Long-Term Outcomes and Associations With Major Adverse Limb Events After Peripheral Artery Revascularization

Antithrombotic Therapy in Patients Undergoing Peripheral Artery Interventions

Patients with peripheral artery disease (PAD) who undergo lower extremity revascularization (LER) are at high risk for cardiovascular and limb-related ischemic events. The role of antithrombotic therapy is to prevent thrombotic complications, but this requires balancing increased risk of bleeding events. The dual pathway inhibition (DPI) strategy including aspirin and low-dose rivaroxaban after LER has been shown to reduce major adverse cardiovascular and limb-related events without significant differences in major bleeding. There is now a need to implement the broad adoption of DPI therapy in PAD patients who have undergone LER in routine practice.

Comparison of efficacy and safety of sarpogrelate-based anti-platelet therapy with non-sarpogrelate-based anti-platelet therapy following arterial endovascular therapy: a systematic review

Objective

Sarpogrelate is a selective serotonin/5-hydroxytryptamine 2A receptor antagonist used in the management of peripheral artery disease (PAD). The drug has emerged as a promising choice for medical management post-endovascular therapy (EVT) due to its anti-platelet aggregation, vasoconstriction, and anti-vascular smooth muscle proliferation properties. The aim of the meta-analysis is to evaluate the efficacy and safety of sarpogrelate-based APT following arterial EVTs in PAD.

Material and methods

PubMed, Google Scholar, Scopus, and the Cochrane were systematically searched from inception to December 2023. Any randomized controlled trial studies in English that evaluated the efficacy and safety of sarpogrelate-based APT after EVT in patients with PAD was included. Data on the restenosis rate, target lesion revascularization (TLR), and safety parameters were extracted and studied. The pooled differences in efficacy and safety parameters between sarpogrelate-based APT and non-sarpogrelate-based APT was calculated using the relative risk (RR) with a 95% CI.

Results

A total of three randomized controlled trials were included out of 354 articles obtained through a literature search. No significant differences were observed in the risk of restenosis (RR=0.74, 95% CI= 0.55-1.00, P=0.954) and TLR (RR=0.76, 95% CI= 0.47-1.23, P=0.476) among patients being treated with sarpogrelate and non-sarpogrelate-based APT. Likewise, sarpogrelate-based APT had a similar safety profile as non-sarpogrelate-based APT.

Conclusion

Sarpogrelate-based APT can be considered an effective alternative to clopidogrel-based conventional APT after EVTs. However, there is a huge need for a larger multicenter, multinational, and multiethnic global trial with sufficient participants in order to produce generalizable findings.

Antithrombotic Strategies for Patients With Peripheral Artery Disease: JACC Scientific Statement

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.

A Scoping Review of Decision Support Tools for Patients with Lower Extremity Arterial Disease: Toward Shared Decision-Making

BACKGROUND

In recent years, decision support tools (DSTs) in various fields of medicine have emerged to aid clinicians and patients in the process of shared decision-making (SDM). This scoping review aims to identify the existing DSTs for selecting treatments in lower extremity arterial disease and to evaluate their effectiveness in facilitating SDM.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews were followed. A literature search was conducted across MEDLINE, EMBASE, and Cochrane databases, along with the Decision Aid Library Inventory, for studies published between January 2000 and June 2023. Articles reporting the development and/or clinical application of a DST specific to lower extremity arterial disease were included. A narrative synthesis of the results was performed and findings were presented in tabular formats.

RESULTS

Five studies and 5 unique DSTs were included. Presenting formats included websites, booklets, brochures, and pocket cards. Overall, a high degree of heterogeneity was observed across all DSTs in their format, content, and delivery. A widespread acceptability and satisfaction were reported among patients and clinicians. However, their effect at improving SDM remains uncertain due to the lack of standardized outcome metrics.

CONCLUSIONS

The development and implementation of DSTs for lower limb arterial disease treatment discussion remain in the early stages. This review lays the foundation for future studies to continue exploring optimal strategies for DST development and their role in supporting SDM.

Association of colchicine use with cardiovascular and limb events in peripheral artery disease: Insights from a retrospective cohort study

BACKGROUND AND AIMS

Colchicine has demonstrated efficacy in treating coronary artery disease, but its efficacy in peripheral artery disease (PAD) remains uncertain. This study aims to address this gap in knowledge.

METHODS

A retrospective cohort study was conducted using the TriNetX Network, selecting patients with lower limb PAD between January 1, 2011, and January 1, 2024. Colchicine users were matched 1:1 with non-users through propensity score matching, considering demographics, medical conditions, medications, and psychosocial factors. The primary outcome was a composite of major adverse cardiovascular and limb events (MACLE) - including lower limb amputation, revascularization for lower limb ischemia, acute myocardial infarction, ischemic stroke, and all-cause mortality - over a ten-year follow-up.

RESULTS

From 53,568 colchicine-treated and 1,499,969 untreated patients with lower limb PAD, 52,350 pairs were successfully matched. Over ten years, colchicine was associated with a significant reduction in MACLE (hazard ratio, [HR] 0.90, 95% CI 0.88-0.92, p < 0.001), any lower limb amputation (HR 0.84, 95% CI 0.75-0.94, p = 0.002), revascularization for lower limb ischemia (HR 0.85, 95% CI 0.82-0.88, p < 0.001), major adverse cardiovascular events (HR 0.93, 95% CI 0.91-0.95, p < 0.001), and all-cause mortality (HR 0.90, 95% CI 0.87-0.92, p < 0.001). It also result in a reduced risk of ischemic stroke (HR 0.95, 95% CI 0.92-0.98, p = 0.001), but not of acute myocardial infarction (HR 0.98, 95% CI 0.95-1.01, p = 0.24).

CONCLUSIONS

Colchicine significantly reduced major adverse cardiovascular and limb events in patients with lower limb PAD, supporting the need for further investigation.

Major Adverse Limb Events in Patients Undergoing Revascularisation for Lower Limb Peripheral Arterial Disease: A Nationwide Observational Study

OBJECTIVE

Major adverse limb events (MALEs) are frequent in patients with lower extremity peripheral arterial disease (PAD). However, routine care MALE rate estimations after revascularisation are scarce. This study aimed to determine post-procedural MALE rates in revascularised patients with PAD and identify predictors of post-procedural MALEs.

METHODS

This was a population based observational study on merged national registry data. Patients with PAD undergoing lower limb revascularisation between 2008 and 2016 were retrieved from the Swedish National Registry for Vascular Surgery. Information on comorbidities, medications, and post-procedural MALE endpoints were identified in national healthcare registries. Primary outcomes of interest were categorised as 2 - 4 point MALE composites that included limb amputation, acute lower limb ischaemia, progression to or relapse of chronic limb threatening ischaemia (CLTI), and ipsilateral re-interventions regardless of indication. Patients with intermittent claudication (IC) and CLTI were analysed separately using Kaplan-Meier estimates. Stepwise Cox proportional hazard models were used for predictor candidate analysis.

RESULTS

Overall, 28 021 revascularised patients with PAD were analysed (IC, n = 10 506, 37.5%; CLTI, n = 17 515, 62.5%). During a mean follow up ± standard deviation of 3.2 ± 2.4 years, 5 226 (18.7%), 9 423 (33.6%), and 12 696 (45.3%) patients experienced a 2, 3, and 4 point MALE, respectively. The estimated one year 4 point MALE rates were 21.4% (95% confidence interval [CI] 20.6 - 22.2%) in IC and 46.9% (95% CI 46.1 - 47.7%) in CLTI. Adjusted predictors for experiencing a 4 point MALE in IC were chronic kidney disease (CKD) (hazard ratio [HR] 1.33, 95% CI 1.12 - 1.59) and previous lower limb revascularisation (HR 1.29, 95% CI 1.19 - 1.40). In CLTI, previous contralateral lower limb amputation (HR 1.60, 95% CI 1.47 - 1.73) and CKD (HR 1.25, 95% CI 1.17 - 1.34) were adjusted predictors.

CONCLUSION

This study emphasises the very high MALE rates in revascularised patients with lower limb PAD, especially in CLTI. Prior lower limb revascularisation correlated with increased MALE rates in IC patients, while prior lower limb amputation was linked to subsequent MALEs in CLTI. In both IC and CLTI, CKD was associated with poorer outcomes, regardless of applied MALE definition.

Effect of Peripheral Interventions in Patients with Peripheral Artery Disease Receiving Rivaroxaban and Aspirin: Analyses from the XATOA Registry

OBJECTIVE

To assess the characteristics and clinical outcomes of patients with lower extremity peripheral artery disease (PAD) in XATOA receiving dual pathway inhibition (DPI) with rivaroxaban 2.5 mg twice daily plus aspirin according to lower extremity revascularisation (LER) history.

METHODS

XATOA is an international, multicentre, prospective, single arm registry study. This subanalysis investigated patients with lower extremity PAD according to LER history. Patients with coronary artery disease, PAD, or both, receiving DPI were followed for 12 or more months. Baseline characteristics and clinical outcomes were assessed according to LER history. A time dependency analysis assessed outcomes by time between the most recent LER procedure and the start of DPI. A multivariable analysis assessed the influence of patient characteristics on clinical outcomes.

