Medical and lifestyle management of peripheral arterial disease

Updates in Arterial Ulcers

Arterial ulcers are a clinical symptom of a complex array of underlying comorbid factors, namely peripheral artery disease (PAD). Chronic limb-threatening ischemia is representative of end-stage PAD. Ulcers of other etiologies can carry an arterial component, mandating recognition of risk factors, a comprehensive history and physical examination, and appropriate diagnostic testing in lower extremity ulcers. The primary therapy for arterial ulcers is re-establishment of in-line arterial flow, achieved by endovascular therapy or open revascularization. Medical management is essential to slow disease progression, and topical therapies are crucial to promote rapid ulcer closure and reduce infection risk.

Diabetes in Peripheral Artery Disease: Prevalence, Complications, and Polypharmacy

Background: Patients with peripheral artery disease (PAD) and diabetes face high risks of comorbidities, tissue loss, and cardiovascular events. As global type 2 diabetes (T2DM) prevalence rises, so does its incidence in symptomatic patients with PAD, though this population is under-studied in Australia. This cross-sectional analysis sought to characterize PAD patients with diabetes regarding prevalence, major complications, medication use, and prescribing patterns, comparing them to non-diabetic PAD patients. We also examined PAD complications in relation to diabetic control. Methods: This cross-sectional study looked at the baseline data from 105 PAD participants in the TEAM-PAD randomized controlled trial that were analyzed using descriptive statistics, prevalence odds ratios and regression analysis. Participants were recruited between June 2023 and August 2024 from public clinics, private surgeons, and Concord Repatriation General Hospital, Sydney. Results: Diabetes prevalence was 52.83% (n = 56) with 29.5% (n = 31) of participants with T2DM having uncontrolled hyperglycemia (HbA1c ≥ 7%), which was weakly negatively correlated with age (r = -0.372, p = 0.039). Participants with T2DM were twice as likely to have a history of coronary artery disease (POR 2.43; 95% with a 95% confidence interval (CI) between 1.09-5.43, and over three times as likely to have tissue loss (POR 3.39; 95% CI 1.22-9.43). The odds of polypharmacy (≥5 medications) were 10 times greater in participants with T2DM (POR 10.8; 95% CI 2.31-50.4), affecting 96.4% of this group. Conclusions: Diabetes prevalence and associated complications were higher than previous estimates, underscoring the challenges in managing diabetes and polypharmacy in participants with PAD. A multidisciplinary approach may improve outcomes.

Analysis and Visualization of Confounders and Treatment Pathways Leading to Amputation and Non-Amputation in Peripheral Artery Disease Patients Using Sankey Diagrams: Enhancing Explainability

Background/Objectives: This study uses Sankey diagrams to analyze treatment pathways in patients with peripheral artery disease (PAD), which is a vascular condition characterized by atherosclerotic occlusion of the arteries, particularly in the lower limbs, affecting up to 14% of the general population. This study focuses on the treatment pathways that lead to amputation versus those that do not, utilizing the STARR dataset and the All of Us dataset. Methods: The study utilized Sankey diagrams to visualize treatment pathways, highlighting the progression from initial treatments to outcomes. Odds ratio analysis was performed to quantify the association between treatment pathways and outcomes. Recognizing potential confounders, analyses were conducted by filtering patients with PAD into subgroups based on these coexisting conditions. Sankey diagrams were then generated for each sub-cohort to visualize treatment pathways. Results: Pathways including antiplatelet and lipid-lowering treatments accounted for 56% of non-amputation cases in the STARR data and 50% in the All of Us data. Amputation pathways frequently included revascularization procedures, representing 15% of amputations in the STARR data and 20% in the All of Us data. Confounder analysis revealed that most amputated PAD patients were over 50 years old and had one or more conditions, such as diabetes, hypertension, or hyperlipidemia. Conclusions: These visualizations provide insights into treatment pathways and their associations with outcomes in PAD patients, highlighting the potential impact of specific treatments on amputation and non-amputation cases. Future work should build on these findings by incorporating predictive models using machine learning techniques to further explore and quantify these relationships.

Discrepancy in opioid prescription patterns for Black or African American patients following lower extremity bypass surgery for chronic limb-threatening ischemia

BACKGROUND

Disparity in the allocation of medical services and resources based on race is present within the health care industry today, including the prescription of postoperative analgesics. The purpose of this study was to evaluate the presence of race-based disparity in the prescription of postdischarge opioids after lower extremity bypass (LEB) surgery for chronic limb-threatening ischemia (CLTI).

METHODS

Retrospective analysis was conducted on adult CLTI patients who underwent LEB from 2000 to 2023 in the TrinetX database. Patients were stratified into two groups based on race: White (group I) and black or African American (AA) (group II). Primary outcomes were defined as oral opioid prescriptions at 7 days and 30 days after discharge, and mortality at 1 year postoperatively. Secondary outcomes included length of stay and 30-day postoperative outcomes, including myocardial infarction, pulmonary embolism, cerebral vascular accident, deep vein thrombosis, acute kidney injury, major amputation, minor amputation, major adverse cardiac events, and major adverse limb events. Stratified analysis was conducted based on disease stage (rest pain vs lower extremity ulcer vs gangrene). Univariate analysis was performed via two-sample t test and χ2 test. Logistic regression was performed to estimate the association of Black or AA (vs White) race while controlling for pertinent preoperative potential confounders.

RESULTS

There were 3345 patients who met the inclusion criteria. Group I included 2661 White patients and group II included 684 Black or AA patients. Group II patients were more likely to be younger, female, present with gangrene, and have a history of hypertension, diabetes, chronic kidney disease, or diabetic neuropathy. At both 7 and 30 days after discharge, the Black or AA cohort had significantly lower rates of opioid prescriptions (33.2% vs 42.5% and 35.8% vs 47.2%, respectively) (all P < .05). Stratification by indication showed that opioid prescription disparity persisted despite black or AA patients presenting at worse stages of disease both at 7 and 30 days after discharge (7 days: rest pain 43.4% vs 33.7% [P = .013], ulcer 41.4% vs 31.7% [P = .027], gangrene, 42.7% vs 33.6% [P = .006] and 30 days: rest pain 47.8% vs 37.1% [P = .007], ulcer 45.4% vs 33.5% [P = .007], gangrene, 48.2% vs 36.1% [P < .001]). Adjusted analysis confirmed that Black or AA race was associated with lower rates of 7- (adjusted odds ratio, 0.607; P = .001) and 30-day (adjusted odds ratio, 0.56; P = .001) postdischarge opioid prescriptions.

CONCLUSIONS

Black or AA patients were less likely to receive postdischarge opioid prescriptions compared with their White counterparts at 7 and 30 days after LEB for CLTI.

Pharmacist-led interventions for vascular surgery patients: a prospective study on reducing drug-related problems

BACKGROUND

Vascular surgery patients are at a high risk of polypharmacy and drug-related problems. Only a limited number of studies have explored the impact of hospital pharmacists being members of a multidisciplinary team in the care of vascular surgery patients. The clinical study (Trial Registration Number NCT04930302, 16th June 2021) aimed to assess the impact of pharmacist-led interventions on the prevalence of drug-related problems among patients hospitalised at the vascular surgery department.

METHODS

The study, conducted at a specialised hospital in Slovakia during a 1-year period, included adult patients with carotid artery disease or lower extremity artery disease, taking ≥3 medications. Medication reconciliation and medication reviews were performed by hospital pharmacists at both admission and discharge. Pharmacist-proposed interventions were documented and communicated to the physician, patients were educated about their medications upon discharge.

