Peripheral Artery Disease: Past, Present, and Future

Rivaroxaban and Aspirin in Drug-Coated Balloon Angioplasty for Femoropopliteal In-Stent Restenosis: A Retrospective Cohort Study

BACKGROUND

After drug-coated balloon (DCB) treatment of the femoropopliteal artery in-stent restenosis (ISR), a certain proportion of patients also experience target lesion restenosis. The purpose of this study was to explore the efficacy and safety of rivaroxaban combined with aspirin in the treatment of ISR after DCB intervention.

METHODS

Patients who underwent DCB treatment for ISR after femoropopliteal artery intervention at our center from March 2017 to February 2022 were included consecutively. According to the drug treatment after DCB intervention of ISR, the patients were divided into rivaroxaban and aspirin group (RA Group) and dual antiplatelet therapy (DAPT) group. The outcomes of 2 groups during the 12-month follow-up after DCB intervention were compared.

RESULTS

A total of 92 patients were included in final analysis, with 43 in RA group and 49 in DAPT group. During 12-month follow-up, a total of 15 cases of recurrent ISR were detected, and the recurrence rate of ISR and clinically driven target lesion revascularization in the RA group were lower than those in the DAPT group (P < 0.05). The vascular patency rate in the RA group was higher than that in the DAPT group at 6 and 12 months of follow-up (P < 0.05). During the follow-up, there were no adverse events such as death, myocardial infarction, stroke, amputation, or major bleeding, and only a total of 5 cases of minor bleeding occurred.

CONCLUSIONS

Compared with the standard DAPT regimen, rivaroxaban combined with aspirin can safely improve the follow-up outcome after DCB for femoropopliteal ISR.

Editor's Choice - Ten Year Time Trends of Amputation Surgery in Peripheral Arterial Disease in Germany: Before and During the COVID-19 Pandemic

OBJECTIVE

Peripheral arterial disease (PAD) has been associated with suboptimal treatment, high mortality, and high amputation rates. It is unclear how the COVID-19 (coronavirus disease 2019) pandemic affected this development in a long term context.

METHODS

This is a registry based, retrospective, nationwide cohort study including patients hospitalised with PAD as a main or secondary diagnosis and amputation surgery between 2012 - 2021 in Germany. Primary endpoints were population wide major and minor amputation rates, in hospital death, and in hospital mortality rates. Secondary endpoints were same admission revascularisations and in hospital death in the event of complications, i.e., failure to rescue (FTR). Pre-pandemic and pandemic trends, focusing on lockdown periods, were analysed.

RESULTS

A total of 365 926 patient records with PAD and amputation surgery were analysed. The median patient age was 75 years and 28.8% were female. Overall population wide amputation and in hospital mortality rates (monthly decrease -0.002/100 000, p < .001, and -0.001/100 000, p< .001, respectively) and in hospital mortality rate (8.0% for 2012 - 2014 vs. 6.5% for 2020 - 2021; p < .001) declined between 2012 and 2020. Concurrently, same admission revascularisations increased (41.0% for 2012 - 2014 vs. 47.0% for 2020 - 2021; p < .001), while FTR decreased in a subset of complications (acute ischaemia, major bleeding, compartment syndrome, and mesenterial ischaemia). In the first pandemic lockdown, there was a temporary trend change to higher major amputations rates (+0.02/100 000; p < .001) and higher in hospital mortality rates (+0.007/100 000; p < .001), which changed to a decrease as of the second lockdown (-0.03/100 000, p = .034, and -0.010/100 000, p < .001, respectively) in an interrupted time series analysis. There was no statistically significant change in observed amputation rates during lockdowns, while observed in hospital mortality rates decreased by 12.0% in the first lockdown (0.22/100 000 vs. 0.25/100 000; p = .005) compared with reference periods of the two previous years.

CONCLUSION

Between 2012 and 2021, pre-pandemic trends toward decreasing population wide overall amputation rates, fewer major amputations, more amputation related revascularisation procedures, and lower in hospital mortality were maintained despite a temporary trend to increased major amputations and in hospital mortality during the first COVID-19 related lockdown in Germany.

Omega-3 fatty acids for intermittent claudication

BACKGROUND

Peripheral artery disease (PAD) is a progressive disorder characterised by stenosis or occlusion of arteries, or both, due to arteriosclerosis. Intermittent claudication (IC) and diminished walking ability are often present as the main symptoms of PAD. Omega-3 fatty acids have been used in the treatment and prevention of coronary artery disease, although current evidence suggests they may be of limited benefit. Peripheral arterial disease and coronary artery disease share a similar pathogenesis. It is uncertain whether omega-3 fatty acids benefit people with IC. This is an update of the review first published in 2004 and updated in 2013.

OBJECTIVES

To evaluate the benefits and harms of omega-3 fatty acid supplementation in people with intermittent claudication.

SEARCH METHODS

We used standard, extensive Cochrane search methods, and searched the Cochrane Vascular Specialised Register via the Cochrane Register of Studies, CENTRAL, MEDLINE Ovid, Embase Ovid, and two trials registers on 19 April 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of omega-3 fatty acids versus placebo or non-omega-3 fatty acids in people with intermittent claudication.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were quality of life, pain-free walking distance, and maximal walking distance. Secondary outcomes were ankle-brachial index, revascularisation procedures in the lower limb, amputation rate/frequency, lipid levels, blood pressure, all-cause and vascular mortality, non-fatal vascular events, and adverse effects of therapy. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 15 RCTs (1830 participants) comparing omega-3 fatty acid supplementation with placebo or alternative therapies. The follow-up was four weeks to six years. The majority of the studies had unclear risk of bias, and many could not be included in our meta-analysis, so were reported narratively. The evidence is very uncertain about the effect of omega-3 fatty acids on quality of life. One study measured quality of life but did not present any data. The study authors reported there was no improvement in any of the eight self-reported quality-of-life parameters in the SF-36 questionnaire between entry and 16 weeks for the intervention group. No results were presented for the control group (very low-certainty evidence). Omega-3 fatty acids may result in little to no effect on pain-free walking distance (mean difference (MD) 1.01 metre (m), 95% confidence interval (CI) -34.23 to 36.24; 3 studies, 147 participants; very low-certainty evidence), or maximal walking distance (MD -4.18 m, 95% CI -37.10 to 28.74; 3 studies, 164 participants; very low-certainty evidence). Omega-3 compared with a control may have little to no effect on ankle-brachial index (MD -0.02, 95% CI -0.08 to 0.04; 3 studies, 168 participants; very low-certainty evidence). One study assessed the incidence of revascularisation procedures (lower limb angioplasty/bypass surgery) and rate of amputation (progression of critical limb ischaemia/amputation) in the lower limb. Results showed that omega-3 may have little to no effect on either outcome (very low-certainty evidence). Seven studies reported adverse events. Details of reporting varied amongst studies, and we were unable to combine the results. A total of 47 adverse effects were reported in the intervention groups compared to 33 events in the control groups (7 studies, 488 participants; low-certainty evidence). The evidence suggests that omega-3 results in little to no difference in adverse events. Meta-analyses showed no differences between intervention and placebo groups for cholesterol, triglycerides, or blood pressure. Two studies assessed mortality. All-cause mortality and vascular mortality were reported by one study, and vascular mortality by another. We were unable to pool the studies, but both studies individually reported there were no differences between the omega-3 and the control groups. There was no difference between the intervention and placebo groups for the incidence of non-fatal coronary events (odds ratio (OR) 0.59, 95% CI 0.13 to 2.60; 2 studies, 141 participants), or the incidence of non-fatal stroke/transient ischaemic attack (OR 0.95, 95% CI 0.13 to 6.77; 2 studies, 110 participants).

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of omega-3 fatty acids in people with intermittent claudication on quality of life, walking distance (pain-free or maximal), ankle-brachial index, and the incidence of revascularisation procedures or frequency of amputation in the lower limb. The evidence suggests that omega-3 results in little to no difference in adverse events. Further high-quality research is needed to fully evaluate short- and long-term effects of omega-3 fatty acids on the most clinically relevant outcomes in people with intermittent claudication.

Self-care dependency assessment of person with lower limb amputation: an exploratory study

BACKGROUND

(1) Dysvascular major lower limb amputation interferes with activities of daily living.

BACKGROUND

(2) Self-care with the highest level of dependency is "walking".

BACKGROUND

(3) Self-care with the lowest level of dependency is "feeding".

BACKGROUND

(4) Develop future interventions on the degree of dependency of patients with dysvascular amputation.

BACKGROUND

to identify the sociodemographic and clinical characteristics of the person with dysvascular major lower limb amputation and to assess their degree of dependence and autonomy in self-care activities at home.

BACKGROUND

quantitative, exploratory, cross-sectional and descriptive study. The convenience sample consisted of 40 participants. A sociodemographic questionnaire and the short version of the Self-Care Dependence Assessment Form were used for data collection.

BACKGROUND

of the 40 (100%) participants, the majority were male; 75% were over 65 years of age, 77.5% had a transfemoral amputation, and 72.5% were confined to a wheelchair. The higher levels of dependency predominated in self-care: "walking", "bathing", "dressing and undressing", "using the toilet" and "transferring".

BACKGROUND

this study showed that the self-care domain with the highest level of dependence is "walking" self-care, and the lowest is "feeding". Greater autonomy in using the toilet, walking and transferring from bed to chair were shown to be self-care activities with the best ability to predict patient autonomy.

