Emma Levine
- Larner College of Medicine, University of Vermont Medical Center, Burlington, VT
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Kathryn Nuzzolo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
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Zamzam A, Syed MH, Rotstein OD, Eikelboom J, Klein DJ, Singh KK, Abdin R, Qadura M. Validating fatty acid binding protein 3 as a diagnostic and prognostic biomarker for peripheral arterial disease: A three-year prospective follow-up study. EClinicalMedicine 2023; 55:101766. [PMID: 36531981 PMCID: PMC9755058 DOI: 10.1016/j.eclinm.2022.101766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with peripheral arterial disease (PAD) often remain undiagnosed and therefore suboptimally managed. Here, we investigated the diagnostic and prognostic potential of fatty acid binding protein 3 (FABP3) in patients with PAD. METHODS In the discovery phase, 374 PAD and 184 non-PAD patients were recruited from vascular surgery ambulatory clinics at St. Michael's Hospital (Toronto, Ontario, Canada) between October 4, 2017 to October 29, 2018. The diagnostic ability of baseline FABP3 level was investigated through receiver operator characteristic (ROC) curves to determine two cutoff points: 1) an exclusionary "rule out" cutoff point, and 2) a confirmatory "rule in" cutoff point. Next, these cutoff points were confirmed in the external validation phase using a separate cohort of 312 patients (180 PAD and 132 non-PAD) recruited from ambulatory vascular surgery clinics at St. Michael's Hospital (Canada) between November 6, 2018-July 30, 2019. Cox regression analyses were used to explore the independent association between FABP3 and major adverse limb events (MALE - defined as need for arterial revascularization or major amputation) and decrease in ankle-brachial index (ABI -defined as drop ≥0.15) during 3 years of follow-up. FINDINGS In the discovery phase, FABP3 levels were significantly elevated in patients with PAD compared to non-PAD patients. ROC analysis demonstrated that FABP3 had an AUC of 0.83 (95% CI: 0.81-0.86, p-value < 0.001). FABP3 exclusionary cutoff was <1.55 ng/ml (sensitivity = 96%; specificity = 40%), whereas FABP3 confirmatory cutoff was >3.55 ng/ml (sensitivity = 43%; specificity = 95%) - values that were confirmed in the external validation phase. Cox regression analysis demonstrated FABP3 to be an independent predictor of increase in MALE [HR = 1.14 (1.03-1.29); p-value = 0.010] and worsening PAD status (drop in ABI >0.15 [HR = 1.11 (1.02-1.19); p-value = 0.009]). INTERPRETATION Our findings suggested that FABP3 levels can be used as both a diagnostic and prognostic biomarker for PAD, and may facilitate risk stratification in select individuals for purposes of vascular evaluation or intensive medical management. FUNDING Funding for this study was provided by the Bill and Vicky Blair Foundation.
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Affiliation(s)
- Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
| | - Muzammil H. Syed
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
| | - Ori D. Rotstein
- Department of Surgery, University of Toronto, Toronto, ON, M5S 1A1, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - David J. Klein
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
| | - Krishna K. Singh
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London ON, N6A 5C1, Canada
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Mohammad Qadura
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
- Department of Surgery, University of Toronto, Toronto, ON, M5S 1A1, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
- Corresponding author. St. Michael's Hospital, 30 Bond St, 7-076 Bond Wing, Toronto, Ontario, M5B 1W8, Canada.
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Kindell DG, Marulanda K, Caruso DM, Duchesneau E, Agala C, Farber M, Marston WA, McGinigle KL. Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular intervention. J Vasc Surg Venous Lymphat Disord 2023; 11:61-69. [PMID: 36182086 PMCID: PMC10681019 DOI: 10.1016/j.jvsv.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a well-known postoperative complication; however, the incidence of VTE after peripheral vascular intervention (PVI) has not been well described. Despite the minimally invasive nature of these procedures, the patients undergoing PVI have significant risk factors for the development of VTE. In the present study, our objective was to describe the short-term incidence of VTE after PVI, identify differences between sexes, and examine the periprocedural antiplatelet and anticoagulation regimens. METHODS We identified adults (age >66 years) who had undergone PVI from January 1, 2008 to September 30, 2015 from the inpatient Medicare claims data. The patients were followed for 365 days after the procedure. VTE events during follow-up were identified using the International Classification of Diseases, 9th revision, diagnosis codes. The covariate-standardized 30- and 90-day cumulative incidence of VTE events, overall and stratified by sex, were estimated using Aalen-Johansen estimators, accounting for death as a competing risk. Differences in sex between females and males were identified using Gray's test. Any antiplatelet or anticoagulant prescription fill was defined as any fill from 14 days before the endovascular intervention through the date of the VTE event. Persistence with antiplatelet and anticoagulant therapy was assessed by creating daily logs of antiplatelet and anticoagulant coverage using the dispensing dates and days of supply. Over-the-counter medications (ie, aspirin) were not evaluated. RESULTS We identified 31,593 qualifying patients with a mean age of 76.8 ± 7.4 years. Of the 31,593 patients, 46% were male, and 12% had a history of VTE. After the procedure, deep vein thrombosis (DVT) was a commonly diagnosed complication (3.8% and 4.8% at 30 and 90 days, respectively). The cumulative incidence of pulmonary embolism was 0.9% and 1.2% at 30 and 90 days after the procedure, respectively. Throughout the 90-day postoperative period, females had had a slightly increased risk of DVT compared with males (30-day risk difference, 0.007; P < .01; 90-day risk difference, 0.008; P = .02). We found no sex-based differences