RESULTS

In XATOA (n = 5 532), 2 820 (51.0%) patients had lower extremity PAD, of whom 1 736 (61.6%) had prior LER and 1 084 (38.4%) had no prior LER. Baseline characteristics were generally similar between patients with or without prior LER. A higher proportion of patients with prior LER experienced any treatment emergency clinical events compared with those without prior LER (15.0% vs. 9.4%, respectively), with greater differences observed between incidence rates of limb events, including major adverse limb events (9.06 vs. 4.09 events per 100 patient years, respectively). Similar rates of myocardial infarction, stroke, and major bleeding were observed in both subgroups. Clinical event rates were generally higher in patients who had previous LER for six months or less compared with patients who had previous LET for more than six months before starting DPI, regardless of LER type. Multivariable analyses showed that prior LER was predictive of limb events.

CONCLUSION

This subanalysis of XATOA found that prior LER was associated with increased rates of limb events, consistent with results of COMPASS and VOYAGER PAD. Rates of bleeding were also low regardless of LER history and consistent with the findings from these trials.

Development and validation of a major adverse limb events prediction model for peripheral arterial disease with frailty

OBJECTIVE

To investigate the risk factors for major limb adverse events (MALE) in peripheral arterial disease (PAD) combined with frailty and to develop and validate a risk prediction model of MALE.

METHODS

This prospective study was performed in the vascular surgery department of patients in six hospitals in southwest China. Prospective collection of patients with PAD combined with frailty from February 1 to December 20, 2021, with MALE as the primary outcome, and followed for 1 year. The cohort was divided into a development cohort and a validation cohort. In the development cohort, a multivariate risk prediction model was developed to predict MALE using random forests for variable selection and multivariable Cox regression analysis. The model is represented by a visualized nomogram and a web-based calculator. The model performance was tested with the validation cohort and assessed using the C-statistic and calibration plots.

RESULTS

A total of 1179 patients were prospectively enrolled from February 1 to December 20, 2021. Among 816 patients with PAD who were included in the analysis, the median follow-up period for this study was 9 ± 4.07 months, the mean age was 74.64 ± 9.43 years, and 249 (30.5%) were women. Within 1 year, 222 patients (27.2%) developed MALE. Target lesion revascularizations were performed in 99 patients (12.1%), and amputations were performed in 131 patients (16.1%). The mortality rate within the whole cohort was 108 patients (13.2%). After controlling for competing risk events (death), the cumulative risk of developing MALE was not statistically different. Prealbumin (hazard ratio [HR], 0.6; 95% confidence interval [CI], 0.41-0.89; P = .010), percutaneous coronary intervention (HR, 2.31; 95% CI, 1.26-4.21; P = .006), Rutherford classification (HR, 1.77; 95% CI, 1.36-2.31; P < .001), white blood cell (HR, 1.85; 95% CI, 1.20-2.87; P = .005), high altitude area (HR, 3.1; 95% CI, 1.43-6.75; P = .004), endovascular treatment (HR, 10.2; 95% CI, 1.44-72.50; P = .020), and length of stay (HR, 1.01; 95% CI, 1.00-1.03; P = .012) were risk factors for MALE. The MALE prediction model had a C-statistic of 0.76 (95% CI, 0.70-0.79). The C-statistic was 0.68 for internal validation and 0.66 for external validation for the MALE prediction model. The MALE prediction model for PAD presented an interactive nomogram and a web-based network calculator.

CONCLUSIONS

In this study, the MALE prediction model has a discriminative ability to predict MALE among patients with PAD in frailty. The MALE model can optimize clinical decision-making for patients with PAD in frailty.

Outcomes of Revascularisation for Treating Lifestyle-Limiting Intermittent Claudication in Aboriginal and Torres Strait Islander People and Non-Indigenous Patients from North Queensland: A Retrospective Cohort Study

Background: This retrospective analysis of an ongoing prospective cohort study aimed to assess the outcome of revascularisation for treating lifestyle-limiting intermittent claudication caused by peripheral artery disease (PAD) in Aboriginal and Torres Strait Islander Peoples and non-Indigenous North Queenslanders. Methods: Consenting patients with PAD who underwent endovascular or open revascularisation procedures for treating lifestyle-limiting intermittent claudication were included. The primary outcome measure was major adverse limb events (MALEs), defined as major amputation or the requirement for repeat open or endovascular revascularisation. Results: Of the 378 included patients, 18 (4.8%) identified as Aboriginal and/or Torres Strait Islander Peoples. During a mean follow-up (standard deviation) of 6.0 (3.9) years, the incidence of MALE was similar in the Aboriginal and Torres Strait Islander People and non-Indigenous Australians (absolute percentage: 50.0% vs. 40.6%, log rank p = 0.59). In both unadjusted and adjusted analyses, Aboriginal and Torres Strait Islander Peoples and non-Indigenous Australians had similar risks of MALE (unadjusted hazard ratio, HR, 1.20, 95% confidence interval, CI, 0.61, 2.36; adjusted HR 1.02, 95%CI 0.50, 2.06). Conclusions: This study suggests that Aboriginal and Torres Strait Islander People are under-represented in the population of patients undergoing revascularisation to treat intermittent claudication. Due to small numbers it cannot be reliably concluded that Aboriginal and Torres Strait Islander People and non-Indigenous Australians have similar rates of MALE.

Editor's Choice - Revascularisation for Peripheral Artery Disease in France: Implications for the Implementation of VOYAGER-PAD

OBJECTIVE

The VOYAGER-PAD trial demonstrated the interest in dual pathway inhibition (DPI) (low dose rivaroxaban plus aspirin) to reduce limb and cardiovascular events after revascularisation for peripheral artery disease (PAD), but its applicability in clinical practice has not yet been assessed. This study aimed to assess the number of patients revascularised in France for PAD and to estimate the proportion of those matching the VOYAGER-PAD trial selection criteria. A secondary objective was to examine the prognosis of revascularised patients in a real world setting.

METHODS

This observational retrospective study was conducted on the national hospital discharge database and included all patients with PAD who underwent lower extremity revascularisation for PAD (without lower extremity revascularisation in the two years prior to inclusion) from 1 January 2016 to 31 December 2019. Available VOYAGER-PAD selection criteria were then applied to the study population.

RESULTS

In total, 180 870 patients were included (mean age 72.0 ± 12.2 years, 30.9% female), with approximately 45 000 patients revascularised annually. Among them, 90 379 (50.0%) matched the VOYAGER-PAD trial criteria (VOYAGER-PAD eligible subgroup; mean age 69.8 ± 12.1 years, 29.5% female). In the study population and the VOYAGER-PAD eligible subgroup, 33.9% and 26.6% of patients had diabetes, 28.1% and 19.9% had chronic coronary artery disease, and 14.6% and 5.7% had renal failure, respectively. Overall, 73.1% of study patients were treated by an endovascular approach (75.5% in the VOYAGER-PAD eligible subgroup). In patients with more than one year of follow up, 45.4% of study patients and 36.0% of the VOYAGER-PAD eligible subgroup experienced a limb or cardiovascular event. The median time until the first event and in hospital death was 4.8 months and 7.8 months, respectively (6.7 months and 12.9 months in the VOYAGER-PAD eligible subgroup).

CONCLUSION

The burden of PAD for revascularisation and secondary events is considerable. One half of revascularised patients in France are eligible for DPI therapy. Those patients are younger, with fewer comorbidities, and better outcomes.

Adherence and Persistence to Antiplatelet Therapy in Lower Extremity Peripheral Arterial Disease: A Danish Population Based Cohort Study

OBJECTIVE

Adherence to antiplatelet therapy is recommended but unexplored in patients with symptomatic lower extremity peripheral arterial disease (PAD). Therefore, this study aimed to determine adherence and persistence to antiplatelet therapy in patients with PAD, defined as intermittent claudication and chronic limb threatening ischaemia.

DESIGN

Population based nationwide cohort study.

METHODS

This study included all Danish citizens aged ≥ 40 years with a first inpatient or outpatient diagnosis of symptomatic PAD between 2010 - 2017, and who had at least one prescription claim for aspirin and/or clopidogrel within 90 days after diagnosis. Adherence was determined by the proportion of days covered (PDC) during the first year after diagnosis. Persistence was defined as no treatment gap ≥ 30 days between prescription renewals over three year follow up.

RESULTS

A total of 39 687 patients were eligible for inclusion, of whom 23 279 (58.7%) claimed a prescription for aspirin and/or clopidogrel within 90 days of diagnosis. Among these, 12 898 (55.4%) were prevalent users, while the remainder comprised new users who initiated the therapy after the index PAD diagnosis. The mean PDC was 74.5% (SD 35.0%) for prevalent users and 60.5% (SD 30.5%) for new users. Adherence increased with age and number of concomitant drugs. The overall one year cumulative incidence treatment discontinuation was 13.0% (95% CI 12.5 - 13.4%) overall, 17.2% (CI 16.6 - 17.9%) for prevalent users, and 7.9% (CI 7.4 - 8.4%) for new users. At three year follow up, the cumulative incidence of discontinuation was 31.5% (CI 30.9 - 32.2%) overall, 44.6% (CI 43.7 - 45.4%) for prevalent users, and 14.6% (CI 13.9 - 15.3) for new users.