RESULTS

Among our study participants (n = 105), the average number of drug-related problems at admission was 2.3 ± 2.1, significantly decreasing to 1.6 ± 1.8 at discharge (p < 0.001). The predominant drug classes associated with drug-related problems were those related to the cardiovascular system (41.9%). At admission, the most frequent drug-related problem was untreated indication (40.3%), mostly caused by the failure to prescribe statin in patients with lower extremity artery disease. The highest acceptance rate of pharmacist-led interventions was at hospital admission (66.1%). More than 50% of patients were classified as those with good understanding of their pharmacotherapy.

CONCLUSIONS

This study demonstrates that pharmacist-led interventions significantly reduce drug-related problems in vascular surgery patients during hospitalisation, contributing to patient safety and clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Trial Registration Number: NCT04930302, 16th June 2021.

Multimodal Prehabilitation for Peripheral Arterial Disease Patients with Intermittent Claudication-A Pilot Randomized Controlled Trial

BACKGROUND

To establish the feasibility and safety of multimodal prehabilitation (MP), and to obtain pilot data on the change in quality of life, functional walking capacity, and the need for surgery for a full-scale trial.

METHODS

Pilot randomized controlled trial that included patients older than 50 years old suffering from moderate to severe intermittent claudication and who were candidates for endovascular revascularization (ER). Participants were excluded if they presented with ischemic rest pain, gangrene or ulceration of the index leg, significant lesions in the iliac vessels, planned surgical bypass, comorbidities in which exercise was contraindicated or if they were unable to speak English or French. Participants were randomized in a 1:1 ratio to 12 weeks of MP or institutional standard of care (unsupervised walking advice). MP consisted of i)1 weekly supervised exercise session; ii) home-based exercise prescription; iii) nutritional counseling and supplementation; iv) smoking cessation therapy; and v) psychosocial support. Feasibility and safety were measured with recruitment and retention rates, as well as the occurrence of any adverse events. In addition, barriers to attend supervised sessions and compliance to each component were assessed. Change in functional walking capacity, health-related quality of life, and the rates of patients deciding not to undergo ER were collected and analyzed throughout the follow-up period of 12 months.

RESULTS

Of the 37 patients referred for eligibility, 27 (73%) accepted to participate in the trial and were randomized. Of the 27 patients included, 24 completed the 12-week program. Adherence to each prehabilitation component was 83% interquartile range [72,93] for supervised exercise, 90% [83,96] for home-based exercise and 69% [45,93] for nutritional sessions. Fifty percent of patients were referred for and underwent psychosocial intervention and 40% of the active smokers enrolled in the smoking cessation program. No adverse events were observed during the program. The 2 main barriers for not fully adhering to the intervention were excessive pain while performing the exercises and the difficulty to keep up with the prescribed exercises. A statistically significant mean change (standard deviation (SD)) was seen in the MP group versus standard of care for functional capacity, mean (SD) 6 Min Walk Test 60 (74) vs. -11 (40) meters P < 0.05, and quality of life mean (SD) VascuQol 1.15 (0.54) vs. -0.3 (1.09) points P < 0.05. There was no statistically significant difference between groups in the rates of patients deciding to undergo ER during the 1-year follow-up period.

CONCLUSIONS

The results of this pilot trial demonstrate that MP is safe and feasible. A 12-week MP program seems to improve quality of life and functional walking capacity to a greater extent than unsupervised walking advice. There is a need for a large-scale trial to investigate the effectiveness of MP at improving quality of life and assessing its impact on the rates of patients deciding not to undergo or delay ER. The long-term functional and quality of life outcomes of the patients deciding to undergo ER after prehabilitation also need to be assessed.

Investigating the Prognostic Potential of Plasma ST2 in Patients with Peripheral Artery Disease: Identification and Evaluation

Soluble interleukin 1 receptor-like 1 (ST2) is a circulating protein demonstrated to be associated with cardiovascular diseases; however, it has not been studied as a biomarker for peripheral artery disease (PAD). Using a prospectively recruited cohort of 476 patients (312 with PAD and 164 without PAD), we conducted a prognostic study of PAD using clinical/biomarker data. Plasma concentrations of three circulating proteins [ST2, cytokine-responsive gene-2 (CRG-2), vascular endothelial growth factor (VEGF)] were measured at baseline and the cohort was followed for 2 years. The outcome of interest was a 2-year major adverse limb event (MALE; composite of major amputation, vascular intervention, or acute limb ischemia). Using 10-fold cross-validation, a random forest model was trained using clinical characteristics and plasma ST2 levels. The primary model evaluation metric was the F1 score. Out of the three circulating proteins analyzed, ST2 was the only one that was statistically significantly higher in individuals with PAD compared to patients without PAD (mean concentration in plasma of 9.57 [SD 5.86] vs. 11.39 [SD 6.43] pg/mL, p < 0.001). Over a 2-year period, 28 (9%) patients with PAD experienced MALE. Our predictive model, incorporating clinical features and plasma ST2 levels, achieved an F1 score of 0.713 for forecasting 2-year MALE outcomes. Patients identified as high-risk by this model showed a significantly increased likelihood of developing MALE (HR 1.06, 95% CI 1.02-1.13, p = 0.003). By combining clinical characteristics and plasma ST2 levels, our proposed predictive model offers accurate risk assessment for 2-year MALE in PAD patients. This algorithm supports risk stratification in PAD, guiding clinical decisions regarding further vascular evaluation, specialist referrals, and appropriate medical or surgical interventions, thereby potentially enhancing patient outcomes.

Inflammatory Protein Panel: Exploring Diagnostic Insights for Peripheral Artery Disease Diagnosis in a Cross-Sectional Study

Cytokine-induced neutrophil chemoattractant 1 (CINC-1), a cluster of differentiation 95 (CD95), fractalkine, and T-cell immunoglobulin and mucin domain 1 (TIM-1) are circulating proteins known to be involved in inflammation. While their roles have been studied in neurological conditions and cardiovascular diseases, their potential as peripheral artery disease (PAD) biomarkers remain unexplored. We conducted a cross-sectional diagnostic study using data from 476 recruited patients (164 without PAD and 312 with PAD). Plasma levels of CINC-1, CD95, fractalkine, and TIM-1 were measured at baseline. A PAD diagnosis was established at recruitment based on clinical exams and investigations, defined as an ankle-brachial index < 0.9 or toe-brachial index < 0.67 with absent/diminished pedal pulses. Using 10-fold cross-validation, we trained a random forest algorithm, incorporating clinical characteristics and biomarkers that showed differential expression in PAD versus non-PAD patients to predict a PAD diagnosis. Among the proteins tested, CINC-1, CD95, and fractalkine were elevated in PAD vs. non-PAD patients, forming a 3-biomarker panel. Our predictive model achieved an AUROC of 0.85 for a PAD diagnosis using clinical features and this 3-biomarker panel. By combining the clinical characteristics with these biomarkers, we developed an accurate predictive model for a PAD diagnosis. This algorithm can assist in PAD screening, risk stratification, and guiding clinical decisions regarding further vascular assessment, referrals, and medical/surgical management to potentially improve patient outcomes.

Prediction of Peripheral Artery Disease Prognosis Using Clinical and Inflammatory Biomarker Data

Purpose

Inflammatory biomarkers associated with peripheral artery disease (PAD) have been examined separately; however, an algorithm that includes a panel of inflammatory proteins to inform prognosis of PAD could improve predictive accuracy. We developed predictive models for 2-year PAD-related major adverse limb events (MALE) using clinical/inflammatory biomarker data.

Methods

We conducted a prognostic study using 2 phases (discovery/validation models). The discovery cohort included 100 PAD patients that were propensity-score matched to 100 non-PAD patients. The validation cohort included 365 patients with PAD and 144 patients without PAD (non-matched). Plasma concentrations of 29 inflammatory proteins were determined at recruitment and the cohorts were followed for 2 years. The outcome of interest was 2-year MALE (composite of major amputation, vascular intervention, or acute limb ischemia). A random forest model was trained with 10-fold cross-validation to predict 2-year MALE using the following input features: 1) clinical characteristics, 2) inflammatory biomarkers that were expressed differentially in PAD vs non-PAD patients, and 3) clinical characteristics and inflammatory biomarkers.

