Ankle-brachial Index Test Research Articles

Ankle- and Toe-Brachial Index for Peripheral Artery Disease Identification: Unlocking Clinical Data Through Novel Methods.

Despite its high prevalence and clinical impact, research on peripheral artery disease (PAD) remains limited due to poor accuracy of billing codes. Ankle-brachial index (ABI) and toe-brachial index can be used to identify PAD patients with high accuracy within electronic health records. We developed a novel natural language processing (NLP) algorithm for extracting ABI and toe-brachial index values and laterality (right or left) from ABI reports. A random sample of 800 reports from 94 Veterans Affairs facilities during 2015 to 2017 was selected and annotated by clinical experts. We trained the NLP system using random forest models and optimized it through sequential iterations of 10-fold cross-validation and error analysis on 600 test reports and evaluated its final performance on a separate set of 200 reports. We also assessed the accuracy of NLP-extracted ABI and toe-brachial index values for identifying patients with PAD in a separate cohort undergoing ABI testing. The NLP system had an overall precision (positive predictive value) of 0.85, recall (sensitivity) of 0.93, and F1 measure (accuracy) of 0.89 to correctly identify ABI/toe-brachial index values and laterality. Among 261 patients with ABI testing (49% PAD), the NLP system achieved a positive predictive value of 92.3%, sensitivity of 83.1%, and specificity of 93.1% to identify PAD when compared with a structured chart review. The above findings were consistent in a range of sensitivity analysis. We successfully developed and validated an NLP system for identifying patients with PAD within the Veterans Affairs electronic health record. Our findings have broad implications for PAD research and quality improvement.

Detection of Lower Extremity Occlusive Peripheral Artery Disease (LEOPAD) by Measuring Systolic Pressure Index in Type 2 Diabetic Patients

Objective: The aims of our study are to identify the prevalence of LEOPAD in type 2 diabetes, to study the predictive factors of LEOPAD and to demonstrate the importance of establishing a specialized screening consultation in diabetic patients with LEOPAD and with high cardiovascular risk. Research design and methods: We carried out a prospective and descriptive study. The study involved 150 patients with type 2 diabetes who were followed on a regular basis. The different epidemiological, clinical and biological data were collected patient’s medical file. Each patient was investigated for cardiovascular risk factors. A thorough physical examination was performed in addition to biological assessment (fasting plasma glucose, HbA1c, lipid profile). After consent had been obtained, all patients underwent the ankle-brachial systolic pressure index (ABI) test. Results: The mean age of our patients was 57.46 ± 8.04 of the 150 patients, 24.7% had abnormal ABI suggestive of lower limb ischemia. Among them, 8.7% had an ABI of 1, 3, a presumed marker of vascular stiffness. The mean age of the LEOPAD population was 58 years. LEOPAD was predominantly asymptomatic in our population (88.1%). Only 5 patients (11.9%) had intermittent claudication. The comparative study of patients with LEOPAD showed a statistically conversely significant correlation between LEOPAD and lower levels of HDL. However, there is no statistically significant correlation with the following factors: smoking, sex, hypertension, dyslipidemia, obesity or overweight android pattern, the presence of microalbuminuria, renal failure and sedentary lifestyle. In terms of glycemic control, it did not show a statistically significant difference between the two groups. Moreover, it was noted that the patients with LEOPAD had had more micro vascular complications compared to patients without LEOPAD. Conclusion: Lower extremity occlusive peripheral artery disease occurred more commonly than it was expected in the diabetic population, associated with a high cardiovascular comorbidity. The sensitivity, specificity and simplicity of the ABI measurement promote its routine use and integration into the clinical approach of high-risk LEOPAD patients, especially the diabetics.

An assessment of a screening method for peripheral arterial disease of the lower limbs in patients aged at least 65 years at the Yaoundé Central Hospital, Cameroon

The automatic measurement of the Ankle-Brachial Index (ABI) constitutes a reliable, simple, safe, rapid, and inexpensive alternative diagnostic screening test compared with the Doppler method for peripheral arterial disease (PAD). We aimed to compare the diagnostic performance of automatic ABI measurement tests to Doppler ultrasound for PAD in patients aged ≥ 65. This was an experimental comparative study of Doppler ultrasound's performance to the automated ABI test in diagnosing PAD in patients aged ≥ 65 years followed up at the Yaoundé Central Hospital, Cameroon, between January to June 2018. An ABI threshold < 0.90 defined a PAD. We compare the sensitivity, and specificity of the high Ankle-Brachial Index (ABI-HIGH), low Ankle-Brachial Index (ABI-LOW), and the mean Ankle-Brachial Index (ABI-MEAN) for both tests. We included 137 subjects with an average age of 71.7 ± 6.8 years. In the ABI-HIGH mode, the automatic device had a sensitivity of 55% and a specificity of 98.35% with a difference between the two techniques of d = 0.024 ( P = 0.016). In the ABI-MEAN mode, it had a sensitivity of 40.63% and a specificity of 99.15%; d = 0.071 ( P < 0.0001). In the ABI-LOW mode, it had a sensitivity of 30.95% and a specificity of 99.11%; d = 0.119 ( P < 0.0001). Compared to the Doppler method, the ABI-HIGH mode of the automatic measuring device had better diagnostic performance and can thus be used as a screening test for PAD patients aged ≥ 65 years in our context.

