Smoking and the patency of lower extremity bypass grafts: A meta-analysis

Primary Limb-Based Patency for Chronic Limb-Threatening Ischemia Treated with Endovascular Therapy Based on the Global Limb Anatomic Staging System

PURPOSE

To validate the correlation between the Global Limb Anatomic Staging System (GLASS) and primary limb-based patency (LBP) and to identify the risk factors associated with LBP loss.

MATERIALS AND METHODS

A single-center retrospective analysis was performed on patients with chronic limb-threatening ischemia (CLTI) who underwent endovascular therapy (EVT) between January 2018 and May 2022. All lesions were categorized into 3 groups (GLASS Stages I, II, and III). The primary LBP rates were analyzed and compared across the GLASS stages. The risk factors for the loss of primary LBP were identified using Cox regression analysis.

RESULTS

In total, 236 limbs from 231 patients were included, with 52 (22%) limbs stratified as GLASS Stage I, 59 (25%) limbs as GLASS Stage II, and 125 (53%) limbs as GLASS Stage III. The 1-year LBP rates for limbs classified as GLASS Stages I, II, and III were 78.8%, 69.5%, and 41.6%, respectively (P < .001). The long-term LBP rate was 54.2% in GLASS Stage I, 38.6% in GLASS Stage II, and 10.5% in GLASS Stage III (P < .001). Multivariate analysis revealed that GLASS stages (GLASS Stage Ⅰ vs Ⅲ, hazard ratio [HR], 0.36; 95% CI, 0.18-0.72; P = .004; GLASS Stage Ⅱ vs Ⅲ, HR, 0.47; 95% CI, 0.25-0.86; P = .02), diabetes, smoking, and sex were independently associated with LBP.

CONCLUSIONS

GLASS Stage III was associated with lower LBP rates in patients with CLTI who underwent EVT. The GLASS stages may serve as prognostic indicators for patients with CLTI after intervention.

Predictive ability of the pedal medial arterial calcification (pMAC) score for major adverse limb events among patients with Chronic Limb-Threatening Ischemia

OBJECTIVE

Pedal medial arterial calcification (pMAC) is a potential predictor of major adverse limb events (MALE) among patients with critical limb-threatening ischemia (CLTI). This study aims to validate the prognostic value of the pMAC score in predicting major lower limb amputation (MLLA) and need for re-do revascularisation.

METHODS

A single centre study involving 196 patients diagnosed with CLTI, reviewed between 2012 and 2022. Patients' pMAC scores were obtained through X-ray assessments. Correlations between pMAC scores and the incidence of MALE and re-do revascularisation, were analysed. A power analysis using G* Power 3 software determined a needed sample size of 157 participants. Statistical analysis employed SPSS 26, utilising descriptive statistics, Chi Square, Mann-Whitney, Kaplan-Meier with log-rank test, and Cox regression for predictor identification.

RESULTS

The cohort was predominantly male (79.1%) and diabetic (59.2%). Re-do revascularisation need was 15.3%, increasing with pMAC scores: 3.3% (low), 24.5% (medium), and 50% (high) (p<0.001). MLLA frequency also rose with pMAC scores: 6.7%, 27.5%, and 50% respectively (p<0.001). Higher pMAC scores correlated with a higher incidence of MALE (p=0.029). Multivariate analysis showed medium pMAC (HR 4.159, p=0.002), high pMAC (HR 7.366, p=0.015), and GLASS stage 3 (HR 3.529, p=0.011) as independent MLLA predictors. Re-do revascularisation predictors included female sex (HR 2.106, p=0.063), Black race (HR 64.498, p=0.001), medium pMAC (HR 6.812, p=0.002), high pMAC (HR 11.455, p=0.008), and GLASS stage 3 (HR 2.899, p=0.037).

CONCLUSION

The pMAC score effectively predicts MALE in CLTI patients and enhances risk stratification. Using both, pMAC scores and GLASS stages enhances predictive accuracy, identifying patients at higher risk for MLLA, Informing clinical decision-making and therapeutic strategies.

Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease

Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.

Markers of optimal medical therapy are associated with improved limb outcomes after elective revascularization for intermittent claudication

BACKGROUND

Optimal medical therapy (OMT) is a modifiable factor that decreases mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized that preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates after elective endovascular revascularization for intermittent claudication (IC).

METHODS

Using the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and nonsmoking status defined OMT components and created three groups: complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR).

RESULTS

There were 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2127 [5.4%] no OMT) who met our criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (P < .0001). Patients without OMT were more likely to be Black or with Medicare or Medicaid (P < .05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; P < .001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; P < .001) were decreased by partial or complete OMT compared with no OMT. Complete OMT significantly decreased the adjusted odds of reintervention and MALE by 28% (aOR, 0.72, 95% confidence interval [95% CI], 0.59-0.88) and 30% (aOR, 0.70; 95% CI, 0.58-0.85), respectively, compared with no OMT. Partial OMT decrease the adjusted odds of reintervention and MALE by 24% (aOR, 0.76; 95% CI, 0.63-0.92) and 26% (aOR, 0.74; 95% CI, 0.62-0.89), respectively.

CONCLUSIONS

Preintervention OMT is an underused, modifiable risk factor associated with improved 1-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC before revascularization to optimize patient outcomes.

Retrospective Multicenter Comparison Between Viabahn Covered Stent-Grafts and Supera Interwoven Nitinol Stents for Endovascular Treatment in Severely Calcified Femoropopliteal Artery Disease: The ARMADILLO Study (Adjusted Retrospective coMparison of scAffolDs In caLcified LesiOns)

PURPOSE

The previous single-arm registries showed the acceptable primary patency after endovascular therapy (EVT) using covered stent-graft (CSG) and Supera interwoven nitinol stent (Supera peripheral stent [SPS]) in calcified femoropopliteal lesions. The aim of this study was to compare the safety and efficacy between CSG and SPS in calcified femoropopliteal lesions in clinical practice.

MATERIALS AND METHODS

We retrospectively analyzed 341 cases who had Rutherford class 2 to 6 peripheral artery disease and underwent EVT with either CSG (n=137) or SPS (n=204) for femoropopliteal lesions with bilateral calcification in fluoroscopic image, based on the Peripheral Arterial Calcium Scoring System (PACSS) classification, between April 2017 and February 2021 at 7 cardiovascular centers in Japan.

