ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC)

Long-Term Follow-up of Subjects With Iliac Occlusive Disease Treated With the Viabahn VBX Balloon-Expandable Endoprosthesis

INTRODUCTION

This physician-initiated study provides 5-year (i.e., long-term) treatment durability data from 3 top recruitment sites that participated in the prospective, multicenter, nonrandomized, single-arm VBX FLEX clinical study (ClinicalTrials.gov identifier: NCT02080871). It evaluates the long-term treatment durability of the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (VBX Stent-Graft) in the treatment of subjects with de novo or restenotic aortoiliac lesions.

MATERIALS AND METHODS

A total of 59 subjects with 94 treated lesions were enrolled at the 3 participating sites from the original 140 intent-to-treat subjects in the VBX FLEX study. The primary durability endpoint was long-term primary patency. Secondary long-term outcomes included freedom from target lesion revascularization (TLR), freedom from target vessel revascularization (TVR), as well as resting ankle-brachial index (ABI), Rutherford category, EuroQol 5 Dimensions, and Walking Impairment status.

RESULTS

Fifty-nine subjects participated and twenty-eight (47.5%) were available through the end of the study at 5-year follow-up (the median follow-up time was 6.6 years due to complications resulting from COVID-19 precautions). At 3 and 5 years, the Kaplan-Meier estimates for freedom from all-cause mortality were 94.5% and 81.7%, respectively. The Kaplan-Meier estimates for primary patency at 3 and 5 years were 94.0% and 89.5% (by lesion) and 91.7% and 84.4% (by subject). Primary assisted patency at 3 and 5 years were 93.3% and 93.3%. Kaplan-Meier estimate for freedom from TLR at 5 years was 89.1%. The majority of subjects were asymptomatic (Rutherford category 0) at 3 years (29/59; 72%), and at 5-year follow-up (18/28; 64%). The 5-year mean resting ankle-brachial index was 0.95±0.18, an improvement of 0.15±0.26 from the baseline (p<0.001). Quality of life measures also showed sustained improvement through long-term follow-up.

CONCLUSION

The 5-year long-term follow-up data underscore the robustness and durability of the Viabahn Balloon-Expandable Endoprosthesis for treating aortoiliac occlusive disease.

CLINICAL IMPACT

Durable improvement after endovascular treatment of iliac occlusive disease is clinically important because many of these patients are claudicants with significant life expectancy. This study is the first to evaluate the long-term outcomes in patients with iliac occlusive disease treated with the Viabahn VBX balloon-expandable endopirostheses. The study reports excellent long-term patency outcomes with prolonged clinical benefit. These durable results are likely to be an important consideration for clinicians undertaking iliac artery revascularization procedures.

Use of an embolic protection device during carotid artery stenting is associated with lower periprocedural risk

OBJECTIVE

To investigate associations between individual embolic protection device (EPD) use and respective center policy with periprocedural outcomes after carotid artery stenting (CAS).

METHODS

This analysis is based on the nationwide German statutory quality assurance database and was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their policy towards EPD use, hospitals were categorized as routine EPD (>90%), selective EPD (10-90%), or sporadic EPD (<10%) centers. Primary study outcome was in-hospital stroke or death. Univariate and multivariate regression analyses were performed.

RESULTS

Overall, 19 302 patients who had undergone CAS between 2013 and 2016 were included. The highest in-hospital stroke or death rate was found in sporadic EPD centers, followed by selective and routine EPD centers (3.1% vs 2.9% vs 1.8%; P<0.001). Across the whole cohort, EPD use was associated with a lower in-hospital stroke or death rate (OR=0.60; 95% CI 0.50 to 0.72). In the multivariate regression analysis, EPD use was independently associated with a lower in-hospital stroke rate (aOR=0.66; 95% CI 0.46 to 0.94). Regarding center policy, routine EPD centers showed a significantly lower in-hospital mortality compared with sporadic EPD centers (aOR=0.44; 95% CI 0.22 to 0.88).

CONCLUSIONS

In a contemporary real-world cohort with low risk of selection bias, EPD use was associated with a lower in-hospital risk of stroke. A center policy of routine EPD use was associated with lower mortality. These data support routine use of EPD during CAS to enhance patient safety.

External validation of the OAC3-PAD risk score after endovascular revascularisation

Background: The OAC3-PAD bleeding risk score was developed to assess the bleeding risk in patients with peripheral arterial disease (PAD), however its performance in patients treated exclusively with endovascular revascularisation has not yet been tested. We aimed to externally validate the bleeding risk score for this patient cohort. Patients and methods: A retrospective observational study, analysing the data of all PAD patients successfully treated with endovascular revascularisation in a single centre within a five-year period. The performance of the Cox proportional hazards (CPH) model, upon which the OAC3-PAD bleeding risk score is based, was tested using calibration methods, discrimination, and a scaled Brier score for overall performance. The OAC3-PAD bleeding risk score was calculated for all patients, classifying them into the four respective risk groups. Kaplan-Meier curves were plotted for all risk groups and discrimination was tested using log-rank tests. Results: While discrimination of the CPH model was adequate, calibration of the model was poor and the scaled Brier score was 3.27% (95% CI 0.65%-4.40%). Of the 1,434 patients, 33 (2.3%) experienced a major bleeding event. The frequency of bleeding was 0.4% in the low risk group (3/736 patients), 0.8% in the low-to-moderate risk group (2/243 patients), 5.8% in the moderate-to-high risk group (15/258 patients), and 6.6% in the high risk group (13/197 patients). The OAC3-PAD score successfully discriminated each of the two lower bleeding risk groups from one of the two higher risk groups, but failed to discriminate among the two lower risk groups and the two higher risk groups, respectively. Conclusions: Although the OAC3-PAD score did not stratify patients into the four respective risk groups, it allowed discrimination between the low risk patients and the high risk patients. It could therefore become a useful tool for predicting major bleeding events in patients with PAD after endovascular revascularisation.

Impact of intravascular ultrasound on limb events in endovascular therapy for patients with peripheral arterial disease: insights from the TOMA-CODE registry

Intravascular ultrasound (IVUS) has become a standard procedure for performing coronary intervention, but its impact on peripheral endovascular therapy (EVT) remains unclear. To assess the usefulness of IVUS during EVT, this study analyzed over 2000 consecutive patients from the TOkyo-taMA peripheral vascular intervention research COmraDE (TOMA-CODE) registry with peripheral arterial disease (PAD) in Japan. The primary outcome was chronic limb events (a composite of clinically driven target lesion revascularization (cTLR) and major amputation) during a two-year follow-up period. The secondary outcomes included the procedural success rate, in-hospital major adverse limb events (MALE), and major cardiac and cerebrovascular events (MACCE). Patients with and without IVUS were compared using propensity score matching. Among the 2227 eligible cases enrolled, with a median follow-up period of 10.4 months, there were no significant differences in limb events between IVUS (784 patients) and non-IVUS (1443 patients) groups during the follow-up period (15.4% vs. 14.4%, P = 0.53, unadjusted; 14.8% vs. 15.4%, P = 0.77, adjusted). In contrast, the IVUS group had higher procedural success rates (98.7% vs. 96.7%, P = 0.02) and lower in-hospital MALE (1.6% vs. 4.1%, P = 0.01), even after multiple adjustments. Additionally, there was no significant difference in the MACCE incidence (10.9% vs. 12.2%, P = 0.47) between the groups. This study demonstrated that IVUS usage did not reduce the occurrence of limb events among EVT patients in the chronic phase, but IVUS may improve in-hospital outcomes. Further research is necessary to verify these findings.

Prognostic Role of Neutrophil Percentage-to-Albumin Ratio in Patients with Non-ST-Elevation Myocardial Infarction

Background and Objectives: This study aimed to investigate whether neutrophil percentage-to-albumin ratio (NPAR) levels on admission have prognostic significance regarding one-year major adverse cardiovascular and cerebrovascular events (MACCEs) in non-ST-elevation myocardial infarction (NSTEMI) patients. Materials and Methods: A total of 464 patients aged 59.2 ± 11.6 years constituted the cohort of this retrospectively designed study. Considering a 1-year follow-up period, the patients were divided into two groups: those with MACCEs and those without. The complete blood count, serum C-reactive protein and serum albumin levels were measured at admission. The NPAR, C-reactive protein/albumin ratio (CAR) and systemic immune-inflammation (SII) index were calculated for all patients, and the associations of these inflammatory-based biomarkers with 1-year MACCEs were evaluated. Results: During the 12-month follow-up period, MACCEs were observed in 75 (16.2%) patients, of which 35 (7.5%) patients died. The patients with MACCEs had higher CRP (p < 0.001), a higher percentage of neutrophils (p < 0.001), lower albumin levels (p < 0.001), a higher CAR (p < 0.001), a higher SII index (p = 0.008) and a higher NPAR (p < 0.001). A high anatomical SxSI score, a high low-density lipoprotein cholesterol level, hypoalbuminemia, high neutrophil counts, a high NPAR level and a high CAR level were independent predictors for one-year MACCEs (all p < 0.05). The NPAR (area under the curve [AUC] = 0.775, p < 0.001) and albumin level (AUC = 0.708, p < 0.001) had better and sufficient discriminatory power and predictive accuracy in determining one-year MACCEs, when compared to the neutrophil (AUC = 0.693, p < 0.001), CAR (AUC = 0.639, p < 0.001) and SII index (AUC = 0.660, p < 0.001), in terms of the receiver operating characteristic curve. The DeLong test revealed that the predictive performance of the NPAR was superior to that of the other inflammatory parameters. In particular, individuals with an NPAR value greater than 17.6 were at greater risk of developing MACCEs (p < 0.001). Conclusions: The NPAR can be used as a newly identified promising inflammatory biomarker to predict one-year MACCEs in NSTEMI patients undergoing revascularization therapy.

Coronary-subclavian steal syndrome: A case series and review of the literature

OBJECTIVE

To report a case series of three patients with symptomatic coronary-subclavian steal syndrome (CSSS) and to review the literature on published case series.

METHODS

We retrospectively reviewed three cases of CSSS patients treated with open and endovascular surgery at a single center over a period of three decades (1996-2024). A comprehensive review of case series involving more than three patients was also performed.