CONCLUSION

Less than 60% of patients with newly diagnosed symptomatic PAD claimed a prescription for antiplatelet therapy within 90 days of diagnosis, and both adherence and persistence were moderate during the first year after diagnosis. These findings underscore the importance of efforts to improve the initiation and continuation of antiplatelet therapy in patients with PAD.

Quantitative Benefit-Risk Evaluation of Rivaroxaban in Patients After Peripheral Arterial Revascularization: The VOYAGER PAD Trial

BACKGROUND

The VOYAGER PAD (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities) trial compared rivaroxaban (2.5 mg twice a day) plus aspirin with aspirin alone in patients with symptomatic peripheral artery disease requiring endovascular or surgical limb revascularization, with 50% receiving clopidogrel background therapy. The New Drug Indication application includes benefit-risk assessments using clinical judgment to balance benefits against risks. During its review, the US Food and Drug Administration requested additional quantitative benefit-risk analyses with formal weighting approaches.

METHODS AND RESULTS

Benefits and risks were assessed using rate differences between treatment groups (unweighted analysis). To account for clinical importance of the end points, a multi-criteria decision analysis was conducted using health state utility values as weights. Monte Carlo simulations incorporated statistical uncertainties of the event rates and utility weights. Intent-to-treat and on-treatment analyses were conducted. For unweighted intent-to-treat analyses, rivaroxaban plus aspirin would result in 120 (95% CI, -208 to -32) fewer events of the primary composite end point (per 10 000 patient-years) compared with aspirin alone. Rivaroxaban caused an excess of 40 (95% CI, 8-72) Thrombolysis in Myocardial Infarction major bleeding events, which was largely driven by nonfatal, nonintracranial hemorrhage Thrombolysis in Myocardial Infarction major bleeding events. For weighted analyses, rivaroxaban resulted in the utility equivalent of 13.7 (95% CI, -85.3 to 52.6) and 68.1 (95% CI, 7.9-135.7) fewer deaths per 10 000 patient-years (intent-to-treat and on-treatment, respectively), corresponding to probabilities of 64.4% and 98.7%, respectively, that benefits outweigh risks favoring rivaroxaban per Monte Carlo simulation.

CONCLUSIONS

These analyses show a favorable benefit-risk profile of rivaroxaban therapy in the VOYAGER PAD trial, with findings generally consistent between the unweighted and weighted approaches.

External Validation of the OAC3-PAD Bleeding Score in a Nationwide Population of Patients Undergoing Invasive Treatment for Peripheral Arterial Disease

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.

The relationship between plasma atherogenic index and long-term outcomes after endovascular intervention in superficial femoral artery lesions

OBJECTIVES

Peripheral arterial disease (PAD) results from the systemic atherosclerotic process. In this study, we aimed to determine the relationship between plasma atherogenic index (AIP), a ratio of molar concentrations of triglycerides to HDL-cholesterol, and long-term outcomes after endovascular therapy (EVT) in patients with superficial femoral artery (SFA) stenosis.

METHODS

We retrospectively evaluated 673 patients who underwent EVT for PAD in our tertiary center between January 2015 and December 2020. In the receiver operating characteristic (ROC) curve analysis, the AIP value with the optimum cutoff value was determined as 0.576 to detect the presence of major adverse limb events (MALEs). Patients were divided into two groups according to low AIP (<0.576 as group 1) and high AIP (>0.576 as group 2).

RESULTS

Among the major endpoints, long-term restenosis rates were significantly higher in patients in the high-AIP group than in the low-AIP group (p<.001). The lower extremity amputation rate was not statistically significant between the two groups. All-cause mortality rate (54 (31.6) versus 117 (68.4), p<.001) was significantly higher in patients in the high-AIP group than in the low-AIP group. In addition, the MALE rate (94 (29.2) versus 218 (62.1), p<.001) was significantly higher in patients in the high-AIP group than in those in the low-AIP group.

CONCLUSIONS

In conclusion, we found that AIP is a significant independent predictor of long-term MALE in patients who underwent EVT for SFA.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Rivaroxaban plus aspirin vs. dual antiplatelet therapy in endovascular treatment in peripheral artery disease and analysis of medication utilization of different lesioned vascular regions

Background

In the management of Peripheral Arterial Disease (PAD), the administration of anticoagulant or antiplatelet agents is imperative. The use of Dual Antiplatelet Therapy (DAPT) in conjunction with rivaroxaban has shown potential in mitigating adverse outcomes. Given the heterogeneity in the pathology of lower limb arteries, there is a compelling case for individualized treatment strategies.

Methods

In a single-center retrospective study on pharmacotherapy for peripheral artery disease, patients were treated with either aspirin combined with rivaroxaban or aspirin coupled with clopidogrel. The primary efficacy outcome encompassed a composite of increases in the Rutherford classification, acute limb ischemia, amputations due to vascular causes, target lesion revascularization, myocardial infarction, ischemic stroke, and cardiovascular death. The primary safety outcome was major bleeding, as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria; meanwhile, major bleeding as categorized by the International Society on Thrombosis and Haemostasis (ISTH) served as a secondary safety outcome. The study differentiated between two subgroups: patients with only above-the-knee and below-the-knee arterial lesions.

Results

From January 2016 to December 2021, 455 patients received either clopidogrel plus aspirin or rivaroxaban plus aspirin following endovascular treatment (EVT). The rivaroxaban group (n = 220) exhibited a lower incidence of primary efficacy outcomes [49.1% vs. 60.4%, hazard ratio (HR) 0.77, P = 0.006] but had more TIMI major bleeding events (5.9% vs. 2.1%, HR 2.6, P = 0.04). ISTH major bleeding events did not show a significant difference, though a higher percentage of rivaroxaban patients discontinued medication due to bleeding (10% vs. 4.7%, HR 2.2, P = 0.03). In the above-the-knee arterial disease subgroup, the rivaroxaban group demonstrated a lower incidence of primary efficacy outcomes (28.2% vs. 45.2%, HR 0.55, P = 0.02). In the below-the-knee arterial disease subgroup, no significant difference was observed in the occurrence of primary efficacy events between the two groups (58.7% vs. 64.8%, HR 0.76, P = 0.14).

Conclusion

Rivaroxaban plus aspirin improved outcomes compared to DAPT in patients with lower extremity artery disease. Similar findings were observed in the above-the-knee artery lesion-only group. However, in the below-the-knee artery lesion-only group, rivaroxaban plus aspirin did not surpass DAPT in efficacy. Regarding safety, rivaroxaban plus aspirin exhibited higher bleeding risks and more frequent treatment discontinuation than aspirin combined with clopidogrel.

Oral factor Xa inhibitor underutilization following lower extremity peripheral vascular intervention

OBJECTIVE

Patients undergoing peripheral vascular intervention (PVI) (ie, endovascular revascularization) for symptomatic lower extremity peripheral artery disease remain at high risk for major adverse limb and cardiovascular events. High-quality evidence demonstrates the addition of a low-dose oral factor Xa inhibitor to single antiplatelet therapy, termed dual pathway inhibition (DPI), reduces the incidence of major adverse events in this population. This study aims to describe the longitudinal trends in factor Xa inhibitor initiation after PVI, identify patient and procedural characteristics associated with factor Xa inhibitor use, and describe temporal trends in antithrombic therapy post-PVI before vs after VOYAGER PAD.

METHODS

This retrospective cross-sectional study was performed using data from the Vascular Quality Initiative PVI registry from January 2018 through June 2022. Multivariate logistic regression was utilized to determine predictors of factor Xa inhibitor initiation following PVI, reported as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

A total of 91,569 PVI procedures were deemed potentially eligible for factor Xa inhibitor initiation and were included in this analysis. Overall rates of factor Xa inhibitor initiation after PVI increased from 3.5% in 2018 to 9.1% in 2022 (P < .0001). The strongest positive predictors of factor Xa inhibitor initiation after PVI were non-elective (OR, 4.36; 95% CI, 4.06-4.68; P < .0001) or emergent (OR, 8.20; 95% CI, 7.14-9.41; P < .0001) status. The strongest negative predictor was postoperative dual antiplatelet therapy prescription (OR, 0.20; 95% CI, 0.17-0.23; P < .0001), highlighting significant hesitation about use of DPI after PVI and limited translation of VOYAGER PAD findings into clinical practice. Antiplatelet medications remain the most common antithrombotic regimen after PVI, with almost 70% of subjects discharged on dual antiplatelet therapy and approximately 20% discharged on single antiplatelet therapy.