Results

The model discovery cohort was well-matched on age, sex, and comorbidities. Of the 29 proteins tested, 5 were elevated in PAD vs non-PAD patients (MMP-7, MMP-10, IL-6, CCL2/MCP-1, and TFPI). For prognosis of 2-year MALE on the validation cohort, our model achieved AUROC 0.63 using clinical features alone and adding inflammatory biomarker levels improved performance to AUROC 0.84.

Conclusion

Using clinical characteristics and inflammatory biomarker data, we developed an accurate predictive model for PAD prognosis.

Diabetic peripheral arterial disease in COVID-19 pandemic

Both diabetes and peripheral arterial disease (PAD) have complex interactions with COVID-19. PAD is one of the most important underlying factors in the development of diabetic foot. The COVID-19 pandemic has also caused an increase in cardiovascular complications in those with chronic diseases, including diabetics, due to both the thrombophilic course of the viral disease and the lockdown measures applied for prevention. Since both COVID-19 and diabetes mellitus predispose to thrombosis, PAD is likely to have a more severe course in diabetic patients with COVID-19. The aim of our study is to discuss the complications, prophylaxis, and treatment of PAD, which is a serious complication of diabetes, during the pandemic period.

The Identification and Evaluation of Interleukin-7 as a Myokine Biomarker for Peripheral Artery Disease Prognosis

Background/Objectives: Myokines have been demonstrated to be associated with cardiovascular diseases; however, they have not been studied as biomarkers for peripheral artery disease (PAD). We identified interleukin-7 (IL-7) as a prognostic biomarker for PAD from a panel of myokines and developed predictive models for 2-year major adverse limb events (MALEs) using clinical features and plasma IL-7 levels. Methods: A prognostic study was conducted with a cohort of 476 patients (312 with PAD and 164 without PAD) that were recruited prospectively. Their plasma concentrations of five circulating myokines were measured at recruitment, and the patients were followed for two years. The outcome of interest was two-year MALEs (composite of major amputation, vascular intervention, or acute limb ischemia). Cox proportional hazards analysis was performed to identify IL-7 as the only myokine that was associated with 2-year MALEs. The data were randomly divided into training (70%) and test sets (30%). A random forest model was trained using clinical characteristics (demographics, comorbidities, and medications) and plasma IL-7 levels with 10-fold cross-validation. The primary model evaluation metric was the F1 score. The prognostic model was used to classify patients into low vs. high risk of developing adverse limb events based on the Youden Index. Freedom from MALEs over 2 years was compared between the risk-stratified groups using Cox proportional hazards analysis. Results: Two-year MALEs occurred in 28 (9%) of patients with PAD. IL-7 was the only myokine that was statistically significantly correlated with two-year MALE (HR 1.56 [95% CI 1.12-1.88], p = 0.007). For the prognosis of 2-year MALEs, our model achieved an F1 score of 0.829 using plasma IL-7 levels in combination with clinical features. Patients classified as high-risk by the predictive model were significantly more likely to develop MALEs over a 2-year period (HR 1.66 [95% CI 1.22-1.98], p = 0.006). Conclusions: From a panel of myokines, IL-7 was identified as a prognostic biomarker for PAD. Using a combination of clinical characteristics and plasma IL-7 levels, we propose an accurate predictive model for 2-year MALEs in patients with PAD. Our model may support PAD risk stratification, guiding clinical decisions on additional vascular evaluation, specialist referrals, and medical/surgical management, thereby improving outcomes.

Overview and comparison of contemporary Society for Vascular Surgery, American Heart Association/American College of Cardiology, and European Society for Vascular Surgery guidelines for the management of patients with intermittent claudication

Intermittent claudication (IC) is a phenotype of peripheral artery disease that is characterized by pain in the lower extremity muscles during activity that is relieved by rest. Medical management, risk factor control, smoking cessation, and exercise therapy have historically been the mainstays of treatment for IC, but advances in endovascular technology have led to increasing use of peripheral vascular interventions in this patient population. There are meaningful differences in published society guidelines and appropriate use criteria relevant to the management of IC, especially regarding indications for peripheral vascular interventions. The current review aims to highlight similarities and differences between major society recommendations for the management of IC, and to discuss practice trends, disparities, and evidence gaps in the use of peripheral vascular interventions for IC in the context of existing guidelines.

Role and molecular mechanism of Salvia miltiorrhiza associated with chemical compounds in the treatment of diabetes mellitus and its complications: A review

Diabetes mellitus (DM) is one of the most prevalent diseases worldwide, greatly impacting patients' quality of life. This article reviews the progress in Salvia miltiorrhiza, an ancient Chinese plant, for the treatment of DM and its associated complications. Extensive studies have been conducted on the chemical composition and pharmacological effects of S miltiorrhiza, including its anti-inflammatory and antioxidant activities. It has demonstrated potential in preventing and treating diabetes and its consequences by improving peripheral nerve function and increasing retinal thickness in diabetic individuals. Moreover, S miltiorrhiza has shown effectiveness when used in conjunction with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers (ARBs), and statins. The safety and tolerability of S miltiorrhiza have also been thoroughly investigated. Despite the established benefits of managing DM and its complications, further research is needed to determine appropriate usage, dosage, long-term health benefits, and safety.

Bleeding After Dental Extraction in Patients Undergoing Percutaneous Coronary Intervention During Uninterrupted Single and Dual Antiplatelet Therapy

Purpose

This study aimed to assess bleeding risk after exodontia in patients with recent percutaneous coronary intervention during uninterrupted single or dual antiplatelet therapy.

Study design

A total of 100 patients who had a history of percutaneous stent insertion during the past year candidate for extraction of teeth were included in the study. Fifty patients took aspirin 100mg (monotherapy group), and 50 patients took a combination of aspirin 100mg and clopidogrel 75mg (dual therapy group). After exodontia, the bleeding status was categorized as "complete hemostasis," "persistent bleeding," and "delayed bleeding." Personal data, underlying diseases, number of teeth and roots extracted, and type of procedure required for exodontia were statistically analyzed.

Results

No significant difference was observed in the status of bleeding between the two groups regarding sex, age, underlying diseases, number of teeth and roots extracted, and type of procedure (p > 0.05). 39/50 (78%) of monotherapy patients and 32/50 (64%) of dual therapy patients achieved complete hemostasis. Persistent bleeding was noted in 11/50 (22%) of monotherapy participants, and 14/50 (28%) of dual therapy patients. Only 4/50 (8%) of dual therapy patients experienced delayed bleeding. However, these differences were not significant (p = 0.08). All persistent and delayed bleeding was easily controlled via local measures.

Conclusion

Simple or complicated extraction of multiple teeth can be performed safely during the first year after percutaneous coronary intervention without interruption of antiplatelet therapy.

A machine learning algorithm for peripheral artery disease prognosis using biomarker data

Peripheral artery disease (PAD) biomarkers have been studied in isolation; however, an algorithm that considers a protein panel to inform PAD prognosis may improve predictive accuracy. Biomarker-based prediction models were developed and evaluated using a model development (n = 270) and prospective validation cohort (n = 277). Plasma concentrations of 37 proteins were measured at baseline and the patients were followed for 2 years. The primary outcome was 2-year major adverse limb event (MALE; composite of vascular intervention or major amputation). Of the 37 proteins tested, 6 were differentially expressed in patients with vs. without PAD (ADAMTS13, ICAM-1, ANGPTL3, Alpha 1-microglobulin, GDF15, and endostatin). Using 10-fold cross-validation, we developed a random forest machine learning model that accurately predicts 2-year MALE in a prospective validation cohort of PAD patients using a 6-protein panel (AUROC 0.84). This algorithm can support PAD risk stratification, informing clinical decisions on further vascular evaluation and management.

