Influence of systemic factors on pre-existing intimal hyperplasia and their effect on the outcome of infrainguinal arterial reconstruction with vein

Sex-based differences in the inflammatory profile of peripheral artery disease and the association with primary patency of lower extremity vein bypass grafts

OBJECTIVE

This study was conducted to determine if there are sex-based differences in the inflammatory phenotype of patients undergoing lower extremity bypass (LEB) and if they correlate with clinical outcomes.

METHODS

This was a retrospective analysis of a prospective cohort of 225 patients (161 men and 64 women) who underwent autogenous vein LEB between February 2004 and May 2008. Fasting baseline blood samples were obtained before LEB, and the inflammatory biomarkers high-sensitivity C-reactive protein (CRP) and fibrinogen were assessed. All patients underwent ultrasound graft surveillance. CRP levels were dichotomized at 5 mg/L and fibrinogen levels at 600 mg/dL.

RESULTS

There were no significant differences in age, race, history of hypertension or diabetes mellitus, body mass index, or coronary artery disease between men and women. Men were more likely to be current smokers (P = .02), have a history of hypercholesterolemia (P = .02), and be taking statins (P = .02). Women were more likely to present with critical limb ischemia (P = .03) and had higher median baseline CRP levels (5.15 mg/L; interquartile range [IQR], 1.51-18.62 mg/L) than men (2.70; IQR, 1.24-6.98 mg/L; P = .02). Median follow-up was 893 days (IQR, 539-1315 days). A multivariable Cox proportional hazards model for primary vein graft patency showed a significant interaction between sex and CRP (P = .03) and fibrinogen (P = .02). After adjustment for key covariates, primary vein graft patency was significantly less in women with CRP >5 mg/L compared with women with CRP <5 mg/L (P = .02). No such difference was seen in men (P = .95). Primary graft patency was also decreased in women with fibrinogen >600 mg/dL vs women with fibrinogen <600 mg/dL (P = .002); again, this pattern was not evident in men (P = .19).

CONCLUSIONS

Women undergoing LEB for advanced peripheral artery disease have a different inflammatory phenotype than men. Elevated baseline levels of CRP and fibrinogen are associated with inferior vein graft patency in women but not in men. These findings indicate an important interaction between sex and inflammation in the healing response of vein grafts for LEB. Women with elevated preoperative CRP and fibrinogen levels may benefit from more intensive postoperative graft surveillance protocols.

Risk factors for lower-extremity vein graft failure

Lower-extremity vein graft failure causes significant morbidity, increases health care costs, and negatively impacts patient quality of life. Identification of risk factors is essential for patient selection, risk factor modification, and identifying individuals who would benefit from more stringent surveillance protocols. Risk factors can be considered as either patient-related or technical. Here we discuss the patient-related risk factors for vein graft failure. Nontechnical factors related to the indication for operation include operation after a previously failed graft, or redo bypass, critical limb ischemia, and infection. Risk factors for vein graft failure are distinct from the risk factors for cardiovascular events. Young age and African American and Hispanic race are risk factors for lower-extremity vein graft failure. Hypercoaguable and inflammatory states also increase risk for vein graft failure. Therapy with statins is indicated in patients with peripheral atherosclerosis and may have beneficial effects on vein graft function, although further studies are needed in this area.

The role of established and emerging risk factors in peripheral vascular graft occlusion

Several studies have evaluated the association between established as well as emerging vascular risk factors with peripheral graft occlusion. There is evidence for a link between the risk for graft occlusion and total serum cholesterol, low-density lipoprotein cholesterol and triglyceride levels. The overall effect of smoking shows a 2.35-fold increase in risk of graft failure. Studies involving diabetic patients undergoing peripheral bypass may have failed to detect higher occlusion rates, possibly due to increased morbidity and mortality as well as higher amputation rates even if the graft is patent. Both antiplatelet agents and anticoagulation seem to be effective in the prevention of graft occlusion. Unconvincing data have been published with regards to the effect of hypertension on graft patency. Emerging factors such as fibrinogen, lipoprotein (a), C-reactive protein and homocysteine levels should also be considered when assessing the risk of graft occlusion. More research is needed to prevent graft occlusion due to the obvious clinical relevance, quality of life and cost issues.

