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Avranas K, Pitoulias AG, Taneva GT, Beropoulis E, Donas KP. Sex-Specific Analysis of Mid-Term Outcomes of Atherectomy-Assisted Endovascular Treatment in Severe Peripheral Arterial Disease. J Clin Med 2024; 13:3235. [PMID: 38892949 PMCID: PMC11172504 DOI: 10.3390/jcm13113235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Endovascular treatment of lower-extremity peripheral disease (PAD) is associated with higher complication rates and suboptimal outcomes in women. Atherectomy has shown favourable outcomes in calcified lesions, minimising the incidence of stent placement caused by recoil or flow-limiting dissection. To date, there are no published mid-term outcomes evaluating the performance of atherectomy differentiated by sex. This study aims to evaluate sex-specific outcomes and prognostic factors affecting the results of atherectomy-assisted endovascular treatment in severe PAD. Methods: A retrospective analysis was conducted at a single centre in Germany, initiated by physicians and not sponsored by industry, on patients presenting with Rutherford categories ranging from III to V and featuring de novo occlusive or stenotic lesions of the superficial femoral (SFA) and/or popliteal arteries. The intervention involved rotational atherectomy-assisted angioplasty utilising the Jetstream (Boston, US®) device. The point of interest of this study was postinterventional clinical improvement as well as mid-term outcomes, including primary patency, over a targeted 2-year follow-up period. Statistical analysis utilised Cox regression (survival analysis) to calculate hazard ratios according to sex category. Comparative survival analysis was performed using the log-rank test and visually represented through Kaplan-Meier curves. Risk factors associated with absence of clinical improvement were examined across both sex groups utilising the chi-square or Fisher exact test, as appropriate. Results: A total of 98 patients (103 limbs) were initially included, with >75% having moderate-to-severe lesion calcification (>50%). A total of 84 patients (97 limbs, 62 male and 35 female) proceeded to a 2-year follow-up (mean 16.4 months for males and 16.1 for females) after a successful index procedure. Age distribution, Rutherford class, diabetes, chronic kidney disease (CKD), target vessel, lesion type, and length were balanced among both groups. Similar primary patency rates, of 89% among female and 91% among male limbs, were observed (p = 0.471). Female patients exhibited a lower rate of clinical improvement based on the Rutherford scale in comparison to males (80.6% vs. 94.5%, p = 0.048). CDK was the only significant prognostic factor across pooled data (odds ratio for CKD: 15.15, p < 0.001). Conclusions: Rotational atherectomy showed comparably high rates of mid-term primary patency, with low rates of bailout stent placement. These findings highlight the beneficial use of atherectomy in female patients who are per se at risk for higher rates of complications during and after endovascular interventions.
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Mehta H, Chan WC, Aday AW, Jones WS, Parmar GM, Hance K, Thors A, Alli A, Wiley M, Tadros P, Gupta K. Outcomes of peripheral artery disease and polyvascular disease in patients with end-stage kidney disease. J Vasc Surg 2024; 79:1170-1178.e10. [PMID: 38244643 DOI: 10.1016/j.jvs.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVE Patients with peripheral artery disease (PAD) and end-stage kidney disease are a high-risk population, and concomitant atherosclerosis in coronary arteries (CAD) or cerebral arteries (CVD) is common. The aim of the study was to assess long-term outcomes of PAD and the impact of coexistent CAD and CVD on outcomes. METHODS The United States Renal Data System was used to identify patients with PAD within 6 months of incident dialysis. Four groups were formed: PAD alone, PAD with CAD, PAD with CVD, and PAD with CAD and CVD. PAD-specific outcomes (chronic limb-threatening ischemia, major amputation, percutaneous/surgical revascularization, and their composite, defined as major adverse limb events [MALE]) as well as all-cause mortality, myocardial infarction, and stroke were studied. RESULTS The study included 106,567 patients (mean age, 71.2 years; 40.8% female) with a median follow-up of 546 days (interquartile range, 214-1096 days). Most patients had PAD and CAD (49.8%), 25.8% had PAD alone, and 19.2% had all three territories involved. MALE rate in patients with PAD was 22.3% and 35.0% at 1 and 3 years, respectively. In comparison to PAD alone, the coexistence of both CAD and CVD (ie, polyvascular disease) was associated with a higher adjusted rates of all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.24-1.31), myocardial infarction (HR, 1.78; 95% CI, 1.69-1.88), stroke (HR, 1.66; 95% CI, 1.52,1.80), and MALE (HR, 1.07; 95% CI, 1.04-1.11). CONCLUSIONS Patients with end-stage kidney disease have a high burden of PAD with poor long-term outcomes, which worsen, in an incremental fashion, with the involvement of each additional diseased arterial bed.
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Affiliation(s)
- Harsh Mehta
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Wan-Chi Chan
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Aaron W Aday
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - W Schuyler Jones
- Department of Medicine, Duke University Health System, Durham, NC
| | - Gaurav M Parmar
- Section of Vascular Medicine, Massachusetts General Hospital, Boston, MA
| | - Kirk Hance
- Department of Surgery, University of Kansas School of Medicine, Kansas City, KS
| | - Axel Thors
- Department of Surgery, University of Kansas School of Medicine, Kansas City, KS
| | - Adam Alli
- Department of Radiology, University of Kansas School of Medicine, Kansas City, KS
| | - Mark Wiley
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Peter Tadros
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS.
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Nakhaei P, Hamouda M, Malas MB. The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease. Ann Vasc Surg 2024:S0890-5096(24)00151-1. [PMID: 38599491 DOI: 10.1016/j.avsg.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages. METHODS This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD. RESULTS CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates. CONCLUSIONS The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.
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Affiliation(s)
- Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mohammed Hamouda
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
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Månsson T, Rosso A, Ellström K, Abul-Kasim K, Elmståhl S. Chronic kidney disease and its association with cerebral small vessel disease in the general older hypertensive population. BMC Nephrol 2024; 25:93. [PMID: 38481159 PMCID: PMC10936027 DOI: 10.1186/s12882-024-03528-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Cerebral small vessel disease can be identified using magnetic resonance imaging, and includes white matter hyperintensities, lacunar infarcts, cerebral microbleeds, and brain atrophy. Cerebral small vessel disease and chronic kidney disease share many risk factors, including hypertension. This study aims to explore an association between chronic kidney disease and cerebral small vessel disease, and also to explore the role of hypertension in this relationship. METHODS With a cross sectional study design, data from 390 older adults was retrieved from the general population study Good Aging in Skåne. Chronic kidney disease was defined as glomerular filtration rate < 60 ml/min/1,73m2. Associations between chronic kidney disease and magnetic resonance imaging markers of cerebral small vessel disease were explored using logistic regression models adjusted for age and sex. In a secondary analysis, the same calculations were performed with the study sample stratified based on hypertension status. RESULTS In the whole group, adjusted for age and sex, chronic kidney disease was not associated with any markers of cerebral small vessel disease. After stratification by hypertension status and adjusted for age and sex, we observed that chronic kidney disease was associated with cerebral microbleeds (OR 1.93, CI 1.04-3.59, p-value 0.037), as well as with cortical atrophy (OR 2.45, CI 1.34-4.48, p-value 0.004) only in the hypertensive group. In the non-hypertensive group, no associations were observed. CONCLUSIONS In this exploratory cross-sectional study, we observed that chronic kidney disease was associated with markers of cerebral small vessel disease only in the hypertensive subgroup of a general population of older adults. This might indicate that hypertension is an important link between chronic kidney disease and cerebral small vessel disease. Further studies investigating the relationship between CKD, CSVD, and hypertension are warranted.