Outcomes and use of healthcare resources after an intervention for chronic limb-threatening ischaemia

BACKGROUND

The fate of patients with chronic limb-threatening ischaemia undergoing revascularization or a primary amputation is unclear. The aim of this study was to assess the postoperative outcomes and post-procedural healthcare resource use/costs over 1 year after revascularization or a primary amputation for chronic limb-threatening ischaemia.

METHODS

The UK Kent Integrated Dataset, which links primary, community, and secondary care for 1.6 million people, was interrogated. All patients with a new diagnosis of chronic limb-threatening ischaemia undergoing revascularization or a major amputation between January 2016 and January 2019 (3 years) were identified. Postoperative events across all healthcare settings and post-procedure healthcare resource use were analysed over 1 year (until the end of 2019).

RESULTS

Overall, 4252 patients with a new diagnosis of chronic limb-threatening ischaemia were identified (65 per cent were male and the mean age was 73 years) between January 2016 and January 2019, of whom 579 (14 per cent) underwent an intervention (studied population); 296 (7 per cent) had an angioplasty, 75 (2 per cent) had bypass surgery, 141 (3 per cent) had a primary major lower limb amputation, 11 had a thrombo-embolectomy (0.3 per cent), and 56 had an endarterectomy (1.3 per cent). Readmissions (median of 2) were similar amongst different procedures within 1 year; bypass surgery was associated with more hospital appointments (median of 4 versus 2; P = 0.002). Patients undergoing a primary amputation had the highest number of cardiovascular events and 1-year mortality. In a linear regression model, index procedure type and Charlson co-morbidity index score were not predictors of appointments in primary/secondary care, community care visits, or readmissions after discharge. There were no statistically significant differences regarding post-procedural healthcare costs between procedures over 1 year.

CONCLUSION

Revascularization is not associated with more hospital, primary/community care appointments or increased post-procedural healthcare costs over 1 year when compared with primary amputation, in people with chronic limb-threatening ischaemia.

Best medical treatment in patients with PAD

Background: Guidelines recommend comprehensive lifestyle change in patients with peripheral arterial disease (PAD) to prevent cardiovascular events and death. When compared with other populations, patients with PAD are less likely to receive best medical therapies (BMT). The aim of this pilot study was to integrate all aspects of BMT in an intervention program and to determine the feasibility of such an approach by highlighting strengths and obstacles of a multi-aspect intervention. Patients and methods: Patients consecutively hospitalized due to symptomatic PAD between 01 December 2021 and 28 February 2022 were included and followed for ten weeks. We randomized into a lifestyle intervention (education on BMT, a list of regional contact data for supervised exercise, weekly counselling by phone for ten times) vs. standard of care (one contact to talk about BMT). Vascular Quality of Life Questionnaire - 6 (VascuQoL-6) was used to collect patient reported outcomes. Results: Of 50 eligible patients 40 agreed to participate (32.5% female, 72.5 years in mean). During follow-up nine patients dropped out (4 in intervention group vs. 5). As for risk factor modification one patient was able to reach a normal weight body-mass-index (BMI) and nine reduced weight. Two patients stopped smoking, three reduced their consumption. The reported adherence to medication was a hundred percent. No patient attended supervised exercise therapy but eight trained at a home-based setting according to guidelines. The mean score of VascuQoL-6 at follow-up was higher in the intervention group compared to the control group (17.4 vs. 13.8 points) at last contact with both groups increasing from baseline. Conclusions: This pilot study followed 40 patients for up to 10 weeks after inpatient treatment while we randomized a multi-aspect lifestyle intervention versus standard of care. Thereby, the current study illustrated the numerous obstacles and provided pragmatic solutions for the planning of studies on BMT in this target population.

Status and influencing factors of frailty in patients with restenosis after percutaneous transluminal angioplasty for peripheral arterial disease: A cross-sectional study

This study aimed to investigate the frailty of patients with restenosis after percutaneous transluminal angioplasty (PTA) for peripheral arterial disease, explore the influencing factors, and determine its key factors to take targeted care measures and provide a basis for further interventional care. We recruited as many eligible subjects as possible and a total of 106 patients with restenosis after PTA for peripheral arterial disease in our hospital finished this study from January 2016 to August 2021. The Shorter 12-item version of health-related quality of life scale, Chinese Tilburg debility scale, Pittsburgh sleep quality index scale and activities of daily living score scale were used for investigation, and the independent influencing factors of patients' frailty were evaluated by multivariate logistic regression analysis. The incidence of frailty in restenosis after PTA was 72.6%. Logistic regression analysis found that high levels of C-reactive protein (odds ratios [OR] = 1.080, 95% confidence interval [CI] 1.012-1.153), diabetes (OR = 2.531, 95% CI 1.024-6.257) and advanced age (OR = 1.170, 95% CI 1.042-1.314) were risk factors for restenosis patients frailty, and higher scores of shorter 12-item version of health-related quality of life scale (OR = 0.889, 95% CI 0.813-0.973) was a protective factor for frailty in these patients. The incidence of debilitation in patients with restenosis after PTA for peripheral arterial disease is high, and high C-reactive protein levels, diabetes mellitus and advanced age are significantly associated with restenosis patients. Improving the quality of life of restenosis patients can reduce the occurrence of frailty.

Sarcopenia is a risk factor for major adverse cardiac events after surgical revascularization for critical limb ischemia

OBJECTIVES

We examined the effect of sarcopenia on early surgical outcomes in patients with critical limb ischemia (CLI) in terms of major adverse cardiac events (MACE) and major adverse limb events (MALE), as well as the value of inflammatory markers of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte ratios (PLR) as indicators of sarcopenia in CLI patients.

METHODS

This was an observational retrospective single-center study. Patients who required surgical revascularization for CLI between October 2015 and December 2020 were identified. Psoas muscle areas were calculated from computed tomography images for psoas muscle index (PMI) calculations. Sarcopenia was defined as PMI < 5.5 cm²/m² for men and PMI < 4.0 cm²/m² for women. Risk factors for 30-day major adverse cardiac events (MACE) and major adverse limb events (MALE) were analyzed. NLR and PLR were compared between sarcopenic and non-sarcopenic patients.

RESULTS

The mean age of 217 study patients was 61.5 ± 10.9, and 16 (7.4%) patients were female. 82 (37.8%) patients were sarcopenic. Patients with sarcopenia were older (65.1 ± 9.3 vs 59.4 ± 11.2, p < .001) and history of myocardial infarction was more frequent (23.2% vs 12.6%, p = 0.042) among sarcopenic patients. Sarcopenic patients more frequently encountered MACE (9.8% vs 0.7%, p = 0.002), but not MALE. Sarcopenia increased early postoperative MACE in our cohort with an odds ratio of 11.925. NLR was not different between the two groups, while PLR was higher (127.16 vs 104.06, p = 0.010) among sarcopenic patients. The platelet-to-lymphocyte ratio of 125.11 had a sensitivity of 53.7% and a specificity of 68.1% for differentiating sarcopenia.

CONCLUSIONS

Sarcopenia was associated with more frequent 30-day MACE and perioperative mortality after revascularization for CLI. 30-day MALE was not increased in patients with sarcopenia. The use of PLR as a simple marker of sarcopenia is limited by its low sensitivity and specificity.

Factors that influence the feasibility and implementation of a complex intervention to improve the treatment of peripheral arterial disease in primary and secondary care: a qualitative exploration of patient and provider perspectives

OBJECTIVES

Our aim was to examine the feasibility and implementation of a complex intervention to improve the care of patients with peripheral arterial disease (the LEGS intervention) from the perspective of patients, general practitioners and secondary care clinicians.