Catheter-based infrared light scanner as a tool to assess conduit quality in coronary artery bypass surgery

OBJECTIVES

Endothelial disruption within saphenous vein and radial artery grafts increases thrombosis risk. However, no clinically applicable method for imaging the intima currently exists. We used a novel infrared imaging technology, optical coherence tomography (OCT; LightLab Imaging, Inc, Westford, Mass), to visualize the intima within harvested conduits.

METHODS

Conduits were procured endoscopically (37 saphenous vein grafts and 8 radial artery grafts) or with the open technique (9 radial artery grafts) from 50 patients. Surplus segments were analyzed by means of OCT for evidence of preexisting pathology or traumatic injury. Focal plaques in radial artery grafts and the intimal hyperplasia area in saphenous vein grafts were quantified as having an intimal/medial thickness ratio of greater than 0.5. Biopsy specimens were obtained for histologic confirmation and to analyze matrix metalloproteinase 2 levels (saphenous vein grafts) and prostacyclin/nitric oxide metabolites (radial artery grafts). Interobserver kappa coefficients and a Bland-Altman analysis were used to determine the reproducibility and accuracy of OCT interpretations.

RESULTS

Radial artery imaging revealed plaque in 76%. Endoscopically harvested vessels showed intraluminal clot (38%) and intimal tears ranging from severe (6%) to mild (88%). In saphenous vein grafts intimal thickening was detected in 86% and intraluminal clotting in 68%. The intimal/medial thickness ratio determined by means of OCT correlated directly with matrix metalloproteinase 2 levels (R = 0.6804) in saphenous vein grafts and inversely with metabolites of prostacyclin (R = -0.55) and nitric oxide (R = -0.58) in radial artery grafts. OCT imaging was reproducible (interobserver kappa coefficients of >0.81 for the characterization of plaque types) and showed a strong correlation with histology (R = 0.8, P < .001).

CONCLUSIONS

OCT imaging provides an accurate, real-time, and reproducible means for assessing saphenous vein graft and radial artery graft bypass conduits. As a quality assurance tool, this technology might afford a more objective basis for conduit selection.

Homocysteine Levels, Haemostatic Risk Factors and Patency Rates After Endovascular Treatment of the Common Iliac Arteries

OBJECTIVES

To investigate the impact of clinical risk factors, plasma homocysteine and haemostatic variables on the results after endovascular treatment of symptomatic atherosclerosis of the common iliac artery.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENTS AND METHOD

The study included 139 technically successful interventions in 103 patients. Technical success was defined as < or = 30% residual stenosis as seen on the post treatment angiogram. Blood samples for analyses of fasting plasma values of homocysteine, fibrinogen, D-dimer, activated protein C resistance were drawn upon admission. Median follow-up for all procedures was 22 months (range 0-55 months). Patency was defined as freedom from > or = 50% restenosis or reocclusion.

RESULTS

The technical success rate for all procedures was 93%. The 1-year cumulative primary patency rate based on intention to treat was 85%. Multivariate analysis revealed a significant independent association between patency rates and levels of fibrinogen and homocysteine and the nature of the lesion treated (stenosis vs. occlusion).

CONCLUSION

The aetiology of restenoses and reocclusions is probably multifactorial. Procoagulant activity, the nature of the lesion treated and homocysteine levels within and above the upper range of normal limits are important risk factors for failure after endovascular treatment of the common iliac arteries.