in the risk of pulmonary embolism. Of the patients who had developed VTE at 90 days, 970 (55%) had had no prescription fill for an antiplatelet or anticoagulant. Assuming all the patients had been taking aspirin, only 15% of the patients who had developed VTE had been taking prescribed dual antiplatelet medication persistently after PVI. In addition, among the patients who had developed VTE at 90 days, females were less likely to have had a prescription fill for an anticoagulant. CONCLUSIONS The findings from our study have demonstrated that the incidence of VTE after PVI is high, with an increased risk of deep vein thrombosis for females. We also found that females were less likely to have been prescribed an anticoagulant after PVI. Future studies are needed to characterize the variables associated with an increased risk of VTE after PVI and to identify strategies to increase dual antiplatelet therapy or anticoagulant prescription adherence to reduce the risk of VTE.
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Affiliation(s)
- Daniel G Kindell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Kathleen Marulanda
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deanna M Caruso
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emilie Duchesneau
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris Agala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark Farber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Sivagangan P, Harwood AE, Stather PW. Patient and Healthcare Professional Priorities for a Mobile Phone Application for Patients With Peripheral Arterial Disease. Cureus 2023; 15:e33993. [PMID: 36824553 PMCID: PMC9941040 DOI: 10.7759/cureus.33993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 01/21/2023] Open
Abstract
Introduction Supervised exercise therapy (SET) is the first-line treatment for the peripheral arterial disease (PAD), however, access and compliance are low. An alternative method of delivering this therapy is through mobile health applications, which can be more accessible and convenient for patients. The aim of this study is to evaluate patient, public and healthcare professional (HCP) priorities with regard to a dedicated mobile phone application to deliver remote SET. Methods Bespoke questionnaires were designed for patients and HCPs to assess app functionality and prioritisations for development. These were distributed through social media and the Norfolk and Norwich University Hospital. Results Functionality questionnaires were completed by 62 patients and 44 HCPs. Eighty-four per cent of patients wanted their therapy to be monitored by their vascular team with the majority (78%) interested in measuring walking distances. Most patients (76%) were interested in watching exercise videos. These views were shared by HCPs. A communication platform was prioritised for messaging and pictures by the patient (74% and 68% respectively), but not so by HCPs (40%). Documenting other forms of physical activity and the use of wearable technology was less valuable to patients but favoured by HCPs (50%). The ability to interact with other users was not prioritised by either group. Conclusion Delivery of a mobile phone application to deliver health programmes for SET in patients with PAD is an acceptable method for patients and HCPs. This data will enable the next stages of mobile phone application development to be appropriately prioritised, focusing on building exercise videos, a communication platform and further walking tests.
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Affiliation(s)
| | - Amy E Harwood
- Centre for Sports, Exercise and Life Sciences, Coventry University, Coventry, GBR
| | - Philip W Stather
- Vascular Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, GBR
- Norwich Medical School, University of East Anglia, Norwich, GBR
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Use of direct-acting oral anticoagulants associated with improved survival and bypass graft patency compared with warfarin after infrageniculate bypass. J Vasc Surg 2022; 77:1453-1461. [PMID: 36563710 DOI: 10.1016/j.jvs.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE No consensus has yet been reached regarding the optimal antiplatelet and anticoagulant regimen for patients after lower extremity bypass. Usually, patients who have undergone below-the-knee bypass will begin oral anticoagulation therapy. Historically, the bypass has been with prosthetic conduits and the anticoagulation therapy has been warfarin. However, the use of direct-acting oral anticoagulants (DOACs) has been increasing owing to their relative ease of dosing. The goal of the present study was to evaluate whether a difference exists in the postoperative outcomes for patients who have undergone infrageniculate bypass stratified by the use of on DOACs vs warfarin. METHODS The Vascular Quality Initiative infrainguinal bypass database was queried for all patients who had undergone infrageniculate bypass, been anticoagulation naive at baseline, and been discharged with anticoagulation therapy. A survival analysis was performed for patients for ≤2 years postoperatively to determine whether discharge with warfarin vs DOACs was associated with differences in overall mortality, loss of primary patency, risk of amputation, and risk of major adverse limb events (MALE). A multivariable Cox proportional hazards analysis was performed to control for differences in the baseline demographic factors between the two groups. RESULTS During the study period (2007-2020) 57,887 patients had undergone infrageniculate bypass. Of these patients, 2786 had been anticoagulation naive and discharged with either warfarin (n = 1889) or DOACs (n = 897). Discharge with a DOAC was associated with a lower risk of overall mortality (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.47-0.83; P = .001), loss of primary patency (HR, 0.74; 95% CI, 0.62-0.87; P < .001), risk of amputation (HR, 0.70; 95% CI, 0.57-0.86; P = .001), and risk of MALE (HR, 0.83; 95% CI, 0.71-0.97; P = .017). CONCLUSIONS Anticoagulation-naive patients who had undergone infrageniculate bypass had had higher rates of overall survival, bypass patency, amputation-free survival, and freedom from MALE when discharged with a DOAC than with warfarin.