CONCLUSIONS

Factor Xa inhibitor initiation after PVI has increased in recent years, although the absolute rate remains low, and most eligible patients are not prescribed this treatment.

Long-Term Patient Outcomes After Femoropopliteal Peripheral Vascular Intervention in Patients With Intermittent Claudication

BACKGROUND

In patients with intermittent claudication (IC), short-term amputation rates from clinical trial data following lower extremity femoropopliteal (FP) peripheral vascular intervention (PVI) are <1% with unknown longer-term rates.

OBJECTIVES

The aim of this study was to identify revascularization and amputation rates following PVI in the FP segment and to assess 4-year amputation and revascularization rates after FP PVI for IC.

METHODS

From 2016 to 2020, 19,324 patients undergoing FP PVI for IC were included from the PINC AI Healthcare Database and evaluated by treatment level (superficial femoral artery [SFA], popliteal artery [POP], or both). The primary outcome was index limb amputation (ILA) assessed by Kaplan-Meier estimate. The secondary outcomes were index limb major amputation and repeat revascularization. HRs were estimated using Cox proportional hazard regression.

RESULTS

The 4-year index limb amputation rate following FP PVI was 4.3% (95% CI: 4.0-4.7), with a major amputation rate of 3.2% (95% CI: 2.9-3.5). After POP PVI, ILA was significantly higher than SFA alone (7.5% vs 3.4%) or both segment PVI (5.5%). In multivariate analysis, POP PVI was associated with higher ILA rates at 4 years compared with isolated SFA PVI (HR: 2.10; 95% CI: 1.52-2.91) and index limb major amputation (HR: 1.98; 95% CI: 1.32-2.95). Repeat FP revascularization rates were 15.2%; they were highest in patients undergoing both SFA and POP PVI (18.7%; P < 0.0001) compared with SFA (13.9%) and POP (17.1%) only.

CONCLUSIONS

IC patients undergoing FP PVI had 4-year rates of index limb repeat revascularization of 16.7% and ILA rates of 4.3%. Further risk factors for amputation requires further investigation.

Catheter Directed Thrombolysis for Not Immediately Threatening Acute Limb Ischaemia: Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis reports the outcomes of catheter directed thrombolysis (CDT) in patients with not immediately threatening (Rutherford I) acute lower limb ischaemia (ALI).

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

A systematic search of PubMed, Embase, and the Cochrane Library was performed to identify observational studies and trials published between 1990 and 2022 reporting on the results of CDT in patients with Rutherford I ALI. A meta-analysis was performed using a random effects model with 95% confidence intervals (CIs). The outcomes of interests were treatment duration, angiographic success, bleeding complications, amputation and mortality rates, primary and secondary patency, and functional outcome expressed as pain free walking distance.

RESULTS

Thirty-nine studies were included, comprising 1 861 patients who received CDT for not immediately threatening ALI. Funnel plots showed an indication of publication bias, and heterogeneity was substantial. Data from 5 to 13 studies were included in the meta-analysis. The pooled treatment duration was 2 days (95% CI 1 - 2), with an angiographic success rate of 80% (95% CI 73 - 86) and a 30 day freedom of amputation rate of 98% (95% CI 92 - 100). The major bleeding rate was 5% (95% CI 2 - 14), with a 30 day mortality rate of 3% (95% CI 1 - 5). The amputation free survival rate was 71% (95% CI 62 - 80) at the one year and 63% (95% CI 51 - 73) at the three year follow up. Long term patency rates were retrieved from four studies: 48% at one year (95% CI 27 - 70). No data could be retrieved on patient walking distance.

CONCLUSION

Although CDT in the treatment of not immediately threatening ALI showed high angiographic success, the long term outcomes were relatively poor, with low patency and a substantial risk of major amputation. Further research is required to interpret the outcome of CDT in the context of potential confounders such as age and comorbidities.

Patient Characteristics in the Recording Courses of Vascular Diseases (Reccord) Registry: Comparison with the Voyager Pad Endovascular Cohort

Background: To compare the characteristics of a “real world” population included in a prospective registry to patients enrolled in a randomized, controlled trial (RCT) after endovascular revascularization (EVR) for symptomatic peripheral artery disease (PAD). Methods: The RECcording COurses of vasculaR Diseases (RECCORD) registry is an observational registry prospectively recruiting patients undergoing EVR for symptomatic PAD in Germany. VOYAGER PAD was an RCT which demonstrated the superiority of rivaroxaban and aspirin versus aspirin to reduce major cardiac and ischemic limb events following infrainguinal revascularization for symptomatic PAD. For this exploratory analysis, the clinical characteristics of 2.498 patients enrolled in RECCORD and of 4.293 patients from VOYAGER PAD who underwent EVR were compared. Results: The rate of patients aged ≥ 75 years was considerably higher in the registry (37.7 vs. 22.5%). More patients in the registry had undergone previous EVR (50.7 vs. 38.7%) or suffered from critical limb threatening ischemia (24.3 vs. 19.5%). Registry patients were more commonly active smokers (51.8 vs. 33.6%), but less frequently suffered from diabetes mellitus (36.4 vs. 44.7%). While statins (70.5 vs. 81.7%) were less frequently used, antiproliferative catheter technologies (45.6 vs. 31.4%) and postinterventional dual antiplatelet therapy (64.5 vs. 53.6%) were more commonly applied in the registry. Conclusions: There were many similarities but some clinically meaningful differences in clinical characteristics between PAD patients who underwent EVR and were included in a nationwide registry and PAD patients from the VOYAGER PAD trial.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A multicenter, randomized, open-labelled, non-inferiority trial of sustained-release sarpogrelate versus clopidogrel after femoropopliteal artery intervention

Optimal antiplatelet therapy after endovascular therapy (EVT) for peripheral artery disease is controversial. This trial aimed to evaluate whether sarpogrelate plus aspirin was non-inferior for preventing early restenosis after femoropopliteal (FP) EVT compared to clopidogrel plus aspirin. In this open-label, prospective randomized trial, 272 patients were enrolled after successful EVT for FP lesions. Patients in each group received aspirin 100 mg and clopidogrel 75 mg or sarpogrelate 300 mg orally once per day for 6 months. The primary outcome was target lesion restenosis at 6 months, tested for noninferiority. Patient characteristics and EVT patterns were similar, except for increased inflow procedures in the sarpogrelate group and increased outflow procedures in the clopidogrel group. The sarpogrelate group showed a tendency of less restenosis at 6 months than the clopidogrel group (13.0% vs. 19.1%, difference 6.1 percentage points, 95% CI for noninferiority - 0.047 to 0.169). Secondary endpoints related to safety outcomes were rare in both groups. Risks of target lesion restenosis of the two intervention arm were uniform across most major subgroups except for those with coronary artery disease. In conclusion, Sarpogrelate plus aspirin is non-inferior to clopidogrel plus aspirin in preventing early restenosis after FP EVT. Larger multi-ethnic trials are required to generalize these findings. Trial registration: National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier: NCT02959606; 09/11/2016).

LATE RESULTS OF TREATING PATIENTS WITH OCCLUSIVE-STENOTIC LESIONS OF THE AORTA INFRARENAL SEGMENT'S MAIN ARTERIES

OBJECTIVE

The aim: To analyze the results of surgical treatment in the late postoperative period after using modern types of surgical technologies for occlusive-stenotic atherosclerotic lesions of the infrarenal aorta's main arteries.

PATIENTS AND METHODS

Materials and methods: The total of 420 patients were operated on. The patient's age ranged from 45 to 87 years (in the mean, 66.7±2.3 years). Men pre¬dominated - 375 (89.29%), and women were 45 (10.71%). According to the ischemia classification by Rutherford - 324 (77%) patients fell under categories 4, 5, 6 of the classification. 98 patients were operated on by the open method, 243 by the endovascular method, and 79 by the hybrid method. We assessed such indices as: postoperative thrombosis, limb amputations, mortality, and repeated operations performed due to complications or unsuccessful results of the primary operation.

RESULTS

Results: It was ascertained, a decrease in the number of postoperative complications from 7.87% to 4.39% (t=2,11, p=0,035), repeated operations - from 7.87% to 4.39% (t=2,11, p=0,035), amputations - from 3.63% to 2.19% (t=1,24, p=0,214) and mortality - from 3.03% to 1.09% (t=2,03, p=0,042) in the group where in-depth examination methods were applied, a treatment algorithm based on individual anatomical and hemodynamic features was implemented, techniques for performing operations were improved.

CONCLUSION

Conclusions: The analysis of late results of surgical interventions showed that the largest number of complications was found in the group of patients with multistory occlusive-stenotic lesions of arteries.

