Real-world outcomes of endovascular treatment in a non-selected population with peripheral artery disease - prospective study with 2-year follow-up

Rationale and design for the randomized placebo-controlled double-blind trial studying the effect of single antiplatelet therapy (clopidogrel) versus dual antiplatelet therapy (clopidogrel/acetylsalicylic acid) on the occurrence of atherothrombotic events following lower extremity peripheral transluminal angioplasty (CLEAR-PATH)

RATIONALE

Antiplatelet therapy (APT) is the standard of care after endovascular revascularization (EVR) in patients with peripheral artery disease (PAD). APT aims to prevent both major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nonetheless, the rates of MACE and MALE after EVR remain high. In coronary artery and cerebrovascular disease, dual APT (DAPT)compared to acetylsalicylic acid alone has been proven to reduce MACE without increasing the risk of major bleeding when applied for a restricted number of weeks. However, within the PAD population, insufficient data are available to understand the potential attributable effect of DAPT over single APT (SAPT). Therefore, prospective randomized studies in targeted study populations are warranted.

TRIAL DESIGN

CLEAR-PATH is a Dutch multicenter, double-blind, placebo-controlled, randomized trial comparing SAPT (clopidogrel 75 mg plus placebo) with DAPT (clopidogrel 75 mg plus acetylsalicylic acid 80 mg) in patients with PAD undergoing EVR. CLEAR-PATH includes a time-to-event analysis with a follow-up of one year. The primary composite efficacy endpoint consists of all-cause mortality, nonfatal stroke, nonfatal myocardial infarction, severe limb ischemia, (indication for) re-intervention due to any symptomatic restenosis, re-occlusion, or due to acute limb ischemia, and major amputation. The primary safety endpoint contains major bleeding following the Thrombolysis in Myocardial Infarction classification. The enrolment started in August 2022. In total 450 primary efficacy outcome events are required which expectedly amounts to 1696 subjects. Recruitment will take approximately 36 months.

CONCLUSION

CLEAR-PATH will assess the efficacy and safety of DAPT compared to SAPT following EVR in PAD patients.

TRIAL REGISTRATION NUMBER

NL80009.041.21.

In-patient characteristics of peripheral artery disease in Germany

Background: Peripheral artery disease (PAD) frequently leads to hospital admission. Sex related differences in in-patient care are a current matter of debate. Patients and methods: Data were provided from the German national in-patient sample provided by the Federal Bureau of Statistics (DESTATIS). Trends on risk profiles, therapeutic procedures, and outcomes were evaluated from 2014 until 2019 stratified by sex and PAD severity. Results: Two-thirds of an annual >191,000 PAD in-patient cases applied to male sex. Chronic limb-threatening ischemia (CLTI) was recorded in 49.6% of male and 55.2% of female cases (2019). CLTI was as a major risk factor of in-hospital amputation (OR 229) and death (OR 10.5), whereas endovascular revascularisation (EVR) with drug-coated devices were associated with decreased risk of in-hospital amputation (OR 0.52; all p<0.001). EVR applied in 47% of CLTI cases compared to 71% in intermittent claudication (IC) irrespective of sex. In-hospital mortality was 4.3% in male vs. 4.8% in female CLTI cases, minor amputations 18.4% vs. 10.9%, and major amputation 7.5% vs. 6.0%, respectively (data 2019; all p<0.001). After adjustment, female sex was associated with lower risk of amputation (OR 0.63) and death (OR 0.96) during in-patient stay. Conclusions: Male PAD patients were twice as likely to be admitted for in-patient treatment despite equal PAD prevalence in the general population. Among in-patient cases, supply with invasive therapy did not relevantly differ by sex, however is strongly reduced in CLTI. CLTI is a major risk factor of adverse short-term outcomes, whereas female sex was associated with lower risk of in-patient amputation and/or death.

Quality of Life in Chronic Limb Threatening Ischaemia: Systematic Review and Meta-Analysis

OBJECTIVE

To assess the comparative effectiveness and temporal changes in quality of life (QoL) outcomes after revascularisation, major lower extremity amputation (MLEA), and conservative management (CM) in chronic limb threatening ischaemia (CLTI).

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science.

REVIEW METHODS

A systematic review and meta-analysis were performed on QoL measured by any QoL instrument in adult patients with CLTI after open surgery (OS), endovascular intervention (EVI), MLEA, or CM. Randomised controlled trials and prospective observational studies published in any language between 1 January 1990 and 21 May 2021 were included. There was a pre-specified measurement time point of six months. Random effects meta-analysis was conducted on total scores for each QoL instrument. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO registration: CRD42021253953).