RESULTS

The first patient was a 65-year-old male with a 12-year history of coronary artery bypass grafting (CABG), presenting with unstable angina. Coronary angiography revealed a patent left internal mammary artery (LIMA) graft with retrograde flow through the left subclavian artery (LSA) and occlusion at the LSA ostium. He underwent a successful carotid-subclavian bypass, which significantly improved his symptoms. He died 6 years later from heart failure. The second patient was a 73-year-old woman with a 15-year history of CABG and balloon angioplasty of the grafts. She presented with dyspnea, stable angina, and progressive functional decline. Critical stenosis in the LSA was identified, and her symptoms resolved after successful stent placement. She died 6 years later from progressive heart failure. The third patient was a 75-year-old woman with diabetes, hypertension, and heart failure, who also had a history of CABG. She presented with worsening dyspnea, orthopnea, and edema. Imaging revealed occlusion of the circumflex artery graft and severe LSA stenosis. Successful stenting of the LSA alleviated her symptoms and restored normal blood flow from the LIMA graft. She was discharged after 2 days and remains well at the six-month follow-up.

CONCLUSION

CSSS should be considered in the differential diagnosis of patients with a history of CABG who present with angina or heart failure. Prompt treatment can lead to significant symptom improvement.

Balloon-expandable cobalt chromium stent versus self-expandable nitinol stent for the Atherosclerotic Iliac Arterial Disease (SENS-ILIAC Trial) Trial: a randomized controlled trial

Iliac artery angioplasty with stenting is an effective alternative treatment modality for aortoiliac occlusive diseases. Few randomized controlled trials have compared the efficacy and safety between self-expandable stent (SES) and balloon-expandable stent (BES) in atherosclerotic iliac artery disease. In this randomized, multicenter study, patients with common or external iliac artery occlusive disease were randomly assigned in a 1:1 ratio to either BES or SES. The primary end point was the 1-year clinical patency, defined as freedom from any surgical or percutaneous intervention due to restenosis of the target lesion after the index procedure. The secondary end point was a composite event from major adverse clinical events at 1 year. A total of 201 patients were enrolled from 17 major cardiovascular intervention centers in South Korea. The mean age of the enrolled patients was 66.8 ± 8.5 years and 86.2% of the participants were male. The frequency of critical limb ischemia was 15.4%, and the most common target lesion was in the common iliac artery (75.1%). As the primary end point, the 1-year clinical patency as primary end point was 99% in the BES group and 99% in the SES group (p > 0.99). The rate of repeat revascularization at 1 year was 7.8% in the BES group and 7.0% in the SES group (p = 0.985; confidence interval, 1.011 [0.341-2.995]). In our randomized study, the treatment of iliac artery occlusive disease with self-expandable versus balloon-expandable stent was comparable in 12-month clinical outcomes without differences in the procedural success or geographic miss rate regardless of the deployment method in the distal aortoiliac occlusive lesion (ClinicalTrials.gov, NCT01834495).

Evaluation of acute and midterm outcomes after complex combined antegrade/retrograde recanalization for occlusions of the femoropopliteal and infrapopliteal arteries

BACKGROUND

When antegrade recanalization of femoropopliteal and/or infrapopliteal occlusions fails, retrograde access has become an established option. To evaluate the results of combined antegrade and retrograde recanalization of femoropopliteal and infrapopliteal occlusions, patients undergoing secondary retrograde recanalization attempts were analyzed retrospectively.

METHODS

The primary end point was the success of the procedure (successful occlusion crossing using the antegrade/retrograde technique). Secondary end points include complication rate, primary patency and target lesion revascularization (TLR) rate, amputation rate, changes in ankle-brachial index, and Rutherford-Becker class. Predictors for procedure failure and TLR were analyzed.

RESULTS

We included 888 patients: 362 with femoropopliteal (group 1), 353 with infrapopliteal (group 2), and 173 with multilevel (group 3) recanalization. Critical limb-threatening ischemia was present in group 1, 2, and 3 in 36%, 62%, and 76% of patients, respectively. The intervention was successful in 92.5%, 93.8%, and 90.8% of the respective cases (P = .455). The overall peri-interventional complication rate was 7.2%. At 6, 12, and 24 months, primary patency was highest in group 1 (63.9%, 45.8%, and 33.3%), followed by group 3 (59.8%, 46.1%, and 33.3%), and group 2 (58.5%, 43.1%, and 30.4%; P = .537). The risk of undergoing repeated TLR within 24 months was 31.4% for group 1, 39.1% for group 2, and 45.7% for group 3. At 24 months, the survival rates in groups 1, 2, and 3 were 93.8%, 79.4%, and 87.5%, respectively. Over 24 months, 75 patients (8.4%) had to undergo amputation. Significant improvements in both ankle-brachial index and Rutherford-Becker class were present at discharge as well as at 6, 12, and 24 months (P < .001). Dialysis dependency was a predictor of unsuccessful antegrade/retrograde recanalization (P = .048). Lesion length (P = .0043), dialysis (P = .033), and recanalization level (P = .013) increase the risk of TLR.

CONCLUSIONS

Using a combined antegrade/retrograde access, recanalization of occluded femoropopliteal and/or infrapopliteal arteries can be achieved in a large number of cases. Owing to the high rate of repeated TLR across all lesion localizations, the indication for antegrade and retrograde recanalization may be limited to patients with critical limb-threatening ischemia.

Impact of hyper-polypharmacy due to non-cardiovascular medications on long-term clinical outcomes following endovascular treatment for lower limb artery disease: A sub-analysis of the I-PAD Nagano registry

BACKGROUND

Lower limb artery disease (LEAD) is accompanied by multiple comorbidities; however, the effect of hyperpolypharmacy on patients with LEAD has not been established. This study investigated the associations between hyperpolypharmacy, medication class, and adverse clinical outcomes in patients with LEAD.

METHODS

This study used data from a prospective multicenter observational Japanese registry. A total of 366 patients who underwent endovascular treatment (EVT) for LEAD were enrolled in this study. The primary endpoints were major adverse cardiac events (MACE), including myocardial infarction, stroke, and all-cause death.

RESULTS

Of 366 patients with LEAD, 12 with missing medication information were excluded. Of the 354 remaining patients, 166 had hyperpolypharmacy (≥10 medications, 46.9 %), 162 had polypharmacy (5-9 medications, 45.8 %), and 26 had nonpolypharmacy (<5 medications, 7.3 %). Over a 4.7-year median follow-up period, patients in the hyperpolypharmacy group showed worse outcomes than those in the other two groups (log-rank test, p < 0.001). Multivariate analysis revealed that the total number of medications was significantly associated with an increased risk of MACE (hazard ratio per medication increase 1.07, 95 % confidence interval 1.02-1.13 p = 0.012). Although an increased number of non-cardiovascular medications was associated with an elevated risk of MACE, the increase in cardiovascular medications was not statistically significant (log-rank test, p = 0.002 and 0.35, respectively).

CONCLUSIONS

Hyperpolypharmacy due to non-cardiovascular medications was significantly associated with adverse outcomes in patients with LEAD who underwent EVT, suggesting the importance of medication reviews, including non-cardiovascular medications.

Recurrent cardiovascular and limb events in 294,428 patients with coronary or peripheral artery disease or ischemic stroke on antiplatelet monotherapy: The RESRISK cohort study

BACKGROUND AND AIMS

Utilising real-world data, we quantified the burden of cardiovascular risk factors and long-term residual risk of atherothrombotic events among routine care cohorts with coronary (CAD) or peripheral (PAD) artery disease or ischemic stroke (IS) on guideline-recommended antiplatelet monotherapy (APMT).

METHODS

Retrospective cohort study using data (2010-2020) from the United Kingdom Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics, including adults with CAD, PAD or IS who were first prescribed APMT (CAD/IS: aspirin; PAD: clopidogrel). Primary outcomes (recurrent events): major adverse cardiovascular events (MACE) for CAD/PAD/IS cohorts, major adverse limb events (MALE) for PAD.

RESULTS

266,478 CAD, 13,162 PAD, and 14,788 IS patients were included (mean age: 71 years; women 37.7%-47.5 %). Risk factor burden was high and attainment of recommended goals was low. There were 73,691, 3,121 and 7,137 MACE among CAD, PAD and IS patients, respectively (median follow-up: 89.9, 42.4 and 75.9 months, respectively), and 4,767 MALE among PAD patients. MACE incidence rate per 1000 person-years was higher in IS (268.7; 95%CI 265.3-272.0) than CAD (92.9; 95%CI 92.5-93.4) or PAD cohorts (97.2; 95%CI 94.6-99.8). MALE incidence rate was 195.9 (95%CI 192.2-199.6) per 1000 person-years. IS patients presented a lower rate of hospitalisations and longer time-to-first hospitalisation, but once hospitalised, they had a longer length-of-stay. PAD patients had the highest hospitalisation rate.

CONCLUSIONS

Among a contemporary cohort with cardiovascular disease on APMT, long-term residual atherothrombotic risk remains high despite being on APMT. Greater attention to risk factor control and use of appropriate evidence-based therapy is required to reduce residual risk among this very high-risk population.

Antithrombotic Therapy in High Bleeding Risk, Part II: Noncardiac Percutaneous Interventions

Over the past decades, there have been great advancements in the antithrombotic management of patients undergoing percutaneous interventions, but most of the available evidence derives from studies conducted in the setting of cardiac interventions. Antithrombotic treatment regimens used in patients undergoing percutaneous cardiac interventions, in particular coronary, are frequently extrapolated to patients undergoing noncardiac interventions. However, the differences in risk profile of the population treated and the types of interventions performed may translate into differences is the safety and efficacy associated with antithrombotic therapy. Noncardiac percutaneous interventions are commonly performed in patients at high bleeding risk, which may indeed impact outcomes, hence underscoring the importance of risk stratification to guide clinical decision-making processes. In this review, we appraise the available evidence on antithrombotic therapy in high-bleeding-risk patients undergoing noncardiac percutaneous interventions.

Impact of vascular biomarkers and supine hypertension on cardiovascular outcomes in hypertensive patients: first results from the Cardiovascular Prognostic COUPLING Study in Japan

The prognostic impact of vascular biomarkers and supine blood pressure (BP) is not well understood. The multicenter, prospective Coupling study determined the prognostic impact of vascular biomarkers and supine BP in outpatients aged ≥30 years with ≥1 cardiovascular risk factor. Occurrence of major cardiovascular events during follow-up was recorded. The primary outcome was time to onset of a major cardiovascular event. Office and supine BP, the cardio-ankle vascular index (CAVI), and the ankle-brachial index (ABI) were determined annually. Of the 5109 participants in the Coupling study, 4716 were analyzed (51.9% male, mean age 68.5 ± 11.4 years); participants mostly had hypertension treated based on seated office/home BP according to relevant guidelines. During a median follow-up of 5.0 years (interquartile range 3.6-5.2), 231 major cardiovascular events occurred. After adjustment for age, sitting office systolic BP, and other covariates, a 1-unit increase in CAVI (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.01-1.24) and a 0.1-unit decrease in ABI (HR 1.41, 95% CI 1.18-1.68) were significantly associated with cardiovascular event risk; risk was greatest when CAVI was ≥8.0 and ABI was ≤1.10. Uncontrolled supine hypertension (≥140/90 mmHg) was also significantly associated with adjusted cardiovascular event risk (HR 1.36, 95% CI 1.02-1.81); seated office BP control was not significantly associated with cardiovascular event risk. Increased arterial stiffness, mildly lower ABI, and supine hypertension are risk factors for cardiovascular events during standard clinical practice. Supine evaluation of BP and vascular biomarkers has highlighted a blind spot in current hypertension management (Clinical trial registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000018474).