Bleeding Risk in Patients with Peripheral Arterial Disease

Patients with peripheral arterial disease (PAD) are at high risk of major adverse cardiac events (MACE) and major adverse limb events (MALE). Recently, antithrombotic therapies employing antiplatelet and anticoagulant drugs have proven to be valid in reducing MACE in patients with PAD and polyvascular disease and MALE, particularly in patients who have already been revascularized and remain at increased risk of MALE. However, more aggressive antithrombotic therapies lead to an increased risk of bleeding. Antithrombotic therapy and revascularization procedures entail an increased hemorrhagic risk that is also linked to having received more vigorous antithrombotic therapies. Therefore, it appears crucial to have specifically targeted scores for a PAD patient to assess bleeding and thrombotic risks. The correct utilization of a risk score will determine the variable risk factors for bleeding that can be corrected or modified, as well as identify patients at high risk that require regular reexamination and follow-up. Clinical risk scores do not represent the absolute reality, and inter-score variability must be taken into account. Moreover, several risk scores have been created to be basic and to facilitate and improve clinical decisions in daily practice. Many risk scores based on points vary according to the configuration of the studies, population type, and ethnic group, and many of the risk factor elements in a specific score are unlikely to sustain same weight for that risk. The best approach continues to be devising an uncomplicated, functional, validated, and precise score that can be adjusted to different clinical contexts and populations, while considering the mutable composition of clinical risk.

Association of Lipoprotein(a) Levels With Incidence of Major Adverse Limb Events

IMPORTANCE

High lipoprotein(a) (Lp[a]) levels are involved in the development of cardiovascular events, particularly in myocardial infarction, stroke, and peripheral artery disease. Studies assessing the Lp(a) levels associated with adverse lower-limb events are lacking.

OBJECTIVE

To assess the association between Lp(a) levels and incidence of major adverse limb events in unselected hospitalized patients.

DESIGN, SETTING, AND PARTICIPANTS

This large retrospective monocentric cohort study was conducted from January 1, 2000, to December 31, 2020. Data were derived from the clinical information system of the Hôpital Européen Georges-Pompidou, a Paris-based university hospital. Patients who underwent at least 1 Lp(a) measurement at the center during the study period were included. Patients who had no follow-up data or who had the first Lp(a) measurement after the study outcome had occurred were excluded. Data analyses were performed from May 2021 to January 2022.

MAIN OUTCOMES AND MEASURES

The primary outcome was the first inpatient major adverse limb event, defined as a major amputation, peripheral endovascular revascularization, or peripheral surgical revascularization, during follow-up. Secondary outcomes included individual components of the primary outcome. Lipoprotein(a) levels were categorized as follows: normal (<50 mg/dL), high (50 to <134 mg/dL), and very high (≥134 mg/dL); to convert Lp(a) values to milligrams per liter, multiply by 0.1.

RESULTS

A total of 16 513 patients (median [IQR] age, 58.2 [49.0-66.7] years; 9774 men [59.2%]) were included in the cohort. The median (IQR) Lp(a) level was 24 (10.0-60.0) mg/dL. The 1-year incidence of major adverse limb event was 2.44% in the overall population and 4.54% among patients with very high Lp(a) levels. High (adjusted accelerated failure time [AFT] exponential estimate: 0.43; 95% CI, 0.24-0.78; Benjamini-Hochberg-corrected P = .01) and very high (adjusted AFT exponential estimate: 0.17; 95% CI, 0.07-0.40; Benjamini-Hochberg-corrected P < .001) Lp(a) levels were independently associated with an increased risk of major adverse limb event.

CONCLUSIONS AND RELEVANCE

Results of this study showed that higher Lp(a) levels were independently associated with an increased risk of a major adverse limb event in hospitalized patients. The Lp(a) measurement needs to be taken into account to improve lower-limb vascular risk assessment.

Management of Peripheral Arterial Disease: Lifestyle Modifications and Medical Therapies

Peripheral artery disease (PAD) commonly refers to atherosclerotic narrowing of noncoronary arteries, primarily those supplying the lower extremities. The risk factors for PAD include smoking, hyperlipidemia, hypertension, and diabetes mellitus. Patients with PAD are at a heightened risk of major adverse cardiovascular events (including myocardial infarction, stroke, and cardiovascular death) and major adverse limb events (including progressive symptoms or limb ischemia requiring peripheral revascularization, amputation, and acute limb ischemia), highlighting the need for guideline-directed therapies. Lifestyle modifications and medical therapies are utilized to improve function and outcomes in this patient population. Adherence to a healthy diet and smoking cessation are both associated with better outcomes in patients with PAD. Medical therapies targeting axes of risk, including lipid-modifying therapies, antithrombotic therapies, and targeted diabetes therapies, are available to reduce this risk in patients with PAD; however, significant residual risk remains. Unfortunately, despite guideline recommendations and efforts at education, even available medical therapies remain underutilized in patients with PAD. Continued development of novel therapies and efforts to improve the provision of care in patients with PAD are needed.

Intravascular ultrasound in peripheral venous and arterial interventions: A contemporary systematic review and grading of the quality of evidence

Although angiography has been the primary imaging modality used in peripheral vascular intervention, this technique has major limitations due to the evaluation of three-dimensional vessels in two dimensions. Intravascular ultrasound (IVUS) is an important adjunctive tool that can address some of these limitations. This systematic review assesses the appropriateness of IVUS as an imaging modality for guiding peripheral intervention through evidence collection and clinical appraisal of studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a cohort of 48 studies (29 arterial; 19 venous) detailing IVUS use in peripheral vascular intervention were extracted. Qualitative assessment of the studies evaluated pre- and postprocedure efficacy of IVUS and revealed that IVUS-guided peripheral intervention in arterial and venous diagnosis and treatment was superior to other imaging techniques alone. Each study in the cohort was further assessed for reliability and validity using the Oxford Centre for Evidence Based Medicine (CEBM) level of evidence scale. The majority of both arterial (79.3%) and venous (73.7%) studies received a 2b rating, the second highest level of evidence rating. The evidence to date indicates that IVUS results in better clinical outcomes overall and should be more widely adopted as an adjunctive imaging modality during peripheral intervention. (PROSPERO Registration No.: CRD42021232353).

High Rates of Recurrent Revascularization in Acute Limb Ischemia - a National Surgical Quality Improvement Program Study

OBJECTIVES

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI.

METHODS

A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012-2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection.

RESULTS

2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. 13.8% required reoperation and 7.9% required readmission within 30 days. 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. 58.7% of patients were female and either overweight or obese. Younger age (OR 0.991 [0.984-0.999], p=0.02), underweight patients (OR 1.159 [0.667-2.01], p=0.05), pre-operative steroid use (OR 1.61 [1.07-2.41], p=0.02), and perioperative transfusion (OR 2.02 [1.04-3.95], p=0.04) predicted reoperations.

CONCLUSIONS

This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.

Clinical experience with dual pathway inhibition therapy: case series and mini review

Background

Dual pathway inhibition (DPI) with rivaroxaban 2.5 mg twice daily plus aspirin has demonstrated reductions in major adverse cardiovascular and limb events in eligible patients with chronic coronary artery disease (CAD), peripheral artery disease, or both. Patients with polyvascular disease, heart failure, renal impairment, or diabetes can benefit particularly from this therapy. We present our clinical experience to elucidate practical issues regarding the selection of patients eligible for DPI and the timing of initiation.

Case summary

The first patient was at high risk of recurrent cardiovascular events due to his history of multi-vessel CAD, myocardial infarction, heart failure, and diabetes. Following a period of post-myocardial infarction dual antiplatelet therapy, he was transitioned to DPI therapy. The second patient was at high risk of cardiovascular events due to his history of polyvascular disease, diffuse CAD, and diabetes. He was hospitalized for unstable angina, which was medically managed because no target lesion was identified. DPI was initiated a day after admission. The third patient was at high risk of cardiovascular events due to an extensive history of polyvascular disease, revascularization, and renal impairment. Although the patient was asymptomatic at routine follow-up, DPI was initiated to reduce the risk of further cardiovascular events.

Discussion

In eligible patients who are at high risk of cardiovascular events, DPI therapy with low-dose rivaroxaban should be considered. Treatment can be started at various times, including at the end of dual antiplatelet therapy, at routine follow-up, or after new events or diagnoses.

Clinical Outcomes after Endovascular Revascularisation of the Femoropopliteal Arterial Segment in Patients with Anticoagulant versus Antiplatelet Therapy: A Single-Centre Retrospective Cohort Study

To prevent atherothrombotic events, patients with peripheral arterial disease are typically prescribed antiplatelet therapy (APT). However, some of them receive anticoagulant therapy (ACT) due to comorbidities. Our aim was to determine possible differences in the effectiveness and safety of both treatments in patients after endovascular femoropopliteal revascularisation. We retrospectively analysed 1247 patients after successful femoropopliteal revascularisation performed in a single tertiary medical centre and classified them into the ACT or APT group, based on their prescribed treatment. The groups were characterised by descriptive statistics, and their characteristics were adjusted for confounders by propensity score matching. Effectiveness and safety outcomes were assessed within one year after revascularisation. The odds ratio for the composite outcome of all-cause death, PAD exacerbation, and major amputation due to vascular causes with ACT versus APT was 1.21 (95% CI 0.53–2.21; p = 0.484). The odds ratio for major bleeding as defined by the International Society on Thrombosis and Haemostasis with ACT versus APT was 0.77 (95% CI 0.13–3.84; p = 0.251). We found no statistically significant difference in the effectiveness and safety of ACT, when compared to APT in patients with similar cardiovascular risk factors and other baseline characteristics. Further prospective research is warranted.

