2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Inflammatory Macrophage-Targeted Atherosclerosis Treatment by miRNA-Delivered, MRI-Visible, and Anti-Inflammatory Nanomedicine

Atherosclerosis, a principal cause of fatal cardiovascular diseases, is fundamentally a chronic inflammatory disease. Addressing this, the combined regulation of oxidative stress and inflammation through synergistic modalities offers an efficient therapeutic avenue. In this work, we rationally designed and engineered a highly efficient functional nanosystem, referred to as polydopamine nanoparticles doped with arginine and gadolinium ions (AGPDAR-146a), for the targeted delivery of therapeutic oligonucleotides, specifically microRNA-146a (miR-146a), to inflammatory macrophages within atherosclerotic plaques. AGPDAR-146a nanoparticles effectively load and deliver miR-146a, achieving enhanced accumulation in inflammatory macrophages through the specific interaction between miR-146a and class A scavenger receptors. Functionally, AGPDAR-146a nanoparticles excel in eliminating reactive oxygen species and exert anti-inflammatory effects, principally by modulating the nuclear factor kappa-light-chain-enhancer of activated B cells pathway and the interferon regulatory factor 5 protein, consequently helping to reduce and stabilize atherosclerotic plaques. Additionally, the intrinsic T1 magnetic resonance imaging capability of AGPDAR-146a nanoparticles enables real-time visualization of the progression of plaque inflammation. Therefore, the engineered nanosystem not only underscores the therapeutic potential of miR-146a in atherosclerosis but also illustrates a versatile microRNA delivery strategy applicable to various diseases characterized by oxidative stress and inflammation.

Home-Based Exercise and Patient-Reported Outcome Measures in Peripheral Artery Disease: The LITE Randomized Clinical Trial

In patients with peripheral artery disease (PAD), we evaluated the effects of 12 months of walking exercise at a pace inducing ischemic leg symptoms (high intensity) on the attainment of meaningful improvement in patient-reported outcome measures (PROMs) and 6-minute walk, compared to walking exercise at a comfortable pace (low intensity) and a nonexercise control. Participants completed the 6-minute walk test (6MWT) to evaluate objective walking ability. PROMs included the Walking Impairment Questionnaire (WIQ) distance and speed scores (range 0 to 100, 100-best, minimal clinically important difference (MCID) = 15 and 11, respectively). 240 participants (61.7% Black, 48.3% female) participated. High intensity exercise increased 6MWT compared to control (+44.8 meters (95% CI:21.7,68.0) and compared to low-intensity exercise (+37.6 meters [95% CI:18.6,56.5]). Low intensity exercise had no significant benefit compared to control (+7.3 meters [95% CI:-16.3,30.9]). High intensity significantly increased attainment of the MCID for the 6MWT compared to low intensity (OR:2.43 [95% CI:1.35,4.38]) and compared to control (OR:5.22 [95% CI:2.32,11.76]). Compared to control, high intensity exercise significantly increased the odds of attaining an MCID for the WIQ distance score (OR:2.30 [95% CI:1.05,5.04]) and WIQ speed score (OR:2.94 [95% CI:1.27,6.83]). Compared to low intensity, high intensity did not significantly increase the odds of attaining an MCID for the WIQ distance (OR:0.93 [95% CI:0.53,1.66]) or the WIQ speed score (OR:1.31 [95% CI:0.71,2.43]). In conclusion, in people with PAD, high intensity walking exercise increased the odds of meaningful improvement in PROMs compared to control, but not compared to low-intensity exercise. Despite this, high intensity exercise improved 6MWT more than the low intensity exercise and nonexercise control groups (NCT02538900).

Postoperative Direct Oral Anticoagulants Are Associated with Improved Amputation-Free Survival in Infra-Geniculate Bypasses Performed by Prosthetic Grafts in Patients with Chronic Limb-Threatening Ischemia

OBJECTIVES

Autogenous single-segment great saphenous vein graft is the conduit of choice in infra-inguinal bypasses particularly when the distal target of bypass is infra-geniculate. However, use of prosthetic grafts for infra-geniculate bypass (IGB) is required in certain patients. Different measures have been used to increase the durability of prosthetic grafts in IGB. We aimed to investigate the effect of postoperative anticoagulation on outcomes of IGBs performed by prosthetic conduits in patients with chronic limb-threatening ischemia (CLTI).

METHODS

The Vascular Quality Initiative-Medicare-linked database was queried for IGBs performed for CLTI (rest pain or tissue loss) between May 2014 to December 2019. All included patients underwent IGB by polytetrafluoroethylene (PTFE) grafts. The patients were stratified based on postoperative anticoagulation status: no discharge anticoagulation, warfarin, and direct oral anticoagulants (DOACs). DOACs included rivaroxaban or dabigatran. The primary outcome was amputation-free survival (AFS). Secondary outcomes were overall survival, limb salvage, and freedom from reintervention. Kaplan-Meier survival estimates, and Cox regression were used for statistical analysis.

RESULTS

The study included three cohorts: No discharge anticoagulation (N=1,170, 63.5%), warfarin (N=482, 26.2%), and DOAC (N=189, 10.3%). After adjusting for potential confounders, discharge warfarin and DOAC were associated with lower risk of death in one-year (aHR, 0.60 [95% CI:0.46-0.78], P<.001 and aHR, 0.63 [95% CI:0.43-0.93], P=0.021, respectively) and three-year (aHR, 0.72 [95% CI:0.59-0.89], P=0.002 and aHR, 0.64 [95% CI:0.45-0.90], P=0.011, respectively) compared to no anticoagulation. Patients receiving warfarin were at greater risk of major amputation at three years postoperatively (aHR, 1.33 [95% CI:1.03-1.72], P=0.029) compared to the non-anticoagulated patients, while patients receiving DOACs did not have a greater risk of major amputation. At three years, DOAC was associated with improved AFS compared to warfarin (aHR, 0.76 [95% CI:0.58-0.99], P=0.045). Neither warfarin nor DOAC was associated with reintervention at three-year follow-up compared to no anticoagulation.

CONCLUSIONS

We found that postoperative anticoagulation use was associated with improved survival in patients undergoing IGB with PTFE graft for CLTI. Moreover, patients receiving DOACs were associated with greater AFS at three years postoperatively compared to warfarin. This study supports the use of anticoagulants, DOAC preferably to achieve favorable outcomes in IGBs when a prosthetic graft is being used. However, further prospective studies are necessary to confirm our findings.

Palliative Care and Advanced Cardiovascular Disease in Adults: Not Just End-of-Life Care: A Scientific Statement From the American Heart Association

Cardiovascular disease remains a leading cause of morbidity and mortality in adults despite recent scientific advancements. Although people are living longer lives, there may be an adverse impact on quality of life, necessitating a greater need for palliative care services and support. Palliative care for adults with advanced cardiovascular disease has the potential to significantly improve quality of life for individuals living with cardiovascular disease and their informal care partners. Effective communication, shared decision-making, age-friendly care principles, and advance care planning are vital components of palliative care and support comprehensive and holistic care throughout the advanced cardiovascular disease trajectory and across care settings. Current evidence highlights the benefits of palliative care in managing symptoms, reducing psychological distress, and supporting both people with cardiovascular disease and their care partners. However, significant gaps exist in palliative care research related to non-heart failure populations, care partner outcomes, and palliative care implementation in diverse populations. This scientific statement (1) discusses the application of effective communication, shared decision-making, age-friendly care, and advance care planning in advanced cardiovascular disease palliative care; (2) provides a summary of recent evidence related to palliative care and symptom management, quality of life, spiritual and psychological support, and bereavement support in individuals with advanced cardiovascular disease and their care partners; (3) discusses issues involving diversity, equity, and inclusion in cardiovascular disease palliative care; (4) highlights the ethical and legal concerns surrounding palliative care and implanted cardiac devices; and (5) provides strategies for palliative care engagement in adults with advanced cardiovascular disease for the care team.

Antiplatelet and Anticoagulation Therapy for Peripheral Arterial Disease: Risks Versus Benefits

Peripheral arterial disease (PAD) affects millions of people worldwide. It is a progressive atherosclerotic condition that ranges from asymptomatic disease to severe manifestations such as chronic limb-threatening ischemia and acute limb ischemia. Major risk factors-diabetes mellitus, smoking, hypertension, and hypercholesterolemia-contribute to its pathogenesis by promoting oxidative stress, endothelial dysfunction, and platelet activation. Optimizing antiplatelet and anticoagulant therapy is essential to reducing major adverse cardiovascular events and major adverse limb events. Aspirin and clopidogrel remain standard therapies, but recent trials such as COMPASS and VOYAGER PAD highlight the benefits of combination therapy with low-dose rivaroxaban and aspirin, particularly postrevascularization. Dual antiplatelet therapy is beneficial in select patients, but bleeding risks necessitate individualized treatment approaches. Emerging therapies and procedural advancements offer promising options for high-risk populations, such as those with diabetes, chronic kidney disease, and frailty. This review presents a multidisciplinary approach to PAD management, emphasizing risk stratification and personalized pharmacologic strategies that balance ischemic event prevention with bleeding risk mitigation.

Polygenic Prediction of Peripheral Artery Disease and Major Adverse Limb Events

Importance

Peripheral artery disease (PAD) is a heritable atherosclerotic condition associated with functional decline and high risk for limb loss. With growing knowledge of the genetic basis for PAD and related risk factors, there is potential opportunity to identify individuals at high risk using polygenic risk scores (PRSs).

Objective

To develop a novel integrated, multiancestry polygenic score for PAD (PRS-PAD) and evaluate its risk estimation for PAD and major adverse limb events in 3 populations.

Design, Setting, and Participants

This longitudinal cohort study was conducted among individuals with genotyping and electronic health record data in the UK Biobank (2006-2021), All of Us (AoU, 2018-2022), and the Mass General Brigham Biobank (MGBB, 2010-2023). Data were analyzed from July 2023 to February 2025.

Exposures

PRS-PAD, previously published PAD polygenic scores, and clinical risk factors.

