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Pinto P, Ochoa Chaar CI. Atherectomy - The Options, the Evidence, and When Should It Be Used. Ann Vasc Surg 2024; 107:127-135. [PMID: 38583766 DOI: 10.1016/j.avsg.2023.12.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/18/2023] [Accepted: 12/25/2023] [Indexed: 04/09/2024]
Abstract
The use of atherectomy for peripheral vascular interventions (PVIs) has increased exponentially and reached 18% of all PVI in the United States. The theoretical benefit on extensive arterial calcification relies on the concept of plaque modification and removal instead of displacement, as with other endovascular techniques. To date, there are no prospective studies comparing the different atherectomy technologies (directional, rotational, orbital, and laser). Moreover, most related prospective comparative studies have a small number of patients, and larger studies are single arm in patients with relatively mild to moderate disease burden. While available literature shows lower dissection risk and reduced bailout stenting, the superiority of this technology compared to other endovascular techniques has yet to be proven. Despite the lack of level 1 evidence to support its superiority, the lucrative reimbursement fueled the overuse of this technology as first-line therapy, particularly in office-based laboratories and ambulatory surgery centers. The use of atherectomy ought to be selective and complementary to other endovascular technologies, and individualized patient-level decision-making based on the practitioner's preference and expertise is essential to selectively incorporate atherectomy in managing complex atherosclerotic lesions.
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Affiliation(s)
- Paula Pinto
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT, USA.
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT, USA
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2
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Zhang W, Gao X, Zhang H, Sun G, Zhang G, Li X, Qi H, Guo J, Qin L, Shi D, Shi X, Li H, Zhang D, Guo W, Ding J. Maglev-fabricated long and biodegradable stent for interventional treatment of peripheral vessels. Nat Commun 2024; 15:7903. [PMID: 39256371 PMCID: PMC11387404 DOI: 10.1038/s41467-024-52288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 08/30/2024] [Indexed: 09/12/2024] Open
Abstract
While chronic limb-threatening ischemia is a serious peripheral artery disease, the lack of an appropriate stent significantly limits the potential of interventional treatment. In spite of much progress in coronary stents, little is towards peripheral stents, which are expected to be both long and biodegradable and thus require a breakthrough in core techniques. Herein, we develop a long and biodegradable stent with a length of up to 118 mm based on a metal-polymer composite material. To achieve a well-prepared homogeneous coating on a long stent during ultrasonic spraying, a magnetic levitation is employed. In vivo degradation of the stent is investigated in rabbit abdominal aorta/iliac arteries, and its preclinical safety is evaluated in canine infrapopliteal arteries. First-in-man implantation of the stent is carried out in the below-the-knee artery. The 13 months' follow-ups demonstrate the feasibility of the long and biodegradable stent in clinical applications.
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Affiliation(s)
- Wanqian Zhang
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai, China
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Xian Gao
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Hongjie Zhang
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai, China
| | - Guoyi Sun
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Gui Zhang
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Xin Li
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai, China
| | - Haiping Qi
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Jingzhen Guo
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai, China
| | - Li Qin
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Daokun Shi
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai, China
| | - Xiaoli Shi
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Haifeng Li
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China
| | - Deyuan Zhang
- National and Local Joint Engineering Laboratory of Interventional Medical Biotechnology and System, Biotyx Medical (Shenzhen) Co., Ltd, Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China.
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China.
| | - Jiandong Ding
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai, China.
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3
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Mohammedi K, Pigeyre M, Bosch J, Yusuf S, Gerstein HC. Relationships between ankle blood pressure indices and major adverse cardiovascular events in people with and without type 2 diabetes. Cardiovasc Diabetol 2024; 23:325. [PMID: 39227845 PMCID: PMC11373129 DOI: 10.1186/s12933-024-02383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 07/30/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND The relationship between ankle blood pressure (BP) and cardiovascular disease remains unclear. We examined the relationships between known and new ankle BP indices and major cardiovascular outcomes in people with and without type 2 diabetes. METHODS We used data from 3 large trials with measurements of ankle systolic BP (SBP), ankle-brachial index (ABI, ankle SBP divided by arm SBP), and ankle-pulse pressure difference (APPD, ankle SBP minus arm pulse pressure). The primary outcome was a composite of cardiovascular mortality, myocardial infarction, hospitalization for heart failure, or stroke. Secondary outcomes included death from cardiovascular causes, total (fatal and non-fatal) myocardial infarction, hospitalization for heart failure, and total stroke. RESULTS Among 42,929 participants (age 65.6 years, females 31.3%, type 2 diabetes 50.1%, 53 countries), the primary outcome occurred in 7230 (16.8%) participants during 5 years of follow-up (19.4% in people with diabetes, 14.3% in those without diabetes). The incidence of the outcome increased with lower ankle BP indices. Compared with people whose ankle BP indices were in the highest fourth, multivariable-adjusted hazard ratios (HRs, 95% CI) of the outcome for each lower fourth were 1.05 (0.98-1.12), 1.17 (1.08-1.25), and 1.54 (1.54-1.65) for ankle SBP; HR 1.06 (0.99-1.14), 1.26 (1.17-1.35), and 1.48 (1.38-1.58) for ABI; and HR 1.02 (0.95-1.10), 1.15 (1.07-1.23), and 1.48 (1.38-1.58) for APPD. The largest effect size was noted for ankle SBP (HRs 1.05 [0.90-1.21], 1.21 [1.05-1.40], and 1.93 [1.68-2.22]), and APPD (HRs 1.08 [0.93-1.26], 1.30 [1.12-1.50], and 1.97 [1.72-2.25]) with respect to hospitalization for heart failure, while only a marginal association was observed for stroke. The relationships were similar in people with and without diabetes (all p for interaction > 0.05). CONCLUSIONS Inverse and independent associations were observed between ankle BP and cardiovascular events, similarly in people with and without type 2 diabetes. The largest associations were observed for heart failure and the smallest for stroke. Including ankle BP indices in routine clinical assessments may help to identify people at highest risk of cardiovascular outcomes.
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Affiliation(s)
- Kamel Mohammedi
- Population Health Research Institute, McMaster University, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada.
- Université de Bordeaux, INSERM, BMC, U1034, Avenue de Magellan, 33604, Pessac, France.
| | - Marie Pigeyre
- Population Health Research Institute, McMaster University, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada
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Bonaca MP, Barnes GD, Bauersachs R, Bessada Y, Conte MS, Dua A, Hess CN, Serhal M, Mena-Hurtado C, Weitz JI, Beckman JA. Antithrombotic Strategies for Patients With Peripheral Artery Disease: JACC Scientific Statement. J Am Coll Cardiol 2024; 84:936-952. [PMID: 39197984 DOI: 10.1016/j.jacc.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/06/2024] [Accepted: 06/21/2024] [Indexed: 09/01/2024]
Abstract
Patients with peripheral artery disease (PAD) experience major cardiovascular and limb events. Antithrombotic strategies including antiplatelets and anticoagulants remain a cornerstone of treatment and prevention. Recent trials have shown heterogeneity in the response to antithrombotic therapies in patients presenting primarily with PAD when compared to those presenting primarily with coronary artery disease. In addition, there is observed heterogeneity with regards to the effects of antiplatelets and anticoagulants with respect to different outcomes including cardiovascular and major adverse limb events. This, coupled with risks of bleeding, requires a patient-centered and holistic assessment of benefit-risk when selecting antithrombotic strategies for patients with PAD. A global multidisciplinary work group was convened to evaluate antithrombotic strategies in PAD and to summarize the current state of the art. Common clinical scenarios around antithrombotic decision making were provided. Finally, insights with regard to implementation future investigation were described.
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Affiliation(s)
- Marc P Bonaca
- CPC Clinical Research, Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien, Frankfurt, Germany, and the Center for Vascular Research, Munich, Germany
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Michael S Conte
- Vascular Surgery and Center for Limb Preservation, University of California-San Francisco, San Francisco, California, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Connie N Hess
- CPC Clinical Research, Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Maya Serhal
- Cardiovascular Division, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Joshua A Beckman
- Vascular Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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5
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Ramacciotti E, Volpiani GG, Britto KF, Agati LB, Ribeiro CM, Aguiar VCR, Paganotti A, Pereira FM, Caffaro RA, Krakauer R, Rached HRS, Fareed J, Wolosker N, Anand SS, Eikelboom JW, Chang C, Lopes RD. Rivaroxaban for Patients with Intermittent Claudication. NEJM EVIDENCE 2024; 3:EVIDoa2400021. [PMID: 39185955 DOI: 10.1056/evidoa2400021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
BACKGROUND The combination of rivaroxaban plus aspirin compared with aspirin alone reduces the risk of major adverse cardiovascular and limb events for high-risk patients with peripheral artery disease. It is unknown whether rivaroxaban plus aspirin improves intermittent claudication for adults with lower-risk peripheral arterial disease. METHODS In this randomized, open-label, multicenter, 24-week clinical trial, we randomly assigned patients with peripheral artery disease and intermittent claudication to receive either 2.5 mg of rivaroxaban twice daily plus 100 mg of aspirin once daily or 100 mg of aspirin once daily. The primary outcome was a 24-week change in total walking distance, measured by the 6-minute walking test. The primary safety outcome was the incidence of major bleeding or clinically relevant nonmajor bleeding. RESULTS Eighty-eight patients were randomly assigned to either rivaroxaban plus aspirin (n=46) or aspirin alone (n=42). The mean age was 67 years, and 54% were female. The total walking distance measured by 6-minute walk test improved by 89 ± 18 m (mean±standard error) in the rivaroxaban-plus-aspirin group versus 21 ± 16 m in the aspirin-alone group. This corresponded to an absolute difference of 68 ± 24 m (95% confidence interval [CI], 19 to 116 m; P=0.007) and a relative improvement over the aspirin-alone group of 327% (95% CI, 94 to 560%). No major bleeding events were observed in either group. CONCLUSIONS In patients with peripheral artery disease and intermittent claudication, 2.5 mg of rivaroxaban twice daily plus 100 mg of aspirin daily improved the total walking distance by a 6-minute walking test compared with 100 mg of aspirin daily alone. (Funded by Bayer S.A.; Clinicaltrials.gov number, NCT04853719.).
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Affiliation(s)
- Eduardo Ramacciotti
- Science Valley Research Institute, São Paulo
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, São Paulo
- Hemostasis & Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, IL
| | - Giuliano Giova Volpiani
- Science Valley Research Institute, São Paulo
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, São Paulo
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo
| | | | | | | | | | | | | | | | - Rogério Krakauer
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, São Paulo
| | | | - Jawed Fareed
- Hemostasis & Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, IL
| | | | - Sonia S Anand
- Department of Medicine, Population Health Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - John W Eikelboom
- Department of Medicine, Population Health Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Chiann Chang
- Department of Statistics, Institute of Mathematics and Statistics, University of São Paulo, São Paulo
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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6
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Altin SE, Parise H, Hess CN, Rosenthal NA, Julien HM, Curtis JP. Co-Morbidity Differences Associated With Long-Term Amputation and Repeat Revascularization Rates After Femoropopliteal Artery Intervention for Intermittent Claudication by Sex, Race, and Ethnicity. Am J Cardiol 2024; 226:40-49. [PMID: 38834142 DOI: 10.1016/j.amjcard.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/29/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
Use of peripheral vascular intervention (PVI) for intermittent claudication (IC) continues to expand, but there is uncertainty whether baseline demographics, procedural techniques and outcomes differ by sex, race, and ethnicity. This study aimed to examine amputation and revascularization rates up to 4 years after femoropopliteal (FP) PVI for IC by sex, race, and ethnicity. Patients who underwent FP PVI for IC between 2016 and 2020 from the PINC AI Healthcare Database were analyzed. The primary outcome was any index limb amputation, assessed by Kaplan-Meier estimate. Secondary outcomes included index limb major amputation, repeat revascularization, and index limb repeat revascularization. Unadjusted and adjusted hazard ratios (HRs) were estimated using Cox proportional hazard regression models. This study included 19,324 patients with IC who underwent FP PVI, with 41.2% women, 15.6% Black patients, and 4.7% Hispanic patients. Women were less likely than men to be treated with atherectomy (45.1% vs 47.8%, p = 0.0003); Black patients were more likely than White patients to receive atherectomy (50.7% vs 44.9%, p <0.001), and Hispanic patients were less likely than non-Hispanic patients to receive atherectomy (41% vs 47%, p = 0.0004). Unadjusted rates of any amputation were similar in men and women (6.4% for each group, log-rank p = 0.842), higher in Black patients than in White patients (7.8% vs 6.1%, log-rank p = 0.007), and higher in Hispanic patients than in non-Hispanic patients (8.8% vs 6.3%, log-rank p = 0.031). After adjustment for baseline characteristics, Black race was associated with higher rates of repeat revascularization (adjusted HR 1.13, 95% confidence interval 1.04 to 1.22) and any FP revascularization (adjusted HR 1.10, 95% confidence interval 1.01 to 1.20). No statistical difference in amputation rate was observed among comparison groups. Women and men with IC had similar crude and adjusted amputation and revascularization outcomes after FP PVI. Black patients had higher repeat revascularization and any FP revascularization rates than did White patients. Black and Hispanic patients had higher crude amputation rates, but these differences were attenuated by adjustment for baseline characteristics. Black patients were more likely to receive atherectomy and had higher rates of any repeat revascularization and specifically FP revascularization. Further study is necessary to determine whether these patterns are related to disease-specific issues or practice-pattern differences among different populations.