Lipid-associated GWAS loci as important markers of the risk, severity, and clinical course of peripheral artery disease

BACKGROUND

This study investigated the relationship between lipid-associated loci identified through genome-wide association studies (GWAS) and the risk of peripheral artery disease (PAD), its severity, as well as clinical and laboratory features.

RESEARCH DESIGN AND METHODS

A study included 1263 unrelated Russian subjects, consisting of 620 patients diagnosed with PAD and 643 healthy controls. Thirteen single nucleotide polymorphisms (SNP) were genotyped using the MassArray-4 system.

RESULTS

Polymorphisms rs1689800, rs55730499 and rs881844 were found to be associated with an increased risk of PAD, whereas SNPs rs1883025, rs3136441, rs3764261 and rs6065906 showed protective effects against disease (Pperm ≤ 0.05). SNPs rs1689800, rs217406, rs1883025, and rs3136441 exhibited combined effects with cigarette smoking on the PAD risk (Pperm ≤ 0.05). Polymorphisms rs55730499 (beta = 0.124, Pperm = 0.04), rs9987289 (beta = 0.558, Pperm = 0.03), and rs881844 beta = -0.171, Pperm = 0.03) correlated with the ankle-brachial index. Multiple associations have been found between the SNPs and clinically significant characteristics, including disease severity, risk of gangrene, early disease onset, plasma procoagulant and atherogenic lipid changes (Pperm ≤ 0.05).

CONCLUSIONS

We identified novel genetic markers associated with PAD susceptibility and disease-related clinical and laboratory features. The identified biomarkers enhance the potential for predictive genetic testing related to the risk and progression of PAD, facilitating the integration of molecular diagnostics into clinical decision-making processes.

Emerging trends in nationwide mortality, limb loss, and resource utilization for critical limb ischemia in young adults

BACKGROUND/OBJECTIVES

Recent trends indicate a rise in the incidence of critical limb ischemia (CLI) among younger adults. This study examines trends in CLI hospitalization and outcomes among young adults with peripheral arterial disease (PAD) in the United States.

METHODS

Adult hospitalizations (18-40 years) for PAD/CLI were analyzed from the 2016-2020 nationwide inpatient sample database using ICD-10 codes. Rates were reported per 1000 PAD or 100,000 cardiovascular disease admissions. Outcomes included trends in mortality, major amputations, revascularization, length of hospital stay (LOS), and hospital costs (THC). We used the Jonckheere-Terpstra tests for trend analysis and adjusted costs to the 2020 dollar using the consumer price index.

RESULTS

Approximately 63,045 PAD and 20,455 CLI admissions were analyzed. The mean age of the CLI cohort was 32.7 ± 3 years. The majority (12,907; 63.1 %) were female and white (11,843; 57.9 %). Annual CLI rates showed an uptrend with 3265 hospitalizations (227 per 1000 PAD hospitalizations, 22.7 %) in 2016 to 4474 (252 per 1000 PAD hospitalizations, 25.2 %) in 2020 (Ptrend<0.001), along with an increase in PAD admissions from 14,405 (188 per 100,000, 0.19 %) in 2016 to 17,745 (232 per 100,000, 0.23 %%) in 2020 (Ptrend<0.0001). Annual in-hospital mortality increased from 570 (2.8 %) in 2016 to 803 (3.9 %) in 2020 (Ptrend = 0.001) while amputations increased from 1084 (33.2 %) in 2016 to 1995 (44.6 %) in 2020 (Ptrend<0.001). Mean LOS increased from 5.1 (SD 2.7) days in 2016 to 6.5 (SD 0.9) days in 2020 (Ptrend = 0.002). The mean THC for CLI increased from $50,873 to $69,262 in 2020 (Ptrend<0.001). The endovascular revascularization rates decreased from 11.5 % (525 cases) in 2016 to 10.7 % (635 cases) in 2020 (Ptrend = 0.025). Surgical revascularization rates also increased from 4.9 % (225 cases) in 2016 to 10.4 % (600 cases) in 2020 (Ptrend = 0.041).

CONCLUSION

Hospitalization and outcomes for CLI worsened among young adults during the study period. There is an urgent need to enhance surveillance for risk factors of PAD in this age group.

Lipoprotein Apheresis Alleviates Treatment-Resistant Peripheral Artery Disease Despite the Normal Range of Atherogenic Lipoproteins: The LETS-PAD Study

AIM

Peripheral artery disease (PAD) severely impairs patient prognosis and quality of life (QOL). Although lipoprotein apheresis (LA) has been applied to patients with PAD and elevated serum atherogenic lipoproteins, we hypothesized that LA can be effective for treating PAD even in patients with controlled serum lipoproteins through pleiotropic anti-atherosclerotic effects beyond lipoprotein removal. This study aimed to evaluate the efficacy of LA in patients with treatment-resistant PAD and controlled serum lipoproteins focusing on QOL.

METHODS

In a single-arm prospective study, 30 patients with refractory PAD who had controlled serum lipoproteins underwent sequential LA sessions using dextran sulfate adsorption columns, aiming to complete 10 sessions. The ankle-brachial pressure index (ABI) and vascular QOL (VascuQOL) score were evaluated as the primary outcomes. Secondary outcomes included reactive hyperemia index (RHI) and biological antioxidant potential (BAP) as an endothelial function test and serum antioxidative-capacity evaluation, respectively.

RESULTS

ABI significantly increased after LA sessions (pre-treatment 0.60±0.09 vs. post-treatment 0.65±0.13, p=0.023). Total VascuQOL score (3.7±1.1 vs 4.6±1.1, p＜0.001) and RHI (1.70±0.74 vs 2.34±1.76, p=0.023) significantly improved after the LA sessions. BAP tended to increase after the LA sessions, and the change reached statistical significance 3 months after treatment.

CONCLUSION

ABI and QOL improved after a series of LA sessions in conventional treatment-resistant PAD patients with controlled serum lipoprotein levels. Increased antioxidative capacity and ameliorated endothelial function were observed after the LA treatment.

Prevalence of peripheral arterial disease among individuals with type 2 diabetes mellitus in India - A systematic review and meta-analysis

BACKGROUND

Peripheral arterial disease (PAD) is a prevalent complication of type 2 diabetes mellitus (T2DM). As India ranks second in the population afflicted by T2DM, and the objective of this systematic review was to estimate the pooled prevalence of PAD in individuals living with T2DM in India.

METHODS

Five databases (Cochrane (CENTRAL), MEDLINE (via PubMed), CINAHL (via EBSCO), PEDro, and Scopus) were searched using database-specific search terms from inception to August 2023. Inclusion criteria included studies reporting the prevalence of PAD in Indian adults diagnosed with T2DM of either or both sexes, employing ankle brachial index measurements with a Doppler test or sphygmomanometer. The risk of bias was evaluated using the JBI checklist, and the certainty of evidence was determined via the GRADE approach.

RESULTS

Twenty-three articles met the inclusion criteria which comprised of 196,883 individuals with T2DM aged between 30 and 70 years from nine states and one union territory. Utilizing a random effects model, the meta-analysis revealed that the pooled prevalence of PAD among individuals with T2DM in India was 18 % (95 % confidence interval: 10-28 %), with statistically significant heterogeneity observed between studies (I2 = 100 %, P < 0.001). Overall certainty in the evidence was low.

CONCLUSION

The combined prevalence of PAD among individuals with T2DM in India is 18 %, indicating a significant portion of the Indian population has been affected. Epidemiological studies utilizing precise assessment tools can enhance the early detection and prevention of PAD in T2DM and improve the certainty of findings.

Outcomes of Patients with Critical Limb Ischemia and Chronic Kidney Disease: A National Perspective

INTRODUCTION

Studies exploring the relationship between peripheral arterial disease (PAD), critical limb ischemia (CLI), and chronic kidney disease (CKD) and its effect on in-hospital outcomes are limited. We aimed to analyze the outcomes of patients with CKD and PAD who are admitted for CLI.

METHODS

We utilized the National Inpatient Sample (NIS) to capture hospitalizations for CLI from 2012 to 2020 and then identified cases with concomitant CKD. The primary outcome was mortality, and secondary outcomes were cerebrovascular accident, major bleeding, vasopressor requirement, percutaneous coronary intervention, cardiac arrest, acute respiratory failure, transfusion, length of stay, and total hospital charges. Multivariable logistic regression was performed to adjust for covariates.

RESULTS

A total of 441,245 patients with CLI were identified, of which 122,370 (27.7%) reported concomitant CKD. Patients with CKD had higher in-patient mortality (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.17-1.68, p < 0.001), vascular complications (OR 1.31, 95% CI, 1.17-1.48, p < 0.001), acute kidney injury requiring hemodialysis (OR 3.17, 95% CI, 2.64-3.80, p < 0.001), and major bleeding (OR 1.12, 95% CI, 1.05-1.19, p < 0.001). Patients with CKD underwent minimally invasive endovascular therapy (31.08% vs. 36.73%, p < 0.0001) and invasive procedures (14.73% vs. 23.55%, p < 0.0001) less often. PAD-CLI with CKD was associated with major (20.54% vs. 16.17%, OR 1.04; p < 0.0001) and minor (26.87% vs. 19.53%, OR 1.2, p < 0.0001) amputations more often.

CONCLUSION

Patients admitted for PAD-CLI with concomitant CKD have significantly higher in-hospital mortality as compared to patients without CKD. Moreover, patients with CKD and PAD-CLI are less likely to receive revascularization and more likely to undergo amputation.