Screening for Peripheral Vascular Disease: The Role of Ankle-Brachial Index (ABI) and Estimated Glomerular Filtration Rate (eGFR) Changes in Chronic Kidney Disease

Background Chronic kidney disease (CKD) is a significant public health issue worldwide, closely linked with cardiovascular events such as atherosclerosis, peripheral arterial disease (PAD), stroke, coronary artery disease (CAD), and heart failure. The ankle-brachial index (ABI) is a simple tool that compares blood pressure in the ankle and arm, helping to detect PAD and assess the risk of cardiovascular events. An increased ABI signifies an increased risk of cardiovascular disease (CVD), whereas a diminished ABI correlates with angiographically verified atherosclerosis along with heightened death rates. Recent research indicates a U-shaped relationship between ABI and mortality, underscoring the necessity for early detection and action to mitigate potential consequences. Aim This study aimed to correlate ABI changes with estimated glomerular filtration rate (eGFR) changes in CKD patients to screen for the development of peripheral vascular disease. Materials and methods This prospective cross-sectional study was conducted in the outpatient department of a tertiary care hospital in India, focusing on patients diagnosed with CKD admitted to the general medicine department. The inclusion criteria were CKD patients with an eGFR less than 60 ml/min/1.73 m², accompanied by indicators of renal damage such as albuminuria, reduced kidney size on ultrasound, abnormal urinary sediment, or biopsy-proven kidney disease. Patients with peripheral vascular disease, with end-stage renal disease (on dialysis), with limb amputations, with hemodynamic instability, or who declined participation were excluded. eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) equation, and the ABI was measured at baseline, three months, and six months. ABI values below 0.9 indicated peripheral vascular disease, and the study aimed to correlate changes in ABI with eGFR to assess vascular disease development in non-dialyzed CKD patients. Results By the end of the third month, a positive correlation was observed between ABI and eGFR (r=0.259), which persisted at the end of the sixth month (r=0.245). Conclusion The study concludes that a direct relationship exists between decreasing eGFR and ABI, which increases susceptibility to PAD and CVD. A low ABI is linked to an accelerated decline in eGFR, indicating that systemic atherosclerosis predicts kidney function deterioration.

Directional Atherectomy for Critical Lower Limb Ischemia: A Retrospective Observational Study

OBJECTIVE

Chronic arterial obstructive disease of the lower limbs is a significant global health issue. Directional atherectomy offers advantages in treating critical ischemia. The objective of this study is to determine the clinical outcomes of patients with critical ischemia who underwent directional atherectomy using the TurboHawkdevice.

METHODS

A retrospective review was conducted at Alma Mater Hospital in Medellín, Colombia, on all medical records of patients with critical limb ischemia (Rutherford Classes V and VI) who underwent directional atherectomy for infra-inguinal arterial disease.

RESULTS

A total of 42 atherectomies were performed in 41 patients, with 61% classified as Rutherford V and 24.4% as Rutherford VI. The average lesion length to be treated was 60 mm. Calcifications were found in 45.2% of cases, and predilatation angioplasty was used in 42.9% of cases. Atherectomy sites included femoropopliteal segment (40%), superficial femoral (29%), infrapopliteal vessels (14.2%), and more than one vessel in 50% of cases. Technical success was achieved in 78.6% of cases and procedural success in 97.6%, and the need for adjunctive conventional balloon angioplasty was 21.4%, while drug-coated balloon angioplasties were performed in 50% of limbs. The overall complication rate was 14.4%, with embolism at 4.8%, dissection at 4.8%, puncture at 2.4%, and perforation at 2.4%. The average follow-up duration was 12 months, and major amputations were required in 23.8% of cases. Improvement in ankle-brachial index to ≥0.1 was seen in 77% of limbs. Limb survival at 30 days was 85%, and at 90 days, it was 83%. The overall survival rate in the study was 79%.

CONCLUSIONS

Directional atherectomy is a safe alternative for managing critical ischemia in Rutherford V and VI patients.

Quantitative flow ratio for the functional assessment of extracranial internal carotid artery stenosis

BACKGROUND

In asymptomatic patients presenting with significant internal carotid artery (ICA) stenoses undergoing endovascular revascularization, a selective angiography before stenting (CAS) is required. Sometimes, angiographic findings could be discordant from non-invasive assessment and a tool able to evaluate functional relevance of the stenosis could be of value. We sought to evaluate the usefulness of quantitative flow ratio (QFR) as angiography-based tool for functional assessment of ICA stenoses.

METHODS

We prospectively enrolled 50 asymptomatic patients undergoing CAS. Peak systolic velocity (PSV, cm/s) assessed at color Doppler echocardiography was used to identify significant stenoses (PSV >125 cm/s). At angiography, assessment of ICA stenosis was obtained visually (%DSVISUAL) and according NASCET criteria (%DSNASCET). Stenoses were considered significant if >60%. After exclusion of 20 vessels, QFR, area stenosis (AS, %) and minimal lumen area (MLA, mm2) were obtained in the remaining 80 vessels.

RESULTS

At linear regression analysis, QFR significantly correlated with PSV (r2=0.52, P<0.001) as well as with %DSNASCET (r2=0.68, P<0.001) and %DSVISUAL (r2=0.71, P<0.001). Using PSV as reference, QFR showed good accuracy to predict functionally significant stenosis (AUC=0.98, P<0.001) with a cut-off value of 0.93. As compared with %DSNASCET and %DSVISUAL, QFR showed a significantly higher accuracy (61% vs. 73% vs. 94%, respectively; P<0.05), sensitivity (43% vs. 61% vs. 93%, respectively; P<0.05) and negative predictive value (46% vs. 51% vs. 85%, respectively; P<0.05) for detecting hemodynamically significant ICA stenoses.

CONCLUSIONS

This study suggest the potential benefit of adopting QFR for functional assessment of extracranial ICA stenoses. These data should be validated in larger studies.

The Untold Story: Early and Mid-Term Results of Subintimal Angioplasty in Superficial Femoral Artery Versus Popliteal Artery Chronic Total Occlusion

OBJECTIVES

This study aims to compare the immediate and mid-term outcomes of subintimal angioplasty (SIA) of chronic total occlusions (CTOs) of superficial femoral artery (SFA) versus popliteal artery (PA) and to identify possible predictors of loss of limb-based patency (LBP).

METHODS

This is a retrospective analysis of chronic lower-limb ischemia (CLI) patients (Rutherford classes 3-6) presenting with CTO of SFA or PA treated by SIA and selective stenting in the period 2018 to 2021. Immediate outcomes were compared between the SFA and PA groups, including technical success, perioperative complications, and 30-day major amputation and mortality rates. Mid-term outcomes for technically successful procedures included limb-based patency (LBP), wound healing rate, amputation-free survival (AFS), and major adverse limb events (MALEs).

RESULTS

A total of 450 CLI patients underwent SIA of CTO at the SFA (n=260, 57.8%) and the PA (n=190, 42.2%). The indication for revascularization was chronic limb-threatening ischemia in 80.8% of SFA group and 84.2% of PA group. Technical success rate was higher in the PA group compared to the SFA group (96.3% vs 91.2%; p=0.03). The 30-day amputation rates were comparable between the SFA and PA groups (7.7% vs 6.8%, p=0.7, respectively). No perioperative mortality or systemic major complications occurred in the present study. Kaplan-Meier estimate of the 1-year rates were significantly better for SFA group regarding LBP (82% for SFA group vs 43% for PA group, p=0.006), AFS (88% vs 64%, p=0.02), and wound healing (79% vs 58%, p=0.027), respectively. The number of runoff vessels was the only factor associated with loss of LBP (hazard ratio [HR], 0.055; 95% confidence interval [CI]: 0.001-3.020, p=0.039).

CONCLUSIONS

Subintimal angioplasty is an effective and safe endovascular treatment option of CTO at SFA and PA with satisfactory immediate outcomes. The mid-term outcomes, however, are better for SFA lesions in terms of improved LBP, AFS, and wound healing rates.

CLINICAL IMPACT

Subintimal angioplasty is a valuable tool in the armamentarium of endovascular surgeons, as re-entry devices aren't always widely accessible. This study aims to assess the technical outcomes of peripheral vascular interventions for infrainguinal chronic total occlusions and identify possible predictors for successful subintimal angioplasty .Subintimal angioplasty is an effective treatment option for infrainguinal CTO with difference in result of immediate outcomes in popliteal lesions and SFA lesions.

Revision Surgery for Venous Graft Stenosis of SMA Bypass

A 67-year-old male with postprandial abdominal pain for 4 months obtained medical attention for severe pain. He was diagnosed with small intestinal necrosis, secondary to chronic mesenteric ischemia by CT scan. We performed the surgery including a partial resection of the small intestine and left external iliac artery to the superior mesenteric artery bypass using saphenous vein graft. His symptoms improved after surgery. However, 5 months later, abdominal pain appeared after eating. A CT scan identified graft stenosis, leading to a revascularization. A synthetic vessel was used to perform the re-bypass surgery. Postoperatively, the patient's abdominal pain improved.

Collapse and Occlusion of Balloon-Expandable Covered Stent in the Right Common Iliac Arteries Due to External Stress

The patient previously underwent surgery for cervical cancer. She reported intermittent claudication, and computed tomography (CT) revealed total occlusion of the left iliac artery. We conducted endovascular treatment (EVT) using balloon-expandable covered stents (BECS). The patient underwent colostomy closure after EVT. The patient reported intermittent claudication beginning the day after the procedure. The CT showed a collapse of the distal side of the stent implanted in the right common iliac artery, accompanied by localized thrombo-occlusion. During open surgery, metal hooks typically affect the iliac artery; force transmission through the tissue may indirectly compress the iliac artery, leading to BECS failure.

