Inflammatory Markers and Restenosis in Peripheral Percutaneous Angioplasty With Intravascular Stenting: Current Concepts

SGLT2 inhibitor improves the prognosis of patients with coronary heart disease and prevents in-stent restenosis

Coronary heart disease is a narrowing or obstruction of the vascular cavity caused by atherosclerosis of the coronary arteries, which leads to myocardial ischemia and hypoxia. At present, percutaneous coronary intervention (PCI) is an effective treatment for coronary atherosclerotic heart disease. Restenosis is the main limiting factor of the long-term success of PCI, and it is also a difficult problem in the field of intervention. Sodium-glucose cotransporter 2 (SGLT2) inhibitor is a new oral glucose-lowering agent used in the treatment of diabetes in recent years. Recent studies have shown that SGLT2 inhibitors can effectively improve the prognosis of patients after PCI and reduce the occurrence of restenosis. This review provides an overview of the clinical studies and mechanisms of SGLT2 inhibitors in the prevention of restenosis, providing a new option for improving the clinical prognosis of patients after PCI.

Omentin-1 enhances the inhibitory effect of endothelial progenitor cells on neointimal hyperplasia by inhibiting the p38 MAPK/CREB pathway

AIMS

Endothelial progenitor cells (EPCs) play an important role in vascular repair. However, they are dysfunctional in the inflammatory microenvironment during restenosis. In this study, we investigated whether omentin-1, an anti-inflammatory factor, could reduce neointima formation after carotid artery injury (CAI) in rats by improving EPC functions that were damaged by inflammation and the underlying mechanisms.

MAIN METHODS

EPCs were transfected with adenoviral vectors expressing human omentin-1 or green fluorescent protein (GFP). Then, the rats received 2 × 106 EPCs expressing omentin-1 or GFP by tail vein injection directly after CAI and again 24 h later. Hematoxylin-eosin staining and immunohistochemistry were used for analyzing neointimal hyperplasia. Besides, EPCs were treated with omentin-1 and TNF-α to examine the underlying mechanism.

KEY FINDINGS

Our results showed that omentin-1 could significantly improve EPC functions, including proliferation, apoptosis and tube formation. Meanwhile, EPCs overexpressed with omentin-1 could significantly reduce neointimal hyperplasia and tumor necrosis factor-α (TNF-α) expression after CAI in rats. TNF-α could notably induce EPC dysfunction, which could be markedly reversed by omentin-1 through the inhibition of the p38 MAPK/CREB pathway. Furthermore, a p38 MAPK agonist (anisomycin) significantly abrogated the protective effects of omentin-1 on EPCs damaged by TNF-α.

SIGNIFICANCE

Our results indicated that genetically modifying EPC with omentin-1 could be an alternative strategy for the treatment of restenosis.

A Novel Marker Indicating Restenosis in Superficial Femoral Artery: C Reactive Protein to Albumin Ratio

AIM

In this study, we aimed to investigate the prognostic value of CAR for predicting restenosis in SFA lesions and its association with subsequent clinical outcomes in patients undergoing endovascular intervention.

METHODS

The records of 685 consecutive patients who underwent endovascular intervention due to symptomatic peripheral artery disease were analyzed. Patients were divided into 2 groups based on the CAR values. For each group, technical aspects of procedures and subsequent clinical outcomes were analyzed.

RESULTS

According to our study, patients with high CAR values had higher rates of restenosis (30.2% vs 10.3%, p<0.05) and mortality (31.3% vs 12.9%, p<0.05). The rate of lower extremity amputations was also significantly higher in patients with high CAR values compared to those with low CAR values (9.1% vs 3%, p<0.05). With respect to ROC curves of inflammatory markers, the area under the curve (AUC) value of CAR was statistically significant (AUC: 0.659; 95% CI: 0.611-0.706; p<0.01).

CONCLUSION

Our data showed that CAR is an independent predictor of restenosis and poor clinical outcomes in patients undergoing endovascular intervention.