2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease: An Executive Summary

This article is an executive summary of the Wound, Ostomy, and Continence Nurses Society's (WOCN) 2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease. It is part of the Society's Clinical Practice Guideline Series. This article presents an overview of the systematic process used to update and develop the guideline. It also lists specific recommendations from the guideline for screening and diagnosis, assessment, management, and education of patients with wounds due to lower extremity arterial disease (LEAD). Suggestions for implementing recommendations from the guideline are also summarized. The guideline is a resource for WOC nurse specialists, other nurses, and health care professionals who work with adults who have/or are at risk of wounds due to LEAD. The complete guideline includes the evidence and references supporting the recommendations, and it is available from the WOCN Society's Bookstore (www.wocn.org). Refer to the Supplemental Digital Content Appendix (available at: http://links.lww.com/JWOCN/A123) associated with this article for a complete reference list for the guideline.

Sex Differences in Mortality Risk after the First Hospitalisation with Lower Extremity Peripheral Arterial Disease

OBJECTIVE

Lower extremity peripheral arterial disease (PAD) is a severe condition that increases the risk of major adverse cardiovascular events, major adverse limb events, and all cause mortality. This study aimed to investigate the mortality risk among females and males hospitalised for the first time with lower extremity PAD.

METHODS

Three cohorts of patients who were admitted for the first time with lower extremity PAD in 2007 - 2010, 2011 - 2014, and 2015 - 2018 were constructed. For the 2007 - 2010 and 2011 - 2014 cohorts, the 28 day, one year, and five year mortality rates were calculated, assessing survival time from date of hospital admission until date of death, end of study period, or censoring. For the 2015 - 2018 cohort, only 28 day and one year mortality were investigated due to lack of follow up data. Mortality rates of these cohorts were compared with the general population using standardised mortality rates (SMRs), and the risk of death between sexes was evaluated using Cox proportional hazards models. Cox models were adjusted for age, cardiovascular disease, and diabetes mellitus to account for potential confounding factors.

RESULTS

In total, 7 950, 9 670, and 13 522 patients were included in the 2007 - 2010, 2011 - 2014, and 2015 - 2018 cohorts, respectively. Over 60% of individuals in each cohort were males. Mortality rates at 28 day and one year remained stable across all cohorts, while the five year mortality rate increased for both males and females in the 2011 - 2014 cohort. The SMRs both of females and males with PAD were significantly higher than in the general population. Multivariable regression analyses found no significant differences in mortality risk between sexes at 28 day and one year. However, the five year mortality risk was lower in females, with a hazard ratio of 0.89 (95% confidence interval [CI] 0.83 - 0.97) in the 2007 - 2010 cohort and 0.88 (95% CI 0.82 - 0.94) in the 2011 - 2014 cohort.

CONCLUSION

The five year mortality risk has increased, and females face a lower mortality risk than males. Lower extremity PAD still carries unfavourable long term consequences compared with the general population.

Estimating an embolic source in peripheral artery disease using non-obstructive general angioscopy and histopathology

Spontaneously ruptured aortic plaques are known to scatter frequently. Peripheral artery disease (PAD) is assumed to be exacerbated by aortic embolism besides local atherosclerosis. However, it has been challenging to show where the embolic plug came from. We estimated the embolic source of PAD in a 78-year-old male with a history of repetitive occlusion in the right peroneal artery by demonstrating and sampling using non-obstructive angioscopy (NOGA) for peripheral arteries and the aorta. Screening of the aorta, the iliac artery, and the femoral artery by computed tomography angiography, and NOGA revealed aortic dissection in the infrarenal abdominal artery. Four puff-chandelier ruptures that scattered like puffs were detected, and sampling was successful from puff-chandelier ruptures in the thoracic aorta, in the suprarenal abdominal artery, and in the dissected infrarenal abdominal artery. Among three puff-chandelier ruptures, a puff-chandelier rupture in the dissected infrarenal abdominal artery had the highest homology regarding the structure and the degree of fatty globules and cholesterol crystals. Endovascular graft replacement in the infrarenal dissected abdominal artery stopped the patient's repeated worsening of PAD.

Learning objective

The potential cause of peripheral artery disease is embolism from the upstream arteries beside local atherosclerosis. Homological comparison between materials from the occluded site and scattering plaques at the aorta and upstream arteries may suggest the embolic mechanism. In this case, repetitive occlusion in the right peritoneal artery was attributed to the embolism from the dissected infrarenal aorta because the highest homology was shown between the dissected infrarenal aorta where stent graft replacement stopped worsening of peripheral artery disease.

Innovative nomogram for predicting 1-year clinically driven revascularization outcomes in endovascular femoropopliteal disease

Purpose

Femoropopliteal artery disease (FPAD) is a common vascular disease that usually requires surgical treatment. The aim of this study was to apply predictive modeling to develop predictive models for predicting clinically driven target revascularization (CD-TLR) events 1 year after intervention in patients with FPAD.

Materials and methods

In this study, clinical data were collected from a total of 484 patients who underwent FPAD endovascular intervention from 2014 to 2019. According to the inclusion and exclusion criteria, 400 patients will be finally included and assigned to the training cohort and test cohort in the ratio of 7:3. By analyzing these data through statistical methods, we will explore the effects of different factors on target revascularization events 1 year after intervention in FPAD patients, and build the corresponding prediction model of the column line graph.

Results

The final nomogram model consisted of 5 independent predictors: history of cerebrovascular disease, lesion length >15 cm, no atherectomy device used, no medicated balloon used and procedure time. The C-index of the model was 0.766 and 0.726 for the training cohort and validation cohort, respectively. The calibration curves also showed that the model had satisfactory agreement in both cohorts.

Conclusions

The newly developed prediction model can accurately predict clinically driven target revascularization events at 1 year in patients with FPAD, providing valuable information for the development of individualized treatment plans.

Oral Nanoformulations in Cardiovascular Medicine: Advances in Atherosclerosis Treatment

Atherosclerosis (AS) is the formation of atherosclerotic plaques on the walls of the arteries, causing them to narrow. If this occurs in the coronary arteries, the blood vessels may be completely blocked, resulting in myocardial infarction; if it occurs in the blood vessels of the brain, the blood vessels may be blocked, resulting in cerebral infarction, i.e., stroke. Studies have shown that the pathogenesis of atherosclerosis involves the processes of inflammation, lipid infiltration, oxidative stress, and endothelial damage, etc. SIRT, as a key factor regulating the molecular mechanisms of oxidative stress, inflammation, and aging, has an important impact on the pathogenesis of plaque formation, progression, and vulnerability. Statistics show that AS accounts for about 50 per cent of deaths in Western countries. Currently, oral medication is the mainstay of AS treatment, but its development is limited by side effects, low bioavailability and other unfavourable factors. In recent years, with the rapid development of nano-preparations, researchers have combined statins and natural product drugs within nanopreparations to improve their bioavailability. Based on this, this paper summarises the main pathogenesis of AS and also proposes new oral nanoformulations such as liposomes, nanoparticles, nanoemulsions, and nanocapsules to improve their application in the treatment of AS.

A Practical Guide to Understanding and Treating Peripheral Artery Disease

ABSTRACT

Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic morbidity after coronary heart disease and stroke yet is widely underdiagnosed and undertreated. Treatment of risk factors such as diabetes and cigarette smoking can benefit patients with PAD. Patients should have adequate blood pressure and lipid control to decrease clinical manifestations and symptoms of PAD. Use of antithrombotic medications should be individualized to the patient depending on the presence of symptoms, revascularization, and comorbidities. All patient care providers, including physicians, pharmacists, nurse practitioners, and physician assistants, should incorporate PAD screening in their at-risk patients to improve access for appropriate earlier diagnosis, initiation of guideline directed therapy, and risk factor modification to reduce both major adverse CV and limb outcomes. The purpose of this narrative review is to provide an overview of PAD and summarize clinical trial evidence and guideline recommendations for screening and treatment to increase awareness among health care providers to ultimately have a positive impact on patient care.

Correlation and risk factors of peripheral and cervicocephalic arterial atherosclerosis in patients with ischemic cerebrovascular disease

Patients with ischemic cerebrovascular disease (ICVD) frequently develop concomitant peripheral artery disease (PAD) or renal artery stenosis (RAS), and multiterritorial atherosclerotic patients usually have a worse prognosis. We aimed to evaluate the status of peripheral atherosclerosis (AS) and cervicocephalic AS (CAS) in ICVD patients with AS, their correlation, and related risk factors contributing to coexisting cervicocephalic-peripheral AS (CPAS). Based on the severity and extent of AS evaluated by computed tomography angiography and ultrasound, the degree of AS was triple categorized to assess the correlation between CAS and PAD/RAS. CAS and PAD/RAS were defined as the most severe stenosis being ≥ 50% luminal diameter in cervicocephalic or lower limb arteries, and a peak systolic velocity at the turbulent site being ≥ 180 cm/s in the renal artery. Among 403 patients with symptom onset within 30 days, CAS, PAD, and RAS occurrence rates were 68.7%, 25.3%, and 9.9%, respectively. PAD was independently associated with the degree of extracranial and intracranial CAS (p = 0.042, OR = 1.428, 95% CI 1.014-2.012; p = 0.002, OR = 1.680, 95% CI 1.206-2.339), while RAS was independently associated with the degree of extracranial CAS (p = 0.001, OR = 2.880, 95% CI 1.556-5.329). Independent CPAS risk factors included an ischemic stroke history (p = 0.033), increased age (p < 0.01), as well as elevated fibrinogen (p = 0.021) and D-dimer levels (p = 0.019). In conclusion, the occurrence rates of RAS and PAD in ICVD patients with AS is relatively high, and with the severity of RAS or PAD increase, the severity of CAS also increase. Strengthening the evaluation of peripheral AS and controlling elevated fibrinogen might be crucial for preventing and delaying the progression of multiterritorial AS in ICVD patients with AS, thereby improving risk stratification and promoting more effective prevention and treatment strategies.