RESULTS

After propensity score (PS) matching, the final study population consisted of 150 matched patients with no remarkable intergroup difference in baseline characteristics. The primary patency at 1 year was not statistically different between CSG and SPS groups (81.4% vs 71.2%, p=0.32). There was also no significant difference in freedom from target lesion revascularization (82.8% vs 77.6%, p=0.28) and overall survival rate (88.6% vs 87.2%, p=0.81). The stratification analysis demonstrated that advanced age, current smoking, diabetes mellitus, and PACSS grade 4 had a significant interaction on the association of CSG versus SPS implantation with restenosis (interaction p<0.05).

CONCLUSIONS

In patients with bilaterally calcified femoropopliteal lesions, 1-year primary patency was not significantly different between treatments using CSG and SPS after the PS matching.

CLINICAL IMPACT

Covered stent-graft (CSG) and Supera interwoven nitinol stent (SPS) are reliable endovascular devices in calcified femoropopliteal lesions. This retrospective multicenter study compared the clinical outcomes between the two devices. After propensity score matching, 150 matched patients with no remarkable intergroup difference in baseline characteristics. The primary patency at 1 year was not statistically different between the CSG and SPS group (81.4% vs. 71.2%, p=0.32). There was also no significant difference in freedom from target lesion revascularization (82.8% vs. 77.6%, p=0.28) and overall survival rate (88.6% vs 87.2%, p=0.81). The two devices showed the similar efficacy in calcified femoropopliteal lesions.

Smoking cessation: why is it a persistent problem in patients with peripheral artery disease?

Nurses play a key role in advising patients to quit smoking, especially those with long-term conditions including cardiovascular disease. Peripheral artery disease (PAD) is an increasingly prevalent condition, and is the third most common presentation of atherosclerotic disease after coronary heart disease and stroke. Smoking cessation is crucial for patients with PAD but can be very challenging. Stopping smoking reduces cardiovascular morbidity and mortality, and improves claudication symptoms in patients with PAD. Those who continue to smoke are at higher risk of disease progression, amputation, myocardial infarction and death, and have poorer therapeutic outcomes. Quitting smoking is difficult, and patients should be offered a combination of behavioural and drug therapy. Nurses can provide several interventions to help patients quit and prevent relapse. A pilot study in a large London hospital found that no smokers had been referred to smoking cessation services by their vascular clinician (although some had been referred by their GP), given brief cessation advice or told how smoking cessation was essential for vascular preservation. Many thought smoking cessation programmes would not work.

The Effect of Smoking on the Activated Clotting Time and the Incidence of Complications in Noncardiac Arterial Procedures

PURPOSE

Smoking is a well-known risk factor for developing arterial diseases and for an increase of complications during and after vascular procedures. Although smoking has a proven effect on hemostasis, no literature is available on the effect of smoking on the activated clotting time (ACT), which is used to monitor the effect of heparin during noncardiac arterial procedures (NCAP). The aim of this study was to examine the effect of smoking on ACT values and the incidence of complications during the same admission or 30 day follow-up of NCAP.

MATERIALS AND METHODS

A post hoc analysis of a prospective multicenter cohort study was performed. Patients older than 18 years, who underwent NCAP between December 2016 and April 2021, were enrolled. Patients were divided into 2 groups based on smoking status: never/former smokers and current smokers. Two heparin dosing protocols were used: an initial bolus of 5000 IU or 100 IU/kg bodyweight.

RESULTS

In total, 773 patients met the inclusion criteria. Five minutes after administration of 5000 IU of heparin, mean ACT values were 190 and 196 seconds for nonsmokers and smokers, respectively (p=0.078). After 100 IU/kg of heparin, mean ACT values were 229 and 226 seconds for nonsmokers and smokers, respectively (p=0.37). Incidence of complications in the whole study cohort was not significantly different for nonsmokers compared with smokers (arterial thrombo-embolic complication [ATEC] 4.7% vs 5.7% p=0.55; hemorrhagic complications 15% vs 18% p=0.29). In subgroup-analysis, a significant difference between smoking groups was found for hemorrhagic complications after open aneurysm repair (p=0.024). However, after adjusting for confounders, the difference between the smoking groups annulled.

CONCLUSION

The results of this study suggest that smoking does not have a significant effect on ACT values or on the incidence of complications in NCAP. Large-scale studies are required to further analyze potential factors having an effect on the ACT and perioperative and postoperative complications, which could help individualize heparinization strategy.

CLINICAL IMPACT

There is high variance between patients in their response on administration of heparin, this is not yet fully understood. This study investigated the effect of smoking in a large prospective multicentre cohort. The results suggests that active smoking does not have an effect on the activated clotting time after administration of heparin. Also no significant effect of smoking could be found on the incidence of all registered complications. Monitoring of the effect of heparin remains important to provide patients with safe anticoagulation during vascular procedures.

Long-term outcomes after lower extremity bypass in the actively smoking claudicant

OBJECTIVE

Smoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is for elective general surgery procedures. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants.

METHODS

We queried the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 36 clinical variables (age, gender, race, ethnicity, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS).

RESULTS

Propensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (HR, 0.93; 95% CI, 0.70-1.24; P = .61), LS (HR, 1.07; 95% CI, 0.63-1.82; P = .80), FR (HR, 0.9; 95% CI,0.71-1.21; P = .59), or AFS (HR, 0.93; 95% CI,0.71-1.22; P = .62). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI,0.94-1.97; P = .11) or FR (HR, 1.02; 95% CI,0.88-1.19; P = .76). However, we did find a significant increase in OS (HR, 1.37; 95% CI,1.15-1.64, P <.001) and AFS (HR, 1.38; 95% CI,1.18-1.62; P < .001) in FS compared with CS.

CONCLUSIONS

Claudicants represent a unique nonemergent vascular patient population that may require LEB. Our study found that FS have better OS and AFS when compared with CS. Additionally, FS mimic nonsmokers at 5-year outcomes for OS, LS, FR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before elective LEB procedures in claudicants.

