Non-Invasive Management of Peripheral Arterial Disease

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

The impact of class I compression stockings on the peripheral microperfusion of the lower limb: A prospective pilot study

OBJECTIVE

The use of medical compression stockings (MCS) in patients with peripheral arterial disease (PAD) and diabetes is the subject of an ongoing critical debate. While reducing leg edema of various origins by improving venous back flow, there is a concern about additional arterial flow obstruction when compression therapy is applied in pre-existing PAD. The aim of this study is to obtain further information on the use of class I MCS in patients with advanced PAD and to evaluate the framework conditions for a safe application.

METHODS

The total collective (n = 55) of this prospective, clinical cohort study consisted of 24 patients with PAD Fontaine stage IIb and higher studied before revascularization, of whom 16 patients were examined again after revascularization, and 15 healthy participants included for reference. The microperfusion of the lower extremity of all participants was examined in a supine, elevated, and sitting position using the oxygen to see (O2C) method.

RESULTS

The results indicate that leg positioning had the strongest influence on microcirculation (SO2 and flow: p = 0.0001), whereas MCS had no significant effect on the perfusion parameters (SO2: p = 0.9936; flow: p = 0.4967) and did not lead to a deterioration of values into critical ranges.

CONCLUSION

Mild medical compression therapy appears to be feasible even in patients with advanced PAD. Larger studies are warranted to observe any long-term effects, in particular for the treatment of reperfusion edema after revascularization.

Neuromuscular Electrical Stimulation for Intermittent Claudication (NESIC): multicentre, randomized controlled trial

METHODS

This was an open, multicentre, randomized controlled trial. Patients with intermittent claudication attending vascular surgery outpatient clinics were randomized (1:1) to receive either neuromuscular electrical stimulation (NMES) or not in addition to local standard care available at study centres (best medical therapy alone or plus supervised exercise therapy (SET)). The objective of this trial was to investigate the clinical efficacy of an NMES device in addition to local standard care in improving walking distances in patients with claudication. The primary outcome was change in absolute walking distance, measured by a standardized treadmill test at 3 months. Secondary outcomes included intermittent claudication (IC) distance, adherence, quality of life, and haemodynamic changes.

RESULTS

Of 200 participants randomized, 160 were included in the primary analysis (intention to treat, Tobit regression model). The square root of absolute walking distance was analysed (due to a right-skewed distribution) and, although adjunctive NMES improved it at 3 months, no statistically significant effect was observed. SET as local standard care seemed to improve distance compared to best medical therapy at 3 months (3.29 units; 95 per cent c.i., 1.77 to 4.82; P < 0.001). Adjunctive NMES improved distance in mild claudication (2.88 units; 95 per cent c.i., 0.51 to 5.25; P = 0.02) compared to local standard care at 3 months. No serious adverse events relating to the device were reported.

CONCLUSION

Supervised exercise therapy is effective and NMES may provide further benefit in mild IC.This trial was supported by a grant from the Efficacy and Mechanism Evaluation Program, a Medical Research Council and National Institute for Health and Care Research partnership. Trial registration: ISRCTN18242823.

Quality of life for patients with in-stent restenosis after interventional therapy of peripheral artery disease

OBJECTIVE

The aim of this study was to investigate the quality of life for patients with in-stent restenosis after interventional therapy of peripheral artery disease and the influencing factors.

METHODS

A total of 72 in-stent restenosis patients after interventional therapy of peripheral artery disease were enrolled, whose general data were obtained. SF-12 scale was used to evaluate the quality of life. Tilburg Frailty Scale was used to assess senile debilitation. Pittsburgh Quality Index Scale was used to evaluate sleep quality. Activity of Daily Living Scale was used to evaluate the self-care ability. The general data and in-stent restenosis-related indicators were compared between patients with low and high quality of life, respectively. Multivariate regression analysis was made on the factors affecting quality of life.

RESULTS

The average total quality of life score of 72 patients was 74.06±19.26 points. The gender, Fontaine stage and smoking, Activity of Daily Living Scale score, painless walking distance, senile debilitation score, sleep quality score, white blood cells, and C-reactive protein had significant differences between the two groups, respectively (p<0.05). Multivariate regression analysis showed that the female gender, low Fontaine stage (OR=0.186), low senile debilitation score (OR=0.492), and high sleep quality score (OR=0.633) were the protective factors for high quality of life (all p<0.05), and the low Activity of Daily Living score (OR=1.282) was the risk factor for high quality of life (p<0.05).

CONCLUSION

Quality of life of in-stent restenosis patients after interventional therapy of peripheral artery disease is low. Gender, Fontaine stage, senile debilitation, sleep quality, and Activity of Daily Living score are the influencing factors of quality of life for in-stent restenosis patients.