Main Outcomes and Measures

The primary outcomes were PAD and major adverse limb events, defined as a surrogate of major amputation and acute limb ischemia.

Results

The study populations included 400 533 individuals from the UK Biobank (median [IQR] age, 58.2 [45.0-71.4] years; 216 215 female participants [53.9%]), 218 500 from AoU (median [IQR] age, 53.6 [37.7-65.0] years; 132 647 female participants [60.7%]), and 32 982 from MGBB (median [IQR] age, 56.0 [32.0-80.0] years; 18 277 female participants [55.4%]). In the UK Biobank validation cohort, PRS-PAD was associated with an odds ratio [OR] per SD increase of 1.63 (95% CI, 1.60-1.68; P < .001). After adjusting for clinical risk factors, the OR for the top 20% of PRS-PAD was 1.68 (95% CI, 1.62-1.74; P < .001) compared to the remainder of the population. Among PAD cases without a history of diabetes, smoking, or chronic kidney disease (n = 3645), 1097 individuals (30.1%) had a high PRS-PAD (top 20%). In incident disease analysis, PRS-PAD improved discrimination (C statistic, 0.761), which was nearly equivalent to the performances of diabetes (C statistic, 0.760) and smoking (C statistic, 0.765). Among individuals with prevalent PAD, high PRS-PAD was associated with an increased risk of incident major adverse limb events in the UK Biobank (hazard ratio [HR], 1.75; 95% CI, 1.18-2.57; P = .005), MGBB (HR, 1.56; 95% CI, 1.06-2.30; P = .02), and AoU (HR, 1.57; 95% CI, 1.06-2.33; P = .03).

Conclusions and Relevance

This cohort study develops a new PRS that stratifies risk of PAD and adverse limb outcomes. Incorporating polygenic risk into PAD care warrants further investigation to guide screening and tailor management to prevent major adverse limb events.

Lipoprotein(a) and peripheral artery disease: contemporary evidence and therapeutic advances

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is a major cause of global health burden, including amputation and impaired quality of life. This review examines the evidence implicating lipoprotein(a) [Lp(a)] in PAD, which is timely as novel therapies lowering Lp(a) are currently being tested in several clinical trials.

RECENT FINDINGS

Human observational studies demonstrate strong associations between elevated Lp(a) levels and increased risk of PAD incidence, severity of chronic limb-threatening ischemia, and major adverse limb events. Emerging therapies including small interfering RNA, antisense oligonucleotides, proprotein convertase subtilisin-kexin type 9 inhibitors and lipoprotein apheresis demonstrate significant Lp(a)-lowering effects. However, whether these treatments benefit patients with PAD is currently unknown.

SUMMARY

Lp(a) may be involved in PAD pathogenesis. Lp(a)-lowering therapies may significantly reduce PAD-related events and improve outcomes. Future studies are needed to test Lp(a)-lowering therapies in people with PAD and to explore how the association of Lp(a) varies in different sexes and ethnicities and understand mechanisms by which Lp(a) may contribute to limb ischemia.

Interpretable machine learning prediction model for major adverse cardiovascular events in patients with peripheral artery disease

BACKGROUND

Major adverse cardiovascular events (MACE) are severe complications of peripheral arterial disease (PAD), associated with poor prognosis and disease burden. Therefore, the early identification of high-risk individuals is of paramount importance. This study aimed to develop and validate an interpretable machine learning-based prediction model for MACE risk in patients with PAD.

METHODS

This retrospective study included patients with PAD enrolled between January 2022 and December 2023, with follow-up completed in December 2024. The primary outcome was MACE, defined as a composite of myocardial infarction, stroke, and cardiovascular mortality, and patients were followed up for 12-24 months using data sourced from non-overlapping datasets of four centers: three for model training and internal validation; and one for external validation. Feature selection was performed using univariate analysis, LASSO logistic regression, and Random Forest algorithm. Ten different machine learning (ML) algorithms were employed to construct the risk prediction model. Model performance was evaluated based on discrimination and calibration. The SHapley Additive exPlanations (SHAP) method was used to visualize model features and individual case predictions. The final risk prediction model was presented as a web-based calculator.

RESULTS

This multicenter study involved both model development dataset (n = 1110) and external validation dataset (n = 448). Among the 1558 enrolled patients with PAD, 469 (30.1%) experienced MACE. The incidence of MACE was higher in the training cohort (32.0%, 249/777) compared to the internal validation cohort (30.6%, 102/333) and external validation cohort (26.3%, 118/448). The mean follow-up duration was 19.0 ± 11.3 months. Participants' mean age was 73.1 ± 10.8 years, with males comprising 70.0% (1091/1558). We developed ML models incorporating eight clinically significant variables, with Gradient Boosting (GraBoost) demonstrating comparatively better performance by achieving AUC values of 0.864 (95% confidence interval [CI]: 0.822-0.905) in internal validation cohort and 0.777 (95% CI: 0.720-0.833) in external validation cohort. The key predictors included: polyvascular disease, cerebrovascular disease, hemoglobin A1c, C-reactive protein, albumin, peripheral arterial surgery, coronary heart disease, and neutrophils.

CONCLUSION

The GraBoost algorithm outperformed other models in predicting MACE risk in patients with PAD, with external validation confirming its clinical applicability. The SHAP framework and web-based calculator enhanced the model's interpretability, enabling clinicians to better understand the factors contributing to MACE. This tool potentially helps clinicians identify MACE risk of patients with PAD and implement preventive measures more effectively.

Indications and Treatment Outcomes of Below-the-Knee Peripheral Artery Interventions in the XLPAD Registry

BACKGROUND

There are unresolved questions regarding indications and outcomes of endovascular below-the-knee (BTK) interventions in patients with symptomatic peripheral artery disease (PAD) in real-world clinical practice.

METHODS

We analyzed 884 patients from the multicenter XLPAD registry between 2006-2023 with non-stent BTK PAD interventions.

PRIMARY OUTCOME

freedom from major adverse limb events (MALE) at 1 year, a composite of all-cause death, major amputation, or clinically driven revascularization.

RESULTS

Majority (62.8%) of the BTK interventions were performed for chronic limb threatening ischemia (CLTI), while remaining (37.2%) in patients with intermittent claudication (IC), performed together with an inflow femoropopliteal artery intervention in 58% or involving complex lesion crossings (11.8%). Nearly, 74% were men, mean age 68.0 ± 10.7 years. Mean Rutherford class was 4.65 in CLTI and 2.71 in IC groups. Moderate to severe calcification was present in 25% of cases. Significantly greater number of lesions were treated in the CLTI group (1.84 ± 1.52 vs 2.08 ± 1.61; p=0.029). Lesion lengths (CLTI: 129.3 ± 85.1 mm vs. IC: 115.5 ± 82.5; p=0.075) were comparable. Nearly, 92% of lesions were treated with balloon angioplasty. Drug-coated balloon use was higher in IC (5% vs 15%, p<0.001), whereas atherectomy use was high in both groups (CLTI: 45.4% vs. IC: 49.9%; p=0.201). Procedural success was similar (CLTI: 92% vs. IC: 88.8%; p=0.098), however 1-year MALE was significantly higher in CLTI patients (30.5% vs. 15.8% vs; p<0.0.001), driven by higher all-cause mortality (5.6% vs. 2.1% vs.; p=0.014) and major amputations (14% vs. 3.7%; p<0.001).

CONCLUSION

Endovascular treatment for BTK PAD is more often performed in patients with CLTI compared with IC, where it is often combined with an inflow artery intervention or complex lesion crossings. Despite similar procedural success, 1-year MALE is significantly higher in CLTI, driven mainly by over a two-fold increase in all-cause mortality and major amputations.

Outcomes of Different Regimens of Rivaroxaban and Aspirin in Cardiovascular Diseases: A Network Meta-Analysis

Background/Objectives: Rivaroxaban is widely used to prevent thrombotic events in cardiovascular diseases (CVD). While various doses and combinations with aspirin have been evaluated across CVD subtypes, the optimal regimen remains unclear. This network meta-analysis aims to identify the most effective and safe rivaroxaban regimens, with or without aspirin, for patients with CVD. Methods: A systematic search of PubMed, Scopus, Cochrane Library, and Web of Science identified randomized-controlled trials (RCTs) assessing rivaroxaban, with or without aspirin, in CVD. Key outcomes included thromboembolic, hemorrhagic, and mortality events. A frequentist network meta-analysis (MetaInsight tool) was performed, using aspirin monotherapy as the reference. Subgroup analyses for coronary artery disease (CAD) were conducted. Results: Seven RCTs were included. Rivaroxaban 2.5 mg twice daily ("bis in die" (BID)) with aspirin showed the most significant venous thromboembolism (VTE) prevention (RR = 0.61, 95% CI [0.43-0.86]) but had the highest major bleeding risk (RR = 1.58, 95% CI [1.26-2]). Rivaroxaban 5 mg BID with aspirin showed the lowest myocardial infarction risk (RR = 0.78). Higher doses (20 mg BID) with aspirin were associated with an increased fatal bleeding risk (RR = 7.14, 95% CI [2.83-17.98]). Rivaroxaban 5 mg BID monotherapy had the highest hemorrhagic stroke risk (RR = 2.7, 95% CI [1.31-5.58]). In CAD, rivaroxaban 2.5 mg BID plus aspirin offered the lowest all-cause mortality (RR = 0.76, 95% CI [0.63-0.93]). Conclusions: Rivaroxaban 2.5 mg BID plus aspirin reduces VTE and lowers mortality in CAD but carries higher bleeding risks. Optimal regimen selection requires a careful risk-benefit balance.