Homocysteine Levels, Haemostatic Risk Factors and Patency Rates after Endovascular Treatment of the Above-Knee Femoro-Popliteal Artery

OBJECTIVES

To investigate the relationship between plasma homocysteine and other haemostatic variables and restenoses or reocclusions after endovascular treatment of symptomatic atherosclerosis of the above-knee femoro-popliteal artery.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENTS AND METHODS

The study included 103 patients (116 limbs), treated with subintimal angioplasty in 58 cases (50%) and with intraluminal PTA in 58 (50%): 39 (34%) patients were treated for critical limb ischaemia. Blood samples for analyses of fasting plasma values of homocysteine, fibrinogen, D-dimer, activated protein C resistance were drawn upon admission. Median follow-up for all procedures was 11 months (range 0-42 months). Outcome events (arterial patency) were defined as > or =50% restenosis or reocclusion in the treated arterial segment. Patency rates were estimated with the product limit method and Kaplan-Meier curves. Variables found to be related significantly to patency were included in multivariate analysis performed with the Cox proportional hazard model.

RESULTS

The 1-year cumulative primary patency rate for all procedures was 48%. One-year limb salvage rate in cases of critical ischaemia was 74%. Multivariate analysis demonstrated significant independent associations between patency rates and plasma D-dimer, diabetes mellitus, the nature of the lesion treated (stenosis vs. occlusion) and antithrombotic therapy with aspirin after the procedure. Plasma levels of homocysteine, fibrinogen or activated protein C resistance were not associated with patency rates. Homocysteine levels were higher in patients with critical limb ischaemia than those with intermittent claudication.

CONCLUSIONS

Early restenosis or reocclusion after endovascular intervention of lesions in the above-knee femoro-popliteal artery was more frequent following treatment of occlusion (versus stenosis), for patients with diabetes, patients with elevated D-dimer and those without antithrombotic therapy after the procedure. Plasma homocysteine did not appear to influence the outcome of endovascular intervention.

Homocysteine Levels, Haemostatic Risk Factors and Restenosis after Carotid Thrombendarterectomy

OBJECTIVES

To investigate the effect of elevated serum homocysteine and haemostatic as well as clinical risk factors on the tendency to restenosis after carotid artery thrombendarterectomy.

DESIGN

A prospective, observational study.

PATIENTS AND METHODS

In the period from October 1999 to October 2002, 86 patients were subjected to 96 carotid endarterectomies because of internal carotid artery stenoses. The carotid stenoses were symptomatic in 86 cases (90%). Fasting plasma homocysteine, fibrinogen, D-dimer and activated protein C resistance were measured the day before surgery. Follow-up was done 1, 3, 6, 12 and 18 months postoperatively and yearly thereafter with clinical assessment and triplex ultrasonography. The median follow-up time was 17 months (range 9-42 months). Freedom from restenosis was estimated with Kaplan-Meier curves, using log-rank test for comparison between groups. Variables found to be significantly related to restenosis rates were included in a multivariate analysis performed with the Cox proportional hazards model. Comparison of means of continuous data between two groups was done with Student's t-test and more than two groups with one-way analysis of variance.

RESULTS

Restenoses within 12 months of the operation occurred in 11 cases (11%). Univariate analysis revealed that plasma homocysteine values < or =10 micromol/l and freedom from ischaemic heart disease were both significantly associated with an increased risk of restenosis (p=0.0076 and 0.0059). However, multivariate analysis showed that only plasma homocysteine values <10 micromol/l were independently and significantly associated with an increased risk of restenosis (p=0.046). There were no associations between the degree of atherosclerotic affection of the precerebral circulation or symptoms on one hand and the levels of homocysteine, fibrinogen, D-dimer and activated protein C resistance on the other.

CONCLUSION

There seems to be an independent, significant association between homocysteine values within the lower two thirds of the normal range and restenosis after carotid endarterectomy. Studies on the biological properties of human endothelial cells from different types of vasculature and different locations, specifically with respect to homocysteine metabolism and its effect, are warranted.

Homocysteine in myointimal hyperplasia

INTRODUCTION

homocysteine, a sulphur-containing non-essential amino acid, appears to play a role in the pathophysiology of atherosclerosis. However, its role in myointimal hyperplasia, the cause of almost 30% of failures of interventional therapeutic procedures, is much less clear.

METHODS

a review of the published scientific data concerning the role of homocysteine in myointimal hyperplasia was performed using MEDLINE and other on-line databases. Evidence was sought from cell culture experiments, animal models and clinical studies.

