Atherosclerotic Risk Factors and Segmental Distribution in Symptomatic Peripheral Artery Disease

Association of sex and cardiovascular risk factors with atherosclerosis distribution pattern in lower extremity peripheral artery disease

Objective

Atherosclerosis expression varies across not only coronary, cerebrovascular, and peripheral arteries but also within the peripheral vascular tree. The underlying pathomechanisms of distinct atherosclerosis phenotypes in lower extremity peripheral artery disease (PAD) is poorly understood. We investigated the association of cardiovascular risk factors (CVRFs) and atherosclerosis distribution in a targeted approach analyzing symptomatic patients with isolated anatomic phenotypes of PAD.

Methods

In a cross-sectional analysis of consecutive patients undergoing first-time endovascular recanalization for symptomatic PAD, data of patients with isolated anatomic phenotypes of either proximal (iliac) or distal (infrageniculate) atherosclerosis segregation were extracted. We performed a multivariable logistic regression model with backward elimination to investigate the association of proximal and distal PAD with CVRFs.

Results

Of the 637 patients (29% females) with endovascular recanalization, 351 (55%) had proximal and 286 (45%) had distal atherosclerosis. Female sex [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.20-0.54, p = 0.01], active smoking (OR 0.16, 95% CI 0.09-0.28, p < 0.001), and former smoking (OR 0.33, 95% CI 0.20-0.57, p < 0.001) were associated with proximal disease. Diabetes mellitus (DM) (OR 3.25, 95% CI 1.93-5.46, p < 0.001), chronic kidney disease (CKD) (OR 1.18, 95% CI 1.08-1.28, p < 0.001), and older age (OR 1.31, 95% CI 1.06-1.61, p = 0.01) were associated with distal disease.

Conclusion

Female sex, particularly in the context of smoking, is associated with clinically relevant, proximal atherosclerosis expression. Our additional findings that distal atherosclerosis expression is associated with DM, CKD, and older age suggest that PAD has at least two distinct atherosclerotic phenotypes with sex-specific and individual susceptibility to atherogenic risk factors.

Old and Novel Predictors for Cardiovascular Risk in Diabetic Foot Syndrome—A Narrative Review

Diabetic foot syndrome (DFS) is a complication associated with diabetes that has a strong negative impact, both medically and socio-economically. Recent epidemiological data show that one in six patients with diabetes will develop an ulcer in their lifetime. Vascular complications associated with diabetic foot have multiple prognostic implications in addition to limiting functional status and leading to decreased quality of life for these patients. We searched the electronic databases of PubMed, MEDLINE and EMBASE for studies that evaluated the role of DFS as a cardiovascular risk factor through the pathophysiological mechanisms involved, in particular the inflammatory ones and the associated metabolic changes. In the era of evidence-based medicine, the management of these cases in multidisciplinary teams of “cardio-diabetologists” prevents the occurrence of long-term disabling complications and has prognostic value for cardiovascular morbidity and mortality among diabetic patients. Identifying artificial-intelligence-based cardiovascular risk prediction models or conducting extensive clinical trials on gene therapy or potential therapeutic targets promoted by in vitro studies represent future research directions with a modulating role on the risk of morbidity and mortality in patients with DFS.

Comparative mortality according to peripheral artery disease and coronary heart disease/stroke in the United States

BACKGROUND AND AIMS

A recent trial reported that patients with peripheral artery disease (PAD) without coronary heart disease or stroke (CHD/stroke) had worse prognosis than those with CHD/stroke without PAD. However, community-based data are lacking. The purpose of this study was to compare mortality according to the status of PAD and CHD/stroke in the general population.

METHODS

In 6780 participants (aged ≥40 years) from the National Health and Nutrition Examination Surveys 1999-2004, we compared mortality risk according to PAD (ankle-brachial index ≤0.9) and CHD/stroke (self-report) at baseline using the Kaplan-Meier method and multivariable Cox models accounting for sampling weights.

RESULTS

The prevalence of having both PAD and CHD/stroke was 1.6%. The prevalence of PAD without CHD/stroke and CHD/stroke without PAD was 4.1% and 8.5%, respectively (85.8% without PAD or CHD/stroke). Over a median follow-up of 12.8 years, 21.2% died. Individuals with both PAD and CHD/stroke had the worst survival (25.5% at 12 years). Those with PAD without CHD/stroke had the second worst prognosis (47.7%), followed by those with CHD/stroke without PAD (53.2%) and those without CHD/stroke or PAD (87.2%). Adjusted hazard ratio of mortality was 2.70 (95% CI, 2.07-3.53) for PAD with CHD/stroke, 1.81 (1.54-2.12) in CHD/stroke without PAD, and 1.68 (1.35-2.08) in PAD without CHD/stroke vs. no CHD/stroke or PAD.