DESIGN

A qualitative study involving semistructured individual interviews with patients and providers to gain an understanding of the feasibility of the LEGS intervention as well the barriers and facilitators to implementation in secondary and primary care.

SETTING

Primary and secondary care settings across two National Health Service Trusts.

PARTICIPANTS

Twenty-five semistructured telephone interviews were conducted with (1) patients who had received the intervention (n=11), (2) secondary care clinicians responsible for delivering the intervention (n=8) and (3) general practitioners (n=6).

ANALYSIS

Data were initially analysed using inductive descriptive thematic analysis. The consolidated framework for implementation research was then used as a matrix to explore patterns in the data and to map connections between the three participant groups. Lastly, interpretive analysis allowed for refining, and a final coding frame was developed.

RESULTS

Four overarching themes were identified: (1) the potential to make a difference, (2) a solution to address the gap in no man's land, (3), prioritising and making it happen and (4) personalised information and supportive conversations for taking on the advice. The impetus for prioritising and delivering the intervention was further driven by its flexibility and adaptability to be tailored to the individual and to the environment.

CONCLUSIONS

The LEGS intervention can be tailored for use at early and late stages of peripheral arterial disease, provides an opportunity to meet patient needs and can be used to promote shared working across the primary-secondary care interface.

A Community and Hospital cAre Bundle to improve the medical treatment of severe cLaudIcation and critical limb iSchaemia (CHABLIS)

Background

Patients with peripheral artery disease (PAD) often do not receive optimal best medical therapy (BMT). Through interaction with patients and healthcare-professionals (HCPs) we developed the LEaflet Gp letter Structured checklist (LEGS) complex clinical intervention to support HCPs in providing guideline-compliant PAD BMT.

Methods

This was a prospective multicentre study assessing the feasibility and fidelity of delivering the LEGS intervention in primary and secondary care over six months. Intervention fidelity was scored based on the proportion of intervention components used correctly at discharge, 30 days, and six months.

Results

Overall, 129 individuals were screened and 120 took part (33% female, 74% with chronic limb threatening ischaemia; 93% recruitment rate). Of those, 118 (98% retention rate) completed follow-up. Mean intervention fidelity score at discharge (primary outcome measure) was 63% [95% Confidence Interval (CI): 39-68%, SD: 5%], exceeding the success criteria set at 60% by a panel of HCPs and patients. This, however, declined to 51% at six months. Eight patients (6.7%) died (all cardiovascular deaths), four (3.3%) had a major lower limb amputation, 12 (10%) had a cardiovascular event, and 13 (11%) were admitted due to limb ischaemia at six months. Incomplete lipid therapy prescriptions and LEGS intervention documents not received by primary care CHPs were the most common reasons for not complying with the LEGS intervention.

Conclusions

The LEGS intervention can be delivered in PAD care pathways across different hospitals, primary, and community healthcare settings with acceptable fidelity, to streamline and improve PAD BMT short- and medium-term.

Predictive value of 10-year atherosclerotic cardiovascular disease risk equations from the China-PAR for new-onset lower extremity peripheral artery disease

Lower extremity peripheral artery disease (LEPAD) is a common and serious health-threatening disease. The aim of this study was to evaluate the predictive value of 10-year atherosclerotic cardiovascular disease (ASCVD) risk equations from the Prediction for ASCVD Risk in China (China-PAR) project for incident LEPAD after 6.75 ± 0.13 years of follow-up. A total of 3,595 Chinese participants without baseline ASCVD or LEPAD from a community-based cohort were enrolled in our study. The mean (interquartile range) baseline 10-year China-PAR ASCVD risk was 4.35% (2.24–8.44%), and the incidence of new-onset LEPAD during 6.75 ± 0.13 years was 4.23%. In univariable logistic regression analysis, 10-year China-PAR ASCVD risk was significantly associated with LEPAD incidence (odds ratio [OR] for each 1% increase in the risk score = 1.06, 95% confidence interval [CI]: 1.03–1.08, P < 0.001). After adjusting confounders, the relationship remained significant (OR: 1.09, 95% CI: 1.05–1.1. P < 0.001). Participants with the highest risk (≥10%) had significantly increased risk compared to those with the lowest risk (<5%) (OR = 2.65, 95% CI: 1.15–6.07, P = 0.022). Further interaction analyses showed no evidence of heterogeneity according to sex, age, body mass index (BMI), smoking, drinking, hypertension, diabetes mellitus, dyslipidemia, renal function, waist circumference, and family history. In conclusion, 10-year China-PAR ASCVD risk independently predicted the risk of new-onset LEPAD in a Chinese community-based population, indicating the importance of polyvascular diseases (PVDs) and the intrinsic interactions of its components.

Underutilization of medical management of peripheral artery disease among patients with claudication undergoing lower extremity bypass

OBJECTIVE

First-line treatment of peripheral artery disease (PAD) involves medical therapy and lifestyle modification. Multiple professional organizations such as the Society for Vascular Surgery and the American Heart Association/American College of Cardiology make Class I recommendations for medical management including antiplatelet, statin, antihypertensive, and cilostazol medications, as well as lifestyle therapy including exercise and smoking cessation. Although evidence supports up-front medical and lifestyle management prior to surgical intervention, it is unclear how well this occurs in contemporary clinical practice. It is also unclear whether variability in first-line treatment prior to revascularization is associated with postoperative outcomes. This study examined the proportion of patients with claudication actively receiving evidence-based therapy prior to surgery in a statewide surgical registry.

METHODS

We conducted a retrospective cohort study of adult patients undergoing elective open lower extremity bypass for claudication from 2012 to 2021 within a statewide surgical quality registry. The primary exposure was optimal medical therapy, defined as an antiplatelet agent, a statin, and an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (if the patient had hypertension) on the patient's home medication list on admission for surgery, all of which are Class I recommendations. Despite also being Class I recommendations, cilostazol was not included in the primary exposure due to its highly selective use and our inability to capture intolerance and/or contraindications that are common, and lifestyle therapies were not included as they were only recorded at the time of discharge rather than preoperatively. The primary outcomes were mortality, hospital readmission, amputation, wound complication, myocardial infarction (MI), non-patent bypass, and non-independent ambulatory status at 30 days and 1 year after surgery. Multivariable logistic regression was performed to estimate the association of receiving optimal vs non-optimal medical therapy.

RESULTS

A total of 3829 patients with claudication underwent bypass surgery during the study period, with a mean age of 64.8 years (standard deviation, 9.8 years); 2690 (70.3%) were males, and 1873 (48.9%) were current smokers. Of the patients, 1822 (47.6%) were on optimal medical therapy prior to surgery. Additionally, at discharge, 66.5% of smokers received referral to smoking cessation therapy, and 54.1% of patients received referral to exercise therapy. In a multivariable logistic regression, compared with patients not on optimal medical therapy, patients on optimal medical therapy prior to surgery had lower 30-day odds of mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.26-0.78) and MI (aOR, 0.46; 95% CI, 0.28-0.76), lower 1-year odds of mortality (aOR, 0.57; 95% CI, 0.39-0.82), MI (aOR, 0.48; 95% CI, 0.32-0.74), and lower readmission (aOR, 0.79; 95% CI, 0.64-0.96).

CONCLUSIONS

Although medical and lifestyle management is recommended as first-line treatment for patients with PAD, only one-half of patients were on optimal medical therapy prior to surgery. Patients receiving optimal therapy had a lower risk of postoperative mortality, MI, and readmission. This suggests that not only are there significant opportunities to improve clinical utilization of evidence-based treatment of PAD, but that doing so can benefit patients postoperatively.

Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD)

Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.

Prediction of risk factors for intraoperative hypotension during general anesthesia undergoing carotid endarterectomy

Objective

Carotid endarterectomy (CEA) has been considered as “gold standard” treatment for patients with significant carotid stenosis Intra-operative hypotension was a risk factor for post-operative complications in patients undergoing CEA. This study aimed to investigate the predictors for intra-operative hypotension during CEA.