Clinical practice of diabetic foot, nephropathy, and retinopathy in Japan: cross-sectional study using local and nationwide questionnaire surveys.

It is a reality that there are still many diabetic subjects who suffer from serious complications, but there are few statistics of severe eye complications such as vitrectomy or blindness and diabetic foot including amputations in Japan. To determine the status of medical examination, consultation, and the actual practice for diabetic foot, retinopathy, and nephropathy, we conducted two surveys on diabetic subjects under treatment by the local physicians in Asahikawa area or in the nationwide diabetes-specialized facilities, respectively. A total of 3649 diabetic subjects responded to the questionnaire from 35 clinics/hospitals in Asahikawa area. Sixty-five percent of the subjects had a routine eye examination at least once a year, but 29% of them interrupted or never attended eye examination. Besides, only 37.2% of subjects had received ankle-brachial index (ABI) test as a useful screening for diabetic foot. The nationwide survey found that 1,273,103 diabetic subjects were undergoing treatment in 472 diabetes-specialized facilities. There, lower extremity amputations accounted for 0.23% and revascularization accounted for 0.64% of the subjects. However, outpatient foot care and dialysis preventive outpatient services were offered only in 77.3% and 66.5% of the facilities, respectively. Furthermore, we found a lower availability of ophthalmologic treatments even in some of the specialized facilities. We considered that interruption and non-attendance of eye examinations were a barrier to prevent severe retinopathy. Our results also suggested that some of the specialized facilities may be inadequate in their efforts to detect and prevent these complications.

Abstract 11608: DOAC Effect on Cardiovascular Outcomes in Patients with Peripheral Arterial Disease

Introduction: Peripheral arterial disease (PAD) increases cardiovascular (CV) morbidity and mortality, but remains underdiagnosed and undertreated. Several trials support low-dose rivaroxaban in PAD treatment, although this has yet to be widely adopted in clinical practice. The effect of warfarin and direct oral anticoagulants (DOACs) on comprehensive PAD outcomes warrants further study. Hypothesis: Anticoagulant therapy, particularly DOACs, improves CV outcomes in PAD. Methods: We conducted a retrospective study of patients who underwent ankle-brachial index testing (ABI) from 1996 – 2020 at Mayo Clinic. We included patients with PAD defined by abnormal ABI (&lt;1.0 or &gt;/=1.4). Prolonged (&gt;6 months) DOAC or warfarin use was compared to no anticoagulant therapy. Multivariable (MV) regression, controlling for baseline CV risk factors, was used. Results: 21,891 patients had abnormal ABI readings; 3,093 were on warfarin and 267 were on DOAC for any indication. Anticoagulation improved mortality, with DOACs superior to warfarin. DOACs improved critical limb ischemia (CLI)/amputation in univariate analysis, although this was not significant in MV. Patients with poorly compressible vessels (ABI &gt;/=1.4) had increased limb outcomes compared to reduced ABI (&lt;1.0). Ischemic stroke and myocardial infarction occurred more frequently in those on anticoagulation, but the risk was less for DOACs vs. warfarin. Notably, both anticoagulant groups had greater baseline comorbidity than the non-anticoagulant group; the DOAC and warfarin groups were similar. Major bleeding (6.7%) was increased in both anticoagulant groups, but less so with DOACs and this was similar to the bleeding risk seen with aspirin (HR 1.20). Conclusion: Anticoagulant therapy improved mortality in a large cohort of PAD patients. The risk of limb events appears improved in those on DOACs. DOACs showed improved risk profiles compared to warfarin regarding CV and bleeding outcomes.

