Major Limb Outcomes Following Lower Extremity Endovascular Revascularization in Patients With and Without Diabetes Mellitus

Surgery or endovascular therapy for patients with chronic limb-threatening ischemia requiring infrapopliteal interventions

OBJECTIVE

The recent publication of randomized trials comparing open bypass surgery to endovascular therapy in patients with chronic limb-threatening ischemia, namely, Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) and Bypass versus Angioplasty in Severe Ischaemia of the Leg-2 (BASIL-2), has resulted in potentially contradictory findings. The trials differed significantly with respect to anatomical disease patterns and primary end points. We performed an analysis of patients in BEST-CLI with significant infrapopliteal disease undergoing open tibial bypass or endovascular tibial interventions to formulate a relevant comparator with the outcomes reported from BASIL-2.

METHODS

The study population consisted of patients in BEST-CLI with adequate single segment saphenous vein conduit randomized to open bypass or endovascular intervention (cohort 1) who additionally had significant infrapopliteal disease and underwent tibial level intervention. The primary outcome was major adverse limb event (MALE) or all-cause death. MALE included any major limb amputation or major reintervention. Outcomes were evaluated using Cox proportional regression models.

RESULTS

The analyzed subgroup included a total of 665 patients with 326 in the open tibial bypass group and 339 in the tibial endovascular intervention group. The primary outcome of MALE or all-cause death at 3 years was significantly lower in the surgical group at 48.5% compared with 56.7% in the endovascular group (P = .0018). Mortality was similar between groups (35.5% open vs 35.8% endovascular; P = .94), whereas MALE events were lower in the surgical group (23.3% vs 35.0%; P<.0001). This difference included a lower rate of major reinterventions in the surgical group (10.9%) compared with the endovascular group (20.2%; P = .0006). Freedom from above ankle amputation or all-cause death was similar between treatment arms at 43.6% in the surgical group compared with 45.3% the endovascular group (P = .30); however, there were fewer above ankle amputations in the surgical group (13.5%) compared with the endovascular group (19.3%; P = .0205). Perioperative (30-day) death rates were similar between treatment groups (2.5% open vs 2.4% endovascular; P = .93), as was 30-day major adverse cardiovascular events (5.3% open vs 2.7% endovascular; P = .12).

CONCLUSIONS

Among patients with suitable single segment great saphenous vein who underwent infrapopliteal revascularization for chronic limb-threatening ischemia, open bypass surgery was associated with a lower incidence of MALE or death and fewer major amputation compared with endovascular intervention. Amputation-free survival was similar between the groups. Further investigations into differences in comorbidities, anatomical extent, and lesion complexity are needed to explain differences between the BEST-CLI and BASIL-2 reported outcomes.

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

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

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

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Nationwide Study of the Outcome of Treatment of Lower Extremity Atherosclerotic Lesions With Endovascular Surgery With or Without Drug Eluting Methods in Patients With Diabetes

CLINICAL IMPACT

This retrospective observational registry trial combines national registries for vascular surgical procedures and diabetes mellitus to clarify results of drug eluting technology in treating diabetic subjects with intermittent claudication or chronic limb threatening ischemia compared to treatment of non-diabetic subjects. As earlier proposed and showed in this trial, there may be an implication for a beneficial treatment efficacy with drug eluting therapy in the diabetic population with PAD compared to the non-diabetic population. A finding worth further exploration.

Prediction model for lower limb amputation in hospitalized diabetic foot patients using classification and regression trees

BACKGROUND

The decision to perform amputation of a limb in a patient with diabetic foot ulcer (DFU) is not an easy task. Prediction models aim to help the surgeon in decision making scenarios. Currently there are no prediction model to determine lower limb amputation during the first 30 days of hospitalization for patients with DFU.

METHODS

Classification And Regression Tree analysis was applied on data from a retrospective cohort of patients hospitalized for the management of diabetic foot ulcer, using an existing database from two Orthopaedics and Traumatology departments. The secondary analysis identified independent variables that can predict lower limb amputation (mayor or minor) during the first 30 days of hospitalization.

RESULTS

Of the 573 patients in the database, 290 feet underwent a lower limb amputation during the first 30 days of hospitalization. Six different models were developed using a loss matrix to evaluate the error of not detecting false negatives. The selected tree produced 13 terminal nodes and after the pruning process, only one division remained in the optimal tree (Sensitivity: 69%, Specificity: 75%, Area Under the Curve: 0.76, Complexity Parameter: 0.01, Error: 0.85). Among the studied variables, the Wagner classification with a cut-off grade of 3 exceeded others in its predicting capacity.

CONCLUSIONS

Wagner classification was the variable with the best capacity for predicting amputation within 30 days. Infectious state and vascular occlusion described indirectly by this classification reflects the importance of taking quick decisions in those patients with a higher compromise of these two conditions. Finally, an external validation of the model is still required.

LEVEL OF EVIDENCE

III.

Risk Factors for 30-day Hospital Readmissions After Peripheral Vascular Interventions in Peripheral Artery Disease Patients at the US-Mexico Border

Peripheral artery disease (PAD) is associated with high rates of readmission following endovascular interventions and contributes to a significant hospital readmission burden. Quality metrics like hospital readmissions affect hospital performance, but must adjust to local trends. Our primary goal was to evaluate risk factors and readmission rates post-percutaneous peripheral intervention in a US-Mexico border city, at a single tertiary university hospital. We performed a retrospective review of patients with PAD undergoing first time peripheral intervention from July 2015 to June 2020. Among 212 patients, 58% were readmitted with median 235-day follow-up (inter-quartile range (IQR) 42-924); 35.3% of readmissions occurred within 30 days, and 30.2% of those were within 7 days. Median time to readmission was 62 days. Active smokers had 84% higher risk of readmission (hazard ratio (HR) 1.84, 95% CI 1.23-2.74, P < .01). Other significant factors noted were insurance status-Medicaid or uninsured (HR 1.94, 95% CI 1.22-3.09), prior amputation (HR 1.69, 95% CI 1.13-2.54), heart failure, both preserved (HR 4.35, 95% CI 2.07-9.16) and reduced ejection fraction (HR 1.88, 95% CI 1.14-3.10). Below the knee, interventions were less likely to be readmitted (adjusted HR .64, 95% CI 0.42-.96). Readmission rates were unrelated to medication adherence.

Risk factors for reamputation in patients with diabetic foot: A case-control study

BACKGROUND

Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals.

METHODS

Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors.

RESULTS

Statistically significant risk factors were artery history of tobacco use (p = 0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound >50 % (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound >50 % remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR.

CONCLUSION

Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation.

LEVEL OF EVIDENCE

III.