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Affiliation(s)
- S Elissa Altin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; West Haven VA Medical Center, West Haven, Connecticut.
| | - Helen Parise
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Connie N Hess
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; CPC Clinical Research, Aurora, Colorado
| | - Ning A Rosenthal
- PINC AI Applied Sciences, Premier Inc., Charlotte, North Carolina
| | - Howard M Julien
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia, Pennsylvania
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
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7
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Divakaran S, Li S, Song Y, Krawisz AK, Carroll BJ, Secemsky EA. Underutilization of supervised exercise therapy for symptomatic peripheral artery disease among Medicare beneficiaries. Vasc Med 2024:1358863X241266859. [PMID: 39129558 DOI: 10.1177/1358863x241266859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Affiliation(s)
- Sanjay Divakaran
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Siling Li
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yang Song
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anna K Krawisz
- Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Brett J Carroll
- Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric A Secemsky
- Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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8
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Feliz JD, Heindel P, Fitzgibbon JJ, Ozaki CK, Gravereaux E, Nguyen LL, Menard M, Belkin M, Hussain MA. Descriptive Analysis of Amputation-Free Survival After First Time Infra-Inguinal Bypass Occlusion. J Surg Res 2024; 300:263-271. [PMID: 38824856 DOI: 10.1016/j.jss.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass. METHODS Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes. RESULTS Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass. CONCLUSIONS Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes.
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Affiliation(s)
- Jessica Dominique Feliz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Edwin Gravereaux
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Matthew Menard
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
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9
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Rice JR, Rothenberg KA, Ramadan OI, Savage D, Kalapatapu V, Julien HM, Schneider DB, Wang GJ. Factors Associated with Urgent Amputation Status and Its Impact on Mortality. Ann Vasc Surg 2024; 105:334-342. [PMID: 38582210 DOI: 10.1016/j.avsg.2023.12.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/11/2023] [Accepted: 12/22/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND Thirty-day mortality is higher after urgent major lower extremity amputations compared to elective lower extremity amputations. This study aims to identify factors associated with urgent amputations and to examine their impact on perioperative outcomes and long-term mortality. METHODS Patients undergoing major lower limb amputation from 2013 to 2020 in the Vascular Quality Initiative were included. Urgent amputation was defined as occurring within 72 hr of admission. Associations with sociodemographic characteristics, comorbidities, and outcomes including postoperative complication, inpatient death, and long-term survival were compared using univariable tests and multivariable logistic regression. Long-term survival between groups was compared using Kaplan-Meier analysis. RESULTS Of the 12,874 patients included, 4,850 (37.7%) had urgent and 8,024 (62.3%) had elective amputations. Non-White patients required urgent amputation more often than White patients (39.8% vs. 37.9%, P = 0.03). A higher proportion of Medicaid and self-pay patients presented urgently (Medicaid: 13.0% vs. 11.0%; self-pay: 3.4% vs. 2.5%, P < 0.001). Patients requiring urgent amputation were less often taking aspirin (55.6% vs. 60.1%, P < 0.001) or statin (62.2% vs. 67.2%, P < 0.001), had fewer prior revascularization procedures (41.0% vs. 48.8%, P < 0.001), and were of higher American Society of Anesthesiologists (ASA) class 4-5 (50.9% vs. 40.1%, P < 0.001). Urgent amputations were more commonly for uncontrolled infection (48.1% vs. 29.4%, P < 0.001) or acute limb ischemia (14.3% vs. 6.2%, P < 0.001). Postoperative complications were higher after urgent amputations (34.7% vs. 16.6%, P < 0.001), including need for return to operating room (23.8% vs. 8.4%, P < 0.001) and need for higher revision (15.2% vs. 4.5%, P < 0.001). Inpatient mortality was higher after urgent amputation (8.9% vs. 5.4%, P < 0.001). Multivariable analysis revealed non-White race, self-pay, homelessness, current smoking, ASA class 4-5, and amputations for uncontrolled infection or acute limb ischemia were associated with urgent status, whereas living in a nursing home or prior revascularization were protective. Furthermore, urgent amputation was associated with an increased odds of postoperative complication or death (odds ratio 1.86 [1.69-2.04], P < 0.001) as well as long-term mortality (odds ratio: 1.24 [1.13-1.35], P < 0.001). Kaplan-Meier analysis corroborated that elective status was associated with improvement of long-term survival. CONCLUSIONS Patients requiring urgent amputations are more often non-White, uninsured, and less frequently had prior revascularization procedures, revealing disparities in access to care. Urgency was associated with a higher postoperative complication rate, as well as increased long-term mortality. Efforts should be directed toward reducing these disparities to improve outcomes following amputation.
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Affiliation(s)
- Jayne R Rice
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA.
| | - Kara A Rothenberg
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Omar I Ramadan
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Dasha Savage
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Venkat Kalapatapu
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Howard M Julien
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Darren B Schneider
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Vascular Surgery and Endovascular Therapy, Hospital of University of Pennsylvania, Philadelphia, PA
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10
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Pereira DAG, Furtado SRC, Pereira JM, Rosa APS, Inácio MCG, de Oliveira LC, Nascimento IDO, de Oliveira LFL. Functional Status in Peripheral Arterial Disease: Rehabilitated Versus Nonrehabilitated. Ann Vasc Surg 2024; 105:343-350. [PMID: 38582195 DOI: 10.1016/j.avsg.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/21/2023] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND To analyze patient perception of functional status related to activity and participation of rehabilitated and nonrehabilitated individuals with peripheral arterial disease. METHODS Cross-sectional study assessing the activity and participation domain using the Human Activity Profile (HAP) questionnaire and the Participation Scale, respectively. Groups were compared using Chi-squared test and unpaired t-test. RESULTS A total of 87 individuals (36 rehabilitated) with 65.28 ± 8.29 years (66.7% male) were included. HAP classified 58.6% of individuals with weak or inactive physical activity level, and approximately half of the sample did not have participation restriction. HAP scores and Participation Scale (locomotion inside and outside home) were lower in nonrehabilitated than in rehabilitated individuals. CONCLUSIONS Individuals with peripheral arterial disease presented little participation restriction and a great activity limitation, the last one being more evident among nonrehabilitated.
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Affiliation(s)
- Danielle Aparecida Gomes Pereira
- Department of Physical Therapy, Rehabilitation Sciences Program, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | | | - Jhessica Macieira Pereira
- Rehabilitation Sciences Program, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Amanda Pereira Santos Rosa
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Lídia Cunha de Oliveira
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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11
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Jourdi G, Hulot JS, Gaussem P. An update on oral antiplatelet drug interactions with proton pump inhibitors: what are the risks? Expert Opin Drug Metab Toxicol 2024:1-16. [PMID: 38980768 DOI: 10.1080/17425255.2024.2378888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Aspirin and anti-P2Y12 are widely prescribed in cardiovascular patients, often in combination with proton pump inhibitors (PPIs) to limit the risk of upper gastrointestinal bleedings. The potential interaction between PPIs and antiplatelet agents has been widely discussed, but doubts remain as to whether PPIs may reduce the cardiovascular protection provided by aspirin, prasugrel, ticagrelor, and clopidogrel. AREAS COVERED Many pharmacokinetic (PK) and pharmacodynamic (PD) studies have confirmed the interaction, especially between PPIs and clopidogrel, but with uncertain consequences on clinical outcomes. Therefore, we aimed to summarize the evidence for the widespread combined use of oral antiplatelet drugs and PPIs, to outline the current evidence supporting or opposing drug-drug interaction, and to discuss the clinical implications of such interactions. EXPERT OPINION A large body of evidence describes the PK/PD interaction of antiplatelet drugs with PPIs and its potential role in increasing clinical cardiovascular adverse events, but no solid clinical data have confirmed these effects. In the light of the published studies, there seems to be no restriction on the choice of PPI with aspirin, prasugrel, and/or ticagrelor. The choice of a PPI with no (or minimal) interference with the hepatic cytochrome P450 2C19 is preferred in patients receiving clopidogrel.
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Affiliation(s)
- Georges Jourdi
- Faculté de Pharmacie de Paris, Université Paris Cité, Inserm, Innovative Therapies in Haemostasis, UMR_S1140, Paris, France
- Laboratory of haematology, Lariboisière University hospital, Paris, France
| | - Jean-Sébastien Hulot
- Université Paris Cité, Inserm, Paris Cardiovascular Research center, UMR_S970, Paris, France
- Clinical investigation center (CIC1418), Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Laboratory of haematology, Hôpital Européen Georges Pompidou, Paris, France
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12
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Bose S, Dun C, Solomon AJ, Black JH, Conte MS, Kalbaugh CA, Woo K, Makary MA, Hicks CW. Infrapopliteal Peripheral Vascular Interventions for Claudication are Performed Frequently in the USA and Are Associated with Poor Long Term Outcomes. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00490-8. [PMID: 38906366 DOI: 10.1016/j.ejvs.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/17/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Infrapopliteal peripheral vascular interventions (PVIs) for claudication are still performed in the USA. This study aimed to evaluate whether infrapopliteal PVI is associated with worse long term outcomes than isolated femoropopliteal PVI for treatment of claudication. METHODS A retrospective analysis of fee for service claims in a national administrative database was conducted using 100% of the Medicare fee for service claims between 2017 and 2019 to capture all Medicare beneficiaries who underwent an index infra-inguinal PVI for claudication. Hierarchical Cox proportional hazards models were performed to assess the association of infrapopliteal PVI with conversion to chronic limb threatening ischaemia (CLTI), repeat PVI, and major amputation. RESULTS In total, 36 147 patients (41.1% female; 89.7% age ≥ 65 years; 79.0% non-Hispanic White ethnicity) underwent an index PVI for claudication, of whom 32.6% (n = 11 790) received an infrapopliteal PVI. Of these, 61.4% (n = 7 245) received a concomitant femoropopliteal PVI and 38.6% (n = 4 545) received an isolated infrapopliteal PVI. The median follow up time was 3.5 years (interquartile range 2.7, 4.3). Patients receiving infrapopliteal PVI had a higher three year cumulative incidence of conversion to CLTI (26.0%; 95% confidence interval [CI] 24.9 - 27.2% vs. 19.9%; 95% CI 19.1 - 20.7%), repeat PVI (56.0%; 95% CI 54.8 - 57.3% vs. 45.7%; 95% CI 44.9 - 46.6%), and major amputation (2.2%; 95% CI 1.8 - 2.6% vs. 1.3%; 95% CI 1.1 - 1.5%) compared with patients receiving isolated femoropopliteal PVI. After adjusting for patient and physician level characteristics, the risk of conversion to CLTI (adjusted hazard ratio [aHR] 1.31, 95% CI 1.23 - 1.39), repeat PVI (aHR 1.12, 95% CI 1.05 - 1.20), and major amputation (aHR 1.72, 95% CI 1.42 - 2.07) remained significantly higher for patients receiving infrapopliteal PVI. An increasing number of infrapopliteal vessels treated during the index intervention was associated with increasingly poor outcomes (p < .001 for trend). CONCLUSION Infrapopliteal PVI for claudication is associated with worse long term outcomes relative to isolated femoropopliteal PVI.