A modern day perspective on smoking in peripheral artery disease

Peripheral artery disease (PAD) is associated with increased risk of cardiovascular morbidity and mortality, poor functional status, and lower quality of life. Cigarette smoking is a major preventable risk factor for PAD and is strongly associated with a higher risk of disease progression, worse post-procedural outcomes, and increased healthcare utilization. The arterial narrowing due to atherosclerotic lesions in PAD leads to decreased perfusion to the limbs and can ultimately cause arterial obstruction and limb ischemia. Endothelial cell dysfunction, oxidative stress, inflammation, and arterial stiffness are among the key events during the development of atherogenesis. In this review, we discuss the benefits of smoking cessation among patients with PAD and the use of smoking cessation methods including pharmacological treatment. Given that smoking cessation interventions remain underutilized, we highlight the importance of incorporating smoking cessation treatments as part of the medical management of patients with PAD. Regulatory approaches to reduce the uptake of tobacco product use and support smoking cessation have the potential to reduce the burden of PAD.

Pulmonary prehabilitation and smoking cessation

PURPOSE OF REVIEW

This review aims to summarize the current literature on pulmonary prehabilitation programs, their effects on postoperative pulmonary complications, and the financial implications of implementing these programs. Additionally, this review has discussed the current trends in pulmonary prehabilitation programs, techniques for improving rates of perioperative smoking cessation, and the optimal timing of these interventions.

RECENT FINDINGS

Prehabilitation is a series of personalized multimodal interventions tailored to individual needs, including lifestyle and behavioral measures. Pulmonary prehabilitation has shown to reduce postoperative pulmonary complications (PPCs).

SUMMARY

The implications of clinical practice and research findings regarding PPCs are an increased burden of postoperative complications and financial cost to both patients and hospital systems. There is convincing evidence that pulmonary prehabilitation based on endurance training should be started 8-12 weeks prior to major surgery; however, similar rates of improved postoperative outcomes are observed with high-intensity interval training (HIIT) for 1-2 weeks. This shorter interval of prehabilitation may be more appropriate for patients awaiting thoracic surgery, especially for cancer resection. Additionally, costs associated with creating and maintaining a prehabilitation program are mitigated by shortened lengths of stay and reduced PPCs. Please see Video Abstract, http://links.lww.com/COAN/A90.

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.

A practical guide for perioperative smoking cessation

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Outcomes of Femoropopliteal Bypass for Lifestyle-Limiting Claudication in the Endovascular Era

INTRODUCTION

Outcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era.

METHODS

A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan-Meier curves and Cox proportional hazards ratios (HR).

RESULTS

A total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011).

CONCLUSIONS

Femoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era.

Factors Affecting Mortality of Critical Limb Ischemia 1 Year after Endovascular Revascularization in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Chronic limb ischemia (CLI) is strongly associated with increased mortality in diabetes patients.

OBJECTIVE

The aim of this study was to evaluate factors affecting mortality within 1 year after endovascular revascularization in CLI patients.

METHODS

This retrospective cohort study was based on medical records from the Integrated Cardiovascular Centre of Dr. Cipto Mangunkusumo National General Hospital, a tertiary care hospital in Jakarta, Indonesia. The study included 199 CLI patients with type 2 diabetes mellitus (T2DM) who underwent endovascular revascularization from January 2008 to June 2018. The patients were followed up for 1 year after endovascular revascularization. Kaplan-Meier and Cox proportional hazard analysis was used to analyze the data.

RESULTS

1-year survival probability was 58.8%. Cox proportional hazard analysis showed that duration of diabetes (HR 3.52; 95% CI 1.34-9.22), anemia (HR 2.59; 95% CI 1.47-4.56), and smoking (HR 2.49; 95% CI 1.46-4.27) were significantly associated with mortality within 1 year after endovascular revascularization.

CONCLUSIONS

In T2DM patients with CLI, duration of diabetes, anemia and smoking were associated with a higher risk of mortality within 1 year post endovascular revascularization

Social Deprivation and Peripheral Artery Disease

The link between peripheral artery disease and socioeconomic status is complex. The objective of this narrative review is to explore this relationship in detail, including how social factors impact the development, management, and outcomes of peripheral artery disease. Although the current literature on this topic is limited, some patterns do emerge. Populations of low socioeconomic status appear to be at increased risk for the development of peripheral artery disease, due to factors such as increased prevalence of cardiovascular risk factors (i.e. cigarette smoking) and decreased access to care. However, variables that are more difficult to quantify, such as chronic stress and health literacy, also likely play a significant role. Among those who are living with peripheral artery disease, socioeconomic status can also affect disease management. Secondary prevention strategies, such as medication use, smoking cessation, and exercise therapy, are underutilized in socially deprived populations. This underutilization of evidence-based management leads to adverse outcomes in these groups, including increased rates of amputation and decreased post-operative survival. The recognition of the importance of social factors in prognosis is an important first step towards addressing this health disparity. Moving forward, interventions that help to identify those who are at high risk and help to improve access to care in populations of low socioeconomic status, will be critical to improving outcomes.

Outcomes of Axillofemoral Bypass for Intermittent Claudication

OBJECTIVE

While endovascular therapy is often first-line treatment for medically refractory intermittent claudication (IC) caused by aorto-femoral disease, suprainguinal bypass is commonly performed. Although this is often aorto-femoral bypass (AoFB), axillo-femoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC.

METHODS

The Vascular Quality Initiative (2009-2019) was queried for suprainguinal bypass performed for IC. Univariable and multivariable analyses were used to compare perioperative and one-year outcomes between AxFB and a comparison cohort of AoFB.