Targeting Mitochondrial Dynamics during Lower-Limb Ischemia Reperfusion in Young and Old Mice: Effect of Mitochondrial Fission Inhibitor-1 (mDivi-1)

Peripheral arterial disease (PAD) strikes more than 200 million people worldwide and has a severe prognosis by potentially leading to limb amputation and/or death, particularly in older patients. Skeletal muscle mitochondrial dysfunctions and oxidative stress play major roles in this disease in relation with ischemia-reperfusion (IR) cycles. Mitochondrial dynamics through impairment of fission-fusion balance may contribute to skeletal muscle pathophysiology, but no data were reported in the setting of lower-limb IR despite the need for new therapeutic options. We, therefore, investigated the potential protective effect of mitochondrial division inhibitor-1 (mDivi-1; 50 mg/kg) in young (23 weeks) and old (83 weeks) mice submitted to two-hour ischemia followed by two-hour reperfusion on systemic lactate, muscle mitochondrial respiration and calcium retention capacity, and on transcripts specific for oxidative stress and mitochondrial dynamics. At the systemic levels, an IR-related increase in circulating lactate was still major despite mDivi-1 use (+305.9% p < 0.0001, and +269.4% p < 0.0001 in young and old mice, respectively). Further, IR-induced skeletal muscle mitochondrial dysfunctions (more severely impaired mitochondrial respiration in old mice (OXPHOS CI state, -68.2% p < 0.0001 and -84.9% p < 0.0001 in 23- and 83-week mice) and reduced calcium retention capacity (-46.1% p < 0.001 and -48.2% p = 0.09, respectively) were not corrected by mDivi-1 preconditioning, whatever the age. Further, mDivi-1 treatment did not oppose superoxide anion production (+71.4% p < 0.0001 and +37.5% p < 0.05, respectively). At the transcript level, markers of antioxidant enzymes (SOD 1, SOD 2, catalase, and GPx) and fission markers (Drp1, Fis) remained unchanged or tended to be decreased in the ischemic leg. Fusion markers such as mitofusin 1 or 2 decreased significantly after IR in both groups. In conclusion, aging enhanced the deleterious effects or IR on muscle mitochondrial respiration, and in this setting of lower-limb IR, mDivi-1 failed to protect the skeletal muscle both in young and old mice.

Pharmacotherapy and revascularization strategies of peripheral artery disease

The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.

Impact of pain and adverse health outcomes on long-term US testicular cancer survivors

BACKGROUND

No study has quantified the impact of pain and other adverse health outcomes on global physical and mental health in long-term US testicular cancer survivors or evaluated patient-reported functional impairment due to pain.

METHODS

Testicular cancer survivors given cisplatin-based chemotherapy completed validated surveys, including Patient-Reported Outcomes Measurement Information System v1.2 global physical and mental health, Patient-Reported Outcomes Measurement Information System pain questionnaires, and others. Multivariable linear regression examined relationships between 25 adverse health outcomes with global physical and mental health and pain-interference scores. Adverse health outcomes with a β^  of more than 2 are clinically important and reported below.

RESULTS

Among 358 testicular cancer survivors (median age = 46 years, interquartile range [IQR] = 38-53 years; median time since chemotherapy = 10.7 years, IQR = 7.2-16.0 years), median adverse health outcomes number was 5 (IQR = 3-7). A total of 12% testicular cancer survivors had 10 or more adverse health outcomes, and 19% reported chemotherapy-induced neuropathic pain. Increasing adverse health outcome numbers were associated with decreases in physical and mental health (P < .0001 each). In multivariable analyses, chemotherapy-induced neuropathic pain (β^ = -3.72; P = .001), diabetes (β^ = -4.41; P = .037), obesity (β^ = -2.01; P = .036), and fatigue (β^ = -8.58; P < .0001) were associated with worse global mental health, while being married or living as married benefited global mental health (β^ = 3.63; P = .0006). Risk factors for pain-related functional impairment included lower extremity location (β^ = 2.15; P = .04) and concomitant peripheral artery disease (β^ = 4.68; P < .001). Global physical health score reductions were associated with diabetes (β^ = -3.81; P = .012), balance or equilibrium problems (β^ = -3.82; P = .003), cognitive dysfunction (β^ = -4.43; P < .0001), obesity (β^ = -3.09; P < .0001), peripheral neuropathy score (β^ = -2.12; P < .0001), and depression (β^ = -3.17; P < .0001).

CONCLUSIONS

Testicular cancer survivors suffer adverse health outcomes that negatively impact long-term global mental health, global physical health, and pain-related functional status. Clinically important factors associated with worse physical and mental health identify testicular cancer survivors requiring closer monitoring, counseling, and interventions. Chemotherapy-induced neuropathic pain must be addressed, given its detrimental impact on patient-reported functional status and mental health 10 or more years after treatment.

New insight of the efficacy trimetazidine in patients with peripheral arterial disease: a meta-analysis

BACKGROUND

This review aims to examine the impact of trimetazidine on skeletal muscle function in patients suffering from peripheral artery disease (PAD).

METHODS

We searched for studies, both experimental and observational research, concerning the comparison of trimetazidine administration to placebo/standard of care in patients with PAD in PubMed, ScienceDirect, and Cochrane. Meta-analyses of the included studies were performed using Review Manager v5.4. Clinical parameters [ankle-brachial index (ABI) and maximum walking distance (MWD)] were analyzed.

RESULTS

Three observational studies involving 378 participants with PAD satisfied predefined criteria. There was no substantial difference between the examined groups' on ABI (pre- and post-intervention) (MD = - 0.06 [- 0.19 to 0.07], p = 0.38, I2 = 90%). Meanwhile, MWD improvement was significantly higher (MD = 14.15 [6.05-22.25], p = 0.0006, I2 = 37%) in trimetazidine group than in the control group.

CONCLUSIONS

Current evidence from our meta-analysis suggests the beneficial role of trimetazidine's anti-ischemic effect in PAD patients by improving MWD, while it has an insignificant influence on ABI.

Pyroptosis-related non-coding RNAs emerging players in atherosclerosis pathology

Globally, atherosclerosis a persistent inflammatory condition of the artery walls continues to be the primary cause of cardiovascular illness and death. The ncRNAs are important regulators of important signalling pathways that affect pyroptosis and the inflammatory environment in atherosclerotic plaques. Comprehending the complex interaction between pyroptosis and non-coding RNAs (ncRNAs) offers fresh perspectives on putative therapeutic targets for ameliorating cardiovascular problems linked to atherosclerosis. The discovery of particular non-coding RNA signatures linked to the advancement of atherosclerosis could lead to the creation of novel biomarkers for risk assessment and customised treatment approaches. A thorough investigation of the regulatory networks regulated by these non-coding RNAs has been made possible by the combination of cutting-edge molecular methods and bioinformatics tools. Studying pyroptosis-related ncRNAs in detail appears to be a promising way to advance our understanding of disease pathophysiology and develop focused therapeutic methods as we work to unravel the complex molecular tapestry of atherosclerosis. This review explores the emerging significance of non-coding RNAs (ncRNAs) in the regulation of pyroptosis and their consequential impact on atherosclerosis pathology.

Exploring the incidence of peripheral arterial occlusive disease following COVID-19 infection: A retrospective cohort study

Peripheral arterial occlusive disease (PAOD) is a clinical manifestation of systemic atherosclerosis and is always associated with cerebrovascular disease and various complications. The aim of our study is to evaluate the relationship between the coronavirus disease 2019 (COVID-19) infection and the subsequent PAOD development. A retrospective cohort study was conducted and individuals with COVID-19 infection were identified from the TriNetX analytics platform. A total of 2 206 065 patients with COVID-19 infection and 2 206 065 patients without COVID-19 infection were recruited after exclusion and matching. The primary outcome was the development of PAOD after the COVID-19 infection. The Cox proportional hazard regression was adopted to yield the hazard ratio (HR) and 95% confidence interval (CI) of PAOD between groups. After the whole follow-up period, the incidence of PAOD was significantly higher in the COVID-19 group at both the 3-month follow-up (HR: 1.27, 95% CI: 1.24-1.30) and the 12-month follow-up (HR: 1.33, 95% CI: 1.31-1.35) The Kaplan-Meier analysis with the log-rank test demonstrated a higher cumulative probability of PAOD in the COVID-19 group compared to the non-COVID-19 group (p < 0.001). In stratified analysis using 65 years as the threshold, both age groups in the COVID-19 group exhibited a higher risk of PAOD. Similarly, in the sex and race stratified analysis, the COVID-19 group performed a higher risk of PAOD in both subgroups. In conclusion, the COVID-19 infections are strongly associated with an increment of PAOD incidence.

Incompressible ankle arteries predict increased morbidity and mortality in patients with an elevated ankle brachial index

OBJECTIVES

Patients with an elevated ankle brachial index (ABI) > 1.3 have a high burden of disease and poorer outcome compared to patients with a lower ABI. Previously differences between patients with ABI > 1.3 have not been studied in detail. The aim of this study was to analyze the morbidity and mortality of patients with ABI > 1.3.

