2D-Perfusion Angiography Using Carbon Dioxide (CO2): A Feasible Tool to Monitor Immediate Treatment Response to Endovascular Therapy of Peripheral Arterial Disease?

P3395Arrival time at hyperemia of below the ankle as a determinant factor for limb salvage: evaluation by 2 dimension perfusion angiography

Surgical Revascularization Versus Endovascular Therapy to Treat Chronic Limb-Threatening Ischemia: Perhaps Less Invasive Is Not Always Better

To determine whether contrast arrival time (AT) at the ankle joint-quantified by intra-procedural frame count (FC) during digital subtraction angiography (DSA)-predicts the time to complete ulcer healing (HT) in patients with chronic limb-threatening ischemia (CLTI). This retrospective study, conducted between January 2020 and December 2022, incorporated 93 patients with CLTI classified as Rutherford category 5 or 6, treated via endovascular therapy. Pre-procedural and post-procedural DSA sequences were reviewed by two blinded interventional radiologiststo determinethe FC at which contrast first reached the ankle joint level in either the anterior tibial artery or the posterior tibial artery, whichever was earliest.AT was calculated as FC/3 from the final angiographic run after infrapopliteal revascularization and patients were followed until complete ulcer healing to document HT. Correlations between post-procedural AT and HT were assessed using the Pearson coefficient. The cutoff points to predict HT grouping (≤ 3months vs. > 3months) were analyzed using a receiver operating characteristic (ROC) curve; outcomes are reported as the area under the curve (AUC) with 95% confidence interval (CI). Pearson correlation analysis showed that post-procedural AT was statistically associated with ulcer HT (r = 0.691, P < 0.001). On multivariable linear regression, post-procedural AT remained independently associated with HT. Backward stepwise logistic regression revealed that post-procedural AT was independently associated with HT grouping (odds ratio (OR) 2.897; 95% CI 1.890-5.150; P < 0.001). The AUC for AT in predicting HT groupingwas0.939, and the optimal cut-off value of post-procedural AT for predicting ulcer healing within 3months was 4.5s. Intra-procedural angiographic assessment using 2D perfusion angiography during endovascular therapy is technically feasible. Post-procedural AT was independently associated with ulcer HT, reflecting a trend whereby faster postoperative blood flow velocity-manifested as a shorter AT-may correlate with improved wound healing. Trial registration Registration number: PJ-KS-KY-2023-31.

Peripheral vascular diseases are important components of cardiovascular medicine. The high prevalence of these disorders in the clinical setting mandates effective communication among healthcare providers. The public health significance of these conditions requires clear and consistent terminology for community audiences. Therefore, the goal of this writing group was to suggest definitions, usage, and nomenclature of specific terms commonly used to describe vascular diseases by cardiovascular specialists and primary care communities. The need for clarity is driven by 2 major challenges: (1) the need for use of common keywords for literature searches; and (2) the need for healthcare professionals to use common, reasoned terminology when communicating with each other and with the public. The major structural components of the vascular system are the veins, lymphatic vessels, and arteries. These serve as the basis of the nomenclature system for vascular diseases (Figure). Figure. Major classification of vascular diseases. *Includes inflammatory, artery dysplasias, congenital, traumatic, and infections. In this report, the writing group focuses only on nomenclature that applies to non–coronary artery diseases. Venous and lymphatic diseases were outside the scope of this conference. Diseases of arteries are classified further into atherosclerotic occlusive disorders, nonatherosclerotic occlusive disorders, and aneurysms. …

To evaluate a novel 2D-perfusion angiography (2D-PA) technique allowing pro- and retrospective flow analysis based on a proximal reference region of interest (ROI) and distal target ROI in patients treated for peripheral arterial disease. 2D-PA allows quantifying blood flow by post-processing of digital subtraction angiography (DSA). 2D-PA was performed pre and post interventional treatment of peripheral arterial disease (PAD; n = 24; 13 angioplasties, 11 stents) in 21 patients (17 men, 72 ± 9y) with Fontaine stage IIB / III. Time-to-peak (TTP), peak density (PD) and area-under-the-curve (AUC) were calculated. Ratios reference/target ROI (TTPOUTFLOW/TTPINFLOW; PDOUTFLOW/PDINFLOW; AUCOUTFLOW/AUCINFLOW) were calculated and correlated to changes in the ankle-brachial-index (ABI). 2D-PA was technically feasible in all cases. A significant increase in ABI was seen after interventional treatment (+39%; p < 0.0001). ABI increase was accompanied by an increase of 36% of PDOUTFLOW/PDINFLOW (p < 0.0001), a 52% decrease of TTPOUTFLOW/TTPINFLOW (p = 0.0007) and a 69% increase of AUCOUTFLOW/AUCINFLOW (p < 0.0001). The difference of TTP pre- and post-intervention showed a correlation with the difference in ABI (r = -0.53, p = 0.0081). The other measured parameters failed to demonstrate significant correlation with improved ABI. The presented 2D-PA technique allows quantitative assessment of arterial flow before, during and after interventional treatment in PAD.