Eluvia stent in endovascular treatment of femoropopliteal occlusive disease: Early results of the challenge study

ObjectivesThe aim of this study was to evaluate the one-year results of the Eluvia drug-eluting vascular stent (Boston Scientific, Marlborough, MA, USA) for the treatment of femoropopliteal occlusive disease (FPOD).MethodsFrom January 2021 to November 2023, this multicenter study prospectively enrolled patients with peripheral artery disease involving the femoropopliteal artery. The primary outcome measures were the rate of freedom from clinically driven target limb revascularization (f-CD-TLR), rate of freedom from major adverse events (f-MAE), rate of freedom from symptom recurrence (f-SR) and rate of freedom from all-cause death (f-ACD). The secondary outcome measures were the Rutherford grade and Vascular Quality of Life (VascuQoL) scale scores.ResultsIn total, 159 patients were enrolled in this study. The mean follow-up time was 370 days, and the follow-up rate was 83.0%. The patients' mean age was 72 years, and 82.4% were male. A total of 159 patients received 199 stent deployments. The mean lesion length was 194.4 ± 118.9 mm, and 76.7% had total occlusions. The technical success rate for endovascular treatment was 100%, and five complications occurred during the perioperative period. At one, three, six, and 12 months, the f-CD-TLR rate was 99.3%, 97.9%, 96.4%, and 92.8%, respectively; the f-MAE rate was 98.0%, 96.7%, 93.1%, and 91.3%, respectively; the f-SR rate was 94.6%, 85.5%, 80.3%, and 73.4%, respectively; and the f-ACD rate was 98.0%, 98.0%, 95.9% and 94.1%, respectively. There was a substantial increase in the Rutherford grade and average VascuQoL scores at the one-, three-, six-, and 12-month follow-ups (p < .001).ConclusionsThe Eluvia stent had a favorable effect on FPOD throughout 12 months of follow-up. Further studies with larger sample sizes and longer-term follow-up are required to confirm the real-world performance of the Eluvia stent.

Global, regional, and national trends in peripheral arterial disease among older adults: findings from the global burden of disease study 2021

IMPORTANCE

Lower extremity peripheral arterial disease (PAD) is a significant health concern among older adults globally, affecting both mortality and quality of life.

OBJECTIVE

To evaluate the temporospatial trends and its risk factors in lower extremity PAD-related burden among adults aged 60 years and older from 1990 to 2021.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study utilized data from the Global Burden of Disease Study 2021, encompassing 204 countries and territories. The study population included adults aged 60 years and older.

EXPOSURE

Lower extremity PAD among older adults from January 1990 to December 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes included age-standardized prevalence rates (ASPR), mortality rates (ASMR), disability-adjusted life-years (DALYs), and average annual percentage changes (AAPCs). Trends were analyzed by age, sex, and sociodemographic index (SDI). Joinpoint regression analysis was used to identify significant trend changes.

RESULTS

From 1990 to 2021, global trends showed decreases in lower extremity PAD-related prevalence, mortality, and DALYs. Significant geographical disparities were observed: high-SDI regions had the highest prevalence (11,171.66 per 100,000 in 2021) but showed declining trends (AAPC, -0.74; 95% CI, -0.80 to -0.68), while low-SDI regions had the lowest prevalence (4,842.40 per 100,000) but demonstrated increasing trends (AAPC, 0.22; 95% CI, 0.21 to 0.24). Regionally, although lower extremity PAD-related prevalence showed a decreasing trend in most regions from 1990 to 2021, there were still some regions with an increasing trend (North Africa and Middle East AAPC, 0.57; 95% CI, 0.55 to 0.59). Temporal analysis showed sex-specific divergent trends in recent years, with males exhibiting an upward trend since 2015 (APC, 0.15; 95% CI, 0.07 to 0.24), while females showed a slowed decline since 2014 (APC, -0.06; 95% CI, -0.12 to -0.01). Decomposition analysis identified population growth as the primary driver of PAD burden increase, with epidemiological changes showing contrasting effects across SDI regions. Among risk factors, high fasting glucose emerged as the leading contributor, while smoking's contribution decreased.

CONCLUSIONS AND RELEVANCE

This study revealed significant disparities in lower extremity PAD burden across different SDI levels and regions, with low-SDI countries facing an increasing burden. The contrasting trends between high- and low-SDI regions, coupled with varying risk factor patterns (particularly the rise in high fasting glucose and decline in smoking), suggest the need for targeted interventions in resource-limited settings to address this growing health challenge among older adults.

Sex Differences in Platelet Response to Common Antiplatelet Medications

OBJECTIVE

Sex differences in platelet aggregation among peripheral artery disease (PAD) patients are not well characterized. This study aimed to evaluate the impact of antiplatelet therapy on platelet reactivity by sex.

METHODS

A prospective cohort study was conducted at a single large tertiary center on patients with PAD undergoing revascularization between 2020 and 2024. Patients were stratified based on antiplatelet therapy (mono antiplatelet therapy-MAPT, or dual antiplatelet therapy-DAPT), with DAPT including aspirin and clopidogrel/ticagrelor. Coagulation profiles, using thromboelastography (TEG) and platelet mapping (PM), were assessed pre-and post-operatively. The Mann-Whitney U test was conducted to assess differences in platelet function between sexes. Linear regression models were used to assess the potential confounding effect of sex. Mediation analysis was also performed to determine if sex mediated the treatment's effect on TEG parameters.

RESULTS

Of the 261 patients analyzed, 35.2% were women, 88.9% were Caucasian, and 74.1% were on MAPT. Women in the MAPT group had higher fibrinogen-related clot strength (CFF MA: 25.5mm vs. 23.3mm, p < 0.002), greater platelet aggregation (93.0% vs. 86.9%, p = 0.009), and lower platelet inhibition (3.9% vs. 13.2%, p = 0.009), while no sex differences were observed in the DAPT group. Sex neither confounded nor mediated the effect of antiplatelet therapy on TEG parameters.

CONCLUSION

Sex differences in platelet reactivity were observed in the MAPT group, suggesting that more aggressive antiplatelet therapy in women may help reduce this disparity.

Sex Disparities in PAD Patients: Retrospective Study Utilizing MIMIC-IV v3.1 Database

Background: Peripheral artery disease (PAD) is a progressive atherosclerotic condition associated with significant morbidity and mortality. While PAD prevalence is comparable between sexes, women tend to have worse clinical outcomes, higher rates of disability, and are underdiagnosed and undertreated compared to men. This study examines sex differences in PAD presentation, diagnosis, and treatment outcomes using the Medical Information Mart for Intensive Care (MIMIC)-IV v3.1 database. Methods: A retrospective cohort study was conducted using electronic health records from the MIMIC-IV v3.1 database, identifying patients diagnosed with PAD between 2008 and 2022. Patient selection was based on International Classification of Diseases (ICD)-9 and ICD-10 codes. The following two datasets were constructed: an admission-level dataset (6468 admissions, 3913 unique patients) and a patient-level dataset aggregating multiple admissions per individual. Key variables included demographics, hospitalization details, procedure rates, and clinical outcomes. Sex-based comparisons were performed to assess disparities in disease burden, intervention rates, and mortality. Results: The study cohort comprised 3913 PAD patients. Women were significantly older than men at time of admission (mean 70.78 vs. 68.97 years, p < 0.05) and had lower rates of procedural intervention across all categories, including angioplasty (12.85% vs. 15.39%) and bypass grafting (14.74% vs. 16.98%). Despite similar Intensive Care Unit (ICU) admission rates (30.56% in females vs. 31.73% in males), women experienced greater delays in PAD diagnosis and treatment initiation. The in-hospital mortality rate was comparable between sexes (6.62% vs. 6.92%). Women presented more frequently with atypical or asymptomatic PAD, leading to delays in diagnosis and specialist referrals. Conclusions: This study highlights significant sex disparities in PAD diagnosis and management. Women with PAD are older at diagnosis, receive fewer procedural interventions, and experience delayed clinical recognition, contributing to a higher cumulative disease burden. These findings underscore the need for sex-specific diagnostic criteria, improved clinical awareness, and equitable treatment strategies to optimize PAD outcomes in women.

Self-reported outcomes following lower extremity, carotid and aortic artery disease: protocol for the Danish Vascular (DanVasc) survey

INTRODUCTION

Among lower extremity artery disease (LEAD), symptomatic carotid stenosis (SCS) and abdominal aortic aneurysm (AAA), the disease burden is insufficiently illuminated from a patient and societal perspective. Such knowledge is central to identifying patients at risk of poorer outcomes. Therefore, the Danish Vascular (DanVasc) survey aims to describe self-reported health status, health literacy, medication adherence and loneliness, including changes over time, and investigate characteristics associated with worse self-reported health at baseline and their associations with poorer outcomes within 1 year (healthcare utilisation and mortality) in patients with LEAD, SCS and AAA.

METHODS AND ANALYSIS

The DanVasc survey, a national prospective cohort study combining survey data measured at several time points with register-based data, includes validated patient-reported outcome measures (PROMs) and ancillary questions developed with patient representatives. Our baseline survey (T0) follows the index contact in vascular outpatient clinics with follow-up surveys determined by the patient's trajectory: (1) newly referred patients in conservative treatment trajectories; the date for the outpatient visit activates 1-month (T1), 3-month (T2) and 12-month (T3) follow-ups. (2) Patients referred for vascular surgery; the surgery date activates 1-month (T1), 3-month (T2) and 12-month (T3) follow-ups. The included PROMs assess health-related quality of life (HRQoL), anxiety and depression, sleep, frailty status, health literacy, medication adherence and loneliness. For LEAD, a disease-specific PROM evaluates HRQoL. For AAA, disease-specific ancillary questions are added. Additionally, the DanVasc survey includes questions on health behaviour, preventive measures and sexual life. The DanVasc survey will be linked to national registries to obtain socio-demographic information and data on redeemed prescriptions, clinical information, healthcare utilisation, comorbidities and mortality. From December 2023 to December 2024, we aim to recruit approximately 5500 patients from all seven DanVasc surgery departments. Patient characteristics will be reported using descriptive statistics. Changes over time and factors associated with poorer health outcomes will be analysed using linear, logistic and Cox proportional hazard models, presented as univariate and multivariate regressions.