Prevalence, patterns, and determinants of vascular complications of type 2 diabetes in a teaching hospital in Addis Ababa, Ethiopia: a retrospective study

BACKGROUND

Patients with type 2 diabetes mellitus (T2D) have an increased risk of vascular complications. Despite the rise in the prevalence of T2D and its complications throughout the globe, there is a paucity of data regarding the prevalence and determinants of vascular complications of T2D in Ethiopia. Hence, this study aimed to assess the prevalence, patterns, and determinants of the microvascular and macrovascular complications of T2D among adult patients attending a teaching hospital in Addis Ababa, Ethiopia.

METHODS

A retrospective study was done by reviewing the electronic health records of adult patients with T2D attending the general medical and endocrine referral clinics of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia, from June 1, 2023, to November 30, 2023. Statistical Package for Social Sciences (SPSS), version 25, was used to analyze the data. Descriptive analysis was used to summarize the sociodemographic, clinical, and laboratory profiles as well as the patterns of vascular complications of T2D. Bivariate and multivariate logistic regression models were fitted, and the crude odds ratio (COR) and adjusted odds ratio (AOR), together with the 95% confidence interval (CI), were computed to identify the determinants of microvascular and macrovascular complications of T2D.

RESULTS

A total of 272 patients with T2D were included in this study; 50.5% were females, and the mean (± standard deviation) age was 56.3 ± 12.8 years. The majority of patients (62.5%) had diabetes for ≥ 5 years. More than half (51.5%) had poor glycemic control with glycated haemoglobin (HbA1c) value of ≥ 7%. The overall prevalence of vascular complications was 39%. The prevalence of microvascular complications was 23.5%, the most common being neuropathy (11.8%), and the prevalence of macrovascular complications was 21%, the most common being coronary artery disease (12.1%). The determinants of microvascular complications were age ≥ 60 years (AOR = 2.25, 95% CI: 1.17, 4.33), diabetes duration of ≥ 5 years (5-10 years [AOR = 3.13, 95% CI: 1.37, 7.18], and > 10 years [AOR = 3.88, 95% CI: 1.66, 9.06], and HbA1c value of ≥ 7% (AOR = 2.21, 95% CI: 1.14, 4.28). The odds of developing macrovascular complications were higher with diabetes duration of ≥ 5 to 10 years (AOR = 2.89, 95% CI: 1.37, 6.12) as compared with diabetes duration of < 5 years.

CONCLUSIONS

This study demonstrated a high prevalence of microvascular and macrovascular complications in adult patients with T2D. Older age, prolonged duration of diabetes, and poor glycemic control were identified as the determinants for the development of microvascular complications  of T2D, while prolonged duration of diabetes was the determining factor for the development of macrovascular complications. Hence, targeted initiatives are required to enhance the prevention and early detection of vascular complications of T2D in resource-limited countries like Ethiopia.

Absolute Lymphocyte Count Predicts Bypass Surgery Outcomes in Patients with Chronic Limb-Threatening Ischemia

Objectives: The aim of this study was to evaluate the relationship between absolute lymphocyte count (ALC) and outcomes of infrainguinal bypass surgery for chronic limb-threatening ischemia (CLTI). Methods: From 2004 to 2020, 209 limbs of 189 patients who underwent infrainguinal bypass surgery for CLTI and whose ALCs were available were included. Patients with survival >2 years and limb salvage >2 years were considered discriminant groups, and an ALC cut-off value was calculated. The relationship between preoperative ALC and outcomes was evaluated. Results: Survivorship of the higher ALC group was significantly higher than that of the lower ALC group (cut-off value 1030/μL, p = 0.0009). The limb salvage rate of the higher ALC group was significantly higher than that of the lower ALC group (cut-off value 1260/μL, p = 0.0081). In the dialysis patient group (103 limbs), the limb salvage rate of the higher ALC group was significantly higher than that of the lower ALC group (cut-off value 1170/μL, p = 0.026). ALC was independently associated with limb loss in multivariate analysis. Conclusion: ALC is promising as a predictor of outcomes after bypass surgery in CLTI. In particular, ALC is expected to be useful for limb prognosis in hemodialysis patients.

Effects of percutaneous endovascular angioplasty for severe stenosis or occlusion of subclavian artery

To investigate the effect and safety of percutaneous endovascular angioplasty (PEA) with optional stenting for the treatment of severe stenosis or occlusion of subclavian artery, patients with severe stenosis ≥ 70% or occlusion of subclavian artery treated with PEA were retrospectively enrolled. The clinical data were analyzed. A total of 222 patients were retrospectively enrolled, including 151 males (68.0%) and 71 females (32.0%) aged 48-86 (mean 63.9 ± 9.0) years. Forty-seven (21.2%) patients had comorbidities. Subclavian artery stenosis ≥ 70% was present in 201 (90.5%) patients and complete subclavian occlusion in 21 (9.5%) cases. Angioplasty was successfully performed in all (100%) patients. Balloon-expandable stents were used in 190 (85.6%) cases, and self-expandable stents in 20 (9.0%) cases. Only 12 (5.4%) cases were treated with balloon dilation only. Among 210 patients treated with stent angioplasty, 71 (33.8% or 71/210) cases underwent balloon pre-dilation, 139 (66.2% or 139/210) had direct deployment of balloon-expandable stents, and 2 (1.0% or 2/210) experienced balloon post-dilation. Distal embolization protection devices were used in 5 (2.3% or 5/222) cases. Periprocedural complications occurred in 3 (1.4%) patients, including aortic dissection in 2 (0.9%) cases and right middle cerebral artery embolism in 1 (0.5%). No hemorrhage occurred. Among 182 (82.0%) patients with 6-month follow-up, restenosis > 70% occurred in 1 (0.5%) patient, and among 68 (30.6%) patients with 12-month follow-up, restenosis > 70% took place in 11 (16.2%) patients. Percutaneous endovascular angioplasty can be safely and efficiently performed for the treatment of severe stenosis ≥ 70% or occlusion of subclavian artery.

Loss of c-Kit in Endothelial Cells Protects against Hindlimb Ischemia

BACKGROUND

Critical limb ischemia (CLI) is the end stage of peripheral artery disease (PAD), and around 30% of CLI patients are ineligible for current treatments. The angiogenic benefits of c-Kit have been reported in the ischemia scenario; however, the present study demonstrates the effects of specific endothelial c-Kit signaling in arteriogenesis during hindlimb ischemia.

METHODS

We created conditional knockout mouse models that decrease c-Kit (c-Kit VE-Cadherin CreERT2-c-Kit) or its ligand (SCF VE-Cadherin CreERT2-SCF) specifically in endothelial cells (ECs) after tamoxifen treatment. These mice and a control group (wild-type VE-Cadherin CreERT2-WT) were subjected to hindlimb ischemia or aortic crush to evaluate perfusion/arteriogenesis and endothelial barrier permeability, respectively.

RESULTS

Our data confirmed the lower gene expression of c-Kit and SCF in the ECs of c-Kit and SCF mice, respectively. In addition, we confirmed the lower percentage of ECs positive for c-Kit in c-Kit mice. Further, we found that c-Kit and SCF mice had better limb perfusion and arteriogenesis compared to WT mice. We also demonstrated that c-Kit and SCF mice had a preserved endothelial barrier after aortic crush compared to WT.

CONCLUSIONS

Our data demonstrate the deleterious effects of endothelial SCF/c-Kit signaling on arteriogenesis and endothelial barrier integrity.

[Peripheral arterial disease in black African diabetics: epidemioclinical, ultrasonographic profile and determining factors]

BACKGROUND

Diabetes can lead to micro and macro-angiopathies. The peripheral arterial disease (PAD) is a serious and an incapacitating disease. It is still under-estimated and under-treated throughout the world, particularly in sub-Saharan Africa. Doppler ultrasound, and in particular ankle brachial index (ABI), can be used to detect it. The aim was to determine the prevalence of PAD to study the clinical and ultrasonographic aspects and to identify the determining factors.

PATIENTS AND METHODS

This was a descriptive and analytical study over a period of 5 years, including a total of 782 diabetic patients hospitalised in the diabetology department of the CHU la Reference Nationale.

RESULTS

Among the 782 patients, 166 (21.2%) had an ABI < 0.9 reflected the PAD and 72 (9.2%) had an ABI > 1.3, suggestive of mediacalcosis. PAD of the lower limb was mild in 102 patients (61.4%), moderate in (26.3%) and severe in (12.3%). The mean age of the arteritic patients was 56.4 ± 10.2 years. Male gender predominated (59.6%) with a sex ratio of 1.6. All patients had type 2 diabetes (100%). The mean duration of diabetes was 13 ± 5.9 years. The majority of our patients with arterial disease had diabetes for at least 10 years (54.2%). The other cardiovascular in this population were obesity (45.2%), followed by hypertension and dyslipidaemia (32.5%). Diabetes was unbalanced (HbA ≥7%) in the majority of cases (75.3%). Clinically, the majority of patients had a trophic disorder (68%). Asymptomatic patients accounted for 24.6% of cases and those with intermittent claudication for 7.4%. Duplex doppler of the lower limbs showed that all patients with PAD had atheromatous lesions. The distal location was predominantly in the tibial arteries (54.8%). The determinants of PAD in this diabetic population were hypertension (p = 0.01) and obesity (p = 0.01).

CONCLUSION

In our series, PAD was often discovered at an advanced stage, with a non-negligible prevalence. The determining factors found were hypertension and obesity. Screening and control of major cardiovascular risk factors is a priority in the management of this disease.

The efficacy and efficiency of percutaneous lidocaine injection for minimizing the carotid reflex in carotid artery stenting: A single-center retrospective study

OBJECTIVE

To assess whether local anesthetic infiltration could minimize the carotid baroreceptor reflex (CBR) which has an incidence after carotid artery stenting (CAS) that varies from 29% to 51%.

METHODS

This retrospective single-center study included 51 patients (mean age, 70.47 years) who underwent CAS for carotid stenosis. The groups included patients who underwent CAS for asymptomatic ischemic stroke (n=41) or symptomatic disease (n=10). Preprocedural percutaneous lidocaine injections (PPLIs) were administered to 70.6% and 5.9% of patients who underwent elective CAS and emergency CAS, respectively.

RESULTS

Among patients who received PPLIs, the mean degree of stenosis was 80.5% (95% confidence interval [CI]: ±10.74, 51-98%). The mean distance from the common carotid artery bifurcation to the most stenotic lesion (CSD) was 8.3 mm (95% CI: ±0.97, 6.3-10.2 mm); the mean angle between the internal carotid artery and common carotid artery (CCA) trunk (IAG) was 65.6° (95% CI: ±2.39, 61-70°). Among patients who did not receive PPLIs, the mean degree of stenosis was 84.0% (95% CI: ±8.96, 70-99%). The mean CSD was 5.9 mm (95% CI: ±1.83, 1.9-9.9 mm); the mean IAG was 60.4° (95% CI: ±4.41, 51-70°). The procedure time was longer in the PPLI group than in the no PPLI group (28.19 [n=39] vs. 18.88 [n=12] days) (P=0.057); the length of intensive care unit stay was shorter in the PPLI group (20.01 [n=36] vs. 28.10 [n=5] days) (P=0.132).