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Affiliation(s)
- Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chen Dun
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Corey A Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Karen Woo
- Division of Vascular Surgery, University of California, Los Angeles, CA, USA
| | - Martin A Makary
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
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13
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Scierka LE, Peri-Okonny PA, Romain G, Cleman J, Spertus JA, Fitridge R, Secemsky E, Patel MR, Gosch KL, Mena-Hurtado C, Smolderen KG. Psychosocial and socioeconomic factors are most predictive of health status in patients with claudication. J Vasc Surg 2024; 79:1473-1482.e5. [PMID: 38266885 PMCID: PMC11180544 DOI: 10.1016/j.jvs.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND As a key treatment goal for patients with symptomatic peripheral artery disease (PAD), improving health status has also become an important end point for clinical trials and performance-based care. An understanding of patient factors associated with 1-year PAD health status is lacking in patients with PAD. METHODS The health status of 1073 consecutive patients with symptomatic PAD in the international multicenter PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry was measured at baseline and 1 year with the Peripheral Artery Questionnaire (PAQ). The association of 47 patient characteristics with 1-year PAQ scores was assessed using a random forest algorithm. Variables of clinical significance were retained and included in a hierarchical multivariable linear regression model predicting 1-year PAQ summary scores. RESULTS The mean age of patients was 67.7 ± 9.3 years, and 37% were female. Variables with the highest importance ranking in predicting 1-year PAQ summary score were baseline PAQ summary score, Patient Health Questionnaire-8 depression score, Generalized Anxiety Disorder-2 anxiety score, new onset symptom presentation, insurance status, current or prior diagnosis of depression, low social support, initial invasive treatment, duration of symptoms, and race. The addition of 19 clinical variables in an extended model marginally improved the explained variance in 1-year health status (from R2 0.312 to 0.335). CONCLUSIONS Patients' 1-year PAD-specific health status, as measured by the PAQ, can be predicted from 10 mostly psychosocial and socioeconomic patient characteristics including depression, anxiety, insurance status, social support, and symptoms. These characteristics should be validated and tested in other PAD cohorts so that this model can inform risk adjustment and prediction of PAD health status in comparative effectiveness research and performance-based care.
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Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Poghni A Peri-Okonny
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Gaelle Romain
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Departments of Biomedical and Health Informatics and Internal Medicine, Section of Cardiovascular Disease, University of Missouri-Kansas City, Kansas City, MO
| | - Robert Fitridge
- Vascular Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Eric Secemsky
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT; Department of Psychiatry, Section of Psychology, Yale University, New Haven, CT.
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14
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Pinxterhuis TH, Ploumen EH, van Vliet D, Gert van Houwelingen K, Stoel MG, de Man FH, Hartmann M, Zocca P, Linssen GC, Geelkerken RH, Doggen CJ, von Birgelen C. Ten-year mortality after treating obstructive coronary atherosclerosis with contemporary stents in patients with or without concomitant peripheral arterial disease. Atherosclerosis 2024; 392:117488. [PMID: 38598970 DOI: 10.1016/j.atherosclerosis.2024.117488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND AND AIMS Previous studies in percutaneous coronary intervention (PCI) patients showed a higher 3-year adverse event risk, including all-cause mortality, in those with concomitant peripheral arterial disease (PADs). Ten-year data of mortality and causes of death are scarce. This analysis assessed PCI patients, treated with contemporary drug-eluting stents, the impact of concomitant PADs on very long-term mortality, and causes of death. METHODS We assessed PCI all-comers from our center who participated in the TWENTE and DUTCH PEERS trials (clinicaltrials.gov:NCT01066650, NCT01331707), comparing patients with versus without PADs. Life status was checked in the Dutch Personal Records Database; causes of death were obtained from medical records. RESULTS Of 2705 study patients, 668 (24.7%) died during follow-up: 88/212 (41.5%) patients with PADs and 580/2493 (23.1%) without PADs. In PADs patients, the 10-year rate of all-cause mortality was about twice as high as in patients without PADs (41.5% vs.23.1%, HR: 2.05, 95%-CI: 1.64-2.57, p<0.001). For both groups, the rates of patients dying from various causes of death were: cardiac (14.1% vs.6.8%), vascular (2.8% vs. 1.1%), non-cardiovascular (17.4% vs. 9.8%), and unclear causes (7.1% vs. 5.3%), without a statistically significant between-group difference. When multivariate analysis was adjusted for between-group differences in cardiovascular risk profile, PADs remained predictor of all-cause mortality (adjusted HR: 1.38, 95%-CI: 1.08-1.75, p=0.01). CONCLUSIONS The 10-year all-cause mortality rate in PCI patients with concomitant PADs was almost twice as high as in those without PADs. Age and other traditional cardiovascular risk factors were higher in patients with PADs, but after correction for these confounders PADs still accounted for almost 40% increase in mortality.
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Affiliation(s)
- Tineke H Pinxterhuis
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands; Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Eline H Ploumen
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands; Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Daphne van Vliet
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - K Gert van Houwelingen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Martin G Stoel
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Frits Haf de Man
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marc Hartmann
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Paolo Zocca
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Gerard Cm Linssen
- Department of Cardiology, Ziekenhuisgroep Twente, Almelo and Hengelo, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Department of Multi-modality Medical Imaging (M3I) group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Carine Jm Doggen
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands; Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands.
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15
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Elsaid NMH, Peters DC, Galiana G, Sinusas AJ. Clinical physiology: the crucial role of MRI in evaluation of peripheral artery disease. Am J Physiol Heart Circ Physiol 2024; 326:H1304-H1323. [PMID: 38517227 PMCID: PMC11381027 DOI: 10.1152/ajpheart.00533.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 03/23/2024]
Abstract
Peripheral artery disease (PAD) is a common vascular disease that primarily affects the lower limbs and is defined by the constriction or blockage of peripheral arteries and may involve microvascular dysfunction and tissue injury. Patients with diabetes have more prominent disease of microcirculation and develop peripheral neuropathy, autonomic dysfunction, and medial vascular calcification. Early and accurate diagnosis of PAD and disease characterization are essential for personalized management and therapy planning. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and multiplanar imaging capabilities and is useful as a noninvasive imaging tool in the comprehensive physiological assessment of PAD. This review provides an overview of the current state of the art of MRI in the evaluation and characterization of PAD, including an analysis of the many applicable MR imaging techniques, describing the advantages and disadvantages of each approach. We also present recent developments, future clinical applications, and future MRI directions in assessing PAD. The development of new MR imaging technologies and applications in preclinical models with translation to clinical research holds considerable potential for improving the understanding of the pathophysiology of PAD and clinical applications for improving diagnostic precision, risk stratification, and treatment outcomes in patients with PAD.
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Affiliation(s)
- Nahla M H Elsaid
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Gigi Galiana
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Albert J Sinusas
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
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Iwata K, Nitta M, Kaneko M, Fushimi K, Ueda S, Shimizu S. Analysis of in-hospital deaths in patients with critical limb ischemia necessitating invasive treatments: based on a Japanese nationwide database. Cardiovasc Interv Ther 2024:10.1007/s12928-024-01003-7. [PMID: 38689203 DOI: 10.1007/s12928-024-01003-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
Critical limb ischemia (CLI) is associated with systemic cardiovascular and non-cardiovascular diseases. Treatments primarily targeting limb-related outcomes may not improve overall life prognosis. We aimed to describe in-hospital mortality and the underlying etiologies in Japanese patients with CLI. We analyzed the Diagnosis Procedure Combination (DPC) database from approximately 1200 Japanese acute-care hospitals between April 2018 and March 2020. The definition of patients with CLI was based on the diagnostic codes listed as the most resource-intensive diagnosis and information regarding invasive procedures (endovascular treatment, bypass, or amputation). The DPC database provides information on whether in-hospital death was caused by the most resource-intensive diagnosis. Among 15,228 distinct patients with CLI, we identified 18,970 records, including 5,378 amputations. In-hospital death occurred in 1238 (6.5%) patients. Among them, 811 (65.5%) were due to causes unrelated to CLI. In patients who underwent amputation (n = 5378), causes unrelated to CLI accounted for 70.0% of in-hospital deaths, whereas among patients who did not undergo amputation (n = 13,592), this proportion was 60.1%. When compared to patients who died due to causes related to CLI, the prevalence of male patients was higher (62.6% vs 52.7%, p = 0.001), and amputation was more frequently performed (58.0% vs 47.1%, p < 0.001) in those who died due to causes unrelated to CLI. The majority of in-hospital deaths among patients with CLI necessitating endovascular treatment, bypass, or amputation were attributable to factors unrelated to the primary condition of CLI. Managing systemic cardiovascular and non-cardiovascular diseases beyond the affected limb is crucial to improve the prognosis of these patients.
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Affiliation(s)
- Kiwamu Iwata
- Department of Cardiology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan
- Wellbe Heart Clinic Konandai, 3-19-1-1F, Konandai, Konan, Yokohama, Kanagawa, 234-0054, Japan
| | - Manabu Nitta
- Department of Cardiology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan.
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, 1-1-1-5F Fukuura, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan.
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa, Japan.
| | - Makoto Kaneko
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Shinichiro Ueda
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa, Japan
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus Graduate School of Medicine, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa, Japan
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Latkovskis G, Krievins D, Zellans E, Kumsars I, Krievina A, Angena A, Jegere S, Erglis A, Lacis A, Zarins C. Ischemia-Guided Coronary Revascularization Following Lower-Extremity Revascularization Improves 5-Year Survival of Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024:15266028241245909. [PMID: 38616613 DOI: 10.1177/15266028241245909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
PURPOSE To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). MATERIALS AND METHODS Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFRCT evaluation with selective post-operative coronary revascularization (FFRCT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFRCT≤0.80 distal to a coronary stenosis with FFRCT≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. RESULTS In the FFRCT group (n=111), FFRCT analysis revealed asymptomatic (silent) coronary ischemia (FFRCT≤0.80) in 69% of patients, with severe ischemia (FFRCT≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFRCT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFRCT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). CONCLUSIONS Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). CLINICAL IMPACT Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.
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Affiliation(s)
- Gustavs Latkovskis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Dainis Krievins
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Edgars Zellans
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | | | | | - Sanda Jegere
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- Riga Stradins University, Riga, Latvia
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. Eur Heart J 2024; 45:1303-1321. [PMID: 38461405 DOI: 10.1093/eurheartj/ehad734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2024] Open
Abstract
All guidelines worldwide strongly recommend exercise as a pillar of the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended for clinicians to promote and assist for the set-up of comprehensive exercise programmes to best advice in patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are narratively described based on the current best evidence. The document ends by highlighting disparities in access to supervised exercise programmes across Europe and the series of gaps for evidence requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Center of Cardiology, Department of Cardiology III-Angiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France
- INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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19
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Pinxterhuis TH, von Birgelen C, Geelkerken RH, Doggen CJM, Menting TP, van Houwelingen KG, Linssen GCM, Ploumen EH. Invasiveness of previous treatment for peripheral arterial disease and risk of adverse cardiac events after coronary stenting. Cardiovasc Interv Ther 2024; 39:173-182. [PMID: 38353865 PMCID: PMC10940370 DOI: 10.1007/s12928-024-00986-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/02/2024] [Indexed: 03/07/2024]
Abstract
Patients with peripheral arterial disease (PADs), undergoing percutaneous coronary intervention (PCI), have higher adverse event risks. The effect of invasiveness of PADs treatment on PCI outcome is unknown. This study assessed the impact of the invasiveness of previous PADs treatment (invasive or non-invasive) on event risks after PCI with contemporary drug-eluting stents. This post-hoc analysis pooled 3-year patient-level data of PCI all-comer patients living in the eastern Netherlands, previously treated for PADs. PADs included symptomatic atherosclerotic lesion in the lower or upper extremities; carotid or vertebral arteries; mesenteric arteries or aorta. Invasive PADs treatment comprised endarterectomy, bypass surgery, percutaneous transluminal angioplasty, stenting or amputation; non-invasive treatment consisted of medication and participation in exercise programs. Primary endpoint was (coronary) target vessel failure: composite of cardiac mortality, target vessel-related myocardial infarction, or clinically indicated target vessel revascularization. Of 461 PCI patients with PADs, information on PADs treatment was available in 357 (77.4%) patients; 249 (69.7%) were treated invasively and 108 (30.3%) non-invasively. Baseline and PCI procedural characteristics showed no between-group difference. Invasiveness of PADs treatment was not associated with adverse event risks, including target vessel failure (20.5% vs. 16.0%; HR: 1.30, 95%-CI 0.75-2.26, p = 0.35), major adverse cardiac events (23.3% vs. 20.4%; HR: 1.16, 95%-CI 0.71-1.90, p = 0.55), and all-cause mortality (12.1% vs. 8.3%; HR: 1.48, 95%-CI 0.70-3.13, p = 0.30). In PADs patients participating in PCI trials, we found no significant relation between the invasiveness of previous PADs treatment and 3-year outcome after PCI. Consequently, high-risk PCI patients can be identified by consulting medical records, searching for PADs, irrespective of the invasiveness of PADs treatment.