RESULTS

We identified 3,261 suprainguinal bypasses performed for IC: 436 AxFB and 2,825 AoFB. Overall, mean age was 61.4 ± 9.1 years, 58.8% of patients were male sex, and 59.7% currently smoked. Patients undergoing AxFB, compared with AoFB, were more often older, male, never-smokers, and ambulated with assistance (all P<.001). They more often had hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, previous outflow peripheral endovascular interventions, and previous inflow or outflow bypass. AxFB, compared with AoFB, were more often uni-femoral (all P<.05). Patients undergoing AxFB, compared with AoFB, had shorter postoperative length of stay (median 4 vs. 6 days) and fewer perioperative pulmonary (3% vs. 7.9%) and renal complications (5.5% vs. 9.9%), but more perioperative ipsilateral major amputations (.9% vs. 0.04%) (all P<.05). There were no significant differences in perioperative myocardial infarction (2.8% vs. 2.7%), stroke (.7% vs. 1.1%), and death (1.8% vs. 1.7%) rates, respectively. At one year, Kaplan-Meier analysis demonstrated that the AxFB, compared with AoFB cohort, exhibited higher rates of death (7.3% vs. 3.6%, P=.002); graft occlusion or death (14.3% vs. 7.2%, P=.001); ipsilateral major amputation or death (12.5% vs. 5.6%, P<.001); and reintervention, amputation, or death (19% vs. 8.6%, P<.001). On multivariable analysis, AxFB was independently associated with increased risk of one-year reintervention, amputation, or death (HR 1.6, 95% CI 1.03-2.4, P=.04).

CONCLUSIONS

This retrospective analysis suggests that long-term complications were more frequent in patients who underwent AxFB as compared to AoFB, although patients treated with AxFB were at higher risk with more comorbidities. Since AxFB is associated with significant perioperative morbidity, mortality, and long-term complications, serious consideration should be given prior to its use for IC.

Medical Management of Peripheral Artery Disease

Peripheral artery disease is a highly morbid yet undertreated atherosclerotic disease. The cornerstones of peripheral artery disease therapy consist of smoking cessation, lipid-lowering therapy, and hypertension treatment. More recently, clinical trials have demonstrated that novel antiplatelet and antithrombotic therapies reduce the risk of both cardiovascular and limb events in this patient population. In this review, we highlight the components of optimal medical therapy of peripheral artery disease and the evidence base for these therapies.

A meta-analysis of randomised controlled trials evaluating the efficacy of smoking cessation interventions in people with peripheral artery disease

OBJECTIVE

This review aimed to systematically pool evidence from randomised clinical trials (RCT) on the efficacy of interventions in assisting smoking cessation in participants with PAD.

METHODS

Publicly available databases were searched for RCTs testing the effect of interventional programs in achieving smoking cessation in participants with PAD who were current smokers. The primary outcome was smoking cessation at the end of follow-up. Meta-analyses were performed using random effect models and reported as risk ratios (RR) and 95% confidence intervals (CI). Risk of bias and publication bias were assessed using a modified version of the Cochrane Collaboration's tool and funnel plots respectively.

RESULTS

Six RCTs testing smoking cessation programs comprising physician advice, behavioural counselling from an expert delivered in-person or over the telephone and provision of nicotine replacement therapy and/or varenicline in 558 smokers with PAD were included. Meta-analysis suggested that overall these interventions did not significantly increase the chance of quitting smoking (RR: 1.48 [95% CI 0.84, 2.61]), with low heterogeneity between studies (I²=20%) which were robust in sensitivity analyses. Risk of bias was high, moderate, and low in one, three and two studies respectively. A funnel plot suggested a low risk of publication bias.

CONCLUSION

Overall previously tested smoking cessation interventions have not been effective in achieving smoking cessation in people with PAD. Further research is needed to develop and test interventions which can effectively help current smokers with PAD quit.

Prevalence, Outcome, and Management of Risk Factors in Patients With Breast Cancer With Peripheral Arterial Disease: A Tertiary Cancer Center's Experience

INTRODUCTION

The risk factors of breast cancer overlap with those of peripheral arterial disease (PAD), with increasing prevalence. In addition, there is under-utilization of risk factor modification measures in patients with PAD.

MATERIALS AND METHODS

Electronic medical records of patients with breast cancer with International Classification of Diseases 9/10 codes for PAD spanning 10 years from June 1, 2009 to June 1, 2019 were reviewed.

RESULTS

A total of 248 patients, 98% women, with a median age of 75 years and with a median follow-up of 76 months, were included. PAD risk factors were identified as smoking (44%), obesity (38%), hyperlipidemia (68%), hypertension (HTN) (74%), and diabetes (42%). Overall, survival was significantly impacted by smoking (P = .0301) and HTN (P = .0052). In a Cox proportion hazard ratio regression, HTN (overall death hazard ratio [HR], 3.1784; 95% CI, 1.0291-6.7490; P = .0070; cancer-related death HR, 2.6354; 95% confidence interval [CI], 1.0291-6.7490; P = .0434) and smoking (overall death HR, 1.7452; 95% CI 1.0707-2.8444; P = .0255; cancer-related death HR, 2.7432; 95% CI, 1.4190-5.3030; P = .0027) were predictors of overall death and cancer-related death. Of all patients, 48% were on statins and 54% were on antiplatelet therapies. Of the patients, 62% of current smokers were offered a smoking cessation program, 27% of obese patients were offered a nutrition consult, 42% of patients with diabetes had blood glucose controlled, and 54% of patients with HTN had blood pressure controlled.

CONCLUSION

Smoking and HTN are risk factors associated with decreased survival and predictive of overall death and cancer-related death. In this population, risk factor modification was under-utilized.

Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease

Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.

Lipid Optimization in Lower Extremity Peripheral Arterial Disease

AIMS

This review aims to explore the current guidance and issues surrounding lipid optimisation of patients with peripheral arterial disease (PAD).

METHODS

A narrative review of the global PAD guidance, specifically focusing on low density lipoprotein cholesterol (LDL-C) reduction methods including; 'treating to target', 'fire and forget' and LDL-C percentage reduction. Advanced literature searches were carried out in Pubmed and Google Scholar databases comparing most recent PAD lipid guidance.

RESULTS

PAD lipid guidance could be improved internationally to help clinicians implement the best lipid-reduction strategies for their patients and challenge the arbitrary 1.4 mmol/L LDL-C target in line with novel proprotein convertase subtilisin/kexin type 9 inhibitors trials. By educating primary and secondary care staff on the benefits of maximal lipid-reduction therapies, we can reduce major adverse cardiovascular events and major adverse limb events. Championing PAD community clinics may lead to earlier prevention. Research comparing lipid-reduction strategies in practice is needed to improve outcomes internationally, and ongoing practice audited to understand the extent of under-prescribing in PAD.