ETHICS AND DISSEMINATION

Approval for the collection of medical record data was granted by the Central Denmark Region, acting on behalf of all Danish regions (record 1-45-70-94-22). Consent to participate is obtained prior to answering the survey. Results will be disseminated through peer-reviewed scientific publications and conference presentations, and findings will be shared with patients and relevant stakeholders via public and social media.

INtravaScular OptIcal Frequency Domain ImaGing EvaluaTion of the Femoropopliteal Lesion With JETSTREAM Atherectomy (INSIGHT JETSTREAM)

BACKGROUND

There have been no prior reports of detailed evaluations using intravascular imaging during Jetstream treatment.

AIMS

This study, therefore, aimed to investigate the effects of calcification characteristics and wire bias on lumen gain in Jetstream atherectomy using optical frequency domain imaging (OFDI).

METHODS

This study enrolled consecutive patients who underwent OFDI-guided Jetstream atherectomy with 1.85 mm, 2.4 mm blade down (BD), and 2.4 mm blade up (BU). Cross-sections were categorized into three groups based on OFDI findings before Jetstream atherectomy: fibrous plaques (FPs), calcified protrusions (CPs), and eruptive calcified nodules (ECNs).

RESULTS

Twenty-seven patients (36 limbs) were enrolled, and 1502 cross-sections were serially analyzed. There were 186 FPs, 753 CPs, and 563 ECNs. The acquired lumen gain after all atherectomy steps was significantly larger in the ECNs group than in the CPs and FPs groups. ECNs had the strongest effect on the variability in the lumen gain. In the effect of wire bias on the degree of debulking, a significant correlation was observed between wire distance and lumen gain in 1.85- and 2.4-mm BD atherectomy procedures. However, in the 2.4-mm BU procedure, no significant correlation was recorded.

CONCLUSIONS

Jetstream atherectomy for ECNs can result in greater lumen gain. In the 1.85- and 2.4-mm BD atherectomy procedures, wire bias may be involved in lumen gain, whereas in the 2.4-mm BU procedure, lumen gain is obtained regardless of wire bias. In Jetstream atherectomy procedures, a detailed assessment using OFDI may contribute to predicting the degree of debulking.

TRIAL REGISTRATION

UMIN ID: UMIN000054588. https://center6.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000061997.

Research priorities for peripheral artery disease: A statement from the Society for Vascular Medicine

Lower-extremity peripheral artery disease (PAD) affects approximately 236 million people worldwide and at least eight million people in the United States (US). Despite availability of new therapies that prevent major adverse cardiovascular events (MACE), these and major adverse limb events (MALE) remain common and occur more frequently in people with PAD, either with or without coronary artery disease (CAD), compared to people with CAD who do not have PAD. The most effective therapies to prevent cardiovascular events are not identical in people with PAD and those with CAD. Walking impairment and the risk of lower-extremity amputation are significantly greater in people with PAD compared to those without PAD. This report from the Society for Vascular Medicine (SVM) proposes and summarizes high-priority topics for scientific investigation in PAD, with the goal of improving health outcomes in people with PAD. To develop this report, a multidisciplinary team of scientists and clinicians reviewed literature, proposed high-priority topics for scientific investigation, and voted to rank the highest priority topics for scientific investigation. Priorities for clinical scientific investigation include: determine the current prevalence of PAD in the US by age, sex, race, and ethnicity; improve methods to diagnose PAD; develop new medical therapies to eliminate walking impairment; and improve implementation of established therapies to reduce rates of MACE and MALE in people with PAD. Priorities in basic science and translational science investigation include: developing animal models that closely resemble the vascular, skeletal muscle, and platelet pathology in patients with PAD and defining the genetic and epigenetic contributors to PAD and PAD-associated outcomes. Successful investigation of these research priorities will require more well-trained investigators focused on scientific investigation of PAD, greater and more efficient enrollment of diverse patients with PAD in randomized clinical trials, and increased research funding dedicated to PAD.

Femoropopliteal Endovascular Intervention: A Review of the Current Landscape

Superficial femoral artery disease poses significant challenges in patients with peripheral artery disease due to its unique anatomic and physiological characteristics. While conservative measures remain the initial approach for chronic, stable symptoms, endovascular therapies have gained prominence due to their minimally invasive nature, expedited recovery times, and preservation of future treatment options when performed correctly. Options for endovascular interventions include balloon angioplasty (percutaneous transluminal angioplasty [standard], drug-coated balloon), stenting (bare metal, drug-eluting, covered stents), with or without adjunct therapy (atherectomy or intravascular lithotripsy). Randomized controlled trials have demonstrated superior outcomes with drug-coated balloons and drug-eluting stents over bare metal stents or percutaneous transluminal angioplasty alone, particularly in long, heavily calcified lesions. However, challenges such as in-stent restenosis, stent fracture, and in-stent thrombosis persist, driving ongoing innovation in device technology and drug formulations on devices. Emerging therapies such as bioresorbable scaffolds and percutaneous bypass devices offer promising alternatives. Further research is needed to refine treatment strategies, minimize risks, and optimize outcomes.

Effect of glucagon-like peptide-1 receptor agonists on the risk of major adverse limb events in patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To evaluate the effect of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on the risk of major adverse limb events (MALE).

METHODS

We conducted a systematic review and meta-analysis of randomized clinical trials assessing the effects of GLP-1RAs therapy on peripheral arterial disease (PAD)-related outcomes in patients with type 2 diabetes mellitus (T2DM). This meta-analysis was performed according to PRISMA guidelines. The random-effects model was performed.

RESULTS

A total of 6 randomized clinical trials were considered eligible for this systematic review. On the other hand, 4 clinical trials were included for the meta-analysis. A total of 15,427 subjects were allocated to the GLP-1RAs group, and 15,476 to the placebo group. Overall, this meta-analysis showed that the use of GLP-1RAs is associated with a lower risk of PAD-related events (OR, 0.78; 95%CI, 0.62-0.98, I2=39%) vs the placebo group. The analytical evaluation did not suggest publication bias, and the sensitivity analysis demonstrated that the result was robust.

CONCLUSION

This meta-analysis demonstrated that the use of GLP-1RAs is associated with fewer PAD-related clinical events. Of note, despite the clinical significance of PAD, most analyzed studies did not specifically report on these events. Future studies should include PAD as a key endpoint. PROSPERO Registration: CRD42024565567.

Society for Vascular Surgery Clinical Practice Guideline on the management of intermittent claudication: Focused update

Intermittent claudication (IC) is the most common symptom of peripheral artery disease, which is a growing public health burden in the United States and globally. Patients with IC present with a broad spectrum of risk factors, comorbid conditions, range of disability, and treatment goals. Informed shared decision-making hinges on a comprehensive evaluation of these factors, patient education, and knowledge of the latest available evidence. In 2015, the Society for Vascular Surgery published a clinical practice guideline on the management of asymptomatic peripheral artery disease and IC. An expert writing group was commissioned to provide a focused update to this guideline on the management of IC. Based on the available evidence from published research conducted since the prior guideline, six specific key questions were formulated spanning the areas of antithrombotic management, exercise therapy, and revascularization for IC. A systematic review and evidence synthesis of each question was conducted by a dedicated methodology team. The GRADE approach was employed to describe the strength of each recommendation and level of certainty of evidence. The review identified major gaps in evidence particularly in the arena of comparative effectiveness for interventions (exercise, revascularization) across defined clinical subgroups and employing meaningful patient-centered outcomes. Twelve recommendations, among which are two best practice statements, are provided in this focused update. They address the use of dual pathway antithrombotic strategies, the role and type of exercise therapy, endovascular interventions for femoropopliteal and infrapopliteal disease, and the identification of specific risk factors that should be incorporated into shared decision-making around revascularization. A comprehensive and individualized approach to the management of patients with IC, relying first on education, risk factor control, optimal medical therapy, and exercise, is emphasized. A rubric for decision-making that includes a thorough assessment of risk, benefits, degree of impairment, and treatment durability, is considered fundamental to a patient-centered approach in IC. Significant unmet research needs in this field are also enumerated.

Sex-based difference in functional performance and quality of life 1 year after supervised exercise training in patients with symptomatic peripheral artery disease

INTRODUCTION

The long-term effects of supervised exercise training (SET) on functional performance and health-related quality of life (HRQoL) in symptomatic peripheral artery disease (PAD) are poorly investigated, especially in women. This study investigated these outcomes 1 year after SET in both women and men.

METHODS

In this single-arm, prospective, nonrandomized study, patients with symptomatic PAD participating in the 3-month SET program were investigated. Functional performance (6-minute walking distance [6MWD], the stair-climbing test [SCT], and the short physical performance battery [SPPB]), and HRQoL (physical component summary [PCS] score of the Short Form-36 questionnaire) were assessed before and following SET, as well as at 6 and 12 months after SET completion.

RESULTS

Ninety patients (women: n = 30; men: n = 60) with chronic symptomatic PAD (ankle-brachial index 0.78 ± 0.22; mean age 65.4 ± 10.2 years) were included in the study. The 6MWD (women: before: 387.2 ± 88.6 m; after: 472.4 ± 57.0 m; 12 months: 469.9 ± 57.8 m; men: before: 431.7 ± 94.0 m; after: 477.5 ± 88.6 m; 12 months: 467.2 ± 73.4 m), SPPB score (women: before: 9.6 ± 2.4; after: 11.3 ± 1.0; 12 months: 11.2 ± 0.5; men: before: 10.6 ± 1.4; after: 11.5 ± 0.9; 12 months: 11.3 ± 0.8), and SCT (women: before: 8.6 ± 4.4 s; after: 5.6 ± 1.6 s; 12 months: 5.8 ± 1.2 s; men: before: 6.2 ± 2.3 s; after: 5.0 ± 1.9 s; 12 months: 5.3 ± 1.6 s) significantly improved over time (p ≤ 0.001), with no significant differences between women and men. The PCS score (women: before: 30.3 ± 8.0; after: 38.8 ± 8.4; 12 months: 35.7 ± 7.4; men: before: 32.4 ± 10.5; after: 35.7 ± 9.5; 12 months: 35.4 ± 7.6) significantly improved in women only (p = 0.020).