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Affiliation(s)
- Tineke H Pinxterhuis
- Department of Cardiology, Thoraxcentrum Twente (A25), Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Clemens von Birgelen
- Department of Cardiology, Thoraxcentrum Twente (A25), Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Multi-Modality Medical Imaging (M3I) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Carine J M Doggen
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Theo P Menting
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - K Gert van Houwelingen
- Department of Cardiology, Thoraxcentrum Twente (A25), Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - Gerard C M Linssen
- Department of Cardiology, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Eline H Ploumen
- Department of Cardiology, Thoraxcentrum Twente (A25), Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands.
- Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
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20
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Ørskov M, Skjøth F, Behrendt CA, Nicolajsen CW, Eldrup N, Søgaard M. External Validation of the OAC 3-PAD Bleeding Score in a Nationwide Population of Patients Undergoing Invasive Treatment for Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2024; 67:621-629. [PMID: 38056523 DOI: 10.1016/j.ejvs.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/30/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE The OAC3-PAD score was developed to predict bleeding risk in patients with lower extremity peripheral arterial disease (PAD), but its performance in concomitant international cohorts is largely unknown. This study aimed to validate the OAC3-PAD score in an unselected nationwide population of patients undergoing invasive treatment for symptomatic PAD. METHODS This was a nationwide cohort study including all patients who underwent a first revascularisation procedure or major amputation for symptomatic PAD in Denmark from 2000 - 2021. The study population was stratified based on OAC3-PAD score, and the one year risk of major bleeding was assessed, accounting for the competing risk of death. The score performance was evaluated using calibration plots, C statistic, Brier score, and the index of prediction accuracy (IPA). RESULTS A total of 52 016 patients were included (mean age 71 years, 43.8% female). The one year risk of major bleeding increased with higher OAC3-PAD score, ranging from 1.6% (95% confidence interval [CI] 1.4 - 1.8%) to 2.3% (95% CI 2.0 - 2.5%), 3.5% (95% CI 3.2 - 3.8%), and 5.2% (95% CI 4.8 - 5.6%) for patients with low, low moderate, moderate high, and high score, respectively. Using patients with low risk as reference, the OAC3-PAD score effectively categorised patients, demonstrating statistically significant differences in bleeding risk across strata. However, the score showed modest discriminative performance, with a C statistic of 65% (95% CI 63 - 66%) and a Brier score of 2.6% (95% CI 2.5 - 2.7%). Nevertheless, it performed significantly better than the null model, as indicated by an IPA of 3.1%. CONCLUSION Among patients who underwent invasive treatment for symptomatic PAD in routine care, the OAC3-PAD score was associated with greater risk of major bleeding with increasing score level. However, its discriminatory ability was modest, and the clinical utility remains to be determined.
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Affiliation(s)
- Marie Ørskov
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark.
| | - Flemming Skjøth
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Research Data and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Chalotte W Nicolajsen
- Department of Surgery, Unit of Vascular Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Mette Søgaard
- Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
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21
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Aronow HD, Bonaca MP, Kolluri R, Beckman JA. Recapturing the Team Approach to Vascular Care. Ann Vasc Surg 2024; 101:84-89. [PMID: 38128694 DOI: 10.1016/j.avsg.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The care of the vascular patient remains decentralized rather than coordinated. METHODS We reviewed the current state of practice and published competency and care documents created by vascular professional societies. RESULTS Vascular professional societies routinely and repeatedly endorse both a team approach and the competency of specialists from disparate training backgrounds. The care of the vascular patient does not always reflect these public endorsements. CONCLUSIONS Centering the vascular patient as the mode of organization of care should improve care processes, expertise brought to bear, and outcomes.
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Affiliation(s)
- Herbert D Aronow
- Henry Ford Health, Detroit, MI; Michigan State University College of Human Medicine, East Lansing, MI
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO; University of Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Raghu Kolluri
- OhioHealth Heart and Vascular, Riverside Methodist Hospital, Columbus, OH
| | - Joshua A Beckman
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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22
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. VASA 2024; 53:87-108. [PMID: 38461401 DOI: 10.1024/0301-1526/a001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Finland
- University of Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, France
- INSERM CIC 1414, Université de Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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Hu C, Chen L, Wu M, Ye Q, Zou J, Zhao B, Li X, Wu H. Efficacy and Safety of Covered Stents Versus Bare-Metal Stents for Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis. J Endovasc Ther 2024:15266028241237387. [PMID: 38491926 DOI: 10.1177/15266028241237387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
PURPOSE This study aimed to assess the efficacy and safety outcome of covered stents (CSs), as compared with bare-metal stents (BMSs), for the treatment of patients with aortoiliac occlusive disease (AIOD). MATERIALS AND METHODS A systematic literature search was conducted in PubMed, Embase, and Cochrane Library up to August 2023 to identify all studies comparing efficacy and safety outcomes of CSs versus BMSs for treating AIOD. Our outcome was primary patency, secondary patency, technical success, ankle-brachial index (ABI) variation, target lesion revascularization (TLR), limb salvage, complications, and long-term survival. Dichotomous outcomes were pooled as relative risks (RR) or hazard ratio with the 95% confidence interval (CI). Continuous outcomes were pooled as weighted mean differences and 95% CI. Model selection was based on the heterogeneity of the included studies. RESULTS There were 10 studies (2 randomized controlled trials, 8 retrospective cohort studies), comprising 1676 sample size. Compared with BMSs, CSs use was associated with better primary patency of patients with a Trans-Atlantic Inter-Society Consensus II (TASC) D lesion (RR, 1.15, 95% CI, 1.04 to 1.27, p=0.007), TLR (RR, 0.39, 95% CI, 0.27 to 0.56, p<0.001), technical success (RR, 1.01, 95% CI, 1.00 to 1.02, p=0.010), and long-term survival (RR, 1.06, 95% CI, 1.01 to 1.11, p=0.020). There is no difference between CSs and BMSs regarding primary patency of all patients, secondary patency, variation in ABI, limb salvage, and complications. CONCLUSIONS Compared with BMSs, CSs used in AIOD was associated with more favorable primary patency in patients with TASC D lesions, TLR, technical success rates, and patient long-term survival. These results provide evidence of the advantages of using CSs for AIOD treatment. Future studies focusing on long-term variations in ABI, primary patency of different degrees of calcification, vascular segments, and TASC classification are warranted. CLINICAL IMPACT Although several studies evaluated the clinical efficacy of CS in the context of AIOD treatment, the significance and consistency of these findings were not determined to date. We found that CS was used in AIOD associated with better technical success rate, long-term patient survival, lower target lesion revascularization, and higher primary patency of patients with a Trans-Atlantic Inter-Society Consensus II D lesion when compared with BMSs. Our study provides evidence supporting the superiority of CSs over BMSs in the treatment of AIOD, and furnishing clinicians with guidance for treatment decisions.
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Affiliation(s)
- Chenming Hu
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
- Department of Vascular Surgery, Dazhou Central Hospital, Dazhou, China
| | - Lang Chen
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Min Wu
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Qianling Ye
- Department of Vascular Surgery, Dazhou Central Hospital, Dazhou, China
| | - Jun Zou
- Department of Vascular Surgery, Dazhou Central Hospital, Dazhou, China
| | - Bin Zhao
- Department of Vascular Surgery, Dazhou Central Hospital, Dazhou, China
| | - Xiang Li
- Department of Vascular Surgery, Dazhou Central Hospital, Dazhou, China
| | - Huaping Wu
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
- Department of Vascular Surgery, Dazhou Central Hospital, Dazhou, China
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24
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Li J, Varcoe R, Manzi M, Kum S, Iida O, Schmidt A, Shishehbor MH. Below-the-Knee Endovascular Revascularization: A Position Statement. JACC Cardiovasc Interv 2024; 17:589-607. [PMID: 38244007 DOI: 10.1016/j.jcin.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024]
Abstract
Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.
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Affiliation(s)
- Jun Li
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ramon Varcoe
- Prince of Wales Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Manzi
- Interventional Radiology Unit, Foot and Ankle Clinic, Policlinico Abano Terme, Abano Terme, Italy
| | - Steven Kum
- Department of Surgery, Changi General Hospital, Singapore
| | - Osamu Iida
- Kasai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Andrej Schmidt
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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25
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Colombijn JMT, Idema DL, van Beem S, Blokland AM, van der Braak K, Handoko ML, in ’t Veld LFH, Kaul T, Kolagasigil-Akdemir N, Kusters MPT, Meijvis SCA, Oosting IJ, Spijker R, Bots ML, Hooft L, Verhaar MC, Vernooij RWM. Representation of Patients With Chronic Kidney Disease in Clinical Trials of Cardiovascular Disease Medications: A Systematic Review. JAMA Netw Open 2024; 7:e240427. [PMID: 38451526 PMCID: PMC10921252 DOI: 10.1001/jamanetworkopen.2024.0427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/27/2023] [Indexed: 03/08/2024] Open
Abstract
Importance Patients with chronic kidney disease (CKD) are at high risk for cardiovascular disease, but their systematic underrepresentation in cardiovascular randomized clinical trials (RCTs) limits the generation of appropriate evidence to guide cardiovascular risk management (CVRM). Objective To evaluate the underrepresentation of patients with CKD in cardiovascular RCTs, and to highlight evidence gaps in CVRM medications in this population. Evidence Review A systematic search was conducted in ClinicalTrials.gov from February 2000 through October 2021 for RCTs with full-text publications. If no full-text publications were found in ClinicalTrials.gov, MEDLINE, Embase, and Google Scholar were also searched. Eligible RCTs were those evaluating the effectiveness of antiplatelets, anticoagulants, blood pressure-lowering drugs, glucose-lowering drugs, or cholesterol-lowering drugs in adults with cardiovascular disease or cardiovascular risk factors. Trials with a sample size of fewer than 100 patients were excluded. Findings In total, 1194 RCTs involving 2 207 677 participants (mean [SD] age, 63 [6] years; 1 343 970 males [64%]) were included. Since 2000, the percentage of cardiovascular RCTs excluding patients with CKD has increased from 66% to 79% (74% overall [884 RCTs]). In 864 RCTs (72%), more patients were excluded than anticipated on safety grounds (63% [306] of trials required no dose adjustment, and 79% [561] required dose adjustment). In total, 158 RCTs (13%) reported results for patients with CKD separately (eg, in subgroup analyses). Significant evidence gaps exist in most CVRM interventions for patients with CKD, particularly for those with CKD stages 4 to 5. Twenty-three RCTs (2%) reported results for patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m2, 15 RCTs (1%) reported for patients receiving dialysis, and 1 RCT (0.1%) reported for recipients of kidney transplant. Conclusions and Relevance Results of this systematic review suggest that representation of patients with CKD in cardiovascular RCTs has not improved in the past 2 decades and that these RCTs excluded more patients with CKD than expected on safety grounds. Lack of reporting or underreporting of results for this patient population is associated with evidence gaps in the effectiveness of most CVRM medications in patients with all stages of CKD, particularly CKD stages 4 to 5.
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Affiliation(s)
- Julia M. T. Colombijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Demy L. Idema
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sanne van Beem
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anna Marthe Blokland
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kim van der Braak
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M. Louis Handoko
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences (Heart Failure and Arrhythmias), Amsterdam, the Netherlands
| | - Linde F. Huis in ’t Veld
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Tabea Kaul
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nurda Kolagasigil-Akdemir
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mike P. T. Kusters
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sabine C. A. Meijvis
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ilse J. Oosting
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rene Spijker
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Robin W. M. Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Chinaroonchai K. Oxygen Therapy to Enhance Wound Healing After Revascularization. INT J LOW EXTR WOUND 2024; 23:49-54. [PMID: 38311897 DOI: 10.1177/15347346231215201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Oxygen is one of the important factors for wound healing and infection control. The revascularization procedure is amended to correct the tissue hypoxia problem by increasing the blood flow to obtain an adequate amount of oxygen. Hypoxic wounds are still the issue in the cases of unsuccessful or incomplete revascularization. The issue needs to be clarified and confirmed by proper methods for management to achieve wound healing and prevent limb loss. Oxygen therapy may benefit in the case of remaining hypoxia or wound infection in postrevascularization.