Methods

This retrospective study included consecutive patients underwent CEA from June 1, 2020 to May 31, 2021 in the neurosurgery department of Xuanwu Hospital, Capital Medical University. The intraoperative hypotension was defined as blood pressure (BP) of 20% below standard value for longer than 5 min. Univariable and multivariable analyses were performed to identify the prediction of risk factors for intraoperative hypotension.

Results

Overall, 367 patients were included, and 143 (39.0%) patients had hypotension during CEA procedure. Univariate analysis indicated Grade 3 hypertension (P = 0.002), peripheral artery disease (P = 0.006) and shunting (P = 0.049) were associated with occurrence of intraoperative hypotension during CEA procedure. On multivariable analysis, Grade 3 hypertension (P = 0.005), peripheral artery disease (P = 0.009), and shunting (P = 0.034) were all found to be independent predicting factors of hypotension during the CEA process.

Conclusion

Intraoperative hypotension is a dynamic phenomenon may be affected by patients with grade 3 hypertension, peripheral artery disease and intra-operative shunting. It is necessary to pay special attention to these patients, both intraoperatively and postoperatively, to improve the final clinical outcome.

Impact of risk factor control on peripheral artery disease outcomes and health disparities

BACKGROUND

Peripheral artery disease (PAD) is associated with modifiable atherosclerotic risk factors like hypertension, diabetes, hyperlipidemia, and smoking. However, the effect of risk factor control on outcomes and disparities in achieving control is less well understood.

METHODS

All patients in an integrated, regional health system with PAD-related encounters, fee-for-service Medicare, and clinical risk factor control data were identified. Component risk factors were dichotomized into controlled and uncontrolled categories (control defined as low-density lipoprotein < 100 mg/dL, hemoglobin A1c < 7.0%, SBP < 140 mmHg, and current nonsmoker) and composite categories (none, 1, ⩾ 2 uncontrolled RFs) created. The primary outcome was major adverse vascular events (MAVE, a composite of all-cause mortality, myocardial infarction, stroke, and lower-extremity revascularization and amputation).

RESULTS

The cohort included 781 patients with PAD, average age 72.5 ± 9.8 years, of whom 30.1% were Black, and 19.1% were Medicaid dual-enrolled. In this cohort, 260 (33.3%) had no uncontrolled risk factors and 200 (25.6%) had two or more uncontrolled risk factors. Patients with the poorest risk factor control were more likely to be Black (p < 0.001), Medicaid dual-enrolled (p < 0.001), and have chronic limb-threatening ischemia (p = 0.009). Significant differences in MAVE by degree of risk factor control were observed at 30 days (none uncontrolled: 5.8%, 1 uncontrolled: 11.5%, ⩾ 2 uncontrolled: 13.6%; p = 0.01) but not at 1 year (p = 0.08). risk factor control was not associated with outcomes at 1 year after adjustment for patient and PAD-specific characteristics.

CONCLUSIONS

risk factor control is poor among patients with PAD. Significant disparities in achieving optimal risk factor control represent a potential target for reducing inequities in outcomes.

Effectiveness of (Active) Lifestyle Interventions in People With a Lower Limb Amputation: A Systematic Review

Objective

To explore the effectiveness of (active) lifestyle interventions for the health of people with a lower limb amputation in order to offer effective interventions during rehabilitation that may improve physical and psychosocial functioning of people with lower limb amputation.

Data Sources

PubMed, CINAHL and Embase were searched from inception to February 2021.

Study Selection

Inclusion criteria were (1) (quasi-)randomized controlled trial; (2) minimum of 10 participants with a lower limb amputation; (3) lifestyle intervention focusing on physical activity, smoking habits, alcohol use, nutrition, and/or stress management; (4) focus on health outcomes; (5) participants older than 18 years; (6) studies in Dutch, German, or English; and (7) primary research. Title, abstract, and full-text screening and quality assessment were performed by 2 independent assessors.

Data Extraction

Of 2460 studies identified, 13 studies were included in this review. Two studies were of moderate methodological quality, 2 studies were of medium quality, and 9 studies were of poor quality.

Data Synthesis

Lifestyle interventions in the included studies focused on physical activity and stress management. These interventions seemed effective for improving physical fitness, walking capacity, changes in body mass, quality of life, and intensity of physical activity.

Conclusion

Lifestyle interventions focusing on physical activity and stress management seem effective for improving physical and psychosocial functioning of people with a lower limb amputation. However, the findings should be interpreted with caution given the limited methodological quality of the included studies. Future research should evaluate the effectiveness of interventions on nutrition, smoking habits, and alcohol use and the effectiveness of combined interventions in people with a lower limb amputation.

Independent predictors of major adverse cardiovascular events at 3 years after aortoiliac stent implantation

PURPOSE

To identify risk factors for major adverse cardiovascular events (MACE) in real-world practice for symptomatic peripheral artery disease (PAD) in Japan.

MATERIALS AND METHODS

Data on Japanese patients (N=880) from the Observational prospective Multicenter registry study on Outcomes of peripheral arTErial disease patieNts treated by AngioplaSty tHerapy for aortoIliac artery (OMOTENASHI) who underwent de novo aortoiliac stent placement. The 3-year risk of incident MACE was investigated.

RESULTS

The median age of the patients was 72.6 years (range, 34-97 years), and 83.1% were male. Patients had the following conditions: smoking, 35.6%; hypertension, 94.1%; dyslipidemia, 81.7%; diabetes, 48.0%; renal failure on dialysis, 12.6%; myocardial infarction, 12.7%; stroke, 15.8%; and chronic limb-threatening ischemia (CLTI), 7.1%. Femoropopliteal lesions were present in 38.8% of the limbs with aortoiliac lesions. The 3-year rate of freedom from MACE was 89.1%. The baseline characteristics age, renal failure on dialysis, myocardial infarction, stroke, and femoropopliteal lesions were independently associated with the risk of incident MACE. When the study population was stratified according to these risk factors, the rate of MACE was highest in patients with at least 3 risk factors (32.9% at 3 years).

CONCLUSION

The 3-year rate of freedom from MACE was reported. The baseline characteristics age, renal failure on dialysis, myocardial infarction, stroke, and femoropopliteal lesions are independent risk factors for MACE after aortoiliac stent placement.

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

Background and aims

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

Methods

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

Results

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

Conclusion

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

Association Between Cumulative Exposure to Increased Low-Density Lipoprotein Cholesterol and the New Occurrence of Peripheral Artery Disease

Background and Purpose: Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis with increased risk of severe cardiovascular and cerebrovascular events. The relationship between one-time measuring of low-density lipoprotein cholesterol (LDL-C) and PAD is inconsistent. Increasing evidence shows that the predictive value of non-high-density lipoprotein cholesterol (non-HDLC) on atherosclerosis disease is superior to LDL-C. We aimed to investigate the relationship between cumulative exposure to increased LDL-C and the risk of newly developed PAD and compare the predictive value of LDL-C with non-HDLC. Materials and Methods: In the Asymptomatic Polyvascular Abnormalities Community study, we enrolled 2,923 participants with LDL-C and non-HDLC measured every 2 years from 2006 to 2012. Cumulative exposure to increased LDL-C and non-HDLC, defined as LDL-C burden and non-HDLC burden, respectively, was calculated as the weighted sum of the difference between the measured value and the cutoff value. A new occurrence of PAD was identified through ankle brachial index measured in 2010 and 2012. Multivariate models were adopted to analyze the association of LDL-C burden and non-HDLC burden with the newly developed PAD. The receiver operating curve was drawn, and the area under the curve was calculated to compare the predictive performance of LDL-C burden with a single measure of LDL-C in 2006 and non-HDL-C burden adjusted with a model including traditional risk factors. Results: Of the 2,923 participants, 5.4% (158/2,923) were diagnosed as newly developed PAD. In the univariate analysis, the highest quartile of LDL-C burden was significantly associated with new occurrence of PAD [odds ratio (OR) 1.75, 95% confidence interval (CI) 1.13-2.73]. After adjustment for confounding factors, the same result was obtained (OR 1.59, 95%CI 1.01-2.49). The non-HDLC burden failed to show any statistical significance on the newly developed PAD (OR 1.31, 95% CI 0.84-2.04). Though LDL-C burden had a tendency to show better predictive performance than non-HDLC, it did not reach statistical significance (AUCLDL-C = 0.554 vs. AUCnon-HDLC = 0.544, P = 0.655). Conclusions: Cumulative exposure to increased LDL-C is an independent risk factor of newly developed PAD. The predictive value of non-HDLC burden was not revealed.

