ROC analysis of noninvasive tests for peripheral arterial disease

Association of plasma aldosterone concentration with peripheral artery disease in hypertensive patients: insights from a large cross-sectional analysis

Objectives

To investigate the relationship between plasma aldosterone concentration (PAC) and the prevalence of peripheral artery disease (PAD) in hypertensive patients and to determine any potential threshold effects.

Methods

This cross-sectional study analyzed data from 13,157 hypertensive individuals from the People's Hospital of Xinjiang Uygur Autonomous Region, China. PAD was diagnosed based on an ankle-brachial index (ABI) of ≤0.90. A multivariate logistic regression model was utilized to evaluate the association between PAC and PAD, and a generalized additive model (GAM) was employed to explore non-linear relationships.

Results

The fully adjusted logistic regression model revealed a significant positive association between PAC and PAD, with an odds ratio (OR) [95% confidence interval (CI)] of 1.06 (1.04, 1.08) per unit increase in PAC. The GAM identified a critical threshold at 17.00 ng/dl for PAC, above which the prevalence of PAD increased by 9% for each unit increase in PAC, with an OR (95% CI) of 1.09 (1.06, 1.11). Sensitivity and subgroup analyses confirmed the robustness of these findings.

Conclusion

This study establishes a non-linear relationship between PAC and the prevalence of PAD in hypertensive patients, with a critical threshold at 17.00 ng/dl. These findings underscore the importance of aldosterone homeostasis in vascular health and the need for further large-scale, prospective studies to validate these results and explore their clinical implications.

Evaluation of Computerized Tomography Utilization in Comparison to Digital Subtraction Angiography in Patients with Peripheral Arterial Disease

BACKGROUND

Perform literature review to analyze current practices in imaging patient with peripheral arterial disease (PAD) and examine patterns in our practice in order to assess whether a lower extremity computed tomography angiography (CTA) in addition to digital subtraction angiography enhanced the assessment of vessel calcification, percentage of stenosis, and affected outcomes in patients with PAD.

METHODS

The study included patients who underwent lower extremity imaging and were followed up to 12 months. This population was divided into cases who had both an angiogram and CTA performed within 30 days (n = 20), and controls who underwent angiography only (n = 19). Baseline characteristics, imaging results, and clinical outcomes were analyzed.

RESULTS

Thirty-nine patients met study criteria (mean age was 58.4 years, 69.2% were males, and 33.3% had diabetes). Patients mostly presented with tissue loss/rest pain (10.3%), claudication (15.4%), acute limb (10.3%), and trauma (15.4%). We have not observed any statistically significant differences in various examined blood vessels when their features (e.g., vessel diameter, stenosis, calcifications) were assessed by CTA combined with angiography versus angiography alone. The exceptions were external iliac artery, superficial femoral artery and dorsalis pedis vessels. In external iliac artery percentage of stenosis was 1.11% as determined by computed tomography (CT) scan versus 30% by angiography (P = 0.009). For superficial femoral artery stenosis, the percentage determined by CT was 48.68% vs. 81.41% by angiography, and observed difference between 2 modalities was statistically significant (P = 0.025). For dorsalis pedis percentage of stenosis detected by CT scan was 60.63% vs. 22.73% by angiography, and the differences in findings by these modalities were statistically significant (P = 0.039). The most frequent perioperative complication was cardiac-related (35.5%). Nineteen patients were readmitted and 8 had reinterventions within 12 months.

CONCLUSIONS

Both imaging modalities yielded similar results for assessing vessel calcification and percentage of stenosis regardless of anatomic vessel location. Overall, utilization of CTA in addition to angiography for large vessels above the knee (e.g., iliac artery, superficial femoral artery) and below the knee for dorsalis pedis provided more detailed information on the properties of these vessels. Therefore, during preoperative assessments, CTA may be helpful in addition to angiography for planning surgical and endovascular interventions for symptomatic PAD treatment in larger vessels.

Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients

Peripheral arterial disease (PAD) prevalence and diabetes mellitus (DM) prevalence are continuously increasing worldwide. The strong relationship between DM and PAD is highlighted by recent evidence. PAD diagnosis in diabetic patients is very important, particularly in patients with diabetic foot disease (DFD); however, it is often made difficult by the characteristics of such diseases. Diagnosing PAD makes it possible to identify patients at a very high cardiovascular risk who require intensive treatment in terms of risk factor modification and medical therapy. The purpose of this review is to discuss the diagnostic methods that allow for a diagnosis of PAD in diabetic patients. Non-invasive tests that address PAD diagnosis will be discussed, such as the ankle-brachial index (ABI), toe pressure (TP), and transcutaneous oxygen pressure (TcPO2). Furthermore, imaging methods, such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), are described because they allow for diagnosing the anatomical localization and severity of artery stenosis or occlusion in PAD. Non-invasive tests will also be discussed in terms of their ability to assess foot perfusion. Foot perfusion assessment is crucial in the diagnosis of critical limb ischemia (CLI), the most advanced PAD stage, particularly in DFD patients. The impacts of PAD diagnosis and CLI identification in diabetic patients are clinically relevant to prevent amputation and mortality.

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.

Long-term exposure to reduced specific-size ambient particulate matter and progression of arterial stiffness among Chinese adults

To assess the associations of ambient specific-size PM with brachial-ankle pulse wave velocity (baPWV) and the progression of arterial stiffness. Participants were included from the Kailuan study, the cross-sectional study involved 36,486 participants, while the longitudinal study enrolled 16,871 participants. PM exposures was assessed through satellite-based random forest approaches at a 1 km resolution. Initial observations indicated a link between baseline baPWV and heightened levels of PM1, PM2.5, and PM10 exposure, and greater effects were observed for PM1 (β: 22.52, 95% CI: 18.14-26.89), followed by PM2.5 (β: 9.76, 95% CI: 7.52-12.00), and PM10 (β: 8.88, 95% CI: 7.32-10.45). Furthermore, the growth rate of baPWV was higher in participants exposed to high levels of PM1 exposure (β: 2.77, 95% CI: 1.19-4.35), succeeded by PM2.5 and PM10. Throughout a median follow-up period of 4.04 years, arterial stiffness was diagnosed in 1709 subjects. Long-term exposure to PM was linked with an increased risk of incident arterial stiffness, estimated HR for fixed 10 µg/m3 increments in annual average PM1 was 2.20 (95% CI: 2.01-2.42), PM2.5 was 1.48 (95% CI: 1.41-1.55), and PM10 1.32 (95% CI: 1.27-1.36). PM had a greater impact on men and older individuals (P for interaction <0.001). Long-term exposures to ambient PM1, PM2.5, and PM10 were positively associated with baPWV and an increased risk of arterial stiffness. Higher estimated effects were observed for PM1 than PM2.5 and PM10.