Diabetes mellitus and femoropopliteal in-stent restenosis

Summary: Background: The influence of diabetes mellitus (DM) on recurrent in-stent restenosis (ISR) of femoropopliteal arteries remains understudied. We investigated whether DM has an impact on recurrent restenosis after femoropopliteal stenting in patients included in the dRug-coatEd balloon angioPlasty for femoropopliteAl In-stent Restenosis (REPAIR) cooperation. Patients and methods: The REPAIR cooperation pooled the patient-level data from 3 randomized trials in which patients with ISR of femoropopliteal arteries received either drug-coated balloon (DCB) or plain balloon angioplasty. For this analysis, patients were divided in two groups based on whether they had or had not a DM diagnosis at the time of enrollment. The primary outcome was target lesion revascularization (TLR). The main secondary outcome was recurrent ISR. Other outcomes of interest were death, Rutherford class improvement and ankle-brachial index at follow-up. Results: 256 patients (DM, n=99 vs. non-DM, n=157) with 12-month follow-up were included in the analysis. Compared to non-DM patients, DM patients displayed no difference in terms of TLR [adjusted hazard ratio (95% Confidence intervals): 0.96 (0.55, 1.69), p=0.89] and recurrent ISR [1.04 (0.61, 1.77), p=0.88], whilst mortality was higher [9.38 (1.06, 83.11), p=0.044]. There were no differences between groups with respect to other secondary outcomes. The percutaneous treatment with DCB as compared to plain balloon angioplasty significantly reduced the risk of TLR and recurrent ISR without an excess risk of death irrespective of DM (p for interaction ≥0.70). Conclusions: In patients with femoropopliteal ISR, diabetes has a neutral effect on the risk of recurrence, but increases mortality at 12-month follow-up. DCB as compared to plain balloon angioplasty is associated with superior efficacy without trade-off in safety, regardless of diabetes.

ERICVA Risk Scale simplified as a predictor of amputation in critical limb ischemia

OBJECTIVE

Demonstrate that simplified ERICVA (Valladolid Critical Limb Ischaemia Risk Scale) is useful in predicting amputation in chronic limb-threatening ischemia (CLI) after one year of revascularization.

METHODS

A retrospective cohort study was performed. We analyzed the medical records of 93 patients over the age of 35 with the diagnosis of CLI who were treated in the Department of Internal Medicine, Orthopedics or in the Cardiovascular Surgery Unit of the Víctor Lazarte Echegaray Hospital and the High Complexity Virgen de La Puerta Hospital during the period 2015-2018. The simplified ERICVA score was determined in patients before surgical and endovascular revascularization. We included 31 patients who scored 2 or more points in the exposed group and 62 patients who scored less than 2 points in the group not exposed to amputation risk. The collected data was analyzed with the statistical program SPSS where the Relative Risk and significance was obtained with Pearson's Chi-square. The multivariate analysis was also carried out in order to obtain the adjusted relative risk.

RESULTS

It was identified that the simplified ERICVA score greater than or equal to 2 points was more frequent in those who underwent amputation (90.3%) compared to patients who did not undergo amputation (4.8%), increasing the risk of amputation in those patients with CLI who underwent revascularization (RR: 18.67, P<0.001). It was also possible to identify that within the group of patients that showed a high risk of amputation according to the ERICVA scale, they had a higher risk of major amputation (RR: 9.32, P<0.001) as opposed to the risk of minor amputation (RR: 1, 89, P=0.193). Among the items of the simplified ERICVA scale, the preoperative neutrophil-lymphocyte ratio and hematocrit were significantly higher in the group of amputated patients (P<0.001). In addition, it was possible to identify that the score greater than or equal to 2 was independently associated with the risk of amputation in patients revascularized with CLI (RR: 13.5, P<0.001).

CONCLUSION

In our patient population, the simplified ERICVA scale is useful in predicting major and minor amputation in critical limb ischemia after revascularization. The present data showed that the patients who had a simplified ERICVA score greater than or equal to 2 had a higher risk of major amputation compared to the risk of minor amputation. However, it is important to highlight that the impact on the prediction of minor amputation is greater because in some circumstances major amputation can appear as a complication of CLI.

Cardiovascular and Limb Events Following Endovascular Revascularization Among Patients ≥65 Years Old: An American College of Cardiology PVI Registry Analysis

Background We aimed to characterize the occurrence of major adverse cardiovascular and limb events (MACE and MALE) among patients with peripheral artery disease (PAD) undergoing peripheral vascular intervention (PVI), as well as associated factors in patients with chronic limb threatening ischemia (CLTI). Methods and Results Patients undergoing PVI in the American College of Cardiology's (ACC) National Cardiovascular Data Registry's PVI Registry who could be linked to Centers for Medicare and Medicaid Services data were included. The primary outcomes were MACE, MALE, and readmission within 1 month and 1 year following index CLTI-PVI or non-CLTI-PVI. Cox proportional hazards regression was used to identify factors associated with the development of the primary outcomes among patients undergoing CLTI-PVI. There were 1758 (49.7%) patients undergoing CLTI-PVI and 1779 (50.3%) undergoing non-CLTI-PVI. By 1 year, MACE occurred in 29.5% of patients with CLTI (n=519), and MALE occurred in 34.0% of patients with CLTI (n=598). By 1 year, MACE occurred in 8.2% of patients with non-CLTI (n=146), and MALE occurred in 26.1% of patients with non-CLTI (n=465). Predictors of MACE at 1 year in CLTI-PVI included end-stage renal disease on hemodialysis, congestive heart failure, prior CABG, and severe lung disease. Predictors of MALE at 1 year in CLTI-PVI included treatment of a prior bypass graft, profunda femoral artery treatment, end-stage renal disease on hemodialysis, and treatment of a previously treated lesion. Conclusions Patients ≥65 years old undergoing PVI experience high rates of MACE and MALE. A range of modifiable and non-modifiable patient factors, procedural characteristics, and medications are associated with the occurrence of MACE and MALE following CLTI-PVI.

Microvascular Permeability and Texture Analysis of the Skeletal Muscle of Diabetic Rabbits With Critical Limb Ischaemia Based on DCE-MRI

BACKGROUND

We evaluated skeletal muscle vascular permeability in diabetic rabbits with critical limb ischaemia using quantitative dynamic contrast agent-enhanced (DCE) magnetic resonance imaging (MRI) and explored the feasibility of using DCE-MRI K^trans-based texture analysis for assessing early slight ischaemia-related skeletal muscle structural changes.

METHOD

Twenty-four male New Zealand white rabbits (2.7 ± 0.3 kg; n = 12 each in sham-operated and experimental groups) underwent axial MRI of the vastus lateralis muscle at 1, 2, and 3 weeks after alloxan injection. Between-group and intra-group postoperative permeability and texture parameters were compared. Texture features of experimental groups in the third week were modelled by receiver operating characteristic (ROC) curve analysis. Correlations of permeability and of statistical texture parameters with peripheral blood endothelial progenitor cells (EPCs) and microvascular density (MVD) were analysed.

RESULTS

In the experimental group, the transfer constant (K^trans) was statistically significant at all time-points (F = 5.800, P = 0.009). Their vastus lateralis muscle K^trans was significantly lower in the third than in the first week (P = 0.018) and correlated positively with peripheral blood EPCs in the experimental group [r = 0.598, (95% CI: 0.256, 0.807)]. The rate constant was negatively associated with vastus lateralis muscle MVD [r = -0.410, (95% CI: -0.698, -0.008)]. The area under the ROC curve of texture parameters based on K^trans in ischaemic limbs was 0.882.