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Yang L, Rong GC, Wu QN. Diabetic foot ulcer: Challenges and future. World J Diabetes 2022; 13:1014-1034. [PMID: 36578870 PMCID: PMC9791573 DOI: 10.4239/wjd.v13.i12.1014] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/07/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot ulcers (DFUs) have become one of the important causes of mortality and morbidity in patients with diabetes, and they are also a common cause of hospitalization, which places a heavy burden on patients and society. The prevention and treatment of DFUs requires multidisciplinary management. By controlling various risk factors, such as blood glucose levels, blood pressure, lipid levels and smoking cessation, local management of DFUs should be strengthened, such as debridement, dressing, revascularization, stem cell decompression and oxygen therapy. If necessary, systemic anti-infection treatment should be administered. We reviewed the progress in the clinical practice of treating DFUs in recent years, such as revascularization, wound repair, offloading, stem cell transplantation, and anti-infection treatment. We also summarized and prospectively analyzed some new technologies and measurements used in the treatment of DFUs and noted the future challenges and directions for the development of DFU treatments.
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Affiliation(s)
- Li Yang
- Department of Endocrinology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
| | - Gui-Chuan Rong
- Department of Gynaecology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
| | - Qi-Nan Wu
- Department of Endocrinology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
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Leslie R, May S, Scordis C, Isgar V, Poulton P, Garnham A. Outcomes following supervised exercise and home-based exercise for patients with intermittent claudication. JOURNAL OF VASCULAR NURSING 2022; 40:157-161. [PMID: 36435597 DOI: 10.1016/j.jvn.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Intermittent claudication (IC) is the most common symptom of peripheral arterial disease (PAD) which presents as a consequence of muscle ischaemia resulting from the atherosclerotic obstruction to arterial flow. High-quality evidence (Lane et al., 2017) shows that exercise programmes provide important benefits compared with usual care in improving pain-free and maximum walking distance in people with IC, but do not improve ankle-brachial pressure index (ABPI). METHODS Retrospective data were analysed to examine walking and ABPI outcomes for participants who completed a 12-week course of supervised or home-based exercise. All participants had a history of IC. RESULTS 46 participants (mean age 69±11 years; 76% male; 29% current smokers) referred for exercise were assessed, completed a 12-week course of exercise (home-based or supervised) and subsequently attended for re-assessment. Claudication onset distance (COD) increased by 363% (mean improvement 344.7 ± 265.1m; p < .001) and peak walking distance (PWD) by 324.4% in the supervised exercise group; COD increased by 30.6% (mean improvement 32.8 ± 57.2 m; p = 0.026) and PWD by 31.5% in the home-based exercise group. Resting ABPI for the total cohort significantly improved from 0.82 ± 0.25 at A1 to 0.88 ± 0.25 at A2 (p = 0.027). DISCUSSION A 12-week course of supervised exercise results in significantly greater walking distance outcomes (COD and PWD) than unmonitored home-based exercise. In contrast with previous findings (Lane et al. 2017), this retrospective study demonstrated a significant improvement in resting ABPI with both supervised exercise as well as home-based exercise. CONCLUSION A 12-week programme of exercise favourably influenced walking and ABPI outcomes for patients with IC. Both home-based exercise and supervised individualised exercise increased walking distances, but the magnitude of the improvement in walking outcomes was greater in individuals who attended supervised exercise therapy.