CONCLUSIONS

Targeted PPLI administration to the carotid bulb decreased aberrant heart rates and blood pressure changes induced by carotid stent deployment and balloon inflation. As CBR sensitivity increases with decreasing distance to the stenotic lesion from the CCA bifurcation, PPLIs may help stabilize patients during procedures for stenotic lesions closer to the CCA.

Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair

OBJECTIVE

Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR.

METHODS

Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention.

RESULTS

Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency.

CONCLUSIONS

Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.

Polyvascular Disease Influences Long-Term Cardiovascular Morbidity in Carotid Endarterectomy

INTRODUCTION/OBJECTIVE

Carotid stenosis (CS) is an important cause of ischemic stroke. Secondary prevention lies in performing a carotid endarterectomy (CEA) procedure, the recommended treatment in most cases. When 2 or more vascular regions are simultaneously affected by atherosclerosis, mainly the carotid arteries, coronary arteries, or limb arteries, a multivessel disease polyvascular disease (PVD) is present. This study aims to assess the potential role of PVD as a long-term predictor of major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to CEA.

METHODS

From January 2012 to December 2021, patients submitted to CEA for carotid stenosis in a tertiary care and referral center were eligible from a prospective database. A posthoc survival analysis was performed using the Kaplan-Meier survival curve method. The primary outcome was the incidence of long-term MACE and all-cause mortality. Secondary outcomes included acute myocardial infarction (AMI), major adverse limb events (MALE), stroke, and acute heart failure (AHF).

RESULTS

A total of 207 patients were enrolled, with a median follow-up of 63 months. The mean age was 70.4 ± 8.9, and 163 (78.7%) were male. There were 65 (31.4%) patients that had 2 arterial vascular territories affected, and 29 (14.0%) patients had PVD in 3 arterial beds. On multivariable analysis, both MACE and all-cause mortality had as independent risk factors age (aHR 1.039, P = 0.003; aHR 1.041, P = 0.019), chronic kidney disease (aHR 2.524, P = 0.003; aHR 3.377, P < 0.001) and PVD2 (aHR 3.381, P < 0.001; aHR 2.665, P = 0.013). PVD1 was only associated with MACE as a statistically significant risk factor (aHR 2.531, 1.439-4.450, P < 0.001).

CONCLUSIONS

PVD in patients with cerebrovascular disease (CVD) was revealed to carry a 2-fold increased risk for all-cause mortality and MACE during long-term follow-up. PVD may be a simple yet valuable tool in predicting all-cause mortality, MACE, AMI, and MALE after CEA.

Repurposing Drugs to Modulate Sortilin: Structure-Guided Strategies Against Atherogenesis, Coronary Artery Disease, and Neurological Disorders

Sortilin (SORT1) is a multifunctional protein intricately involved in atherogenesis, coronary artery disease (CAD), and various neurological disorders. It has materialized as a potential pharmacological target for therapeutic development due to its diverse biological roles in pathological processes. Despite its central role under these conditions, effective therapeutic strategies targeting SORT1 remain challenging. In this study, we introduce a drug repurposing strategy guided by structural insights to identify potent SORT1 inhibitors with broad therapeutic potential. Our approach combines molecular docking, virtual screening, and molecular dynamics (MD) simulations, enabling the systematic evaluation of 3648 FDA-approved drugs for their potential to modulate SORT1. The investigation reveals a subset of repurposed drugs exhibiting highly favorable binding profiles and stable interactions within the binding site of SORT1. Notably, two hits, ergotamine and digitoxin, were carefully chosen based on their drug profiles and subjected to analyze their interactions with SORT1 and stability assessment via all-atom MD simulations spanning 300 ns (ns). The structural analyses uncover the complex binding interactions between these identified compounds and SORT1, offering essential mechanistic insights. Additionally, we explore the clinical implications of repurposing these compounds as potential therapeutic agents, emphasizing their significance in addressing atherogenesis, CAD, and neurological disorders. Overall, this study highlights the efficacy of structure-guided drug repurposing and provides a solid foundation for future research endeavors aimed at the development of effective therapies targeting SORT1 under diverse pathological conditions.

Cilostazol for peripheral arterial disease - a position paper from the Italian Society for Angiology and Vascular Medicine

Cilostazol is a quinolinone-derivative selective phosphodiesterase inhibitor and is a platelet-aggregation inhibitor and arterial vasodilator for the symptomatic treatment of intermittent claudication (IC). Cilostazol has been shown to improve walking distance for patients with moderate to severe disabling intermittent claudication who do not respond to exercise therapy and who are not candidates for vascular surgical or endovascular procedures. Several studies evaluated the pharmacological effects of cilostazol for restenosis prevention and indicated a possible effect on re-endothelialization mediated by hepatocyte growth factor and endothelial precursor cells, as well as inhibiting smooth muscle cell proliferation and leukocyte adhesion to endothelium, thereby exerting an anti-inflammatory effect. These effects may suggest a potential effectiveness of cilostazol in preventing restenosis and promoting the long-term outcome of revascularization interventions. This review aimed to point out the role of cilostazol in treating patients with peripheral arterial disease, particularly with IC, and to explore its possible role in restenosis after lower limb revascularization.

Serum lipoprotein subfractions are associated with the periodontal status: Results from the population-based cohort SHIP-TREND

AIM

To investigate the medium-term associations of serum protein subfractions derived from proton nuclear magnetic resonance (1 H-NMR) spectroscopy with periodontitis and tooth loss.

MATERIALS AND METHODS

A total of 3031 participants of the cohort Study of Health in Pomerania (SHIP-TREND) were included. In addition to conventional serum testing, serum lipoprotein contents and subfractions were analysed by 1 H-NMR spectroscopy. Confounder-adjusted associations of lipoprotein variables with periodontitis and the number of missing teeth variables were analysed using mixed-effects models with random intercepts for time across individuals, accounting for multiple testing.

RESULTS

While only spurious associations between lipoprotein levels from conventional blood tests were found-that is, triglycerides were associated with mean clinical attachment level (CAL) and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol (LDL-C/HDL-C) ratio with the number of missing teeth - several associations emerged from serum lipoprotein subfractions derived from 1 H-NMR analysis. Specifically, elevated LDL triglycerides were associated with higher levels of mean probing depth (PD), mean CALs, and increased odds of having <20 teeth. HDL-4 cholesterol levels were inversely associated with mean PD. Systemic inflammation (C-reactive protein) might mediate the effects of LDL and HDL triglyceride contents on periodontitis severity.

CONCLUSIONS

Several associations between serum lipoprotein subfractions and periodontitis were observed. As the underlying biochemical mechanisms remain unclear, further research is needed.

Evidence for clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications among adults with peripheral artery disease: protocol for a systematic review and meta-analysis

INTRODUCTION

International guidelines recommend that adults with peripheral artery disease (PAD) be prescribed antiplatelet, statin and antihypertensive medications. However, it is unclear how often people with PAD are underprescribed these drugs, which characteristics predict clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications, and whether underprescription and non-adherence are associated with adverse health and health system outcomes.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2006 onwards. Two investigators will independently review abstracts and full-text studies. We will include studies that enrolled adults and reported the incidence and/or prevalence of clinician underprescription of or patient non-adherence to guideline-recommended cardiovascular medications among people with PAD; adjusted risk factors for underprescription of/non-adherence to these medications; and adjusted associations between underprescription/non-adherence to these medications and outcomes. Outcomes will include mortality, major adverse cardiac and limb events (including revascularisation procedures and amputations), other reported morbidities, healthcare resource use and costs. Two investigators will independently extract data and evaluate study risk of bias. We will calculate summary estimates of the incidence and prevalence of clinician underprescription/patient non-adherence across studies. We will also conduct subgroup meta-analyses and meta-regression to determine if estimates vary by country, characteristics of the patients and treating clinicians, population-based versus non-population-based design, and study risks of bias. Finally, we will calculate pooled adjusted risk factors for underprescription/non-adherence and adjusted associations between underprescription/non-adherence and outcomes. We will use Grading of Recommendations, Assessment, Development and Evaluation to determine estimate certainty.

ETHICS AND DISSEMINATION

Ethics approval is not required as we are studying published data. This systematic review will synthesise existing evidence regarding clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications in adults with PAD. Results will be used to identify evidence-care gaps and inform where interventions may be required to improve clinician prescribing and patient adherence to prescribed medications.

PROSPERO REGISTRATION NUMBER

CRD42022362801.

Research progress of drug eluting balloon in arterial circulatory system

The arterial circulatory system diseases are common in clinical practice, and their treatment options have been of great interest due to their high morbidity and mortality. Drug-eluting balloons, as a new type of endovascular interventional treatment option, can avoid the long-term implantation of metal stents and is a new type of angioplasty without stents, so drug-eluting balloons have better therapeutic effects in some arterial circulatory diseases and have been initially used in clinical practice. In this review, we first describe the development, process, and mechanism of drug-eluting balloons. Then we summarize the current studies on the application of drug-eluting balloons in coronary artery lesions, in-stent restenosis, and peripheral vascular disease. As well as the technical difficulties and complications in the application of drug-eluting balloons and possible management options, in order to provide ideas and help for future in-depth studies and provide new strategies for the treatment of more arterial system diseases.

Poor short-term outcomes for prognostic high-risk patients with chronic limb-threatening ischemia undergoing endovascular therapy

BACKGROUND

The prognosis of chronic limb-threatening ischemia (CLTI) is poor, with an expected life expectancy of 2 or more years, which significantly influences treatment decisions. However, death may occur at the early stages of treatment for wound healing, and aggressive treatment may limit the quality of life of such patients. In patients with CLTI undergoing endovascular therapy (EVT), the Wound, Ischemia, and foot Infection (WIfI) clinical stage, male sex, older age, non-ambulatory status, low body mass index, and dialysis have been reported as predictors of mortality risk. However, most studies have not fully investigated the WIFI clinical stage as a prognostic predictor of CLTI. This study aimed to evaluate short-term prognosis and wound healing rates using the prognostic predictors (PPs) indicated above in risk-stratified patients with CLTI who underwent EVT.