Assessment of the burden of disease for patients with peripheral artery disease undergoing revascularization in England

Background: Symptoms, severity, and acuteness of peripheral artery disease (PAD) are major determinants of severe limb symptoms, subsequent risk of cardiovascular events, and mortality. Lower-extremity revascularization (LER) is a key option to relieve symptoms and to prevent limb loss in symptomatic patients with PAD. This study aimed to quantify the burden of disease among patients with PAD-LER in England. Methods: A retrospective population-based study of linked primary and secondary care electronic health records, included 13,869 adult patients (aged ⩾ 18 years) with PAD-LER from 2003 to 2018. The incidence of first ever PAD-LER was estimated both overall and by type of procedure (endovascular/surgical). Health resource utilization associated with PAD-related complications and treatment patterns were assessed. Results: A high annual incidence of lower-limb revascularization (41.2 per 1000 person years) and a nearly double incidence of endovascular first revascularization compared with open surgery were observed. More than 70% of patients with PAD-LER had a history of hyperlipidemia and hypertension and roughly one-third were diabetic and had a history of coronary artery disease. Cardiovascular mortality accounted for one-third (34.1 per 1000 person years) of all-cause mortality. Over 93% of patients were hospitalized for any reason and the commonest reasons for hospitalization were cardiovascular diseases and PAD with about one-third hospitalized for revascularization reoccurrence. Conclusion: There is a significant burden of PAD-LER to the individual and society with ongoing healthcare resource utilization, treatment, and increasing mortality.

Rivaroxaban and Risk of Venous Thromboembolism in Patients With Symptomatic Peripheral Artery Disease After Lower Extremity Revascularization

IMPORTANCE

Prior studies have observed an association between the burden of atherosclerotic vascular disease and the risk of venous thromboembolism (VTE). The association is not well described in peripheral artery disease (PAD) after lower extremity revascularization (LER).

OBJECTIVE

To describe the risk of, factors associated with, and outcomes after VTE, as well as the association of low-dose rivaroxaban plus antiplatelet therapy with VTE after LER.

DESIGN, SETTING, AND PARTICIPANTS

This global, multicenter cohort study used data from the Vascular Outcomes Study of ASA (acetylsalicylic acid) Along With Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD (VOYAGER PAD) randomized clinical trial, which enrolled patients from 2015 to 2018 with median follow-up of 28 months. Participants included patients with PAD undergoing LER. Patients with an indication for therapeutic anticoagulation were excluded. Data were analyzed from September 2020 to September 2021.

EXPOSURE

Randomization to rivaroxaban 2.5 mg twice daily or placebo on a background of aspirin 100 mg daily; short-term clopidogrel was used at the discretion of the treating physician.

MAIN OUTCOMES AND MEASURES

Symptomatic VTE was a prespecified secondary outcome and prospectively collected.

RESULTS

Among 6564 patients (median [IQR] age, 67 [61-73] years; 4860 [74.0%] men), 66 patients had at least 1 VTE. The 3-year rate of VTE in patients receiving placebo was 1.7%, and the pattern of risk was linear (year 1: 0.5%; year 2: 1.1%). After multivariable modeling, weight (hazard ratio [HR], 3.04; 95% CI, 1.09-8.43), hypertension (HR, 2.11; 95% CI, 0.91-4.89), prior amputation (HR, 2.07; 95% CI, 0.95-4.53), and older age (HR, 1.81; 95% CI, 1.06-3.11) were associated with increased risk of VTE. VTE was associated with risk of subsequent mortality (HR, 7.22; 95% CI, 4.66-11.19). Compared with aspirin alone, rivaroxaban plus aspirin was associated with lower VTE risk (HR, 0.61; 95% CI, 0.37-0.998; P = .047), with benefit apparent early and sustained over time. This association was not modified by use of clopidogrel at randomization (without clopidogrel: HR, 0.55; 95% CI, 0.29-1.07; with clopidogrel: HR, 0.69; 95% CI, 0.32-1.48; P for interaction = .67).

CONCLUSIONS AND RELEVANCE

In this cohort study, there was continuous risk for VTE after LER in patients with PAD, with greater risk in patients who were older and had obesity and those with more severe PAD, as reflected by prior amputation. Low-dose rivaroxaban plus aspirin was associated with lower VTE risk compared with aspirin alone, with benefits apparent early and continued over time. The spectrum of venous and arterial thrombotic events and overall benefits of more potent antithrombotic strategies for prevention should be considered after LER for PAD.

Mono or Dual Antiplatelet Therapy for Treating Patients with Peripheral Artery Disease after Lower Extremity Revascularization: A Systematic Review and Meta-Analysis

The efficacy of dual antiplatelet therapy (DAPT) for patients with peripheral artery disease (PAD) after lower-limb intervention remains controversial. Currently, the prescription of DAPT after an intervention is not fully recommended in guidelines due to limited evidence. This study compares and analyzes the prognosis for symptomatic PAD patients receiving DAPT versus monotherapy after lower-limb revascularization. Up to November 2021, PubMed/MEDLINE, Embase, and Cochrane databases were searched to identify studies reporting the efficacy, duration, and bleeding complications when either DAPT or monotherapy were used to treat PAD patients after revascularization. Three randomized controlled trials and seven nonrandomized controlled trials were included in our study. In total, 74,651 patients made up these ten studies. DAPT in PAD patients after intervention was associated with lower rates of all-cause mortality (HR = 0.86; 95% CI, 0.79−0.94; p < 0.01), major adverse limb events (HR = 0.60; 95% CI, 0.47−0.78; p < 0.01), and major amputation (HR = 0.78; 95% CI, 0.64−0.96) when follow-up was for more than 1-year. DAPT was not associated with major bleeding events when compared with monotherapy (OR = 1.22; 95% CI, 0.69−2.18; p = 0.50) but was associated with a higher rate of minor bleeding as a complication (OR = 2.54; 95% CI, 1.59−4.08; p < 0.01). More prospective randomized studies are needed to provide further solid evidence regarding the important issue of prescribing DAPT.

Prevention of arterial and venous thrombotic events in symptomatic peripheral arterial disease patients after lower extremity revascularization in the VOYAGER PAD trial: Dual anticoagulant/antiplatelet regimen vs antiplatelet therapy alone

BACKGROUND

Vascular disease burden after lower extremity revascularization (LER) comprises more than the first event, more vascular beds than the local arteries, and more than one clinical event type.

OBJECTIVES

Assess total arterial and venous thrombotic burden after LER for symptomatic peripheral artery disease (PAD) and effect of low-dose anticoagulation added to low-dose antiplatelet therapy.

PATIENTS/METHODS

VOYAGER PAD randomized 6564 symptomatic PAD patients undergoing LER to rivaroxaban 2.5 mg twice-daily or placebo on aspirin background. Marginal proportional-hazards models used to generate treatment hazard ratios and associated 95% CIs for first and total events; non-thrombotic deaths treated as competing terminal events. Incidence rates calculated as number of events per 100 patient-years follow-up.

RESULTS

Over 2.5 years (median), first and total thrombotic event rates: 7.1 and 10.3 events/100 patient-years, respectively, in placebo group. Two-thirds (925/1372) of total thrombotic events (arterial 95%, venous 5%) were nonfatal first events. Nearly one-third of patients with first event had a second arterial or venous thrombotic event. Rivaroxaban plus aspirin reduced first and total arterial and venous thrombotic events to 5.4 and 7.9 events/100 patient-years, respectively, a reduction in total thrombotic events over aspirin of 23% (HR: 0.77, 95%CI: 0.67-0.89, p = .0005), preventing 6.1 total arterial and venous thrombotic events at 3 years.

CONCLUSIONS

Assessing total arterial and venous thrombotic events, not just first events, provides more complete information about disease burden and absolute on-treatment impact. Following LER, judicious modulation of more than one coagulation pathway can provide broader benefit than intensifying inhibition of one hemostatic system component.

Comorbid Depression is Associated with Increased Major Adverse Limb Events in Peripheral Arterial Disease: A systematic review and meta-analysis

OBJECTIVE

Depression is a significant risk factor for mortality in coronary artery disease. On the contrary, the research surrounding depression and peripheral arterial disease is limited. This review aims to systematically evaluate the available literature on the impact of comorbid depression on adverse outcomes in peripheral arterial disease.

DATA SOURCES

A systematic review and meta-analysis were performed using the following databases: MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Library from inception until July 2021.

REVIEW METHODS

Included studies compared depressed and non-depressed patients with peripheral arterial disease. The outcomes included mortality, major adverse cardiovascular events, and major adverse limb events.