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Affiliation(s)
- R Leslie
- Chief Allied Health Professional, Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton WV10 0QP, United Kingdom.
| | - S May
- Exercise Physiologist Cardiac Rehabilitation, Royal Wolverhampton NHS Trust, United Kingdom
| | - C Scordis
- Specialist Exercise Physiologist Cardiac Rehabilitation, Royal Wolverhampton NHS Trust, United Kingdom
| | - V Isgar
- Clinical Nurse Specialist Vascular, Royal Wolverhampton NHS Trust, United Kingdom
| | - P Poulton
- Clinical Nurse Specialist Vascular, Royal Wolverhampton NHS Trust, United Kingdom
| | - A Garnham
- Vascular Surgeon, Royal Wolverhampton NHS Trust, United Kingdom
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DHRUVA SANKETS, BACHHUBER MARCUSA, SHETTY ASHWIN, GUIDRY HAYDEN, GUDUGUNTLA VINAY, REDBERG RITAF. A Policy Approach to Reducing Low-Value Device-Based Procedure Use. Milbank Q 2022; 100:1006-1027. [PMID: 36573334 PMCID: PMC9836248 DOI: 10.1111/1468-0009.12595] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.
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Affiliation(s)
- SANKET S. DHRUVA
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
| | - MARCUS A. BACHHUBER
- Louisiana State University Health Sciences Center School of Medicine
- Louisiana Department of Health
| | - ASHWIN SHETTY
- Louisiana State University Health Sciences Center School of Medicine
| | - HAYDEN GUIDRY
- Louisiana State University Health Sciences Center School of Medicine
| | | | - RITA F. REDBERG
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
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Katorkin SE, Krivoshchekov EP, Elshin EB, Kushnarchuk MY. Modern possibilities and prospects of conservative treatment of patients with peripheral arterial diseases. AMBULATORNAYA KHIRURGIYA = AMBULATORY SURGERY (RUSSIA) 2022. [DOI: 10.21518/1995-1477-2022-19-2-50-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The most common clinical manifestation of peripheral arterial disease is intermittent claudication due to insufficient blood supply to the affected limb. The article summarizes and systematizes the latest achievements in the field of conservative treatment of patients with intermittent claudication. In accordance with the requirements of evidence-based medicine, an overview of modern promising trends in conservative therapy presented in the latest Russian and foreign consensus documents, is given. The basis of the complex treatment of patients with peripheral arterial diseases is: non-drug and drug treatment to relieve the symptoms of chronic ischemia, pharmacotherapy for the secondary prevention of cardiovascular complications, open or endovascular revascularization to increase the distance of painfree walking. With the development of atherosclerosis, disturbances in the peptide composition of the endothelium occur, which reduce the ability of the vascular wall to resist inflammation and the associated triggering of pathological processes. It has been experimentally proven that the use of a complex of peptides obtained from the vessels of healthy and young animals in this situation restores the endothelial function of the arteries, affecting the main links of pathogenesis. Decrease in oxidative stress, decrease in atherogenic and lipidemic action, normalization of vascular tone and blood coagulation parameters, increase in the microvascular bed – these are the mechanisms that justify the indication of peptides to patients with atherosclerosis obliterans. Angioprotector based on a complex of polypeptides isolated from blood vessels can become an important part of the treatment of patients with obliterating diseases of the arteries of the lower extremities, providing a complex pathogenetic effect. It is necessary to further study in multicenter clinical trials the duration of the therapeutic effect of a drug in a longer period after a course of treatment, its effect on long-term outcomes of the disease, the possibility of using repeated courses, in chronic obliterating diseases of the arteries of the lower extremities III-IV stages according to the Fontaine classification, as well as the use drug for the treatment of systemic atherosclerosis of various arterial basins.
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140
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George EL, Wagner TH, Arya S. Atherectomy Overuse: Do Policy Solutions Exist? J Am Heart Assoc 2022; 11:e027422. [DOI: 10.1161/jaha.122.027422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elizabeth L. George
- Department of Surgery, Division of Vascular Surgery Stanford University School of Medicine Stanford CA
- VA Palo Alto Health Care System, Surgical Service Line Palo Alto CA
| | - Todd H. Wagner
- Veterans Affairs Health Economic Resource Center Palo Alto CA
| | - Shipra Arya
- Department of Surgery, Division of Vascular Surgery Stanford University School of Medicine Stanford CA
- VA Palo Alto Health Care System, Surgical Service Line Palo Alto CA