CONCLUSIONS

In the US adults, PAD contributed to increased mortality in persons with and without CHD/stroke. The prognosis of PAD without CHD/stroke was no better than that of CHD/stroke without PAD. These results suggest the importance of recognizing the presence of PAD in the community.

Toe pressure and toe brachial index are predictive of cardiovascular mortality regardless of the most diseased arterial segment in symptomatic lower-extremity artery disease-A retrospective cohort study

OBJECTIVE

Although lower extremity arterial disease (LEAD) is most often multisegmental, the predominant disease location and risk factors differ between patients. Ankle-brachial index (ABI), toe-brachial index (TBI), and toe pressure (TP) are predictive of outcome in LEAD patients. Previously, we reported a classification method defining the most diseased arterial segment (MDAS); crural (CR), femoropopliteal (FP), or aortoiliac (AOI). Current study aimed to analyze the associations between MDAS, peripheral pressure measurements and cardiovascular mortality.

MATERIALS AND METHODS

We reviewed retrospectively 729 consecutive LEAD patients (Rutherford 2-6) who underwent digital subtraction angiography between January, 2009 to August, 2011 and had standardized peripheral pressure measurements.

RESULTS

In Cox Regression analyses, cardiovascular mortality was associated with MDAS and non-invasive pressure indices as follows; MDAS AOI, TP <30 mmHg (HR 3.00, 95% CI 1.13-7.99); MDAS FP, TP <30 mmHg (HR 2.31, 95% CI 1.36-3.94), TBI <0.25 (HR 3.20, 95% CI 1.34-7.63), ABI <0.25 (HR 5.45, 95% CI 1.56-19.0) and ≥1.30 (HR 6.71, 95% CI 1.89-23.8), and MDAS CR, TP <30 mmHg (HR 4.26, 95% CI 2.19-8.27), TBI <0.25 (HR 7.71, 95% CI 1.86-32.9), and ABI <0.25 (HR 2.59, 95% CI 1.15-5.85).

CONCLUSIONS

Symptomatic LEAD appears to be multisegmental with severe infrapopliteal involvement. Because of this, TP and TBI are strongly predictive of cardiovascular mortality and they should be routinely measured despite the predominant disease location or clinical presentation.

The relation of anatomical distribution of symptomatic peripheral arterial disease (PAD) with HbA1c level in patients with type 2 diabetes mellitus

AIMS

Increased level of glycated hemoglobin (HbA1c) is associated with an increased prevalence of peripheral arterial disease (PAD). This study aimed to assess the relationship between the anatomical distribution of symptomatic PAD lesions in patients with type 2 diabetes and HbA1c levels at the time of PAD diagnosis.

PATIENTS AND METHODS

A retrospective study was conducted at King Abdullah University Hospital during the period August 2011 to December 2015. Consecutive patients with type 2 diabetes presented with symptomatic PAD confirmed by computed tomography-angiography (CTA) were included in this study. CTA images were reviewed. Relevant information including demographic data, PAD symptoms, comorbidities, HbA1c level, lipid profile, C-reactive protein and the mean platelets volume were retrieved from medical records.

RESULTS

A total of 332 patients with type 2 diabetes (255 males and 77 females) were included in this study. The mean HbA1c at the time of PAD diagnosis was 8.68% (±2.06%). The prevalence of hemodynamic relevant atherosclerotic lesions of the superficial femoral artery, popliteal artery, leg vessels, femoro-popliteal, and crural segments was significantly higher in patients with HbA1c >7.5% compared with patients with HbA1c ⩽7.5%.

CONCLUSION

The anatomical distribution of symptomatic PAD in patients with type 2 diabetes mellitus differed significantly according to HbA1c level at the time of PAD diagnosis.

Endovascular Treatment for Critical Limb Ischemia in Type II Diabetes Mellitus Involving Femoropopliteal and Infrapopliteal Segments: Revascularization Strategy

Purpose

To determine if further endovascular infrapopliteal angioplasty in combination with femoropopliteal revascularization improves the clinical outcomes regarding major amputation rate, rate of secondary interventions, and mortality in diabetic type-II patients presented with critical lower limb ischemia (CLI).

Patients and Methods

This is a retrospective study in which all type-II diabetic patients with CLI at King Abdullah University Hospital between October 2015 and September 2019 were identified. Patients with concomitant femoropopliteal and infrapopliteal vessels atherosclerotic lesions (total occlusion or more than 50% stenosis) who received successful endovascular treatment were included. Patients were divided into 2 groups. Group-I included patients treated for femoropopliteal segment alone, while Group-II included patients treated for both femoropopliteal and infrapopliteal segments. The outcomes of the two groups were compared regarding major amputation rate, rate of secondary interventions, and mortality. In addition, demographic data, atherosclerotic lesions distributions and cardiovascular risk factors were also collected and analyzed.