RESULTS

several clinical studies have recently been published linking plasma homocysteine levels to restenosis in coronary and peripheral arterial disease. However, several contradictory studies also exist making the role of homocysteine unclear. There are currently no published randomised trials. Cell culture and animal model experiments have elucidated several potential mechanisms by which may stimulate myointimal hyperplasia. Possible mechanisms include endothelial cell activation with the enhanced release of inflammatory cytokines and growth factors and a direct effect on vascular smooth muscle cell migration and proliferation.

CONCLUSIONS

further studies are required before the true role of homocysteine in the pathogenesis of myointimal hyperplasia can be clearly evaluated. If evidence does confirm a role, the ease with which homocysteine levels can be normalised makes it an attractive alternative therapeutic target for intervention.

Intraoperative flow predicts the development of stenosis in infrainguinal vein grafts

OBJECTIVE

There are data to suggest that the development of myointimal hyperplasia is affected by long-term alterations in blood flow. However, the clinical relevance of these findings has not been demonstrated.

METHODS

In this retrospective clinical study, intraoperative volume flow measurement with transit time flowmeter was performed in 257 infrainguinal vein grafts carried out in 241 patients. The patients were enrolled in an intensive duplex scanning-based surveillance program. The relationship between the intraoperative graft flow and subsequent occlusion or development of stenosis was evaluated and controlled for other pertinent risk factors.

RESULTS

The median follow-up time was 13.6 months. A graft stenosis was found in 58 grafts. The mean graft flow for event-free grafts was 98 mL/min, which was significantly higher compared with 78 mL/min for stenosed or 69 mL/min for occluded grafts. The patients were divided into four groups according to quartiles of the sample distribution of graft flow measurements. The respective 2-year primary and assisted primary patency rates in the lowest to the highest graft flow groups were 39%, 49%, 47%, and 72% (P =.003) and 55%, 67%, 71%, and 84% (P =.01). Analogous significant differences were observed for maximal flow capacity measurements. Female sex (P =.009) and low graft flow in maximal flow capacity measurements (P =.003) were independent predictors of stenosis development in the multiple regression model.

CONCLUSION

Intraoperative graft volume flow is a predictor of bypass occlusion after infrainguinal bypass. In addition, this study verifies an association between the development of clinically evident graft stenoses and low graft flow.

Preimplant vein intimal thickness is not a predictor of bypass graft stenosis

PURPOSE

Preimplant vein morphology has been implicated as a risk factor for subsequent vein graft failure. It is controversial whether microscopic intimal thickening in random saphenous vein biopsy specimens is associated with an increased risk of graft failure. The purpose of this study was to determine the incidence of preexisting intimal thickening in a macroscopically normal preimplant vein, and to evaluate whether preimplant vein intimal thickness was predictive of future vein graft stenosis.

METHODS

As part of an ongoing protocol, samples of preimplant veins were obtained at the time of the primary leg bypass. Routine duplex surveillance identified 14 patients who required operative revision for severe graft stenosis (n = 12) or graft occlusion (n = 2). Verhoeff's staining of specimens was performed to delineate the internal elastic lamina. Morphometric analysis of preimplant vein specimens was performed. The results were compared to a control group of 13 preimplant vein specimens selected from patients whose grafts have remained patent and stenosis-free by duplex.

RESULTS

Preoperative risk factors were identical between the two groups. Mean intimal thickness in all 27 specimens was measured by two blinded observers. Almost 50% of specimens exhibited marked intimal thickening (>0.08 mm). The mean preimplant intimal thickness of the stenosis group was 0.108 mm +/- 0.155 compared to 0.100 mm +/- 0.064 for the control group (P = 0.866, NS).

CONCLUSION

Although grossly normal preimplant veins often exhibit prominent microscopic intimal thickening, preimplant vein intimal thickness determined from a random saphenous vein biopsy at the time of primary leg bypass is not predictive to the subsequent development of vein graft stenosis.