Implications of Kidney Disease in Patients with Peripheral Arterial Disease and Vascular Calcification

Persons with chronic kidney disease (CKD) are at a higher risk of developing peripheral artery disease (PAD) and its adverse health outcomes than individuals with normal renal function. Among patients with CKD, PAD is predominantly characterized by the calcification of the medial layer of arterial vessels in addition to intimal atherosclerosis and calcification. Vascular calcification (VC) is initiated by CKD-associated hyperphosphatemia, hypercalcemia, high concentrations of parathyroid hormone (PTH) as well as inflammation and oxidative stress. VC is widely prevalent in this cohort (>80% dialysis and 50% patients with CKD) and contributes to reduced arterial compliance and symptomatic peripheral arterial disease (PAD). The most severe form of PAD is critical limb ischemia (CLI) which has a substantial risk for increased morbidity and mortality. Percutaneous endovascular interventions with transluminal angioplasty, atherectomy, and intravascular lithotripsy are the current nonsurgical treatments for severe calcific plaque. Unfortunately, there are no randomized controlled trials that address the optimal approach to PAD and CLI revascularization in patients with CKD.

Limb and cardiovascular event risk in type 1 and 2 diabetic patients with peripheral artery disease

Background: Peripheral artery disease (PAD) is a risk factor for adverse limb events (LE) and cardiovascular events (CVE) that coexists with type 1 (T1) and 2 (T2) diabetes mellitus (DM). Little is known about comparative risk of LE and CVE in T1/T2 DM patients with PAD. Patients and methods: We queried our database of 40,144 patients ≥18 years old who underwent ankle brachial index (ABI) measurement from 01/1996-02/2020. We isolated T1/T2 DM patients with PAD diagnosed by ankle brachial index (ABI; low [<1.0] or elevated [>1.4]) and retrieved demographics including glycated hemoglobin (HbA1c). Primary outcomes were LE (critical limb ischemia/vascular amputation) and CVE (myocardial infarction/ischemic stroke). All-cause mortality was a secondary outcome. Multivariable Cox proportional regression yielded hazard ratios (HR) with 95% confidence intervals (CI) after adjusting for pertinent risk factors including age, hypertension, hyperlipidemia, smoking, and HbA1c. Results: Our study found 10,156 patients with PAD and DM (34% T1DM, 66% T2DM) with median follow-up time 34 mo (IQR 85 mo). T1DM patients were younger than T2DM (mean age 67 vs. 70 years), with higher median HbA1c (7.7 [IQR 1.9] vs. 6.7% [IQR 1.6]), and more prevalent hypertension, hyperlipidemia, CAD, and CKD. Antiplatelet and statin use was equivocal. Elevated ABI was more common in T1DM (47 vs. 28%). LE occurred in 23% and CVE in 12% patients. LE risk was higher in T1 than T2 DM patients (HR 1.58 [95% CI 1.44, 1.73], p<0.0001), but CVE and all-cause mortality were equivocal. These observations were preserved across ABI and HbA1c subgroup analyses. Conclusions: PAD patients with T1DM had a higher LE risk than those with T2DM, even after adjustment for glycemic control and pertinent risk factors, but CVE risk and all-cause mortality were equivocal. These data suggest a potential role for more intensive LE risk modification in PAD patients with T1DM, but further investigation is needed.

Emergent management of diabetic foot problems in the modern era: Improving outcomes

Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage ("time is tissue"). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.

Chronic Limb-Threatening Ischemia and the Need for Revascularization

BACKGROUND

Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones.

METHODS

We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis.

RESULTS

Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue.

CONCLUSIONS

The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

Combined Evaluation of Arterial Stiffness and Blood Pressure Promotes Risk Stratification of Peripheral Arterial Disease

BACKGROUND

Previous studies have reported the separate association of arterial stiffness (AS) and blood pressure with peripheral arterial disease (PAD).

OBJECTIVES

The aim of this study was to investigate the risk stratification capacity of AS on incident PAD beyond blood pressure status.

METHODS

A total of 8,960 participants from Beijing Health Management Cohort were enrolled at the first health visit between 2008 and 2018 and then followed until the incidence of PAD or 2019. Elevated AS was defined as brachial-ankle pulse-wave velocity (baPWV) >1,400 cm/s, including moderate stiffness (1,400 ≤ baPWV <1,800 cm/s) and severe stiffness (baPWV ≥1,800 cm/s). PAD was defined as ankle-brachial index <0.9. A frailty Cox model was used to calculate the HR, integrated discrimination improvement, and net reclassification improvement.

RESULTS

During follow-up, 225 participants (2.5%) developed PAD. After adjusting for confounding factors, the highest risk for PAD was observed in the group with elevated AS and blood pressure (HR: 2.253; 95% CI: 1.472-3.448). Among participants with ideal blood pressure and those with well-controlled hypertension, PAD risk was still significant for severe AS. The results remained consistent in multiple sensitivity analyses. In addition, baPWV significantly improved the predictive capacity for PAD risk beyond systolic and diastolic blood pressures (integrated discrimination improvement 0.020 and 0.190, net reclassification improvement 0.037 and 0.303).

CONCLUSIONS

This study suggests the clinical importance of combined evaluation and control of AS and blood pressure for the risk stratification and prevention of PAD.

Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia

INTRODUCTION

The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI).

METHODS

We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs.

RESULTS

GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters.

CONCLUSIONS

The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.

Impact of supervised exercise on skeletal muscle blood flow and vascular function measured with MRI in patients with peripheral artery disease

Supervised exercise is a common therapeutic intervention for patients with peripheral artery disease (PAD), however, the mechanism underlying the improvement in claudication symptomatology is not completely understood. The hypothesis that exercise improves microvascular blood flow is herein tested via temporally resolved magnetic resonance imaging (MRI) measurement of blood flow and oxygenation dynamics during reactive hyperemia in the leg with the lower ankle-brachial index. One hundred and forty-eight subjects with PAD were prospectively assigned to standard medical care or 3 mo of supervised exercise therapy. Before and after the intervention period, subjects performed a graded treadmill walking test, and MRI data were collected with Perfusion, Intravascular Venous Oxygen saturation, and T2* (PIVOT), a method that simultaneously quantifies microvascular perfusion, as well as relative oxygenation changes in skeletal muscle and venous oxygen saturation in a large draining vein. The 3-mo exercise intervention was associated with an improvement in peak walking time (64% greater in those randomized to the exercise group at follow-up, P < 0.001). Significant differences were not observed in the MRI measures between the subjects randomized to exercise therapy versus standard medical care based on an intention-to-treat analysis. However, the peak postischemia perfusion averaged across the leg between baseline and follow-up visits increased by 10% (P = 0.021) in participants that were adherent to the exercise protocol (completed >80% of prescribed exercise visits). In this cohort of adherent exercisers, there was no difference in the time to peak perfusion or oxygenation metrics, suggesting that there was no improvement in microvascular function nor changes in tissue metabolism in response to the 3-mo exercise intervention.NEW & NOTEWORTHY Supervised exercise interventions can improve symptomatology in patients with peripheral artery disease, but the underlying mechanism remains unclear. Here, MRI was used to evaluate perfusion, relative tissue oxygenation, and venous oxygen saturation in response to cuff-induced ischemia. Reactive hyperemia responses were measured before and after 3 mo of randomized supervised exercise therapy or standard medical care. Those participants who were adherent to the exercise regimen had a significant improvement in peak perfusion.

Combination of Exercise Testing Criteria to Diagnose Lower Extremity Peripheral Artery Disease

Objectives: Nothing is known about the interest of the combination of exercise tests to diagnose Lower-extremity Peripheral Artery Disease (LEPAD). The aim of this study was to assess if combining exercise testing criteria [post-exercise Ankle-Brachial Index (ABI) + exercise-oximetry (exercise-TcPO2)] improves the detection of lower limbs arterial stenoses as compared with post-exercise ABI using American Heart Association (AHA) criteria, or exercise-TcPO2 alone. Material and Methods: In a prospective monocentric study, consecutive patients with exertional-limb pain and normal resting-ABI referred to our vascular center (Rennes, France) were assessed from May 2016 to February 2018. All included patients had a computed tomography angiography (CTA), a resting-ABI, a post-exercise ABI and an exercise-TcPO2. AHA post-exercise criteria, new validated post-exercise criteria (post-exercise ABI decrease ≥18.5%, post-exercise ABI decrease <0.90), and Delta from Rest of Oxygen Pressure (Total-DROP) ≤-15mmHg (criterion for exercise-TcPO2) were used to diagnose arterial stenoses ≥50%. For the different combinations of exercise testing criteria, sensitivity or specificity or accuracies were compared with McNemar's test. Results: Fifty-six patients (mean age 62 ± 11 years old and 84% men) were included. The sensitivity of the combination of exercise testing criteria (post-exercise ABI decrease ≥18.5%, or post-exercise ABI decrease <0.90 or a Total-DROP ≤-15mmHg) was significantly higher (sensitivity = 81% [95% CI, 71-92]) than using only one exercise test (post-exercise AHA criteria (sensitivity = 57% [43-70]) or exercise-TcPO2 alone (sensitivity = 59% [45-72]). Conclusions: Combination of post-exercise ABI with Exercise-TcPO2 criteria shows better sensitivity to diagnose arterial stenoses compared with the AHA post-exercise criteria alone or Exercise-TcPO2 criteria used alone. A trend of a better accuracy of this combined strategy was observed but an external validation should be performed to confirm this diagnostic strategy.

Long-Term (7-Year) Clinical Implications of Newly Unveiled Asymptomatic Abnormal Ankle-Brachial Index in Patients With Coronary Artery Disease

Background The long-term impact of newly discovered, asymptomatic abnormal ankle-brachial index (ABI) in patients with significant coronary artery disease is limited. Methods and Results Between January 2006 and December 2009, ABI was evaluated in 2424 consecutive patients with no history of claudication or peripheral artery disease who had significant coronary artery disease. We previously reported a 3-year result; therefore, the follow-up period was extended. The primary end point was a composite of all-cause death, myocardial infarction (MI), and stroke over 7 years. Of the 2424 patients with significant coronary artery disease, 385 had an abnormal ABI (ABI ≤0.9 or ≥1.4). During the follow-up period, the rate of the primary outcome was significantly higher in the abnormal ABI group than in the normal ABI group (P<0.001). The abnormal ABI group had a significantly higher risk of composite of all-cause death/MI/stroke than the normal ABI group, after adjustment with multivariable Cox proportional hazards regression analysis (hazard ratio [HR], 2.07; 95% CI, 1.67-2.57; P<0.001) and propensity score-matched analysis (HR, 1.97; 95% CI, 1.49-2.60; P<0.001). In addition, an abnormal ABI was associated with a higher risk of all-cause death, MI, and stroke, but not repeat revascularization. Conclusions Among patients with significant coronary artery disease, asymptomatic abnormal ABI was associated with sustained and increased incidence of composite of all-cause death/MI/stroke, all-cause death, MI, and stroke during extended follow-up over 7 years.