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Levin SR, Farber A, King EG, Giles KA, Eslami MH, Patel VI, Hicks CW, Rybin D, Siracuse JJ. Female Sex is Associated with More Reinterventions after Endovascular and Open Interventions for Intermittent Claudication. Ann Vasc Surg 2022; 86:85-93. [PMID: 35809741 PMCID: PMC9846811 DOI: 10.1016/j.avsg.2022.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Intermittent claudication (IC) is a commonly treated vascular condition. Patient sex has been shown to influence outcomes of interventions for other vascular disorders; however, whether outcomes of interventions for IC vary by sex is unclear. We sought to assess the association of patient sex with outcomes after IC interventions. METHODS The Vascular Quality Initiative was queried from 2010-2020 for all peripheral endovascular interventions (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for any degree IC. Univariable and multivariable analyses compared peri-operative and long-term outcomes by patient sex. RESULTS There were 24,701 female and 40,051 male patients undergoing PVI, 2,789 female and 6,525 male patients undergoing IIB, and 1,695 female and 2,370 male patients undergoing SIB for IC. Guideline-recommended pre-operative medical therapy differed with female patients less often prescribed aspirin for PVI (73.4% vs. 77.3%), IIB (71.5% vs. 74.8%), and SIB (70.9% vs. 74.3%) or statins for PVI (71.8% vs. 76.7%) and IIB (73.1% vs. 76.0%) (all P < 0.05). Female compared with male patients had lower 1-year reintervention-free survival after PVI (84.4% ± 0.3% vs. 86.3% ± 0.2%, P < 0.001), IIB (79.0% ± 0.9% vs. 81.2% ± 0.6%, P = 0.04), and SIB (89.4% ± 0.9% vs. 92.6% ± 0.7%, P = 0.005), but similar amputation-free survival and survival across all procedures. Multivariable analysis confirmed that female sex was associated with increased 1-year reintervention for PVI (HR 1.16, 95% CI 1.09-1.24, P < 0.001), IIB, (HR 1.16, 95% CI 1.03-1.31, P = 0.02), and SIB (HR 1.60, 95% CI 1.20-2.13, P = 0.001). CONCLUSIONS Female patients undergoing interventions for IC were less often pre-operatively medically optimized than male patients, though the difference was small. Furthermore, female sex was associated with more reinterventions after interventions. Interventionists treating female patients should increase their efforts to maximize medical therapy. Future research should clarify reasons for poorer intervention durability in female patients.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Kristina A Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Denis Rybin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA.
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Choudhry AJ, Shaw PM. Endovascular Aorto-Iliac Reconstruction vs. Aortobifemoral Bypass as First Choice for a Durable Revascularization for Aorto-Iliac Occlusive Disease. Vasc Endovascular Surg 2022; 57:88-92. [PMID: 36172836 DOI: 10.1177/15385744221130870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Aortoiliac occlusive disease (AIOD) is defined as atherosclerotic obstruction of the distal abdominal aorta and iliac arteries. Multiple options exist for management of AIOD including endovascular aortoiliac reconstruction and aortobifemoral bypass. As new technologies are developed, the best approach to manage this condition is evolving. METHODS We performed a literature review to assess the current state of endovascular aortoiliac reconstruction and aortobifemoral bypass as options for revascularization of aortoiliac occlusive disease. CONCLUSION Endovascular aortoiliac reconstruction and aortobifemoral bypass are both feasible and clinically effective options for management of aortoiliac occlusive disease. No randomized controlled trial has been performed to show one option to be more effective than the other. Recent literature demonstrates comparable long-term patency, limb salvage and survival among endovascular approaches to the treatment of AIOD with quicker recovery, lower costs and improved quality of life when compared to open aortobifemoral bypass (ABF) surgery. Selection of procedure should be tailored to the individual patient in order to develop an effective long-term successful strategy for management of aortoiliac occlusive disease. Further study is warranted to define durability of these endovascular approaches as well as patient specific characteristics that influence outcomes.
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Affiliation(s)
- Asad J Choudhry
- Division of Vascular and Endovascular Surgery, 12302SUNY Upstate Medical UniversityHospital, Syracuse, NY, USA
| | - Palma M Shaw
- Division of Vascular and Endovascular Surgery, 12302SUNY Upstate Medical UniversityHospital, Syracuse, NY, USA
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Aspirin Resistance in Vascular Disease: A Review Highlighting the Critical Need for Improved Point-of-Care Testing and Personalized Therapy. Int J Mol Sci 2022; 23:ijms231911317. [PMID: 36232618 PMCID: PMC9570127 DOI: 10.3390/ijms231911317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/17/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Aspirin resistance describes a phenomenon where patients receiving aspirin therapy do not respond favorably to treatment, and is categorized by continued incidence of adverse cardiovascular events and/or the lack of reduced platelet reactivity. Studies demonstrate that one in four patients with vascular disease are resistant to aspirin therapy, placing them at an almost four-fold increased risk of major adverse limb and adverse cardiovascular events. Despite the increased cardiovascular risk incurred by aspirin resistant patients, strategies to diagnose or overcome this resistance are yet to be clinically validated and integrated. Currently, five unique laboratory assays have shown promise for aspirin resistance testing: Light transmission aggregometry, Platelet Function Analyzer-100, Thromboelastography, Verify Now, and Platelet Works. Newer antiplatelet therapies such as Plavix and Ticagrelor have been tested as an alternative to overcome aspirin resistance (used both in combination with aspirin and alone) but have not proven to be superior to aspirin alone. A recent breakthrough discovery has demonstrated that rivaroxaban, an anticoagulant which functions by inhibiting active Factor X when taken in combination with aspirin, improves outcomes in patients with vascular disease. Current studies are determining how this new regime may benefit those who are considered aspirin resistant.
