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Wadström BN, Wulff AB, Pedersen KM, Jensen GB, Nordestgaard BG. Elevated remnant cholesterol increases the risk of peripheral artery disease, myocardial infarction, and ischaemic stroke: a cohort-based study. Eur Heart J 2021; 43:3258-3269. [PMID: 34661640 DOI: 10.1093/eurheartj/ehab705] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/04/2021] [Accepted: 09/25/2021] [Indexed: 01/22/2023] Open
Abstract
AIMS The atherogenic potential of cholesterol in triglyceride-rich lipoproteins, also called remnant cholesterol, is being increasingly acknowledged. Elevated remnant cholesterol is associated with increased risk of myocardial infarction and ischaemic stroke. We tested the hypothesis that elevated remnant cholesterol is also associated with increased risk of peripheral artery disease (PAD). METHODS AND RESULTS We studied 106 937 individuals from the Copenhagen General Population Study recruited in 2003-15. During up to 15 years of follow-up, 1586 were diagnosed with PAD, 2570 with myocardial infarction, and 2762 with ischaemic stroke. We also studied 13 974 individuals from the Copenhagen City Heart Study recruited in 1976-78. During up to 43 years of follow-up, 1033 were diagnosed with PAD, 2236 with myocardial infarction, and 1976 with ischaemic stroke. Remnant cholesterol was calculated from a standard lipid profile. Diagnoses were from Danish nationwide health registries. In the Copenhagen General Population Study, elevated remnant cholesterol levels were associated with higher risk of PAD, up to a multivariable adjusted hazard ratio (HR) of 4.8 (95% confidence interval 3.1-7.5) for individuals with levels ≥1.5 mmol/L (58 mg/dL) vs. <0.5 mmol/L (19 mg/dL). Corresponding results were 4.2 (2.9-6.1) for myocardial infarction and 1.8 (1.4-2.5) for ischaemic stroke. In the Copenhagen City Heart Study, corresponding HRs were 4.9 (2.9-8.5) for PAD, 2.6 (1.8-3.8) for myocardial infarction, and 2.1 (1.5-3.1) for ischaemic stroke. CONCLUSION Elevated remnant cholesterol is associated with a five-fold increased risk of PAD in the general population, higher than for myocardial infarction and ischaemic stroke.
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Affiliation(s)
- Benjamin Nilsson Wadström
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 1, entrance 62, DK-2730 Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73 entrance 7, 4th floor, M3, Herlev DK-2730, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b 33.5., Copenhagen DK-2200, Denmark
| | - Anders Berg Wulff
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 1, entrance 62, DK-2730 Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73 entrance 7, 4th floor, M3, Herlev DK-2730, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b 33.5., Copenhagen DK-2200, Denmark
| | - Kasper Mønsted Pedersen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 1, entrance 62, DK-2730 Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73 entrance 7, 4th floor, M3, Herlev DK-2730, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b 33.5., Copenhagen DK-2200, Denmark
| | - Gorm Boje Jensen
- The Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Fasanvej 57, Hovedvejen, entrance 5, Frederiksberg DK-2000, Denmark
| | - Børge Grønne Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 1, entrance 62, DK-2730 Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 73 entrance 7, 4th floor, M3, Herlev DK-2730, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b 33.5., Copenhagen DK-2200, Denmark.,The Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Fasanvej 57, Hovedvejen, entrance 5, Frederiksberg DK-2000, Denmark
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How I treat unexplained arterial thrombosis. Blood 2021; 136:1487-1498. [PMID: 32584955 DOI: 10.1182/blood.2019000820] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/22/2020] [Indexed: 12/27/2022] Open
Abstract
Most arterial thrombotic events have a clear atherosclerotic or cardioembolic etiology, but hematologists are frequently asked to assist in the diagnosis and management of a patient with a nonatherosclerotic and noncardioembolic arterial event, referred to here as an unexplained arterial thrombosis. Because there is an assorted list of factors that can precipitate an arterial event, we present a systematic diagnostic approach to ensure consideration of not only primary hypercoagulable disorders, but also pro-thrombotic medications or substances, vascular and anatomic abnormalities, and undiagnosed systemic disorders, such as malignancy and autoimmune diseases. We also review existing literature of the role of hypercoagulable disorders in arterial thrombosis and discuss our approach to thrombophilia workup in patients after an unexplained arterial event. We conclude with 3 representative cases to both illustrate the application of the outlined diagnostic schema and discuss common management considerations, specifically the selection of anticoagulation vs antiplatelet therapy for secondary prevention.
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Jeong S, Kwon TW, Han Y, Cho YP. Effectiveness of Surgical Treatment with Complete Cyst Excision for Cystic Adventitial Disease of the Popliteal Artery. Ann Vasc Surg 2020; 72:261-269. [PMID: 32946995 DOI: 10.1016/j.avsg.2020.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cystic adventitial disease is a rare, nonatherosclerotic disease that affects various arteries and veins, involving the formation of a mucinous cyst within the adventitia. The etiology of the cystic adventitial disease is currently unclear, with several hypotheses having been suggested. The purpose of this retrospective observational study was to evaluate the etiology of popliteal cystic adventitial disease based on imaging and surgical findings and to evaluate the efficacy of surgical treatment. METHODS From April 2013 to January 2020, nine patients were diagnosed with the popliteal cystic adventitial disease and underwent surgical treatment. We performed complete resection of the cyst and the affected segment of the popliteal artery, followed by interposition with autologous reversed small saphenous vein or great saphenous vein. RESULTS The resected adventitial cyst tissue was multilobular, filled with high-viscosity mucus. Pathologic examination of the surgical specimen revealed intramural cysts filled with gelatinous material located between the media and the adventitia, consistent with the clinical diagnosis of cystic adventitial disease. The median follow-up period was 27.5 months (range: 2-91 months). All patients underwent cyst excision with graft interposition, and the overall graft patency was 80.9 months (95% CI: 62.2-99.6 months). CONCLUSIONS Computed tomography, magnetic resonance imaging, and surgical findings confirmed communication between the synovial cyst and arterial adventitia. It is recommended that priority be given to surgical resection and graft interposition because this can eliminate the disease's cause and reduce its recurrence.