METHODS

ABI measurements were performed in the vascular laboratory of Turku university hospital 2011-2013. Patients with ABI>1.3 in at least one lower limb were included in the study and divided into 3 groups: At least one lower limb ABI 1.3-2.5 but both limbs <2.5 (group 1), one limb ABI ≥2.5 (group 2), both limbs ABI ≥ 2.5 (group 3).

RESULTS

534 patients were included in the study. The patients in groups 2 and 3 were more often female (p < .001), older (p < .001), had more diabetes (p = .013), coronary artery disease (p = .001) and chronic heart (p = .010) and kidney failure (p = .013) compared to patients in group 1. The survival of patients in group 2 and 3 was significantly poorer compared to the patients in group 1 (HR1.6, 95% CI 1.2-2.2, p = .002 and 1.7, 95% CI 1.2-2.3, p < .001, respectively). Overall and cardiovascular mortality was higher in groups 2 and 3 than group 1.39.5% of patients with incompressible ankle arteries (ABI ≥ 2.5) in both lower limbs had toe pressure (TP) <50 mmHg and a poorer survival compared to patients with a higher TP.

CONCLUSIONS

Patients with incompressible ankle arteries have significantly higher overall and cardiovascular mortality and a greater burden of disease compared to the patients with a measurable yet abnormally high ABI. TP is a useful diagnostic tool when ABI is immeasurably high. All patients with ABI > 1.3 should be considered as high cardiovascular risk patients.

Translational Relevance of Advanced Age and Atherosclerosis in Preclinical Trials of Biotherapies for Peripheral Artery Disease

Approximately 6% of adults worldwide suffer from peripheral artery disease (PAD), primarily caused by atherosclerosis of lower limb arteries. Despite optimal medical care and revascularization, many PAD patients remain symptomatic and progress to critical limb ischemia (CLI) and risk major amputation. Delivery of pro-angiogenic factors as proteins or DNA, stem, or progenitor cells confers vascular regeneration and functional recovery in animal models of CLI, but the effects are not well replicated in patients and no pro-angiogenic biopharmacological procedures are approved in the US, EU, or China. The reasons are unclear, but animal models that do not represent clinical PAD/CLI are implicated. Consequently, it is unclear whether the obstacles to clinical success lie in the toxic biochemical milieu of human CLI, or in procedures that were optimized on inappropriate models. The question is significant because the former case requires abandonment of current strategies, while the latter encourages continued optimization. These issues are discussed in the context of relevant preclinical and clinical data, and it is concluded that preclinical mouse models that include age and atherosclerosis as the only comorbidities that are consistently present and active in clinical trial patients are necessary to predict clinical success. Of the reviewed materials, no biopharmacological procedure that failed in clinical trials had been tested in animal models that included advanced age and atherosclerosis relevant to PAD/CLI.

Copper homeostasis and cuproptosis in atherosclerosis: metabolism, mechanisms and potential therapeutic strategies

Copper is an essential micronutrient that plays a pivotal role in numerous physiological processes in virtually all cell types. Nevertheless, the dysregulation of copper homeostasis, whether towards excess or deficiency, can lead to pathological alterations, such as atherosclerosis. With the advent of the concept of copper-induced cell death, termed cuproptosis, researchers have increasingly focused on the potential role of copper dyshomeostasis in atherosclerosis. In this review, we provide a broad overview of cellular and systemic copper metabolism. We then summarize the evidence linking copper dyshomeostasis to atherosclerosis and elucidate the potential mechanisms underlying atherosclerosis development in terms of both copper excess and copper deficiency. Furthermore, we discuss the evidence for and mechanisms of cuproptosis, discuss its interactions with other modes of cell death, and highlight the role of cuproptosis-related mitochondrial dysfunction in atherosclerosis. Finally, we explore the therapeutic strategy of targeting this novel form of cell death, aiming to provide some insights for the management of atherosclerosis.

Prevalence of and Risk Factors for Peripheral Artery Disease in Rural South Africa: A Cross-Sectional Analysis of the HAALSI Cohort

BACKGROUND

The burden of peripheral artery disease (PAD) is increasing in low- and middle-income countries. Existing literature from sub-Saharan Africa is limited and lacks population-representative estimates. We estimated the burden and risk factor profile of PAD for a rural South African population.

METHODS AND RESULTS

We used data from 1883 participants from a rural, low-income cohort of South African adults aged 40 to 69 years with available ankle-brachial index measurements. We defined clinical PAD as ankle-brachial index ≤0.90 or >1.40, and borderline PAD as ankle-brachial index >0.90 and ≤1.00. We compared the distribution of sociodemographic variables, biomarkers, and comorbidities across PAD classifications. To identify associated factors, we calculated unadjusted and age-sex-adjusted prevalence ratios (PRs) with log-binomial models. Overall, 6.6% (95% CI, 5.6-7.7) of the sample met the diagnostic criteria for clinical PAD, while 44.7% (95% CI, 42.4-47.0) met the diagnostic criteria for borderline PAD. Age (PR: 1.9 [95% CI, 1.2-3.1] for ages 50-59 years compared with 40-49 years; PR: 2.5 [95% CI, 1.5-4.0] for ages 60-69 years compared with 40-49 years); diagnosed hypertension (PR: 1.53 [95% CI, 1.08-2.17]); and C-reactive protein (PR: 1.08 [95% CI, 1.03-1.12]) were associated with increased prevalence of clinical PAD. All other examined factors were not significantly associated with clinical PAD.

CONCLUSIONS

We found high PAD prevalence for younger age groups compared with previous research and a lack of statistical evidence for the influence of traditional risk factors for this rural, low-income population. Future research should focus on identifying the underlying risk factors for PAD in this setting. South African policymakers and clinicians should consider expanded screening for early PAD detection in rural areas.

Understanding the use of evidence-based medical therapy in patients with peripheral artery disease: A qualitative study using the Tailored Implementation for Chronic Diseases Framework

Introduction

The global burden of peripheral artery disease (PAD) has been increasing. Guidelines for PAD recommend evidence-based medical therapy (EBMT) to reduce the risks of cardiovascular events and death but the implementation of this is highly variable. This study aimed to understand the current practices regarding EBMT prescription in PAD patients and the key barriers and facilitators for implementing PAD guidelines.

Method

A qualitative study was conducted in the largest tertiary hospital in Singapore from December 2021 to March 2023. The participants included healthcare professionals and in-patient pharmacists involved in the care of PAD patients, as well as patients with PAD who had undergone a lower limb angioplasty revascularisation procedure. Data were collected through in-depth, individual semi-structured interviews conducted face-to-face or remotely by a trained research assistant. Interviews were audio-recorded, transcribed and systematically coded using data management software NVivo 12.0. The Tailored Implementation for Chronic Diseases (TICD) framework was used to guide the interviews and analysis.

Results

Twelve healthcare professionals (4 junior consultants, 7 senior consultants, and 1 senior in-patient pharmacist) and 4 patients were recruited. Nine themes in 7 domains emerged. Only a small proportion of doctors were aware of the relevant guidelines, and the generalisability of guidelines to patients with complicated conditions was the doctors' main concern. Other barriers included cost, frequent referrals, lack of interprofessional collaboration, not being the patients' long-term care providers, short consultation time and patients' limited medication knowledge.

Conclusion

Findings from this study may inform strategies for improving healthcare professionals' adherence to guidelines and patients' medication adherence.

Effects of exercise training on heart rate variability in individuals with lower extremity arterial disease and claudication: A systematic review

PURPOSE

To perform a systematic review of studies assessing the effects of regular exercise on heart rate variability (HRV) in individuals with lower extremity arterial disease (LEAD) and symptoms of claudication.

METHODS

A systematic search in the electronic databases MEDLINE, Embase, and Scielo, was conducted and updated on January 21, 2023. Randomized clinical trials investigating patients with LEAD and IC, assessing ≥ 4 wk of exercise interventions, and reporting at least one HRV measure (e.g., time or frequency domains) at baseline and follow-up were included. Two reviewers independently screened studies for inclusion, performed data extraction, and quality assessment of included studies.

RESULTS

Data from 7 trials were included (i.e., 5 walking, 1 resistance, and 1 isometric handgrip training), totaling 327 patients (66% males; range: 61 - 68 yr; ankle brachial index: 0.4 - 0.7). Following exercise training, three studies investigating walking training reported an increase in parasympathetic modulation indices and/or a decrease in sympathetic modulation indices (n = 2) as well as an increase in non-linear indices (n = 1).

CONCLUSION

The current evidence is weak, and larger randomized controlled trials are needed to confirm the efficacy of exercise training in improving HRV. Additionally, the high divergence in the methodology of studies indicated the need for standard tools to improve the quality of HRV measurements in exercise trials. It is recommended to use standard procedures in future trials investigating HRV.

Adipose-Derived Stem Cells to Treat Ischemic Diseases: The Case of Peripheral Artery Disease

Critical limb ischemia incidence and prevalence have increased over the years. However, there are no successful treatments to improve quality of life and to reduce the risk of cardiovascular and limb events in these patients. Advanced regenerative therapies have focused their interest on the generation of new blood vessels to repair tissue damage through the use of stem cells. One of the most promising sources of stem cells with high potential in cell-based therapy is adipose-derived stem cells (ASCs). ASCs are adult mesenchymal stem cells that are relatively abundant and ubiquitous and are characterized by a multilineage capacity and low immunogenicity. The proangiogenic benefits of ASCs may be ascribed to: (a) paracrine secretion of proangiogenic molecules that may stimulate angiogenesis; (b) secretion of microvesicles/exosomes that are also considered as a novel therapeutic prospect for treating ischemic diseases; and (c) their differentiation capability toward endothelial cells (ECs). Although we know the proangiogenic effects of ASCs, the therapeutic efficacy of ASCs after transplantation in peripheral artery diseases patients is still relatively low. In this review, we evidence the potential therapeutic use of ASCs in ischemic regenerative medicine. We also highlight the main challenges in the differentiation of these cells into functional ECs. However, significant efforts are still needed to ascertain relevant transcription factors, intracellular signaling and interlinking pathways in endothelial differentiation.