Results

In all, 90 patients (65 males and 25 females) with a mean age of 67.5±12 years were included. In Group-I; 44 patients (48.9%) were included (36 males and 8 females) with a mean age of 67±12 years. In group-II; 46 patients (51.1%) were included (29 males and 17 females) with a mean age of 68±13 years. The major amputation rate was higher and statistically significant in Group-I (38.6% vs 17.4%, p-value = 0.034). However, the secondary interventions and the mortality rates showed no statistically significant differences (56.8% vs 39.1%, p-value = 0.139) and (22.7% vs 28.3%, p-value = 0.632), respectively.

Conclusion

Endovascular infrapopliteal angioplasty in combination with femoropopliteal revascularization in diabetic type-II patients with CLI improves the clinical outcome regarding major amputation rate. However, there were no significant differences regarding the rate of secondary interventions and the mortality rate.

A Novel Scoring System for Small Artery Disease and Medial Arterial Calcification Is Strongly Associated With Major Adverse Limb Events in Patients With Chronic Limb-Threatening Ischemia

Purpose:

To evaluate the roles of small artery disease (SAD) and medial arterial calcification (MAC) in patients with chronic limb-threatening ischemia (CLTI) and to identify any correlation between these factors and peripheral artery disease (PAD) or outcomes after treatment.

Materials and Methods:

A retrospective review was conducted of 259 limbs with tissue loss among 223 CLTI patients (mean age 72.2±11.4 years; 194 men) having an angiographic foot vessel study, foot radiography, and at least 6 months of follow-up after intervention. SAD and MAC were quantified using a 3-level score (0=absent, 1=moderate, 2=severe) based on angiography for SAD and foot radiographs for MAC. The MAC score was validated and compared with the SAD score, evaluating their associations with PAD distribution and clinical outcomes.

Results:

Based on the MAC score, the 259 limbs were classified as 55 group 0 (21.2%), 89 group 1 (34.4%), and 115 group 2 (44.4%). The SAD score stratified the 259 limbs as 67 group 0 (25.9%), 76 group 1 (29.3%), and 116 group 2 (44.8%). Interobserver reproducibility of the MAC score was high (correlation coefficient 0.96). Sensitivity and specificity of the MAC score in detecting SAD was 100% and 98.1%, respectively, in SAD groups 0 and 2 vs 99.1% and 92.7%, respectively, for SAD group 1. PAD was more proximal in MAC and SAD groups 0 and more distal in groups 1 and 2. Both MAC and SAD scores were able to predict clinical endpoints. Multivariable analysis demonstrated that the MAC score represents an independent risk factor for adverse limb events.

Conclusion:

SAD and MAC must be considered expressions of the same obstructing disease, able to adversely impact the fate of CLTI patients. SAD and MAC scores are powerful prognostic indicators of major adverse limb events in CLTI patients.

Rationale and design for the study Apixaban versus ClopidoGRel on a background of aspirin in patient undergoing InfraPoPliteal angioplasty for critical limb ischemia: AGRIPPA trial

BACKGROUND

New antithrombotic strategies that reduce primary thrombosis and restenosis might improve vascular outcomes in patients with peripheral artery disease (PAD) undergoing arterial angioplasty. The study objective is to evaluate the potential benefit of apixaban plus aspirin compared with standard of care dual antiplatelet therapy (DAPT) in reducing thrombotic restenosis and artery re-occlusion in patients undergoing endovascular infrapopliteal revascularization.

STUDY DESIGN

This multicenter, parallel-group, prospective, randomized, open-label, blinded-endpoint adjudication, proof-of-concept, exploratory trial aims to randomize 200 patients 72 hours after successful infrapopliteal angioplasty for critical limb ischemia (CLI). Patients will be randomly assigned in a 1:1 ratio to receive oral apixaban (2.5 mg twice daily) plus aspirin (100 mg once daily) for 12 months or clopidogrel (75 mg daily) for at least 3 months on a background of aspirin (100 mg once daily) for 12 months. The primary endpoint is the composite of target lesion revascularization (TLR), major amputation, or restenosis/occlusion (RAS) in addition to major adverse cardiovascular events - MACE (myocardial infarction, stroke or cardiovascular death) at 12 months. The primary safety endpoint is the composite of major bleeding or clinically relevant non-major bleeding at 12 months.

SUMMARY

This study will evaluate the efficacy and safety of apixaban 2.5 mg twice daily plus aspirin compared with DAPT (clopidogrel plus aspirin) in patients with CLI undergoing endovascular infrapopliteal revascularization and might prove the concept of an alternative antithrombotic regimen for these patients to be tested in a future large randomized clinical trial.

Comparison of mid-term graft patency in common femoral versus superficial femoral artery inflow for infra-geniculate bypass in the vascular quality initiative

OBJECTIVES

The superficial femoral artery can be used as inflow for infra-geniculate bypass, but progressive proximal occlusive disease may affect graft durability. We sought to evaluate the effect of superficial femoral artery versus common femoral artery inflow on infra-geniculate bypass patency within a large contemporary multicenter registry.