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Affiliation(s)
- Tomas Månsson
- Department of Clinical Sciences in Malmö, Division of Geriatric Medicine, Lund University and Skåne University Hospital, Jan Waldenströms gata 35, pl 13, 205 02, Malmö, Sweden.
| | - Aldana Rosso
- Department of Clinical Sciences in Malmö, Division of Geriatric Medicine, Lund University and Skåne University Hospital, Jan Waldenströms gata 35, pl 13, 205 02, Malmö, Sweden
| | - Katarina Ellström
- Department of Clinical Sciences in Malmö, Division of Geriatric Medicine, Lund University and Skåne University Hospital, Jan Waldenströms gata 35, pl 13, 205 02, Malmö, Sweden
| | - Kasim Abul-Kasim
- Department of Clinical Sciences in Lund, Division of Diagnostic Radiology, Lund University, 221 85, Lund, Sweden
| | - Sölve Elmståhl
- Department of Clinical Sciences in Malmö, Division of Geriatric Medicine, Lund University and Skåne University Hospital, Jan Waldenströms gata 35, pl 13, 205 02, Malmö, Sweden
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Palzkill VR, Tan J, Yang Q, Morcos J, Laitano O, Ryan TE. Activation of the Aryl Hydrocarbon Receptor in Endothelial Cells Impairs Ischemic Angiogenesis in Chronic Kidney Disease. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.24.550410. [PMID: 37546909 PMCID: PMC10401998 DOI: 10.1101/2023.07.24.550410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Rationale Chronic kidney disease (CKD) is a strong risk factor for peripheral artery disease (PAD) that is associated with worsened clinical outcomes. CKD leads to accumulation of tryptophan metabolites that associate with adverse limb events in PAD and are ligands of the aryl hydrocarbon receptor (AHR) which may regulate ischemic angiogenesis. Objectives To test if endothelial cell-specific deletion of the AHR (AHRecKO) alters ischemic angiogenesis and limb function in mice with CKD subjected to femoral artery ligation. Findings Male AHRecKO mice with CKD displayed better limb perfusion recovery and enhanced ischemic angiogenesis compared to wildtype mice with CKD. However, the improved limb perfusion did not result in better muscle performance. In contrast to male mice, deletion of the AHR in female mice with CKD had no impact on perfusion recovery or angiogenesis. Using primary endothelial cells from male and female mice, treatment with indoxyl sulfate uncovered sex-dependent differences in AHR activating potential and RNA sequencing revealed wide ranging sex-differences in angiogenic signaling pathways. Conclusion Endothelium-specific deletion of the AHR improved ischemic angiogenesis in male, but not female, mice with CKD. There are sex-dependent differences in Ahr activating potential within endothelial cells that are independent of sex hormones.
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Affiliation(s)
- Victoria R. Palzkill
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Jianna Tan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Qingping Yang
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Juliana Morcos
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Orlando Laitano
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- The Myology Institute, The University of Florida, Gainesville, FL, USA
| | - Terence E. Ryan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- The Myology Institute, The University of Florida, Gainesville, FL, USA
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Balestrieri N, Palzkill V, Pass C, Tan J, Salyers ZR, Moparthy C, Murillo A, Kim K, Thome T, Yang Q, O’Malley KA, Berceli SA, Yue F, Scali ST, Ferreira LF, Ryan TE. Activation of the Aryl Hydrocarbon Receptor in Muscle Exacerbates Ischemic Pathology in Chronic Kidney Disease. Circ Res 2023; 133:158-176. [PMID: 37325935 PMCID: PMC10330629 DOI: 10.1161/circresaha.123.322875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) accelerates the development of atherosclerosis, decreases muscle function, and increases the risk of amputation or death in patients with peripheral artery disease (PAD). However, the mechanisms underlying this pathobiology are ill-defined. Recent work has indicated that tryptophan-derived uremic solutes, which are ligands for AHR (aryl hydrocarbon receptor), are associated with limb amputation in PAD. Herein, we examined the role of AHR activation in the myopathy of PAD and CKD. METHODS AHR-related gene expression was evaluated in skeletal muscle obtained from mice and human PAD patients with and without CKD. AHRmKO (skeletal muscle-specific AHR knockout) mice with and without CKD were subjected to femoral artery ligation, and a battery of assessments were performed to evaluate vascular, muscle, and mitochondrial health. Single-nuclei RNA sequencing was performed to explore intercellular communication. Expression of the constitutively active AHR was used to isolate the role of AHR in mice without CKD. RESULTS PAD patients and mice with CKD displayed significantly higher mRNA expression of classical AHR-dependent genes (Cyp1a1, Cyp1b1, and Aldh3a1) when compared with either muscle from the PAD condition with normal renal function (P<0.05 for all 3 genes) or nonischemic controls. AHRmKO significantly improved limb perfusion recovery and arteriogenesis, preserved vasculogenic paracrine signaling from myofibers, increased muscle mass and strength, as well as enhanced mitochondrial function in an experimental model of PAD/CKD. Moreover, viral-mediated skeletal muscle-specific expression of a constitutively active AHR in mice with normal kidney function exacerbated the ischemic myopathy evidenced by smaller muscle masses, reduced contractile function, histopathology, altered vasculogenic signaling, and lower mitochondrial respiratory function. CONCLUSIONS These findings establish AHR activation in muscle as a pivotal regulator of the ischemic limb pathology in CKD. Further, the totality of the results provides support for testing of clinical interventions that diminish AHR signaling in these conditions.
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Affiliation(s)
- Nicholas Balestrieri
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Victoria Palzkill
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Caroline Pass
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Jianna Tan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Zachary R. Salyers
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Chatick Moparthy
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Ania Murillo
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Kyoungrae Kim
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Trace Thome
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Qingping Yang
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Kerri A. O’Malley
- Department of Surgery, The University of Florida, Gainesville, FL, USA
| | - Scott A. Berceli
- Department of Surgery, The University of Florida, Gainesville, FL, USA
| | - Feng Yue
- Department of Animal Sciences, The University of Florida, Gainesville, FL, USA
- Myology Institute, The University of Florida, Gainesville, FL, USA
| | | | - Leonardo F. Ferreira
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- Myology Institute, The University of Florida, Gainesville, FL, USA
| | - Terence E. Ryan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- Myology Institute, The University of Florida, Gainesville, FL, USA
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7
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Balestrieri N, Palzkill V, Pass C, Tan J, Salyers ZR, Moparthy C, Murillo A, Kim K, Thome T, Yang Q, O'Malley KA, Berceli SA, Yue F, Scali ST, Ferreira LF, Ryan TE. Chronic activation of the aryl hydrocarbon receptor in muscle exacerbates ischemic pathology in chronic kidney disease. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.16.541060. [PMID: 37292677 PMCID: PMC10245783 DOI: 10.1101/2023.05.16.541060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Chronic kidney disease (CKD) accelerates the development of atherosclerosis, decreases muscle function, and increases the risk of amputation or death in patients with peripheral artery disease (PAD). However, the cellular and physiological mechanisms underlying this pathobiology are ill-defined. Recent work has indicated that tryptophan-derived uremic toxins, many of which are ligands for the aryl hydrocarbon receptor (AHR), are associated with adverse limb outcomes in PAD. We hypothesized that chronic AHR activation, driven by the accumulation of tryptophan-derived uremic metabolites, may mediate the myopathic condition in the presence of CKD and PAD. Both PAD patients with CKD and mice with CKD subjected to femoral artery ligation (FAL) displayed significantly higher mRNA expression of classical AHR-dependent genes ( Cyp1a1 , Cyp1b1 , and Aldh3a1 ) when compared to either muscle from the PAD condition with normal renal function ( P <0.05 for all three genes) or non-ischemic controls. Skeletal-muscle-specific AHR deletion in mice (AHR mKO ) significantly improved limb muscle perfusion recovery and arteriogenesis, preserved vasculogenic paracrine signaling from myofibers, increased muscle mass and contractile function, as well as enhanced mitochondrial oxidative phosphorylation and respiratory capacity in an experimental model of PAD/CKD. Moreover, viral-mediated skeletal muscle-specific expression of a constitutively active AHR in mice with normal kidney function exacerbated the ischemic myopathy evidenced by smaller muscle masses, reduced contractile function, histopathology, altered vasculogenic signaling, and lower mitochondrial respiratory function. These findings establish chronic AHR activation in muscle as a pivotal regulator of the ischemic limb pathology in PAD. Further, the totality of the results provide support for testing of clinical interventions that diminish AHR signaling in these conditions.