Valsartan Prevented Neointimal Hyperplasia and Inhibited SRSF1 Expression and the TLR4-iNOS-ERK-AT1 Receptor Pathway in the Balloon-injured Rat Aorta

Valsartan has the potential to attenuate neointimal hyperplasia and to suppress the inflammatory response. This study aimed to evaluate the role of valsartan in neointimal hyperplasia and the toll-like receptor 4 (TLR4)-nitric oxide synthase (NOS) pathway in the balloon-injured rat aorta.Forty-eight Wistar rats were randomly allocated to three groups: sham control (control), balloon-injured group (surgery), and balloon-injured+valsartan-treated group (valsartan). Rats were killed at 14 and 28 days after balloon-injury, and then the aortic tissues were collected for morphometric analysis as well as for measurements of the mRNA or protein expression of angiotensin II, angiotensin II type 1 (AT1) receptor, angiotensin II type 2 (AT2) receptor, TLR4, endothelial nitric oxide synthase (eNOS), inducible NOS (iNOS), serine/arginine-rich splicing factor 1(SRSF1) and extracellular signal regulated kinase (ERK). Valsartan at a dose of 20 mg/kg/day markedly decreased neointimal hyperplasia in the aorta of balloon-injured rats, and significantly reduced the mRNA or protein expression of TLR4, AT1 receptor, SRSF1 and phosphorylated-ERK (p-ERK) as well as the aortic levels of iNOS (all p < 0.05). Moreover, valsartan increased the eNOS level and AT2 receptor mRNA and protein expression levels (all p < 0.05). Valsartan prevented neointimal hyperplasia and inhibited SRSF1 expression and the TLR4-iNOS-ERK-AT1 receptor pathway in the balloon-injured rat aorta.

Predictive value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for primary patency of percutaneous transluminal angioplasty in hemodialysis arteriovenous fistula stenosis

OBJECTIVE

The aim of this study is to investigate the potential association of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with the primary patency of percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistula (AVF) stenosis.

METHODS

This study conducted a retrospective review of patients with end-stage renal disease referred for hemodialysis AVF stenosis in one center. The study consisted of 114 patients with significant (significant stenosis was defined as a reduction in the caliber of the fistula vein of > 50% with respect to the non-aneurysmal venous segment). AVF stenosis patients were treated with PTA, with conventional balloon angioplasty. The NLR and PLR were calculated from the pre-interventional blood samples. The patients were classified into two groups: group A, primary patency < 12 months (n = 35) and group B, and primary patency ≥ 12 months (n = 79). Comparisons between the groups were performed using the Mann-Whitney U test. Kaplan-Meier analysis was performed to compare the factors, NLR and PLR, for association with primary patency AVFs. A receiver-operating characteristic curve analysis was performed to identify the sensitivity and specificity of the NLR and PLR cut-off values in the prediction of primary patency time.

RESULTS

There was no difference in gender; age; side of AVF; AVF type; comorbid diseases such as diabetes mellitus and hypertension; or blood parameters such as white cell count, erythrocytes, hemoglobin, neutrophils, lymphocytes, monocytes, eosinophils, basophils, C-reactive protein, NLR, or PLR between the two groups (p > 0.05). There was also no significant difference in the patency rate between the NLR < 4.13 and NLR ≥ 4.13 groups at 12 months (NLR cut-off point = 4.13, p = 0.273). There were statistically significant differences between the primary patency rates of the PLR < 187.86 and PLR ≥ 187.86 groups at 12 months (PLR cut-off point = 187.86, p = 0.023). The cut-off value for PLR for the determination of primary patency was 187.86, with a sensitivity of 57.0% and specificity of 34.4%.

CONCLUSION

An increased level of PLR may be a risk factor for the development of early AVF restenosis after successful PTA. However, more studies are needed to validate this finding.

A Multilayer Functionalized Drug-Eluting Balloon for Treatment of Coronary Artery Disease

Drug-eluting balloons (DEBs) have been mostly exploited as an interventional remedy for treating atherosclerosis instead of cardiovascular stents. However, the therapeutic efficacy of DEB is limited due to their low drug delivery capability to the disease site. The aim of our study was to load drugs onto a balloon catheter with preventing drug loss during transition time and maximizing drug transfer from the surface of DEBs to the cardiovascular wall. For this, a multilayer-coated balloon catheter, composed of PVP/Drug-loaded liposome/PVP, was suggested. The hydrophilic property of 1st layer, PVP, helps to separate drug layer in hydrophilic blood vessel, and the 2nd layer with Everolimus (EVL)-loaded liposome facilitates drug encapsulation and sustained release to the targeted lesions during inflation time. Additionally, a 3rd layer with PVP can protect the inner layer during transition time for preventing drug loss. The deionized water containing 20% ethanol was utilized to hydrate EVL-loaded liposome for efficient coating processes. The coating materials showed negligible toxicity in the cells and did not induce pro-inflammatory cytokine in human coronary artery smooth muscle cells (HCASMCs), even in case of inflammation induction through LPS. The results of hemocompatibility for coating materials exhibited that protein adsorption and platelet adhesion somewhat decreased with multilayer-coated materials as compared to bare Nylon tubes. The ex vivo experiments to confirm the feasibility of further applications of multilayer-coated strategy as a DEB system demonstrated efficient drug transfer of approximately 65% in the presence of the 1st layer, to the tissue in 60 s after treatment. Taken together, a functional DEB platform with such a multilayer coating approach would be widely utilized for percutaneous coronary intervention (PCI).