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Affiliation(s)
- Kusuma Chinaroonchai
- Trauma Surgery Division, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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27
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Lee AHH, Wright AP, Westcott MJ, Shan LL, Choong PF, Davies AH. A Systematic Review of the Quality of Clinical Practice Guidelines for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2024; 100:81-90. [PMID: 38122972 DOI: 10.1016/j.avsg.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/14/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND To assess the quality of clinical practice guidelines (CPGs) for chronic limb-threatening ischemia (CLTI) using the Appraisal of Guidelines for Research and Evaluation II instrument. METHODS A systematic review of Medline, Embase, and online CPG databases was carried out. Four CPGs on CLTI were identified: Global Vascular Guidelines (GVG), European Society of Cardiology (ESC), American College of Cardiology, and National Institute for Health and Care Excellence guidelines on lower limb peripheral arterial disease. Two independent appraisers analyzed the 4 CPGs using the Appraisal of Guidelines for Research and Evaluation II instrument. CPGs were ranked across 6 domains with 23 items that ranged from 1 (strongly disagree) to 7 (strongly agree). A scaled domain score was calculated as a percentage of the maximum possible score achievable. A domain score of ≥50% and an overall average domain score of ≥80% reflected a CPG of adequate quality recommended for use. RESULTS GVG had the highest overall score (82.9%), as an average of all domains, and ESC had the lowest score (50.2%). GVG and National Institute for Health and Care Excellence guidelines had all domains scoring >50%, while American College of Cardiology had 5 and ESC had 3. Two domains, rigor of development and applicability, scored the lowest among the CPGs. There was a lack of detail in describing systematic methods used in the literature review, how guidelines were formulated with minimal bias, and the planned procedure for updating the guidelines. Implications of guideline application and monitoring of outcomes after implementations were not explicitly discussed. CONCLUSIONS The GVG guideline published in 2019 discussing CLTI is assessed to be of high quality and recommended for use. This review helps to improve clinical decision-making and quality of future CPGs for CLTI.
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Affiliation(s)
| | | | - Mark J Westcott
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Australia
| | - Leonard L Shan
- Department of Vascular Surgery, St Vincent's Hospital, Melbourne, Australia
| | - Peter F Choong
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
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28
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Sohn M, Lim S. The Role of Cilostazol, a Phosphodiesterase-3 Inhibitor, in the Development of Atherosclerosis and Vascular Biology: A Review with Meta-Analysis. Int J Mol Sci 2024; 25:2593. [PMID: 38473840 DOI: 10.3390/ijms25052593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) stands as the leading global cause of mortality. Addressing this vital and pervasive condition requires a multifaceted approach, in which antiplatelet intervention plays a pivotal role, together with antihypertensive, antidiabetic, and lipid-lowering therapies. Among the antiplatelet agents available currently, cilostazol, a phosphodiesterase-3 inhibitor, offers a spectrum of pharmacological effects. These encompass vasodilation, the impediment of platelet activation and aggregation, thrombosis inhibition, limb blood flow augmentation, lipid profile enhancement through triglyceride reduction and high-density lipoprotein cholesterol elevation, and the suppression of vascular smooth muscle cell proliferation. However, the role of cilostazol has not been clearly documented in many guidelines for ASCVD. We comprehensively reviewed the cardiovascular effects of cilostazol within randomized clinical trials that compared it to control or active agents and involved individuals with previous coronary artery disease or stroke, as well as those with no previous history of such conditions. Our approach demonstrated that the administration of cilostazol effectively reduced adverse cardiovascular events, although there was less evidence regarding its impact on myocardial infarction. Most studies have consistently reported its favorable effects in reducing intermittent claudication and enhancing ambulatory capacity in patients with peripheral arterial disease. Furthermore, cilostazol has shown promise in mitigating restenosis following coronary stent implantation in patients with acute coronary syndrome. While research from more diverse regions is still needed, our findings shed light on the broader implications of cilostazol in the context of atherosclerosis and vascular biology, particularly for individuals at high risk of ASCVD.
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Affiliation(s)
- Minji Sohn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 13620, Republic of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 13620, Republic of Korea
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29
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise Therapy for Chronic Symptomatic Peripheral Artery Disease: A Clinical Consensus Document of the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases in Collaboration With the European Society of Vascular Medicine and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2024; 67:S1078-5884(24)00011-X. [PMID: 38467522 DOI: 10.1016/j.ejvs.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland.
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Helsinki; Department of Vascular Surgery, University of Helsinki, Helsinki
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital; EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University; National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France; INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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30
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Kalbaugh CA, Witrick B, Howard KA, Sivaraj LB, McGinigle KL, Robinson WP, Cykert S, Hicks CW, Lesko CR. Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation. Vasc Med 2024; 29:17-25. [PMID: 37737127 PMCID: PMC10922837 DOI: 10.1177/1358863x231196139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Non-Hispanic Black and Hispanic patients with symptomatic PAD may receive different treatments than White patients with symptomatic PAD. The delivery of guideline-directed medical treatment may be a modifiable upstream driver of race and ethnicity-related disparities in outcomes such as limb amputation. The purpose of our study was to investigate the prescription of preoperative antiplatelets and statins in producing disparities in the risk of amputation following revascularization for symptomatic peripheral artery disease (PAD). METHODS We used data from the Vascular Quality Initiative, a vascular procedure-based registry in the United States (2011-2018). We estimated the probability of preoperative antiplatelet and statin prescriptions and 1-year incidence of amputation. We then estimated the amputation risk difference between race/ethnicity groups that could be eliminated under a hypothetical intervention. RESULTS Across 100,579 revascularizations, the 1-year amputation risk was 2.5% (2.4%, 2.6%) in White patients, 5.3% (4.9%, 5.6%) in Black patients, and 5.3% (4.7%, 5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive antiplatelet and statin therapy. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received these medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (-2.9%, 21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (-0.7%, 38.6%). CONCLUSION Even though guideline-directed care appeared evenly distributed by race/ethnicity, increasing access to such care may decrease health care disparities in major limb amputation.
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Affiliation(s)
- Corey A Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Brian Witrick
- West Virginia Clinical and Translational Sciences Institute, Morgantown, WV, USA
| | - Kerry A Howard
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC, USA
| | | | - Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William P Robinson
- Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Maruhashi T, Kajikawa M, Kishimoto S, Yamaji T, Harada T, Hashimoto Y, Mizobuchi A, Tanigawa S, Yusoff FM, Nakano Y, Chayama K, Nakashima A, Goto C, Higashi Y. Percentage of mean arterial pressure as a marker of atherosclerosis for detecting patients with coronary artery disease. Hypertens Res 2024; 47:281-290. [PMID: 37794241 PMCID: PMC10838767 DOI: 10.1038/s41440-023-01442-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
The percentage of mean arterial pressure (%MAP) is the height of the mean arterial waveform divided by the peak amplitude of the waveform of pulse volume recording. The purpose of this study was to determine whether the cutoff value of 45% for %MAP at the ankle, which is recommended for the diagnosis of lower extremity artery disease, in combination with ankle-brachial index (ABI) is useful for detecting patients with clinical coronary artery disease (CAD) and investigate the optimal cutoff value of %MAP to diagnose patients with CAD. We measured ABI and %MAP in 2213 subjects (mean age: 61.2 ± 15.5 years). Multivariate analysis revealed that %MAP ≥ 45% was significantly associated with a higher risk of CAD after adjusting for traditional cardiovascular risk factors (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.43-3.21; p < 0.001). However, the association was no longer significant after adjusting for ABI (OR, 1.39; 95% CI, 0.83-2.33; p = 0.21), whereas ABI was significantly associated with CAD (OR, 0.98; 95% CI, 0.97-0.99; p = 0.005). The optimal cutoff value of %MAP derived from a receiver operating characteristic curve to diagnose CAD was 40.3%. Multivariate analysis revealed that %MAP ≥ 40.3% was significantly associated with a higher risk of CAD (OR, 1.63; 95% CI, 1.19-2.24; p = 0.002) independent of ABI (OR, 0.98; 95% CI, 0.97-0.99; p = 0.002). The cutoff value of 40.3%, but not 45%, for %MAP may be useful for detecting patients with advanced atherosclerosis and for cardiovascular risk assessment independent of ABI. REGISTRATION INFORMATION: http://www.umin.ac.jp (University Hospital Medical Information Network Clinical Trials Registry) (UMIN000039512).
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Masato Kajikawa
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Takayuki Yamaji
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Takahiro Harada
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Yu Hashimoto
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Aya Mizobuchi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Shunsuke Tanigawa
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Farina Mohamad Yusoff
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Medicine and Molecular Science, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Ayumu Nakashima
- Department of Stem Cell Biology and Medicine, Graduate School of Biomedical and Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan
| | - Chikara Goto
- Department of Rehabilitation, Faculty of general Rehabilitation, Hiroshima International University, 555-36, Kurosegakuendai, Higashihiroshima, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan.
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, Japan.
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Aalaa M, Vahdani AM, Mohajeri Tehrani M, Mehrdad N, Zohdirad M, Sadati M, Amini M, Mehrpour S, Ebrahimi M, Larijani B, Amini MR, Sanjari M. Epidemiological Insights into Diabetic Foot Amputation and its Correlates: A Provincial Study. Clin Med Insights Endocrinol Diabetes 2024; 17:11795514241227618. [PMID: 38298327 PMCID: PMC10826372 DOI: 10.1177/11795514241227618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024] Open
Abstract
Background Diabetic foot ulcer and potential subsequent lower extremity amputation are major complications of diabetes mellitus and are also prominent morbidity factors that could affect patients' quality of life. Objectives This study aimed to assess the prevalence of diabetic foot amputation and explore correlates of amputation cause and type among subjects with diabetes mellitus in Tehran, Iran. Methods A descriptive cross-sectional study was conducted to assess the demographic, sociological, and clinical characteristics of subjects who had undergone lower extremity amputation due to diabetic foot ulcers, from 2011 to 2020, in two educational medical centers in Tehran, Iran. We examined the medical records of 4676 individuals who were admitted to Shariati and Sina hospitals due to diabetic foot issues. Information related to patient demographics (age, gender, marital status), social factors (education level, insurance), and clinical data (medical history, laboratory results, and characteristics of diabetic foot ulcers) was collected for subjects who had undergone lower extremity amputation due to diabetic foot ulcer. The collected data was reported using average values, standard deviations and proportions and analyzed using statistical tests. Results During one decade, 882 out of 4676 (18.8%) patients with diabetic foot ulcers underwent lower extremity amputations of various types in Sina and Shariati hospitals in Tehran, Iran. Of these, 692 (14.5%) were included for further analysis in the study and the rest were excluded due to lack of sufficient recorded data. About 75.9% of the study population was male, and the average age including both sexes was 60 years. About 92.7% were married, and on average, subjects had been afflicted with diabetes mellitus for 15.1 years. Statistical analysis using Pearson's chi-square test showed there was a significant association between the treatment regimen for diabetes mellitus and the type of amputation (P = .01), as well as between the duration of the disease and the cause of amputation (P = .01) and its type (P = .04). Conclusion diabetes mellitus related treatment regimen and duration of disease are significantly associated with amputation cause and type.
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Affiliation(s)
- Maryam Aalaa
- Evidence Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammadreza Mohajeri Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Mehrdad
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehri Zohdirad
- Department of Endocrinology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Sadati
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Amini
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeid Mehrpour
- Department of Orthopedics and Trauma Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Ebrahimi
- Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Amini
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Sanjari
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Dzewaltowski A, Pipinos II, Schieber MN, Johanning J, Casale GP, Myers S, Malcolm P. Lower limb revascularization leads to faster walking but with less efficient mechanics in claudicating patients. J Biomech 2024; 162:111880. [PMID: 38070293 DOI: 10.1016/j.jbiomech.2023.111880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 01/16/2024]
Abstract
Peripheral artery disease (PAD) is characterized by reduced blood flow to the extremities due to atherosclerosis. Studies report impaired gait mechanics in patients with lower extremity PAD. We hypothesized that revascularization surgery would improve gait mechanics when quantified by net lower limb joint work across the stance phase of walking. We performed gait analyses in 35 patients with PAD and 35 healthy, older adults. Patients with PAD performed a walking protocol prior to and six months following revascularization surgery. Healthy adults only took part in a single walking session. Lower limb joint powers were calculated using inverse dynamics and were integrated across early, middle, and late stance phases to determine the work performed during each phase (J kg-1). The work mechanical ratio between positive-producing and negative-producing phases of stance was calculated for each lower-limb joint. Self-selected walking speed significantly increased from 1.13 ± 0.2 ms-1 to 1.26 ± 0.18 ms-1 in patients following revascularization (p < 0.001). We observed a significant decrease in positive late stance work (p < 0.001) in conjunction with more negative work during early stance (p < 0.001) in patients following revascularization. Revascularization surgery led to faster walking without an increase in the ankle joint's mechanical ratio. Our results suggest faster walking was achieved via work done at the hip rather than the ankle. These findings suggest that additional therapies that facilitate the restoration of muscle, tissue, and nervous system damage caused by years of having reduced blood flow to the limbs might still be beneficial following revascularization.