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Cyrek AE, Flögel L, Pacha A, Kaths M, Treckmann J, Paul A, Schulze M. Kidney transplantation following iliac revascularization in severe atherosclerosis: a comparative study. Langenbecks Arch Surg 2023; 408:105. [PMID: 36840760 PMCID: PMC9968260 DOI: 10.1007/s00423-023-02838-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/13/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Kidney transplantation (KT) has become the standard of care for patients with end-stage renal disease. However, as atherosclerosis progresses with time on dialysis, it causes increasing difficulties in implanting the graft. This is a comparative study analyzing complications and graft survival of recipients with iliac revascularization before transplantation. METHODS Between January 2006 and December 2015, 1691 kidney transplants were performed at our institution. We retrospectively analyzed eighteen patients with peripheral arterial disease (PAD) with the necessity of vascular revascularization before kidney transplantation to protect the inflow to the renal graft and to optimizing blood supply to the extremities. The primary endpoint included patient survival and graft survival. The secondary endpoints evaluate perioperative and early postoperative complication rates after kidney transplantation. RESULTS All patients enrolled in this study underwent two consecutive surgical procedures. No patient reported limb loss, and there was no additional perioperative morbidity or mortality related to the vascular procedure. Primary endpoints such as graft survival without dialysis and overall patient survival show 1-month survival of 100%, 1-year survival of 94.1%, and 5-year survival of 84.70%, respectively. One graft failure occurred 8 months after transplantation due to acute rejection, and there were two deaths over follow-up period due to myocardial infarction. CONCLUSIONS Vascular repair before kidney transplantation is safe, and results are suggestive that it prolongs graft survival. These promising results should encourage other centers to address vascular repair before the transplantation to optimize blood supply to the extremity and the future graft. Although, the interpretation of our results must be cautiously because of the small and heterogeneous sample size, and the limitations of retrospective study design. Prospective trials with larger study populations are needed to confirm the results of this study and to identify significant differences.
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Affiliation(s)
- Anna E Cyrek
- Division of Vascular and Endovascular Surgery, Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Lena Flögel
- Department of Urology, Evangelical Hospital Witten gGmbH, Witten, Germany
| | - Arkadius Pacha
- Institute of Pharmacology and Toxicology, Ruhr-University Bochum, Bochum, Germany
| | - Moritz Kaths
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jürgen Treckmann
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Maren Schulze
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Lee RE, Patel A, Soon SXY, Chan SL, Yap CJQ, Chandramohan S, Tay LHT, Chong TT, Tang TY. One year clinical outcomes of Rutherford 6 chronic limb threatening ischemia patients undergoing lower limb endovascular revascularisation from Singapore. CVIR Endovasc 2022; 5:32. [PMID: 35792985 PMCID: PMC9259774 DOI: 10.1186/s42155-022-00306-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
Background Percutaneous transluminal angioplasty (PTA) is widely used as a first-line revascularisation option in patients with chronic limb threatening ischemia (CLTI). This study aimed to evaluate the short-term endovascular revascularisation treatment outcomes of a cohort of Rutherford 6 (R6) CLTI patients, from a multi-ethnic Asian population in Singapore. Patients with R6 CLTI who underwent endovascular revascularisation from June 2019 to February 2020 at Singapore General Hospital, a tertiary vascular centre in Singapore, were included and followed up for one year. Primary outcome measures included number and type of reinterventions required, 3-, 6- and 12-month mortality, 6- and 12-month amputation free survival (AFS), wound healing success and changes in Rutherford staging after 3, 6 and 12 months. Results Two hundred fifty-five procedures were performed on 86 patients, of whom 78 (90.7%) were diabetics, 54 (62.8%) had coronary artery disease (CAD) and 54 (62.8%) had chronic kidney disease (CKD). 42 patients (48.8%) required reintervention within 6 months. Multivariate analysis revealed that the presence of CAD was a significant independent predictor for reintervention. Mortality was 15.1%, 20.9% and 33.7% at 3, 6 and 12 months respectively. AFS was 64.0% and 49.4% at 6 and 12 months. Inability to ambulate, congestive heart failure (CHF), dysrhythmia and CKD were significant independent predictors of lower 12-month AFS. Conclusions PTA for R6 CLTI patients was associated with relatively high mortality and reintervention rates at one year. CAD was an independent predictor of reintervention. More research is required to help risk stratify which CLTI patients would benefit from an endovascular-first approach versus conservative treatment or an immediate major lower extremity amputation policy.
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Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD). Int J Mol Sci 2022; 23:ijms231810814. [PMID: 36142725 PMCID: PMC9504787 DOI: 10.3390/ijms231810814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022] Open
Abstract
Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.
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Kotov A, Blasche DA, Peters F, Pospiech P, Rother U, Stavroulakis K, Remig J, Schmidt-Lauber C, Zeller T, Görtz H, Teßarek J, Behrendt CA. The Impact of Chronic Kidney Disease on Mid-Term Outcomes after Revascularisation of Peripheral Arterial Occlusive Disease: Results from a Prospective Cohort Study. J Clin Med 2022; 11:jcm11164750. [PMID: 36012989 PMCID: PMC9409847 DOI: 10.3390/jcm11164750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: The current study aimed to determine the relationship between chronic kidney disease (CKD) and major 12-month outcomes for patients with in-hospital treatment for symptomatic peripheral arterial occlusive disease (PAOD). Methods: An analysis of the prospective longitudinal multicentric cohort study with 12-month follow-up was conducted including patients who underwent endovascular or open surgery for symptomatic PAOD at 35 German vascular centres (initial study protocol: NCT03098290). Severity of CKD was grouped into four stages combining information about the estimated glomerular filtration rate (eGFR) at baseline and dialysis dependency. Outcomes included overall mortality as well as the two composite endpoints of amputation or death, and of major cardiovascular events (MACE). 12-month incidences and adjusted hazard ratios were estimated using the Kaplan–Meier function and Cox proportional hazard models. Results: A total of 4354 patients (32% female, 69 years mean age, 68% intermittent claudication, 69% percutaneous endovascular revascularisation) were included and followed for 244 days in median. Thereof, 22% had any CKD and 5% had end stage kidney disease (ESKD) at baseline. The 12-month overall mortality rate was 3.6% (95% CI 2.3–4.9) with 96 events in the entire cohort: 147 were amputated or died (5.3%, 95% CI 5.2–5.3), and 277 had a MACE (9.5%, 95% CI 9.4–9.5). When compared with patients without kidney disease, ESKD was significantly associated with overall mortality (HR 1.9; 95% CI 1.1–3.5), amputation or death (HR 2.4; 95% CI 1.4–4.1), and MACE (HR 2.0; 95% CI 1.3–3.2). Conclusions: In the current study on mid-term outcomes after invasive revascularisation for symptomatic PAOD, one out of five patients suffered from any CKD while those few with ESKD had twice the odds of death, of amputation or death, and of major adverse cardiovascular events after twelve months. These results emphasise that concomitant CKD and its impact on outcomes should be considered by severity while mild and moderate grades should not lead to ineffectual treatment strategies.