Neutrophil-lymphocyte ratio as a link between complex pedal ulcers and poor clinical results after infrainguinal surgical revascularization

BACKGROUND

Our aim was to evaluate the influence of preoperative neutrophil-lymphocyte ratio (NLR) on patency and clinical results after infrainguinal surgical revascularization for chronic limb ischemia.

METHODS

Retrospective analysis of 150 infrainguinal autologous bypasses performed to infragenicular popliteal artery or tibial vessels in 140 (93%) patients with chronic limb-threatening ischemia (CLTI) and in 10 (7%) with disabling claudication. NLR was calculated using blood samples obtained 24 hours preoperatively. The cohort was stratified into 2 groups according to interquartile ranges of NLR: "ELEVATED-NLR" (Quartile 4 N.=37) and "LOW-NLR" (Quartile 1-2-3 N.=113). Reperfused ulcers were described using the WIfI classification. Patency, freedom from MALE and amputation-free survival at 24 months were calculated using the Kaplan-Meier method. Univariate comparisons between NLR groups were performed using the Log-Rank test. Statistical differences on univariate analysis were adjusted in a multivariate model (Cox regression).

RESULTS

NLR values were similar between CLTI and claudication. Ischemic ulcers were more frequent, (83.4% vs. 59.3% P<0.01), more severe (W2-3: 37.8% vs. 22.1% P=0.01) and pedal infection was deeper (fI 2-3: 40.5% vs. 18.6% P=0.003) in "ELEVATED-NLR" group. Severe ischemia (I3) was similar between groups. High NLR values were independent predictors of patency loss (HR: 1.77 CI95% [1.01-3.10] P=0.04), MALE (HR: 2.04 CI95% [1.03-4.04] P=0.04) and worse amputation-free survival (HR:2.10 CI95% [1.06-4.14] P=0.03) rates at 24 months.

CONCLUSIONS

High preoperative NLR values are associated with severe and deep infected ulcers and predicts primary patency loss, higher major adverse limb events and worse amputation-free survival rates on long-term follow-up after infrainguinal surgical revascularization.

Quantifying stent-induced damage in coronary arteries by investigating mechanical and structural alterations

Vascular damage develops with diverging severity during and after percutaneous coronary intervention with stent placement and is the prevailing stimulus for in-stent restenosis. Previous work has failed to link mechanical data obtained in a realistic in vivo or in vitro environment with data collected during imaging processes. We investigated whether specimens of porcine right coronary arteries soften when indented with a stent strut shaped structure, and if the softening results from damage mechanisms inside the fibrillar collagen structure. To simulate the multiaxial loading scenario of a stented coronary artery, we developed the testing device 'LAESIO' that can measure differences in the stress-stretch behavior of the arterial wall before and after the indentation of a strut-like stamp. The testing protocol was optimized according to preliminary experiments, more specifically equilibrium and relaxation tests. After chemical fixation of the specimens and subsequent tissue clearing, we performed three-dimensional surface and second-harmonic generation scans on the deformed specimens. We analyzed and correlated the mechanical response with structural parameters of high-affected tissue located next to the stamp indentation and low-affected tissue beyond the injured area. The results reveal that damage mechanisms, like tissue compression as well as softening, fiber dispersion, and the lesion extent, are direction-dependent, and the severity of them is linked to the strut orientation, indentation pressure, and position. The findings highlight the need for further investigations by applying the proposed methods to human coronary arteries. Additional data and insights might help to incorporate the observed damage mechanisms into material models for finite element analyses to perform more accurate simulations of stent-implantations.