Early ABI Testing May Decrease Risk of Amputation for Patients With Lower Extremity Ulcers

Patients with lower extremity wounds from diabetes mellitus or peripheral artery disease (PAD) have a risk of amputation as high as 25%. In patients with arterial disease, revascularization decreases the risk of amputation. We aimed to determine if the early assessment of arterial perfusion correlates with the risk of amputation. We retrospectively reviewed patients referred to the vascular clinic over 18 months with Rutherford Grade 5 and 6 chronic limb-threatening ischemia to determine if patients had a pulse exam done at the time the wound was identified and when ankle brachial index (ABI) testing to evaluate perfusion was performed. Kaplan Meier analysis was used to determine if the timing of ABI testing affected the time to revascularization, wound healing, and risk of amputation. Ninety-three patients with lower extremity wounds were identified. Of these, 59 patients (63%) did not have a pulse exam performed by their primary care provider when the wound was identified. Patients were classified by when they underwent ankle brachial index testing to assess arterial perfusion. Twenty-four had early ABI (<30 days) testing, with the remaining 69 patients having late ABI testing. Patients in the early ABI group were more likely to have a pulse exam done by their PCP than those in the late group, 12 (50%) vs. 22 (32%), P = 0.03. Early ABI patients had a quicker time to vascular referral (13 days vs. 91 days, P < 0.001). Early ABI patients also had quicker times to wound healing than those in the late group (117 days vs. 287 days, P < 0.001). Finally, patients that underwent early ABI were less likely to require amputation (Fig.1), although this did not reach statistical significance (P=0.07). Early ABI testing expedites specialty referral and time to revascularization. It can decrease the time to wound healing. Larger cohort studies are needed to determine the overall effect of early ABI testing to decrease amputation rates.

The effects of auricular acupuncture on vascular parameters on the risk factors for diabetic foot: A randomized clinical trial

Aims and objectivesTo evaluate the effects of auricular acupuncture on vascular parameters on the risk factors for Diabetic Foot. MethodsRandomized and masked clinical trial. The sample was composed of 44 individuals with type 2 Diabetes Mellitus and they were randomly assigned to two groups: intervention (n = 22), which received five sessions of auricular acupuncture, and control (n = 22), which did not receive the therapy. Three evaluations were performed: before the intervention; one day after the last acupuncture session and 15 days after the second evaluation. For this, the subject's characterization instrument, the Ankle-Brachial Index measurement, and thermography were used. For data analysis, Mann-Whitney, Wilcoxon, Wilcoxon signed-rank, Fisher's Exact and Chi-Square tests were used. ResultsAuriculotherapy provided results in the Ankle-Brachial Index Test, as well as in thermography, which showed significant temperature improvement. ConclusionsThe technique proved to be efficient in improving circulatory conditions and plantar temperature.

Association of Abnormal Brachial Index with Diabetic Nephropathy as an Independent Risk Factor for Coronary Arterial Disease in Type 2 Diabetic Patients - A Retrospective Single Centre Real-World Evidence Study in Indian Population

Objective: To study the association between ankle brachial index (ABI) and microvascular complications in Type 2 diabetes (T2DM) patients with the coronary arterial disease (CAD). Methodology: A retrospective study was carried out on 3,458 T2DM patients reportedly with CAD, G1 (n=33), and without CAD, G2 (n=3125), who had given the ABI test. ABI was defined as normal (1.0 - 1.4) and abnormal (&lt;1.0 and &gt;1.4). The logistic regression analysis was used to identify the determinants of CAD positive outcomes in T2DM patients. Results: Overall, patient percentage-wise CAD 10% (333), abnormal ABI 26% (913), neuropathy 37% (1278), nephropathy, 8% (293), and retinopathy &lt;1% (24). The ABI abnormality and CAD positives were higher in patients with nephropathy (32 and 20%) than in neuropathy (28 and 13%). Age-wise, 52 and 62% of neuropathy and nephropathy patients, respectively, were &gt;60 years and had shown increased ABI abnormality from age 50 years onwards. The logistic model had shown nephropathy patients, [OR-1.8 [1.26-2.58], - p-0.001] in association with abnormal ABI, [OR-1.27 [95% CI, 0.99–1.63], p- 0.057] predicted to have CAD positive outcomes. While neuropathy, OR-0.69, [0.54 - 0.90], and hypertension, OR-0.43 [0.33 - 0.57] were not contributing towards CAD in our study population. Conclusion: Type 2 diabetes patients with abnormal ABI were predicted to have a 27% increased odds ratio of CAD outcome and 80% in the presence of nephropathy. Thus, as part of comprehensive diabetes care, albuminuria screening along with ABI measurement is being suggested.