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Affiliation(s)
- Alex Dzewaltowski
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, Nebraska, USA; Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine & Science, North Chicago, Illinois, USA
| | - Iraklis I Pipinos
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA; Department of Surgery and Veterans Affairs Research Service, Nebraska-Western Iowa Health, Care System, Omaha, Nebraska, USA
| | - Molly N Schieber
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jason Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA; Department of Surgery and Veterans Affairs Research Service, Nebraska-Western Iowa Health, Care System, Omaha, Nebraska, USA
| | - George P Casale
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara Myers
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, Nebraska, USA; Department of Surgery and Veterans Affairs Research Service, Nebraska-Western Iowa Health, Care System, Omaha, Nebraska, USA
| | - Philippe Malcolm
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, Nebraska, USA.
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Nguyen CH, Marzolini S. Pre-participation Withdrawal and Noncompletion of Cardiac Rehabilitation in Peripheral Artery Disease: MATCHED COMPARISONS TO CORONARY ARTERY DISEASE. J Cardiopulm Rehabil Prev 2024; 44:55-63. [PMID: 37624048 DOI: 10.1097/hcr.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE Despite the mortality benefit of cardiac rehabilitation (CR) participation, as well as its cost-effectiveness for people with peripheral artery disease (PAD), there are limited data on adherence and completion of CR in those with and without concomitant coronary artery disease (CAD). The objective of this study was to compare CR pre-participation withdrawal and noncompletion between patients with PAD and concomitant PAD and CAD (PAD/CAD) versus matched and unmatched patients with CAD (uCAD). METHODS Consecutively referred patients between 2006-2017 with PAD (n = 271) and PAD/CAD (n = 610) were matched to CAD by age, sex, diabetes, smoking status, and referral year. The uCAD (n = 14 487) group was included for comparison. Reasons for withdrawal were ascertained by interview. RESULTS There were no significant differences in pre-participation withdrawal between PAD and matched CAD (46 vs 43%, P = .49), nor in noncompletion (22 vs 18%, P = .28). Results were similar for PAD/CAD and matched CAD (withdrawal: 36 vs 34%, P = .37) and (noncompletion: 25 vs 23%, P = .46). A smaller proportion of patients with uCAD withdrew (28%) than patients with PAD ( P < .001) and PAD/CAD ( P < .001), with no difference in noncompletion ( P > .40, both). There were no differences between PAD and PAD/CAD and their matched counterparts for medical and nonmedical reasons for withdrawal and noncompletion ( P ≥ .25, all). CONCLUSION Pre-participation withdrawal rates were similar between patients with PAD, PAD/CAD, and their matched cohorts but greater than patients with uCAD. Once patients started CR, there were similar completion rates among all groups. Reports that patients with PAD are less likely to start CR may be related to their complex medical profile rather than PAD alone. Strategies to improve participation among patients with PAD should focus on the immediate post-referral period.
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Affiliation(s)
- Cindy H Nguyen
- Michael DeGroote School of Medicine, McMaster University-Niagara Regional Campus, St Catharines, Ontario, Canada (Dr Nguyen); KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada (Drs Nguyen and Marzolini); Department of Exercise Sciences, Faculty of Kinesiology and Physical Education (Dr Marzolini), and Rehabilitation Sciences Institute, Temerty Faculty of Medicine (Dr Marzolini), University of Toronto, Toronto, Ontario, Canada; and Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Toronto, Ontario, Canada (Dr Marzolini)
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Kharawala A, Nagraj S, Pargaonkar S, Seo J, Kokkinidis DG, Altin SE. Hypertension Management in Peripheral Artery Disease: A Mini Review. Curr Hypertens Rev 2024; 20:1-9. [PMID: 38083897 DOI: 10.2174/0115734021267004231122061712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 06/01/2024]
Abstract
Lower extremity peripheral artery disease (PAD) affects over 230 million adults globally, with hypertension being one of the major risk factors for the development of PAD. Despite the high prevalence, patients with hypertension who have concomitant PAD are less likely to receive adequate therapy. Through this review, we present the current evidence underlying hypertension management in PAD, guideline-directed therapies, and areas pending further investigation. Multiple studies have shown that both high and relatively lower blood pressure levels are associated with worse health outcomes, including increased morbidity and mortality. Hence, guideline-directed recommendation involves cautious management of hypertensive patients with PAD while ensuring hypotension does not occur. Although any antihypertensive medication can be used to treat these patients, the 2017 American Heart Association/American College of Cardiology (AHA/ACC), 2017 European Society of Cardiology (ESC), and 2022 Canadian guidelines favor the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) as the initial choice. Importantly, data on blood pressure targets and treatment of hypertension in PAD are limited and largely stem from sub-group studies and post-hoc analysis. Large randomized trials in patients with PAD are required in the future to delineate hypertension management in this complex patient population.
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Affiliation(s)
- A Kharawala
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - S Nagraj
- Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - S Pargaonkar
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - J Seo
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - D G Kokkinidis
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - S E Altin
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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Sahinturk S. Cilostazol induces vasorelaxation through the activation of the eNOS/NO/cGMP pathway, prostanoids, AMPK, PKC, potassium channels, and calcium channels. Prostaglandins Other Lipid Mediat 2023; 169:106782. [PMID: 37741358 DOI: 10.1016/j.prostaglandins.2023.106782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/02/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE This study aimed to investigate vasoactive effect mechanisms of cilostazol in rat thoracic aorta. MATERIALS AND METHODS The vessel rings prepared from the thoracic aortas of the male rats were placed in the chambers of the isolated tissue bath system. The resting tone was adjusted to 1 g. Following the equilibration phase, potassium chloride or phenylephrine was used to contract the vessel rings. When achieving a steady contraction, cilostazol was applied cumulatively (10-8-10-4 M). In the presence of potassium channel blockers or signaling pathway inhibitors, the same experimental procedure was performed. RESULTS Cilostazol exhibited a significant vasorelaxant effect in a concentration-dependent manner (pD2: 5.94 ± 0.94) (p < .001). The vasorelaxant effect level of cilostazol was significantly reduced by the endothelial nitric oxide synthase inhibitor L-NAME (10-4 M), soluble guanylate cyclase inhibitor methylene blue (10 µM), cyclooxygenase 1/2 inhibitor indomethacin (5 µM), adenosine monophosphate-activated protein kinase inhibitor compound C (10 µM), non-selective potassium channel blocker tetraethylammonium chloride (10 mM), large-conductance calcium-activated potassium channel blocker iberiotoxin (20 nM), voltage-gated potassium channel blocker 4-Aminopyridine (1 mM), and inward-rectifier potassium channel blocker BaCl2 (30 µM) (p < .001). Moreover, incubation of cilostazol (10-4 M) significantly reduced caffeine (10 mM), cyclopiazonic acid (10 µM), and phorbol 12-myristate 13-acetate-induced (100 µM) vascular contractions (p < .001). CONCLUSIONS In the rat thoracic aorta, the vasodilator action level of cilostazol is quite noticeable. The vasorelaxant effects of cilostazol are mediated by the eNOS/NO/cGMP pathway, prostanoids, AMPK pathway, PKC, potassium channels, and calcium channels.
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Affiliation(s)
- Serdar Sahinturk
- Bursa Uludag University Medicine School, Physiology Department, 16059, Bursa, Turkey.
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Kentoffio K, Sun T, Xu J, Parikh RV, Hsue PY, Secemsky EA. Longitudinal outcomes following peripheral vascular intervention among older persons living with HIV. Vasc Med 2023; 28:564-570. [PMID: 37638877 DOI: 10.1177/1358863x231191822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Persons living with human immunodeficiency virus (HIV, PLWH) have an increased risk of peripheral artery disease (PAD) in comparison to the general population. However, a gap remains in understanding optimal management for this condition. This study assesses longitudinal outcomes associated with peripheral endovascular intervention (PVI) for PAD among PLWH. METHODS All Medicare fee-for-service patients undergoing femoropopliteal artery PVI between April 1, 2015 and December 31, 2018 were identified and stratified by HIV serostatus. The primary outcome was major adverse limb events (MALE), defined as major amputation or arterial embolism/thrombosis following an index procedure. The subdistribution hazard was used to evaluate the association between HIV serostatus and MALE, accounting for the competing risk of death. Results were adjusted for sociodemographics and major comorbidities. RESULTS Of 168,553 patients who underwent PVI, 357 (0.21%) were PLWH. The average age was 77.0 ± 7.6 years; 80.3% had hypertension, 70.3% had hyperlipidemia, and 24.6% had tobacco use disorder. Compared to those without HIV, PLWH were younger and had a higher burden of cardiovascular risk factors. MALE were substantially more frequent among PLWH, with a cumulative incidence of 24.6%, compared to 14.5% among those without HIV. The adjusted subdistribution hazard ratio was 1.26 (95% CI 1.00-1.58, p = 0.05). The use of guideline-directed statin therapy was low in both groups in the 90 days following revascularization (57.9% in PLWH vs 58.1% in those without HIV, p = 0.95). CONCLUSION Among US Medicare beneficiaries, PLWH had poorer long-term outcomes following PVI. Greater attention to the management of symptomatic PAD is warranted for the HIV population, particularly following revascularization.
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Affiliation(s)
- Katherine Kentoffio
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tianyu Sun
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jiaman Xu
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rushi V Parikh
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Priscilla Y Hsue
- Department of Medicine, Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Parkington T, Broom D, Maden-Wilkinson T, Nawaz S, Klonizakis M. Low-intensity resistance exercise with blood flow restriction for patients with claudication: A randomized controlled feasibility trial. Vasc Med 2023; 28:554-563. [PMID: 37819259 PMCID: PMC10693738 DOI: 10.1177/1358863x231200250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Claudication is a common and debilitating symptom of peripheral artery disease, resulting in poor exercise performance and quality of life (QoL). Supervised exercise programs are an effective rehabilitation for patients with claudication, but they are poorly adhered to, in part due to the high pain and effort associated with walking, aerobic, and resistance exercise. Low-intensity resistance exercise with blood flow restriction (BFR) represents an alternative exercise method for individuals who are intolerant to high-intensity protocols. The aim of this study was to evaluate the feasibility of a supervised BFR program in patients with claudication. METHODS Thirty patients with stable claudication completed an 8-week supervised exercise program and were randomized to either BFR (n = 15) or a control of matched exercise without BFR (control; n = 15). Feasibility, safety, and efficacy were assessed. RESULTS All success criteria of the feasibility trial were met. Exercise adherence was high (BFR = 78.3%, control = 83.8%), loss to follow up was 10%, and there were no adverse events. Clinical improvement in walking was achieved in 86% of patients in the BFR group but in only 46% of patients in the control group. Time to claudication pain during walking increased by 35% for BFR but was unchanged for the control. QoL for the BFR group showed improved mobility, ability to do usual activities, pain, depression, and overall health at follow up. CONCLUSION A supervised blood flow restriction program is feasible in patients with claudication and has the potential to increase exercise performance, reduce pain, and improve QoL. (Clinicaltrials.gov Identifier: NCT04890275).