CONCLUSION

One year after SET, both women and men with PAD exhibit similar functional benefits, whereas HRQoL improvements were observed exclusively in women.

A systematic review supporting the Society for Vascular Surgery guideline update on the management of intermittent claudication

OBJECTIVE

This systematic review and meta-analysis evaluates the current evidence on the management of intermittent claudication (IC), a prevalent manifestation of peripheral arterial disease (PAD).

METHODS

We conducted comprehensive searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. We addressed six questions developed by a guideline committee from the Society for Vascular Surgery, addressing pharmacological treatments, exercise regimens, endovascular interventions, and predictors of major adverse cardiovascular, limb-related events, and mortality.

RESULTS

The search resulted in 5333 citations, from which we included 73 studies (46 randomized trials). In patients with PAD and IC who had one or more high-risk comorbidities, low-dose rivaroxaban and aspirin were associated with lower risk of major adverse limb events and major adverse cardiovascular events than aspirin alone. In patients who have undergone surgical or endovascular interventions for PAD, the addition of low-dose rivaroxaban to aspirin may improve limb outcomes. Of note, rivaroxaban trials excluded patients at high risk of bleeding. Single antiplatelet agents showed no significant efficacy differences head-to-head in ambulatory patients with IC and had a lower bleeding risk compared with combination therapy or anticoagulation. Home exercise programs were feasible and may be an alternative to supervised exercise in ambulatory patients with IC and in those who had revascularization. Several comorbidities increased the risk of adverse outcomes after revascularization for IC, such as advanced age, diabetes, coronary artery disease, chronic obstructive pulmonary disease, previous interventions, congestive heart failure, infrapopliteal artery involvement, and longer lesion lengths. In patients with IC undergoing endovascular intervention for superficial femoral artery disease, plain balloon angioplasty was associated with worse outcomes than drug elution or stent implantation for intermediate or longer lesions (ie, >5 cm).

CONCLUSIONS

This systematic review summarizes the current evidence base for the management of IC, offering insights into the relative benefits and risks of various therapeutic strategies. The findings underscore the need for individualized patient care, considering both the potential benefits and risks associated with different interventions.

Liraglutide improves peripheral perfusion and markers of angiogenesis and inflammation in people with type 2 diabetes and peripheral artery disease: An 18-month follow-up of a randomized clinical trial

AIMS

In a six-month randomized clinical trial, improved peripheral perfusion has been shown with liraglutide, associated with favourable vascular effects in people with type 2 diabetes and peripheral artery disease (PAD). We aimed to evaluate the durability of these benefits and to elucidate some mechanisms underlying liraglutide's effect over an 18-month follow-up.

METHODS

STARDUST was a randomized clinical trial which compared liraglutide up to 1.8 mg/day with tailored therapeutic prescriptions to manage cardiovascular risk factors in 55 participants with type 2 diabetes and PAD. We report data of people who have reached the 18-month follow-up for the primary outcome (transcutaneous oxygen pressure, TcPO2) and also for additional secondary outcomes (markers of inflammation, angiogenesis and kidney function), as well as glycemic and metabolic parameters. TcPO2 was assessed with transcutaneous oximetry. Circulating levels of angiogenic progenitor cells and serum inflammation markers were evaluated by flow cytometry and enzyme-linked immunosorbent assay, respectively.

RESULTS

Compared with the control group, significant differences favouring the liraglutide group were observed at 18 months for TcPO2 [estimated treated difference (95% CI), 10.9 mmHg (7.6 to 14.1 mmHg), p < 0.001]. At 18 months of follow-up, participants in the liraglutide group, as compared with those in the control group, had a significant reduction in urine albumin to creatinine ratio (estimated difference, -103.9 mg/g Cr, 95%CI, -170.8 to -37.1, p = 0.003), C-reactive protein (-0.5 mg/dL, 95%CI, -0.8 to -0.2, p = 0.002), as well as interleukin-6 (-32.6 pg/mL, 95%CI, -54.6 to -10.5, p = 0.004). Compared with the control group, participants in the liraglutide group showed significantly higher concentrations of circulating progenitor cells and endothelial progenitor cells at both 6 and 18 months, for CD34+, CD133+, KDR+, CD34+/KDR+ and CD34+/CD133+/KDR+. Liraglutide was also associated with a higher increase in vascular endothelial growth factor A at 18 months (70.1 pg/mL, 95%CI, 44.7 to 95.4, p < 0.001).

CONCLUSIONS

In people with type 2 diabetes and PAD, liraglutide increased peripheral perfusion, with amelioration of markers of angiogenesis and inflammation over an 18-month follow-up.

Patterns and Timings of Recurrence After Fluoropolymer-Coated Drug-Eluting Stent Use for Femoropopliteal Artery Diseases - Results of the PLANET Study

BACKGROUND

Fluoropolymer-coated drug-eluting stents (FP-DESs) are widely used to treat femoropopliteal artery (FPA) disease. However, data on the pattern and timing of recurrence after FP-DES implantation are limited. This study aimed to address this knowledge gap.

METHODS AND RESULTS

This multicenter retrospective study analyzed 439 limbs of 398 patients treated with FP-DESs for de novo FPA lesions. The outcome measures were clinical outcomes in cases of recurrence, defined as a composite of restenosis and reocclusion. The timing of recurrence was categorized into early (within 1 year of treatment) and late (after 1 year). The factors associated with recurrence were analyzed by comparing cases of early and late recurrence. The early recurrence group showed a significantly higher frequency of reocclusion, particularly stent thrombosis. In addition, in this group, patients with reocclusion tended to exhibit significantly more severe clinical symptoms than those with restenosis. Deployment of FP-DES beyond the P1 segment was independently associated with early recurrence. Chronic total occlusion was independently associated with early reocclusion. Female sex, diabetes, not using statins, and long lesions were independently associated with late recurrence. Not using statins, warfarin use, and long lesions were independent predictive factors for late reocclusion.

CONCLUSIONS

The patterns and clinical symptoms of recurrence after FP-DES implantation for FPA differed according to the timing of recurrence, as did the factors associated with recurrence.

Serum P-Cresyl Sulfate Levels Correlate with Peripheral Arterial Disease in Hypertensive Patients

Background/Objectives:p-Cresyl sulfate (PCS) is implicated in inflammation, oxidative stress and vascular dysfunction. Hypertension is a major risk factor for peripheral arterial disease (PAD), which is linked to increased mortality in patients with hypertension. This study aimed to evaluate the association between serum PCS levels and PAD in hypertension cases. Methods: We analyzed fasting blood samples and clinical data from 105 patients with hypertension in a cardiovascular outpatient clinic. Serum PCS levels were quantified using high-performance liquid chromatography-mass spectrometry. Ankle-brachial index (ABI) was measured using an automated oscillometric device; ABI < 0.9 indicated PAD. Results: A total of 24 patients (22.9%) had PAD. The PAD group had a higher prevalence of diabetes mellitus (p = 0.026), elevated serum C-reactive protein (CRP) levels (p < 0.001) and increased PCS levels (p = 0.002) than the normal ABI group. Multivariate logistic regression showed that PCS (odds ratio [OR]: 1.154, 95% confidence interval [CI]: 1.013-1.315, p = 0.031) and CRP (per 0.1 mg/dL increase, OR: 1.649, 95% CI: 1.138-2.389, p = 0.008) were independently associated with PAD. According to Spearman's correlation analysis, log-transformed PCS (log-PCS) levels negatively correlated with left or right ABI (p = 0.001 and p = 0.004, respectively) and estimated glomerular filtration rate (p = 0.001) but positively correlated with log-CRP (p = 0.024). Conclusions: Elevated serum PCS and CRP levels are significantly associated with PAD in patients with hypertension, suggesting the potential role of PCS in PAD pathogenesis.

Association between S100A12 and risk of peripheral arterial disease in patients with dyslipidemia: a cross-sectional study

OBJECTIVE

S100A12 acts as a pro-inflammatory agent in vivo, with a close relationship with plaque formation in patients with acute coronary syndrome (ACS), end-stage renal disease, and diabetes. Peripheral arterial disease (PAD) can lead to mobility difficulties and ultimately disability and amputation. The association between S100A12 and risk of peripheral arterial disease remains unclear. This study aims to investigate the association between S100A12 and the risk of PAD in patients with dyslipidemia.

METHODS

From March 2023 to June 2024, 478 patients were included in this cross-sectional study. They were divided into PAD group (n = 105) and control group (n = 373) according to the presence or absence of PAD (The diagnosis of PAD is a combination of the patient's clinical symptoms, imaging evidence and ankle-brachial index). Plasma S100A12 was detected by available kit. General information, disease history, smoking history, and laboratory indicators were collected from both groups. The relationship between S100A12 and the risk of PAD was analyzed using statistical methods.

RESULTS

Levels of S100A12 were significantly higher in the PAD group of dyslipidemia [0.22 (0.13,1.49) ng/cL vs. 0.13 (0.10,0.18)ng/cL, p value < 0.001]. Univariate and multivariate logistic regression analyses suggested that the risk of PAD was significantly higher with increasing levels of S100A12 [Odd ratio (OR) (95%CI) = 2.264 (1.681, 3.047), p value < 0.05]. In addition, lower high-density lipoprotein cholesterol (HDL-C) level and diabetes mellitus (DM) were independent risk factors for PAD [OR (95%CI) = 0.388 (0.186,0.809), p value = 0.012; OR = 2.375 (1.527,3.695), p value < 0.001]. Subgroup analysis suggested that S100A12 was significantly and positively associated with the risk of PAD in all subgroups, regardless of whether HDL-C levels < 1.03 mmol/L, age > 60 years, and presence of diabetes or hypertension. Restricted cubic spline (RCS) curves suggested that the correlation between S100A12 and the risk of PAD was nonlinear (p-non-linear value < 0.05). The RCS curves showed that the positive correlation between S100A12 and the risk of PAD was stronger when the S100A12 level was less than 1.00ng/cL.