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Brahmandam A, Chan SM, Dardik A, Nassiri N, Aboian E. A narrative review on the application of high-intensity focused ultrasound for the treatment of occlusive and thrombotic arterial disease. JVS Vasc Sci 2022; 3:292-305. [PMID: 36276806 PMCID: PMC9579503 DOI: 10.1016/j.jvssci.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/17/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives High-intensity focused ultrasound (HIFU) is a noninvasive therapeutic modality with a variety of applications. It is approved for the treatment of essential tremors, ablation of prostate, hepatic, breast, and uterine tumors. Although not approved for use in the treatment of atherosclerotic arterial disease, there is a growing body of evidence investigating applications of HIFU. Currently, percutaneous endovascular techniques are predominant for the treatment of arterial pathology; however, there are no endovascular techniques of HIFU available. This study aims to review the state of current evidence for the application of HIFU in atherosclerotic arterial disease. Methods All English-language articles evaluating the effect of HIFU on arterial occlusive and thrombotic disease until 2021 were reviewed. Both preclinical and human clinical studies were included. Study parameters such as animal or clinical model and outcomes were reviewed. In addition, details pertaining to settings on the HIFU device used were also reviewed. Results In preclinical models, atherosclerotic plaque progression was inhibited by HIFU, through decreases in oxidized low-density lipoprotein cholesterol and increases in macrophage apoptosis. Additionally, HIFU promotes angiogenesis in hindlimb ischemic models by the upregulation of angiogenic and antiapoptotic factors, with increased angiogenesis at higher line densities of HIFU. HIFU also promotes thrombolysis and conversely induces platelet activation at low frequencies and higher intensities. Various clinical studies have attempted to translate some of these properties and demonstrated positive clinical outcomes for arterial recanalization after thrombotic stroke, decreased atherosclerotic plaque burden in carotid arteries, increase in tissue perfusion and a decrease in diameter stenosis in patients with atherosclerotic arterial disease. Conclusions In current preclinical and clinical data, the safety and efficacy of HIFU shows great promise in the treatment of atherosclerotic arterial disease. Future focused studies are warranted to guide the refinement of HIFU settings for more widespread adoption of this technology.
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Small Diameter Cell-Free Tissue-Engineered Vascular Grafts: Biomaterials and Manufacture Techniques to Reach Suitable Mechanical Properties. Polymers (Basel) 2022; 14:polym14173440. [PMID: 36080517 PMCID: PMC9460130 DOI: 10.3390/polym14173440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 12/25/2022] Open
Abstract
Vascular grafts (VGs) are medical devices intended to replace the function of a blood vessel. Available VGs in the market present low patency rates for small diameter applications setting the VG failure. This event arises from the inadequate response of the cells interacting with the biomaterial in the context of operative conditions generating chronic inflammation and a lack of regenerative signals where stenosis or aneurysms can occur. Tissue Engineered Vascular grafts (TEVGs) aim to induce the regeneration of the native vessel to overcome these limitations. Besides the biochemical stimuli, the biomaterial and the particular micro and macrostructure of the graft will determine the specific behavior under pulsatile pressure. The TEVG must support blood flow withstanding the exerted pressure, allowing the proper compliance required for the biomechanical stimulation needed for regeneration. Although the international standards outline the specific requirements to evaluate vascular grafts, the challenge remains in choosing the proper biomaterial and manufacturing TEVGs with good quality features to perform satisfactorily. In this review, we aim to recognize the best strategies to reach suitable mechanical properties in cell-free TEVGs according to the reported success of different approaches in clinical trials and pre-clinical trials.
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Tsujimura T, Iida O, Takahara M, Soga Y, Yamaoka T, Fujihara M, Kawasaki D, Ichihashi S, Kozuki A, Nanto S, Sakata Y, Mano T. Clinical Impact of Intravascular Ultrasound-Guided Fluoropolymer-Based Drug-Eluting Stent Implantation for Femoropopliteal Lesions. JACC Cardiovasc Interv 2022; 15:1569-1578. [PMID: 35926923 DOI: 10.1016/j.jcin.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Treatment with a fluoropolymer-based drug-eluting stent (FP-DES has been widely applied to the contemporary femoropopliteal practice with durable outcomes. Nevertheless, the impact of intravascular ultrasound (IVUS) utilization on clinical outcomes after FP-DES implantation has not been determined. OBJECTIVES This study aimed to investigate the impact of IVUS on 1-year clinical outcomes after FP-DES) implantation for femoropopliteal lesions in patients with symptomatic peripheral artery disease. METHODS As a subanalysis of the CAPSICUM (contemporary outcomes after paclitaxel-eluting peripheral stent implantation for symptomatic lower limb ischemia with superficial femoral or proximal popliteal lesion) study, the present investigation analyzed 1,091 patients with symptomatic peripheral artery disease who underwent endovascular therapy with FP-DES for femoropopliteal lesions. One-year clinical outcomes were compared between patients treated with IVUS and those treated without IVUS after propensity score matching. The primary outcome measure was 1-year restenosis. The incidence of aneurysmal degeneration was also assessed. RESULTS A total of 843 (77.2%) patients underwent IVUS-guided FP-DES implantation. After propensity score matching, the 1-year restenosis was not significantly different between the groups (11.5% [95% CI: 9.1%-14.0%] vs 15.5% [95% CI: 10.9%-20.1%]; P = 0.22). The frequency of aneurysmal degeneration at 1 year was significantly higher in the IVUS group than in the non-IVUS group (19.8% [95% CI: 16.3%-23.4%] vs 7.1% [95% CI: 3.3%-11.0%]; P < 0.001). IVUS use was associated with a lower restenosis risk in patients with chronic total occlusion but not in those without (P for interaction = 0.044). CONCLUSIONS The present study revealed that 1-year restenosis risk was not significantly different between the 2 groups, whereas the incidence of aneurysmal degeneration was significantly higher in the IVUS group.