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Affiliation(s)
- Artur Kotov
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Deven A. Blasche
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Frederik Peters
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Philip Pospiech
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Medical Centre Erlangen, 91054 Erlangen, Germany
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
| | - Konstantinos Stavroulakis
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, 80539 Munich, Germany
| | - Jürgen Remig
- Bonn Community Hospital, Haus St. Petrus, 53113 Bonn, Germany
| | - Christian Schmidt-Lauber
- III. Department of Medicine, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Thomas Zeller
- Clinic for Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, 79189 Bad Krozingen, Germany
| | - Hartmut Görtz
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
- St. Boniface Hospital Lingen, 49808 Lingen, Germany
| | - Jörg Teßarek
- St. Boniface Hospital Lingen, 49808 Lingen, Germany
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
- Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
- Correspondence:
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Cho NY, Mabeza RM, Lee C, Verma A, Madrigal J, Hadaya J, de Virgilio C, Benharash P. Association of Chronic Kidney Disease with perioperative outcomes following acute lower limb revascularization. Surg Open Sci 2022; 9:94-100. [PMID: 35755163 PMCID: PMC9213817 DOI: 10.1016/j.sopen.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/23/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022] Open
Abstract
Background There is a paucity of data examining the impact of advancing chronic kidney disease stages on outcomes following revascularization for acute limb ischemia. The present study examined the association of chronic kidney disease with in-hospital mortality, amputation, and resource utilization following revascularization for acute limb ischemia using a nationally representative cohort. Methods The 2016–2018 National Inpatient Sample was queried to identify all adult hospitalizations with lower extremity acute limb ischemia requiring surgical and/or endovascular interventions. Patients were grouped according to the presence of chronic kidney disease and its severity: no chronic kidney disease, chronic kidney disease 1–3 (chronic kidney disease stages 1 through 3), chronic kidney disease 4–5 (chronic kidney disease stages 4 through 5), and end-stage renal disease. Multivariable logistic and linear models were used to evaluate association of chronic kidney disease stage with outcomes of interest. Results Of an estimated 82,610 patients meeting study criteria, 14.8% had chronic kidney disease (chronic kidney disease 1–3: 63.4%, chronic kidney disease 4–5: 12.1%, end-stage renal disease: 24.5%). Compared to those with chronic kidney disease, chronic kidney disease patients were on average older, were more frequently female, and had a higher median Elixhauser Comorbidity Index. Increasing severity of chronic kidney disease was associated with a stepwise increase in unadjusted mortality rates (4.7% in no chronic kidney disease to 12.6% in end-stage renal disease, P < .001). Following risk adjustment, only end-stage renal disease was associated with increased odds of mortality (adjusted odds ratio 3.10, 95% confidence interval 2.28–4.22) and limb amputation (adjusted odds ratio 1.99, 95% confidence interval 1.59–2.48) compared to patients with no chronic kidney disease. Similarly, advancing chronic kidney disease stage conferred increased odds of prolonged length of stay and greater hospitalization costs. Conclusion Advanced renal dysfunction demonstrated inferior perioperative outcomes and greater health care expenditures in the study population. These findings imply that quality improvement efforts in acute limb ischemia revascularization should target patients with chronic kidney disease 4–5 and end-stage renal disease.
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Kim S, Pendleton AA, McGinigle K. Peripheral Artery Disease: Diagnosis, Treatment, and Outcomes in Females. Semin Vasc Surg 2022; 35:155-161. [DOI: 10.1053/j.semvascsurg.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022]
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Goldstein J, Dieter RS, Bansal V, Wieschhaus K, Dieter RS, Bontekoe E, Hoppensteadt D, Fareed J. Arterial-renal Syndrome in Patients with ESRD, a New Disease Paradigm. Clin Appl Thromb Hemost 2022; 28:10760296211072820. [PMID: 35018865 PMCID: PMC8761876 DOI: 10.1177/10760296211072820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Patients with end-stage renal disease (ESRD) often present with an increased risk of cardiovascular disease. Conditions of compromised cardiovascular health such as atrial fibrillation (AFIB) and peripheral arterial disease (PAD) may alter biomarker levels in a way that reflects worsening ESRD. This study profiled biomarkers and laboratory parameters of endothelium dysfunction in patients with ESRD, categorized by additional AFIB and PAD conditions. Methods Citrated blood samples were collected from 95 patients with ESRD. Biomarker levels were measured from plasma samples using sandwich ELISAs, including tissue plasminogen activator (tPA), D-dimer, and nitrotyrosine. Lab parameters, including BUN, calcium, creatinine, parathyroid hormone, phosphate, alkaline phosphatase, ferritin, transferrin, and total iron capacity, and patient comorbidities were obtained from patient medical records. The comorbidities were determined through provider notes, and evidence of applicable testing. Results 14.89% of patients were found to have atrial fibrillation (n = 14), 30.85% of patients were found to have peripheral arterial disease (n = 29), and 6.38% of patients were found to have both peripheral arterial disease and atrial fibrillation (n = 6). When compared to patients with only ESRD, patients with ESRD and PAD showed elevated levels of D-Dimer (p = .0314) and nitrotyrosine (p = .0330). When compared to patients with only ESRD, patients with atrial fibrillation showed elevated levels of D-Dimer (p = .0372), nitrotyrosine (p = .0322), and tPA (p = .0198). Conclusion When compared to patients with just ESRD, patients with concomitant PAD had elevated levels of Nitrotyrosine and D-dimer; while patients with concomitant Afib had elevated levels of nitrotyrosine, D-dimer, as well as tPA.
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Affiliation(s)
- Jake Goldstein
- Loyola University Stritch School of Medicine, Maywood, IL, USA
| | - Robert S Dieter
- Loyola University Medical Center, Department of Cardiovascular Medicine Maywood, IL, USA
| | - Vinod Bansal
- Loyola University Medical Center, Department of Nephrology, Maywood, IL, USA
| | | | - Robert S Dieter
- Northwestern's McCormick School of Engineering, Evanston, IL, USA
| | - Emily Bontekoe
- Loyola University Medical Center, Department of Pathology and Pharmacology Maywood, IL, USA
| | - Debra Hoppensteadt
- Loyola University Medical Center, Department of Pathology and Pharmacology Maywood, IL, USA
| | - Jawed Fareed
- Loyola University Medical Center, Department of Pathology and Pharmacology Maywood, IL, USA
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Taha AG, Saleh M, Ali H. Safety and Efficacy of Hybrid Angiography in Chronic Lower Extremity Ischemia Patients at Risk of Contrast-Induced Acute Kidney Injury. Vasc Endovascular Surg 2021; 56:180-189. [PMID: 34783267 DOI: 10.1177/15385744211055908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The aim of the study was to assess the feasibility and safety of hybrid angiography consisting of carbon dioxide (CO2) angiography supplemented by small doses of iodinated contrast medium (ICM) in the endovascular treatment of chronic limb threatening ischemia (CLTI) patients with pre-existing chronic kidney disease (CKD). PATIENTS AND METHODS This prospective study comprised all non-dialysis-dependent CKD patients presenting for endovascular management of CLTI. All endovascular interventions were done using CO2 as a contrast medium whether alone or supplemented by ICM (hybrid angiography) to treat unilateral arterial steno-occlusive lesions of iliac, femoropopliteal, or BTK arteries. Study outcomes included feasibility of the device, technical success, and freedom from contrast-induced acute kidney injury (CI-AKI), renal replacement therapy, and CO2 angiography-related complications. RESULTS A total of 206 CKD patients underwent endovascular intervention using CO2 only as a contrast medium (159 patients, 77.2%), or hybrid CO2-ICM angiography (47 patients, 22.8%). The overall technical success was 95.6%. Patients were followed up for a mean period of 17.9 ± 4.6 months. The mean volumes of CO2, and ICM consumption were 200.7 ± 95.1 mL, and 11.8 ± 4.4 mL, respectively. The mean procedural, and fluoroscopy times were 95.6 ± 12.5 and 49.5 ± 10.8 minutes, respectively. BTK lesions were significantly associated with the need for hybrid angiography (P = <.0001). The mean pre- and postoperative serum creatinine levels were comparable (P = .08). Two patients (4.3%) showed transient manifestations of CI-AKI, but neither required renal replacement therapy. No statistically significant differences were encountered between the two study groups regarding procedure outcomes. CONCLUSION Hybrid CO2-ICM angiography is safe, feasible, effective, and a fairly simple alternative during endovascular interventions to treat chronic lower extremity ischemia. Using supplemental small volumes of ICM to overcome the suboptimal images generated by CO2 alone does not jeopardize the renal functions in CKD patients.