CONCLUSION

In conclusion, elevated S100A12 level is an independent risk factor for PAD in patients with dyslipidemia. In different subgroups, S100A12 was significantly and positively associated with the risk of PAD after adjusting for different factors. There is a non-linear relationship between S100A12 and the risk of PAD, with a stronger positive correlation at S100A12 levels below 1.00ng/cL. These findings implied that S100A12 is a potential biomarker for identifying patients with dyslipidemia who are at high risk of developing PAD. They also implied that S100A12 levels can be routinely monitored in dyslipidemic populations for the early detection of PAD and to guide the management of PAD. Finally, the results of this study emphasize that inflammation in dyslipidemia patients plays an important role in the development of PAD, suggesting that lipid control and immunomodulation may be effective in the prevention of PAD.

CLINICAL TRIAL NUMBER

MR-35-24-038431.

Hypertension in atherosclerotic cardiovascular disease: insights into epidemiology, management strategies, and outcomes

PURPOSE OF REVIEW

To provide a comprehensive review of hypertension among patients with atherosclerotic vascular disease. Although there is significant alignment in treatment goals and strategies, blood pressure targets and therapies differ among atherosclerosis in varying vascular territories. Hypertension is a prominent risk factor for the development and amplification of atherosclerosis, as well as the cause of significant downstream morbidity and mortality.

RECENT FINDINGS

Hypertension is the greatest contributor to population attributable cardiovascular risk. Hypertension accelerates the development of atherosclerotic cardiovascular disease (ASCVD), and treatment of hypertension is a central tenet to managing ASCVD. Patients with ASCVD often merit a multidisciplinary approach, require multiple specialists and medications, and may suffer from additional consequences of therapy due to multimorbidity. Significant arterial stenoses may lead to unintended consequences of antihypertensive therapy. Further, there have been recent advances in the interventional management of hypertension, including techniques like renal denervation.

SUMMARY

In recent years, there have been significant changes in management guidelines of hypertension and peripheral arterial disease, new evidence in coronary artery disease, and simultaneously there's been an evolution in interventional management of hypertension, such as renal denervation. We provide an update on hypertension treatment in atherosclerotic disease among different vascular beds.

Effects of a Cloud-Based Synchronous Telehealth Program on Valvular Regurgitation Regression: Retrospective Study

BACKGROUND

Telemedicine has been associated with better cardiovascular outcomes, but its effects on the regression of mitral regurgitation (MR) and tricuspid regurgitation (TR) remain unknown.

OBJECTIVE

This study aimed to evaluate whether telemedicine could facilitate the regression of MR and TR compared to usual care and whether it was associated with better survival.

METHODS

This retrospective cohort study enrolled consecutive patients with moderate or greater MR or TR from 2010 through 2020, excluding those with concomitant aortic stenosis, aortic regurgitation, or mitral stenosis greater than mild severity. All patients underwent follow-up transthoracic echocardiography (TTE) at least 3 months apart. Patients receiving telehealth services for at least two weeks within 90 days of baseline TTE were categorized as the telehealth group; the remainder constituted the nontelehealth group. Telemedicine participants transmitted daily biometric data-blood pressure, pulse rate, blood glucose, electrocardiogram, and oxygen saturation-to a cloud-based platform for timely monitoring. Experienced case managers regularly contacted patients and initiated immediate action for concerning measurements. The primary endpoint was MR or TR regression from ≥moderate to

RESULTS

The MR cohorts consisted of 264 patients (mean age 67 years), including 97 regressors and 74 telehealth participants. Telehealth participation (hazard ratio 2.20, 95% CI 1.35-3.58; P=.001) was robustly associated with MR regression; MR regressors were linked to reverse cardiac remodeling, indicated by improved left ventricular ejection fraction (LVEF), and reduced left ventricular (LV) and left atrial (LA) dimensions (all P≤.005). Determinants of ACD were age (P<.001), LVEF (P<.001), percutaneous coronary intervention (P<.001), and MR regressors (P=.02). The TR cohort consisted of 245 patients (mean age 68 years), including 87 TR regressors and 61 telehealth participants. Telehealth (P=.05) was one of the univariable determinants of TR regression, while beta-blocker use (P=.048) and baseline TR severity (P=.01) remained strong predictors of TR regression in multivariable analysis.

CONCLUSIONS

Patients in the telehealth group were 2.2 times more likely to experience MR regression. Moreover, MR regressors had better survival and reverse cardiac remodeling compared to nonregressors. These findings may have important implications for future guidelines.

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Key Words

• cardiac remodeling
• mitral regurgitation
• telehealth
• telemedicine
• tricuspid regurgitation

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MESH Headings

• Humans
• Retrospective Studies
• Male
• Telemedicine
• Female
• Aged
• Mitral Valve Insufficiency/therapy
• Mitral Valve Insufficiency/mortality
• Cloud Computing
• Middle Aged
• Tricuspid Valve Insufficiency/therapy
• Tricuspid Valve Insufficiency/mortality
• Echocardiography

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Affiliation(s)

Li-Tan Yang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Han Wu Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Jen-Kuang Lee Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Wei-Jyun Wang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Ying-Hsien Chen Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Ching-Chang Huang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Sheng Hung Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Kuang-Chien Chiang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Yi-Lwun Ho Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Hui-Wen Wu Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan

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Prevalence of peripheral arterial disease and its association with claudication in individuals with type 2 Diabetes Mellitus: a prospective cross-sectional study in Brazil

Background

Few studies have described the prevalence of peripheral arterial disease (PAD) in the diabetic population of Brazil.

Objectives

To evaluate the prevalence of PAD and its association with the presence of claudication and to compare risk factors for atherosclerosis between subjects with and without PAD.

Methods

An analytical, observational, prospective, cross-sectional study was conducted with 150 volunteers with type 2 Diabetes Mellitus (T2DM) treated at a university endocrinology outpatient clinic (Federal University of Paraná, Curitiba, Brazil) and assessed using the ankle-brachial index (ABI) and the Edinburgh Claudication Questionnaire.

Results

ABI was evaluated in 143 volunteers (7 did not meet the inclusion criteria). Six individuals had an ABI > 1.4. Excluding these cases and adopting an ABI ≤ 0.9 to identify PAD, the prevalence of PAD was 14.6% (20 of 137), 15.8% in men (6 of 38), and 14.1% in women (14 of 99). We identified twenty-five participants with borderline ABI (18.2%). Claudication was present in 25% of subjects with PAD; however, only 15% had typical claudication. A significant association with the presence of typical claudication was observed only when ABI values were stratified above or below 1.0 (p = 0.04, Fisher's exact test). Participants with PAD were older (median difference: 5.5 years, 95% CI 3.0 to 9.0, p < 0.001) and tended to have a longer duration of DM and higher BMI.

Conclusions

The prevalence of PAD in T2DM volunteers with no prior screening was 14.6% and 75% were asymptomatic.

Senescent Macrophages Promote Age-Related Revascularization Impairment by Increasing Antiangiogenic VEGF-A165B Expression

Peripheral arterial disease is a common vascular disease in the elderly. Therapeutic revascularization, including angiogenic and arteriogenic therapy, is a promising treatment approach for peripheral arterial disease. However, the progress of clinical trials is not ideal, possibly due to insufficiency of preclinical models, such as not taking into account the effect of aging on vascular regeneration. Macrophages are crucial in angiogenesis and arteriogenesis. The aging microenvironment typically makes recruited monocytes and macrophages more susceptible to senescence. However, the feature of macrophages in ischemic hindlimb muscle of old individuals and their underlying role remains unclear. In this study, we reveal that macrophages of ischemic skeletal muscle in old mice are more senescent and proinflammatory. By transplanting macrophages into mice following hindlimb ischemia, we find senescent macrophages inhibit revascularization. Mechanistically, these senescent macrophages induce endothelial dysfunction via increasing vascular endothelial growth factor A-165B (VEGF-A165B) expression and secretion, and eventually impair revascularization. Notably, plasma VEGF-A165B levels are elevated in old patients with PAD and positively associated with a lower ankle brachial index (ABI). Our study suggests that targeting the senescent macrophages presents an avenue to improve age-related revascularization damage.

Evaluation of the Safety and Biocompatibility of a Novel Galvanized Vascular Stent in a Rabbit Atherosclerosis Model

BACKGROUND

Compared to traditional pure zinc stents, the novel galvanized vascular stent (GVS) combines the mechanical advantages of cobalt-chromium alloy with the biological functions of zinc. This study aims to evaluate the safety and biocompatibility of the GVS in a rabbit atherosclerosis model.

METHODS

A rabbit atherosclerosis model was established using a high-fat diet (HFD), and a galvanized cobalt-chromium alloy stent was implanted in the abdominal aorta. The experimental animals were followed up at 1, 3, and 6 months postsurgery. Safety was assessed through hematological parameters and histopathological analysis, and scanning electron microscopy and tissue section staining were used to evaluate re-endothelialization and intimal hyperplasia in the stented arterial segment. Proteomics was employed to uncover potential molecular mechanisms.

RESULTS

At each time point following GVS implantation, no significant abnormalities were observed in hematological parameters or histopathological examination of major organs. No significant restenosis was observed in the stented segment at 6 months postimplantation. A complete endothelial layer was formed on the stent surface at 1 month postsurgery, and the stent remained fully covered at 6 months. The intimal thickness adjacent to the stent struts gradually increased postsurgery but showed no significant pathological hyperplasia. Proteomics suggests that the GVS may promote vascular repair through signaling pathways, such as phosphatidylinositol 3-kinase-protein kinase B, cyclic guanosine monophosphate-protein kinase G, and cyclic adenosine monophosphate, and may have potential advantages in inducing macrophage polarization to the anti-inflammatory M2 type and inhibiting oxidative stress responses.

CONCLUSIONS

The GVS demonstrates good safety and biocompatibility in a rabbit atherosclerosis model.