Compression therapy in peripheral artery disease: a literature review

OBJECTIVE

Our objective is to examine the pathophysiology of oedema in the ischaemic and post-revascularised limb, compare compression stockings to pneumatic compression devices, and summarise compression regimens in patients with severe peripheral artery disease (PAD) without revascularisation, after revascularisation, and in mixed arterial and venous disease.

METHOD

A scoping literature review of the aforementioned topics was carried out using PubMed.

RESULTS

Compression therapy has been shown to increase blood flow and aid in wound healing through a variety of mechanisms. Several studies suggest that intermittent pneumatic compression (IPC) devices can be used to treat critical limb ischaemia in patients without surgical options. Additionally, compression stockings may have a role in preventing oedema after peripheral artery bypass surgery, thereby diminishing pain and reducing the risk of surgical wound dehiscence.

CONCLUSION

Oedema may occur in the ischaemic limb after revascularisation surgery, as well as in combination with venous disease. Clinicians should not fear using compression therapy in PAD.

Lumbar Sympathetic Ganglion Block Facilitates Wound Healing in a Rat Ischemic Hindquarter Model

Lumbar sympathetic nerve block (LSNB) improves blood flow in the lower limbs and relieves pain involving the sympathetic afferents. This study examines the use of LSNB, but there are no reports of its use for the purpose of wound healing. Therefore, the authors planned the following study.

Methods

An ischemic limb ulcer was created on both lower limbs using a rat model (N = 18). The rats were divided into three groups, namely, A, B, and C. Group A received LSNB on one side (N = 6). Group B was sprayed with basic fibroblast growth factor preparation (trafermin/fiblast) on one side (N = 6). Group C was used as a control (N = 6). Lower limb temperature and the ulcer area were measured over time in each group. Furthermore, the correlation between the ulcer temperature and the ulcer area reduction rate was analyzed.

Results

Group A had higher skin temperature on the LSNB-treated side than on the nontreated side (P = 0.0022 < 0.05). Regarding the correlation between the average temperature and the ulcer area reduction rate, the correlation coefficient was as high as 0.691 in group A.

Conclusions

In the LSNB group, the skin temperature increased and the ulcer area decreased significantly. Conventionally, LSNB has been used for pain relief purposes, although the authors consider that it will be useful in the treatment of ischemic ulcers and that it is a potential treatment option for future chronic limb ischemia/chronic limb-threatening ischemia cases.

Comparison of intermittent pneumatic compression device and compression stockings for workers with leg edema and pain after prolonged standing: a prospective crossover clinical trial

BACKGROUND

During prolonged standing, insufficient calf muscle pumping accompanies venous stasis and hypertension in the lower legs, resulting in valve dysfunction, venous wall problems, and sub-sequent inflammation. Compression therapy, which includes medical compression stockings (MCS) and mechanical intermittent pneumatic compression (IPC), is one of the most effective therapeutic interventions for treating chronic venous diseases. This study aimed to compare the therapeutic effect among resting, IPC and MCS alone, and IPC with MCS in long-standing workers (> 8 h daily).

METHODS

This crossover trial was conducted with 39 participants with complaints of leg edema and pain whose work involved standing for more than 8 h daily. Four treatment protocols were established for each visit as follows: protocol A (not wear MCS during work and rest without IPC after work), protocol B (wear MCS during work and rest without IPC after work), protocol C (not wear MCS during work and treat with IPC after work), and protocol D (wear MCS during work and treat with IPC after work). The primary outcome was the visual analogue scale (VAS) score for leg pain. The secondary outcomes were leg volume (mL), circumference (cm), extracellular fluid/total body fluid (ECF/TBF), and extracellular water/total body water (ECW/TBW) through bioelectrical impedance analysis. Outcomes were assessed before work (T0), after work (T1), and 60 min after intervention (T2).

RESULTS

All four protocols had significantly increased leg pain after work (T0-1) but improved 60 min after intervention (T1-2), particularly protocol C (decreased VAS by 1.9). When leg swelling was compared at T0 and T1, protocols A and C showed significant increases in leg volume and circumference, indicating significant work-induced edema, whereas protocols B and D showed no change or even a decrease. After interventions, leg volume and circumference significantly decreased in protocols A and C, although protocols B and C did not show significant improvement. The ECF/TBF and ECW/TBW of all protocols decreased after interventions.

CONCLUSIONS

Leg pain and edema after prolonged standing (T1-T2) in adults were safely and effectively improved by both IPC alone and IPC with MCS. Although the use of MCS during the workday did not show improvement in leg pain immediately after work (T0-T1), both MCS with resting and MCS with IPC decreased leg pain at T1-T2 and prevented leg edema at T0-T1.