The relationship between neutrophil-lymphocyte ratio and in-stent restenosis in superficial femoral artery

The present study aimed to investigate the relationship between an increase in the pre- and post-operative neutrophil–lymphocyte ratio (NLR) and superficial femoral artery in-stent restenosis (ISR) rate. We recruited 199 patients that underwent superficial femoral artery stenting for lower extremity arteriosclerosis obliterans at our hospital from March 2015 to July 2018. Patients were divided into two groups according to the occurrence of ISR within 1 year (group 1, ISR and group 2, Non-ISR). The after NLR (NLR_after) and NLR change ratio (NLR_ratio) (P<0.001) were significantly higher in group 1. A NLR_after > 4.3 was associated with an odds ratio of 1.946 (95% CI [1.51–2.50]; P<0.001) for the presence of ISR. A NLR_ratio > 37.5% was associated with an odds ratio of 3.6 (95% CI [2.03–6.36]; P<0.001) for occurrence of ISR. A NLR_after level > 4.3 had 75% sensitivity and 76% specificity for the prediction of ISR, as identified by the ROC curve. A NLR_ratio level > 37.5% predicted ISR with 77% sensitivity and 60% specificity. Multivariate logistic regression analysis demonstrated that NLR_ratio was the strongest independent predictor of ISR (P<0.001). In conclusions, NLR_ratio could be used as a prognostic marker in superficial femoral artery stents.

Platelet to lymphocyte ratio predicting 6-month primary patency of drug-coated balloon for femoropopliteal disease

Background

Inflammatory reaction is an essential factor in the occurrence, development and prognosis of femoropopliteal disease (FPD). The ratio of platelets to lymphocytes (PLR) is a new indicator reflecting platelet aggregation and burden of systemic inflammation. Our study is to explore the association between preoperative platelet-to-lymphocyte ratio (pre-PLR) and 6-month primary patency (PP) after drug-coated balloon (DCB) in FPD.

Methods

There were 70 patients who underwent DCB for FPD contained in the study. According to 6-month PP, patients were divided into group A (PP ≥6 months, n = 54) and group B (PP < 6 months, n = 16). Logistic regression analysis was used to identify potential predictors for 6-month PP after DCB in FPD. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value of pre-PLR to predict 6-month PP.

Results

Logistic regression analysis showed that pre-PLR (OR: 1.008, 95% CI: 1.001–1.016, P = 0.031) and lesion length > 10 cm (OR: 4.305, 95% CI: 1.061–17.465, P = 0.041) were independently predictive for 6-month PP. The cutoff value of pre-PLR obtained from the ROC analysis was 127.35 to determine 6-month PP with the area of 0.839. Subgroup analysis was conducted based on the cutoff value of pre-PLR. The 6-month PP in the group of pre-PLR < 127.35 was higher than that of pre-PLR ≥ 127.35 group (p < 0.001).

Conclusions

The present study indicated that an elevated pre-PLR was an effective additional indicator for predicting early PP in FPD after DCB.

One step bulk modification of poly(L-lactic acid) composites with functional additives to improve mechanical and biological properties for cardiovascular implant applications

Poly(L-lactic acid) (PLLA) has been widely used as a promising biomaterial in biomedical applications due to its biodegradability and high mechanical strength. However, because of the inherent brittleness, low impact resistance, and weak thermal stability of PLLA, the modification process is usually required to utilize it for biomedical devices. Furthermore, acidic byproducts resulting from the hydrolysis of PLLA after implantation reduce the pH of the surrounding environment and cause inflammatory responses in the implanted area, leading to the failure of their clinical applications. To this end, here, we demonstrate a novel modification process for the PLLA composite with various functional additives, such as cis-aconitic anhydride (AA), triacetin (TA), isosorbide derivative (ISB), and/or Pluronic® F127 (F). The modified PLLA composite with TA and F (PLLA/TF) showed significantly improved elongation at break and Young's modulus and retained tensile strength. Moreover, incorporating magnesium hydroxide (MH) nanoparticles (PLLA/TFMH) significantly reduced acid-induced inflammation responses caused by the acidic degradation products of PLLA. Reduced plasma protein adsorption was observed in the PLLA/TFMH. These results suggest that the one step bulk modification of biodegradable PLLA using TA, F, and MH will have great potential in cardiovascular implant applications.

Primary stenting for femoropopliteal peripheral arterial disease: analysis up to 24 months

Background

Primary stenting is a well-established treatment option for femoropopliteal arterial obstructive disease. There is a shortage of Brazilian studies of the subject.

Objectives

To evaluate short and mid-term clinical and radiological outcomes in patients classified as Rutherford 3-6 and treated with stenting of femoropopliteal lesions.

Methods

Analysis based on a prospectively populated database of patients treated from July 2012 to July 2015. The primary endpoint was primary patency. Secondary endpoints were clinical and ankle/brachial index changes. Target Vessel Revascularization, limb salvage rate and death, within a 24-month follow-up period.