CONCLUSIONS

This review highlights the current PAD lipid-reduction treatments and the clarity issues of global guidance. Further research is needed to tackle ongoing mortality and morbidity rates in PAD patients against their better off cardiovascular disease (CVD) peers. MESH KEY TERMS: "Cholesterol", "Hydroxymethylglutaryl-CoA Reductase Inhibitors", "Ezetimibe", "Evolocumab", "Alirocumab", "Peripheral Arterial Disease", "Vascular Disease", "Atherosclerosis", "Secondary Prevention", "Lipoprotein, LDL".

A rare presentation and management of thrombosis of an aberrant right subclavian artery related to thoracic outlet syndrome

OBJECTIVES

We present a case in which a 44-year-old female smoker with a complex medical and surgical history presented with acute upper limb ischemia.

METHODS

The patient was diagnosed with thoracic outlet syndrome causing symptomatic thrombosis of an aberrant right subclavian artery associated with diverticulum of Kommerell. The patient had history of extensive surgeries and radiation in the right chest with fibrotic changes, so surgical dissection in the area was associated with significant risk of nerve injury. Therefore, revascularization of the arm was performed via carotid to brachial artery bypass with reversed saphenous vein and the thoracic outlet was decompressed with segmental clavicular resection.

RESULTS

Patient has been symptom free for 3 years with patent bypass.

CONCLUSIONS

This case demonstrates a unique presentation of distal thrombosis of a symptomatic aberrant right subclavian artery related to thoracic outlet syndrome. The combined claviculectomy-vein bypass is a safe and efficacious surgical approach that provides durable relief.

Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview

In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication

OBJECTIVE

Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC.

METHODS

We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance.

RESULTS

Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001).

CONCLUSIONS

Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

Lumen Loss at 1 Year After Bare Nitinol Stent Implantation in the Superficial Femoral Artery

PURPOSE

To investigate lumen loss (LL) at 1 year after bare nitinol stent (BNS) implantation for de novo superficial femoral artery (SFA) lesions.

MATERIALS AND METHODS

The subjects were 701 consecutive patients (mean age 74±9 years; 492 men) with 817 de novo SFA lesions treated with BNS implantation between January 2004 and September 2015. The mean lesion length was 141±88 mm and the mean vessel diameter was 5.4±0.9 mm. The endpoint was LL at 1 year after BNS implantation. Secondary outcomes were restenosis and target lesion revascularization (TLR) estimated using the Kaplan-Meier method; estimates are reported with the 95% confidence interval (CI). LL was defined as the minimum lumen diameter immediately after BNS implantation minus that at 1 year measured by angiographic quantitative vessel analysis. The distribution of LL in the overall population was estimated using an accelerated failure time model.

RESULTS

Mean LL at 1 year was estimated to be 1.74±1.28 mm (95% CI 1.63 to 1.84). Current smoking was positively associated with LL (p=0.015), whereas lack of cilostazol use was correlated with an increase in LL (p=0.001). Reference vessel diameter and lesion length did not have any significant association with LL at 1 year. The 1-year cumulative estimate of restenosis was 25% (95% CI 22% to 28%); the corresponding value for TLR was 18% (95% CI 15% to 21%).

CONCLUSION

Mean LL progressed by at least 1.6 mm up to 1 year after BNS implantation. The risk factors for increased LL were current smoker and lack of cilostazol use.

Multiscale, patient-specific computational fluid dynamics models predict formation of neointimal hyperplasia in saphenous vein grafts

Stenosis due to neointimal hyperplasia (NIH) is among the major causes of peripheral graft failure. Its link to abnormal hemodynamics in the graft is complex, and isolated use of hemodynamic markers is insufficient to fully capture its progression. Here, a computational model of NIH growth is presented, establishing a link between computational fluid dynamics simulations of flow in the lumen and a biochemical model representing NIH growth mechanisms inside the vessel wall. For all three patients analyzed, NIH at proximal and distal anastomoses was simulated by the model, with values of stenosis comparable to the computed tomography scans.

Premature atherosclerotic peripheral artery disease: An underrecognized and undertreated disorder with a rising global prevalence

Premature atherosclerotic peripheral artery disease (PAD) of the lower extremities is characterized by disease diagnosis before the age of 50 years. The global prevalence of premature PAD has increased, and the disease is often underdiagnosed given heterogenous patient symptoms. Traditional cardiovascular risk factors like smoking, diabetes, hypertension, and hyperlipidemia as well as non-traditional risk factors like elevated lipoprotein(a), family history of PAD, hypercoagulability, and systemic inflammation are associated with premature PAD. Patients with premature PAD tend to have an aggressive vascular disease process, a high burden of cardiovascular risk factors, and other concomitant atherosclerotic vascular diseases like coronary artery disease. Prevention of cardiovascular events, improvement of symptoms and functional status, and prevention of adverse limb events are the main goals of patient management. In this review, we discuss the epidemiology, risk factors, clinical evaluation, and management of patients with premature PAD.

Underutilization of Evidence-Based Smoking Cessation Support Strategies Despite High Smoking Addiction Burden in Peripheral Artery Disease Specialty Care: Insights from the International PORTRAIT Registry

Background

Smoking is the most important risk factor for peripheral artery disease (PAD). Smoking cessation is key in PAD management. We aimed to examine smoking rates and smoking cessation interventions offered to patients with PAD consulting a vascular specialty clinic; and assess changes in smoking behavior over the year following initial visit.

Methods and Results

A total of 1272 patients with PAD and new or worsening claudication were enrolled at 16 vascular specialty clinics (2011–2015, PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry). Interviews collected smoking status and cessation interventions at baseline, 3, 6, and 12 months. Among smokers, transition state models analyzed smoking transitions at each time point and identified factors associated with quitting and relapse. On presentation, 474 (37.3%) patients were active, 660 (51.9%) former, and 138 (10.8%) never smokers. Among active smokers, only 16% were referred to cessation counseling and 11% were prescribed pharmacologic treatment. At 3 months, the probability of quitting smoking was 21%; among those continuing to smoke at 3 months, the probability of quitting during the next 9 months varied between 11% and 12% (P<0.001). The probability of relapse among initial quitters was 36%. At 12 months, 72% of all smokers continued to smoke.