This study evaluated the incidence, predictors, and impact of bleeding requiring hospitalization following successful endovascular therapy (EVT) for peripheral artery disease. Platelet inhibition after EVT reduces the risk of major adverse limb events but increases the risk of bleeding. The incidence of post-discharge bleeding after EVT, its independent predictors, and its prognostic importance in clinical practice have not been fully addressed. We evaluated 779 consecutive patients who underwent EVT. We found that 77 patients (9.9%) were hospitalized for major bleeding during follow-up after EVT (median 39 months, range 22-66 months), with almost half (48.1%) of the bleeding categorized as gastrointestinal bleeding. Significant predictors of post-discharge bleeding were hemodialysis (hazard ratio (HR), 3.12; 95% CI: 1.93 to 5.05; p < 0.001) and dual antiplatelet therapy (DAPT) use (HR, 1.87; 95% CI: 1.03 to 3.41; p = 0.041). During follow-up, the all-cause mortality-free survival rate was significantly worse in patients who had experienced major bleeding than in those who had not (log-rank test χ2 = 54.6; p < 0.001). Cox proportional hazards analysis showed that major bleeding (HR, 2.78; 95% CI: 1.90 to 4.06; p < 0.001) was an independent predictor of all-cause death after EVT. Hospitalization for post-discharge bleeding after EVT is associated with a substantially increased risk of death, even after successful EVT. We concluded that patients' predicted bleeding risk should be considered when selecting patients likely to benefit from EVT, and that the risk should be considered especially thoroughly in hemodialysis patients.

Clinical Value of 2D Perfusion Angiography for Chronic Limb-Threatening Ischemia Revascularization.

Malnutrition is Associated with Increased Morbidity and Death in Dialysis Patients Undergoing Endovascular Therapy for Peripheral Artery Disease

Peripheral artery disease of the lower extremities is a common disease and present in 15% to 20% of persons older than 65 years. Endovascular or surgical therapy fails or is not applicable in approximately one fourth of patients who would need revascularization therapies, which makes alternative approaches such as arteriogenesis (the positive remodeling of preformed collateral arterioles) necessary. Despite the fact that numerous studies have pursued the important therapeutic strategy of improving collateral function, there is no method available to quantify collateral arterial function of the lower limb and thus to determine therapeutic effects. The present study demonstrates for the first time a quantitatively assessed functional and clinically relevant collateral circulation in the lower limb. Using direct invasive pressure measurements in humans, we show that collateral flow index of the superficial femoral artery in the absence of any significant stenosis amounts to more than half the normal antegrade flow at rest (4517% after 1 minute, 5517% after 3 minutes). The amount of collateral flow observed in the present study is remarkably high, especially compared with what has been described previously for normal (188%) and stenotic (2215%) coronary arteries. Importantly, this preexistent collateral blood supply in the absence of significant stenoses is sufficient to completely prevent symptoms during 5 minutes of acute ischemia at rest. Because only indirect and weak end points have been used in past studies to evaluate collateral growth, we propose that the method described in the present study may possibly be used as a gold standard in future clinical studies.