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Affiliation(s)
- Thomas Parkington
- Department of Nursing and Midwifery, Lifestyle, Exercise and Nutrition Improvement Research Group, Sheffield Hallam University, Sheffield, UK
- Department of Sport and Physical Activity, Physical Activity, Wellness and Public Health Research Group, Sheffield Hallam University, Sheffield, UK
| | - David Broom
- Centre for Sport, Exercise and Life Sciences, Coventry University, Coventry, UK
| | - Thomas Maden-Wilkinson
- Department of Sport and Physical Activity, Physical Activity, Wellness and Public Health Research Group, Sheffield Hallam University, Sheffield, UK
| | - Shah Nawaz
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Markos Klonizakis
- Department of Nursing and Midwifery, Lifestyle, Exercise and Nutrition Improvement Research Group, Sheffield Hallam University, Sheffield, UK
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Heitner TJ, Livneh A, Landesberg A. Novel Peripheral Perfusion Dynamics Indices for Detecting and Grading Arterial Stenosis. Cardiovasc Eng Technol 2023; 14:774-785. [PMID: 37985616 DOI: 10.1007/s13239-023-00686-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/11/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Peripheral artery disease causes severe morbidity, especially in diabetics and the elderly. There is a need for accurate noninvasive detection of peripheral arterial stenosis. The study has tested the hypothesis that arterial stenosis and the associated adaptation of the downstream circulation yield characteristic changes in the leg perfusion dynamics that enable early diagnosis, utilizing impedance plethysmography. METHODS The arterial perfusion dynamic was derived from impedance plethysmography (IPG). Two degrees of arterial stenosis were emulated by inflating a blood-pressure cuff around the thigh to 45 and 90 mmHg, in healthy volunteers (n = 30). IPG signals were acquired continuously throughout the experiment. Ankle and brachial blood pressures were measured at the beginning of each experiment and at the end of each emulated stenosis phase. RESULTS Thigh compressions did not affect the pulse-transit time, but prolonged the time to the peak perfusion wave. Segmentation of the perfusion upstroke into two phases, at the time point of maximum acceleration (MAT), revealed that arterial compression prolonged only the initial slow phase duration (SPd). The MAT and SPd were proportional to the emulated stenosis severity and detected the arterial stenosis with high sensitivity (> 93%) and specificity (100%). The SPd increased from 46.4 ± 21.2 ms at baseline to 75.4 ± 38.5 ms and 145 ± 39 ms under 45 mmHg and 90 mmHg compressions (p < 0.001), without affecting the pulse-transit time. CONCLUSIONS The novel method and indices can identify and grade the emulated arterial stenosis with high accuracy and may assist in differentiating between focal arterial stenosis and widespread arterial hardening.
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Affiliation(s)
- Tomer Joshua Heitner
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Technion City, 32000, Haifa, Israel
| | - Amit Livneh
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Technion City, 32000, Haifa, Israel
| | - Amir Landesberg
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Technion City, 32000, Haifa, Israel.
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Guo L, Yang Q, Wei R, Zhang W, Yin N, Chen Y, Xu C, Li C, Carney RP, Li Y, Feng M. Enhanced pericyte-endothelial interactions through NO-boosted extracellular vesicles drive revascularization in a mouse model of ischemic injury. Nat Commun 2023; 14:7334. [PMID: 37957174 PMCID: PMC10643472 DOI: 10.1038/s41467-023-43153-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Despite improvements in medical and surgical therapies, a significant portion of patients with critical limb ischemia (CLI) are considered as "no option" for revascularization. In this work, a nitric oxide (NO)-boosted and activated nanovesicle regeneration kit (n-BANK) is constructed by decorating stem cell-derived nanoscale extracellular vesicles with NO nanocages. Our results demonstrate that n-BANKs could store NO in endothelial cells for subsequent release upon pericyte recruitment for CLI revascularization. Notably, n-BANKs enable endothelial cells to trigger eNOS activation and form tube-like structures. Subsequently, eNOS-derived NO robustly recruits pericytes to invest nascent endothelial cell tubes, giving rise to mature blood vessels. Consequently, n-BANKs confer complete revascularization in female mice following CLI, and thereby achieve limb preservation and restore the motor function. In light of n-BANK evoking pericyte-endothelial interactions to create functional vascular networks, it features promising therapeutic potential in revascularization to reduce CLI-related amputations, which potentially impact regeneration medicine.
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Affiliation(s)
- Ling Guo
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China.
- Key Laboratory of Tropical Biological Resources of Ministry of Education, School of Pharmaceutical Sciences, Hainan University, Haikou, 570228, P. R. China.
| | - Qiang Yang
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China
| | - Runxiu Wei
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China
| | - Wenjun Zhang
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China
| | - Na Yin
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China
| | - Yuling Chen
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China
| | - Chao Xu
- Key Laboratory of Tropical Biological Resources of Ministry of Education, School of Pharmaceutical Sciences, Hainan University, Haikou, 570228, P. R. China
| | - Changrui Li
- Guangzhou Zhixin High School, Zhixin South Road, Guangzhou, 510080, P.R. China
| | - Randy P Carney
- Department of Biomedical Engineering, University of California Davis, Davis, CA, 95616, USA.
| | - Yuanpei Li
- Department of Biochemistry and Molecular Medicine, UC Davis Comprehensive Cancer Center, University of California Davis, Davis, CA, 95616, USA.
| | - Min Feng
- School of Pharmaceutical Sciences, Sun Yat-sen University, University Town, Guangzhou, 510006, P.R. China.
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Perks J, Mcbride P, Rayt H, Payne T, Edwardson C, Rowlands AV, Messeder SJ, Yates T, Sayers R. Efficacy of a personalised activity plan for BREAKing UP sitting time in patients with intermittent claudication (the BREAK UP study). Diabetes Res Clin Pract 2023; 204:110925. [PMID: 37774979 DOI: 10.1016/j.diabres.2023.110925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/11/2023] [Accepted: 09/27/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION The aim of this study was to investigate the concept of an 8-week personalised activity plan, using short periods of physical activity to break up sitting time in people with Intermittent Claudication (IC), to improve walking ability, and reduce time spent sitting. METHODS The study was designed as a single centre, single arm, before and after study and is registered with clinicaltrials.gov (NCT04572737). The co-primary outcomes are time spent sitting and walking ability measured via the walking impairment questionnaire. Normally distributed data was analysed using paired samples T-tests; non-normally distributed data was analysed using related-samples Wilcoxon signed rank tests. RESULTS There was a significant improvement in both co-primary outcomes: walking ability and time spent sitting, as well as the following secondary outcomes: total bouts and time spent in prolonged sitting, time spent standing and stepping, anxiety, depression, and activity levels reported on the vascular quality of life questionnaire. CONCLUSION An 8-week personalised activity plan to break up sitting time shows promise as a treatment for people with IC, improving walking ability and reducing time spent sitting. This study supports the use of large randomised controlled trials to further develop this treatment in people with IC.
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Affiliation(s)
- Jemma Perks
- Department of Cardiovascular Sciences, University of Leicester, On-Call Suite OC9, Glenfield General Hospital, Groby Road, Leicester LE3 9QP, UK.
| | - Philip Mcbride
- Leicester Diabetes Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Harjeet Rayt
- Department of Cardiovascular Sciences, University of Leicester, On-Call Suite OC9, Glenfield General Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Tanya Payne
- Department of Cardiovascular Sciences, University of Leicester, On-Call Suite OC9, Glenfield General Hospital, Groby Road, Leicester LE3 9QP, UK
| | | | - Alex V Rowlands
- Leicester Diabetes Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Sarah Jane Messeder
- Department of Cardiovascular Sciences, University of Leicester, On-Call Suite OC9, Glenfield General Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Thomas Yates
- Leicester Diabetes Centre, University of Leicester, Leicester LE5 4PW, UK; NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, UK
| | - Robert Sayers
- Department of Cardiovascular Sciences, University of Leicester, On-Call Suite OC9, Glenfield General Hospital, Groby Road, Leicester LE3 9QP, UK
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Machado I, Ferreira J, Magalhães C, Sousa P, Dias L, Santarém D, Sousa N, Paredes H, Abrantes C. Six-month effects of supervised exercise on walking ability and health-related factors in peripheral arterial disease: a pilot study. INT ANGIOL 2023; 42:371-381. [PMID: 37870494 DOI: 10.23736/s0392-9590.23.05085-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND In peripheral arterial disease (PAD) patients with intermittent claudication (IC), the combination of aerobic and resistance exercises could counteract muscle loss and attenuate disease progression. This study analyzed the effects of six months of a combined exercise program on walking ability, lower limb body composition, cardiovascular risk factors, and Ankle-Brachial Index (ABI). METHODS Twenty-three patients (age 63.2±1.5 years and ABI 0.58±0.07) with PAD and IC were allocated to a control group (CG) or a supervised exercise group (SUP). Ten patients underwent six months of treadmill walking combined with resistance exercises, three times a week. The CG (N.=13) received a recommendation for walking. All patients were measured at baseline (M0), after three months (M3), and six months (M6). RESULTS During constant treadmill protocol, the claudication onset time/distance (COT/COD), absolute claudication time/distance (ACT/ACD), and number of pauses of overall patients significantly improved at M3 and M6. Between groups were found significant differences in COT and COD at M6 (P=0.005 and P=0.007, respectively); and in ACT and ACD at M3 (P=0.003 for both) and at M6 (P=0.005 and P=0.005, respectively), with major improvements in the SUP. Over the six months, a significant group effect was found in fat-free mass (P=0.041) and predicted muscle mass (P=0.039) of the lower ABI leg, with greater improvements in the SUP. CONCLUSIONS A supervised exercise program that combines aerobic and resistance training improves PAD symptoms and has additional benefits for patients. Patients in the program showed improvements in walking ability, lower-limb body composition, perceived exertion, and heart rate during treadmill walking.
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Affiliation(s)
- Isabel Machado
- Department of Sports Sciences, Exercise and Health, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal -
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal -
| | - Joana Ferreira
- Department of Angiology and Vascular Surgery, Trás-os-Montes e Alto Douro Hospital Center (CHTMAD), Vila Real, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - Carlos Magalhães
- Department of Physical Medicine and Rehabilitation, Trás-os-Montes e Alto Douro Hospital Center (CHTMAD), Vila Real, Portugal
| | - Pedro Sousa
- Department of Imagiology, Trás-os-Montes e Alto Douro Hospital Center (CHTMAD), Vila Real, Portugal
| | - Lúcia Dias
- Department of Physical Medicine and Rehabilitation, Trás-os-Montes e Alto Douro Hospital Center (CHTMAD), Vila Real, Portugal
| | - Daniel Santarém
- Department of Sports Sciences, Exercise and Health, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Nelson Sousa
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal
- Public Health Unit of Santo Tirso, ACES Grande Porto I-Santo Tirso/Trofa, Santo Tirso, Portugal
| | - Hugo Paredes
- Department of Engineering, School of Sciences and Technology, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal
- Institute for Systems and Computer Engineering, Technology and Science (INESC TEC), Center for Human Center Computing and Information Science (HUMANISE), Porto, Portugal
| | - Catarina Abrantes
- Department of Sports Sciences, Exercise and Health, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal
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Lanzi S, Pousaz A, Calanca L, Mazzolai L. Time-course evolution of functional performance during a 3-month supervised exercise training program in patients with symptomatic peripheral artery disease. Vasc Med 2023; 28:404-411. [PMID: 37642643 PMCID: PMC10559646 DOI: 10.1177/1358863x231191908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Functional performance is impaired in patients with peripheral artery disease (PAD). The effects of a supervised exercise training (SET) program on functional performance have yet to be clearly determined. The aim was to investigate the time-course evolution of functional performance during a 3-month SET program. METHODS Patients with chronic symptomatic PAD participating in a 3-month SET program were investigated. Six-minute walking distance (6MWD), the stair climbing test (SCT), and the Short Physical Performance Battery (SPPB) were assessed before SET, after the first and second months of SET, and following the SET program. The ankle- and toe-brachial indices were measured before and after the SET program. RESULTS Ninety patients with PAD (age 65.4 ± 10.2 years) were analyzed. The 6MWD significantly improved after the first (+7%, p ⩽ 0.001) and second months (+13%, p ⩽ 0.001) and following SET (+14%, p ⩽ 0.001) compared to before the SET program. The 6MWD significantly improved after the 2nd month (+6%, p ⩽ 0.001) and following SET (+7%, p ⩽ 0.001) compared to after the first month of the SET program. The SPPB score and SCT performance significantly improved after the first (SPPB score: +9%, p ⩽ 0.001; SCT: +17%, p ⩽ 0.001) and second months (SPPB score: +11%, p ⩽ 0.001; SCT: +24%, p ⩽ 0.001) and following SET (SPPB score: +12%, p ⩽ 0.001; SCT: +25%, p ⩽ 0.001) compared to before the SET program. No significant differences were observed following SET compared to the second month of the SET program. Vascular parameters did not change significantly. CONCLUSIONS A 3-month SET program improves several components of functional performance, and adaptations mainly occur during the 1st and 2nd months of the SET program.