Results

64 patients were enrolled, including 61 TASC II A / B lesions (95%). The primary patency rates at 6, 12, and 24 months were 95.2%, 79.1% and 57.9%, respectively. Cox regression analysis revealed lower patency rates in patients with occlusive disease (hazard ratio [HR], 6.64; 95% confidence interval [CI], 1.52-28,99, p = 0.02), as well as patency loss about 6 times higher in TASC B than in TASC A patients ([HR], 5.95, 95% CI, 1.67-21.3, p = 0.0061). At 12 months, 90.38% of the patients remained asymptomatic. The limb salvage rate at 24 months was 94.3% (95% CI, 87.9-100%). Freedom from TVR at 24 months was 90.5% (95% CI 82.8-98.9%).

Conclusions

Results of primary patency were compatible with international studies, despite the more advanced stage of the vascular disease observed in our group. Occlusive disease and complex lesions were both associated with worse outcomes.

Influence of stenting with open-cell stents vs close-cell stents on the outcomes of patients with bilateral carotid stenosis

BACKGROUND

Carotid artery stenting (CAS) is an effective way to prevent stroke in patients with severe carotid stenosis. However, several studies comparing the outcomes of stenting with open-cell stents (OCS) vs closed-cell stents (CCS) have yielded inconclusive results. This study aimed to compare the outcomes of CAS with OCS vs CCS in the same patients.

METHODS

From year 2000 to 2016, we included 52 patients with severe bilateral carotid stenosis who underwent OCS deployment in one artery and CCS deployment in the contralateral artery. Stents were selected according to arterial anatomy and lesion morphology, and the peri-procedural and long-term outcomes of treatment with OCS vs CCS, were compared in terms of rates of ischemic spot development on early post-procedural diffusion-weighted imaging (ISDWI), in-stent restenosis (ISR), and recurrent stroke.

RESULTS

After stenting with OCS vs CCS, the number (rate) of arteries with no lesion, < 5 lesions, and ≥ 5 lesions on DWI was 9 (32%) vs 8 (27%), 8 (29%) vs 17 (57%), and 11 (39%) vs 5 (17%) (p = .10); number (rate) of arteries with 0%, < 50%, and >50% ISR was 34 (65%) vs 34 (65%), 9 (17%) vs 11 (21%), and 9 (17%) vs 7 (13%) (p = .71); number (rate) of recurrent strokes after CAS was 2 (4%) vs 0 (0%).

CONCLUSION

The rates of peri-procedural cerebral ischemic insult, long-term stent patency, and stroke recurrence indicate that no one carotid stent cell design is superior to the other. We suggest both OCS and CCS are reasonable options for the treatment of severe carotid stenosis.

Delivery of viral vectors for gene therapy in intimal hyperplasia and restenosis in atherosclerotic swine

Cardiovascular diseases including atherosclerosis are a major financial and health burden globally. Inflammation associated with atherosclerosis results in the development of plaques that can rupture causing thrombosis, stroke, or death. The most widely used treatment for the removal of atherosclerotic plaques is percutaneous transluminal coronary angioplasty (PTCA) with or without stenting. Although this is a safer and minimally invasive method, restenosis and intimal hyperplasia after interventional procedure remains a major hurdle and more refined approaches are needed. Studies in large animal models such as pigs have facilitated a greater understanding of the underlying mechanisms of the disease and provided novel targets for therapeutic intervention. In pre-clinical studies, viral vector gene therapy has emerged as a promising option for the reduction and/or prevention of restenosis and intimal hyperplasia. Although studies in animal models have generated promising results, clinical trials have yet to prove the clinical efficacy of gene therapy in coronary artery diseases. In this review, we examined and critically reviewed the most recent advances in viral vector gene therapy obtained from studies using porcine model of atherosclerosis.

Relationship Between Postoperative Neutrophil-Lymphocyte Ratio and 6-Month Primary Patency of Percutaneous Transluminal Angioplasty in Femoropopliteal disease With Drug-Coated and Uncoated Balloons