METHODS

The vascular quality initiative was queried from 2013 to 2019 to identify patients with >30-day patency follow-up, Rutherford chronic limb ischemia stage 1-6, and an infra-geniculate bypass, excluding those with prior ipsilateral bypass. The cohort was stratified by inflow vessel, with primary, primary-assisted, and secondary patency serving as the primary outcome variables. Multivariate Cox-proportional hazard models and radius-based propensity-score matching were performed to reduce treatment-selection bias due to clinical covariates.

RESULTS

A total of 11,190 bypass procedures were performed (8378 common femoral artery inflow, 2812 superficial femoral artery) on 10,110 patients, with a mean follow-up of 12.8 months (range 1-98). Patients receiving superficial femoral artery inflow bypasses were more commonly male (p = 0.002), obese (p < 0.0001) and had chronic, limb threatening ischemia (p < 0.0001), whereas those with common femoral artery inflow were older (p < 0.0004), and had higher baseline comorbidities including smoking (p < 0.0001), coronary disease (p < 0.0001), and pulmonary disease (p < 0.0001). On life-table analysis, there was no significant difference in three year estimated primary (32.1 vs 30.1%, p = 0.928), primary assisted (60.5 vs 65.8%, p = 0.191), or secondary patency (62.5 vs 66.7%, p = 0.139) between superficial femoral artery and common femoral artery inflow groups, respectively. A multivariate Cox model found no significant association between inflow vessel and primary patency (0.96 [0.88-1.04], HR [95%CI]), primary-assisted (1.07 [0.95-1.20], HR [95%CI]), or secondary patency (1.08 [0.96-1.22]). In a propensity-matched cohort (n = 11,151), there were small but statistically significant differences in primary, primary-assisted, and secondary patency at latest follow-up (non-time-to-event data) between groups. The largest difference was observed when evaluating secondary patency, with common femoral artery inflow having a marginally higher secondary patency of 88.1% compared to 85.6% for those with superficial femoral artery inflow at latest follow-up (p = 0.009).

CONCLUSIONS

Within the vascular quality initiative, there is no significant difference in life-table determined three-year primary, primary-assisted, and secondary patency between infra-geniculate bypasses using common femoral artery inflow compared to superficial femoral artery inflow. Small, statistically significant differences exist in primary, primary-assisted, and secondary patency favoring common femoral artery inflow after propensity score matching. Long-term follow-up data are required in the vascular quality initiative to better evaluate bypass graft durability as this study was limited by a mean follow-up of one year.

Subclinical Peripheral Arterial Disease in Patients with Acute Ischemic Stroke: A Study with Ultrasonography

BACKGROUND

Peripheral arterial disease (PAD) is an advanced form of atherosclerosis defined by an abnormal ankle-brachial index (ABI). However, the ABI provides no information about the location of atherosclerosis. We investigated the clinical implication of PAD confirmed using lower-extremity ultrasonography (LEUS), with consideration of the atherosclerosis location.

METHODS

Patients with acute ischemic stroke who underwent LEUS were enrolled. Patients with PAD were further divided into those with PAD at the proximal (above-popliteal artery, PADP) and distal (below-tibialis artery, PADD) segments. The clinical outcome was compared between patients with and without PAD, and between PADP and PADD. The atherosclerosis location in the cerebral artery was also compared between groups.

RESULTS

Among 289 patients, PAD was observed in 108 (37.4%) patients (43 had PADP and 65 had PADD). Patients with PAD were slightly older (P < .001) and had more significant carotid artery stenosis (30.6% versus 12.7%, P < .001) than those without. Patients with PAD had poor 3-month functional outcome than those without (modified-Rankin Scale score: 3 [interquartile range, 1-4] versus 2 [1-3], respectively, P = .003). Diabetes, high-stroke severity, and the presence of PADP (odds ratio, 3.893; 95% confidence interval, 1.454-10.425; P = .007) were independently associated with poor functional outcome at 3 months. Patients with PADP showed higher prevalence of extracranial stenosis than those with PADD (41.9% versus 23.1%; P = .038).

CONCLUSIONS

Our study suggests that subclinical PAD, especially PADP, is associated with poor functional outcome at 3 months after stroke onset. Interestingly, the location of cerebral atherosclerosis differed according to the location of PAD.

Gender variation in symptomatic peripheral arterial occlusive disease among type-2 diabetic patients

Purpose:

Little is known about the existence of potential gender disparities in peripheral arterial occlusive disease. To our knowledge, this is the first study to analyze differences attributed to gender in type-2 diabetic patients with symptomatic peripheral arterial occlusive disease, with regard to clinical presentations, risk factors and anatomical distributions of atherosclerosis.