Small but strong: the emerging role of small nucleolar RNA in cardiovascular diseases

Cardiovascular diseases (CVDs) are the leading cause of mortality and disability worldwide. Numerous studies have demonstrated that non-coding RNAs (ncRNAs) play a primary role in CVD development. Therefore, studies on the mechanisms of ncRNAs are essential for further efforts to prevent and treat CVDs. Small nucleolar RNAs (snoRNAs) are a novel species of non-conventional ncRNAs that guide post-transcriptional modifications and the subsequent maturation of small nuclear RNA and ribosomal RNA. Evidently, snoRNAs are extensively expressed in human tissues and may regulate different illnesses. Particularly, as the next-generation sequencing techniques have progressed, snoRNAs have been shown to be differentially expressed in CVDs, suggesting that they may play a role in the occurrence and progression of cardiac illnesses. However, the molecular processes and signaling pathways underlying the function of snoRNAs remain unidentified. Therefore, it is of great value to comprehensively investigate the association between snoRNAs and CVDs. The aim of this review was to collate existing literature on the biogenesis, characteristics, and potential regulatory mechanisms of snoRNAs. In particular, we present a scientific update on these snoRNAs and their relevance to CVDs in an effort to cast new light on the functions of snoRNAs in the clinical diagnosis of CVDs.

Endothelial progenitor cells as biomarkers of diabetes-related cardiovascular complications

Diabetes mellitus (DM) constitutes a chronic metabolic disease characterized by elevated levels of blood glucose which can also lead to the so-called diabetic vascular complications (DVCs), responsible for most of the morbidity, hospitalizations and death registered in these patients. Currently, different approaches to prevent or reduce DM and its DVCs have focused on reducing blood sugar levels, cholesterol management or even changes in lifestyle habits. However, even the strictest glycaemic control strategies are not always sufficient to prevent the development of DVCs, which reflects the need to identify reliable biomarkers capable of predicting further vascular complications in diabetic patients. Endothelial progenitor cells (EPCs), widely known for their potential applications in cell therapy due to their regenerative properties, may be used as differential markers in DVCs, considering that the number and functionality of these cells are affected under the pathological environments related to DM. Besides, drugs commonly used with DM patients may influence the level or behaviour of EPCs as a pleiotropic effect that could finally be decisive in the prognosis of the disease. In the current review, we have analysed the relationship between diabetes and DVCs, focusing on the potential use of EPCs as biomarkers of diabetes progression towards the development of major vascular complications. Moreover, the effects of different drugs on the number and function of EPCs have been also addressed.

Current Medical Therapy and Revascularization in Peripheral Artery Disease of the Lower Limbs: Impacts on Subclinical Chronic Inflammation

Peripheral artery disease (PAD), coronary artery disease (CAD), and cerebrovascular disease (CeVD) are characterized by atherosclerosis and inflammation as their underlying mechanisms. This paper aims to conduct a literature review on pharmacotherapy for PAD, specifically focusing on how different drug classes target pro-inflammatory pathways. The goal is to enhance the choice of therapeutic plans by considering their impact on the chronic subclinical inflammation that is associated with PAD development and progression. We conducted a comprehensive review of currently published original articles, narratives, systematic reviews, and meta-analyses. The aim was to explore the relationship between PAD and inflammation and evaluate the influence of current pharmacological and nonpharmacological interventions on the underlying chronic subclinical inflammation. Our findings indicate that the existing treatments have added anti-inflammatory properties that can potentially delay or prevent PAD progression and improve outcomes, independent of their effects on traditional risk factors. Although inflammation-targeted therapy in PAD shows promising potential, its benefits have not been definitively proven yet. However, it is crucial not to overlook the pleiotropic properties of the currently available treatments, as they may provide valuable insights for therapeutic strategies. Further studies focusing on the anti-inflammatory and immunomodulatory effects of these treatments could enhance our understanding of the mechanisms contributing to the residual risk in PAD and pave the way for the development of novel therapies.

Machine learning for the prediction of atherosclerotic cardiovascular disease during 3-year follow up in Chinese type 2 diabetes mellitus patients

AIMS/INTRODUCTION

Clinical guidelines for the management of individuals with type 2 diabetes mellitus endorse the systematic assessment of atherosclerotic cardiovascular disease risk for early interventions. In this study, we aimed to develop machine learning models to predict 3-year atherosclerotic cardiovascular disease risk in Chinese type 2 diabetes mellitus patients.

MATERIALS AND METHODS

Clinical records of 4,722 individuals with type 2 diabetes mellitus admitted to 94 hospitals were used. The features included demographic information, disease histories, laboratory tests and physical examinations. Logistic regression, support vector machine, gradient boosting decision tree, random forest and adaptive boosting were applied for model construction. The performance of these models was evaluated using the area under the receiver operating characteristic curve. Additionally, we applied SHapley Additive exPlanation values to explain the prediction model.

RESULTS

All five models achieved good performance in both internal and external test sets (area under the receiver operating characteristic curve >0.8). Random forest showed the highest discrimination ability, with sensitivity and specificity being 0.838 and 0.814, respectively. The SHapley Additive exPlanation analyses showed that previous history of diabetic peripheral vascular disease, older populations and longer diabetes duration were the three most influential predictors.

CONCLUSIONS

The prediction models offer opportunities to personalize treatment and maximize the benefits of these medical interventions.

Low-iodine 40-keV virtual monoenergetic CT angiography of the lower extremities

Introduction

To evaluate a reduced iodine volume protocol for lower extremity CT angiography (CTA) using dual-energy CT (DECT).

Methods

This retrospective study included consecutive patients who underwent lower extremity CTA from June to December 2022. A 10 ml 1:1 mixed test bolus was performed, followed by a 40 ml full bolus at a 2.5/s injection rate, using 400 mg/ml iodine contrast media. Conventional and 40 keV virtual monoenergetic images (VMI) were reconstructed. For both reconstructions, five main artery segments were assessed with a 3-point image quality score as well as quantitative attenuation, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) measurements with diagnostic quality thresholds (respectively >150 HU and >3).

Results

Forty patients were included in the study (mean age 68 ± 12 yo). 200 artery segments were assessed. Median qualitative image scores were 3 [IQR, 3, 3] for both reconstructions. 40 keV VMI upgraded qualitative scores for 51 (26%) of patients, including 9 (5%) from nondiagnostic to diagnostic quality. 40 keV VMI obtained attenuation and CNR diagnostic quality for respectively 100% and 100% of segments, compared with 96% and 98% for conventional images (p < 0.001). Distal artery segments showed the most differences between 40 keV VMI and conventional images.

Conclusion

A low-iodine lower extremity CTA protocol is feasible, with 40 keV virtual monoenergetic spectral reconstruction enabling maintained diagnostic image quality at the distal artery segments.

Development of Biocompatible 3D-Printed Artificial Blood Vessels through Multidimensional Approaches

Within the human body, the intricate network of blood vessels plays a pivotal role in transporting nutrients and oxygen and maintaining homeostasis. Bioprinting is an innovative technology with the potential to revolutionize this field by constructing complex multicellular structures. This technique offers the advantage of depositing individual cells, growth factors, and biochemical signals, thereby facilitating the growth of functional blood vessels. Despite the challenges in fabricating vascularized constructs, bioprinting has emerged as an advance in organ engineering. The continuous evolution of bioprinting technology and biomaterial knowledge provides an avenue to overcome the hurdles associated with vascularized tissue fabrication. This article provides an overview of the biofabrication process used to create vascular and vascularized constructs. It delves into the various techniques used in vascular engineering, including extrusion-, droplet-, and laser-based bioprinting methods. Integrating these techniques offers the prospect of crafting artificial blood vessels with remarkable precision and functionality. Therefore, the potential impact of bioprinting in vascular engineering is significant. With technological advances, it holds promise in revolutionizing organ transplantation, tissue engineering, and regenerative medicine. By mimicking the natural complexity of blood vessels, bioprinting brings us one step closer to engineering organs with functional vasculature, ushering in a new era of medical advancement.

Double-layered blood vessels over 3 mm in diameter extruded by the inverse-gravity technique

One of the most promising techniques for treating severe peripheral artery disease is the use of cellular tissue-engineered vascular grafts (TEVGs). This study proposes an inverse-gravity (IG) extrusion technique for creating long double-layered cellular TEVGs with diameters over 3 mm. A three-layered coaxial laminar hydrogel flow in an 8 mm-diameter pipe was realised simply by changing the extrusion direction of the hydrogel from being aligned with the direction of gravity to against it. This technique produced an extruded mixture of human aortic smooth muscle cells (HASMCs) and type-I collagen as a tubular structure with an inner diameter of 3.5 mm. After a 21 day maturation period, the maximal burst pressure, longitudinal breaking force, and circumferential breaking force of the HASMC TEVG were 416 mmHg, 0.69 N, and 0.89 N, respectively. The HASMC TEVG was endothelialised with human umbilical vein endothelial cells to form a tunica intima that simulated human vessels. Besides subcutaneous implantability on mice, the double-layered blood vessels showed a considerably lower adherence of platelets and red blood cells once exposed to heparinised mouse blood and were considered nonhaemolytic. The proposed IG extrusion technique can be applied in various fields requiring multilayered materials with large diameters.