Great saphenous vein versus expanded polytetrafluoroethylene graft in patients undergoing elective treatment of popliteal artery aneurysm with posterior approach

BACKGROUND

Aim of this study is to compare 30-day and 5-year outcomes of great saphenous vein (GSV) vs. expanded polytetrafluoroethylene (ePTFE) graft in patients undergoing elective treatment of popliteal artery aneurysm (PAA) using a posterior approach.

METHODS

Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs who underwent open repair with posterior approach or endovascular repair in 40 centers was investigated. Out of of 971 cases, 525 patients were included in the present analysis. These were further divided into: posterior approach with GSV graft (252, GSV Group), and posterior approach with ePTFE graft (273, ePTFE Group). Thirty-day outcomes were assessed and compared. During follow-up, survival, primary patency, secondary patency, freedom from reintervention(s), and amputation-free survival were compared between the two groups using log-rank tests. Uni- and multivariate Cox regression analyses were performed in ePTFE Group to find predictive factors of poor outcomes.

RESULTS

Two groups were homogeneous in terms of preoperative risk factors and morphological data. Median follow-up duration was similar [24 months (IQR 10 - 36) GSV Group vs. 21 months (IQR 7-47) ePTFE Group; p = .123]. At 5 years, there were no differences between the two groups in terms of survival (84.7% GSV Group vs. 86.1% ePTFE Group; p = .097, log-rank = 2.756), secondary patency (94.9% GSV Group vs. 89.4% ePTFE Group; p = .068, log-rank = 3.336), and amputation-free survival (99.1% GSV Group vs. 99.6% ePTFE Group; p = .567, log-rank = .328). Five-year primary patency (89.5% GSV Group vs. 76.2% ePTFE Group; p = .007, log-rank = 7.239), and freedom from reintervention(s) (92.8% GSV Group vs. 80.6% ePTFE Group; p = .011, log-rank = 6.449) were significantly higher in GSV Group. Using multivariate analysis in ePTFE Group, factors compromising primary patency were patients on dialysis (p = .054, OR = 3.641), and patients that were not on any preoperative antiplatelet therapy or anticoagulation (p = .019, OR = 5.532), whilst none of the perioperative factors affected freedom from reintervention(s).

CONCLUSION

GSV as graft guaranteed better primary patency with less reinterventions rates at mid-term follow-up after treatment of PAAs via a posterior approach. Patients on dialysis and who were not on any preoperative antiplatelet therapy or anticoagulation had lower patency rates.

Study protocol for a randomized clinical trial evaluating the safety and efficacy of autologous adipose-derived stem cell therapy for ulcers in patients with critical limb ischemia

BACKGROUND

Peripheral artery disease (PAD) can develop into critical limb ischemia (CLI), which is characterized by resting pain at rest, ulcerations, or gangrene, with a high risk of amputation. The optimum course of treatment at this point is arterial revascularization, although this has a significant financial cost and is not always feasible or successful in reducing pain, healing ulcers, or preventing amputations. In situations where traditional alternatives for treating PAD have been exhausted, recent developments in cell therapy may offer a viable substitute.

OBJECTIVE

The purpose of this study is to assess the safety and effectiveness of using expanded autologous adipose-derived stem cells (ASCs) in cellular therapy for the treatment of PAD patients who developed chronic artery ulcers.

METHODS

An open randomized clinical trial will be carried out with two groups of twenty patients with CLI: In group 1, 2g of abdominal adipose tissue will be taken to produce ASCs. These cells will then be expanded in a lab (cell processing center) for 14-21 days before being applied to the lesion using bio-dressings and perilesional subcutaneous injections. Group 2 will receive conventional treatment with hydrogel-based dressing. There will be regular clinical assessments, supplementary tests, and photo documentation. The main efficacy outcome will be partial or complete healing of the wound. Safety outcomes will be monitored for infections, gangrene, amputations, and death. Participants will be monitored for 90 days. Cases of major amputation of the studied limb will not be included. The results will be evaluated by an independent external evaluator who is blind to the groups. Considering the high prevalence and socioeconomic consequences related to CLI and limb amputation, this study is expected to provide a positive social and financial impact on the Brazilian Unified Health System. ClinicalTrials.gov: NCT06326203.

Sex Differences in Peripheral Vascular Disease: A Scientific Statement From the American Heart Association

Sex differences in the risk factors, diagnosis, treatment, and outcomes of patients with cardiovascular disease have been well described; however, the bulk of the literature has focused on heart disease in women. Data on sex differences in peripheral vascular disease are ill defined, and there is a need to report and understand those sex-related differences to mitigate adverse outcomes related to those disparities. Although peripheral vascular disease is a highly diverse group of disorders affecting the arteries, veins, and lymphatics, this scientific statement focuses on disorders affecting the peripheral arteries to include the aorta and its branch vessels. The purpose of this scientific statement is to report the current status of sex-based differences and disparities in peripheral vascular disease and to provide research priorities to achieve health equity for women with peripheral vascular disease.

Endovascular Treatment of Infrainguinal Peripheral Artery Disease With Stent Versus Nonstent Strategies in the XLPAD Registry

Anatomic location of infrainguinal peripheral arteries has continually challenged endovascular revascularization strategies based on the use of stent vs. nonstent strategies. The objective of our study is to compare stent vs. nonstent outcomes of patients enrolled in the multicenter, core laboratory adjudicated XLPAD registry (NCT01904851) between 2005 and 2023. We analyzed 12-month cumulative incidence of major adverse cardiac and vascular events (MACVE), a composite outcome of all-cause death, nonfatal myocardial infarction, stroke, lower limb revascularization and any amputation in patients treated with clinically indicated stent or nonstent interventions, analyzed within a competing risk framework; group differences assessed using the Gray's test. To minimize confounding bias, we also implemented propensity score matching. About 5,067 patients (5,876 lesions), mean age 67.2 ± 10.3 years, underwent stent (n = 2,571) or nonstent (n = 2,496) predominantly femoropopliteal artery (68%) interventions. 42.8% were current smokers, 57.3% diabetic; 17% had chronic kidney disease and 56.5% coronary artery disease. 50.7% presented with Rutherford class (II-III) symptoms, with mean ankle-brachial index 0.64 ± 0.24. 61% lesions in stent group and 38.6% in the nonstent group had chronic total occlusions (p <0.001). Significantly greater calcified (36.6% vs. 33%; p = 0.004) and longer lesions (142.9 ± 96.5 mm vs. 115.8 ± 91.3 mm; p <0.001) were treated in the stented group. Drug-coated balloon and atherectomy use were 18% and 34.2%, respectively. Procedural success was higher in the stent group (96.9% vs. 89.5%; p <0.001). Peri-procedural period flow-limiting dissections were higher in the stent (2.7% vs. 0.3%; p <0.001), and any amputation in the nonstent (3.0% vs. 4.4%; p = 0.008). 12-month MACVE was higher in the stent group (22.2% vs. 19.2%, p = 0.009) mainly driven by greater need for repeat endovascular revascularization (13.1% vs. 10.4%, p = 0.003), and this was consistent even after adjusting for chronic limb threatening ischemia presentation (adjusted odds ratio [OR], 1.193; 95% confidence interval [CI], 1.039 to 1.370; p = 0.013). The stented group had 29.6% increased odds of MACVE compared to nonstent (adjusted OR, 1.296, 95% CI: 1.115 to 1.506, p = 0.001), even after adjusting for residual confounders with propensity matching. Stent-based interventions are used to treat more complex infrainguinal PAD, with greater procedural success, but higher 12-month MACVE compared with nonstent interventions.

The incidence and significance of delayed bleeding events after lower extremity revascularization in patients with advanced peripheral arterial disease

OBJECTIVE

As novel medications are used in various combinations to prevent thrombosis, few studies have focused on bleeding events after lower extremity revascularization (LER) in patients with peripheral artery disease (PAD). Moreover, the impact of bleeding events on long-term outcomes and the prescription of antithrombotic therapy is not well-reported. This study examines the incidence of bleeding events after LER and their significance in patients with advanced PAD.

METHODS

A retrospective review of patients undergoing LER for PAD in a tertiary care center was performed. Bleeding was classified into major and minor based on the International Society of Thrombosis definitions and captured outside the 30-day perioperative period of LER. Characteristics and outcomes of patients who experienced bleeding events more than 30 days after initial LER were compared with patients who did not.

RESULTS

A total of 1932 patients underwent LER, and 529 (27.4%) experienced a bleeding event (53% major, 47% minor) over 4.3 years. Patients who experienced a bleeding event were more likely to have hypertension (93% vs 89%; P = .005), coronary artery disease (58% vs 53%; P = .047), chronic renal insufficiency (25% vs 16%; P < .001), end-stage renal disease (12% vs 6.8%; P < .001), a history of smoking (84% vs 79%; P = .007), and be on dual antiplatelet therapy (31% vs 25%; P = .029) at baseline. Patients who experienced a bleeding event after 30 days were also more likely to have developed perioperative bleeding (7.6% vs 5.2%; P = .049) after the first LER. On follow-up, patients with bleeding were more likely to have reinterventions (51% vs 43%; P = .002), major amputation (14% vs 7.1%; P < .001), myocardial infarction (33% vs 17%; P < .001), stroke (9.5% vs 5.1%; P < .001), and mortality (48% vs 38%; P < .001). The most common type of bleeding was gastrointestinal (47%), followed by surgical site unrelated to LER (13%), and intracranial. Blood transfusion was used in 48% of patients. Moreover, 40% of patients with an initial bleeding episode had at least one recurrent bleeding episode, with a mean of 2.9 bleeding episodes per patient. After the first bleeding episode, 15% of patients were discharged without any antithrombotic therapy and 13%, 16%, and 11% had discontinuation of ASA, P2Y12 inhibitors, and anticoagulation respectively.

CONCLUSIONS

Bleeding events are common after LER for advanced PAD and are associated with worse overall outcomes. Recurrent bleeding events are likely and significantly affect antithrombotic medication prescriptions.