Quality of economic evaluations of drug-coated balloons and drug-eluting stents in peripheral artery disease: a systematic review

OBJECTIVE

We aimed to perform a systematic review of economic evaluations of drug-coated balloons (DCBs) and drug-eluting stents (DESs) in peripheral artery disease (PAD) and to assess the level of evidence of relevant studies. The purpose was not to present economic findings.

METHODS

A systematic review was performed using four electronic databases to identify health economic evaluation studies reporting on the use of DCBs and DESs in PAD. The methodological and reporting quality of the studies was assessed using three different tools, the Drummond, Cooper, and CHEERS (Consolidated Health Economic Evaluation Reporting Standards) checklists.

RESULTS

Six articles were included in this review of the 1,728 publications identified. Four studies were cost-effectiveness analyses and two cost-utility analyses. According to the Cooper hierarchy scale, the studies used good-quality data sources. The level of evidence used for clinical effect sizes, safety data, baseline clinical data, and costs was of high quality in general. In contrast, an evaluation of the reporting quality suggested that essential information was lacking.

CONCLUSION

The present study demonstrates that clinical data used in economic evaluations of DCBs and DESs in PAD are from clinical studies of high quality in general. However, the quality of reporting represents a concern when interpreting the results provided by these economic studies.

Medical Management of Peripheral Arterial Disease: Deciphering the Intricacies of Therapeutic Options

Due to the pathophysiology of atherosclerosis, the management for coronary artery disease and peripheral arterial disease (PAD) were considered homogenous, with therapies focused on the use of lipid-lowering medications, antiplatelet therapy, glucose control, and blood pressure management. However, more recently, studies have supported the use of tailored therapeutics and medical targets for patients with PAD that sometimes differ from those for coronary artery disease. Moreover, we are now witnessing large randomized PAD-specific trials that have altered therapeutic regimens and targets. Given these updates, dissemination of knowledge is lacking, as evidenced by discordant guideline recommendations. This comprehensive review provides an overview of contemporary therapeutic options for secondary prevention for patients with PAD.

Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis

AIMS

Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes.

METHODS AND RESULTS

This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations.

CONCLUSION

Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

A systematic review and meta-analysis of gender differences in long-term mortality and cardiovascular events in peripheral artery disease

OBJECTIVE

Individual studies of peripheral artery disease (PAD) have indicated that gender discrepancies exist in the symptoms, functional status, and treatment usage. It remains uncertain whether these discrepancies result in different long-term outcomes. We examined the potential gender differences in mortality and major adverse cardiovascular events (MACE) in patients with symptomatic PAD.

METHODS

The PubMed and Embase databases were searched for studies from 2000 to January 2019. After a review of 13,582 citations, 14 articles were analyzed. The reported age-adjusted hazard ratios (HRs) for gender differences in mortality and MACE were included in the meta-analysis. The mortality outcomes were stratified according to the clinical presentation and study context.

RESULTS

Male gender was associated with a greater risk of all-cause mortality (HR, 1.13; 95% confidence interval [CI], 1.10-1.16; P < .001) and MACE (HR, 1.10; 95% CI, 1.06-1.14; P < .001). In a stratified analysis, male gender was associated with a higher mortality risk for patients presenting with either critical limb ischemia (HR, 1.08; 95% CI, 1.05-1.10; P < .001) or mixed clinical presentations (HR, 1.16; 95% CI, 1.11-1.21; P < .001) but not for those with intermittent claudication (HR, 1.13; 95% CI, 0.98-1.30; P = .09). Elevated mortality risk was evident after revascularization (HR, 1.11; 95% CI, 1.04-1.19; P = .003), hospitalization (HR, 1.15; 95% CI, 1.08-1.22; P < .001), and amputation (HR, 1.09; 95% CI, 1.08-1.10; P < .001), although not in outpatient clinics (HR, 1.13; 95% CI, 0.97-1.32; P = .13), in men compared with women.

CONCLUSIONS

Greater mortality and MACE rates in men with PAD occurred despite other accepted gender disparities. The mechanisms underlying these gender differences in the outcomes for PAD patients require further investigation.

Combined Exercise and Nutrition Optimization for Peripheral Arterial Disease: A Systematic Review

BACKGROUND

Patients with peripheral arterial disease (PAD) who suffer from claudication have a low exercise capacity, poor quality of life, and often severe disability. Exercise and healthy nutrition have been shown to be important factors to prevent disease progression. This systematic review aims to assess the evidence supporting the use of combined nutrition and structured exercise in patients with intermittent claudication.

METHODS

Publications that included a combination of structured exercise (SE) and a nutritional intervention and that reported quality of life, exercise capacity, pain-free walking distance, limb blood flow hemodynamics, need for revascularization surgery, or surgical outcomes were systematically searched. Publications were screened, selected, and reviewed by 2 independent reviewers.

RESULTS

Four publications were found reporting the effects of combined SE and nutrition programs. Pooled statistical analysis across trials was not performed because of the heterogeneity of study designs and type of interventions. Only 2 randomized controlled trials were found, reporting conflicting results with regard to the effects of combined SE and nutrition on exercise capacity. Only one trial reported quality of life measures. Blood flow was increased in the intervention involving inorganic nitrate in addition to SE.

CONCLUSIONS

There are conflicting results and lack of quality data proving the benefit of nutrition and SE programs on patient-centered outcomes and limb blood flow. There are no data on the effects of combined nutrition and exercise on the need for revascularization surgery or postrevascularization outcomes. More randomized controlled trials are needed to assess the effects of multimodal interventions on patient-centered outcomes and clinical outcomes of PAD.

Post-extraction bleeding complications in patients on uninterrupted dual antiplatelet therapy-a prospective study

BACKGROUND

Dental surgeons consider patients on antiplatelet therapy (APT) to be at a risk for perioperative bleeding during dental extraction. This fear often prompts them to consider a temporary withdrawal of the medication for a few days before extraction. Such withdrawal can have serious consequences, especially in patients on dual antiplatelet therapy (DAPT).

OBJECTIVES

The purpose of this study was to analyze if patients on uninterrupted DAPT undergoing dental extractions had an increased risk of bleeding complications when compared with patients on no antiplatelet therapy.

METHODS

This prospective study included 120 DAPT patients and an equal number of age- and gender-matched non-APT patients undergoing dental extractions. Immediate and delayed bleeding complications in both groups were recorded. Interventions required to control the post-extraction hemorrhage were also analyzed.

RESULTS

Duration of DAPT medication ranged from 6 months to 13 years. Post-percutaneous coronary intervention was the most common cause for DAPT. A vast majority of patients in both groups underwent extraction of one or two teeth. Patients on DAPT had a 7-fold increased risk of immediate bleeding complications when compared with control group. All bleeding episodes were controlled with local hemostatic measures. Transalveolar extractions and localized periodontitis had a significant relationship to bleeding complications.