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Affiliation(s)
- Ashraf G Taha
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt
| | - Mahmoud Saleh
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt
| | - Haitham Ali
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt
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Mahbub MH, Yamaguchi N, Nakagami Y, Hase R, Takahashi H, Ishimaru Y, Watanabe R, Saito H, Shimokawa J, Yamamoto H, Kikuchi S, Tanabe T. Association of Plasma Branched-Chain and Aromatic Amino Acids with Reduction in Kidney Function Evaluated in Apparently Healthy Adults. J Clin Med 2021; 10:jcm10225234. [PMID: 34830517 PMCID: PMC8625145 DOI: 10.3390/jcm10225234] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 01/09/2023] Open
Abstract
The published literature on the association of circulatory branched-chain amino acids (BCAAs) and aromatic amino acids (AAAs) with reduced kidney function is inconsistent or conflicting. Clarification of it might help to better understand the underlying pathophysiology and to determine potential biomarkers for early detection and evaluation of kidney function decline. Our main purpose was to explore and clarify the potential relationships of individual BCAAs and AAAs with estimated glomerular filtration rate (eGFR) decline. We included the data from 2804 healthy subjects and categorized them into three groups based on eGFR tertiles. The associations between individual amino acids and eGFR were explored by covariate-adjusted logistic regression models. There was a progressive increase in the concentrations of BCAAs and AAAs from the upper to the lower tertiles. We revealed significant positive associations of isoleucine, leucine, and phenylalanine with lower tertiles of eGFR in the adjusted models (p < 0.01-0.001). The findings hold a promising potential of using plasma isoleucine, leucine, and phenylalanine levels for evaluation of kidney function decline. Future longitudinal studies should investigate the causal association between altered levels of these amino acids and impaired kidney function and also the utility of the former as potential biomarkers for evaluating the risk and early detection of the latter.
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Affiliation(s)
- MH Mahbub
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
- Correspondence: ; Tel.: +81-836-22-2231
| | - Natsu Yamaguchi
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Yuki Nakagami
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Ryosuke Hase
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Hidekazu Takahashi
- Department of Public Health, Faculty of Veterinary Medicine, Okayama University of Science, Imabari 794-8555, Japan;
| | - Yasutaka Ishimaru
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Rie Watanabe
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Hiroyuki Saito
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Junki Shimokawa
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Hiroshi Yamamoto
- Institute for Innovation, Ajinomoto Co., Inc., Kawasaki 210-8681, Japan; (H.Y.); (S.K.)
| | - Shinya Kikuchi
- Institute for Innovation, Ajinomoto Co., Inc., Kawasaki 210-8681, Japan; (H.Y.); (S.K.)
| | - Tsuyoshi Tanabe
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
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Arinze NV, Yin W, Lotfollahzadeh S, Napoleon MA, Richards S, Walker JA, Belghasem M, Ravid JD, Hassan Kamel M, Whelan SA, Lee N, Siracuse JJ, Anderson S, Farber A, Sherr D, Francis J, Hamburg NM, Rahimi N, Chitalia VC. Tryptophan metabolites suppress Wnt pathway and promote adverse limb events in CKD patients. J Clin Invest 2021; 132:142260. [PMID: 34752422 PMCID: PMC8718145 DOI: 10.1172/jci142260] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Chronic kidney disease (CKD) imposes a strong and independent risk for peripheral artery disease (PAD). While solutes retained in CKD patients (uremic solutes) inflict vascular damage, their role in PAD remains elusive. Here, we show that the dietary tryptophan-derived uremic solutes including indoxyl sulfate (IS) and kynurenine (Kyn) at concentrations corresponding to those in CKD patients suppress β-catenin in several cell types, including microvascular endothelial cells (ECs), inhibiting Wnt activity and proangiogenic Wnt targets in ECs. Mechanistic probing revealed that these uremic solutes downregulated β-catenin in a manner dependent on serine 33 in its degron motif and through the aryl hydrocarbon receptor (AHR). Hindlimb ischemia in adenine-induced CKD and IS solute–specific mouse models showed diminished β-catenin and VEGF-A in the capillaries and reduced capillary density, which correlated inversely with blood levels of IS and Kyn and AHR activity in ECs. An AHR inhibitor treatment normalized postischemic angiogenic response in CKD mice to a non-CKD level. In a prospective cohort of PAD patients, plasma levels of tryptophan metabolites and plasma’s AHR-inducing activity in ECs significantly increased the risk of future adverse limb events. This work uncovers the tryptophan metabolite/AHR/β-catenin axis as a mediator of microvascular rarefaction in CKD patients and demonstrates its targetability for PAD in CKD models.
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Affiliation(s)
- Nkiruka V Arinze
- Department of Surgery, Boston University School of Medicine, Boston, United States of America
| | - Wenqing Yin
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Saran Lotfollahzadeh
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Marc Arthur Napoleon
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Sean Richards
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Joshua A Walker
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Mostafa Belghasem
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, United States of America
| | - Jonathan D Ravid
- School of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Mohamed Hassan Kamel
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Stephen A Whelan
- Department of Chemistry, Boston University, Boston, United States of America
| | - Norman Lee
- Department of Chemistry, Boston University, Boston, United States of America
| | - Jeffrey J Siracuse
- Department of Surgery, Boston University School of Medicine, Boston, United States of America
| | - Stephan Anderson
- Department of Radiology, Boston University School of Medicine, Boston, United States of America
| | - Alik Farber
- Department of Surgery, Boston University School of Medicine, Boston, United States of America
| | - David Sherr
- Boston University, Boston, United States of America
| | - Jean Francis
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
| | - Naomi M Hamburg
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, United States of America
| | - Nader Rahimi
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, United States of America
| | - Vipul C Chitalia
- Department of Medicine, Boston University School of Medicine, Boston, United States of America
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Hsia J, Szarek M, Anand S, Patel MR, Debus S, Berkowitz SD, Muehlhofer E, Haskell LP, Bauersachs RM, Bonaca MP. Rivaroxaban in Patients With Recent Peripheral Artery Revascularization and Renal Impairment: The VOYAGER PAD Trial. J Am Coll Cardiol 2021; 78:757-759. [PMID: 34384556 DOI: 10.1016/j.jacc.2021.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/25/2021] [Accepted: 06/02/2021] [Indexed: 10/20/2022]
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Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication. Transplantation 2021; 105:1188-1202. [PMID: 33148978 DOI: 10.1097/tp.0000000000003518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes. This review focuses on the following issues: (1) definition, epidemiological data, diagnosis, risk factors, and pathogenic mechanisms in KT candidates and recipients; (2) adverse clinical consequences and outcomes; and (3) classical and new therapeutic approaches.