We investigated the relationship of postoperative neutrophil-lymphocyte ratio (NLR) with 6-month primary patency of percutaneous transluminal angioplasty (PTA) in femoropopliteal disease using drug-coated balloon (DCB) or uncoated balloon (UCB). This retrospective study included 106 patients who received DCB (n = 44) or UCB (n = 62). The postoperative NLR was lower in the DCB group than that in the UCB group (2.60 vs 3.23; P = .004), and 6-month primary patency rate was significantly higher in DCB group than that in the UCB group (77.3% vs 53.2%; P = .011). Multivariate logistic analysis showed that the postoperative NLR was an independent predictor of 6-month primary patency after PTA in patients with femoropopliteal disease (odds ratio: 1.589, 95% confidence interval: 1.078-2.343; P = .019). The cutoff value of postoperative NLR was 3.05 for prediction of 6-month primary patency, with a sensitivity of 64.1% and specificity of 65.7%. The 6-month primary patency rate in the NLR ≤3.05 group was higher than that in the NLR >3.05 group (75.9% vs 47.9%; P = .003). In conclusion, DCB may improve early primary patency by inhibiting inflammation. A higher postoperative NLR was associated with early restenosis.

Pro-resolving lipid mediators in vascular disease

Unresolved inflammation is central to the pathophysiology of commonly occurring vascular diseases such as atherosclerosis, aneurysm, and deep vein thrombosis - conditions that are responsible for considerable morbidity and mortality. Surgical or catheter-based procedures performed on affected blood vessels induce acute-on-chronic inflammatory responses. The resolution of vascular inflammation is an important driver of vessel wall remodeling and functional recovery in these clinical settings. Specialized pro-resolving lipid mediators (SPMs) derived from omega-3 polyunsaturated fatty acids orchestrate key cellular processes driving resolution and a return to homeostasis. The identification of their potent effects in classic animal models of sterile inflammation triggered interest in their vascular properties. Recent studies have demonstrated that SPMs are locally synthesized in vascular tissues, have direct effects on vascular cells and their interactions with leukocytes, and play a protective role in the injury response. Early translational work has established the potential for SPMs as vascular therapeutics, and as candidate biomarkers in vascular disease. Further investigations are needed to understand the molecular and cellular mechanisms of resolution in the vasculature, to improve tools for clinical measurement, and to better define the potential for "resolution therapeutics" in vascular patients.

The Relationship Between the Neutrophil-Lymphocyte Ratio and In-Stent Restenosis in Patients With Femoropopliteal Chronic Total Occlusions

We investigated the relationship between the neutrophil-lymphocyte ratio (NLR) and in-stent restenosis (ISR) in patients with femoropopliteal chronic total occlusions (CTOs). The study enrolled 180 patients who had undergone successful stenting treatment for femoropopliteal CTO. Patients with ISR were subsequently classified into 2 groups: early-ISR (within 1 year) and late-ISR (after 1 year). The clinical characteristics, angiographic data, and follow-up data were recorded. The baseline NLR was significantly higher in the early-ISR group than that in the non-ISR group [3.96(2.14) and 3.33(2.73), p = .04]. Receiver operating characteristic curve analysis suggested an optimum early ISR NLR cutoff point of 3.62, which showed a sensitivity and specificity of 73.4% and 80.4%, respectively (area under the curve: 0.707, 95% confidence interval: 0.603-0.792, P < .001). A subgroup analysis was performed based on the NLR value (<3.62 vs ≥3.62). In the NLR ≥3.62 subgroup, the incidence of early ISR was higher than that of late ISR ( P < .01). In the multivariate analysis, NLR ≥3.62 was independently and positively associated with a higher risk of early ISR. In conclusion, NLR is independently associated with early ISR after stent implantation in patients with femoropopliteal CTO.

Systemic pentraxin-3 levels reflect vascular enhancement and progression in Takayasu arteritis

Introduction

Progression of arterial involvement is often observed in patients with Takayasu arteritis (TA) thought to be in remission. This reflects the failure of currently used biomarkers and activity criteria to detect smouldering inflammation occurring within arterial wall. Pentraxin-3 (PTX3) is a soluble pattern recognition receptor produced at sites of inflammation and could reveal systemic as well as localized inflammatory processes. We verified whether the blood concentrations of PTX3 and of C-reactive protein (CRP) in patients with Takayasu arteritis (TA) might reflect vascular wall involvement, as assessed by signal enhancement after contrast media administration, and the progression of arterial involvement.

Methods

A cross-sectional single-centre study was carried out on 42 patients with TA that comprised assessment of PTX3, of CRP and erythrocyte sedimentation velocity (ESR). In total, 20 healthy controls and 20 patients with Systemic Lupus Erythematous (SLE) served as controls. Vascular imaging was carried out by magnetic resonance angiography, doppler ultrasonography and computed tomography angiography.