METHODS

This retrospective single-center observational study included 61 CLTI patients undergoing EVT from April 2020 to October 2022. The patients were divided into a high-risk group (PPs ≥ 4, n = 20) and low-risk group (PPs ≤ 3, n = 41) according to the number of PPs. Survival and wound healing rates within one year were compared between these two groups.

RESULTS

The mean age of the patients was 74.7 ± 1.6 years, and 42 (68.9%) were male. Among these patients, the high-risk group compared with the low-risk group had a significantly worse survival rate within one year (46.4% vs. 84.7%, log-rank p < 0.001). Fifteen patients died within one year. Of these, seven deaths were cardiovascular deaths and six were deaths from infectious diseases. Cox proportional hazards analysis showed that WIfI clinical stage 4 (p = 0.043, hazard ratio [HR] = 4.85) and the male sex (p = 0.037, HR = 6.34) influenced the prognosis of this population. The high-risk group tended to have a worse wound healing rate within one year than that had by the low-risk group (55.4% vs. 83.0%, log-rank p = 0.086).

CONCLUSIONS

The assessment of short-term prognosis and wound healing rates using PPs may be useful. Discussing the results of short-term clinical outcome assessments with patients should be considered when determining their individualized treatment plans.

Endovascular treatment of renal artery stenosis in Germany: a retrospective analysis of the DEGIR registry 2018-2021

PURPOSE

To provide an overview of endovascular treatment of renal artery stenosis (RAS) using the data of the Deutsche Gesellschaft für interventionelle Radiologie (DeGIR) quality management system.

MATERIALS AND METHODS

A retrospective analysis was performed. Pre-, peri- and postprocedural data, technical success rates, complication rates, and clinical success rates at dismissal were examined.

RESULTS

Between 2018 and 2021, 2134 angiography examinations of the renal arteries were performed: diagnostic angiography in 70 patients (3 %), balloon angioplasty in 795 (37 %), stent implantation in 1166 (55 %) and miscellaneous procedures in 103 (5 %). The lesion length was less than or equal to 5 mm in 1837 patients (87 %), between 5 and 10 mm in 197 (9 %), and between 10 and 20 mm in 62 (3 %). The degree of stenosis was less than 50 % in 156 patients (7 %), greater than 50 % in 239 (11 %), and greater than 70 % in 1472 (70 %). Occlusion was treated in 235 patients (11 %). Symptoms at discharge resolved in 600 patients (29 %), improved in 1012 (49 %), were unchanged in 77 (4 %), and worsened in 5 (0.2 %). Complications were reported in 51 patients (2.5 %) and the mortality rate was 0.15 %.

CONCLUSION

A substantial number of patients with RAS and occlusions were treated by radiologists in Germany, with high technical success rates and low complication rates. The indication should be determined carefully as the current European guidelines for the treatment of RAS suggest that only carefully selected groups of patients will benefit from recanalizing treatment.

KEY POINTS

· Carefully selected patient groups may benefit from endovascular treatment of renal artery stenosis.. · Analysis of the DEGIR quality management database shows that treatment of renal artery stenosis was performed by radiologists in Germany with high technical success rates and low complication rates.. · Recanalization even led to symptom improvement in a large proportion of patients with occlusions..

Associations of carotid atherosclerosis with cognitive function and brain health: Findings from a UK tri-ethnic cohort study (Southall and Brent Revisited)

Background

Cognitive function has an important role in determining the quality of life of older adults. Cardiovascular disease (CVD) is common in older people and may compromise cognitive performance; however, the extent to which this is related to carotid atherosclerosis is unclear.

Aim

We investigated associations between carotid atherosclerosis and cognitive function and neuroimaging markers of brain health in a UK multi-ethnic community-based sample including older people of European, South Asian, and African-Caribbean ethnicity.

Methods

Carotid plaques and intima-media thickness (cIMT) were assessed using ultrasound in 985 people (mean age 73.2y, 56 % male). Associations of carotid atherosclerosis with cognitive function (memory, executive function, language and CSI-D, a global measure of cognitive state) and neuroimaging measures (total brain volume, hippocampal volume, white matter (WM) lesion volume and coalescence score) were analysed using regression analyses, with and without adjustment for potential confounders using two models: 1) adjustment for age, sex, and ethnicity; 2) model 1 plus education, physical activity category, body mass index, hypertension, diabetes, total and high density lipoprotein cholesterol, atrial fibrillation, smoking, previous CVD, alcohol consumption, and presence of chronic kidney disease.

Results

People with carotid plaque or higher cIMT had lower CSI-D score, poorer memory poorer executive function and higher WM lesion volume and coalescence. Language was poorer in people with plaque but was not correlated with cIMT. Associations with plaque were preserved after full adjustment (model 2) but relationships for cIMT were attenuated. Associations with other plaque characteristics were generally unconvincing after adjustment.

Conclusions

This multi-ethnic cohort study provides evidence that presence of carotid plaque, is associated with poorer cognitive function and brain health.

Prognostic Impact of Reduced Left Ventricular Ejection Fraction After Endovascular Therapy for Lower Extremities

BACKGROUND

The mechanism underlying a poor prognosis in patients with lower-extremity artery disease (LEAD) with heart failure is unknown. We examined the prognostic impact of the left ventricular ejection fraction (LVEF) in patients with LEAD who underwent endovascular therapy (EVT).

METHODS AND RESULTS

From August 2014 to August 2016, 2,180 patients with LEAD (mean age, 73.2 years; male, 71.9%) underwent EVT and were stratified into low-LVEF (LVEF <40%; n=234, 10.7%) and not-low LVEF groups. In the low- vs. not-low LVEF groups, there was a higher prevalence of heart failure (i.e., history of heart failure hospitalization or New York Heart Association functional class III or IV symptoms) (44.0% vs. 8.3%, respectively), diabetes mellitus, chronic kidney disease, below-the-knee lesion, critical limb ischemia, and incidence of major cardiovascular and cerebrovascular events (MACCEs) and major adverse limb events (MALEs) (P<0.001, all). Low LVEF independently predicted MACCEs (hazard ratio: 2.23, 95% confidence interval: 1.63-3.03; P<0.001) and MALEs (hazard ratio: 1.85, 95% confidence interval: 1.15-2.96; P=0.011), regardless of heart failure (P value for interaction: MACCEs: 0.27; MALEs: 0.52).

CONCLUSIONS

Low LVEF, but not symptomatic heart failure, increased the incidence of MACCEs and MALEs. Intensive cardiac dysfunction management may improve LEAD prognosis after EVT.

Polyvascular atherosclerosis and renal dysfunction increase the odds of cognitive impairment in vascular disease: findings of the LipidCardio study

INTRODUCTION

Growing evidence suggests a causal role for atherosclerotic vascular disease in cognitive impairment and dementia. Atherosclerosis may present as monovascular disease (monoVD) or as widespread polyvascular atherosclerotic disease (polyVD). Evidence on the relationship between monoVD or polyVD and cognitive impairment is limited.

METHODS

We conducted a cross-sectional analysis of baseline data from the LipidCardio Study. The main outcome measure was the presence of cognitive impairment, defined as a Mini-Mental State Examination (MMSE) score < 26.

RESULTS

The mean age was 71.5 years, 30.3% were female, 17.3% had no evidence of large-vessel atherosclerosis, 71.1% had monoVD, and 11.7% had polyVD, defined as the presence of atherosclerosis in ≥ 2 vascular territories (coronary, cerebral, aortic, or lower extremity). A total of 21.6% had cognitive impairment according to the prespecified cutoff (MMSE < 26). Overall, the odds of cognitive impairment increased for each additional vascular territory affected by atherosclerosis [adjusted odds ratio 1.76, 95% confidence interval (CI) 1.21-2.57, p = 0.003]. Furthermore, there was evidence for an interaction between vascular disease and chronic kidney disease (CKD). The odds of cognitive impairment were not greater in the monoVD subgroup compared to those without any atherosclerosis, if CKD was absent (OR 0.98, 95% CI 0.48-2.10; p = 0.095), while the odds ratio (OR) of cognitive impairment with polyVD compared to no atherosclerosis was 2.71 (95% CI 1.10-6.92; p = 0.031). In contrast, in patients with CKD, both monoVD and polyVD were associated with significantly higher odds of cognitive impairment than no atherosclerosis.

CONCLUSIONS

PolyVD is associated with increased odds of cognitive impairment. MonoVD is associated with cognitive impairment only in the presence of CKD.

Mobile health technologies to improve walking distance in people with intermittent claudication

BACKGROUND

Peripheral arterial disease (PAD) is the obstruction or narrowing of the large arteries of the lower limbs, which can result in impaired oxygen supply to the muscle and other tissues during exercise, or even at rest in more severe cases. PAD is classified into five categories (Fontaine classification). It may be asymptomatic or various levels of claudication pain may be present; at a later stage, there may be ulceration or gangrene of the limb, with amputation occasionally being required. About 20% of people with PAD suffer from intermittent claudication (IC), which is muscular discomfort in the lower extremities induced by exertion and relieved by rest within 10 minutes; IC causes restriction of movement in daily life. Treatment for people with IC involves addressing lifestyle risk factors. Exercise is an important part of treatment, but supervised exercise programmes for individuals with IC have low engagement levels and high attrition rates. The use of mobile technologies has been suggested as a new way to engage people with IC in walking exercise interventions. The novelty of the intervention, low cost for the user, automation, and ease of access are some of the advantages mobile health (mhealth) technologies provide that give them the potential to be effective in boosting physical activity in adults.

OBJECTIVES

To assess the benefits and harms of mobile health (mhealth) technologies to improve walking distance in people with intermittent claudication.

SEARCH METHODS

The Cochrane Vascular Information Specialist conducted systematic searches of the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL, and also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. The most recent searches were carried out on 19 December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people aged 18 years or over with symptomatic PAD and a clinical diagnosis of IC. We included RCTs comparing mhealth interventions to improve walking distance versus usual care (no intervention or non-exercise advice), exercise advice, or supervised exercise programmes. We excluded people with chronic limb-threatening ischaemia (Fontaine III and IV).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were change in absolute walking distance from baseline, change in claudication distance from baseline, amputation-free survival, revascularisation-free survival. Our secondary outcomes were major adverse cardiovascular events, major adverse limb events, above-ankle amputation, quality of life, and adverse events. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs involving a total of 614 participants with a clinical diagnosis of IC. The duration of intervention of the four included RCTs ranged from 3 to 12 months. Participants were randomised to either mhealth or control (usual care or supervised exercise programme). All four studies had an unclear or high risk of bias in one or several domains. The most prevalent risk of bias was in the area of performance bias, which was rated high risk as it is not possible to blind participants and personnel in this type of trial. Based on GRADE criteria, we downgraded the certainty of the evidence to low, due to concerns about risk of bias, imprecision, and clinical inconsistency. Comparing mhealth with usual care, there was no clear evidence of an effect on absolute walking distance (mean difference 9.99 metres, 95% confidence interval (CI) -27.96 to 47.93; 2 studies, 503 participants; low-certainty evidence). None of the included studies reported on change in claudication walking distance, amputation-free survival, or revascularisation-free survival. Only one study reported on major adverse cardiovascular events (MACE) and found no clear difference between groups (risk ratio 1.37, 95% CI 0.07 to 28.17; 1 study, 305 participants; low-certainty evidence). None of the included studies reported on major adverse limb events (MALE) or above-ankle amputations.