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Affiliation(s)
- Seonjeong Jeong
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Nemoto M, Hosaka A. Spontaneous Regression of Cystic Adventitial Disease of the Popliteal Artery: A Case Report. Ann Vasc Surg 2019; 62:498.e11-498.e13. [PMID: 31449954 DOI: 10.1016/j.avsg.2019.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/11/2019] [Accepted: 06/20/2019] [Indexed: 12/22/2022]
Abstract
Spontaneous regression of cystic adventitial disease (CAD) of the popliteal artery is rare. In this report, we describe a 53-year-old woman who presented with left calf pain and was diagnosed with CAD with popliteal artery stenosis, which regressed without therapy. The disease was diagnosed via computed tomography, and a surgical intervention was planned at the time of diagnosis. However, her symptoms disappeared 2 months after the initial presentation. Ultrasonography and computed tomography revealed spontaneous regression of the cystic lesions and resolution of the popliteal artery stenosis. During the 29-month follow-up period, her symptoms did not recur. Although CAD often requires surgical intervention, it may be acceptable to carefully observe patients with spontaneous regression for some time to check for recurrence.
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Affiliation(s)
- Masaru Nemoto
- Department of Surgery, Ibaraki Prefectural Central Hospital & Cancer Center, Kasama-shi, Ibaraki, Japan
| | - Akihiro Hosaka
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
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Abstract
Atherosclerotic peripheral artery disease is the most common cause of intermittent claudication. Nonatherosclerotic peripheral artery disease is a heterogeneous collection of diseases affecting the extracoronary arteries which is not due to atherosclerosis. These diseases include, but are not limited to, popliteal artery entrapment syndrome, cystic adventitial disease, external iliac endofibrosis, and thromboangiitis obliterans. Due to its relatively low prevalence, nonatherosclerotic peripheral artery disease may be misdiagnosed leading to the mismanagement of potentially treatable conditions. The proper and timely diagnosis of these conditions is paramount to the prevention of adverse outcomes as treatments widely vary. The diagnostic approach to patients presenting with intermittent claudication must take into account both atherosclerotic as well as nonatherosclerotic causes of peripheral artery disease making the differential vital to clinical practice.
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Affiliation(s)
- Ari J Mintz
- Internal Medicine, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA,
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Surgical Treatment of Cystic Adventitial Disease of the Popliteal Artery: Five Case Reports. Case Rep Vasc Med 2015; 2015:984681. [PMID: 26339520 PMCID: PMC4539061 DOI: 10.1155/2015/984681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 07/26/2015] [Indexed: 11/17/2022] Open
Abstract
Cystic adventitial disease (CAD) is a rare cause of intermittent claudication and nonatherosclerotic conditions in middle-aged men without cardiovascular risk factors. The etiology of CAD is unclear; however, the direct communication between a cyst and a joint is presumed to be a cause. We herein report a case series of CAD of the popliteal artery (CADPA), in which patients were treated with surgical resection and vascular reconstruction. Although less invasive treatment modalities, including percutaneous cyst aspiration and percutaneous transluminal angioplasty, have been the subject of recent reports, these treatments have had a higher recurrence rate. Therefore, all of the CAPDA cases in the present series were treated surgically, which lead to good outcomes.
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Apigian AK, Landry GJ. Basic data underlying decision making in nonatherosclerotic causes of intermittent claudication. Ann Vasc Surg 2014; 29:138-53. [PMID: 25277047 DOI: 10.1016/j.avsg.2014.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/17/2014] [Indexed: 01/13/2023]
Abstract
Although most cases of vasculogenic intermittent claudication are caused by atherosclerosis, there is an important minority of cases that are due to nonatherosclerotic causes. Because of their rarity and younger population affected, often without traditional atherosclerotic risk factors, there is frequently a significant delay in diagnosis of nonatherosclerotic peripheral arterial diseases by several months to years in some cases. Here, we review the literature on nonatherosclerotic causes of lower extremity claudication, symptoms, management including surgical and endovascular interventions, and outcomes. Conditions included are popliteal artery entrapment syndrome, cystic adventitial disease, pseudoxanthoma elasticum, persistent sciatic artery, fibromuscular disease, giant cell arteritis, iliac endofibrosis, neurogenic claudication, and chronic exertional compartment syndrome.
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Affiliation(s)
- Aimie K Apigian
- Knight Cardiovascular Institute, Oregon Health & Science University, Sam Jackson Park Road, Portland, OR
| | - Gregory J Landry
- Knight Cardiovascular Institute, Oregon Health & Science University, Sam Jackson Park Road, Portland, OR.
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