Patients and methods:

This study was conducted at King Abdullah University Hospital, Jordan. Medical records of all diabetic (type-2) patients who presented with symptomatic peripheral arterial occlusive disease in the period from January 2012 and November 2017 were reviewed, data were collected retrospectively. In all, 364 patients (282 males and 82 females) were involved. Criteria for diagnosis include the following Ankle-Brachial Index ⩽ 0.9 and intermittent claudication or critical limb ischemia. Risk factors for atherosclerosis (age, smoking and hypertension) and computed tomography-angiogram findings were analyzed using Statistical Package for the Social Sciences. p < 0.05 was considered statistically significant.

Results:

The mean age was higher in females than males (67.61 vs 62.61 years; p = 0.001). Females had greater prevalence of uncontrolled diabetes compared to males (HbA1c 9.07 in females vs 8.51 in males; p = 0.03). High density lipoprotein was higher in females than males (1.02 vs 0.935; p = 0.009). Females presented more with critical limb ischemia than intermittent claudication in comparison with males (p = 0.017). Involvement of superficial femoral artery, deep femoral artery and peroneal artery in hemodynamic relevant atherosclerotic lesion was significantly higher in females than males (p < 0.05). However, involvement of common iliac artery with hemodynamic relevant atherosclerotic lesion was significantly higher in males than females (p = 0.003).

Conclusions:

Clinical presentation, risk factors and anatomical distributions of atherosclerosis among type-2 diabetic patients with symptomatic peripheral arterial occlusive disease are different between males and females. When compared to males, female patients presented more with critical limb ischemia than intermittent claudication. Females showed higher age at presentation, poor control of diabetes mellitus and higher level of high density lipoprotein. Involvement of superficial femoral artery, deep femoral artery and peroneal artery in hemodynamic relevant atherosclerotic lesion were significantly higher in females than males. In contrast, common iliac artery involvement with hemodynamic relevant atherosclerotic lesion was significantly higher in males than females.

A Review of Distribution of Atherosclerosis in the Lower Limb Arteries of Patients With Diabetes Mellitus and Peripheral Vascular Disease

OBJECTIVE

There is a generally accepted hypothesis that patients with diabetes mellitus (DM) have a higher burden of atherosclerotic disease below the knee compared to patients without DM (NDM). The aim of this review was to summarize the evidence regarding this hypothesis.

METHODS

The literature was searched for papers that compared the anatomical distribution of atherosclerotic disease in patients with DM and those without using radiological imaging. Search terms used included "diabetes mellitus," "peripheral vascular disease," "distribution of disease," "angiography," "computed tomography angiography," and "magnetic resonance angiography." Where possible, the number of patients with disease in each arterial segment was extracted and included in a forest plot. A descriptive approach was taken when this was not possible or a scoring system was used.

RESULTS

Fourteen studies were included in the review and it was possible to summarize data from 9 of these in a forest plot. Fifteen different arterial segments were described; however, the most commonly used segments that differentiated between proximal and distal disease were aortoiliac (A-I; DM = 466 patients, NDM = 458), femoropopliteal (F-P; DM = 568, NDM = 585), tibial (DM = 306, NDM = 417). The resulting forest plot showed that those with DM were significantly less likely to have disease in the A-I segment (odds ratio [OR]: 0.25 [0.15-0.42]) and significantly more likely to have disease in the tibial segment (OR 1.94 [1.27-2.96]). In the DM group, there was a trend toward relative sparing in the F-P segment, but this does not reach significance (0.66 [0.33-1.31]).

CONCLUSIONS

These results support the hypothesis that patients with DM are more likely to have atherosclerotic disease in the tibial vessels than NDM. There is however limited information on how individual vessels are affected. Further information on this and a greater understanding of why the distal vessels are more affected are avenues for future research.

BAD transmission and SAD distribution: a new scenario for critical limb ischemia

BACKGROUND

Most of the studies on peripheral artery disease (PAD) focused on above-the-ankle artery disease, while less is known about foot artery disease. We hypothesize a scenario were two different diseases can be present in PAD patients, big artery disease (BAD) and small artery disease (SAD), overlapping at the foot level; the aim of this study is to evaluate their prevalence and their correlation with risk factors and critical limb ischemia (CLI) in a large cohort of patients with symptomatic PAD.

METHODS

We retrospectively reviewed 1915 limbs of 1613 patients (502 females, mean age 72.4±10.8 years) who underwent angiography between September 2009 and November 2013. Age, sex, diabetes, smoke history, high blood pressure, dialysis and BMI were considered as risk factors. Logistic regression was performed to test the association of arterial lesions patterns and CLI, and to evaluate the association between risk factors and lesion localization.

RESULTS

SAD was present in 414 patients (25.2%). Patients with disease of any of plantar, dorsalis pedis arteries and SAD faced higher risk of CLI (OR=13.25, 95% CI: 1.69-104.16). SAD was associated with diabetes and dialysis (both: OR=4.85; dialysis only: OR=3.60; diabetes only: OR=1.70; none: reference OR; P<0.01), weight (underweight: OR=1.10; normal: reference OR; overweight: OR=0.81; obese: OR=0.60; P=0.03), while women and tobacco smokers were less likely to have SAD (women: OR=0.68; P<0.01; tobacco use: OR=0.54; P<0.01).