RESULTS

Fifty-five studies with 8 909 patients were included. There was significant heterogeneity in the methods used to measure QoL, and the study characteristics. In particular, 14 different QoL instruments were used with various combinations of disease specific and generic instruments within each study. A narrative summary is therefore presented. Comparative effectiveness data showed there was reasonable certainty that QoL was similar between OS and EVI at six months. Temporal outcomes suggested small to moderate improvements in QOL six months after OS and EVI compared with baseline. Limited data indicated that QoL can be maintained or slightly improved after MLEA or CM. Treatment effects were overestimated owing to small study effects, selective non-reporting, attrition, and survivorship bias.

CONCLUSION

QoL after OS and EVI appears to be similar. Revascularisation may provide modest QoL benefits, while MLEA or CM can maintain QoL. However, certainty of evidence is generally low or very low, and interpretation is hampered by significant heterogeneity. There is a need for a CLTI specific QoL instrument and methodological standardisation in QoL studies.

Discrete Event Simulation Model for Cost-Effectiveness Evaluation of Screening for Asymptomatic Patients with Lower Extremity Arterial Disease

Lower limb ischemic disease (LEAD) affects a significant portion of the population, with most patients being asymptomatic. Patient screening is necessary because LEAD patients have an increased risk of occurrence of other cardiovascular events and manifestations of disease, in terms of leg symptoms such as intermittent claudication, critical limb ischemia, or amputation. The aim of this work was to evaluate the cost-effectiveness of screening using ABI diagnostics in asymptomatic patients and its impact on limb symptoms associated with LEAD. A discrete event simulation model was created to capture lifetime costs and effects. Costs were calculated from the perspective of the health care payer, and the effects were calculated as QALYs. A cost-effectiveness analysis was performed to compare ABI screening examination and the situation without such screening. A probabilistic sensitivity analysis and scenario analysis were carried out to evaluate the robustness of the results. In the basic setting, the screening intervention was a more expensive intervention, at a cost of CZK 174,010, compared to CZK 70,177 for the strategy without screening. The benefits of screening were estimated at 14.73 QALYs, with 14.46 QALYs without screening. The final ICER value of CZK 389,738 per QALY is below the willingness to pay threshold. Likewise, the results of the probabilistic sensitivity analysis and of the scenario analysis were below the threshold of willingness to pay, thus confirming the robustness of the results. In conclusion, ABI screening appears to be a cost-effective strategy for asymptomatic patients aged 50 years when compared to the no-screening option.

Retrograde Guidewire-Assisted Remodeling Technique: A Novel Technique for Endovascular Recanalization of Occluded Arterial Origins in Critical Limb Ischemia

PURPOSE

The main objective of this study is to describe the retrograde guidewire-assisted remodeling technique (REGART), a novel technique, and assess its feasibility, safety, and effectiveness in the recanalization of ostial arterial occlusions without a visible stump in the critical limb ischemia (CLI).

MATERIALS AND METHODS

A retrospective review of 387 patients who underwent endovascular treatment (EVT) for peripheral artery disease between January 2020 and June 2021 was performed. Among these, 23 patients (14 males [60.8%]) with a mean age of 64.2 (range: 55-72) years who underwent REGART were included. Patient demographics, procedural details, and outcomes were noted.

RESULTS

The technical success rate was 95.6% (22/23). The angiographic success rate was 86.3% (19/22). The procedure-related complication rate was 21.7% (5/23), with 4 (17.4%) major complications and 1 (4.3%) minor complication.

CONCLUSION

In the CLI, results of this trial suggest that REGART is feasible, effective, and with acceptable safety in the catheterization of occluded artery origins without a visible stump when conventional anterograde and retrograde techniques fail. Thus, the target occluded artery can be recanalized while preserving other arterial origins by minimizing dissection risk through subintimal balloon angioplasty at the bi-trifurcation level.

Sex-related differences in outcome after endovascular revascularization for lower extremity artery disease

Background: Sex-related differences may influence the outcome of endovascular revascularization (EVR) in patients with lower extremity arterial disease (LEAD) even under optimized healthcare supply. Patients and methods: LEAD patients who underwent EVR at the Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Germany between 2014 and 2016 were included into the retrospective study. Detailed information on risk factors and co-morbidities, medication, LEAD related measures, and interventional parameters were assessed. Outcome defined as technical success rate, complications, and mortality was analyzed up to 12 months follow-up. Results: In total, 165 female and 437 male LEAD patients were included. Women and men presented with comparable severity of LEAD in terms of critical limb threatening ischemia (46.2%), wound status (34.9%), and amputation rate (9.6%, all n.s.) at index. Intake of platelet inhibitors (65.8% female vs. 70.0% male), oral anticoagulants (21.3% vs. 25.4%), and statins (65.6% vs. 76.0%) was observed less frequently in female patients. Against the background of high technical success (85%), in-hospital death (0.8%), severe adverse cardiac (MCE; 1.7%), and limb events (MALE; 6.1%) occurred at low rates in either sex. Adjusted long-term mortality was not affected by patients' sex (female HR 0.755; p=0.312). Conclusions: Despite critical LEAD stages in every second patient, EVR was performed safe with high technical success rates in female and male patients. Long-term outcomes were observed at comparatively low rates in both sexes at the specialized vascular center. During aftercare, supply with statin therapy turned out improvable particularly in female LEAD patients.