CONCLUSIONS

Quantitative DCE-MRI parameters could evaluate microvascular permeability of ischaemic limb skeletal muscle, and texture analysis based on DCE-MRI K^trans allowed evaluation of early slight skeletal muscle structural changes.

The Impact of Lower Extremity Skeletal Muscle Atrophy and Myosteatosis on Revascularization Outcomes in Patients with Peripheral Arterial Disease

Background: This study investigated whether lower extremity muscle atrophy and myosteatosis in patients with peripheral arterial disease (PAD) are correlated to postoperative outcomes, such as reintervention or amputation-free survival. Methods: In this single-center retrospective cohort study of 462 patients treated for peripheral arterial disease scheduled for intervention, muscle mass and the presence of fattening of the lower extremity muscles were measured semiautomatically in a single computed tomography slice of the treated leg. Binary logistic regression models and Cox proportional hazards models were used to determine the effect of muscle atrophy and myosteatosis on reintervention and amputation. Results: Muscle atrophy and myosteatosis increased in PAD patients with Fontaine class IV compared with Fontaine class IIa. In PAD patients with muscle atrophy or myosteatosis, no association was found with the reintervention rate or reintervention-free survival, but an association was found with amputation-free survival, even after adjustment for patient-related, disease-severity, and comorbidities-related factors. Conclusion: Muscle atrophy and mysosteatosis increased in PAD patients with increasing disease severity. Lower extremity muscle atrophy and myosteatosis are associated with amputation rate and amputation-free survival in PAD patients. No association with reintervention rate or reintervention-free survival was found. Muscle atrophy and myosteatosis may serve as additional risk factors in decision making in the often frail vascular patient.

Insulin-Dependent Status Influences Post-Procedural Outcomes in Diabetic Patients Following Lower Extremity Endovascular Intervention for Peripheral Arterial Disease

PURPOSE

Diabetic patients are at increased risk of developing lower extremity peripheral arterial disease (PAD) requiring revascularization. This study assessed the effect of insulin dependence in diabetics on post-procedural outcomes following infra-inguinal endovascular intervention.

MATERIALS AND METHODS

The American College of Surgeon's National Surgical Quality Improvement Program database was used to identify 8022 patients undergoing infra-inguinal endovascular interventions between 2014 and 2017. Thirty-day post-procedural outcomes for patients without diabetes, with non-insulin-dependent diabetes mellitus (NIDDM), and with insulin-dependent diabetes mellitus (IDDM) were compared.

RESULTS

At presentation, IDDM patients were more likely to present with critical limb ischemia compared to NIDDM and non-diabetic patients. In propensity score-weighted logistic regression analysis, IDDM status was an independent predictor for increased renal complication (odds ratio [OR] = 3.08, confidence interval [CI] = 1.44-6.65), sepsis (OR = 1.68, CI = 1.13-2.48), wound complication (OR = 1.57, CI = 1.09-2.25, p = 0.006), UTI (OR = 2.07, CI = 1.09-3.94, p = 0.03), and readmission (OR = 1.21, CI = 1.03-1.42). NIDDM status was an independent predictor for increased risk of renal complications (OR = 2.80, CI = 1.18-6.63).

CONCLUSIONS

IDDM status is an independent predictor for increased risk of 30-day post-procedural complications and readmission compared to both NIDDM and non-diabetic status in patients undergoing lower extremity endovascular interventions for PAD.

Pilot study of contrast-free MRI reveals significantly impaired calf skeletal muscle perfusion in diabetes with incompressible peripheral arteries

Patients with diabetes mellitus (DM) are more likely to have densely calcified lesions in the below-the-knee tibial arteries. However, the relationship between peripheral arterial calcification and local skeletal muscle perfusion has not been explored. Thirty subjects were prospectively recruited into three groups in this pilot study: (1) Non-DM: 10 people without DM; (2) DM, ABI < 1.3: 10 people with DM and normal ankle-brachial index (ABI) (0.9-1.3); and (3) DM, ABI ⩾ 1.3: 10 people with DM and ABI ⩾ 1.3. All subjects underwent calf perfusion measurements at rest and during an isometric plantarflexion contraction exercise within the magnetic resonance imaging (MRI) system. The noncontrast MRI techniques were applied to quantitatively assess skeletal muscle blood flow (SMBF) and oxygen extraction fraction (SMOEF) in medial gastrocnemius and soleus muscles. Both SMBF and SMOEF reserves were calculated as the ratio of the exercise value to the resting value. Exercise SMBF and SMOEF values in the medial gastrocnemius muscle were lower in the two DM groups than in the non-DM group (p < 0.05). The SMBF reserve in medial gastrocnemius was significantly lower in the DM, ABI ⩾ 1.3 group compared to the DM, ABI < 1.3 group (p < 0.05). This study demonstrates that people with DM and calcified arteries had lower perfusion in gastrocnemius muscle compared to those without DM and those with DM and a normal ABI.

Successful Peripheral Vascular Intervention in Patients with High-risk Comorbidities or Lesion Characteristics

PURPOSE OF REVIEW

Certain comorbidities and lesion characteristics are associated with increased risk for procedural complications, limb events, and cardiovascular events following peripheral vascular intervention (PVI) in patients with peripheral arterial disease (PAD). The purpose of this review is to provide an overview of high-risk modifiable and unmodifiable patient characteristics and its relative impact on clinical outcomes such as amputation risk and mortality. Furthermore, general approaches to potentially mitigating these risks through pre-intervention planning and use of modern devices and techniques are discussed.

RECENT FINDINGS

Diabetes, tobacco use, and older age remain strong risk factors for the development of peripheral arterial disease. Recent data highlight the significant risk of polyvascular disease on major limb and cardiac events in advanced PAD, and ongoing studies are assessing this risk specifically after PVI. Challenging lesion characteristics such as calcified disease and chronic total occlusions can be successfully treated with PVI by utilizing novel devices (e.g., intravascular lithotripsy, re-entry devices) and techniques (e.g., subintimal arterial "flossing" with antegrade-retrograde intervention). Understanding high-risk patient comorbidities and lesion characteristics will improve our ability to counsel and manage patients with advanced PAD. Continued device innovation and novel techniques will aid in procedural planning for successful interventions to improve clinical outcomes.

Soft drinks and sweeteners intake: Possible contribution to the development of metabolic syndrome and cardiovascular diseases. Beneficial or detrimental action of alternative sweeteners?