Evaluation of peripheral arterial disease in type 2 diabetic patients using computed tomography angiography

Background:

Peripheral artery disease (PAD) in patients with Type 2 diabetes mellitus (T2DM) has broad characteristics and various complications.

Aim:

The purpose of this study is to evaluate PAD in T2DM and their association with age, gender, and the duration of T2DM.

Materials and Methods:

This study is a prospective cross-sectional one conducted at the radiology department in Royal Care International Hospital, Khartoum, Sudan, over 3 years. A total of one hundred and ten patients, 69 males and 41 females, were examined using MDCT. A binary logistic regression test was applied to identify independent predictors of PAD.

Results:

PAD in T2DM is found to be 50.91% atherosclerosis, 43.64% plaques, 29.09% stenosis, and 14.55% thrombosis (mean age 65.84 ± 9.57 years; mean duration of T2DM 29.37 ± 6.7 years). The prevalence of PAD was common in patients over 60-year-old. Atherosclerosis is significantly higher in males than females (59.4% vs. 36.6%, 95% confidence interval = 1.092–5.600, P = 0.03%). Plaques and stenosis of lower-extremity arteries were higher in males than females 44.9% vs. 41.5% and 29.0% vs. 29.3%) respectively. The incidence of thrombosis was higher in femoral arteries than lower distal arteries, and the prevalence was higher in females than males (22% vs. 10.1%, odds ratio = 2.228), respectively.

Conclusion:

Atherosclerosis, plaques, stenosis, and thrombosis were the most common PAD findings in patients affected with T2DM. Age, gender, and duration of diabetes, relatively risk factors associated with PAD. Thrombosis is more prevalent in the femoral artery than lower distal arteries.

Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association

Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.

Lower Extremity Peripheral Artery Disease Without Chronic Limb-Threatening Ischemia: A Review

IMPORTANCE

Lower extremity peripheral artery disease (PAD) affects approximately 8.5 million people in the US and approximately 230 million worldwide.

OBSERVATIONS

Peripheral artery disease is uncommon before aged 50 years but affects up to 20% of people aged 80 years and older. It can be noninvasively diagnosed with the ankle-brachial index (ABI), a ratio of Doppler-recorded pressures in the dorsalis pedis and/or posterior tibial artery in each leg to brachial artery pressures. An ABI value less than 0.90 is 57% to 79% sensitive and 83% to 99% specific for arterial stenosis of at least 50%. Intermittent claudication, consisting of exertional calf pain that does not begin at rest and that resolves within 10 minutes of rest, is considered the classic symptom of PAD. However, 70% to 90% of people with an ABI value less than 0.90 either report no exertional leg symptoms (ie, asymptomatic) or report leg symptoms with walking that are not consistent with classic claudication. Over time, people with PAD restrict walking activity or slow walking speed to avoid leg symptoms. Thus, although approximately 75% of people with PAD report no change in leg symptoms over time, those with PAD have significantly greater annual declines in 6-minute walk performance compared with those without it. Approximately 11% of people with PAD develop chronic limb-threatening ischemia, the most severe form of PAD. Compared with people without PAD, those with the disease have approximately twice the rate of all-cause mortality, cardiovascular mortality, and major coronary events at 10-year follow-up. High-dose statins and antiplatelet therapy with or without antithrombotic therapy reduced rates of coronary events and stroke in people with PAD. Supervised treadmill exercise improved 6-minute walk distance by 30 to 35 m, consistent with a clinically meaningful change, whereas effective home-based walking exercise interventions improved 6-minute walk by 42 to 53 m. Effective home-based exercise programs require behavioral methods, including monitoring by a coach.

CONCLUSIONS AND RELEVANCE

Peripheral artery disease affects approximately 230 million people worldwide and is associated with increased rates of cardiovascular events, lower extremity events, and functional decline compared with that of people without PAD. People with PAD should be treated with the highest dose of statin tolerated, antithrombotic and/or antiplatelet therapy, and exercise.

Lower extremity CT angiography in peripheral arterial disease: from the established approach to evolving technical developments

With the advent of multidetector computed tomography (CT), CT angiography (CTA) has gained widespread popularity for noninvasive imaging of the arterial vasculature. Peripheral extremity CTA can nowadays be performed rapidly with high spatial resolution and a decreased amount of both intravenous contrast and radiation exposure. In patients with peripheral artery disease (PAD), this technique can be used to delineate the bilateral lower extremity arterial tree and to determine the amount of atherosclerotic disease while differentiating between acute and chronic changes. This article provides an overview of several imaging techniques for PAD, specifically discusses the use of peripheral extremity CTA in patients with PAD, clinical indications, established technical considerations and novel technical developments, and the effect of postprocessing imaging techniques and structured reporting.

Clinical Benefit, Harm, and Cost Effectiveness of Screening Men for Peripheral Artery Disease: A Markov Model Based on the VIVA Trial

OBJECTIVE

Although screening for peripheral arterial disease (PAD) seems obvious due to its two to three times increased mortality, high prevalence in the elderly, ease of detection, and relatively harmless prevention, the evidence is sparse.

METHODS

A Markov decision model was created to model the lifetime effectiveness and cost effectiveness of general population PAD screening and relevant intervention in 65 year old men. The model was informed by original estimates from the VIVA trial data except for ankle brachial systolic blood pressure index test accuracy, quality of life, and background mortality, which were adopted from the literature. A Markov model was designed for 65 year old men, who were distributed in the starting states of no/detected/undetected PAD. The main outcomes were life years, quality adjusted life years, and costs of healthcare.

RESULTS

Screening for PAD reduced the rates of amputations and stroke by 10.9% and 2.4%, respectively, while it increased the rates of revascularisation, acute myocardial infarction, and major bleeding by 5.5%, 7.1%, and 4.3% respectively. The overall life expectancy was increased by 14 days per invited subject. The cost per life year/quality adjusted life year was estimated at €16 717/€20 673. On the addition of low dose rivaroxaban reduced the costs per life year gained by 40%. If the model ran for only five follow up years, screening reduced relative mortality by 1.71%, suggesting PAD screening accounts for one fourth of the reported overall 7% relative mortality risk reduction of combined abdominal aortic aneurysm, PAD, and hypertension screening.