CONCLUSIONS

SAD was strongly and independently associated with CLI, diabetes and dialysis. Thus, SAD should be regarded as a leading actor in CLI.

New semiquantitative ultrasonographic score for peripheral arterial disease assessment and its association with cardiovascular risk factors

The data concerning the distribution, extent and progression of peripheral arterial disease (PAD), as well as its association with traditional cardiovascular (CV) risk factors, have generally been obtained from studies of patients in advanced stages of the disease undergoing surgical or endovascular treatment. In this study, we have introduced a new semiquantitative ultrasonographic score (ultrasonographic lower limb atherosclerosis (ULLA) score) that is able to categorize lower limb atherosclerotic lesions at all stages of PAD. We then associated these ultrasonographic categories with a CV risk profile. We enrolled 320 consecutive subjects with symptoms suggestive of PAD or with known CV risk factors referring to our angiology unit between 1 July 2014 and 30 June 2015 for ultrasonographic evaluation of the lower limb arteries. Femoropopliteal and run-off segments were categorized together and separately based on their ultrasonographic characteristics. In univariate and multivariate analyses, the ULLA scores were significantly associated with the main CV risk factors, that is, age, male gender, cigarette smoking, arterial hypertension, diabetes, dyslipidemia, sedentary lifestyle, previous CV events and family history of CV disease, and also confirming the specific association of single risk factors with different segments of lower limb arteries. The proposed ULLA score enables a complete evaluation of the entire lower limb atherosclerotic burden, extending the results concerning the association of PAD with CV risk factors to all stages of the disease, including the early stages. It can be feasible that this new score will facilitate better evaluation of the progression of PAD and its prospective role in CV risk stratification.

Noninvasive Physiologic Vascular Studies: A Guide to Diagnosing Peripheral Arterial Disease

Noninvasive physiologic vascular studies play an important role in the diagnosis and characterization in peripheral arterial disease (PAD) of the lower extremity. These studies evaluate the physiologic parameters of blood flow through segmental arterial pressures, Doppler waveforms, and pulse volume recordings. Collectively, they comprise a powerful toolset for defining the functionality of the arterial system, localizing the site of disease, and providing prognostic data. This technology has been widely adopted by diverse medical specialty practitioners, including radiologists, surgeons, cardiologists, and primary care providers. The use of these studies increased substantially between 2000 and 2010. Although they do not employ imaging, they remain a critical component for a comprehensive radiologic vascular laboratory. A strong presence of radiology in the diagnosis of PAD adds value in that radiologists have shifted to noninvasive alternatives to diagnostic catheter angiography (DCA), such as computed tomography (CT) and magnetic resonance (MR) angiography, which provide a more efficient, less-expensive, and lower-risk alternative. Other specialties have increased the use of DCA during the same period. The authors provide a review of the relevant anatomy and physiology of PAD as well as the associated clinical implications. In addition, guidelines for interpreting the ankle-brachial index, segmental pressures, Doppler waveforms, and pulse volume recordings are reviewed as well as potential limitations of these studies. Noninvasive physiologic vascular studies are provided here for review with associated correlating angiographic, CT, and/or MR findings covering the segmental distribution of PAD as well as select nonatherosclerotic diagnoses. ^©RSNA, 2016.

Efficacy and Safety of Endovascular Therapy for Aortoiliac TASC D Lesions

Background:

Although there is increasing evidence of the effectiveness of endovascular therapy for complex aortoiliac (AI) occlusive disease, it is not universally applied to TASC D lesions.

Methods:

A total of 2096 patients, 2601 limbs with AI occlusive disease, were enrolled. The lesions were categorized as TASC D (395) or TASC A-C (2206), and we compared baseline data, procedure, and follow-up result between the 2 groups.

Results:

The success rate of the procedure was significantly lower in the TASC D group (91.6% vs 99.3%, P < .01), and more procedure complications occurred in the TASC D group (11.1% vs 5.2%, P < .01). The results of a 5-year follow-up revealed no significant difference in primary patency (77.9% vs 77.1%, P = .17) and major adverse cardiovascular and limb events (MACLE; 30.5% vs 33.4%, P = .42) between the 2 groups. A multivariate analysis revealed complications and critical limb ischemia are independent predictors of MACLE in the TASC D group.

Conclusion:

The success rate of the procedure was lower in the TASC D group. Complications were more frequent in the TASC D group, and they were related to MACLE.