Physical and psychological functioning of patients with chronic limb ischemia during a 1-year period after endovascular revascularization

OBJECTIVE

Symptoms of peripheral artery disease (PAD) and patients' physical and psychological status are related in a vicious circle. The aim of this study was to determine the relationships between improvement in parameters of PAD after endovascular procedures and changes in patients' physical and psychological status.

METHODS

We studied 140 consecutive PAD patients: 50 patients with chronic limb-threatening ischemia (CLTI), 50 patients with intermittent claudication (IC) undergoing an endovascular procedure, and 40 IC patients who were not qualified for leg revascularization. All participating patients were assessed at the beginning of the study and at 3 and 12 months of follow-up; scores taken included: ankle-brachial index, 6-minute walking test distance, Barthel index, activities of daily living (ADL) index, instrumental activities of daily living (IADL) index, Mini-Mental State Examination (MMSE), and Hospital Anxiety and Depression Scale (HADS).

RESULTS

After 12 months of follow-up, an improvement in PAD-related symptoms following leg revascularization had been maintained in 56% of the patients with CLTI and in 68% of those with IC. Twelve months after endovascular leg revascularization, the scores in respect of ADL, IADL, and MMSE had increased, and scores for HADS had decreased in both CLTI and IC patients. A higher baseline score in the IADL index was associated with a reduction in the 1-year cardiovascular event risk (OR; 95% CI: 0.70; 0.54-0.91; P < .01).

CONCLUSIONS

In PAD patients, endovascular procedures not only improved PAD-related symptoms, but also ameliorated patients' physical state, improved cognitive function, and reduced depression.

Ankle-Brachial Index Is a Good Determinant of Lower Limb Muscular Strength but Not of the Gait Pattern in PAD Patients

The aim of this study was to evaluate the relationship of the ankle-brachial index (ABI) level with kinetic and kinematic parameters of the gait pattern and force-velocity parameters generated by lower limb muscles. Methods: The study group consisted of 65 patients with peripheral arterial disease (PAD). The ABI value, kinetic and kinematic parameters of gait and force-velocity parameters of knee and ankle extensors and flexors were determined in all subjects. The values obtained for right and left limbs as well as the limbs with higher and lower ABI were compared. Results: Regardless of the method of analysis, the values of the gait’s kinematic and kinetic parameters of both lower limbs did not differ significantly. However, significant differences were noted in the values of peak torque, work and power of the extensor muscles of the knee and the flexor muscles of the ankle with the higher and lower ABI. Conclusion: This study demonstrated that a higher degree of ischemia worsened the level of strength, endurance, and performance of ankle flexors and extensors of the knee joint. ABI is not related to the gait pattern. The above-mentioned relationship should be taken into account in the rehabilitation process and methodological assessment.

Effect of Home-based Exercise Therapy for Peripheral Arterial Disease Patients Underwent Endovascular Treatment: A Clinical Controlled Design

OBJECTIVE

This study aimed to clarify the effect of home-based exercise therapy on physical activity in peripheral arterial disease (PAD) patients after EVT.

METHODS

Study design was controlled clinical design. The subjects were 30 patients (76.6% men) who underwent EVT in the Sakakibara Heart Institute of Okayama. Patients with EVT meeting the inclusion criteria were divided into two groups, intervention group (Home-based exercise) and control group. Patients' basic characteristics, the number of steps walked and QOL questionnaire (WIQ, SEPA, Vascu QOL) were assessed before surgery and, at the 3 month after discharge. A two-way analysis of variance (ANOVA) was performed to compare number of steps walked and QOL questionnaire.

RESULTS

Interaction effect were observed in the number of steps walked (F (1,28) =13.89, p<0.01). A multiple comparison test confirmed a significant increase between results of before surgery and at three months after surgery in the intervention group (p<0.01). An interaction between the presence and absence of intervention was found for the WIQ pain score (F(1,28) = 5.86, p=0.01), speed score (F(1,28) = 3.80, p=0.04) and SEPA (F(1,28) = 4.99, p=0.03). In a multiple comparison study, there was a significant increase in WIQ pain and speed scores in both groups before and 3 months after discharge from the hospital.

CONCLUSION

Home-based exercise therapy using physical activity indices has the potential to improve number of steps and quality of life in patients with PAD after EVT.