AUTHORS' CONCLUSIONS

Mobile health technologies can be used to provide lifestyle interventions for people with chronic conditions, such as IC. We identified a limited number of studies that met our inclusion criteria. We found no clear difference between mhealth and usual care in improving absolute walking distance in people with IC; however, we judged the evidence to be low certainty. Larger, well-designed RCTs are needed to provide adequate statistical power to reliably evaluate the effects of mhealth technologies on walking distance in people with IC.

Prevalence and Associations of Peripheral Arterial Disease in China: The Beijing Eye Study

PURPOSE

To explore the prevalence and associations of peripheral arterial disease (PAD) in China.

DESIGN

Population-based incidence estimate and cross-sectional study.

METHODS

The participants (n=3468) of the Beijing Eye Study underwent a detailed ophthalmologic and systemic examination including assessment of the ankle-brachial index (ABI). PAD was defined by an ABI of less than 0.9.

RESULTS

Blood pressure measurements of both arms and ankles were available for 1078 (31.1%) individuals. An ABI (mean: 1.09±0.11; median: 1.10; range: 0.25, 1.36) of <0.9 and <0.95 was found in 32 of 1078 participants (3.0%, 95% CI 2.0, 4.0) and 70 of 1078 individuals (6.5%, 95% CI 5.0, 8.0), respectively. Higher PAD prevalence (multivariable analysis) was associated with older age (odds ratio [OR] 1.08, 95% CI 1.02, 1.15; P = .009), lower level of education (OR 0.62, 95% CI 0.43, 0.90; P = .01), lower quality of life (OR 0.67, 95% CI 1.11, 2.32), higher glucose serum concentration (OR 1.36, 95% CI 1.09, 1.58; P = .006), lower estimated glomerular filtration rate (OR 0.98, 95% CI 0.96, 0.99; P = .04), and higher prevalence of retinal vein occlusions (OR 7.30, 95% CI 1.63, 32.6; P = .009). PAD prevalence was not associated with the prevalence of glaucoma (P = .53) (open-angle glaucoma: P = .42; angle-closure glaucoma: P = .57) and age-related macular degeneration (any AMD: P = .39; early AMD: P = .31; intermediate AMD: P = .92; late AMD: P = .99), prevalence (P = .26) and stage (P = .07) of diabetic retinopathy, prevalence (P = .38) and degree (P = .68) of nuclear cataract, prevalence (P = .39) and degree (P = .72) of cortical cataract, prevalence of subcapsular cataract (P = .86), prevalence of pseudoexfoliation (P = .65), intraocular pressure (P = .50), axial length (P = .56), and peripapillary retinal nerve fiber layer thickness (P = .68).

CONCLUSIONS

The PAD prevalence (3.0%, 95% CI 2.0%, 4.0%) was relatively low in this cohort from rural and urban Beijing, with older age, lower educational level, lower quality of life, higher glucose serum concentration, lower estimated glomerular filtration rate, and higher prevalence of retinal vein occlusions as main associated factors.

A New Drug-Coated Balloon for the Treatment of Superficial Femoropopliteal Artery Disease: 12-Month Results from the IN-DEPT SFA Trial

PURPOSE

To report the outcomes of the IN-DEPT trial assessing the feasibility, preliminary safety data, and 12-month outcomes of a new drug-coated balloon (DCB) product for peripheral artery disease (PAD) in Chinese patients.

MATERIALS AND METHODS

This is a prospective, multicenter, single-arm clinical trial. A total of 160 patients with superficial femoral artery (SFA) and/or proximal popliteal artery lesions were treated with a new paclitaxel-coated DCB. The preliminary effectiveness end point was 12-month primary patency. The primary safety end point was freedom from device- and procedure-related mortality over 30 days and freedom from major target limb amputation and clinically driven target lesion revascularization (CD-TLR) within 12 months after the index procedure.

RESULTS

In total, 160 patients presented with 162 target lesions. A total of 139 lesions (85.8%) were treated with 1 DCB, whereas the other 23 lesions (14.2%) were treated with 2 devices. The device success rate was 100%. A total of 135 subjects reached the preliminary effectiveness end point, with a 12-month primary patency rate of 84.4%. There was no 30-day device- or procedure-related death or unplanned major target limb amputation at 12 months. Five CD-TLRs (3.1%) occurred during the 12-month follow-up period.

CONCLUSIONS

Results from the IN-DEPT SFA trial showed satisfactory feasibility and safety of the new DCB over 12 months in Chinese patients with PAD and femoropopliteal de novo lesions, including both stenoses and total occlusions.

Assessment of atherosclerosis and endothelial dysfunction risk factors in patients with primary glomerulonephritis

INTRODUCTION

Glomerulonephritis are the third cause of chronic kidney disease (CKD) requiring dialysis in Brazil. Mineral and bone disorder (MBD) is one of the complications of CKD and is already present in the early stages. Assessment of carotid intima-media thickness (CIMT) and flow-mediated vasodilatation (FMV) are non-invasive ways of assessing cardiovascular risk.

HYPOTHESIS

Patients with primary glomerulonephritis (PG) have high prevalence of atherosclerosis and endothelial dysfunction, not fully explained by traditional risk factors, but probably influenced by the early onset of MBD.

OBJECTIVE

To evaluate the main markers of atherosclerosis in patients with PG.

METHOD

Clinical, observational, cross-sectional and controlled study. Patients with PG were included and those under 18 years of age, pregnants, those with less than three months of follow-up and those with secondary glomerulonephritis were excluded. Those who, at the time of exams collection, had proteinuria higher than 6 grams/24 hours and using prednisone at doses higher than 0.2 mg/kg/day were also excluded.

RESULTS

95 patients were included, 88 collected the exams, 1 was excluded and 23 did not undergo the ultrasound scan. Patients with PG had a higher mean CIMT compared to controls (0.66 versus 0.60), p = 0.003. After multivariate analysis, age and values for systolic blood pressure (SBP), FMV and GFR (p = 0.02); and FMV and serum uric acid (p = 0.048) remained statistically relevant.

DISCUSSION AND CONCLUSION

The higher cardiovascular risk in patients with PG was not explained by early MBD. Randomized and multicentric clinical studies are necessary to better assess this hypothesis.

The predictive value of internal carotid artery wall thickness in computed tomography angiography to avoid complications of plaque removal failure in modified eversion carotid endarterectomy

AIM

The benefits of computed tomography carotid angiography (CTA) in terms of evaluating the anatomical structure of the carotid arteries, surgical planning, and evaluating possible risks were reported in previous studies. This study aimed to calculate the predictive value of internal carotid wall thickness in CTA that can predict whether a modified carotid eversion endarterectomy (MCEE) will result in a successful or not.

METHOD

This study was designed in a retrospective cross-sectional format. Consecutive 83 symptomatic carotid surgery patients who were operated in our hospital and had CTA were included in this study. The wall thickness of the internal carotid artery (ICA) 20 mm distal from the carotid bifurcation was calculated in axial sections using a three-dimensional imaging technique. In addition, all patients' characteristics and laboratory findings were recorded. Patients who failed MCEE and required classical carotid endarterectomy were compared with patients who had successful MCEE.

RESULTS

MCEE technique was applied to 62 patients. In 21 patients, the MCEE technique failed and the classical endarterectomy technique was required. Preoperative clinical and laboratory characteristics were similar in both groups. The mean ICA wall thickness was 0.65 mm 20 mm distal to from the carotid bifurcation and it was lower in the group with successful MCEE (1.03 ± 0.21 mm vs. 0.56 ± 0.08 mm) (p < 0.001). The critical ICA wall thickness was calculated as 0.76 mm in the group that MCEE failed and classical carotid endarterectomy was required. Cut-off analysis of ICA wall thickness was calculated as 0.755 mm in ROC analysis (p < 0.001), (95% confidence interval, curve area; 0.985).

CONCLUSION

Successful carotid endarterectomy with the MCEE method is associated with distal ICA wall thickness and distal extension of the atheroma plate. The use of ICA wall thickness 20 mm distal to from the bifurcation as a predictive value for the success of the MCEE technique is beneficial to avoid serious complications.

3D Elastomeric Stent Functionalized with Antioxidative and Perivascular Tissue Regenerative Activities Ameliorated PVT Deprivation-Induced Vein Graft Failure

Clinically, arterial injuries are always accompanied with perivascular tissue damage, which may contribute to high failure rate of vein grafts due to intimal hyperplasia and acute thrombosis. In this study, a "perivascular tissue (PVT) deprivation" animal model is constructed to mimic clinical scenarios and identify the contribution of arterial PVT to the success of vein grafts. Proteomics analysis suggests that depriving PVT may exacerbate reactive oxygen species (ROS)-induced endothelial apoptosis by up-regulating inflammation response and oxidative stress. Locally administering metformin on vein grafts through 3D-printed external stent (PGS-PCL) shows antioxidative and anti-inflammatory properties to protect cells from ROS invasion, thereafter decreasing acute thrombosis. Moreover, metformin induce rapid regeneration of perivascular adipose tissue in recipient regions, which improves patency by inhibiting intimal hyperplasia. Proteomics, western blot, and in vitro blocking tests reveal that metformin resists endothelial apoptosis through AMPK/mTOR and NFκB signaling pathways. To conclude, PVT deprivation exacerbates inflammatory response and oxidative stress in vein grafts bridging arterial circulation. Metformin-loaded stent ameliorates "PVT damage" related vein graft failure, and enhances patency of through resisting endothelial apoptosis and regenerating arterial PVAT, offering a promising avenue to improve the success of vein grafts in clinic.

Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network

Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.