The rapid increase in obesity, metabolic syndrome, and cardiovascular diseases (CVDs) has been related to the rise in sugar-added foods and sweetened beverages consumption. An interesting approach has been to replace sugar with alternative sweeteners (AS), due to their impact on public health. Preclinical and clinical studies, which analyze the safety of AS intake, are still limited. Major pathogenic mechanisms of these substances include ROS and AGEs formation. Indeed, endothelial dysfunction involving in the pathogenesis of micro- and macro-vascular diseases is mitochondrial dysfunction dependent. Hyperglycemia and endoplasmic reticulum stress together produce ROS, contributing to the development and progression of cardiovascular complications during type 2 diabetes (T2D), thus causing oxidative changes and direct damage of lipids, proteins, and DNA. Epidemiological studies in healthy subjects have suggested that the consumption of artificial AS can promote CV complications, such as glucose intolerance and predisposition to the onset of T2D, whereas natural AS could reduce hyperglycemia, improve lipid metabolism and have antioxidant effects. Long-term prospective clinical randomized studies are needed to evaluate precisely whether exposure to alternative sugars can have clinical implications on natural history and clinical outcomes, especially in children or during the gestational period through breast milk.

CEPT1-Mediated Phospholipogenesis Regulates Endothelial Cell Function and Ischemia-Induced Angiogenesis Through PPARα

De novo phospholipogenesis, mediated by choline-ethanolamine phosphotransferase 1 (CEPT1), is essential for phospholipid activation of transcription factors such as peroxisome proliferator-activated receptor α (PPARα) in the liver. Fenofibrate, a PPARα agonist and lipid-lowering agent, decreases amputation incidence in patients with diabetes. Because we previously observed that CEPT1 is elevated in carotid plaque of patients with diabetes, we evaluated the role of CEPT1 in peripheral arteries and PPARα phosphorylation (Ser12). CEPT1 was found to be elevated in diseased lower-extremity arterial intima of individuals with peripheral arterial disease and diabetes. To evaluate the role of Cept1 in the endothelium, we engineered a conditional endothelial cell (EC)-specific deletion of Cept1 via induced VE-cadherin-CreERT2-mediated recombination (Cept1Lp/LpCre ⁺). Cept1Lp/LpCre ⁺ ECs demonstrated decreased proliferation, migration, and tubule formation, and Cept1Lp/LpCre ⁺ mice had reduced perfusion and angiogenesis in ischemic hind limbs. Peripheral ischemic recovery and PPARα signaling were further compromised by streptozotocin-induced diabetes and ameliorated by feeding fenofibrate. Cept1 endoribonuclease-prepared siRNA decreased PPARα phosphorylation in ECs, which was rescued with fenofibrate but not PC16:0/18:1. Unlike Cept1Lp/LpCre ⁺ mice, Cept1Lp/LpCre ⁺ Ppara ^-/- mice did not demonstrate hind-paw perfusion recovery after feeding fenofibrate. Therefore, we demonstrate that CEPT1 is essential for EC function and tissue recovery after ischemia and that fenofibrate rescues CEPT1-mediated activation of PPARα.

Characteristics and Outcomes of Patients With Diabetes Mellitus Undergoing Peripheral Vascular Intervention for Infrainguinal Symptomatic Peripheral Artery Disease

PURPOSE

Patients with diabetes mellitus (DM) are known to be at higher risk for peripheral artery disease (PAD), amputations, and major adverse cardiovascular events, though it is unclear whether they are at any higher risk for repeat intervention. LIBERTY 360 offered an opportunity to study a real-world cohort of patients who underwent distal superficial femoral artery endovascular revascularizations. We aimed to describe patients with DM, their outcomes following peripheral vascular intervention, and the effect of DM on outcomes in the LIBERTY 360 cohort.

METHODS

LIBERTY 360 is a prospective, multi-center, non-randomized, mono-industry funded observational study of patients undergoing endovascular revascularization. Outcomes included 30-day and 1-year all-cause mortality, major amputation, target vessel/lesion revascularization, and a composite of those events. A multivariable regression model including DM was constructed to examine the effect of DM on outcomes. Multivariable survival estimates were made using Cox proportional hazards models.

RESULTS

A total of 1,204 patients were enrolled, of whom 727 had DM (60.4%). Patients with DM had significantly more comorbidities and a third required insulin for DM management. Patients with DM had more severe disease based on Rutherford classification at baseline. After adjusting for comorbidities and disease severity, DM patients had more frequent major amputations at 1 year (5.2% versus 1.2%; HR 2.71, 95%CI 1.05-6.98, p = 0.040). The 1-year rates of all-cause mortality and target vessel/lesion revascularization were not significantly higher for patients with DM.

CONCLUSIONS

Diabetes mellitus was associated with increased major amputations at 1 year following endovascular revascularization after accounting for demographics, comorbidities, and PAD-related characteristics. Further research is needed to determine which aspects of PAD and DM are most strongly associated with poor outcomes following lower extremity revascularization.

Diabetes Mellitus And Outcomes Of Lower Extremity Revascularization For Peripheral Artery Disease

INTRODUCTION

The impact of diabetes mellitus (DM) on outcomes of lower extremity revascularization (LER) for peripheral artery disease (PAD) is uncertain. We characterized associations between DM and post-procedural outcomes in PAD patients undergoing LER.

METHODS

Adults undergoing surgical or endovascular LER were identified from the 2014 Nationwide Readmissions Database. DM was defined by ICD-9 diagnosis codes and sub-classified based on the presence or absence of complications (poor glycemic control or end-organ damage). Major adverse cardiovascular and limb events (MACLE) were defined as the composite of death, myocardial infarction, ischaemic stroke, or major limb amputation during the index hospitalization for LER. For survivors, all-cause 6-month hospital readmission was determined.

RESULTS

Among 39,441 patients with PAD hospitalized for LER, 50.8% had DM. The composite of MACLE after LER was not different in patients with and without DM after covariate adjustment, but patients with DM were more likely to require major limb amputation (5.5% vs. 3.2%, p < 0.001; adjusted odds ratio [aOR] 1.22, 95% CI 1.03-1.44) and hospital readmission (59.2% vs. 41.3%, p < 0.001; aOR 1.44, 95% CI 1.34-1.55). Of 20,039 patients with DM hospitalized for LER, 55.7% had DM with complications. These patients were more likely to have MACLE after LER (11.1% vs. 5.2%, p < 0.001; aOR 1.56 95% CI 1.28-1.89) and require hospital readmission (61.1% vs. 47.2%, p < 0.001; aOR 1.41 95% CI 1.27-1.57) than patients with uncomplicated DM.

CONCLUSIONS

DM is present in ≈50% of patients undergoing LER for PAD and is an independent risk factor for major limb amputation and 6-month hospital readmission.

The impact of chronic kidney disease on outcomes following peripheral vascular intervention

BACKGROUND

Patients with chronic kidney disease (CKD) have worsened clinical outcomes following percutaneous coronary intervention; however, limited evidence exists in patients undergoing peripheral vascular intervention (PVI).

PURPOSE

We aimed to assess the effect of CKD on outcomes following PVI for symptomatic peripheral artery disease.

METHODS

Using patients from the LIBERTY 360 study, we compared the rates of 30 day and 1 year major adverse vascular events (MAVE), a composite of all-cause mortality, major amputation, and target vessel/lesion revascularization, between patients with and without CKD (estimated glomular filtration rate less than 60) following PVI. Multivariable adjustment was performed to assess for independent association between CKD and outcomes.