Cost-effectiveness analysis of ankle-brachial index screening in patients with coronary artery disease to optimize medical management

IntroductionScreening for peripheral artery disease (PAD) with the ankle-brachial index (ABI) test is currently not recommended in the general population; however, previous studies advocate screening in high-risk populations. Although providers may be hesitant to prescribe low-dose rivaroxaban to patients with coronary artery disease (CAD) alone, given the reduction in cardiovascular events and death associated with rivaroxaban, screening for PAD with the ABI test and accordingly prescribing rivaroxaban may provide additional benefits. We sought to describe the cost-effectiveness of screening for PAD in patients with CAD to optimize this high-risk populations’ medical management. MethodsWe used a Markov model to evaluate the ABI test in patients with CAD. We assumed that all patients screened would be candidates for low-dose rivaroxaban. We assessed the cost of ABI screening at $100 per patient and added additional charges for physician visits ($100) and rivaroxaban cost ($470 per month). We used a 30-day cycle and performed analysis over 35 years. We evaluated quality-adjusted life years (QALYs) from previous studies and determined the incremental cost-effectiveness ratio (ICER) according to our model. We performed a deterministic and probabilistic sensitivity analyses of variables with uncertainty and reported them in a Tornado diagram showing the variables with the greatest effect on the ICER. ResultsOur model estimates decision costs to screen or not screen at $94,953 and $82,553, respectively. The QALYs gained from screening was 0.060, generating an ICER of $207,491 per QALY. Factors most influential on the ICER were the reduction in all-cause mortality associated with rivaroxaban and the prohibitively high cost of rivaroxaban. If rivaroxaban cost less than $95 per month, this would make screening cost-effective based on a willingness to pay threshold of $50,000 per QALY. ConclusionsAccording to our model, screening patients with CAD for PAD to start low-dose rivaroxaban is not currently cost-effective due to insufficient reduction in all-cause mortality and high medication costs. Nevertheless, vascular surgeons have a unique opportunity to prescribe or advocate for low-dose rivaroxaban in patients with PAD to improve cardiovascular outcomes.

Impact of Buerger-Allen Exercises on Foot Perfusion and Pain Level for Diabetic Patients Risk with Peripheral Arterial Disease

Abstract The risk of peripheral arterial disease is markedly increased among individuals with diabetes. The current study aimed to evaluate diabetic patients' foot perfusion and their pain level after applying Buerger-Allen exercises. Subjects & methods: Quasi-experimental research design was used on a purposive sample of 100 type II diabetic patient in the General medical department and diabetic out-patient clinic, at Minia university hospital. Patients' interview questionnair, Ankle-brachial Index test and Numerical pain rating scale were used as tools for data collection. Results: There were highly statistically significant differences between the study group and control group regard Ankle-brachial Index measurements only post-application of Buerger-Allen exercises for six weeks (p ≤ 0.004). Moreover, results stated that the highest percentage (54.0%) among the study group who had moderate pain pre-application exercises but after they were performed exercises, their pain description became mild or no pain constituted (50.0% & 20.0%) respectively with highly statistical significant. Conclusion: Buerger-Allen exercise was efficient for improvement of lower peripheral arterial perfusion and there are highly statistically significant improvements in pain level among the study group. Recommendations: Diabetic patient must attend health education sessions based on evidence guidelines regard Buerger-Allen exercise which had a positive effect on the improvement of lower peripheral circulation.

Lower Extremity Arterial Disease as a Predictor of Incident Atrial Fibrillation and Cardiovascular Events

ObjectiveTo evaluate the relationship between peripheral arterial disease (PAD) and incident atrial fibrillation (AF) and its clinical and pathophysiologic implications on ischemic stroke and all-cause mortality. Patients and MethodsWe identified all adult patients in the Mayo Clinic Health System without a previous diagnosis of AF undergoing ankle-brachial index (ABI) testing for any indication from January 1, 1996, to June 30, 2018. Retrospective extraction of ABI data and baseline echocardiographic data was performed. The primary outcome of interest was incident AF. The secondary outcomes of interest were incident ischemic stroke and all-cause mortality. ResultsA total of 33,734 patients were included in the study. After adjusting for demographic and comorbidity variables, compared with patients who had normal ABI (1.0 to 1.39), there was an increased risk of incident AF in patients with low ABI (<1.0) (adjusted hazard ratio, 1.14; 95% CI, 1.06 to 1.22) and elevated ABI (≥1.4) (adjusted hazard ratio, 1.18; 95% CI, 1.06 to 1.31). The risk was greater in patients with increasing severity of PAD. Patients with abnormal ABIs had an increased risk of ischemic stroke and all-cause mortality. We found that patients with PAD and incident AF have certain baseline echocardiographic abnormalities. ConclusionIn this large cohort of ambulatory patients undergoing ABI measurement, patients with PAD were at increased risk for incident AF, ischemic stroke, and mortality. In these high-risk patients with abnormal ABI, particularly severe PAD and cardiac structural abnormalities, routine monitoring for AF and management of cardiovascular risk factors may be warranted.