Many vascular specialists have embraced endovascular therapy as the first-line treatment for patients with peripheral arterial disease (PAD) and lifestyle-limiting claudication or critical limb ischemia. Compared to surgical bypass, infrainguinal endovascular interventions are associated with reduced durability. These minimally invasive procedures, however, are associated with an improved safety profile and lower morbidity compared to open surgical bypass, even in the setting of significant medical comorbidities. Given the widespread application of endovascular therapy to the treatment of PAD, it is imperative that practitioners involved in the management of patients with PAD and diabetes understand the strengths and weaknesses of endovascular techniques and devices, peri-procedural management, expected results, and outcome measures. This chapter reviews fundamental principles of infrainguinal endovascular therapy for PAD, with specific attention to treatment guidelines and the impact of diabetes and other comorbidities and lesion characteristics on long-term outcome after endovascular therapy.KeywordsEndovascularAngioplastyAtherectomyOutcomes

The Academic Research Consortium (ARC) recently published a definition of patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. However, the prevalence of the ARC-HBR criteria in patients undergoing endovascular therapy (EVT) for peripheral artery disease in lower extremities has not been thoroughly investigated. This study sought to investigate the prevalence and impact of the ARC-HBR criteria in patients undergoing EVT. We analyzed 277 consecutive patients who underwent their first EVT from July 2011 to September 2019. We applied the full ARC-HBR criteria to the study population. The primary end point was a composite outcome of all-cause mortality, Bleeding Academic Research Consortium 3 or 5 bleeding, and lower limb amputation within 12months of EVT. Among the 277 patients, 193 (69.7%) met the ARC-HBR criteria. HBR patients had worse clinical outcomes compared with non-HBR patients at 12months after EVT, including a higher incidence of the composite primary outcome (19.2% vs. 3.6%, p < 0.001) and all-cause death (7.8% vs. 0%, p = 0.007). In a multivariate Cox proportional hazards regression analysis, presence of the ARC-HBR criteria [hazard ratio (HR) 4.15, 95% confidence interval (CI) 1.25-13.80, p = 0.020], body mass index (HR 1.13, 95% CI 1.01-1.27, p = 0.042), diabetes mellitus (HR 2.70, 95% CI 1.28-5.69, p = 0.009), hyperlipidemia (HR 0.41, 95% CI 0.21-0.80, p = 0.009), and infrapopliteal lesions (HR 3.51, 95% CI 1.63-7.56, p = 0.001) were independent predictors of the primary composite outcome. Approximately 70% of Japanese patients undergoing EVT met the ARC-HBR criteria, and its presence was strongly associated with adverse outcomes within 12months of EVT.

Vascular specialist response to medicare evidence development coverage advisory committee (MEDCAC) panel on peripheral artery disease of the lower extremities.

No. 416 Two-dimensional perfusion angiography and its suitability in diagnosing and documenting early treatment response in patients with non-occlusive mesenteric ischemia: a retrospective analysis

Introduction: Cerebral computed tomography perfusion (CTP) imaging has been well-established for identifying candidates for endovascular therapy (EVT) in acute ischemic stroke. This study investigates the association between CTP parameters and functional independence post-EVT using data from the SELECT study. Methods: We analyzed baseline CTP images from SELECT patients, focusing on those with available cerebral blood volume (CBV), cerebral blood flow (CBF), and time to maximum perfusion (Tmax) maps. Patients who received EVT and medical management only (MM) were included. Logistic regression models were created with age, national institutes of health stroke scale (NIHSS), time to arrival, occlusion location, transfer status, and CT ASPECTS as covariates, and functional independence at 90 days (modified Rankin score 0-2) as the outcome. Receiver operating characteristic (ROC) curves were generated, and area under the curve (AUC) values were calculated and compared using DeLong’s test. Results: Among 361 patients, 171 (139 EVT, 32 MM) had volumetric estimates for CTP parameters with pre-defined thresholds. Median (IQR) age and NIHSS were 68 (56-78) and 16 (12-20), and 48% were females. Estimates of different thresholds within a given CTP parameter showed high correlation (&gt;0.8), and a moderate to high correlation (&gt;0.4-0.6) was observed in estimates across different parameters (all p&lt;0.05, figure 1). ROC curves revealed AUC values &gt;0.7 for all CTP parameters in both EVT (figure 2) and combined (EVT + MM, figure 3) subgroups, with the highest values for CBF thresholds: &lt;30% [EVT – AUC 0.7507, combined – AUC 0.8028], &lt;34% [EVT – AUC 0.737, combined – AUC 0.7857] and &lt;38% [EVT - AUC 0.7351, combined – AUC 0.7831], followed by CBV parameters and then Tmax parameters. No significant differences were found between AUC values of different CTP parameters (EVT: p=0.88; combined: p=0.46). Conclusion: All CTP parameters demonstrated high AUC values (&gt;0.7) for functional independence at 90 days in acute stroke patients, particularly CBF &lt;30%, indicating their potential as prognostic markers.

Exercise Training for Peripheral Arterial Disease