CONCLUSION

Screening of men for PAD is likely to be both clinically effective and cost effective in a lifetime perspective.

The accuracy of toe brachial index and ankle brachial index in the diagnosis of lower limb peripheral arterial disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

We aimed to compare the diagnostic accuracy of ankle brachial index (ABI) and toe brachial index (TBI) for peripheral arterial disease (PAD) in a wide spectrum of PAD populations and reference standard tests, and to examine variables influencing heterogeneity in the estimates.

METHODS

Systematic searches in EMBASE, MEDLINE, Web of Science and the Cochrane Library databases were performed, from inception to January 2020. Hierarchical summary receiver operating characteristic curves (HSROC) were used to summarize the pooled test performance.

RESULTS

Thirty five (patient-level: 1318 patients, limb-level: 5637 limbs) and nine studies (patient-level: 294 patients, limb-level: 826 limbs) were included in ABI and TBI meta-analyses, respectively. The QUADAS-2 tool identified many studies with high risk of bias, especially in the "patient selection" domain. Pooled estimates for ABI in detecting 50% or greater stenosis were sensitivity = 61% (95% CI: 55-69), specificity = 92% (95% CI: 89-95) and dOR = 16.5 (95% CI: 11.5-23.6). Similarly, TBI yielded sensitivity = 81% (95% CI: 70-94), specificity = 77% (95% CI: 66-90) and dOR = 13.1 (95% CI: 7.0-24.8). In a direct comparison of seven studies jointly analyzing ABI and TBI, TBI showed better overall diagnostic accuracy (16.4 vs 11.0 in dOR) at the expense of sensitivity (82% vs 52%), while specificity (77% vs 94%) performed worse in TBI than ABI. Heterogeneity was large in sensitivity for ABI, with variables as different reference standard tests, smoking habit and PAD prevalence accounting for such variability. Similarly, gender, different index test cut-offs and sample size influenced the heterogeneity in TBI specificity.

CONCLUSIONS

Though ABI and TBI showed similar diagnostic performance to diagnose PAD, TBI showed far better sensitivity than ABI, especially in "challenging populations", as those exhibiting calcification.

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.

Discordant Values in Lower Extremity Physiologic Studies Predict Increased Cardiovascular Risk

Background

Ankle‐brachial indexes (ABI) are a noninvasive diagnostic tool for peripheral arterial disease and a marker of increased cardiovascular risk. ABI is calculated using the highest systolic blood pressure of the 4 ankle arteries (bilateral dorsalis pedis and posterior tibial). Accordingly, patients may be assigned a normal ABI when the result would be abnormal if calculated using one of the other blood pressure readings. Cardiovascular outcomes for patients with discordant ABIs are undescribed.

Methods and Results

We performed a retrospective study of patients who underwent ABI measurement for any indication between January 1996 and June 2018. Those with normal ABIs (1.00–1.39) were included. We compared patients with all 4 normal ABIs (calculated using all 4 ankle arteries; n=15 577, median age 64.0 years, 54.4% men) to those with discordant ABIs (at least 1 abnormal ABI ≤0.99; n=2095, median age 66.0 years, 47.8% men). The outcomes assessed were ischemic stroke, myocardial infarction, and all‐cause mortality. Compared with patients with concordant normal ABIs, patients with discordant ABIs were older; women; smoked; and had chronic kidney disease, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, or prior stroke. Patients with discordant ABIs had a greater risk of myocardial infarction (hazard ratio [HR], 1.31; 95% CI, 1.10–1.56), ischemic stroke (HR, 1.53; 95% CI, 1.37–1.72), and all‐cause mortality (HR, 1.27; 95% CI, 1.16–1.39), including after adjustment for baseline comorbidities.

Conclusions

Discordant ABI results were associated with an increased risk of myocardial infarction, stroke, and all‐cause mortality in the studied population. Clinicians should examine ABI calculations using all 4 ankle arteries to better characterize a patient's cardiovascular risk.

[Lower-limb peripheral arterial disease]

Peripheral arterial disease is a result of atheroma. This disease is frequent in subjects with vascular risk factors. This disease is also frequent in low income countries. The detection and the diagnosis of peripheral arterial disease is obtained by calculating the ankle brachial index. Patients with peripheral arterial disease are not always symptomatic thus explaining how this disease is under diagnosed. The symptoms can be absent, and especially in case of diabetes or in women. In case of peripheral arterial disease, atheroma often involves other arterial vascular networks especially the coronaries. An adapted treatment reduces the morbi-mortality linked to this disease. This treatment is based on the correction of the vascular risk factors and especially tobacco cessation, walking rehabilitation and drugs (antiplatelet agent, statin, renin angiotensin system blocker). In case of rest or critic ischemia, the first-line treatment is a revascularisation. In peripheral arterial disease, management of patients is often non optimal and therapeutic targets fairly often obtained.

Peripheral arterial disease diagnosis and management in primary care: a qualitative study

BACKGROUND

Patients diagnosed with peripheral arterial disease (PAD) are at an increased risk of coronary heart disease, stroke, heart attack, and PAD progression. If diagnosed early, cardiovascular risk factors can be treated and the risk of other cardiovascular diseases can be reduced. There are clear guidelines on PAD diagnosis and management, but little is known about the issues faced in primary care with regards adherence to these, and about the impact of these issues on patients.

AIM

To identify the issues for primary care health professionals (HPs) and patients in PAD diagnosis and management, and to explore the impact of these on HPs and PAD patients.

DESIGN & SETTING

Qualitative study conducted in a primary care setting in the North East of England. Data was collected between December 2014 and July 2017.

METHOD

Semi-structured interviews and focus groups were conducted with PAD register patients (n = 17), practice nurses ([PNs], n = 17), district nurses (DNs], n = 20), tissue viability nurses (n = 21), and GPs (n = 21).