Relation of Baseline Renal Dysfunction With Outcomes in Patients Undergoing Popliteal and Infrapopliteal Percutaneous Peripheral Arterial Interventions

Renal dysfunction is a major risk factor for peripheral arterial disease (PAD). Infrapopliteal PAD is associated with more co-morbid conditions and worse prognosis than suprapopliteal PAD. Long-term outcomes of patients with renal dysfunction and popliteal or infrapopliteal PAD undergoing peripheral vascular intervention (PVI) are not well described. We retrospectively evaluated long-term outcomes in 726 patients undergoing infrapopliteal PVI categorized into 3 glomerular filtration rate (GFR)-based groups: GFR (≥60 ml/min/1.73 m(2)), GFR (<60 ml/min/1.73 m(2)), and those on dialysis. At mean follow-up of 36 ± 20 months, amputation rates were 3%, 5%, and 11% with mortality rates of 23%, 36%, and 56% in normal renal function, chronic kidney disease (adjusted odds ratio [OR] for amputation 1.75, 95% CI 0.73 to 4.21; adjusted OR for mortality 1.53, 95% CI 1.05 to 2.23, p = 0.028), and dialysis (adjusted OR for amputation 2.43, 95% CI 0.84 to 7.02, p = 0.100; adjusted OR for mortality 4.51, 95% CI 2.46 to 8.26, p <0.0001) groups, respectively. Repeat revascularization was similar in all 3 groups at roughly 25%. In conclusion, chronic kidney disease and dialysis were associated with increased major amputations and mortality in patients who received PVI for popliteal and infrapopliteal PAD.

Efficacy of autologous bone marrow mononuclear cell therapy in patients with peripheral arterial disease

AIM

Peripheral arterial disease (PAD), particularly critical limb ischemia (CLI), is a severe cause of amputation and mortality. More than 50% of diabetic patients with CLI die within four to five years. The development of novel stem cell therapies may bring new hope to these patients. We aimed to assess the efficacy of autologous bone marrow cell therapy for treating CLI using a meta-analysis.

METHODS

We searched the literature in PubMed, the Cochrane Central Registry of Controlled Trials, the Elsevier database and EBSCO for trials of autologous cell therapy in patients with severe PAD published before October 30, 2013. We chose objective clinical endpoints to assess the efficacy of therapy in the meta-analysis, including changes in the ankle-brachial index (ABI), transcutaneous oxygen tension (TcO2), pain scale (0-10 scale) and amputation-free survival (AFS).

RESULTS

Thirty-one articles reporting clinical trials involving a total of 1,214 patients treated with bone marrow stem cell-based therapy were collected for the meta-analysis, in which the randomized controlled trials (RCTs) and other trials (non-RCTs) were classified into two groups. Regarding the efficacy of stem cell therapy, the ABI showed significant increases (P＜0.05) at 12 , 24 and 48 weeks after therapy in the non-RCT and RCT groups, but not after four to eight weeks in the non-RCT group. The TcO2 values also increased in the RCT group at four to eight weeks after therapy and 24 weeks after therapy (P＜0.001) and in the non-RCT group at four to eight weeks after therapy (P= 0.01), although no significant increases were observed in the RCT group at 12 weeks after therapy or the non-RCT group at 24 weeks after therapy. Meanwhile, pain was significantly reduced (P＜0.05) at four to eight weeks and 24 weeks after therapy in both the non-RCT and RCT groups, but not at four to eight weeks or 12 weeks after therapy in the RCT group. In addition, the long-term clinical trials demonstrated that the AFS rate improved after therapy with bone marrow stem cells (one-year AFS, P＜0.00001; three-year AFS, P=0.0003).

CONCLUSIONS

The present results suggest that autologous bone marrow stem cells have an advantageous therapy effect in PAD patients who are not eligible for revascularization.

Octogenarians develop infrapopliteal arterial occlusive disease in the absence of traditional risk factors

BACKGROUND

With increasing longevity, a growing proportion of patients who present with lower extremity peripheral arterial disease (LE-PAD) are ≥80 years old. While smoking and diabetes mellitus (DM) have traditionally been the main risk factors associated with PAD, we noted a pattern of severe infrapopliteal PAD in patients ≥80 years old in the absence of these traditional risk factors. As recognition of patterns of disease affects decisions regarding diagnostic and therapeutic approach, we sought to confirm this observation.

METHODS

A single-center retrospective review was performed on all patients who underwent lower extremity arteriography between March 2007 and September 2009. Arteriograms were scored in a blinded fashion. Any infrapopliteal PAD was defined as one or more infrapopliteal arteries with either >50% stenosis or total occlusion. Severe infrapopliteal PAD was defined as 2 or more infrapopliteal arteries with >50% stenosis or total occlusion. Fisher's exact test and 2-sample t-test or Wilcoxon rank-sum test were used for analysis.

RESULTS

Two hundred ninety-seven patients comprised the study population. Eighty-two percent (= 145/176) of those ≤70 years old versus 96% (= 46/48) of those ≥80 years old had any infrapopliteal PAD (P = 0.02). Thirty percent of patients ≥80 years old with infrapopliteal PAD had no history of DM or smoking, while only 5% of younger patients had infrapopliteal PAD in the absence of DM or smoking (P < 0.0001). A similar pattern was seen for severe infrapopliteal PAD. Tissue loss was an indication for lower extremity arteriography in 45% of those ≤70 years of age versus 65% of those ≥80 (P = 0.022).