Conclusions

More than one third of patients with claudication consulting a PAD provider are active smokers and few received evidence‐based cessation interventions. Patients appear to be most likely to quit early in their treatment course, but many quickly relapse and 72% of all patients smoking at baseline are still smoking at 12 months. Better strategies are needed to provide continuous cessation support.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01419080.

Peripheral artery disease: the new frontiers of imaging techniques to evaluate the evolution of regenerative medicine

Introduction: Stem cells (ESC, iPSC, MSC) are known to have intrinsic regenerative properties. In the last decades numerous findings have favored the development of innovative therapeutic protocols based on the use of stem cells (Regenerative Medicine/Cell Therapy) for the treatment of numerous diseases including PAD, with promising results in preclinical studies. So far, several clinical studies have shown a general improvement of the patient's clinical outcome, however they possess many critical issues caused by the non-randomized design of the limited number of patients examined, the type cells to be used, their dosage, the short duration of treatment and also their delivery strategy. Areas covered: In this context, the use of the most advanced molecular imaging techniques will allow the visualization of very important physio-pathological processes otherwise invisible with conventional techniques, such as angiogenesis, also providing important structural and functional data. Expert opinion: The new frontier of cell therapy applied to PAD, potentially able to stop or even the process that causes the disease, with particular emphasis on the clinical aspects that different types of cells involve and on the use of more innovative molecular imaging techniques now available.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Cigarette smoking intensity informs outcomes after open revascularization for peripheral artery disease

OBJECTIVE

Cigarette smoking is the leading risk factor for peripheral artery disease (PAD). Existing literature often defines smoking history in broad categories of current, former, and never smokers, which may not sufficiently identify patients at the highest risk for poor outcomes. The purpose of this study was to examine the use of more informative categorization of smoking and to determine the association with important revascularization outcomes.

METHODS

We conducted a retrospective review of all patients undergoing open lower extremity revascularization for symptomatic PAD, defined as claudication (Rutherford 3) or critical limb ischemia (Rutherford 4-6), during a 5-year period (2013-2017). Smoking history, demographics, and comorbidities were abstracted from electronic health records from seven hospitals within our health care system. Smoking history was defined by intensity (packs/day), duration (years), pack-year history, and cessation time. Outcomes included major adverse limb events (MALEs), death, limb loss, and amputation-free survival. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (CIs) for each parameter adjusted for patients' demographics and comorbidities. Cumulative incidence is reported for outcomes at 30, 180, and 365 days of follow-up.

RESULTS

We identified 693 patients undergoing open lower extremity revascularization for PAD (66% critical limb ischemia; 46% diabetes). The 1-year cumulative incidence of MALEs was 29.9% (95% CI, 26.4-33.9), whereas the 1-year incidence of death was 9.8% (95% CI, 7.5-12.7). The broad classification of current and former smokers identified no statistically significant differences in any measured outcomes. Patients who smoked more than one pack/day had 1.48 (95% CI, 1.01-2.16) times increase in risk of MALEs at 1 year compared with patients who smoked one or fewer packs/day. Patients who smoked more than one pack/day also had the highest 1-year amputation incidence (12.7%). Each of the four parameters was associated with increased risk of poor outcomes, although small sample size limited the precision of our estimates.

CONCLUSIONS

We found that smoking intensity is particularly informative of outcomes of patients undergoing open lower extremity revascularization for symptomatic PAD. These findings lay the groundwork for future research on relevant smoking history parameters and benefits of smoking reduction and cessation for clinicians to discuss with patients and to better understand and inform patients of intervention risks and expected outcomes.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

The effect of the duration of preoperative smoking cessation timing on outcomes after elective open abdominal aortic aneurysm repair and lower extremity bypass

OBJECTIVE

Smoking has been associated with poor postoperative outcomes across various surgical procedures. However, the effect of quitting smoking preoperatively for elective operations is unclear. Our goal was to assess the temporal effect of smoking cessation before elective lower extremity bypass (LEB) and open abdominal aortic aneurysm (AAA) repair on perioperative outcomes.

METHODS

The Vascular Quality Initiative was reviewed for all patients with a documented smoking history and who underwent an elective LEB or open AAA repair from 2010 to 2017. Patients were then categorized into three groups: long-term smoking cessation (LTSC; defined as quitting smoking ≥8 weeks before surgery), short-term smoking cessation (STSC; defined as quitting smoking < 8 weeks before surgery), and current smokers (CS). Patient and procedure details were recorded. Univariate and multivariate analysis for crude and propensity-matched data were used to compare outcomes among groups.

RESULTS

We identified 15,950 patients with a documented smoking history who underwent an elective LEB (43.3% LTSC, 2.2% STSC, 54.5% CS) and 5215 patients who underwent an elective open AAA repair (42.9% LTSC, 2.4% STSC, 54.7% CS). LTSC patients compared with STSC and CS, respectively, were more often obese, diabetic, on aspirin, on a statin, had coronary artery disease, and had congestive heart failure, but were less likely to have chronic obstructive pulmonary disease (all P < .05). Perioperative outcomes demonstrated significant differences comparing LTSC with STSC and CS for myocardial infarction (3.4% vs 1.4% vs 1.4%), dysrhythmia (4.2% vs 2.5% vs 2.7%), 30-day mortality (1.6% vs .3% vs .9%), in-hospital mortality (1.1% vs 0% vs 0.5%; all P < .001) and congestive heart failure (1.8% vs .8% vs 1.5%; P = .003). There was no difference in outcomes after analysis of propensity-matched data for LTSC or STSC on any postoperative outcomes for LEB. For open AAA repair, LTSC compared with CS patients, respectively, were older, more often male, obese, on a statin, diabetic, and less frequently had chronic obstructive pulmonary disease (P < .05 for all). Perioperative outcomes demonstrated differences in pulmonary complications when comparing LTSC with STSC and CS (9.5% vs 8.0% vs 12.5%; P = .002). Multivariate analysis demonstrated that LTSC patients compared with CS were less likely to experience pulmonary complications (odds ratio, 0.65; 95% confidence interval, 0.53-0.79; P < .001). Propensity-matched multivariate analysis confirmed that LTSC remained significantly less likely to encounter pulmonary complications (odds ratio, 0.49; 95% confidence interval, 0.33-0.74; P = .001).