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Serra R, Bracale UM, Ielapi N, Del Guercio L, Di Taranto MD, Sodo M, Michael A, Faga T, Bevacqua E, Jiritano F, Serraino GF, Mastroroberto P, Provenzano M, Andreucci M. The Impact of Chronic Kidney Disease on Peripheral Artery Disease and Peripheral Revascularization. Int J Gen Med 2021; 14:3749-3759. [PMID: 34326661 PMCID: PMC8315808 DOI: 10.2147/ijgm.s322417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/05/2021] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD) is a clinical condition characterized by high morbidity and mortality. Globally, CKD is also increasing in prevalence and incidence. The two principal kidney measures namely estimated glomerular filtration rate (eGFR) and albuminuria have been found to be predictors of renal and cardiovascular (CV) endpoints including peripheral artery disease (PAD). The prevalence of PAD was increased in CKD patients and, particularly, in patients with more severe CKD stages. Despite the fact that revascularization strategies are suitable in CKD patients in similar fashion to non-CKD patients, few CKD patients underwent these procedures. In fact, if it is true that revascularization improves prognosis in PAD patients irrespective of baseline eGFR, it was also demonstrated that CKD patients, who underwent revascularization, were at higher risk for amputations, mortality, re-intervention and perioperative complications. With the present review article, we have examined the association between CKD, PAD and peripheral revascularization highlighting data about epidemiology, pathophysiologic mechanisms, and results from previous observational and intervention studies. We have also examined the future perspectives and challenges of research around the association between CKD and PAD.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), "Magna Graecia" University, Catanzaro, Italy.,Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy
| | | | - Nicola Ielapi
- Department of Public Health and Infectious Disease, "Sapienza" University of Rome, Roma, 00185, Italy
| | - Luca Del Guercio
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Maria Donata Di Taranto
- Department of Molecular Medicine and Medical Biotechnology, University Federico II of Naples, Naples, Italy
| | - Maurizio Sodo
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Ashour Michael
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Teresa Faga
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Egidio Bevacqua
- Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, 88100, Italy
| | - Federica Jiritano
- Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, 88100, Italy
| | | | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, 88100, Italy
| | - Michele Provenzano
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy
| | - Michele Andreucci
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
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Johansen KL, Garimella PS, Hicks CW, Kalra PA, Kelly DM, Martens S, Matsushita K, Sarafidis P, Sood MM, Herzog CA, Cheung M, Jadoul M, Winkelmayer WC, Reinecke H. Central and peripheral arterial diseases in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2021; 100:35-48. [PMID: 33961868 PMCID: PMC9833277 DOI: 10.1016/j.kint.2021.04.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 02/08/2023]
Abstract
Chronic kidney disease (CKD) affects about 10% of all populations worldwide, with about 2 million people requiring dialysis. Although patients with CKD are at high risk of cardiovascular disease and events, they are often underrepresented or excluded in clinical trials, leading to important knowledge gaps about how to treat these patients. KDIGO (Kidney Disease: Improving Global Outcomes) convened the fourth clinical Controversies Conference on the heart, kidney and vasculature in Dublin, Ireland, in February 2020, entitled Central and Peripheral Arterial Diseases in Chronic Kidney Disease. A global panel of multidisciplinary experts from the fields of nephrology, cardiology, neurology, surgery, radiology, vascular biology, epidemiology, and health economics attended. The objective was to identify key issues related to the optimal detection, management, and treatment of cerebrovascular diseases, central aortic disease, renovascular disease, and peripheral artery disease in the setting of CKD. This report outlines the common pathophysiology of these vascular processes in the setting of CKD, describes best practices for their diagnosis and management, summarizes areas of uncertainty, addresses ongoing controversial issues, and proposes a research agenda to address key gaps in knowledge that, when addressed, could improve patient care and outcomes.
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Affiliation(s)
- Kirsten L Johansen
- Division of Nephrology, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Division of Nephrology, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - Dearbhla M Kelly
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Sven Martens
- Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus, Münster, Germany
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Pantelis Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Holger Reinecke
- Department of Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany.
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Abstract
PURPOSE OF REVIEW Vascular calcification (VC) is associated with increased cardiovascular event rates, particularly in patients with end-stage kidney disease (ESKD). Dysregulated mineral metabolism and inflammation have been shown to promote VC, however, treatment options targeting VC specifically are not available. This review outlines the pathophysiological mechanisms contributing to VC in ESKD and describes recent studies evaluating the effects of the first-in-class inhibitor of VC, SNF472. RECENT FINDINGS SNF472 directly inhibits calcium phosphate crystal formation and aggregation. SNF472 has completed early phase clinical trials with a favourable safety profile and Phase 2 clinical trial data have shown attenuation of coronary artery and aortic valve calcification in patients receiving hemodialysis. SUMMARY Therapeutic agents that directly target VC may prevent the multiple complications associated with dystrophic calcification in patients with ESKD.
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23
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Ösken A, Akdeniz E, Keskin M, Öz A, Ipek G, Zehir R, Barutça H, Çam N, Şahin S. Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents. Angiology 2021; 72:762-769. [PMID: 33966501 DOI: 10.1177/00033197211014684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study evaluated the impact of the baseline estimated glomerular filtration rate (eGFR) on clinical and angiographic outcomes and long-term in-stent restenosis (ISR) rates in patients undergoing elective carotid artery stenting (CAS) procedures. Consecutive patients who underwent CAS were retrospectively enrolled (n = 456). At the end of 3 years of follow-up, patients who had died or were lost follow-up were excluded from the study and a final analysis was performed using data from the remaining 405 patients. The study population (n = 405) was divided into 3 tertiles based on the tertile values of the eGFR level (T1, T2, and T3); then, clinical and procedural characteristics and 3-year ISR rates were compared between the groups. An ISR of 50% was detected in 49 (12%) surviving patients. The 3-year ISR was higher among patients with the lowest eGFR values (T1) by 3.7 times (95% CI: 2.01-11.38) than that among patients with the highest eGFR values (T3). These significant relationships persisted following adjustment for confounders. A lower baseline eGFR level was significantly associated with an increased ISR rate. Decreased renal function may be a predictor of ISR after CAS using first-generation stents.