RESULTS

Among 1189 patients enrolled, 378 patients (31.8%) had CKD. At 1 year, patients with CKD had higher rates of MAVE (34.6% vs 25.6%), all-cause mortality (11.9% vs 5.5%), and major amputation (5.9% vs 2.6%) when compared with patients without CKD (all P < .05). After adjustment, patients with CKD had higher risks of 1-year MAVE (HR 1.30, 95% CI 1.04-1.64; P = .023) and all-cause mortality (HR 1.88, 95% CI 1.22-2.91; P = .005) when compared with patients without CKD. There was no statistically significant difference in risk of major amputations (HR 1.70, 95% CI 0.91-3.17; P = .094).

CONCLUSIONS

Despite high procedural success and low amputation rates, patients with CKD remain at greater risk for MAVE and all-cause mortality after PVI. Further research is needed to determine treatment strategies to mitigate substantial mortality risk in this vulnerable population.

A Review and Proposed Classification System for the No-Option Patient With Chronic Limb-Threatening Ischemia

A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have "no option" for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed "desert foot," who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I-severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II-lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III-extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV-advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V-presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.

Three-Year Outcomes of Orbital Atherectomy for the Endovascular Treatment of Infrainguinal Claudication or Chronic Limb-Threatening Ischemia

Purpose: To investigate the outcomes of orbital atherectomy (OA) for the treatment of patients with peripheral artery disease (PAD) manifesting as claudication or chronic limb-threatening ischemia (CLTI). Materials and Methods: The database from the LIBERTY study (ClinicalTrials.gov identifier NCT01855412) was interrogated to identify 503 PAD patients treated with any commercially available endovascular devices and adjunctive OA for 617 femoropopliteal and/or infrapopliteal lesions. Cox regression analyses were employed to examine the association between baseline Rutherford category (RC) stratified as RC 2-3 (n=214), RC 4-5 (n=233), or RC 6 (n=56) and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE), and major amputation/death at up to 3 years of follow-up. The mean lesion lengths were 78.7±73.7, 131.4±119.0, and 95.2±83.9 mm, respectively, for the 3 groups. Results: After OA, balloon angioplasty was used in >98% of cases, with bailout stenting necessary in 2.0%, 2.8%, and 0% of the RC groups, respectively. A small proportion (10.8%) of patients developed angiographic complications, without differences based on presentation. During the 3-year follow-up, claudicants were at lower risk for MAE, death, and major amputation/death than patients with CLTI. The 3-year Kaplan-Meier survival estimates were 84.6% for the RC 2-3 group, 76.2% for the RC 4-5 group, and 63.7% for the RC 6 group. The 3-year freedom from major amputation was estimated as 100%, 95.3%, and 88.6%, respectively. Among CLTI patients only, the RC at baseline was correlated with the combined outcome of major amputation/death, whereas RC classification did not affect TVR, MAE, major amputation, or death rates. Conclusion: Peripheral artery angioplasty with adjunctive OA in patients with CLTI or claudication is safe and associated with low major amputation rates after 3 years of follow-up. These results demonstrate the utility of OA for patients across the spectrum of PAD.

Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy

Endovascular revascularization has been increasingly utilized to treat patients with chronic limb-threatening ischemia (CLTI), particularly atherosclerotic disease in the infrapopliteal arteries. Lesions of the infrapopliteal arteries are the result of 2 different etiologies: medial calcification and intimal atheromatous plaque. Although several devices are available for endovascular treatment of infrapopliteal lesions, balloon angioplasty still comprises the mainstay of therapy due to a lack of purpose-built devices. The mechanism of balloon angioplasty consists of adventitial stretching, medial necrosis, and dissection or plaque fracture. In many cases, the diffuse nature of infrapopliteal disease and plaque complexity may lead to dissection, recoil, and early restenosis. Optimal balloon angioplasty requires careful attention to assessment of vessel calcification, appropriate vessel sizing, and the use of long balloons with prolonged inflation times, as outlined in a treatment algorithm based on this systematic review. Further development of specific devices for this arterial segment are warranted, including devices for preventing recoil (eg, dedicated atherectomy devices), treating dissections (eg, tacks, stents), and preventing neointimal hyperplasia (eg, novel drug delivery techniques and drug-eluting stents). Further understanding of infrapopliteal disease, along with the development of new technologies, will help optimize the durability of endovascular interventions and ultimately improve the limb-related outcomes of patients with CLTI.

Safety and Efficacy of Drug-Coated Balloon Angioplasty for the Treatment of Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis

Purpose: To investigate the safety and efficacy of drug-coated balloons (DCB) for the treatment of femoropopliteal or infrapopliteal lesions in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: A systematic literature search was conducted in PubMed, Scopus, and Cochrane Central up to January 2020 to identify randomized trials and observational studies presenting data on the effectiveness and safety of DCBs in the treatment of femoropopliteal or infrapopliteal lesions. A meta-analysis utilizing random effects modeling was conducted to investigate primary patency and all-cause mortality at 12 months; the results are reported as the odds ratios (ORs) and 95% confidence intervals (CIs). Secondary outcomes were procedural success, bailout stenting, target lesion revascularization (TLR), reocclusion, major amputation, wound healing, and major adverse limb events. Results: Twenty-six studies, 12 retrospective and 14 prospective, comprising 2108 CLTI patients treated with DCBs for femoropopliteal (n=1315) or infrapopliteal (n=793) lesions were analyzed. The average lesion lengths were 121±44 and 135±53 mm, respectively. The overall 12-month all-cause mortality and major amputation rates were 9% (95% CI 6% to 13%) and 5% (95% CI 2% to 8%), respectively. Primary patency rates were 82% (95% CI 76% to 87%) and 64% (95% CI 58% to 70%), respectively. A sensitivity analysis of the infrapopliteal lesions demonstrated no difference between DCB and balloon angioplasty in terms of primary patency, TLR, major amputation, or mortality over 12 months. However, patients with infrapopliteal lesions undergoing DCB angioplasty did have a significantly lower risk for reocclusion (10% vs 25%; OR 0.38, 95% CI 0.21 to 0.70, p=0.002). Conclusion: DCB angioplasty of femoropopliteal and infrapopliteal lesions in patients with CLTI results in acceptable 12-month patency rates, although comparative data have not shown a patency benefit for infrapopliteal lesions. The 12-month mortality rate of DCB vs balloon angioplasty was not significantly different, but studies with longer-term outcomes are necessary to determine any association between DCB use and mortality in patients with CLTI.

Comparative 12-Month Outcomes of Drug-Coated Balloon Versus Non-Drug-Coated Balloon Revascularization Strategy in Chronic Limb-Threatening Ischemia: Results From the XLPAD Registry

BACKGROUND

Endovascular therapy is often the preferred first treatment option for chronic limb threatening ischemia (CLTI) patients. Drug coated balloons (DCB) reduce restenosis rates compared to percutaneous transluminal angioplasty (PTA), however DCB use has not been studied systematically in patients with CLTI. Thus, the optimal treatment option for these complex lesions remains controversial.