The Effect of Exercise Modalities on Walking Capacity in Patients With Intermittent Claudication: A NETWORK META-ANALYSIS

INTRODUCTION

Despite extensive research on the effect of supervised exercise therapy on walking performance in patients with symptomatic peripheral arterial disease (PAD), it remains unclear which training modality provides the greatest improvement in walking capacity. The objective of this study was to compare the effect of different types of supervised exercise therapy on walking capacity in individuals with symptomatic PAD.

METHODS

A random-effect network meta-analysis was performed. The following databases were searched from January 1966 to April 2021: SPORTDiscus, CINAHL, MEDLINE, AMED, Academic Search Complete and, Scopus. Trials had to include at least one type of supervised exercise therapy for patients with symptomatic PAD, with an intervention lasting ≥2 wk with ≥5 training sessions, and an objective measure of walking capacity.

RESULTS

Eighteen studies were included for a total sample of 1135 participants. Interventions duration ranged from 6-24 wk and included aerobic exercise (treadmill walking, ergometer, and Nordic walking), resistance training (lower and/or upper body), a combination of both, and underwater exercise. Results showed that combined training improved treadmill walking capacity to a comparable extent to aerobic walking (+122.0 [24.2-219.8] m vs +106.8 [34.2-179.4] m), but with a larger effect size (1.20 [0.50-1.90] vs 0.67 [0.22-1.11]). Similar results were observed for the 6-min walk distance, with combined training being the most promising modality (+57.3 [16.2-98.5] m), followed by underwater training (+56.5 [22.4-90.5] m) and aerobic walking (+39.0 [12.8-65.1] m).

CONCLUSION

While not statistically superior to aerobic walking, combined exercise seems to be the most promising training modality. Aerobic walking and underwater training also improved walking capacity for patients with symptomatic PAD.

The Role Played by Novel Inflammatory Markers in Assessment of Peripheral Artery Disease

Background and Objectives: Atherosclerosis is a multifactorial process in which inflammatory markers have both therapeutic and prognostic roles. Recent studies bring into question the importance of assessing new inflammatory markers in relation to the severity of peripheral artery disease (PAD), such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and lymphocyte-to-C-reactive protein ratio (LCR). Materials and Methods: We conducted a retrospective and descriptive study including 652 patients with PAD, who were divided into two groups according to the severity of the ankle-brachial index value: mild and moderate obstruction (257 patients) and severe obstruction (395 patients). We evaluated demographics, anthropometric data and clinical and paraclinical parameters in relation to the novel inflammatory biomarkers mentioned above. Results: Weight (p = 0.048), smoking (p = 0.033), the number of cardiovascular risk factors (p = 0.041), NLR (p = 0.037), LCR (p = 0.041) and PLR (p = 0.019), the presence of gangrene (p = 0.001) and the number of lesions detected via peripheral angiography (p < 0.001) were statistically significant parameters in our study. For the group of patients with severe obstruction, all three inflammatory biomarkers were statistically significantly correlated with a serum low-density lipoprotein-cholesterol level, the number of cardiovascular risk factors, rest pain, gangrene and a risk of amputation. In addition, directly proportional relationships were found between NLR, PLR and the number of stenotic lesions (p = 0.018, p = 0.016). Also, NLR (area under the curve = 0.682, p = 0.010) and PLR (AUC = 0.692, p = 0.006) were predictors associated with a high risk of amputation in patients with an ABI < 0.5. Conclusions: in our study, we demonstrated the importance of assessing inflammatory markers in relation to the presence of cardiovascular risk factors through the therapeutic and prognostic value demonstrated in PAD.

Association between serum uric acid levels and peripheral artery disease in Chinese adults with hypertension

Background

Higher serum uric acid (SUA) can cause gout, which is principally characterized by arthritis due to monosodium urate crystal deposition in the lower extremities. High levels of SUA have been linked to endothelial dysfunction, oxidative stress, and inflammation, all of which are involved in the pathogenesis of peripheral artery disease(PAD). To date, the relationship between SUA levels and PAD is still poorly understood.

Method

An analysis of 9,839 Chinese adults with essential hypertension from the ongoing China H-type Hypertension Registry Study was conducted in this cross-sectional study. Patients with an ABI ≤0.9 was diagnosed with PAD. Hyperuricemia was defined as SUA levels >420 mol/L in men and >360 mol/L in women. The association between SUA levels and PAD was evaluated using multivariable logistic regression models based on odds ratios (ORs) and their 95% confidence intervals (CIs).

Results

The enrolled subjects ranged in age from 27 to 93 years, with a mean age of 63.14 ± 8.99 years. The proportion of male patients was 46.22%, and the prevalence of hyperuricemia was 50.72%. In males, hyperuricemia was positively associated with the risk of PAD (adjusted OR per SD increase: 1.72, 95% CI 1.17 to 2.53, P =0.006). Males in the highest SUA tertile were significantly more likely to have PAD (adjusted OR: 2.63, 95% CI 1.42 to 4.86, P = 0.002; P for trend = 0.001). However, this positive relationship was not observed in females (adjusted OR: 1.29, 95% CI 0.77 to 2.17, P = 0.327; P for trend = 0.347).

Conclusion

According to this cross-sectional study, higher SUA levels were positively associated with PAD in male hypertensive patients, while this positive relationship disappeared in female participants.

Association between dietary magnesium intake and peripheral arterial disease: Results from NHANES 1999-2004

BACKGROUND

Magnesium has been found to have a strong association with peripheral arterial disease (PAD), and dietary magnesium intake shows promise as a predictor of the condition. However, the relationship between low dietary magnesium intake and an increased risk of PAD remains uncertain, and further research is needed to clarify this relationship.

METHODS

This study analyzed data from 5969 participants in the National Health and Nutrition Examination Survey (NHANES) of the United States from 1999 to 2004. Multifactorial logistic regression models were used to investigate the association between dietary magnesium intake and PAD.

RESULTS

Participants with PAD had lower dietary magnesium intake compared to those without PAD. After adjusting for all covariates, dietary magnesium intake remained negatively associated with PAD (OR: 0.999, 95% CI: 0.998, 1.000). When dietary magnesium intake was divided into quartiles, compared with the fourth quantile, the first quartile is associated with a higher incidence rate of PAD (OR: 1.560, 95%CI: 1.019, 2.386). Subgroup analysis revealed that the link between dietary magnesium intake and PAD remained significant among specific subgroups, including non-white, never or former smokers, and non-hypertensive, non-diabetic individuals (P < 0.05).

CONCLUSION

Our study provides evidence that dietary magnesium intake is negatively associated with the incidence of PAD. Therefore, people with inadequate dietary magnesium intake, particularly those with excessively low intake, should increase their magnesium intake to reduce the risk of PAD.

Hybrid spheroids containing mesenchymal stem cells promote therapeutic angiogenesis by increasing engraftment of co-transplanted endothelial colony-forming cells in vivo

BACKGROUND

Peripheral artery disease is an ischemic vascular disease caused by the blockage of blood vessels supplying blood to the lower extremities. Mesenchymal stem cells (MSCs) and endothelial colony-forming cells (ECFCs) have been reported to alleviate peripheral artery disease by forming new blood vessels. However, the clinical application of MSCs and ECFCs has been impeded by their poor in vivo engraftment after cell transplantation. To augment in vivo engraftment of transplanted MSCs and ECFCs, we investigated the effects of hybrid cell spheroids, which mimic a tissue-like environment, on the therapeutic efficacy and survival of transplanted cells.

METHODS

The in vivo survival and angiogenic activities of the spheroids or cell suspension composed of MSCs and ECFCs were measured in a murine hindlimb ischemia model and Matrigel plug assay. In the hindlimb ischemia model, the hybrid spheroids showed enhanced therapeutic effects compared with the control groups, such as adherent cultured cells or spheroids containing either MSCs or ECFCs.

RESULTS

Spheroids from MSCs, but not from ECFCs, exhibited prolonged in vivo survival compared with adherent cultured cells, whereas hybrid spheroids composed of MSCs and ECFCs substantially increased the survival of ECFCs. Moreover, single spheroids of either MSCs or ECFCs secreted greater levels of pro-angiogenic factors than adherent cultured cells, and the hybrid spheroids of MSCs and ECFCs promoted the secretion of several pro-angiogenic factors, such as angiopoietin-2 and platelet-derived growth factor.

CONCLUSION

These results suggest that hybrid spheroids containing MSCs can serve as carriers for cell transplantation of ECFCs which have poor in vivo engraftment efficiency.

Increasing Awareness for Peripheral Artery Disease through the Identification of Novel Biomarkers

Peripheral artery disease (PAD) is a chronic atherosclerotic disorder that involves the lower extremity arteries, manifesting in claudication, rest pain, and tissue loss [...].

Managing the Patient with Peripheral Vascular Disease before Total Knee Arthroplasty Surgery

Peripheral vascular disease (PVD), defined as decreased arterial perfusion to the lower extremities due to atherosclerotic obstruction, is known to occur in patients undergoing total knee arthroplasty with described rates of between 2% and 4.5% PVD is of significance for patients undergoing TKA as it can increase wound healing and infection complications after TKA and is an independent risk factor for arterial complications following TKA. Our goal is to provide a comprehensive review of the pathophysiology of PVD as it relates to TKA, associated outcomes of patients undergoing TKA in the setting of PVD, diagnostic pearls, and current management strategies recommended in the published literature.