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Affiliation(s)
- Altuğ Ösken
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Evliya Akdeniz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Başkent University Faculty of Medicine, Istanbul, Turkey
| | - Muhammed Keskin
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Öz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Göktürk Ipek
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Kartal Koşuyolu Training and Research Hospital, Istanbul, Turkey
| | - Hakan Barutça
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Neşe Çam
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Sinan Şahin
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
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24
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Subramanian N, Han J, Leeper NJ, Ross EG, Montez-Rath ME, Chang TI. Comparison of Pre-Amputation Evaluation in Patients with and without Chronic Kidney Disease. Am J Nephrol 2021; 52:388-395. [PMID: 33957619 PMCID: PMC8278981 DOI: 10.1159/000516017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) and peripheral artery disease (PAD) are more likely to undergo lower extremity amputation than patients with preserved kidney function. We sought to determine whether patients with CKD were less likely to receive pre-amputation care in the 1-year prior to lower extremity amputation compared to patients without CKD. METHODS We conducted a retrospective observational study of patients with PAD-related lower extremity amputation between January 2014 and December 2017 using a large commercial insurance database. The primary exposure was CKD identified using billing codes and laboratory values. The primary outcomes were receipt of pre-amputation care, defined as diagnostic evaluation (ankle-brachial index, duplex ultrasound, and computed tomographic angiography), specialty care (vascular surgery, cardiology, orthopedic surgery, and podiatry), and lower extremity revascularization in the 1-year prior to amputation. We conducted separate logistic regression models to estimate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) among patients with and without CKD. We assessed for effect modification by age, sex, Black race, and diabetes status. RESULTS We identified 8,554 patients with PAD-related amputation. In fully adjusted models, patients with CKD were more likely to receive diagnostic evaluation (aOR 1.30; 95% CI 1.17-1.44) and specialty care (aOR 1.45, 95% CI 1.27-1.64) in the 1-year prior to amputation. There was no difference in odds of revascularization by CKD status (aOR 1.03, 0.90-1.19). Age, sex, Black race, and diabetes status did not modify these associations. DISCUSSION/CONCLUSION Patients with CKD had higher odds of receiving diagnostic testing and specialty care and similar odds of lower extremity revascularization in the 1-year prior to amputation than patients without CKD. Disparities in access to pre-amputation care do not appear to explain the higher amputation rates seen among patients with CKD.
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Affiliation(s)
- Nivetha Subramanian
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nicholas J. Leeper
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Elsie G. Ross
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, California, USA
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Tara I. Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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25
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Hau HM, Jahn N, Brunotte M, Wagner T, Rademacher S, Branzan D, Sucher E, Seehofer D, Sucher R. Pre-operative ankle-brachial index for cardiovascular risk assessment in simultaneous pancreas-kidney transplant recipients: a simple and elegant strategy! BMC Surg 2021; 21:156. [PMID: 33752640 PMCID: PMC7983212 DOI: 10.1186/s12893-021-01159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Patients with insulin-dependent diabetes mellitus type 1 (IDDM1) and end-stage kidney disease (ESKD) undergoing simultaneous pancreas kidney transplantation (SPKT) are a population with diffuse atherosclerosis and elevated risk of cardio- and cerebrovascular morbidity and mortality. We aimed to investigate the feasibility of preoperative screening for peripheral arterial disease (PAD), specifically ankle-brachial index (ABI) testing, to predict peri- and postoperative outcomes in SPKT recipients. Methods Medical data (2000–2016) from all patients with IDDM and ESKD undergoing SPKT at our transplant center were retrospectively analyzed. The correlation between PAD (defined by an abnormal ABI before SPKT and graft failure and mortality rates as primary end points, and the occurrence of acute myocardial infarction, cerebrovascular and peripheral vascular complications as secondary end points were investigated after adjustment for known cardiovascular risk factors. Results Among 101 SPKT recipients in our transplant population who underwent structured physiological arterial studies, 17 patients (17%) were diagnosed with PAD before transplantation. PAD, as defined by a low ABI index, was an independent and significant predictor of death (HR, 2.99 (95% CI 1.00–8.87), p = 0.049) and pancreas graft failure (HR, 4.3 (95% CI 1.24–14.91), p = 0.022). No significant differences were observed for kidney graft failure (HR 1.85 (95% CI 0.76–4.50), p = 0.178). In terms of the secondary outcomes, patients with PAD were more likely to have myocardial infarction, stroke, limb ischemia, gangrene or amputation (HR, 2.90 (95% CI 1.19–7.04), p = 0.019). Conclusions Pre-transplant screening for PAD and cardiovascular risk factors with non-invasive ABI testing may help to reduce perioperative complications in high-risk patients. Future research on long-term outcomes might provide more in depth insights in optimal treatment strategies for PAD among SPKT recipients.
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Affiliation(s)
- Hans-Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany. .,Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Department of Surgery, University Hospital of Dresden, Fetscherstrasse 74, 03107, Dresden, Germany.
| | - Nora Jahn
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Max Brunotte
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tristan Wagner
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Daniela Branzan
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Elisabeth Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
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26
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Biscetti F, Nardella E, Rando MM, Cecchini AL, Gasbarrini A, Massetti M, Flex A. Outcomes of Lower Extremity Endovascular Revascularization: Potential Predictors and Prevention Strategies. Int J Mol Sci 2021; 22:2002. [PMID: 33670461 PMCID: PMC7922574 DOI: 10.3390/ijms22042002] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 01/02/2023] Open
Abstract
Peripheral artery disease (PAD) is a manifestation of atherosclerosis, which may affect arteries of the lower extremities. The most dangerous PAD complication is chronic limb-threatening ischemia (CLTI). Without revascularization, CLTI often causes limb loss. However, neither open surgical revascularization nor endovascular treatment (EVT) ensure long-term success and freedom from restenosis and revascularization failure. In recent years, EVT has gained growing acceptance among all vascular specialties, becoming the primary approach of revascularization in patients with CLTI. In clinical practice, different clinical outcomes after EVT in patients with similar comorbidities undergoing the same procedure (in terms of revascularization technique and localization of the disease) cause unsolved issues that need to be addressed. Nowadays, risk management of revascularization failure is one of the major challenges in the vascular field. The aim of this literature review is to identify potential predictors for lower extremity endovascular revascularization outcomes and possible prevention strategies.
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Affiliation(s)
- Federico Biscetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (M.M.R.); (A.G.); (M.M.); (A.F.)
- Cardiovascular Internal Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
| | - Elisabetta Nardella
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (E.N.); (A.L.C.)
| | - Maria Margherita Rando
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (M.M.R.); (A.G.); (M.M.); (A.F.)
- Cardiovascular Internal Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
| | - Andrea Leonardo Cecchini
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (E.N.); (A.L.C.)
| | - Antonio Gasbarrini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (M.M.R.); (A.G.); (M.M.); (A.F.)
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (E.N.); (A.L.C.)
| | - Massimo Massetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (M.M.R.); (A.G.); (M.M.); (A.F.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
| | - Andrea Flex
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (M.M.R.); (A.G.); (M.M.); (A.F.)
- Cardiovascular Internal Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (E.N.); (A.L.C.)
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27
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Kabir R, Vuppala S, Liu Y, Tejani I, Weideman R, Banerjee A, Tsai S, Huffman L, Niazi K, Brilakis ES, Shishehbor MH, Banerjee S. Clinical outcomes of patients with and without chronic kidney disease undergoing endovascular revascularization of infrainguinal peripheral artery disease: Insights from the XLPAD registry. Catheter Cardiovasc Interv 2021; 98:310-316. [PMID: 33527684 DOI: 10.1002/ccd.29491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The purpose of the present study was to define clinical outcomes of chronic kidney disease (CKD) patients undergoing endovascular revascularization of infrainguinal peripheral artery disease (PAD). BACKGROUND CKD is an established predictor of advanced PAD. However, clinical outcomes for these patients following endovascular revascularization remain inadequately defined. METHODS Using the ongoing multicenter Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851), we analyzed all-cause death, target limb amputation, and need for repeat revascularization for patients with and without CKD undergoing infrainguinal endovascular revascularization between the years 2005 and 2018. RESULTS Of 3,699 patients, 15.1% (n = 559) had baseline CKD. CKD patients had significantly higher incidence of heavily calcified lesions (48.4% vs. 38.1%, p < .001) and diffuse disease (66.9% vs. 61.5%, p = .007). Kaplan-Meier analysis showed significant differences between CKD and non-CKD patient outcomes at 12 months for freedom from target limb amputation (79.9% vs. 92.7%, p < .001) and all-cause death (90.1% vs. 97.6%, p < .001). However, freedom from target vessel revascularization was similar between the groups. After adjusting for baseline comorbidities in the CKD and non-CKD groups, the hazard ratios for target limb amputation and death at 12 months were 2.28 (95% confidence interval or CI 1.25-4.17, p < .001) and 4.38 (95% CI 2.58-7.45, p < .001), respectively. CONCLUSIONS Following endovascular revascularization for infrainguinal PAD, CKD was an independent predictor of all-cause death and target limb amputation at 12 months.