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Affiliation(s)
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan.
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan; Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Daizo Kawasaki
- Department of Cardiology, Morinomiya Hospital, Osaka, Japan
| | - Shigeo Ichihashi
- Division of Radiology, Nara Medical University, Kashihara, Japan
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Shinsuke Nanto
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
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Taylor J, Stiepel HR, Keefe N. Anticoagulation and Antiplatelet Agents in Peripheral Arterial Interventions. Semin Intervent Radiol 2022; 39:364-372. [PMID: 36406033 PMCID: PMC9671689 DOI: 10.1055/s-0042-1757314] [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: 11/19/2022]
Abstract
Effective revascularization of peripheral artery disease relies on periprocedural pharmacological regulation of the clotting cascade. Patient-specific factors such as cardiovascular risk factors, contraindications, and individual psychosocial factors must be considered when initiating post revascularization management. Management with anticoagulant and antiplatelet agents is discussed to guide the interventionalist on which therapy may be appropriate for their patient. While exact treatment may be institution and provider dependent, the interventionist must be familiar with the available classes of medications and how they can be prescribed in the postprocedural setting to improve cardiovascular outcomes.
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Affiliation(s)
- Jordan Taylor
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Henry R. Stiepel
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Nicole Keefe
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Grémare A, Thibes L, Gluais M, Torres Y, Potart D, Da Silva N, Dusserre N, Fénelon M, Senthilhes L, Lacomme S, Svahn I, Gontier É, Fricain JC, L'Heureux N. Development of a vascular substitute produced by weaving yarn made from human amniotic membrane. Biofabrication 2022; 14. [PMID: 35896106 DOI: 10.1088/1758-5090/ac84ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 11/12/2022]
Abstract
Because synthetic vascular prostheses perform poorly in small-diameter revascularization, biological vascular substitutes are being developed as an alternative. Although their in vivo results are promising, their production involves long, complex, and expensive tissue engineering methods. To overcome these limitations, we propose an innovative approach that combines the human amniotic membrane (HAM), which is a widely available and cost-effective biological raw material, with a rapid and robust textile-inspired assembly strategy. Fetal membranes were collected after cesarean deliveries at term. Once isolated by dissection, HAM sheets were cut into ribbons that could be further processed by twisting into threads. Characterization of the HAM yarns (both ribbons and threads) showed that their physical and mechanical properties could be easily tuned. Since our clinical strategy will be to provide an off-the-shelf allogeneic implant, we studied the effects of decellularization and/or gamma sterilization on the histological, mechanical, and biological properties of HAM ribbons. Gamma irradiation of hydrated HAMs, with or without decellularization, did not interfere with the ability of the matrix to support endothelium formation in vitro. Finally, our HAM-based, woven tissue-engineered vascular grafts (TEVGs) exhibited clinically relevant mechanical properties. Thus, this study demonstrates that human, completely biological, allogeneic, small-diameter TEVGs can be produced from HAM, thereby avoiding costly cell culture and bioreactors.