RESULTS

HPs' attitudes to PAD, difficulty accessing tests, and patient delays impacted upon diagnosis. Some HPs had a reactive approach to PAD identification. Patients lacked understanding about PAD and some reported a delay consulting their GP after the onset of PAD symptoms. After diagnosis, few were attending for regular GP follow-up.

CONCLUSION

Patient education about PAD symptoms and risks, and questioning about exercise tolerance, could address the problem of under-reporting. Annual reviews could provide an opportunity to probe for PAD symptoms and highlight those requiring further investigation. Improved information when PAD is diagnosed and, considering the propensity for patients to tolerate worsening symptoms, the introduction of annual follow-up (at minimum) is warranted.

Vascular Tests for Dermatologists

Dermatologists encounter patients with a variety of lower extremity ulcers including those related to venous insufficiency and peripheral arterial disease. Vascular studies, including ankle brachial pressure index, toe pressure, toe brachial index, Doppler arterial waveform, Duplex ultrasonography, and angiography, play an essential role in the prevention, diagnosis, and management of vascular diseases. In fact, dermatologists are often the first medical providers to see patients with complex vascular conditions. Knowledge of the appropriate indications, interpretations, limitations, and advantages of the various vascular studies is critical to the successful and swift management of each patient presenting with a lower extremity ulcer. This study reviews the most commonly ordered arterial and venous studies and discusses the appropriate indications and interpretation of these studies.

Screening of peripheral arterial disease in primary health care

Background and purpose

The screening tool for diagnosing lower extremity arterial disease is the assessment of the ankle-brachial index (ABI), which is widely used in general practice. However, resting ABI can easily produce a false negative result. In light of this, our goal was to determine the proportion of definitive diagnoses (peripheral arterial disease [PAD] confirmed or refuted) among patients screened in general practice, and the rate of cases in which the need for further specialized examination is necessary, with special attention to groups having non-compressible arteries and ABI negative symptomatic status. The aim of our work is to improve the efficiency of primary health care screening in PAD and reduce the extremely high domestic amputation ratio.

Patients and methods

Eight hundred and sixteen patients were screened. We used the Edinburgh Questionnaire and recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing.

Results

Thirty-three percent complained about lower extremity claudication; 23% had abnormal ABI values; 13% of the patients within the normal ABI range had complaints of dysbasia; and 12% were in the non-compressible artery group. The ABI-negative symptomatic group’s risk factor profile showed a close similarity to the clear PAD-positive and non-compressible artery groups.

Conclusion

The percentage of PAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups, together defined as the “murky zone”. When screening purposely for PAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is high clinical suspicion of PAD in spite of normal ABI values, further assessment may be considered.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Ankle Brachial Pressure Index: An update for the vascular specialist and general practitioner

Objectives

Ankle brachial pressure index (ABPI) is an invaluable tool for assessing the severity of peripheral arterial disease. In addition, it can be used as an independent marker of cardiovascular risk, with a predictive ability similar to the Framingham criteria. Identification of an abnormal ABPI should therefore trigger aggressive cardiac risk factor modulation for a patient. Unfortunately, the significance of abnormal ABPIs is poorly understood within the general medical community. This is compounded by the influence of various comorbidities on accurate measurement of ABPI, potentially leading to a wide variability in readings that need to be considered before interpretation in these patient populations. We aim to address these issues by revealing several common misunderstandings and pitfalls in ABPI measurement, describing accurate methodology, and highlighting patient cohorts in whom additional or alternative approaches may be required.

Methods

We present a narrative review of the role of ABPI in both the community and hospital setting. We have performed a literature review, exploring the validity and reproducibility of methodology for obtaining ABPI, alongside the utility of ABPI in different clinical scenarios.

Results

The measurement of ABPI is often performed incorrectly. Common pitfalls include inadequate patient preparation, failure to obtain the blood pressure from the correct lower limb artery in patients with tibial disease, failure to account for differences in brachial blood pressure between the arms, inappropriately chosen equipment and patient factors such as highly calcified arteries. Standardisation of methodology greatly improves reliability of the test. Exercise ABPI can identify significant peripheral arterial disease in patients with normal resting ABPI. In addition to its role in peripheral arterial disease, ABPI measurement has a role in assessing venous ulcers, entrapment syndromes and injured extremities; conversely, it has a more limited utility in the diabetic population.

Conclusions

A thorough understanding of the correct technique and associated limitations of ABPI measurement is essential in accurately generating and interpreting the data it provides. With this knowledge, the ABPI is an invaluable tool to help manage patients with peripheral arterial disease. Perhaps more importantly, ABPI can be used to identify and risk stratify patients with asymptomatic peripheral arterial disease, itself a major indicator of significant underlying cardiovascular disease. With the emergence of best medical therapy, targeted pharmacotherapy and lifestyle changes can reduce the risk of major cardiovascular events in high-risk patients by approximately 30%, particularly in diabetic patients. Therefore, the utility of ABPI transgresses vascular surgery, with an essential role in general practice and public health.

Hospital Discharge Teaching for Patients with Peripheral Vascular Disease

Peripheral disease affects both arteries and veins and encompasses pathophysiologic conditions that affect arterial, venous, and lymphatic circulations. This article discusses disorders of peripheral vascular disease (PVD) that affect the lower extremity. PVD is an obstruction in the arteries known as arteriosclerosis obliterans, a condition that manifests from insufficient tissue perfusion that results in hardening of the arteries. Peripheral artery disease leads to an inflammatory condition called atherosclerosis. People at greatest risk include smokers, diabetics, those with high blood pressure, and those with elevated cholesterol levels.