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Affiliation(s)
- Ryan Kabir
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Suchith Vuppala
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yulun Liu
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ishita Tejani
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rick Weideman
- Pharmacy Service, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
| | - Avantika Banerjee
- Department of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas, USA
| | - Shirling Tsai
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Pharmacy Service, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
| | - Lynn Huffman
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Khusrow Niazi
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Emmanouil S Brilakis
- Department of Medicine, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Mehdi H Shishehbor
- Department of Medicine, Case Western Reserve University and University Hospitals, Cleveland, Ohio, USA
| | - Subhash Banerjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Pharmacy Service, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
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Karanam LP, Baddam S, Ravikanti SP, Kumar KSS. Role of CO 2 angioplasty as a safe option in endovascular treatment of peripheral arterial disease in high-risk patients using dedicated automated OptiMed CO 2 delivery system. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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29
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Abstract
: Chronic kidney disease (CKD) is a public health threat with impact in cardiovascular risk. All forms of cardiovascular disease and mortality are more common in CKD. Treatment of cardiovascular risk factors, hypertension, dyslipidemia and diabetes is essential for cardiovascular and kidney protection. CKD is a marker of high or very high cardiovascular risk and its presence require early treatment and specific goals. Lifestyle is a pivotal factor, stopping smoking, reducing weight in the overweight or obese, starting regular physical exercise and healthy dietary pattern are recommended. Office BP should be lowered towards 130/80 mmHg or even lower if tolerated with sodium restriction and single pill combination, including angiotensin system blocker. Out-of-office BP monitoring, mainly 24-h assessment, is recommended. Diabetes requires treatment from the moment of diagnosis, but prediabetes benefits with lifestyle changes and metformin in patients stage 2 and 3a. iSGLT2 and GLP-1RA are initially recommended in T2D patients with high or very high cardiovascular risk. Concerning dyslipidemia, for patients in stage 4, LDL-C 55 mg/dl or less (1.4 mmol/l) and an LDL-C reduction of 50% or less from baseline is recommended. In stage 3, LDL-C goal is 70 mg/dl or less (1.8 mmol/l) and an LDL-C. reduction of at least 50% from baseline. Statins are the lipid-lowering therapy of choice with or without ezetimibe. Higher doses of statins are required as GFR declines. Available evidence suggests that combined PCSK9 inhibitors with maximally tolerated dose of statins may have an emerging role in treatment of dyslipidemia in CKD patients.
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30
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Harfouch B, Prasad A. Implications of Renal Disease in Patients Undergoing Peripheral Arterial Interventions. Interv Cardiol Clin 2020; 9:345-356. [PMID: 32471675 DOI: 10.1016/j.iccl.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Since the first peripheral endovascular intervention (PVI) in 1964, the procedure's technical aspects and indications have advanced significantly. Today, endovascular procedures span the spectrum of presentations from acute limb ischemia to critical limb ischemia and symptomatic limiting claudication. Goals of PVI remain restoring limb perfusion, minimizing rates of amputation and mortality, and sparing the need for the high-risk bypass surgery. Unfortunately, there are no large randomized controlled trials that address the optimal approach to peripheral arterial disease revascularization in chronic kidney disease (CKD) patients.
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Affiliation(s)
- Badr Harfouch
- Division of Cardiology, Department of Medicine, UT Health San Antonio, MC 7872, 8300 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, UT Health San Antonio, MC 7872, 8300 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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31
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Gupta A, Dosekun AK, Kumar V. Carbon dioxide-angiography for patients with peripheral arterial disease at risk of contrast-induced nephropathy. World J Cardiol 2020; 12:76-90. [PMID: 32184976 PMCID: PMC7061263 DOI: 10.4330/wjc.v12.i2.76] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/03/2020] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Patients with peripheral arterial disease (PAD) and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow. Patients with PAD often have several comorbidities, including chronic kidney disease, diabetes mellitus, and hypertension. Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy (CIN). The use of carbon dioxide (CO2) as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN. However, CO2 angiography has been underutilized due to concerns regarding safety and image quality. Modern CO2 delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN. Awareness of the need for optimal imaging conditions, contraindications, and potential complications have improved the safety of CO2 angiography. This review aims to highlight current technological advances in the delivery of CO2 in vascular angiography for patients with PAD and critical limb ischemia, which result in limb preservation while preventing kidney damage.
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Affiliation(s)
- Amol Gupta
- Department of Cardiology, Heart, Vascular and Leg Center, Bakersfield, CA 93309, United States
| | | | - Vinod Kumar
- Department of Cardiology, Heart, Vascular and Leg Center, Bakersfield, CA 93309, United States
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32
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De Mauri A, Vidali M, Chiarinotti D, Dianzani U, Rolla R. Lipoprotein-associated phospholipase A2 predicts lower limb ischemia in hemodialysis subjects. Ther Apher Dial 2019; 24:548-553. [PMID: 31863555 DOI: 10.1111/1744-9987.13465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 11/30/2022]
Abstract
Hemodialyzed patients (HD) have high prevalence of peripheral arterial disease. In the general population, lipoprotein-associated phospholipase A2 (Lp-PLA2 ) is associated with peripheral arterial disease but no data are available for renal subjects. The aim of this study was to evaluate the relationship between Lp-PLA2 and lower limb ischemia among dialyzed patients. One hundred and two dialyzed subjects, with median (IQR) age of 71 (59-78) years, enrolled in June 2013 and followed until June 2018, were investigated for Lp-PLA2 activity and the occurrence of peripheral arterial disease and lower limb ischemia. The median (IQR) levels of Lp-PLA2 were 184 nmol/min/mL (156.5-214.5). The 43 HD patients with abnormal Lp-PLA2 activity (>194 nmol/min/mL) had higher levels of total and LDL-cholesterol, ApoB/A1 ratio, and higher occurrence of lower limb ischemia during the follow up (44% vs 17%, P = .003). In multivariate analysis, Lp-PLA2 activity (P = .018) and diabetes (P < .001) were independently associated with time to lower limb ischemia, and when the presence of previous PAD was added to the multivariate model, only presence of previous PAD (P < .001) and Lp-PLA2 (P = .003) remained associated. Lp-PLA2 is an independent predictor of lower limb ischemia in dialyzed patients.
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Affiliation(s)
- Andreana De Mauri
- Nephrology and Dialysis Unit, "Maggiore della Carità" University Hospital, Novara, Italy.,Department of Health Sciences, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Matteo Vidali
- Clinical Chemistry Laboratory, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Doriana Chiarinotti
- Nephrology and Dialysis Unit, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Umberto Dianzani
- Department of Health Sciences, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.,Clinical Chemistry Laboratory, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Roberta Rolla
- Department of Health Sciences, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.,Clinical Chemistry Laboratory, "Maggiore della Carità" University Hospital, Novara, Italy
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Peripheral Artery Disease and African Americans: Review of the Literature. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0621-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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