TRIAL REGISTRATION

This trial protocol was registered at the Clinical Research Information Service (KCT0005383, the date of first registration: 08/09/2020).

The effect of 12-week treatment with intermittent negative pressure on blood flow velocity and flowmotion, measured with a novel Doppler device (earlybird). Secondary outcomes from a randomized sham-controlled trial in patients with peripheral arterial disease

OBJECTIVES

Treatment with intermittent negative pressure (INP) is proposed as an adjunct to standard care in patients with peripheral arterial disease (PAD). The aims of this study were to evaluate the applicability of a novel ultrasound Doppler device (earlybird) to assess blood flow characteristics in patients with PAD during a treatment session with INP, and whether certain flow-properties could determine whom could benefit INP treatment.

METHODS

Secondary outcomes of data from a randomized sham-controlled trial were explored. Patients were randomized to 12 weeks of treatment with 40 mmHg or 10 mmHg INP, for one hour twice daily. Earlybird blood flow velocity recordings were made before and after the 12-week treatment-period and consists of a 5-minute recording in rest, 3-minute during INP treatment and 5-minute recording after ended INP test-treatment. Mean blood flow velocity (v_mean), relative changes in flow and frequency spectrum by Fourier-transform of the respective bandwidths of endothelial, sympathetic, and myogenic functions, were analyzed for the different series of blood flow measurements.

RESULTS

In total, 62 patients were eligible for analysis, where 32 patients were treated with 40 mmHg INP. The acquired recordings were of good quality and was used for descriptive analyses of flow characteristics. An immediate increase in v_mean during the negative pressure periods of the INP test-treatment was observed in the 40 mmHg INP treatment group at both pre- and post-test. There was a significant difference between the treatment groups, with a difference between the medians of 13.7 (p < 0.001) at pretest and 10.7 (p < 0.001) at posttest. This finding was confirmed with spectrum analysis by Fourier-transform of the bandwidth corresponding to INP treatment. The change in amplitude corresponding to myogenic function after 12 weeks of treatment, was significantly different in favor of the 40 mmHg INP treatment group. We were not able to detect specific flow characteristics indicating whom would benefit INP-treatment.

CONCLUSIONS

Earlybird is an applicable tool for assessing blood flow velocity in patients with PAD. Analysis of the flow velocity recordings shows that INP induce an immediate increase in blood flow velocities during INP. The positive effects of INP may be attributed to recruitment of arterioles, and thereby increasing blood flow. In these analyses no flow characteristics was determined which could predict whom would benefit INP-treatment.

High-Frequency External Muscle Stimulation Reduces Depressive Symptoms in Older Male Veterans: A Pilot Study

OBJECTIVE

Late-life depression (LLD) is a severe public health problem. Given that pharmacological treatments for LLD are limited by their side effects, development of efficient and tolerable nonpharmacological treatment for LLD is urgently required. This study investigated whether high-frequency external muscle stimulation could reduce depressive symptoms in LLD.

METHODS

Twenty-two older male veterans with major depression were recruited and randomized into a treatment (n = 9) or sham control group (n = 13). The groups received high-frequency external muscle stimulation or sham intervention 3 times per week for 12 weeks. Clinical symptoms and muscle strength were evaluated at baseline and every 2 weeks.

RESULTS

The 2 groups were homogeneous in age, baseline clinical symptoms, and muscle strength. The treatment group showed significant improvement in depression and anxiety scores and muscle strength (all P < .01), whereas the control group showed no significant change after the 12-week follow-up. Compared to the control group, the treatment group showed significant improvements in depression (Geriatric Depression Scale, P = .009; Hamilton Depression Rating Scale, P = .007) and anxiety scores (HAMA, P = .008) and muscle strength (all P < .001). Changes in depression and anxiety levels were significantly correlated with changes in muscle strength after the study. In the treatment group, we observed a trend of correlation between the reduction in depression and muscle strength gains.

CONCLUSION

High-frequency external muscle stimulation appears to be an effective treatment for older patients with LLD. Large studies with more tests and/or conducted in different populations are warranted to validate these preliminary findings.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee

BACKGROUND

Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.

OBJECTIVES

The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.

METHODOLOGY

A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.

RESULTS

A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

The long-term arterial assist intermittent pneumatic compression generating venous flow obstruction is responsible for improvement of arterial flow in ischemic legs

Background

There is a large group of patients with ischemia of lower limbs not suitable for surgical reconstruction of arteries treated with the help of external assist by intermittent pneumatic compression devices (IPC). Until recently the generally accepted notion was that by compressing tissues below the knee, veins become emptied, venous pressure drops to zero and the increased arterial-venous pressure gradient enables greater arterial flow. We used a pump that, in contradiction to the “empty veins” devices, limited the limb venous outflow by venous obstructions and in a long period therapy expanded the perfusion vessels and brought about persistent reactive hyperemia.