Rapamycin restores peripheral blood flow in aged mice and in mouse models of atherosclerosis and Alzheimer's disease

Peripheral artery disease (PAD), defined as reduced blood flow to the lower limbs, is a serious disorder that can lead to loss of function in the lower extremities and even loss of limbs. One of the main risk factors for PAD is age, with up to 25% of adults over the age of 55 and up to 40% over the age of 80 presenting with some form of the disease. While age is the largest risk factor for PAD, other risk factors include atherosclerosis, smoking, hypertension, and diabetes. Furthermore, previous studies have suggested that the incidence of PAD is significantly increased in patients with Alzheimer's disease (AD). Attenuation of mTOR with rapamycin significantly improves cerebral blood flow and heart function in aged rodents as well as in mouse models of atherosclerosis, atherosclerosis-driven cognitive impairment, and AD. In this study, we show that rapamycin treatment improves peripheral blood flow in aged mice and in mouse models of atherosclerosis and AD. Inhibition of mTOR with rapamycin ameliorates deficits in baseline hind paw perfusion in aged mice and restores levels of blood flow to levels indistinguishable from those of young controls. Furthermore, rapamycin treatment ameliorates peripheral blood flow deficits in mouse models of atherosclerosis and AD. These data indicate that mTOR is causally involved in the reduction of blood flow to lower limbs associated with aging, atherosclerosis, and AD-like progression in model mice. Rapamycin or other mTOR inhibitors may have potential as interventions to treat peripheral artery disease and other peripheral circulation-related conditions.

Demographic and regional trends of peripheral artery disease-related mortality in the United States, 2000 to 2019

INTRODUCTION

Peripheral artery disease (PAD) is a common progressive atherosclerotic disease associated with significant morbidity and mortality in the US; however, data regarding PAD-related mortality trends are limited. This study aims to characterize contemporary trends in mortality across sociodemographic and regional groups.

METHODS

The Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) was queried for data regarding PAD-related deaths from 2000 to 2019 in the overall sample and different demographic (age, sex, race/ethnicity) and regional (state, urban-rural) subgroups. Crude and age-adjusted mortality rates (CMR and AAMR, respectively) per 100,000 people were calculated. Associated annual percentage changes (APC) were computed using Joinpoint Regression Program Version 4.9.0.0 trend analysis software.

RESULTS

Between 2000 and 2019, a total of 1,959,050 PAD-related deaths occurred in the study population. Overall, AAMR decreased from 72.8 per 100,000 in 2000 to 32.35 per 100,000 in 2019 with initially decreasing APCs followed by no significant decline from 2016 to 2019. Most demographic and regional subgroups showed initial declines in AAMRs during the study period, with many groups exhibiting no change in mortality in recent years. However, men, non-Hispanic (NH) Black or African American individuals, people aged ⩾ 85 years, and rural counties were associated with the highest AAMRs of their respective subgroups. Notably, there was an increase in crude mortality rate among individuals 25-39 years of age from 2009 to 2019.

CONCLUSION

Despite initial improvement, PAD-related mortality has remained stagnant in recent years. Disparities have persisted across several demographic and regional groups, requiring further investigation.

Real-World Racial Variation in Treatment and Outcomes Among Patients with Peripheral Artery Disease

INTRODUCTION

Prior studies have found considerable disparities in prevalence and outcomes for patients with peripheral arterial disease (PAD). This study compared rates of diagnostic testing, treatment patterns, and outcomes after diagnosis of PAD among commercially insured Black and White patients in the United States.

METHODS

Optum's de-identified Clinformatics® Data Mart Database (1/2016-6/2021) were used to identify Black and White patients with PAD; first PAD diagnosis was deemed study index date. Baseline demographics, markers of disease severity, and healthcare costs were compared between cohorts. Patterns of medical management and rates of major adverse limb events (MALE; including acute or chronic limb ischemia, lower-limb amputation) and cardiovascular (CV) events (stroke, myocardial infarction) during the available follow-up period were described. Outcomes were compared between cohorts using multinomial logistic regression models, Kaplan-Meier survival analysis, and Cox proportional hazards models.

RESULTS

A total of 669,939 patients were identified, with 454,382 White patients and 96,162 Black patients. Black patients were younger on average (71.8 years vs. 74.2 years), but had higher comorbid burden, concomitant risk factors, and CV medication use at baseline. Prevalence of diagnostic testing, revascularization procedures, and medication use was numerically higher among Black patients. Black patients were also more likely than the White patients to receive medical therapy without a revascularization procedure [adjusted odds ratio with 95% confidence interval (CI) = 1.47 (1.44-1.49)]. However, Black patients with PAD had higher incidence of MALE and CV events than White patients [adjusted hazard ratio for composite event (95% CI) = 1.13, (1.11-1.15)]. Except myocardial infarction, the hazards of individual components of MALE and CV events were also significantly higher among Black patients with PAD.

CONCLUSIONS

Results of this real-world study suggest that Black patients with PAD have higher disease severity at the time of diagnosis and are at increased risk of experiencing adverse outcomes following diagnosis.

Piezo1 (Piezo-Type Mechanosensitive Ion Channel Component 1)-Mediated Mechanosensation in Macrophages Impairs Perfusion Recovery After Hindlimb Ischemia in Mice

BACKGROUND

Angiogenesis is a promising strategy for those with peripheral artery disease. Macrophage-centered inflammation is intended to govern the deficiency of the angiogenic response after hindlimb ischemia. However, little is known about the mechanism of macrophage activation beyond signals from cytokines and chemokines. We sought to identify a novel mechanical signal from the ischemic microenvironment that provokes macrophages and the subsequent inflammatory cascade and to investigate the potential role of Piezo-type mechanosensitive ion channels (Piezo) on macrophages during this process.

METHODS

Myeloid cell-specific Piezo1 (Piezo-type mechanosensitive ion channel component 1) knockout (Piezo1^ΔMΦ) mice were generated by crossing Piezo1^fl/fl (LysM-Cre^-/-; Piezo1 flox/flox) mice with LysM-Cre transgenic mice to assess the roles of Piezo1 in macrophages after hindlimb ischemia. Furthermore, in vitro studies were carried out in bone marrow-derived macrophages to decipher the underlying mechanism.

RESULTS

We found that tissue stiffness gradually increased after hindlimb ischemia, as indicated by Young's modulus. Compared to Piezo2, Piezo1 expression and activation were markedly upregulated in macrophages from ischemic tissues in concurrence with increased tissue stiffness. Piezo1^ΔMΦ mice exhibited improved perfusion recovery by enhancing angiogenesis. Matrigel tube formation assays revealed that Piezo1 deletion promoted angiogenesis by enhancing FGF2 (fibroblast growth factor-2) paracrine signaling in macrophages. Conversely, activation of Piezo1 by increased stiffness or the agonist Yoda1 led to reduced FGF2 production in bone marrow-derived macrophages, which could be blocked by Piezo1 silencing. Mechanistically, Piezo1 mediated extracellular Ca²⁺ influx and activated Ca²⁺-dependent CaMKII (calcium/calmodulin-dependent protein kinase II)/ETS1 (ETS proto-oncogene 1) signaling, leading to transcriptional inactivation of FGF2.

CONCLUSIONS

This study uncovers a crucial role of microenvironmental stiffness in exacerbating the macrophage-dependent deficient angiogenic response. Deletion of macrophage Piezo1 promotes perfusion recovery after hindlimb ischemia through CaMKII/ETS1-mediated transcriptional activation of FGF2. This provides a promising therapeutic strategy to enhance angiogenesis in ischemic diseases.

Bridging vascular physiology to vascular medicine: an integrative laboratory class

Vascular diseases of the legs are highly prevalent and constitute an important part of medical curricula. The understanding of these diseases relies on strongly interwoven aspects of vascular physiology and vascular medicine. We aimed to connect these within a horizontally integrated laboratory class on vascular physiology of the leg that was designed in cooperation between the departments of physiology and vascular surgery. Conceptually, we applied examination techniques of vascular medicine to visualize physiological parameters that are altered by the most frequent diseases. This facilitates integrative discussions on malfunctions, trains diagnostic skills, and bridges to vascular medicine. In four experiments, we use oscillometry and impedance venous occlusion plethysmography to address key aspects of the arterial and venous system of the legs: 1) arterial pulse wave, 2) arterial systolic blood pressure, 3) venous capacitance and venous outflow, and 4) reactive hyperemia. After the experiments, physiological vascular function, the associated diseases, their impact on the recorded parameters, and diagnostic options are discussed. To allow reproduction, we describe the course structure and the experimental setup in detail. We present the experimental data of a cohort of medical students and document learning success and student satisfaction. All experiments were feasible and provided robust data on physiologically and clinically relevant vascular functions. The activity was perceived positively by the students and led to a substantial improvement of knowledge. With this work, we offer a template for reproduction or variation of a proven concept of horizontally integrated teaching of vascular physiology of the leg.NEW & NOTEWORTHY This article presents an integrative laboratory class on vascular physiology bridging to vascular medicine. The four experiments rely on oscillometry and venous occlusion plethysmography. We describe in detail this new class regarding structure, experimental setup, and experimental procedure, and we give insight into the applied materials. Moreover, we present the experimental data of 74 students and a quantitative evaluation of the students' learning success and acceptance.