METHODS

We report on 327 patients with CLTI treated either with DCB (n = 105) or non-DCB (n = 222) for femoropopliteal disease. Data were retrieved from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851). Two DCB types were used at the discretion of the operator: Lutonix® (BARD Peripheral Vascular, Inc., Tempe, AZ, USA) and IN.PACT AdmiralTM (Medtronic, Santa Rosa, CA, USA). Odds ratios and the respective 95% confidence interval were synthesized to examine the association between the two groups in terms of all-cause mortality, target limb repeat endovascular or surgical revascularization, target vessel revascularization (TVR), major and minor amputation at 12 months of follow up.

RESULTS

The mean lesion length was 150.0 mm (SD:123.2) and 151.2 mm (SD:108.3) for the DCB and non-DCB group respectively. No difference between the two groups was detected in terms of all-cause mortality (2.86%vs2.7%,p = .94), target limb repeat endovascular or surgical revascularization (16.19%vs12.61%,p = .25), TVR (16.19%vs.11.71%,p = .26) or minor amputation (15.24%vs10.81%,p = .25) at 12 months of follow up. Although a higher incidence of 12 months major amputation was observed in the DCB group (11%vs.4%,p = .01), after adjusting for several risk factors the odds of major amputation were not statistically different between the DCB and non-DCB groups (OR:1.54;95%CI:0.53-4.51;p = .43).

CONCLUSIONS

Both DCB and non-DCB strategies are effective modalities for revascularization of patients with CLTI. No differences were identified between the DCB and non-DCB group in terms of late outcomes during 12 months of follow up.

The Influence of Diabetes Mellitus on the Outcome of Superficial Femoral Artery Recanalization is Debatable

Notwithstanding technological improvements in endovascular devices treatment of steno-obstructive lesions of the superficial femoral artery (SFA) remains a challenge for today's vascular surgeon. Current opinion dictates that the diabetic population may have worse outcome after revascularization of the lower extremities. Herein we examine the effects of endovascular treatment on steno-obstructive lesions of the SFA in diabetic and non-diabetic patients.

METHODS

A retrospective analysis was carried out on 110 patients who had undergone endovascular treatment of the SFA from 2010 to 2017 comparing outcomes in diabetic (DM) vs non-diabetic patients (nDM).

RESULTS

56 (50.9%) of the patients were diabetic and 54 were non-diabetic (49.1%). 52.7% (62.7% DM vs 35.2% nDM, p = 0.0003) were patients with critical limb ischemia. SFA occlusion was present in 65.5% (60.7% DM vs 70.4% nDM, p = 0.29) of all patients. All had undergone PTA of the SFA and 40.9% had received adjunctive stenting (44.6% DM vs 37.0% nDM, p = 0.41). A multilevel treatment was executed in 39.1% (51.8% DM vs 25.9% nDM) of the cases whereas an infra-popliteal procedure was associated in 27.3% (37.5% DM vs 16.7% nDM). In both groups the presence of diabetes was significantly associated (p = 0.005 e p = 0.014, respectively). Reintervention rate was 22.7%; 13 in the diabetic group (23.2%) and 12 in the non-diabetic group (22.2%). Of those who had had reintervention (p = 0.77); 9 patients (8.2%) had undergone an open surgical operation, 6 of whom had diabetes (p = 0.32). 5 patients (4.5%) had had major amputation, 4 of whom were diabetic (p = 0.20). Curves assessing freedom from target lesion restenosis were substantially overlapping between the two groups.

CONCLUSION

No statistical associations between diabetes and reintervention or amputation rates were found. Indication to treat the SFA were not influenced by the presence of diabetes but further investigation is required to verify our hypothesis.

Peripheral Arterial Disease and Its Associated Factors among Type 2 Diabetes Mellitus Patients at Debre Tabor General Hospital, Northwest Ethiopia

BACKGROUND

Peripheral arterial disease (PAD), one of the major macrovascular complications of diabetes, is associated with cardiovascular mortality and a high rate of disability following the amputation of an extremity in diabetes patients. However, there is no data on the prevalence of PAD among type 2 diabetes patients in Ethiopia. Therefore, the current study is aimed at determining the prevalence and associated factors of PAD among type 2 diabetes patients at Debre Tabor General Hospital, Debre Tabor, Northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among type 2 diabetes mellitus patients from February 1 to August 30, 2019. A pretested interviewer-administered questionnaire was used to collect the data. The presence of stenosis and its grading were determined by color Doppler ultrasonography. Data were entered using EpiData-V.4.6 and analyzed by STATA-14. Bivariable and multivariable logistic regression was performed to identify associated factors of peripheral arterial disease. Adjusted odds ratio (AOR) and its confidence interval were estimated for potential predictors included in the final model. P ≤ 0.05 was used to declare statistical significance.

RESULTS

The mean age of the study participants was 61.2 ± 7.3 years. One hundred seventy-two (61.4%) patients were males. The prevalence of PAD in this study was 30.7% (95% CI (25.3-36.2%)). Of these, 37 (43%) were symptomatic. Age (AOR = 1.09, 95% CI (1.03-1.16)), higher HbA1c (AOR = 1.97, 95% CI (1.03-3.40)), being an ex-smoker (AOR = 4.68, 95% CI (1.93-11.30)), and current cigarette smoking (AOR = 5.84, 95% CI (1.79-19.04)) were significantly associated with PAD.

CONCLUSION

The prevalence of peripheral arterial disease among type 2 diabetes patients was high. Increasing age, high HbA1c, and being cigarette smokers increase the likelihood of developing peripheral arterial disease. Clinicians should prevent PAD; screen T2DM patients who are aged, with high HbA1c, and cigarette smokers; and treat them timely.

Worse cardiovascular prognosis after endovascular surgery for intermittent claudication caused by infrainguinal atherosclerotic disease in patients with diabetes

BACKGROUND

Diabetes mellitus (DM) is an established risk factor for intermittent claudication (IC) and other manifestations of atherosclerotic peripheral arterial disease. Indications for surgery in infrainguinal IC are debated, and there are conflicting reports regarding its outcomes in patients with DM. Aims of this study were to compare both short- and long-term effects on total- and cardiovascular (CV) mortality, major adverse cardiovascular events (MACEs), acute myocardial infarction (AMI), stroke, and major amputation following infrainguinal endovascular surgery for IC in patients with and without DM. We also evaluated potential relationships between diabetic control and outcomes in patients with DM.

METHODS

Nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Registry. Propensity score adjusted comparison of total and CV mortality, MACE, AMI, stroke, and major amputation after elective infrainguinal endovascular surgery for IC in 626 patients with and 1112 without DM at 30 postoperative days and after median 5.2 [interquartile range (IQR) 4.2-6.3] years of follow-up for patients with DM, and 5.4 (IQR 4.3-6.5) years for those without.

RESULTS

In propensity score adjusted Cox regression after 30 postoperative days, there were no differences between groups in morbidity or mortality. At last follow-up, patients with DM showed higher rates of MACE [hazard ratio (HR) 1.26, confidence interval (CI) 1.07-1.48; p < 0.01], AMI (HR 1.48, CI 1.09-2.00; p = 0.01), and major amputation (HR 2.31, CI 1.24-4.32; p < 0.01). Among patients with DM, higher HbA1c was associated with higher total mortality during follow-up (HR 1.01, CI 1.00-1.03; p = 0.045).