Aim

To check the toe and calf arterial inflow measured by venous stasis plethysmography and capillary flow velocity during arterial assist IPC in a long-term therapy of ischemic legs.

Material and methods

Eighteen patients (12M, 6F) age 62 to 75 with leg peripheral arterial disease (PAD, Fontaine stage II) were studied. Pneumatic device with two 10cm wide cuffs (foot, calf) (Bio Compression Systems, Moonachie, NJ, USA) inflated to 120 mmHg for 5–6 sec to obstruct the venous flow, deflation time 16 sec, applied for 45–60 min daily for a period of 2 years.

Results

At pump inflation increase in toe arterial pressure, volume, capillary blood flow velocity and one-minute arterial inflow test was observed. Increased toe volume appeared concomitantly with the inflated chamber venous obstruction. Resting pressure in the great saphenous vein increased. The two years therapy showed persistence of the resting limb increased toe capillary flow. Intermittent claudication distance increased by 20–120%. After two years arterial assist TBI increased from 0.2 to 0.6 (range 0.3 to 0.8) (p<0.05 vs pre-therapy). The toe arterial inflow dominated over that in calf skin and muscles, nevertheless, there was prolongation of the claudication distance presumably due to dilatation of exchange vessels also in muscles.

Conclusions

Our arterial assist IPC brought about increase in the toe capillary flow, long lasting dilatation of toe capillaries and extension of painless walking distance. The crucial factor of rhythmic repeated venous outflow obstructions should be taken into account in designing effective assist devices.

[S1 guideline on intermittent pneumatic compression (IPC)]

Under the direction of the German Society of Phlebology (Deutsche Gesellschaft für Phlebologie) and in cooperation with other specialist associations, the S1 guideline on intermittent pneumatic compression (IPC) was adopted in January 2018. It replaces the previous guideline from March 2005. The aim of the guideline is to optimize the indication and therapeutic use of IPC in vascular diseases and edema. An extensive literature search of MEDLINE, existing guidelines, and work relevant to the topic was performed. In view of the often methodologically weak study quality with often small numbers of cases and heterogeneous treatment protocols, recommendations can often only be derived from the available data using good clinical practice/expert consensus. Intermittent pneumatic compression is used for thromboembolism prophylaxis, decongestive therapy for edema, and to positively influence arterial and venous circulation to improve clinical symptoms and accelerate ulcer healing in both the outpatient and inpatient care setting. The therapy regimens and devices used depend on the indication and target location. They can be used as outpatient and inpatient devices as well as at home for long-term indications. A target indication is thrombosis prophylaxis. IPC should be used in severe chronic venous insufficiency (stages C4b to C6), in extremity lymphedema as an add-on therapy and in peripheral arterial occlusive disease (PAOD) with stable intermittent claudication or critical ischemia. IPC can be used in post-traumatic edema, therapy-resistant venous edema, lipedema and hemiplegia with sensory deficits and edema. Absolute and relative contraindications to IPC must be taken into account and risks considered and avoided as far as possible. Adverse events are extremely rare if IPC is used correctly. If the indication and application are correct-also as an add-on therapy-it is a safe and effective treatment method, especially for the treatment of the described vascular diseases and edema as well as thrombosis prophylaxis.

A multicenter randomized controlled study to evaluate whether neuromuscular electrical stimulation improves the absolute walking distance in patients with intermittent claudication compared with best available treatment

OBJECTIVE

To assess the clinical efficacy of a neuromuscular electrical stimulation (NMES) device to improve the absolute walking distance in patients with intermittent claudication as an adjunct to the local standard care available at the study sites compared with local standard care alone.

METHODS

This open, multicenter, randomized controlled trial included eight participating centers in England. Sites are equally distributed between those that provide supervised exercise therapy programs and those that do not. Patients with intermittent claudication meeting the eligibility criteria and providing consent will be randomized, depending on the center type, to either NMES and locally available standard care or standard care alone. The primary end point is change in absolute walking distance at 3 months (the end of the intervention period) by treadmill testing. Secondary outcomes include quality of life, compliance with the interventions, economic evaluation of the NMES device, and lower limb hemodynamic measures to further the understanding of underlying mechanisms. Recruitment commenced in March 2018 and will continue for a total of 15 months. The Neuromuscular Electrical Stimulation Improves the Absolute Walking Distance in Patients with Intermittent Claudication trial is funded by the UK Efficacy and Mechanism Evaluation Programme, Medical Research Council, and National Institute for Health Research partnership.