Textbook outcomes after revascularization for chronic limb-threatening ischemia remain rare

OBJECTIVE

Suggested performance outcome metrics and traditional surgical benchmarks may be inadequate proxies for evaluating the quality of revascularization in chronic limb-threatening ischemia (CLTI). Textbook outcomes (TOs) following revascularization in CLTI are poorly described and limited to cohorts studying open bypass only. We aim to propose a TO in CLTI to provide a more comprehensive evaluation of modern CLTI outcomes.

METHODS

A 9-year retrospective, single-center analysis of consecutive patients with CLTI undergoing revascularization (open, endovascular, or hybrid) was performed. Data on demographics; length of stay; comorbidities; procedural data; Wound, Ischemia, and foot Infection (WIfI) scores; limb salvage; postoperative complications; wound healing; and return to baseline and/or normalized ambulatory status and survival were collected. TO was defined as a composite of survival, limb-salvage, without reinterventions (wound or vascular), freedom from major complications and reinterventions, ≤1 wound-related procedure, return to baseline function, and complete wound healing. Descriptive statistics and binary logistic regression were used to evaluate factors associated with TO.

RESULTS

Over 9 years, 702 patients with CLTI (n = 445 male [63.4%]; median age, 66.6 years [interquartile range (IQR), 59.2-73.9 years]; 915 limbs; median follow-up, 25 months [IQR, 11-47 months]) were studied. Significant patient-level comorbidities include diabetes mellitus (n = 458; 65.3%); chronic kidney disease (n = 451; 64%), and dialysis dependence (n = 225; 32%). Initially, 915 limbs were treated with 646 endovascular (71%), 215 open (24%), and 49 hybrid (5%) procedures. TO was achieved in 225 limbs (24.6%). For the overall cohort, each component of TO at 1 year were as follows: survival (n = 610; 86.9%), limb salvage (n = 787; 86%), freedom from major postoperative complications (n = 788; 86%), freedom from reinterventions (n = 513; 56%), ≤1 wound procedure (n = 607; 66%), return to baseline and/or normalized ambulatory status (n = 587; 64.2%), and complete wound healing (n = 347; 62%). Multivariable analysis identified factors associated with TO as follows: anticoagulant use (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.4-0.8; P < .01); WIfI stage 1 (OR, 2.6; 95% CI, 1.5-4.5; P < .001), diabetes (OR, 0.42; 95% CI, 0.29-0.60; P < .001), and residence in an assisted living facility (OR, 0.13; 95% CI, 0.03-0.55; P = .006).

CONCLUSIONS

Despite excellent survival and limb-salvage, TO was achieved in less than one-fourth of patients undergoing revascularization for CLTI. Patients with WIfI stage 1 have a greater than two-fold odds of having a TO compared with all other WIfI stages, whereas those living in an assisted living facility, who were diabetics, and/or were taking oral anticoagulants were less likely to achieve a TO. Our data highlight the fact that current performance metrics fail to capture the true procedural burden associated with revascularization, which merits consideration when educating patients, selecting patients for intervention, and outcome adjudication in clinical trials and quality assessments.

Improving large language model applications in biomedicine with retrieval-augmented generation: a systematic review, meta-analysis, and clinical development guidelines

OBJECTIVE

The objectives of this study are to synthesize findings from recent research of retrieval-augmented generation (RAG) and large language models (LLMs) in biomedicine and provide clinical development guidelines to improve effectiveness.

MATERIALS AND METHODS

We conducted a systematic literature review and a meta-analysis. The report was created in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 analysis. Searches were performed in 3 databases (PubMed, Embase, PsycINFO) using terms related to "retrieval augmented generation" and "large language model," for articles published in 2023 and 2024. We selected studies that compared baseline LLM performance with RAG performance. We developed a random-effect meta-analysis model, using odds ratio as the effect size.

RESULTS

Among 335 studies, 20 were included in this literature review. The pooled effect size was 1.35, with a 95% confidence interval of 1.19-1.53, indicating a statistically significant effect (P = .001). We reported clinical tasks, baseline LLMs, retrieval sources and strategies, as well as evaluation methods.

DISCUSSION

Building on our literature review, we developed Guidelines for Unified Implementation and Development of Enhanced LLM Applications with RAG in Clinical Settings to inform clinical applications using RAG.

CONCLUSION

Overall, RAG implementation showed a 1.35 odds ratio increase in performance compared to baseline LLMs. Future research should focus on (1) system-level enhancement: the combination of RAG and agent, (2) knowledge-level enhancement: deep integration of knowledge into LLM, and (3) integration-level enhancement: integrating RAG systems within electronic health records.

Lifetime risk of lower extremity peripheral arterial disease: a Danish nationwide longitudinal study

BACKGROUND AND AIMS

Lower extremity peripheral arterial disease (PAD) presents a substantial disease burden, yet lifetime estimates remain scant. This nationwide study quantified the lifetime risk of PAD and its clinical outcomes in Denmark.

METHODS

This cohort study included 4 275 631 individuals in Denmark aged 40-99 years between 1998 and 2018. We estimated the lifetime risk using a modified survival analysis method, considering death as a competing risk event.

RESULTS

Over a median 15.5-year follow-up, 151 846 individuals were diagnosed with PAD (median age at diagnosis 71.5 years, interquartile range 63.1-79.2). The overall lifetime risk of PAD from age 40 was 11.6% (95% confidence interval 11.6%-11.7%), decreasing from 12.9% in 1998-2002 to 10.7% in 2013-18. Males had a higher lifetime risk than females (12.8% vs. 10.5%). Socioeconomic disparities were evident, with higher risks for those with lower educational levels (risk difference 3.4%, 95% confidence interval 3.2%-3.6%) and lower income (risk difference 0.4%, 95% confidence interval 0.2%-0.5%). One year after PAD diagnosis, 21.4% had undergone lower limb revascularization, 8.0% had experienced a major amputation, and 16.2% had died. At 5 years, the corresponding proportions were 26.4%, 10.8%, and 40.8%, respectively. The risk of lower limb revascularization showed little variation by sex and socioeconomic status, whereas there was a strong socioeconomic gradient for major amputation and all-cause death.

CONCLUSIONS

More than one in 10 Danish individuals are diagnosed with symptomatic PAD during their lifetime. Peripheral arterial disease diagnosis is associated with high morbidity and mortality at 1 and 5 years.

Femoropopliteal Interventions for Peripheral Artery Disease: A Review of Current Evidence and Future Directions

The femoropopliteal segment is a common anatomic location for peripheral artery disease. The clinical presentation of occlusive disease of the femoropopliteal segment can range from symptomatic or severe claudication if in isolation, or acute or chornic limb threatening ischemia often in the setting of multilevel disease. Patients can be treated with various therapies to improve symptoms and restore perfusion, including medical, exercise, endovascular, and open surgical therapies. The current literature is rapidly evolving on the best management algorithms and strategies based on patient presentation, severity of occlusive disease, and desired therapy goals. This paper summarizes current literature on available medical, endovascular, and surgical therapies for treating peripheral artery occlusive disease of the femoropopliteal segment.

Lipidomic insights on abdominal aortic aneurysm and peripheral arterial disease

Abdominal aortic aneurysm (AAA) and peripheral arterial disease (PAD) are two cardiovascular diseases associated with considerable morbidity, mortality and quality of life impairment. As they are multifactorial diseases, several factors contribute to their pathogenesis, including oxidative stress and lipid peroxidation, and these may have key roles in the development of these pathologies. Alterations of the lipid metabolism and lipid profile have been reported in cardiovascular diseases but to a lesser extent in AAA and PAD. Modifications in the profile of some molecular lipid species, in particular, native phospholipid and triglyceride species were mainly reported for AAA, while alterations in the fatty acid profile were noticed in the case of PAD. Oxidized phospholipids were also reported for AAA. Although AAA and PAD have a common atherosclerotic root, lipidomics demonstrates the existence of distinct lipid. Lipidomic research regarding AAA and PAD is still scarce and should be set in motion to increase the knowledge on the lipid changes that occur in these diseases, contributing not only to the discovery of new biomarkers for diagnosis and prognosis assessment but also to tailor precision medicine in the clinical field.

Chronic Limb-Threatening Ischemia: A Comprehensive Review Paper

Chronic limb-threatening ischemia (CLTI) is the end-stage presentation of peripheral artery disease and requires comprehensive care. Despite advancements in treatments, providing timely and equitable care remains challenging. Ongoing research and interdisciplinary collaboration are vital for improving outcomes. Implementing strategies that combine appropriate diagnostics, advanced and innovative revascularization techniques, guideline-directed medical therapies, and efforts to tackle socioeconomic disparities can better address patient needs and enhance quality and quantity of life. This multifaceted approach offers promise for improved long-term outcomes in CLTI patients.

Outcomes of contemporary stents with deep femoral artery coverage

INTRODUCTION

We aimed to investigate deep femoral artery (DFA) status during endovascular treatment (EVT) and the patency of the femoropopliteal (FP) artery and DFA using current stent devices for ostial FP lesions.

METHODS

A multicenter, retrospective study analyzed data from 457 patients who underwent EVT with stent deployment for de novo ostial FP lesions between April 2018 and December 2021 at eight centers in Japan. Propensity score-matched analysis was performed to compare the clinical impacts of DFA coverage for ostial FP lesions with stent deployment. The prognostic value was analyzed based on DFA status during EVT, primary patency of the FP artery, clinically driven-target lesion revascularization (CD-TLR) of the FP artery, and incidence of DFA occlusion/major amputation/acute limb ischemia (ALI) at 3 years.

RESULTS

A total of 132 matched pairs of patients was analyzed using propensity score matching. The percentage of DFA occlusion and stenosis was significantly higher in the DFA coverage group. However, there were no significant differences in terms of primary patency of the FP artery, CD-TLR, DFA occlusion, major amputation, or ALI after 3 years.

CONCLUSIONS

Stent deployment in DFA coverage significantly led to the DFA stenotic events of EVT during the procedure, but patency of the FP artery and DFA, major amputation, and ALI up to 3 years did not differ according to stent deployment for ostial FP lesions.