Carotid artery stenting and endarterectomy surgery techniques: A 30‑year time‑lapse

Carotid endarterectomy or carotid artery stenting (CAS), are the most important axes in carotid artery interventional management. A bibliometric analysis permits an easier access to the current literature trends and information to design future studies. The aim of the present study was to identify the knowledge routes on CAS and examine the research front on the topic. The search was interpreted in Scopus, from 1994 to 2023, and included only original articles and reviews. The BibTex format was used to download all citation and bibliographic data. The present analysis was conducted in two parts, a descriptive one and a network extraction process. Between 1994 and 2023, 34,503 references and 7,758 authors were recorded. The annual growth rate was 21.64%. The CAVATAS trial was the most cited article. As regards word trends, since 2017, trans-carotid stenting, risk factors and plaque characteristics are highlighted. CAS remains an area of high interest with a publication growth rate of >20% per year. As numerous questions remain to be answered, the need to determine the role of CAS may drive further research.

Association between hemoglobin glycation index and 5-year major adverse cardiovascular events: the REACTION cohort study

BACKGROUND

The hemoglobin glycation index (HGI) was developed to quantify glucose metabolism and individual differences and proved to be a robust measure of individual glycosylated hemoglobin (HbA1c) bias. Here, we aimed to explore the relationship between different HGIs and the risk of 5-year major adverse cardiovascular events (MACEs) by performing a large multicenter cohort study in China.

METHODS

A total of 9791 subjects from the Risk Evaluation of Cancers in Chinese Diabetic Individuals: a Longitudinal Study (the REACTION study) were divided into five subgroups (Q1-Q5) with the HGI quantiles (≤5th, >5th and ≤33.3th, >33.3th and ≤66.7th, >66.7th and ≤95th, and >95th percentile). A multivariate logistic regression model constructed by the restricted cubic spline method was used to evaluate the relationship between the HGI and the 5-year MACE risk. Subgroup analysis between the HGI and covariates were explored to detect differences among the five subgroups.

RESULTS

The total 5-year MACE rate in the nationwide cohort was 6.87% (673/9791). Restricted cubic spline analysis suggested a U-shaped correlation between the HGI values and MACE risk after adjustment for cardiovascular risk factors ( χ2 = 29.5, P <0.001). After adjustment for potential confounders, subjects with HGIs ≤-0.75 or >0.82 showed odds ratios (ORs) for MACE of 1.471 (95% confidence interval [CI], 1.027-2.069) and 2.222 (95% CI, 1.641-3.026) compared to subjects with HGIs of >-0.75 and ≤-0.20. In the subgroup with non-coronary heart disease, the risk of MACE was significantly higher in subjects with HGIs ≤-0.75 (OR, 1.540 [1.039-2.234]; P = 0.027) and >0.82 (OR, 2.022 [1.392-2.890]; P <0.001) compared to those with HGIs of ≤-0.75 or >0.82 after adjustment for potential confounders.

CONCLUSIONS

We found a U-shaped correlation between the HGI values and the risk of 5-year MACE. Both low and high HGIs were associated with an increased risk of MACE. Therefore, the HGI may predict the 5-year MACE risk.

Prognostic Factors for Restenosis of Superficial Femoral Artery after Endovascular Treatment

High incidence of superficial femoral artery (SFA) restenosis after percutaneous transluminal angioplasty (PTA) poses a persistent challenge in peripheral arterial disease (PAD) treatment. We studied how the patients' and lesions' characteristics, thrombin generation, overall haemostatic potential (OHP), and single nucleotide polymorphisms (SNPs) of the NR4A2 and PECAM1 genes affected the likelihood of restenosis. In total, 206 consecutive PAD patients with limiting intermittent claudication due to SFA stenosis who were treated with balloon angioplasty with bailout stenting when necessary were included. Patients' clinical status and patency of the treated arterial segment on ultrasound examination were assessed 1, 6, and 12 months after the procedure. Restenosis occurred in 45% of patients, with less than 20% of all patients experiencing symptoms. In the multivariate analysis, predictors of restenosis proved to be poor infrapopliteal runoff, higher lesion complexity, absence of treated arterial hypertension, delayed lag phase in thrombin generation, and higher contribution of plasma extracellular vesicles to thrombin concentration. Poor infrapopliteal runoff increased the risk of restenosis in the first 6 months, but not later. The negative effect of poor infrapopliteal runoff on SFA patency opens questions about the potential benefits of simultaneous revascularisation of below-knee arteries along with SFA revascularisation.

The addition of evolocumab to maximal tolerated statin therapy improves walking performance in patients with peripheral arterial disease and intermittent claudication (Evol-PAD study)

OBJECTIVE

To test the hypothesis that in patients with peripheral arterial disease (PAD) and claudication, treated with maximal tolerated statin therapy, the addition of a monthly subcutaneous injection of evolocumab for 6 months improves treadmill walking performance.

BACKGROUND

Lipid lowering therapy improves walking parameters in patients with PAD and claudication. Evolocumab decreases cardiac and limb adverse events in patients with PAD; however, the effect of evolocumab on walking performance is not known.

METHODS

We performed a double-blind, randomized, placebo-controlled study to compare maximal walking time (MWT) and pain free walking time (PFWT) in patients with PAD and claudication treated with monthly subcutaneous injections of evolocumab 420 mg (n = 35) or placebo (n = 35). We also performed measurements of lower limb perfusion, brachial flow mediated dilatation (FMD), carotid intima media thickness (IMT), and serum biomarkers of PAD disease severity.

RESULTS

After six-months of treatment with evolocumab MWT increased by 37.7 % (87.5 ± 24 s) compared to 1.4 % (-21.7 ± 22.9 s) in the placebo group, p = 0.01. PFWT increased by 55.3 % (67.3 ± 21.2 s) in the evolocumab group compared to 20.3 % (8.5 ± 20.3 s) in the placebo group, p = 0.051. There was no difference in lower extremity arterial perfusion measurements. FMD increased by 42.0 ± 73.9 % (1.01 ± 0.7 %) in the evolocumab group and decreased by 16.29 ± 20.06 % (0.99 ± 0.68 %) in the placebo group (p < 0.001). IMT decreased by 7.16 ± 4.6 % (0.06 ± 0.04 mm) in the evolocumab group and increased by 6.68 ± 4.9 % (0.05 ± 0.03 mm) in the placebo group, (p < 0.001).

CONCLUSIONS

The addition of evolocumab to maximal tolerated statin therapy improves maximal walking time in patients with PAD and claudication, increases FMD, and decreases IMT.

CONDENSED ABSTRACT

Peripheral arterial disease (PAD) impairs quality of life by causing lower extremity intermittent claudication, rest pain, or amputation. Evolocumab is a monthly injectable monoclonal antibody medication that reduces cholesterol. In this study, we randomly treated patients with PAD and claudication, and on background statin therapy, with evolocumab or placebo, and found that evolocumab improves walking performance on a treadmill test by increasing maximal walking time. We also found that evolocumab decreases plasma MRP-14 levels, a marker of PAD severity.

Self-expanding interwoven nitinol stent in severe femoropopliteal arterial disease. Real life results of the Supera Peripheral Stent System®

PURPOSE

The excellent performance of the Supera Peripheral Stent System® by Abbott Vascular in femoropopliteal interventions has already been proven through several trials. This retrospective study aims to evaluate the durability and long-term patency of the Supera stent for the treatment of severe femoropopliteal lesions in a real-world population.

METHODS

A retrospective analysis was conducted of 136 consecutive limbs from 128 patients with atherosclerotic disease in the femoropopliteal region, treated with Supera stents between September 2010 and September 2017. As primary endpoints patency rates and freedom from target lesion revascularization (TLR) were calculated and presented using Kaplan-Meier analysis.

RESULTS

Fifty-five percent were treated for claudication (IC), 45% for chronical limb threatening ischemia (CLTI). The mean treated lesion length was 143 mm (±77.8). The majority of lesions (63%) were Trans-Atlantic Inter-Society Consensus Criteria II (TASC II) C/D lesions. The overall primary patency rates at 12 and 24 months of follow-up were 72.6% and 60.8% respectively. The primary patency at 12 and 24 months for TASC II A/B lesions was respectively 86% and 75.4%. For TASC II C/D lesions primary patency at 12 and 24 months was 64% and 51.1% respectively (p = 0.001). Overall freedom from TLR after 12 and 24 months was 73.8% and 62.8% respectively. No significant patency differences were observed based on calcification rate.

CONCLUSION

Endovascular treatment of femoropopliteal disease with Supera Stent is safe, even in extensive, highly calcified lesions. Patency rates and freedom from TLR are acceptable in a real-life population.

The association between brachial-ankle pulse-wave velocity and adverse cardiovascular events in 5719 community participants a prospective cohort study

BACKGROUND

The brachial-ankle pulse-wave velocity (baPWV) is regarded as the gold standard in the evaluation of arterial stiffness. Its prognostic significance for major adverse cardiovascular events (MACE) has been demonstrated. However, the factors influencing the association between baPWV and MACE risk have not been determined. In this study, we investigated the association of baPWV and MACE risk and whether it is affected by the risk factors for different cardiovascular diseases (CVDs).

METHODS

This was a prospective cohort study that initially enrolled 6850 participants from 12 communities in Beijing. The participants were divided into three subgroups according to their baPWV values. The primary outcome was the first occurrence of MACE, defined as hospitalization from cardiovascular diseases, first occurrence of a nonfatal myocardial infarction, or nonfatal stroke. Cox proportional hazards regression and restricted cubic spline analyses were used to examine the association between baPWV and MACE. The effect of CVD risk factors on the relationship between baPWV and MACE was explored in subgroup analyses.

RESULTS

The final study population consisted of 5719 participants. During a median follow-up of 34.73 months, MACE occurred in 169 participants. The restricted cubic spline analysis indicated a positive linear relationship between baPWV and MACE risk. After adjustment for cardiovascular risk factors, the hazard ratio (HR) for MACE risk per SD increase in baPWV was 1.272 [95% confidence interval (CI): 1.149-1.407, P  < 0.001], and the HR for MACE in the high-baPWV vs. the low-baPWV group was 1.965 (95% CI: 1.296-2.979, P  = 0.001). Adding baPWV to the conventional cardiovascular risk factors significantly improved the model's prediction performance and the net reclassification (NRI) [NRI: 0.379 (95% CI: 0.072-0.710), P  = 0.025] in MACE discrimination. However, in the subgroup analysis, two CVD risk factors, stable coronary heart disease and hypertension, showed significant interaction effects ( Pinteraction both < 0.05). This result indicated that the effect of CVD risk factors must be taken into account when assessing the relationship between baPWV and MACE.

CONCLUSION

baPWV is a potential marker to improve the identification of MACE risk in the general population. A positive linear correlation was firstly determined between baPWV and MACE risk, but it may not be valid in participants with stable coronary heart disease and hypertension.