RESULTS

A total of 9 297 articles were searched. Of these, seven studies were identified. Depressed patients were more likely to be women, be diabetic, have a history of smoking, and have chronic limb threatening ischemia, despite being younger than non-depressed patients. There was a 20% increase in major adverse limb events in depressed patients [RR 1.20, 95% CI (1.11 - 1.31), z =3.9, p<.001, GRADE strength: very low] but no increased risk of mortality [RR 1.03, 95% CI (0.72-1.40), z =0.06, p =.95. GRADE strength: very low] or major adverse cardiovascular events [RR 1.16, 95% CI (0.67 - 2.01), z =0.54, p =.59, GRADE strength: very low]. A follow-up meta-regression of various comorbidities and demographic variables did not demonstrate a significant contribution to the observed risk ratio for major adverse limb events.

CONCLUSION

Depression was reported in 13% of peripheral arterial disease patients, associated with more medical comorbidity, and a 20% increased risk of major adverse limb events. Although the strength of this evidence is very low, the current state of the literature is still limited. Future studies should prospectively assess the impact of depression and its relationship with medical comorbidities and high risk health behaviors.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Inflammation as a mechanism and therapeutic target in peripheral artery disease

Peripheral artery disease is one of three major clinical manifestations of atherosclerosis, the other two being coronary artery and cerebrovascular disease. Despite progress in surgery, antithrombotic therapy and therapies that modify conventional risk factors (lipid-, blood pressure-, and glucose-lowering interventions), patients with peripheral artery disease have unacceptably high risk of vascular complications. Additional strategies to reduce this residual risk are needed. The accumulated evidence that inflammation plays an important role in the pathogenesis of atherosclerosis has spurred recent efforts to evaluate anti-inflammatory agents as an additional therapeutic approach for atherothrombosis prevention and treatment. In this review, we examine the evidence supporting the role of inflammation in atherosclerosis, review recent trials evaluating anti-inflammatory approaches to reduce cardiovascular complications, and offer insights into the opportunities for novel anti-inflammatory strategies to reduce the burden of cardiovascular and limb complications in patients with peripheral artery disease.

Revascularisation for Symptomatic Peripheral Artery Disease: External Applicability of the VOYAGER PAD Trial

OBJECTIVE

In the VOYAGER PAD trial, rivaroxaban 2.5 mg plus aspirin significantly reduced the primary composite efficacy outcome of acute limb ischaemia, major amputation, myocardial infarction, ischaemic stroke, or cardiovascular death compared with aspirin alone. However, patients enrolled in the trial may not reflect patients encountered in daily clinical practice. This study described the proportion of patients eligible for VOYAGER PAD within the nationwide Danish Vascular Registry (DVR), reasons for ineligibility, and outcomes according to eligibility.

METHODS

In total, 32 911 patients who underwent lower extremity revascularisation for symptomatic peripheral arterial disease (PAD) in the DVR (2000-2016) were identified. Trial inclusion and exclusion criteria were applied, and the three year cumulative incidence of primary and secondary trial outcomes was estimated.

RESULTS

Altogether, 27.1% of patients with PAD in the DVR were "VOYAGER eligible". Of those not included, 30.7% had at least one exclusion criterion ("VOYAGER excluded"), and an additional 42.3% did not fulfil the inclusion criteria ("VOYAGER not included"). The main reasons for exclusion were atrial fibrillation (32.3%), poorly regulated hypertension (20.6%), requirement for long term dual antiplatelet therapy (10.9%), cytochrome P450 inhibitors or inducers (9.7%), and renal failure (9.3%). The three year rate of the primary efficacy outcome was 10.08 per 100 person years among the "VOYAGER eligible", 16.32 among "VOYAGER excluded", and 6.98 among the "VOYAGER not included". For the primary safety outcome of thrombolysis in myocardial infarction (TIMI) major bleeding, rates were 2.24, 3.76, and 1.17, respectively. Rates of secondary endpoints were also consistently lower for patients who did not meet the inclusion criteria (predominantly due to central aorto-iliac procedures) and highest for "VOYAGER excluded" patients. "VOYAGER eligible" patients experienced a higher cumulative incidence of most endpoints than patients enrolled in the control arm of the VOYAGER PAD trial.

CONCLUSION

Among patients in routine clinical practice, 27.1% were eligible for the VOYAGER PAD trial. These patients were older, had more severe vascular symptoms, higher bleeding risk, and worse prognosis than trial participants.

Buyang Huanwu Decoction Enhances Revascularization via Akt/GSK3β/NRF2 Pathway in Diabetic Hindlimb Ischemia

Background

Peripheral arterial disease (PAD) is a typical disease of atherosclerosis, most commonly influencing the lower extremities. In patients with PAD, revascularization remains a preferred treatment strategy. Buyang Huanwu decoction (BHD) is a popular Chinese herbal prescription which has showed effects of cardiovascular protection through conducting antioxidant, antiapoptotic, and anti-inflammatory effects. Here, we intend to study the effect of BHD on promoting revascularization via the Akt/GSK3β/NRF2 pathway in diabetic hindlimb ischemia (HLI) model of mice.

Materials and Methods

All db/db mice (n = 60) were randomly divided into 6 groups by table of random number. (1) Sham group (N = 10): 7-0 suture thread passed through the underneath of the femoral artery and vein without occlusion. The remaining 5 groups were treated differently on the basis of the HLI (the femoral artery and vein from the inguinal ligament to the knee joint were transected and the vascular stump was ligated with 7-0 silk sutures) model: (2) HLI+NS group (N = 15): 0.2 ml NS was gavaged daily for 3 days before modeling and 14 days after occlusion; (3) HLI+BHD group (N = 15): 0.2 ml BHD (20 g/kg/day) was gavaged daily for 3 days before modeling and 14 days after occlusion; (4) HLI+BHD+sh-NC group (N = 8): local injection of adenovirus vector carrying the nonsense shRNA (Ad-GFP) in the hindlimbs of mice before treatment; (5) HLI+BHD+sh-NRF2 group (N = 8): knockdown of NRF2 in the hindlimbs of mice by local intramuscular injection of adenovirus vector carrying NRF2 shRNA (Ad-NRF2-shRNA) before treatment; and (6) HLI+BHD+LY294002 group (N = 4): intravenous injection of LY294002 (1.5 mg/kg) once a day for 14 days on the basis of the HLI+BHD group. Laser Doppler examination, vascular cast, and immunofluorescence staining were applied to detect the revascularization of lower limbs in mice. Western blot analysis was used to detect the expression of vascular endothelial growth factor (VEGF), interleukin-1beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor- (TNF-) α, heme oxygenase-1 (HO-1), NAD(P)H dehydrogenase quinone-1 (NQO-1), catalase (CAT), glyceraldehyde-3-phosphate dehydrogenase (GAPDH), phosphorylated protein kinase B (p-AKT), and phosphorylated glycogen synthase kinase-3 beta (p-GSK3β). HE staining was used to assess the level of muscle tissue damage and inflammation in the lower extremities. Local multipoint injection of Ad-NRF2-shRNA was used to knock down NRF2, and qPCR was applied to detect the mRNA level of NRF2. The blood glucose, triglyceride, cholesterol, MDA, and SOD levels of mice were tested using corresponding kits. The SPSS 20.0 software and GraphPad Prism 6.05 were used to do all statistics. Values of P < 0.05 were considered as statistically significant. Results and Conclusions. BHD could enhance the revascularization of lower limbs in HLI mice, while BHD has no effect on blood glucose and lipid level in db/db mice (P > 0.05). BHD could elevate the protein expression of VEGF, HO-1, NQO-1, and CAT (P < 0.05) and decrease the expression of IL-1β, IL-6, and TNF-α (P < 0.05) in HLI mice. Meanwhile, BHD could activate NRF2 and promote the phosphorylation of AKT/GSK3β during revascularization (P < 0.05). In contrast, knockdown of NRF2 impaired the protective effects of BHD on HLI (P < 0.05). LY294002 inhibited the upregulation of NRF2 activated by BHD through inhibiting the phosphorylation of the AKT/GSK3β pathway (P < 0.05). The present study demonstrated that BHD could promote revascularization on db/db mice with HLI through targeting antioxidation, anti-inflammation, and angiogenesis via the AKT/GSK3β/NRF2 pathway.

High lipoprotein(a) is associated with major adverse limb events after femoral artery endarterectomy

BACKGROUNDS AND AIMS

Elevated lipoprotein(a) (Lp[a]) has been identified as a causal risk factor for cardiovascular disease including peripheral arterial disease (PAD). Although Lp(a) is associated with the diagnosis of PAD, it remains elusive whether there is an association of Lp(a) with cardiovascular and limb events in patients with severe PAD.

METHODS

Preoperative plasma Lp(a) levels were measured in 384 consecutive patients that underwent iliofemoral endarterectomy and were included in the Athero-Express biobank. Our primary objective was to assess the association of Lp(a) levels with Major Adverse Limb Events (MALE). Our secondary objective was to relate Lp(a) levels to Major Adverse Cardiovascular Events (MACE) and femoral plaque composition that was acquired from baseline surgery.