CONCLUSIONS

In our propensity-matched, risk-adjusted cohort, LTSC and STSC were not associated with perioperative outcomes after elective LEB. LTSC was associated with a significantly decreased odds of pulmonary complications after elective open AAA repair. STSC was not associated with perioperative outcomes after elective open AAA repair. If time permits, a longer period of smoking cessation should be attempted before elective open AAA repair.

[Conservative treatment of chronic lower limb ischemia in ambulatory practice (in Russian only)]

Peripheral artery disease is still one of the most important surgical problems. General surgeons treat the majority of patients with chronic lower limb ischemia due to the lack of specialized surgical care. Current methods for risk factors adjustment, exercise therapy and the most common drugs for intermittent claudication management are reviewed in the article. The effect of these medicines on subjective (pain-free walking distance, maximal walking distance, etc.) and objective (ankle-brachial index) parameters and the incidence of complications are analyzed.

Anti-phosphorylcholine IgM, an Anti-inflammatory Mediator, Predicts Peripheral Vein Graft Failure: A Prospective Observational Study

OBJECTIVES

One third of infrainguinal vein bypasses may fail within the first 1.5 years. Pro- and anti-inflammatory mechanisms are thought to be involved in these graft stenoses and occlusions. In previous studies, low levels of anti-phosphorylcholine IgM (anti-PC IgM, an innate anti-inflammatory IgM) have been associated with increased cardiovascular events. In this study, the peri-operative dynamics of anti-PC IgM levels were established during leg bypass surgery, and associations assessed between anti-PC IgM levels and primary graft patency.

DESIGN AND METHODS

This was a prospective, observational cohort study of infrainguinal autogenous vein bypass for peripheral arterial occlusive disease involving four university affiliated hospitals. Plasma cytokine and anti-PC IgM levels were measured pre- and post-operatively. The outcome of interest was loss of primary graft patency because of occlusion or intervention for graft stenosis.

RESULTS

One hundred and forty-two consecutive patients were enrolled: mean age 66 (46-91); 91% white race and male; 72.5% critical limb ischaemia (Fontaine III or IV). Median pre-operative anti-PC IgM levels were 49 units/mL (IQR 32.3-107.7, mean 89.8 + 101 sd). During follow up of an average of 1.8 years (1 month-7.4 years), 50 (35.2%) grafts lost primary patency. Pre-operative levels of interleukin 6 or C-reactive protein did not predict graft failure. Patients with pre-operative anti-PC IgM values in the lowest quartile had a twofold increased risk of graft failure (multivariable Cox proportional hazard, p = .03, HR 2.11, 95% CI 1.09-4.07), even after accounting for the other significant factors of conduit diameter, distal anastomosis, smoking, and the severity of leg ischaemia.

CONCLUSIONS

Low levels of anti-PC IgM are associated with vein bypass graft failure. This biological mediator may be a useful marker to identify patients at higher risk, and offers the potential for novel, directed therapies for vascular inflammation and its consequences.

Clinical factors that influence the cellular responses of saphenous veins used for arterial bypass

OBJECTIVE

When an autogenous vein is harvested and used for arterial bypass, it suffers physical and biologic injuries that may set in motion the cellular processes that lead to wall thickening, fibrosis, stenosis, and ultimately graft failure. Whereas the injurious effects of surgical preparation of the vein conduit have been extensively studied, little is known about the influence of the clinical environment of the donor leg from which the vein is obtained.

METHODS

We studied the cellular responses of fresh saphenous vein samples obtained before implantation in 46 patients undergoing elective lower extremity bypass surgery. Using an ex vivo model of response to injury, we quantified the outgrowth of cells from explants of the adventitial and medial layers of the vein. We correlated this cellular outgrowth with the clinical characteristics of the patients, including the Wound, Ischemia, and foot Infection classification of the donor leg for ischemia, wounds, and infection as well as smoking and diabetes.

RESULTS

Cellular outgrowth was significantly faster and more robust from the adventitial layer than from the medial layer. The factors of leg ischemia (P < .001), smoking (P = .042), and leg infection (P = .045) were associated with impaired overall outgrowth from the adventitial tissue on multivariable analysis. Only ischemia (P = .046) was associated with impaired outgrowth of smooth muscle cells (SMCs) from the medial tissue. Co-culture of adventitial cells and SMCs propagated from vein explants revealed that adventitial cells significantly inhibited the growth of SMCs, whereas SMCs promoted the growth of adventitial cells. The AA genotype of the -838C>A p27 polymorphism (previously associated with superior graft patency) enhanced these effects, whereas the factor of smoking attenuated adventitial cell inhibition of SMC growth. Comparing gene expression, the cells cultured from the media overexpress Kyoto Encyclopedia of Genes and Genomes pathways associated with inflammation and infection, whereas those from the adventitia overexpress gene families associated with development and stem/progenitor cell maintenance.

CONCLUSIONS

The adverse clinical environment of the leg may influence the biologic behavior of the cells in the vein wall, especially the adventitial cells. Chronic ischemia was the most significant factor that retards adventitial cell outgrowth. The cells arising from the vein adventitia may be key players in determining a healthy adaptive or a pathologic response to the injuries associated with vein grafting.

Critical limb ischemia: current challenges and future prospects

Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.

Treatment outcomes in diabetic patients with chronic limb-threatening ischemia

OBJECTIVE

There are conflicting reports about outcomes after infrainguinal bypass for chronic limb-threatening ischemia (CLTI) in patients with diabetes. We compared perioperative outcomes between patients with and patients without diabetes in the current era.

METHODS

The National Surgical Quality Improvement Program vascular module, 2011 to 2014, was used to identify patients undergoing infrainguinal revascularization for CLTI. Patients with and without diabetes were compared in terms of presentation, comorbidities, operative approach, and 30-day outcomes. Major adverse limb events (MALEs) included 30-day major reintervention or amputation, and major adverse cardiovascular events (MACEs) included 30-day myocardial infarction, cardiac arrest, stroke, or death. Multivariable logistic regression was used to adjust for baseline differences.