Results

Patients with TA and SLE had higher plasmatic PTX3 and CRP concentrations than healthy controls (P = 0.009 and 0.017, respectively). PTX3 levels did not correlate with those of CRP. Patients with active systemic TA had significantly higher concentrations of CRP but similar levels of PTX3 than patients with quiescent disease. In contrast, patients with vascular inflammation detectable at imaging had higher PTX3 concentrations (P = 0.016) than those in which vessel inflammation was not evident, while CRP levels were similar. The concentration of PTX3 but not that of CRP was significantly higher in TA patients with worsening arterial lesions that were not receiving antagonists of tumor necrosis factor-α or interleukin-6.

Conclusions

Arterial inflammation and progression of vascular involvement influence plasma PTX3 levels in TA, while levels of CRP accurately reflect the burden of systemic inflammation. These results support the contention that PTX3 reflects different aspects of inflammation than CRP and might represent a biomarker of actual arteritis in TA.

Neutrophil-lymphocyte ratio as a prognostic marker of outcome in infrapopliteal percutaneous interventions for critical limb ischemia

BACKGROUND

Endovascular intervention has become a frequently used treatment of critical limb ischemia (CLI) in recent times. The recent Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL) trial consensus recommended endovascular treatment as a first-line treatment in patients who have a life expectancy that was limited to <2 years. Despite these recommendations, there still remains limited data available to clinicians when seeking to risk stratify patients who present with CLI. The neutrophil-lymphocyte ratio (NLR) has been suggested to be a marker for predicting mortality and patency. This study aimed to investigate the use of the NLR as a prognostic marker for primary patency and mortality after an infrapopliteal endovascular intervention in patients with CLI.

METHODS

All patients who underwent tibial angioplasty for CLI were retrospectively analyzed. Demographics, degrees of stenosis, vessel patency rates, mortality, and comorbidities were recorded. NLRs were calculated from preoperative blood samples. Primary end points were all-cause mortality, primary patency, and amputation-free survival (AFS) within the follow-up period of 12 months. Multivariate Cox proportional hazard models were used to identify independent predictors. Overall survival, AFS, and the probability of a vessel remaining patent were evaluated by standard Kaplan-Meier survival curves and groups compared by the log-rank test.

RESULTS

Eighty-three patients were monitored for 12 months. Ninety limbs were identified, with 104 procedural events and 127 vessels undergoing successful angioplasty. The technical success rate was 86%, and patency at 1 year was 19%. Survival at 1 year was 76% and AFS was 61%. Patients with a NLR ≥5.25 had an increased risk of death (hazard ratio, 1.97; 95% confidence interval, 1.08-3.62; P = .03) compared with those with a NLR of <5.25. Furthermore, those with lymphocytes counts of <1.5 × 10(9)/L had higher mortality (hazard ratio, 1.88; 95% confidence interval, 1.02-3.70; P = .045) than those with lymphocyte counts >1.5 × 10(9)/L.

CONCLUSIONS

The NLR and absolute lymphocyte counts are potentially valuable prognostic indicators for risk stratification of patient's presenting with CLI undergoing infrapopliteal angioplasty.

The decline effect in cardiovascular medicine: is the effect of cardiovascular medicine and stent on cardiovascular events decline over the years?

The term decline effect is referred to a diminution of scientifically discovered effects over time. Reasons for the decline effect are multifaceted and include publication bias, selective reporting, outcomes reporting bias, regression to the mean, scientific paradigm shift, overshadowing and habituation, among others. Such effects can be found in cardiovascular medicines through medications (e.g., aspirin, antithrombotics, proton pump inhibitor, beta-blockers, statins, estrogen/progestin, angiotensin converting enzyme inhibitor etc.), as well as with interventional devices (e.g., angioplasty, percutaneous coronary intervention, stents). The scientific community should understand the various dimensions of the decline effects, and effective steps should be undertaken to prevent or recognize such decline effects in cardiovascular medicines.

Abdominal obesity is associated with peripheral artery disease in hemodialysis patients

Background

Peripheral arterial disease (PAD) is a leading cause of morbidity in hemodialysis (HD) patients. Recent evidence suggests that abdominal obesity (AO) may play a role in PAD. However, the association between AO and PAD has not been thoroughly studied in HD patients.

Methods

The present cross-sectional study aimed to examine the relationship between AO and PAD in a cohort of 204 chronic HD patients. The ankle brachial index (ABI) was used as an estimate of the presence of PAD. Plasma adiponectin levels, interleukin-6 (IL-6) levels, high sensitivity C-reactive protein (hs-CRP) levels, asymmetric dimethylarginine (ADMA) levels, and lipid profiles were measured. Logistic regression was used to estimate the association between the presence of PAD and AO as well as other potential risk factors.