RESULTS

During a median follow-up time of 5.6 years, a total of 225 MALE were recorded in 132 patients. Multivariable analysis, including history of peripheral intervention, age, diabetes mellitus, end stage renal disease and PAD disease stages, showed that Lp(a) was independently associated with first (HR of 1.36 (95% CI 1.02-1.82) p = .036) and recurrent MALE (HR 1.36 (95% CI 1.10-1.67) p = .004). A total of 99 MACE were recorded but Lp(a) levels were not associated with MACE.sLp(a) levels were significantly associated with a higher presence of smooth muscle cells in the femoral plaque, although this was not associated with MALE or MACE.

CONCLUSIONS

Plasma Lp(a) is independently associated with first and consecutive MALE after iliofemoral endarterectomy. Hence, in patients who undergo iliofemoral endarterectomy, Lp(a) could be considered as a biomarker to enhance risk stratification for future MALE.

Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review

Background and aims

The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease.

Methods

Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors.

Results

In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease.

Conclusion

We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.

Differences Between Patients With Intermittent Claudication and Critical Limb Ischemia Undergoing Endovascular Intervention: Insights From the Excellence in Peripheral Artery Disease Registry

BACKGROUND

There are limited data on differences in angiographic distribution of peripheral artery disease and endovascular revascularization strategies in patients presenting with intermittent claudication (IC) and critical limb ischemia (CLI). We aimed to compare anatomic features, treatment strategies, and clinical outcomes between patients with IC and CLI undergoing endovascular revascularization.

METHODS

We examined 3326 patients enrolled in the Excellence in Peripheral Artery Disease registry from 2006 to 2019 who were referred for endovascular intervention for IC (n=1983) or CLI (n=1343). The primary outcome was 1-year major adverse limb events, which included death, repeat target limb revascularization, or target limb amputation.

RESULTS

Patients with CLI were older and more likely to have diabetes and chronic kidney disease and less likely to receive optimal medical therapy compared with IC. Patients with IC had higher femoropopliteal artery interventions (IC 87% versus CLI 65%; P<0.001), while below the knee interventions were more frequent in CLI (CLI 47% versus IC 12%; P<0.001). Patients with CLI were more likely to have multilevel peripheral artery disease (CLI 32% versus IC 15%, P<0.001). Patients with IC were predominantly revascularized with stents (IC 48% versus CLI 37%; P<0.001) while balloon angioplasty was more frequent in CLI (CLI 37% versus IC 25%; P<0.001). All-cause mortality was higher in patients with CLI (CLI 4% versus IC 2%; P=0.014). Major adverse limb event rates for patients with IC and CLI were 16% and 26%, respectively (P<0.001) and remained higher in CLI after multivariable adjustment of baseline risk factors.

CONCLUSIONS

Patients with IC and CLI have significant anatomic, lesion, and treatment differences with significantly higher mortality and adverse limb outcomes in CLI. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01904851. Graphic Abstract: A graphic abstract is available for this article.

Low-dose rivaroxaban plus aspirin in older patients with peripheral artery disease undergoing acute limb revascularization: insights from the VOYAGER PAD trial

AIMS

In this secondary analysis of the VOYAGER trial, rivaroxaban 2.5 mg twice/day plus aspirin 100 mg/day was assessed in older adults. Advanced age is associated with elevated bleeding risk and unfavourable net benefit for dual antiplatelet therapy in chronic coronary artery disease. The risk-benefit of low-dose rivaroxaban in patients ≥75 years with peripheral artery disease (PAD) after lower extremity revascularization (LER) has not been described.

METHODS AND RESULTS

The primary endpoint was a composite of acute limb ischaemia, major amputation, myocardial infarction, ischaemic stroke, or cardiovascular death. The principal safety outcome was thrombolysis in myocardial infarction (TIMI) major bleeding analysed by the pre-specified age cut-off of 75 years. Of 6564 patients randomized, 1330 (20%) were >75 years. Absolute 3-year Kaplan-Meier cumulative incidence rates for primary efficacy (23.4% vs. 19.0%) and safety (3.5% vs. 1.5%) endpoints were higher in elderly vs. non-elderly patients. Efficacy of rivaroxaban (P-interaction 0.83) and safety (P-interaction 0.38) was consistent irrespective of age. The combination of intracranial and fatal bleeding was not increased in patients >75 years (2 rivaroxaban vs. 8 placebo). Overall, benefits (absolute risk reduction 3.8%, number needed to treat 26 for the primary endpoint) exceeded risks (absolute risk increase 0.81%, number needed to harm 123 for TIMI major bleeding).

CONCLUSION

Patients ≥75 years with PAD are at both heightened ischaemic and bleeding risk after LER. No excess harm with respect to major, intracranial or fatal bleeding was seen in older patients yet numerically greater absolute benefits were observed. This suggests that low-dose rivaroxaban combined with aspirin should be considered in PAD after LER regardless of age.

Reduction in Acute Limb Ischemia with Rivaroxaban versus Placebo in Peripheral Artery Disease after Lower Extremity Revascularization: Insights from VOYAGER PAD

Background: Patients with peripheral artery disease (PAD) are at heightened risk of acute limb ischemia (ALI), a thrombotic event associated with amputation, disability, and mortality. Prior lower extremity revascularization (LER) is associated with increased ALI risk in chronic PAD. However, the pattern of risk, clinical correlates, and outcomes after ALI early after LER are not well-studied, and effective therapies to reduce ALI post-LER are lacking. Methods: VOYAGER PAD (NCT02504216) randomized patients with PAD undergoing LER to rivaroxaban 2.5 mg twice daily or placebo on a background of low-dose aspirin. The primary outcome was a composite of ALI, major amputation of vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. ALI was prospectively ascertained and adjudicated by a blinded committee. The cumulative incidence of ALI was calculated using Kaplan Meier estimates, and Cox proportional-hazards models were used to generate hazard ratios and associated confidence intervals. Analyses were performed as intention-to-treat. Results: Among 6,564 patients followed for a median of 2.3 years, 382 (5.8%) had a total of 508 ALI events. In placebo patients, the 3-year cumulative incidence of ALI was 7.8%. After multivariable modeling, prior LER, baseline ABI <0.50, surgical LER, and longer target lesion length were associated with increased risk of ALI. Incident ALI was associated with subsequent all-cause mortality (HR 2.59, 95% CI 1.98-3.39) and major amputation (HR 24.87, 95% CI 18.68-33.12). Rivaroxaban reduced ALI relative to placebo by 33% (absolute risk reduction 2.6% at 3 years, HR 0.67, 95% CI 0.55-0.82, P=0.0001), with benefit starting early (HR 0.45, 95% CI 0.24-0.85, P=0.0068 at 30 days). Benefit was present for severe ALI (associated with death, amputation, or prolonged hospitalization and ICU stay, HR 0.58, 95% CI 0.40-0.83, P=0.003) and regardless of LER type (surgical vs endovascular revascularization, p-interaction=0.42) or clopidogrel use (p-interaction=0.59). Conclusions: After LER for symptomatic PAD, ALI is frequent, particularly early after LER, and is associated with poor prognosis. Low-dose rivaroxaban plus aspirin reduces ALI after LER, including ALI events associated with the most severe outcomes. The benefit of rivaroxaban for ALI appears early, continues over time, and is consistent regardless of revascularization approach or clopidogrel use.

Predictors of Underutilization of Medical Therapy in Patients Undergoing Endovascular Revascularization for Peripheral Artery Disease

OBJECTIVES

The aim of this study was to explore discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agent, statin, and ACE inhibitor or angiotensin receptor blocker use after endovascular lower extremity (LE) peripheral vascular intervention.

BACKGROUND

Little is known about contemporary GDMT prescription following LE PVI.

METHODS

Sex, age, and comorbid conditions were related to discharge GDMT prescription among patients undergoing LE PVI for symptomatic peripheral artery disease in the 2014-2018 Vascular Study Group of New England Vascular Quality Initiative. Multivariate logistic regression was used to identify independent predictors of discharge GDMT prescription.

RESULTS

Among 12,316 patients, only 47.4% (n = 5,844) were discharged on GDMT after LE PVI. Most patients were discharged on antiplatelet agents (95.2%), with statins (83.5%) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (55.8%) prescribed less often. A higher proportion of patients were on Class 1 guideline-recommended therapy with antiplatelet agents and statins (80.5%). In multivariate analysis, female sex, older age, end-stage renal disease, chronic limb-threatening ischemia, and congestive heart failure were negative predictors of discharge GDMT prescription, while hypertension, diabetes, coronary artery disease, and prior LE PVI or bypass were positive predictors.

CONCLUSIONS

Fewer than one-half of patients undergoing LE PVI are discharged on appropriate GDMT. As expected, traditional atherosclerotic risk factors and measures of greater atherosclerotic disease burden were associated with a greater likelihood of GDMT prescription. However, women and patients with the highest risk for atherothrombosis and limb loss were least likely to be prescribed these agents. Provider- and patient-directed educational efforts are needed to close these treatment gaps.