RESULTS

We identified 8887 patients undergoing open (5744; 50% diabetic) or endovascular (3143; 62% diabetic) treatment for CLTI. Patients with diabetes were younger and more often nonwhite, nonsmokers, and obese. Patients with diabetes presented more often with tissue loss (71% vs 47%; P < .001) and were more likely to be treated with endovascular intervention (41% vs 29%; P < .001). The 30-day mortality was similar before (open, 3.1% vs 2.8% [P = .53]; endovascular, 2.6% vs 2.1% [P = .37]) and after adjustment for baseline differences (open: odds ratio [OR], 1.1 [95% confidence interval (CI), 0.7-1.5]; endovascular: OR, 1.2 [95% CI, 0.7-2.0]). Patients with diabetes had longer lengths of stay (open, 8 vs 6 days [P < .001]; endovascular, 3 vs 2 days [P < .001]) and higher 30-day readmission rates (open, 21% vs 18% [P < .01]; endovascular, 20% vs 15% [P < .01]); however, these differences were no longer significant after adjustment for baseline differences. Patients with diabetes had a higher rate of MACEs (7.0% vs 5.1%; P < .01) and lower rate of MALEs (8.1% vs 10%; P < .01) after bypass. After adjustment, patients with diabetes still had a lower rate of MALEs (OR, 0.7; 95% CI, 0.6-0.9) but no longer had a higher rate of MACEs (OR, 1.2; 95% CI, 0.9-1.6).

CONCLUSIONS

CLTI patients with diabetes undergoing revascularization have similar 30-day outcomes compared with those without diabetes, although they appear to be at lower risk for MALEs after bypass. Prolonged length of stay and readmission in patients with diabetes is not due to underlying diabetic disease but likely secondary to other baseline comorbidities, such as higher rates of tissue loss. Concern for worse perioperative outcomes in patients with diabetes after lower extremity bypass is unsubstantiated and should not discourage a physician from performing an open bypass.

[Peripheral arterial disease: Treatment]

Medical management of peripheral arterial disease (PAD) patients is aimed at limb symptom relief and reducing systemic major adverse events risk. For the first purpose: exercise therapy is recommended in case of claudication; multidisciplinary evaluation for surgical options is mandatory in case of critical limb ischaemia. Reducing cardiac and stroke risk can be achieved through: statin prescription in most of the cases; antiplatelet agents in symptomatic PAD patients; cardio-vascular risk factors control.

Medical management of claudication

Peripheral artery disease (PAD) is common and associated with significant morbidity and mortality. Optimal medical management of PAD is required for each patient, irrespective of the decision regarding lower extremity revascularization. The goals include reducing cardiovascular morbidity and mortality and improving quality of life. The approach should consist of aggressive and individualized risk factor modification including smoking cessation, antiplatelet therapy, a statin, and an angiotensin-converting enzyme inhibitor. Exercise is critical for cardiovascular health and highly effective for improving claudication symptoms. Cilostazol may be considered for symptomatic treatment in certain patients.

Predictive factors for better bypass patency and limb salvage after prosthetic above-knee bypass reconstruction

BACKGROUND

Peripheral arterial disease (PAD) is one of the most underestimated diseases because of its high prevalence and unfavorable prognosis. Many PAD patients without suitable autologous veins or options for endovascular treatment receive prosthetic above-knee femoropopliteal bypass (PAKB). Until now predictors of prosthetic bypass failure and of increased amputation risk remain indistinct. This study aimed to identify predictive factors associated with better bypass patency and limb salvage to achieve a more favorable outcome after PAKB reconstruction.

METHODS

Pre-, intra-, and postoperative data of 244 PAKB procedures performed at a German university medical center were collected and analyzed using univariate and multivariate methods. To our knowledge this 12-year experience is the largest retrospective study to identify predictors for patency and limb salvage after PAKB reconstruction.

RESULTS

Of the PAD patients 94% (229/244) were followed for an average of 34.9 months. Patient cohorts characteristics were: mean age, 66.1 years, 181 men (74%), claudication (64%), rest pain (16%), ischemic lesions (20%), arterial hypertension (92%), smoking (79%), hyperlipidemia (65%) and type 2 diabetes (43%). Cumulative primary 1- and 3-year graft patency rates were 60.8% and 50.7%, respectively, and cumulative 1- and 3-year limb salvage rates were 89.3% and 86.1%, respectively. One hundred seven bypasses (43.9%) failed, 26 patients (10.7%) required a major and seven patients (2.9%) required a minor amputation. Overall survival rates of PAD patients after 1- and 3-years were 94.4% and 82.9%, respectively. Subjective symptom improvement was found to be the most important prognostic follow-up factor for graft patency and limb salvage. Patients with recurrent symptoms in the follow-up had an increased risk of emerging bypass failure compared with patients with subjective symptom improvement (patency at 1 year: 40.8% vs 100% and at 3 years: 26% vs 100%; P < .001). No patient with subjective improvement in symptoms during follow-up underwent an amputation (limb salvage at 1 year: 100% vs 79% and at 3 years: 100% vs 72.8%; P < .001). Therefore, subjective symptom improvement should be the decisive criterion to determine follow-up intervals of PAD patients. In univariate analysis further significant factors associated with better graft patency and limb salvage rates were: claudication compared with critical ischemia, larger graft diameter (>6 mm), pre- and postoperative antiplatelet therapy, statin therapy independent from lipid values after PAKB revascularization, and an experienced vascular surgeon.

CONCLUSIONS

In our study, we determined the subjective improvement in symptoms as the most important prognostic factor for bypass function and limb salvage after PAKB. Furthermore, disease stage of critical ischemia, graft diameter, preoperative aspirin use, and postoperative statin medication were independent predictive factors. Therefore, PAD patients should be treated with aspirin pre- and postoperatively as well as with a statin postoperatively. In case of PAKB reconstruction only prostheses with a large diameter (>6 mm) should be used and the procedure should be performed by an experienced surgeon. Considering these results with regard to the predictive factors for better graft patency and limb salvage rates a significant more favorable outcome during the follow-up and an increased 5-year patency rate for PAKB reconstructions can be expected.