Recent advances in magnetic resonance imaging for peripheral artery disease

The global burden of peripheral artery disease (PAD) is significant. This has led to numerous recent advances in magnetic resonance imaging (MRI) techniques in PAD. Older techniques such as time of flight MRI or phase contrast MRI are burdened by long acquisition times and significant issues with artifacts. In addition, the most used MRI modality, contrast-enhanced MR angiography (CE-MRA) is limited by the use of gadolinium contrast and its potential toxicity. Novel MRI techniques such as arterial spin labeling (ASL), blood-oxygen-level dependent imaging (BOLD), and first-pass perfusion gadolinium enhancement are advancing the field by providing skeletal muscle perfusion/oxygenation data while maintaining excellent spatial and temporal resolution. Perfusion data can be critical to providing objective clinical data of a visualized stenosis. In addition, there are a number of new MRI sequences assessing plaque composition and lesion severity in the absence of contrast. These approaches used in combination can provide useful clinical and prognostic data and provide critical endpoints in PAD research.

Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study

BACKGROUND

To characterize patients with internal carotid occlusion (ICO) with respect to demographic data, associated diseases, medical management, and risk factors and to compare these patients with those with nonsignificant stenosis (NSS; less than 50% stenosis). Secondary end points were new neurologic events, progression of contralateral degree of stenosis, cardiovascular symptoms, and death during follow-up.

METHODS

Retrospective analysis was performed using data collected from clinical records and added to a prospective database. Missing data were obtained during phone interviews or requested medical appointments.

RESULTS

From 2005 to 2013, 213 patients with ICO and 172 with NSS were studied (medium follow-up 37.81 months). Among the patients with ICO, a greater proportion were men, had a history of smoking, and presented with peripheral arterial disease and a lower creatinine clearance compared with those with NSS (P < 0.05). At the time of diagnosis, 76.1% of the patients with ICO were symptomatic compared with 35.5% of those with NSS (P = 0.000001). The patients in the ICO group exhibited significant progression of contralateral stenosis compared with those in the control group with progression on any side (15.0% vs. 2.3%, P = 0.00011). In addition, 18 patients in the ICO group (8.5%) exhibited new neurological symptoms compared with 13 (7.6%) in the NSS group (P = 0.41). When the ICO and NSS groups were combined, 10.8% of the initially symptomatic patients presented with new symptoms compared with 4.3% of those who were initially asymptomatic (P = 0.0218). The number of deaths was significantly higher among the patients in the ICO group (14.1% vs. 6.4%, P = 0.0150).

CONCLUSIONS

Patients presenting with ICO have more risk factors and higher mortality by any cause. Initially, symptomatic patients will likely present with more neurological symptoms during follow-up, independent of carotid morphology, ICO, or NSS. Efforts must be made to identify those at risk before occlusion and to prevent secondary events and death.

Prevalence of previously unrecognized peripheral arterial disease in patients undergoing coronary angiography

Coronary artery disease (CAD) and peripheral arterial disease (PAD) are serious manifestations of systemic atherosclerosis. A considerable proportion of patients with CAD have associated PAD; however, many are asymptomatic and this condition remains underdiagnosed. Little is known about the prevalence and clinical implication of PAD in patients undergoing coronary angiography in the Middle East with no history of the disease.To study the prevalence of previously unrecognized PAD of the lower limbs in patients undergoing coronary angiography, and to determine the correlation with CAD.This is a prospective study conducted at a university tertiary referral hospital. A total of 2120 patients referred for coronary angiography without a prior diagnosis of PAD, between January 1, 2014 and December 31, 2014, were included. Patients were evaluated through detailed medical history taking, a questionnaire survey to assess symptoms and functional status, ankle-brachial index (ABI) measurement, and coronary angiography. PAD was considered present if the ABI was <0.90 in either leg.In all patients, the prevalence of previously unrecognized PAD was 12.8%. There was no significant difference between men and women (13.4% vs 11.7%, P = .485). Abnormal angiographic results were seen in 82% (1739 of 2120). The prevalence of PAD was 14.7% in patients with abnormal coronary angiographic result, significantly higher than that in patients with normal results (4.5%, P < .0001). The prevalence of abnormal angiographic results among patients with and without PAD was 96% and 80%, respectively (P = .001). Factors independently related to PAD were age (odds ratio [OR] 1.081, 95% confidence interval [CI] 1.053-1.109; P < .001), hypertension (OR 3.122, 95% CI: 1.474-5.678; P < .004), diabetes (OR 1.827, 95% CI: 0.975-2.171; P = .04), smoking (OR 1.301, 95% CI: 0.725-2.076; P < .001), previous coronary artery bypass grafting (OR 2.939, 95% CI: 1.385-5.219; P = .004), previous cerebrovascular accident (OR 3.212, 95% CI: 1.872-9.658; P = .003), left main CAD (OR 9.535, 95% CI: 3.978-20.230; P = .002), and multivessel CAD (OR 1.869, 95% CI: 1.018-2.798; P = .03). Patients with CAD and PAD were associated with a higher prevalence of multivessel CAD (58.2% vs 42.6%, P < .005) and left main disease (3% vs 0.3%, P < .0001).The prevalence of undiagnosed PAD in patients undergoing coronary angiography was 12.8% (14.7% in patients with CAD) and associated with a higher incidence of cardiovascular risk factors, multivessel disease, and left main disease. The high prevalence of PAD in patients with CAD confirms the importance of active screening for PAD by using ABI. Routine determination of ABI in the clinical evaluation of all patients with CAD may help identify high-risk patients.

CT Angiography in the Lower Extremity Peripheral Artery Disease Feasibility of an Ultra-Low Volume Contrast Media Protocol

Purpose

The ALARA principle is not only relevant for effective dose (ED) reduction, but also applicable for contrast media (CM) management. Therefore, the aim was to evaluate the feasibility of an ultra-low CM protocol in the assessment of peripheral artery disease (PAD).

Materials and methods

Fifty PAD patients were scanned on third-generation dual-source computed tomography, from diaphragm to the forefoot, as follows: tube voltage: 70 kV, reference effective tube current: 90 mAs, collimation: 192 × 2 × 0.6 mm, with individualized acquisition timing. The protocol ED (mSv) was quantified with dedicated software. CM protocol consisted of 15 ml test bolus and 30 ml main bolus (300 mgI/ml) injected at 5 ml/s, followed by a 40 ml saline chaser at the same flow rate. Aorto-popliteal bolus transit time was used to calculate the overall acquisition time and delay. Objective (hounsfield units—HU; contrast-to-noise ratio—CNR) and subjective image quality (four-point Likert score) were assessed at different anatomical regions from the aorta down to the forefoot.