Results

The metabolic risk factors and all individual traits, including elevated ln-transformed hs-CRP, were found to be significant (P<0.05) more frequently in HD patients with AO than that in control subjects. Patients with AO had a higher prevalence of PAD than the control individuals, with a mean ABI of 0.96±0.23 and 1.08±0.16 (P<0.0001) and PAD prevalence of 26.9% and 10.8% (P = 0.003), respectively. By multivariate analysis, AO (odds ratio [OR], 4.532; 95% CI, 1.765–11.639; P = 0.002), elevated serum ln-transformed ADMA (OR, 5.535; 95% CI, 1.323–23.155; P = 0.019), and ln-transformed IL-6 (OR, 1.567; 95% CI, 1.033–2.378; P = 0.035) were independent predictors of the presence of PAD.

Conclusions

HD patients with AO exhibited a cluster of metabolic risk factors and lower ABI. AO, elevated serum ln-transformed ADMA, and ln-transformed IL-6 were independent predictors of the presence of PAD.

Patients with unrecognized peripheral arterial disease (PAD) assessed by ankle-brachial index (ABI) present a defined profile of proinflammatory markers compared to healthy subjects

BACKGROUND

Many studies have postulated that atherosclerosis should be considered as an inflammatory disease. In addition, some studies have focused on the relationship between inflammation and peripheral arterial disease (PAD).

OBJECTIVE

Define the plasma levels of soluble markers, including the proinflammatory cytokine interleukin-6 (IL-6), the anti-inflammatory cytokine transforming growth factor-β1 (TGF-β1), the endothelial-specific adhesion factor (E-selectin) and two proteinases involved in extracellular matrix degradation (matrix metalloproteinases-2 and -9, MMP-2, and MMP-9) in previously unrecognized patients with peripheral artery disease (PAD) and non-PAD controls.

RESULTS

Significantly higher levels of IL-6, E-selectin and MMP-2/MMP-9 and significantly reduced levels of TGF-β1 were found in PAD patients (ankle-brachial index, ABI⩽0.9) compared to non-PAD control subjects (1.4>ABI>0.9).

CONCLUSION

The results demonstrated the subjects with unrecognized PAD (ABI⩽0.9) show a characteristic phlogistic pattern differently from healthy subjects and it strongly supports the pivotal role played by inflammatory and immunological mechanisms in the initiation and progression of the atherosclerotic process in peripheral arteries. These biomarkers could be helpful to screen the susceptibility for the diseases in peripheral arteries.

Mis-sizing of stent promotes intimal hyperplasia: impact of endothelial shear and intramural stress

Stent can cause flow disturbances on the endothelium and compliance mismatch and increased stress on the vessel wall. These effects can cause low wall shear stress (WSS), high wall shear stress gradient (WSSG), oscillatory shear index (OSI), and circumferential wall stress (CWS), which may promote neointimal hyperplasia (IH). The hypothesis is that stent-induced abnormal fluid and solid mechanics contribute to IH. To vary the range of WSS, WSSG, OSI, and CWS, we intentionally mismatched the size of stents to that of the vessel lumen. Stents were implanted in coronary arteries of 10 swine. Intravascular ultrasound (IVUS) was used to size the coronary arteries and stents. After 4 wk of stent implantation, IVUS was performed again to determine the extent of IH. In conjunction, computational models of actual stents, the artery, and non-Newtonian blood were created in a computer simulation to yield the distribution of WSS, WSSG, OSI, and CWS in the stented vessel wall. An inverse relation (R(2) = 0.59, P < 0.005) between WSS and IH was found based on a linear regression analysis. Linear relations between WSSG, OSI, and IH were observed (R(2) = 0.48 and 0.50, respectively, P < 0.005). A linear relation (R(2) = 0.58, P < 0.005) between CWS and IH was also found. More statistically significant linear relations between the ratio of CWS to WSS (CWS/WSS), the products CWS × WSSG and CWS × OSI, and IH were observed (R(2) = 0.67, 0.54, and 0.56, respectively, P < 0.005), suggesting that both fluid and solid mechanics influence the extent of IH. Stents create endothelial flow disturbances and intramural wall stress concentrations, which correlate with the extent of IH formation, and these effects were exaggerated with mismatch of stent/vessel size. These findings reveal the importance of reliable vessel and stent sizing to improve the mechanics on the vessel wall and minimize IH.