CONCLUSIONS

A significant proportion of patients ≥80 years of age with PAD develop arterial disease in the infrapopliteal pattern in the absence of the traditional risk factors of smoking and DM. Our data also showed that this pattern of disease is significantly associated with tissue loss and critical limb ischemia, particularly in patients ≥80 years of age. Primary care providers need to be educated to suspect ischemic etiology for foot pain and ulcers in elderly patients not otherwise thought to have risk factors associated with PAD. Vascular specialists need to anticipate this pattern of disease when planning interventions. As smoking becomes less prevalent and as the population ages, octogenarians with severe infrapopliteal arterial occlusive disease will become a larger proportion of the patients treated by vascular specialists.

Patterns of disease distribution of lower extremity peripheral arterial disease

Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis that is associated with an increased risk of mortality and cardiovascular (CV) events. Peripheral arterial disease involves the arteries distal to the aortic bifurcation in a nonuniform manner. Studies have shown that symptoms and prognosis of patients with PAD vary according to the location and size of the affected artery. Several modalities have been used to identify the location of PAD, including noninvasive evaluations and invasive procedures. Peripheral arterial disease has a risk factor profile similar to that associated with coronary artery disease (ie, age, gender, diabetes, smoking, hypertension, and hyperlipidemia). Many studies have shown that the distribution, extent, and progression of PAD are influenced by CV risk factors but the findings are not consistent. Management strategies for PAD are different for proximal and distal PAD. The objective of this review is to discuss the patterns of diseases distribution in patients with PAD.

Disease location is associated with survival in patients with peripheral arterial disease

BACKGROUND

We investigated whether disease location influences survival in patients with peripheral arterial disease.

METHODS AND RESULTS

Patients (n = 12,731; mean age, 67.5 ± 12.7 years; 57.4% male) who underwent outpatient noninvasive lower extremity arterial evaluation were followed up for 5.9 ± 3.1 years for all-cause mortality. Peripheral arterial disease (n = 8930) was defined as a resting or postexercise ankle-brachial index (ABI) ≤ 0.90, and normal ABI (n = 3,801) was defined as a resting and postexercise ABI of 1.00 to 1.30. Presence or absence of disease at the proximal location or distal location was determined on the basis of Doppler signals in leg arteries; 42% had no PD or DD, 45% had proximal (14% postexercise PD only), 30% had distal disease, 17% had both proximal and distal disease, 28% had proximal only and 14% had distal only. We performed multivariable logistic regression to identify factors associated with disease location, and Cox proportional hazard regression to assess the respective effects of proximal or distal disease on survival. Older age, male sex, diabetes, heart failure, and critical limb ischemia were associated with distal disease, whereas female sex, smoking, hypertension, dyslipidemia, coronary heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, and critical limb ischemia were associated with proximal disease. Over a mean follow-up of 5.9 ± 3.1 years, 3039 patients (23.9%) died. After adjustment for potential confounders, the hazard ratios (HRs) of death associated with PD only and DD only were 1.3 (1.3 to 1.4) and 1.5 (1.4 to 1.6), respectively. After additional adjustment for resting ABI, there was no significant association between proximal disease and death, whereas the association of distal disease with death remained significant (HR, 1.2; 95% CI, 1.1 to 1.3).

CONCLUSIONS

In patients with peripheral arterial disease, proximal and distal disease locations were associated with distinctive risk factor and comorbidity profiles. Distal disease was associated with worse survival even after adjustment for risk factors, comorbidities, and resting ABI.

Comparison of cardiovascular risk factors for peripheral artery disease and coronary artery disease in the korean population

Background and Objectives

The objective of this study was to analyze and compare risk factors for peripheral artery disease (PAD) and coronary artery disease (CAD).

Subjects and Methods

The sample included 7936 Korean patients aged ≥20 years who were hospitalized from 1994 to 2004. Of the 7936 subjects, PAD (n=415), CAD (n=3686), and normal controls (Control) (n=3835) were examined at the Health Promotion Center, Samsung Medical Center.

Results

The mean age (years) of PAD subjects was 64.4 (±9.3), while CAD subjects was 61.2 (±9.9), and Control subjects was 59.9 (±9.1) (p<0.01). The proportion of males was 90.6% for PAD, 71.4% for CAD, and 75.5% for Control subjects (p<0.01). The adjusted odds ratios (ORs) for hypertension, diabetes mellitus, hypercholesterolemia, smoking, metabolic syndrome and chronic kidney disease were significantly higher in subjects with PAD or CAD compared to those in Control. However, the ORs for high density lipoprotein, being overweight, and being obese were significantly lower in PAD subjects compared to those in Control.

Conclusion

We found that cardiovascular risk factors were in fact risk factors for both PAD and CAD.