Results

Mean attenuation values were exceeding 250 HU from aorta down to the anterior tibial artery with CNR < 13. However, decline in attenuation was observed in more distal region with mean values of 165 and 199 HU, in left and right dorsalis pedis artery, respectively. Mode subjective image quality from the level of aorta down to the popliteal segment was excellent; below the knee mode score was good. The mean ED per protocol was 1.1 ± 0.5 mSv.

Conclusion

Use of an ultra-low CM volume protocol at 70 kV is feasible in the evaluation of PAD, resulting in good to excellent image quality with mean ED of 1.1 ± 0.5 mSv.

Level of evidence

Level 3, Local non-random sample

Peripheral vascular disease assessment in the lower limb: a review of current and emerging non-invasive diagnostic methods

BACKGROUND

Worldwide, at least 200 million people are affected by peripheral vascular diseases (PVDs), including peripheral arterial disease (PAD), chronic venous insufficiency (CVI) and deep vein thrombosis (DVT). The high prevalence and serious consequences of PVDs have led to the development of several diagnostic tools and clinical guidelines to assist timely diagnosis and patient management. Given the increasing number of diagnostic methods available, a comprehensive review of available technologies is timely in order to understand their limitations and direct future development effort.

MAIN BODY

This paper reviews the available diagnostic methods for PAD, CVI, and DVT with a focus on non-invasive modalities. Each method is critically evaluated in terms of sensitivity, specificity, accuracy, ease of use, procedure time duration, and training requirements where applicable.

CONCLUSION

This review emphasizes the limitations of existing methods, highlighting a latent need for the development of new non-invasive, efficient diagnostic methods. Some newly emerging technologies are identified, in particular wearable sensors, which demonstrate considerable potential to address the need for simple, cost-effective, accurate and timely diagnosis of PVDs.

Medical Management of Functional Impairment in Peripheral Artery Disease: A Review

Lower extremity peripheral artery disease (PAD) now affects 200 million people worldwide and is a major cause of disability. Cilostazol is the only Federal Drug Administration approved medication for PAD-related ischemic symptoms that is recommended by clinical practice guidelines. Supervised treadmill exercise significantly improves treadmill walking performance in PAD. Recent evidence shows that home-based exercise interventions that include occasional medical center visits and incorporate behavioral change techniques also significantly improve walking endurance in PAD. Upper and lower extremity ergometry (cycling) also improve walking ability in PAD. A recent decision by the Center for Medicaid and Medicare Services to cover supervised exercise for people with symptomatic PAD will increase access to exercise for the large number of people disabled by PAD.

Exercise Rehabilitation for Peripheral Artery Disease: A REVIEW

PURPOSE

To summarize evidence regarding exercise therapy for people with lower extremity peripheral artery disease (PAD).

METHODS

Literature was reviewed regarding optimal strategies for delivering exercise interventions for people with PAD. Randomized trial evidence and recent studies were emphasized.

RESULTS

Randomized clinical trial evidence consistently demonstrates that supervised treadmill exercise improves treadmill walking performance in people with PAD. A meta-analysis of 25 randomized trials (1054 participants) concluded that supervised treadmill exercise was associated with 180 m of improvement in maximal treadmill walking distance and 128 m of improvement in pain-free walking distance compared with a control group. Three randomized trials of 493 patients with PAD demonstrated that home-based walking exercise interventions that incorporate behavioral change techniques improve walking ability in patients with PAD. Furthermore, evidence suggests that home-based walking exercise improves the 6-min walk more than supervised treadmill exercise. Upper and lower extremity ergometry also significantly improved walking endurance in PAD. The Centers for Medicare & Medicaid Services recently determined that Medicare would cover 12 wk (36 sessions) of supervised treadmill exercise for patients with PAD.

CONCLUSIONS

Supervised treadmill exercise and home-based walking exercise each improve walking ability in patients with PAD. The availability of insurance coverage for supervised treadmill exercise for patients with PAD will make supervised treadmill exercise more widely available and accessible. Home-based exercise that incorporates behavioral change technique is an effective alternative for patients unwilling or unable to attend 3 supervised exercise sessions per week.

Predictors of Change in the Ankle Brachial Index with Exercise

OBJECTIVE

A 20% or greater decrease in the ankle brachial index (ABI) with exercise is suggestive of peripheral artery disease (PAD), and could identify patients with an increased mortality risk. The predictors of a change in the ABI with exercise have received little attention.

METHODS

This was a cross-sectional analysis. Two hundred and sixty five participants of the San Diego Population Study with a resting ABI between 0.90 and 1.10 performed 50 heel raises and immediately had their ABIs measured again. The relationship between the change in the ABI with exercise and multiple potential risk prediction variables were examined using linear regression. In addition, the categorical percent change in the ABI with exercise was analysed by multinomial logistic regression.

RESULTS

The mean age of participants was 71.8 years, and 80.4% were female. At rest, the average ABI was 1.04 (SD 0.04) before and 0.94 (SD 0.13) after exercise; a mean decrease of 9.5%. In analyses of ABI change as a continuous variable, higher age, any smoking history, and a diagnosis of chronic obstructive pulmonary disease (COPD) were associated with a significant decrease in the ABI with exercise (p = .01, .04, and .03, respectively). Categorical analyses of the risk factors associated with a 20% or greater ABI decrease with exercise confirmed these results. Congestive heart failure was associated with an increased ABI with exercise (p = .04) in continuous ABI change analyses only.

CONCLUSIONS

Older age, a positive history of smoking, and a history of COPD were independently and significantly associated with a greater ABI decrease with exercise. These risk variables may help identify persons with subclinical PAD.

Critical Limb Ischemia: A Practical Up-To-Date Review

Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5