CONCLUSION

This study observed an increase in the risk of prolonged bleeding in uninterrupted DAPT patients undergoing dental extractions. Bleeding episodes were amenable to local hemostatic measures with favorable outcomes.

CLINICAL RELEVANCE

Dental extractions in patients on uninterrupted DAPT can be done safely. Resorting to temporary withdrawal of DAPT due to a fear of excessive bleeding is unnecessary.

Ideal Cardiovascular Health Metrics on the New Occurrence of Peripheral Artery Disease: A Prospective Cohort Study in Northern China

Peripheral artery disease (PAD) is a common atherosclerotic disease which could lead to severe cardiovascular and cerebrovascular events. Previous studies have indicated the ideal cardiovascular health (ICVH) was associated with many atherosclerotic diseases and cardiovascular events. This study aimed to find out the relationship between ICVH metrics and the new occurrence of PAD. We collected information of baseline from 2010 on the seven ICVH metrics (including smoking, body mass index, dietary intake, physical activity, blood pressure, total cholesterol and fasting blood glucose); and assessed PAD by ankle brachial index among the enrolled participants. The relationship between the ICVH metrics and new occurrence of PAD was analyzed using the multivariate logistic regression in 2018. There were 214 participants were diagnosed with the new occurrence of PAD during the follow-up visit. Participants with PAD tend to be older, with a lower level of education and a higher morbidity of hypertension. Among the seven ICVH metrics, BMI seems to be the most sensitive metric to the occurrence of PAD after adjusting the other risk factors (HR (95% CI) = 0.704 (0.529-0.937), P = 0.0163). We further found out as the number of ICVH metric increased, the morbidity of PAD decreased gradually (HR (95% CI) = 0.888 (0.801-0.984), P for trend= 0.0240). There is no difference between different age and gender groups. The ICVH metrics affect the new occurrence of PAD in a Chinese population. It enhances the importance of ideal health behaviors and factors in the prevention of PAD.

Pathophysiology of chronic peripheral ischemia: new perspectives

Peripheral arterial disease (PAD) affects individuals particularly over 65 years old in the more advanced countries. Hemodynamic, inflammatory, and oxidative mechanisms interact in the pathophysiological scenario of this chronic arterial disease. We discuss the hemodynamic, muscle tissue, and oxidative stress (OxS) conditions related to chronic ischemia of the peripheral arteries. This review summarizes the results of evaluating both metabolic and oxidative markers, and also therapy to counteract OxS. In conclusion, we believe different pathways should be highlighted to discover new drugs to treat patients suffering from PAD.

Peripheral Vascular Disease and Implication of Nursing Practice: A Brief Literature Review

Nowadays nurse practitioners are working in several acute hospital settings in different specialized departments. For decades, studies have shown the implications of nurse practice in peripheral vascular disease (PVD) and peripheral vascular intervention (PVI) to have several major benefits. However, there are very limited studies and data on this particular aspect. In this literature review, we briefly discuss the implication of nursing practice in PVD/PVI. This review briefly shows that nursing practice has a major contribution and implication in the treatment of patients with PVD or PVI, especially in patients with diabetes mellitus. From available research, we briefly discuss the implication of nursing practice pre- and postoperatively for PVI. Nurses also contribute significantly in catheter-directed thrombolytic therapy, in smoking cessation programs organized for patients with PVD, and in screening patients for PVD. The vascular nurse practitioners are also involved in providing healthcare advice in order to reduce the risk of disease progression. The major lack of research in this particular field should further inspire scientists to develop and carry out research to further investigate and demonstrate the contribution of nurses in the treatment and management of PVD or PVI, which is gradually becoming a major issue.

Entering Cardiac Rehabilitation With Peripheral Artery Disease: A RETROSPECTIVE COMPARISON TO CORONARY ARTERY DISEASE

PURPOSE

Supervised exercise is recommended for patients with peripheral artery disease (PAD) and patients with coronary artery disease (CAD). Both conditions share common etiology as atherosclerotic diseases. The clinical profile, cardiorespiratory fitness, and exercise prescriptions of PAD, CAD, and patients with concomitant PAD and CAD (BOTH) have yet to be compared upon entry into cardiac rehabilitation (CR).

METHODS

Cardiopulmonary, demographic, and anthropometric assessments were conducted at entry to CR between January 2006 and December 2017.

RESULTS

Among 9701 consecutively enrolled patients, there were 94.6% with CAD (n = 9179), 1.5% with PAD (n = 143), and 3.9% with BOTH (n = 379). Only 5.4% (n = 522) of all patients entering CR had a diagnosis of PAD. Compared with CAD, patients with PAD and BOTH were older (mean ± SD = 62.5 ± 11.1 vs 67.9 ± 11.4 and 69.2 ± 9.8 yr, P < .01), had higher resting systolic blood pressure (124 ± 17 vs 130 ± 17 and 133 ± 18 mm Hg, P < .01), had lower cardiorespiratory fitness (19.7 ± 6.3 vs 15.6 ± 4.8 and 15 ± 4.5 mL/kg/min, P < .01), and were more likely to have diabetes (25% vs 35% and 41%, P < .01), abdominal obesity (39% vs 54% and 51%, P < .01), and initially prescribed lower-intensity exercise (84.4 ± 14.1 vs 74.1 ± 15.7 and 70.0 ± 14.6 m/min exercise pace, P < .01), reflecting the complex nature of patients diagnosed with PAD.

CONCLUSIONS

Patients referred with PAD have a cardiovascular risk profile that places them at a greater risk for a repeat or first cardiac event compared with patients with CAD. Referral to structured exercise and risk factor modification programs should be considered to aid in the management of PAD.

National assessment of availability, awareness, and utilization of supervised exercise therapy for peripheral artery disease patients with intermittent claudication

BACKGROUND

Supervised exercise therapy (SET) is an inexpensive, low-risk, and effective option when compared with invasive therapies for the treatment of patients with peripheral artery disease (PAD) and intermittent claudication. Randomized, controlled trials have demonstrated the benefits of SET in improving maximum walking distance in intermittent claudication patients, and society guidelines recommend SET as first-line therapy. In 2017, the Centers for Medicare & Medicaid Services (CMS) added coverage of SET. We aimed to evaluate the availability and use of SET programs, determine the awareness of SET CMS coverage in the United States, and gauge the academic interest in SET in the vascular community.

METHODS

An eight-question online survey regarding SET coverage, reimbursement, barriers to prescription, and SET use was sent to 900 vascular surgeons, cardiologists, and vascular medicine physicians across the United States. The most recent 2-year programs for the Vascular Annual Meeting, Midwestern Vascular Society, Eastern Vascular Society, and Western Vascular Society were reviewed to identify SET-related abstracts and gauge academic interest and awareness for SET within the vascular surgery community.

RESULTS

We received 135 physician responses (15%) to the survey. All 50 states were represented. The majority of responders (54%) stated that there was no SET program at their facility, and 5% did not know if there was a SET program available. Of those who did have a SET program available, 81% were associated with cardiac rehabilitation and 19% had a PAD-specific program. A significant number of physicians (49%) had never referred a patient for SET. Twenty-six percent were not aware that CMS covered SET sessions. Of the physicians who were aware of CMS reimbursement, 36% had never referred a patient to a SET program. Of all surveyed, 98% indicated they would refer patients to a SET program if one was available. Top barriers to use of a SET program included (1) no SET center availability and (2) significant cost or travel expense to the patient. A review of major vascular surgery meeting programs for the last 2 years yielded no identification of a SET-related abstract.

CONCLUSIONS

There is a lack of both availability and use of SET for patients with PAD with claudication, despite guideline recommendations and CMS reimbursement for SET sessions in the United States. When SET is offered, it is typically through cardiac rehabilitation programs which is not focused on PAD. Travel distance, lack of SET program availability, and low reimbursement rates are primary areas that could be addressed to improve use.