CONCLUSION

Patients with DM have higher rates of MACE, AMI, and major amputation in propensity score adjusted analysis during 5 years of follow-up after infrainguinal endovascular surgery for IC. Furthermore, HbA1c is associated with total mortality in patients with DM. Prevention and treatment of DM is important to improve cardiovascular and limb outcomes.

Adherence to guideline recommended medical therapies in type 2 diabetic patients with chronic critical limb ischemia

AIM

The aim of this study was to evaluate the adherence to guideline recommended medical therapies in type 2 diabetic patients with chronic critical limb ischemia (CCLI).

METHODS

We retrospectively analyzed the data of 1315 admissions performed in our Department, focusing on diabetic foot patients (842-64%) of which 603 consecutive type 2 diabetic patients with CCLI (M/F(%): 73/27; age: 70.3 ± 10.4 yrs; diabetes duration: 17.3 ± 13.7 yrs; BMI: 27.7 ± 5.3 Kg/m²; HbA1c 7.8 ± 1.8%) referred to a third-level Center from 2011 to 2015. We focused on medical therapy of diabetes, dyslipidemia, hypertension, peripheral vascular disease and smoke habits.

RESULTS

In total, at admission, 66.6% of patients had HbA1c levels higher than recommended; 65.9% of patients were on statins; 81.4% on anti-hypertensive treatment and 72.4% on antiplatelet drugs. Concerning smoke habits, 27% of patients were no-smokers; 41% former smokers and 32% active smokers. Among all patients, only 24% were prescribed all five guideline recommended therapies while 32% reached four out of five of these. As for patients treated with anti-hypertensive drugs, we observed higher levels of systolic pressure (138.0 ± 29.5 vs 107.7 ± 36.6 p < 0.02) while no differences were observed in diastolic pressure levels.

CONCLUSIONS

In conclusion, when it comes to diabetic patients with a severe limb and life threatening clinical condition, we noticed a lower-than-expected application of international guideline-recommended medical therapies. In fact, only one out of four patients was following all the recommended therapies. Nevertheless, these patients did not reach the standard targets requested to prevent cardiovascular disease.

One-Year Readmission after Open and Endovascular Revascularization for Critical Limb Ischemia

BACKGROUND

Lower extremity revascularization for critical limb ischemia (CLI) remains a subject of clinical equipoise. Readmissions and repeat lower extremity revascularization increase the cost of care and decrease the value of initial treatment. This study examines readmissions and repeat inpatient revascularization and major amputation up to 1 year after initial open and endovascular lower extremity revascularization.

METHODS

The 2014 Nationwide Readmissions Database (NRD) was reviewed. The NRD provides all subsequent readmissions of any hospitalization for the calendar year. A cohort of patients undergoing lower extremity revascularization in January only was selected based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were divided into open and endovascular groups. Readmissions for repeat lower extremity revascularization (RFR) were identified based on procedural codes. Open and endovascular lower extremity revascularization were compared in terms of patient characteristics as well as readmissions, RFR, major amputation, and inpatient mortality at 1 year. Risk-adjusted outcomes accounting for differences in age, gender, income, and Charlson Comorbidity Index (CCI) were derived using regression analysis.

RESULTS

There were 1,668 open and 1,410 endovascular lower extremity revascularizations. Patients in the endovascular group were significantly older (P < 0.01), more likely to be women (P < 0.01), and had higher CCI (P < 0.01). Patients undergoing endovascular lower extremity revascularization had significantly higher readmission rate (49 vs. 33.7, P < 0.01) and higher mortality (10.4 vs. 5.3, P < 0.01). Readmitted patients after endovascular lower extremity revascularization had significantly higher mean number of repeat readmissions compared to open lower extremity revascularization (2.49 ± 0.12 vs. 2.13 ± 0.08, P = 0.01). There was no difference in RFR (P = 0.82) or major amputation (P = 0.19). Open revascularization was independently associated with decreased readmission (odds ratio = 0.55 [0.43-0.71]) compared to endovascular. However, there was no significant association between the type of lower extremity revascularization and major amputation or RFR.

CONCLUSIONS

Endovascular lower extremity revascularization for CLI is performed on older and sicker patients and seems to be associated with increased readmission at 1 year compared to open lower extremity revascularization. Regardless of the initial modality of treatment, patients are likely to undergo at least 1 revascularization during readmissions.

Drug-Coated Balloon Angioplasty of Infrapopliteal Lesions in Patients with Critical Limb Ischaemia: 1-Year Results of the APOLLO Trial

PURPOSE

This study intended to assess effectiveness and safety of the drug-coated balloon (DCB) angioplasty of infrapopliteal atherosclerotic lesions in patients with critical limb ischaemia (CLI) in a real-world setting.

METHODS

Consecutive patients with critical limb ischaemia who underwent infrapopliteal drug-coated balloon angioplasty with the ELUTAX SV DCB were enrolled into the prospective, multicentre, single-arm observational registry. Primary outcome was clinical improvement at 6 and 12 months. Secondary outcomes were change in quality of life, primary patency, freedom from repeat revascularisation, and amputation-free survival at 6 and 12 months.

RESULTS

A total of 164 patients (74.7 ± 9.2 years) with CLI were included at nine German sites between November 2015 and September 2017. The majority (79.9%) of patients had diabetes mellitus, 57.3% had renal insufficiency, and 35.3% had coronary artery disease. Mean lesion length was 71.2 ± 76.5 mm. The Rutherford category improved by 3.0 ± 2.0 (p < 0.0001) within 12 months, resulting in a clinical improvement by at least one Rutherford category in 80.2% of the patients. Walking impairment questionnaire score, European Quality of Life index, and patient-reported pain improved significantly from baseline to 6 and 12 months. Primary patency was 68.5%, freedom from target lesion revascularisation 90.6%, and amputation-free survival 83.5% at 12 months.

CONCLUSION

Infrapopliteal drug-coated balloon angioplasty with the ELUTAX SV DCB in patients with critical limb ischaemia was efficacious and safe over the medium term. The study is registered with Clinical.Trials.gov (Identifier: NCT02539940).

Preoperative hemoglobin A1c levels and increased risk of adverse limb events in diabetic patients undergoing infrainguinal lower extremity bypass surgery in the Vascular Quality Initiative

BACKGROUND

The impact of preoperative glycemic control on the risk of adverse perioperative outcomes in diabetic patients undergoing lower extremity bypass (LEB) surgery is not well-understood. We determined whether higher preoperative hemoglobin A1c (HbA1c) levels are associated with an increased risk of major adverse limb events, major adverse cardiovascular events, and mortality in diabetic patients undergoing infrainguinal LEB.