Intermittent Claudication and Asymptomatic Peripheral Arterial Disease

BACKGROUND

The conservative treatment of peripheral arterial disease (PAD), as recommended in current guidelines, encompasses measures such as lifestyle modification and risk-factor management. In addition, in patients with vasogenic intermittent claudication (IC), it is recommended that patients first be given drugs to improve perfusion and undergo supervised gait training. Revascularization is not recommended for asymptomatic persons, but it is considered mandatory for patients with critical ischemia. In this article on conservative and revascularizing treatment strategies for IC, we address the following questions: whether all treatment options are available, how effective they are, and whether the reality of treatment for IC in Germany corresponds to what is recommended in the guidelines.

METHODS

In 2014, the German Society for Angiology carried out a comprehensive literature search in order to prepare a new version of the S3 guideline on PAD. This literature search was updated up to 2018, with identical methods, for the present review.

RESULTS

The benefit of lifestyle modification and risk factor treatment is supported by high-level evidence ( evidence level I, recommendation grade A ). The distance patients are able to walk without pain is increased by drug therapy as well (evidence level IIb), but the therapeutic effect is only moderate. Supervised exercise training (SET), though supported by high-level evidence (I, A), is of limited efficacy, availability, and applicability, and patient compliance with it is also limited. In patients with IC, revascularization leads to complete relief of symptoms more rapidly than gait training, and its long-term benefit is steadily improving owing to advances in medical technology. A combination of arterial revascularization and gait training yields the best results. In a clinical trial, patients with IC who underwent combined therapy increased the distance they could walk without pain by 954 m in six months, compared to 407 m in a group that underwent gait training alone.

CONCLUSION

In the treatment of vasogenic IC, SET and drugs to increase perfusion are now giving way to revascularization, which is more effective. As far as can be determined, SET is not currently implemented at all in the German health care system. It would be desirable for SET to be more available and more widely used, both to sustain the benefit of revascularization over the long term and to lower the general cardiovascular risk.

Demographic and procedural characteristics in the RECording COurses of vasculaR Diseases (RECCORD) registry – the first 1000 patients

Summary: Background: The RECcording COurses of vasculaR Diseases (RECCORD) registry established by the German Society of Angiology – Society for Vascular Medicine aimed to address the lack in contemporary real-world data regarding current practice of medical and interventional care in vascular patients. We herein report the demographic and procedural characteristics of the first 1000 patients undergoing endovascular revascularization (EVR) for symptomatic peripheral artery disease (PAD). Patients and methods: RECCORD is an observational, prospective, multicenter, all-comers registry. Only patients undergoing EVR for symptomatic PAD are included and followed up for at least 1 year. Demographic characteristics, comorbidities, previous peripheral vascular interventions, medication, clinical stage of lower extremity artery disease (Rutherford category), hemodynamic parameters, and procedural data including complications are recorded via an entirely web-based platform. Results: Of the first 1000 patients (mean age 70 ± 10 years, 35% female) with 1096 EVR at 1477 vascular segments of the lower extremities, 25.0% were at the stage of chronic limb threatening ischemia (CLTI) and 75.0% at non-CLTI. The femoropopliteal segment was the dominant target lesion site (61.0%), followed by iliac (26.4%) and below-the-knee EVR (10.3%). Only angioplasty was performed in 130 EVR (11.9%), adjunctive drug coated balloons (DCB) in 498 (45.4%), additional stenting in 633 (57.8%). Debulking devices were used in 106 (9.7%) EVR. Clinical (Rutherford categories) and hemodynamic parameters (ankle-brachial-index) as well as secondary preventive medication were significantly improved post EVR. Periprocedural complications occurred in 63 (5.7%) EVR with pseudoaneurysm as the leading complication type in 26 (2.4%) EVR. Conclusions: The baseline data of the first 1000 patients from the RECCORD registry representing the real-world setting illustrate that the majority of EVR are performed in patients with claudication. Adjunctive use of DCB and stenting are the dominant types of EVR, while periprocedural complications are at an acceptable low rate.

Delayed severe median nerve palsy due to undiagnosed brachial pseudoaneurysm

Post-catheterization pseudoaneurysms are a well-known complication of many endovascular procedures at the site of arterial puncture. However, long-term neurological complications due to undiagnosed compression are rare. A 60-year-old man presented to our unit for round, non-pulsatile, painless swelling in the inner side of his upper arm. Clinical examination showed finger paralysis, associated with amyotrophy of the forearm. Large brachial pseudoaneurysm with median nerve compression was diagnosed. The patient underwent autologous vein bypass, with poor 6-month neurological recovery. Early diagnosis of pseudoaneurysms is paramount because, when associated with nerve compression, the longer the diagnostic delay, the poorer the neurological prognosis.