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Affiliation(s)
- Agathe Grémare
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Lisa Thibes
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Maude Gluais
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Yoann Torres
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Diane Potart
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Nicolas Da Silva
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Nathalie Dusserre
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Mathilde Fénelon
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Loïc Senthilhes
- Obstetrics and Gynecology, CHU de Bordeaux, Hopital Pellegrin, 146, Rue Léo Saignat, Bordeaux, Aquitaine, 33076, FRANCE
| | - Sabrina Lacomme
- University of Bordeaux, 146, Rue Léo Saignat, Bordeaux, Aquitaine, 33000, FRANCE
| | - Isabelle Svahn
- University of Bordeaux, 146, Rue Léo Saignat, Bordeaux, Aquitaine, 33000, FRANCE
| | - Étienne Gontier
- University of Bordeaux, 146, Rue Léo Saignat, Bordeaux, Aquitaine, 33000, FRANCE
| | - Jean-Christophe Fricain
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
| | - Nicolas L'Heureux
- Heath Sciences and Technologies, University of Bordeaux, Campus Carreire, 146, Rue Léo Saignat, Bâtiment 4A, 2ième étage, Case 84, Bordeaux, Aquitaine, 33076, FRANCE
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Mieczkowski M, Mrozikiewicz-Rakowska B, Kowara M, Kleibert M, Czupryniak L. The Problem of Wound Healing in Diabetes—From Molecular Pathways to the Design of an Animal Model. Int J Mol Sci 2022; 23:ijms23147930. [PMID: 35887276 PMCID: PMC9319250 DOI: 10.3390/ijms23147930] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 02/07/2023] Open
Abstract
Chronic wounds are becoming an increasingly common clinical problem due to an aging population and an increased incidence of diabetes, atherosclerosis, and venous insufficiency, which are the conditions that impair and delay the healing process. Patients with diabetes constitute a group of subjects in whom the healing process is particularly prolonged regardless of its initial etiology. Circulatory dysfunction, both at the microvascular and macrovascular levels, is a leading factor in delaying or precluding wound healing in diabetes. The prolonged period of wound healing increases the risk of complications such as the development of infection, including sepsis and even amputation. Currently, many substances applied topically or systemically are supposed to accelerate the process of wound regeneration and finally wound closure. The role of clinical trials and preclinical studies, including research based on animal models, is to create safe medicinal products and ensure the fastest possible healing. To achieve this goal and minimize the wide-ranging burdens associated with conducting clinical trials, a correct animal model is needed to replicate the wound conditions in patients with diabetes as closely as possible. The aim of the paper is to summarize the most important molecular pathways which are impaired in the hyperglycemic state in the context of designing an animal model of diabetic chronic wounds. The authors focus on research optimization, including economic aspects and model reproducibility, as well as the ethical dimension of minimizing the suffering of research subjects according to the 3 Rs principle (Replacement, Reduction, Refinement).
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Affiliation(s)
- Mateusz Mieczkowski
- Department of Diabetology and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.M.); (M.K.); (L.C.)
| | - Beata Mrozikiewicz-Rakowska
- Department of Diabetology and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.M.); (M.K.); (L.C.)
- Correspondence:
| | - Michał Kowara
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland;
| | - Marcin Kleibert
- Department of Diabetology and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.M.); (M.K.); (L.C.)
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland;
| | - Leszek Czupryniak
- Department of Diabetology and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.M.); (M.K.); (L.C.)
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Corriere MA, Kim GY, Byrnes ME, Sales A, Keith D, Ip EH, Burke GL, Boone DS, Easterling D. Focus group study of factors relevant to treatment decisions and experiences among patients with symptomatic peripheral artery disease. J Vasc Surg 2022; 76:1316-1324. [PMID: 35863556 DOI: 10.1016/j.jvs.2022.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/07/2022] [Accepted: 06/17/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Clinical guidelines recommend shared decision-making for treatment of peripheral artery disease (PAD), which requires understanding of patient perspectives and preferences. We conducted a focus group study of patients with symptomatic PAD to identify factors important and relevant to treatment choices, and to characterize aspects of the healthcare process that contribute to positive versus negative experiences apart from the specific treatment(s) received. METHODS Participants were recruited from an academic medical center over two years using a purposeful sampling approach based on a clinical diagnosis of symptomatic PAD (either claudication or chronic limb threatening ischemia [CLTI]) confirmed by abnormal ankle or toe brachial index. Focus groups were led by a non-physician moderator, consisted of 5-12 participants, and were conducted separately for patients with CLTI and claudication. Audio recordings converted to verbatim transcripts were used for qualitative analysis. RESULTS 51 patients (26 with CLTI and 25 with claudication) were enrolled and participated in focus groups. Major themes related to the process of care included: decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care). Major themes related to the process of care included: decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care). CONCLUSIONS The results provide insights into patient preferences, perspectives, and experiences related to PAD treatment. These observations can be used to inform patient-centered approaches to shared decision making, communication, and assessment of PAD treatment outcomes.
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Affiliation(s)
- Matthew A Corriere
- Department of Surgery, Section of Vascular Surgery; Center for Health Outcomes and Policy.
| | - Gloria Y Kim
- Department of Surgery, Section of Vascular Surgery; Center for Health Outcomes and Policy
| | - Mary E Byrnes
- Department of Surgery, Section of Vascular Surgery; Center for Health Outcomes and Policy
| | - Anne Sales
- Department of Learning Health Sciences, University of Michigan
| | - Donna Keith
- Department of Vascular and Endovascular Surgery
| | | | | | - Derrick S Boone
- Wake Forest School of Medicine; School of Business, Wake Forest University
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