METHODS

A retrospective review of all infrainguinal LEB surgeries in the Vascular Quality Initiative registry from January 2012 to February 2017 was performed. Only surgeries performed on diabetic patients with complete demographic and clinical data, including HbA1c value at the time of LEB, were included for analysis (n = 7727). Entries were stratified according to the following HbA1c levels: 6 or less (n = 1087), greater than 6 to 7 or less (n = 2137), greater than 7 to 8 or less (n = 1657), and greater than 8 (n = 2846). Multivariate logistic regression was used to determine the association of preoperative HbA1c levels on the risk of in-hospital major adverse limb events (above ankle amputation, loss of primary graft patency), major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiac arrhythmia), and mortality.

RESULTS

The number of surgeries complicated by adverse limb and cardiovascular events were 356 (4.6%) and 1314 (17.0%), respectively. There were 72 in-hospital deaths (0.9%). After adjustment for clinical and demographic variables, patients with high HbA1c values (≥8%) were at an increased risk of adverse limb events (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.01-1.86) compared with those with a normal HbA1c (>6% to ≤7%). High HbA1c values were not associated with an increased risk of cardiovascular events (OR, 1.07; 95% CI, 0.81-1.43) or mortality (OR, 1.57; 95% CI, 0.83-3.03). Patients with low HbA1c values (≤6%) did not experience a significantly higher risk for any of the three outcomes. In a stratified analysis, the association of high HbA1c values with adverse limb events was only present in those presenting without critical limb ischemia (OR 1.82; 95% CI, 1.05-3.16).

CONCLUSIONS

Poor preoperative glycemic control in diabetic individuals undergoing infrainguinal LEB, particularly in those without critical limb ischemia, is associated with an increased risk of in-hospital limb events. Further study should evaluate whether improved efforts to identify individuals with poorly controlled diabetes and subsequent interventions to better optimize glycemic control during the preoperative period improve limb outcomes after LEB.

Algal Polysaccharides as Therapeutic Agents for Atherosclerosis

Seaweed-derived polysaccharides including agar and alginate, have found widespread applications in biomedical research and medical therapeutic applications including wound healing, drug delivery, and tissue engineering. Given the recent increases in the incidence of diabetes, obesity and hyperlipidemia, there is a pressing need for low cost therapeutics that can economically and effectively slow the progression of atherosclerosis. Marine polysaccharides have been consumed by humans for millennia and are available in large quantities at low cost. Polysaccharides such as fucoidan, laminarin sulfate and ulvan have shown promise in reducing atherosclerosis and its accompanying risk factors in animal models. However, others have been tested in very limited context in scientific studies. In this review, we explore the current state of knowledge for these promising therapeutics and discuss the potential and challenges of using seaweed derived polysaccharides as therapies for atherosclerosis.

Lower extremity arterial disease in patients with diabetes: a contemporary narrative review

Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.

Role of Hyperglycemia-Induced Advanced Glycation End Product (AGE) Accumulation in Atherosclerosis

There is a growing body of evidence that cumulative hyperglycemic exposure plays a central role in the development and progression of atherosclerotic cardiovascular disease in diabetic patients. Monosaccharides, such as glucose, fructose, and glyceraldehyde can react non-enzymatically with amino groups of proteins, lipids, nucleic acids to form senescent macromolecules termed advanced glycation end products (AGEs), whose formation and accumulation has been known to progress in diabetic patients, especially in those with a long history of disease. The sustained accumulation of AGEs could contribute to the phenomenon of metabolic memory or legacy effects observed in long-term follow-up clinical studies of diabetic patients. AGE modification alters the structural integrity and function of various types of macromolecules, and interaction of AGEs with a receptor for AGEs (RAGE) has been shown to evoke inflammatory and thrombotic reactions. Therefore, the AGE–RAGE axis is a novel therapeutic target of atherosclerotic cardiovascular disease in diabetic patients. In this paper, we briefly review the pathological role of AGEs and their receptor RAGE system in atherosclerotic cardiovascular disease, including peripheral artery disease and discuss the clinical utility of measuring AGEs in evaluating the severity of atherosclerosis in patients with diabetes.

Role of Ligands of Receptor for Advanced Glycation End Products (RAGE) in Peripheral Artery Disease

Atherosclerotic cardiovascular disease, including peripheral artery disease (PAD), is more common and severe in diabetic patients compared with nondiabetic individuals. Indeed, diabetes is associated with the increased risk of limb amputation and all-cause mortality in patients with symptomatic PAD. Proteins and lipids are nonenzymatically modified by sugars, resulting in the formation and accumulation of advanced glycation end products (AGEs), whose process is accelerated under diabetic conditions, especially patients with a long duration of diabetes. Accumulating evidence shows that nonenzymatic modification by sugars alters the structural integrity of collagens and lipoproteins in large vessels, thereby being involved in vascular stiffness and atherosclerotic plaque instability. Furthermore, engagement of receptor for AGEs (RAGE) with its ligands, such as AGEs, high mobility group box 1, and S100A proteins evokes inflammatory and thrombotic reactions, thus playing a central role in the development and progression of atherosclerotic cardiovascular disease. In this article, we review the pathophysiological role of RAGE ligands in PAD and discuss the clinical utility of measurement of plasma, serum, or tissue RAGE ligands for assessment of the severity and prognosis of PAD. This review suggests that RAGE ligands may be a novel biomarker and also a therapeutic target of PAD, especially in patients with diabetes.

Color Doppler Ultrasonography Is a Useful Tool for Diagnosis of Peripheral Artery Disease in Type 2 Diabetes Mellitus Patients with Ankle-Brachial Index 0.91 to 1.40

BACKGROUND

The clinical utility of ankle-brachial index (ABI) is not clear in subjects with less severe or calcified vessel. Therefore, we investigated the usefulness of color Doppler ultrasonography for diagnosing peripheral artery disease (PAD) in type 2 diabetes mellitus (T2DM) subjects.

METHODS

We analyzed 324 T2DM patients who concurrently underwent ABI and carotid intima-media thickness (CIMT) measurements and color Doppler ultrasonography from 2003 to 2006. The degree of stenosis in patients with PAD was determined according to Jager's criteria, and PAD was defined as grade III (50% to 99% stenosis) or IV stenosis (100% stenosis) by color Doppler ultrasonography. Logistic regression analysis and receiver operating characteristic curve analysis were performed to evaluate the risk factors for PAD in patients with ABI 0.91 to 1.40.

RESULTS

Among the 324 patients, 77 (23.8%) had ABI 0.91 to 1.40 but were diagnosed with PAD. Color Doppler ultrasonography demonstrated that suprapopliteal arterial stenosis, bilateral lesions, and multivessel involvement were less common in PAD patients with ABI 0.91 to 1.40 than in those with ABI ≤0.90. A multivariate logistic regression analysis demonstrated that older age, current smoking status, presence of leg symptoms, and high CIMT were significantly associated with the presence of PAD in patients with ABI 0.91 to 1.40 after adjusting for conventional risk factors. CIMT showed significant power in predicting the presence of PAD in patients with ABI 0.91 to 1.40.

CONCLUSION

Color Doppler ultrasonography is a useful tool for the detection of PAD in T2DM patients with ABI 0.91 to 1.40 but a high CIMT.