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Affiliation(s)
- Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Anina Pousaz
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Luca Calanca
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Suzuki K, Kamo T, Momosaki R, Kimura A, Koike T, Watanabe S, Kondo T. Rehabilitation contributes to lower readmission rates for individuals with peripheral arterial disease: A retrospective observational study. Ann Phys Rehabil Med 2023; 66:101768. [PMID: 37883830 DOI: 10.1016/j.rehab.2023.101768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Non-pharmacological interventions, such as rehabilitation, are crucial for the treatment of people with peripheral arterial disease (PAD). Although several studies have shown rehabilitation is effective in improving the functional prognosis of PAD, there is currently insufficient evidence regarding its effect on readmission rates. OBJECTIVES To examine the impact of rehabilitation on readmission rates for people with PAD. METHODS A retrospective analysis of the JMDC hospital database was performed on data from two groups of people aged ≥20 years who were hospitalized between 2014 and 2020 with PAD, as based on a previous diagnosis. Participants were divided according to whether they did, or did not, receive any form of rehabilitation as part of their treatment in hospital. The primary outcome was readmission rates at 30, 60, 90, and 180 days after initial admission. A one-to-one propensity score matching was used to compare readmission rates between rehabilitation and non-rehabilitation groups. RESULTS We included 13,453 people with PAD, of whom 2701 pairs (5402 subjects) were selected after being matched in the rehabilitation and non-rehabilitation groups. The rehabilitation group participants had significantly lower mortality and readmission rates at 30, 60, 90, and 180 days. The odds ratios (95% confidence interval) for both groups were 0.79 (0.69-0.91; 30 days), 0.81 (0.71-0.91; 60 days), 0.78 (0.69-0.88; 90 days), and 0.79 (0.71-0.88; 180 days). CONCLUSIONS This large, nationwide study found that rehabilitation treatment during hospitalization was associated with lower readmission rates and mortality for people following hospitalization with PAD and supports its inclusion as a standard PAD treatment.
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Affiliation(s)
- Keisuke Suzuki
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Sciences, Gifu, Japan.
| | - Tomohiko Kamo
- Department of Physical Therapy, Faculty of Health Science, Gunma Paz University, Gunma, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Akira Kimura
- Department of Physical Therapy, Faculty of Health Science, Gunma Paz University, Gunma, Japan
| | - Takayasu Koike
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Sciences, Gifu, Japan
| | - Shinichi Watanabe
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Sciences, Gifu, Japan
| | - Takashi Kondo
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Sciences, Gifu, Japan
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Suwannasom P, Phinyo P, Leemasawat K, Chichareon P, Nantsupawat T, Osataphan N, Thonghong T, Suwanugsorn S, Wongvipaporn C, Phrommintikul A. Prognostic Value of Ankle-Brachial Index in Prediction of Cardiovascular Events in an Asian Population with Multiple Atherosclerotic Risk Factors. Angiology 2023; 74:848-858. [PMID: 36062408 DOI: 10.1177/00033197221124772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We aimed to evaluate the incremental prognostic value after incorporation of the ankle-brachial index (ABI) into the 10-year pool cohort equation (PCE) risk model in patients with multiple risk factors (MRFs). A total of 4332 MRFs patients were divided into 2 groups as ABI ≤.9 or >.9. The primary outcome was hard cardiovascular events (hCVE: including cardiovascular death, myocardial infarction, or ischemic stroke) over a median follow-up of 36 months. The Cox proportional hazards survival model, C-statistic, and net reclassification indices (NRI) were used. The occurrence of the primary outcome in the ABI ≤.9 group (3.7%) was significantly greater than in the ABI > .9 group (1.3%), P < .001. ABI is an independent predictor of hCVE in addition to the variables in the standard risk model (age, gender, and smoking status). ABI modestly improved the C-index when added to the PCE risk model (PCE .70 vs ABI+PCE .74). The addition of ABI to the PCE risk model did not significantly improve the classification of patients (NRI -.029; 95% CI: -.215 to .130). Despite ABI being one of the independent predictors of hCVE, integration of ABI into the PCE model did not improve the efficacy of risk reclassification in patients with MRFs.
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Affiliation(s)
- Pannipa Suwannasom
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Krit Leemasawat
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ply Chichareon
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Teerapat Nantsupawat
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nichanan Osataphan
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tasalak Thonghong
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Saranyou Suwanugsorn
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Ren B, Li B, Pan T, Zhao E, Ju S, Li X, Li X, Zhu Y, Cai Y, Huang L, Fu W, Dong Z. Risk factors for at-risk foot and peripheral artery disease among the population with diabetes: A multicommunity-based cross-sectional study. Diabetes Res Clin Pract 2023; 203:110869. [PMID: 37562660 DOI: 10.1016/j.diabres.2023.110869] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/16/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
AIMS This study aimed to investigate the prevalence, characteristics, and influence factors of the at-risk foot with diabetes mellitus (DM). METHODS This study included 3030 DM patients from the at-risk foot screening program of Shanghai in China between March 21 and April 30 in 2021. Data were collected from the questionnaire survey, physical examination, and fasting blood sample. RESULTS The prevalence of at-risk foot was 27.8% among DM patients. After adjusted, the risk of higher at-risk grade increased with age and urinary albumin creatinine ratio (OR = 1.04, 95%CI = 1.02-1.06; OR = 1.001, 95%CI = 1.000-1.002, respectively), whereas decreased with estimated glomerular filtration rate (eGFR) (OR = 0.991, 95%CI = 0.984-0.998). The incidence of peripheral artery disease (PAD) was 11.1% in all people with DM, and age, pulse rate, and low-density lipoprotein were independent risk factors for PAD. In contrast, high-density lipoprotein, eGFR, and lymphocyte-to-monocyte ratio were independent protective factors for PAD. Glycated hemoglobin HbA1c was not an independent risk factor for increased risk grade or more severe PAD. CONCLUSIONS The at-risk foot accounted for a high percentage among DM patients. Advanced age and renal dysfunction are independent risk factors for the at-risk foot. Glycemic control does not reduce the risk grade of at-risk foot and the incidence of PAD.
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Affiliation(s)
- Bichen Ren
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China
| | - Bingzhe Li
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Tianyue Pan
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China
| | - Enhui Zhao
- School of Public Health, Fudan University, Shanghai 200032, China
| | - Shuai Ju
- National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China; Department of Vascular and Wound Treatment Center, Jinshan Hospital, Fudan University, Shanghai 200540, China
| | - Xiaoyan Li
- National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China; Department of Vascular and Wound Treatment Center, Jinshan Hospital, Fudan University, Shanghai 200540, China
| | - Xiaomu Li
- Department of Endocrinology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yizhun Zhu
- State Key Laboratory of Quality Research in Chinese Medicine and School of Pharmacy, Macau University of Science and Technology, Macau
| | - Yunmin Cai
- National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China; Department of Vascular and Wound Treatment Center, Jinshan Hospital, Fudan University, Shanghai 200540, China
| | - Lihong Huang
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
| | - Weiguo Fu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China.
| | - Zhihui Dong
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; National Clinical Research Center for Interventional Medicine, Zhongshan-Jinshan Diabetic Foot Center, Shanghai 200032, China.
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Chilbert MR, Woodruff AE, Saber M, Goriacko P, Sinnet M, Jacobs D. Comparison of bleeding and ischemic events with apixaban vs. rivaroxaban in triple antithrombotic therapy regimens. Blood Coagul Fibrinolysis 2023; 34:370-376. [PMID: 37577874 DOI: 10.1097/mbc.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To compare the risk of readmissions for major bleeding within one year between apixaban and rivaroxaban as a component of triple antithrombotic therapy. METHODS This study was a multicenter, retrospective cohort study conducted at two academic medical centers in the Western New York and New York City region between July 1, 2011 and September 25, 2019. Adult patients were included if they were diagnosed with atrial fibrillation or venous thromboembolism and discharged on new triple antithrombotic therapy. The primary outcome compared the rates of 1-year readmission for major bleeding between apixaban and rivaroxaban groups. Secondary outcomes included rate of ischemic outcomes. Time to event analysis was determined with a Kaplan-Meier plot and Cox proportional hazard ratios (HR). RESULTS A total of 378 patients were included in the study, 212 in the apixaban group and 166 in the rivaroxaban group. Within 1 year, readmission for major bleeding events occurred in six (2.8%) patients in the apixaban group and four (2.4%) patients in the rivaroxaban group ( P = 1.000). After adjustment, the major bleeding event rate was not statistically significantly different between apixaban and rivaroxaban [adjusted hazard ratio (aHR) 0.68, 95% confidence interval (CI) 0.12-3.77; P = 0.6624]. Higher albumin levels were identified to be protective against major bleeding related readmission events (aHR 0.18, 95% CI 0.05-0.63; P = 0.0072). The ischemic outcome occurred in seven (3.3%) patients in the apixaban group and three (1.8%) in the rivaroxaban group ( P = 0.7368). CONCLUSION Use of apixaban or rivaroxaban in a triple antithrombotic regimen was not associated with bleeding or ischemic outcomes.
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Affiliation(s)
- Maya R Chilbert
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
- Buffalo General Medical Center, Buffalo
| | - Ashley E Woodruff
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
- Buffalo General Medical Center, Buffalo
| | - Marissa Saber
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
| | | | - Mark Sinnet
- Montefiore Medical Center, The Bronx, New York, USA
| | - David Jacobs
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
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Leeper NJ, Adkar SS. A Glimpse Into the Black Box: Using Machine Learning to Prioritize Predictors of Vascular Disease. JACC. ADVANCES 2023; 2:100563. [PMID: 38939483 PMCID: PMC11198632 DOI: 10.1016/j.jacadv.2023.100563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Nicholas J. Leeper
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Stanford Cardiovascular Institute, Stanford, California, USA
| | - Shaunak S. Adkar
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Stanford Cardiovascular Institute, Stanford, California, USA
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Bierowski M, Galanis T, Majeed A, Mofid A. Peripheral Artery Disease: Overview of Diagnosis and Medical Therapy. Med Clin North Am 2023; 107:807-822. [PMID: 37541709 DOI: 10.1016/j.mcna.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Peripheral artery disease (PAD) affects approximately 230 million people worldwide and is associated with an increased risk of major adverse cardiovascular and limb events. Even though this condition is considered a cardiovascular equivalent, it remains an underrecognized and undertreated entity. Antiplatelet and statin therapy, along with smoking cessation, are the foundations of therapy to reduce adverse events but are challenging to fully implement in this patient population. Race and socioeconomic status also have profound impacts on PAD outcomes.
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Affiliation(s)
- Matthew Bierowski
- Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Taki Galanis
- Division Vascular Medicine, Jefferson Vascular Center, Sidney Kimmel Medical College, Philadelphia, PA, USA.
| | - Amry Majeed
- Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Alireza Mofid
- Vascular Surgery, Thomas Jefferson University Hospital, 111 South 11th Street, Suite 6210 Gibbon, Philadelphia, PA 19107, USA
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Zhang M, Chen Y, Qiu Y, Sun J, He J, Liu Z, Shi J, Wei W, Wu G, Liang J. PCSK9 Promotes Hypoxia-Induced EC Pyroptosis by Regulating Smac Mitochondrion-Cytoplasm Translocation in Critical Limb Ischemia. JACC Basic Transl Sci 2023; 8:1060-1077. [PMID: 37791316 PMCID: PMC10544082 DOI: 10.1016/j.jacbts.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 10/05/2023]
Abstract
Hypoxia-induced endothelial cell death and impaired angiogenesis are the main pathophysiological features of critical limb ischemia. Mechanistically, proprotein convertase subtilisin/kexin type 9 (PCSK9) promoted Smac translocation from mitochondria to the cytoplasm. Inhibition of Smac release into the cytoplasm attenuated PCSK9-mediated hypoxia-induced pyroptosis. Functionally, PCSK9 overexpression impaired angiogenesis in vitro and reduced blood perfusion in mice with lower limb ischemia, but the effect was reversed by PCSK9 inhibition. This study demonstrates that PCSK9 aggravates pyroptosis by regulating Smac mitochondrion-cytoplasm translocation in the vascular endothelium, providing novel insights into PCSK9 as a potential therapeutic target in critical limb ischemia.
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Affiliation(s)
- Meixin Zhang
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yixi Chen
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yumin Qiu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiapan Sun
- Department of Geriatrics, Peking University Shenzhen Hospital, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, Guangdong, China
| | - Jiang He
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhefu Liu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian Shi
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Wenbin Wei
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Guifu Wu
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Jianwen Liang
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
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