Pre-operative ankle-brachial index for cardiovascular risk assessment in simultaneous pancreas\u2013kidney transplant recipients: a simple and elegant strategy!

BackgroundPatients 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.MethodsMedical 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.ResultsAmong 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).ConclusionsPre-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.

Use of the walking impairment questionnaire as a measure of functional assessment.

Background: A significant consequence of peripheral arterial disease (PAD) is an impaired functional capacity and deteriorated quality of life. Therefore, our study aimed to investigate the usefulness of a symptom questionnaire and walk tests for the determination of the functional capacity of patients with intermittent claudication. Patients and methods: The study included 53 patients (38 males) with stable claudication distance (50-300m). A detailed history and physical examination, ankle-brachial index (ABI), treadmill exercise test, and 6-minute walk test were performed and compared to walking impairment questionnaire (WIQ). Results: Claudication distance reported from patients' history and 6-minute walk test were significantly correlated with ABI (p=0.033, p=0.044). There were no significant correlations between ABI and treadmill walk test or WIQ. Results of WIQ were significantly correlated with the history and the most of performed walk tests: treadmill initial and maximal claudication distance (p=0.004 and 0.012, respectively) and 6-minute walk test (p=0.026). 6-minute walk test was correlated with maximal claudication distance of treadmill (p=0.018), but not with an initial claudication distance. Conclusions: The validity of WIQ is comparable to walk tests and represents the useful technique for the investigation of the functional capacity of patients with PAD. A self-report based on WIQ enables a longer period of observation. It should be routinely used as a basic diagnostic tool for the estimation of the functional capacity of PAD patients with stable intermittent claudication.

Comparison of Color Doppler Ultrasound and Ankle-Brachial Pressure Index Measurement in Peripheral Vascular Diseases

Peripheral vascular diseases (PVD) are a group of common degenerative (organic) and vasospastic (functional) disease processes that result in significant morbidity and are strong predictors of subsequent mortality. It is diagnosed by definitive history of intermittent claudication or if one or more of peripheral pulses are absent in one or both lower limbs. A variety of non-invasive techniques, viz., ankle-brachial pressure index (ABPI) test and color Doppler imaging, are available to diagnose the presence of PVD as well as to localize areas of stenosis, assess severity of disease, and follow patients for disease progression or response to therapy. Therefore, the focus of this study is to compare color Doppler ultrasound and ABPI individually and in combination in diagnosing cases of peripheral vascular diseases, considering CT angiography the gold standard investigation. Patients were assessed on the basis of history; clinical examination and relevant investigations done were noted in the data sheet according to the proforma including the Edinburgh Claudication Questionnaire. Comparison of color Doppler ultrasound and ankle-brachial pressure index measurement in peripheral vascular diseases was determined using relevant statistical tests. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for comparison of ABPI and color Doppler imaging with CT angiography. Color Doppler ultrasound proved to be a better modality as compared to the ankle-brachial pressure index for diagnosis of peripheral vascular disease, considering CT angiography the gold standard investigation.

Cost-effectiveness of cardiovascular risk classification based on Ankle-Brachial Index test in association to Framingham risk score

Abstract Objectives An individual patient-data meta-analysis conducted on 24,955 men and 23,339 women showed that Ankle-Arm Index (ABI) in combination with FRS classifies female subjects with higher accuracy with no difference for male. The objective of this analysis is assessing the cost-effectiveness of ABI combine with FSR in primary prevention. Methods A decisional analytical model was developed to simulate CV risk of asymptomatic female subjects, stratified in 3 CV risk categories. The model compares the primary prevention intervention (treatment of subjects at intermediate and high risk) based on the classification with FRS alone or in association with ABI&amp;lt;0.9 (FRS-ABI). The cost-effectiveness model used 10 years time-horizon and the point of view of the Italian National Health System. Results were presented as incremental cost-effectiveness ratios (ICERs) per QALY gained. Cost and outcomes were discounted at 3%. Results FRS-ABI determined a reclassification to higher risks in 7% of the female population, with an increase in costs per patient (€3,373 vs €3,198) but also greater efficacy (8,683 vs 8,689 QALYs) over a 10 years time horizon, with an ICER of €47.065 per QALY gained. While using an ABI&amp;lt;1.10 cut-off we obtained an ICER of €28.688 per QALY gained over 10 years simulation. In the probabilistic sensitivity analysis, the FRS-ABI reported a 50% probability to be cost-effective with ABI&amp;lt;0.9 cut-off and 80% probability with ABI&amp;lt;1.1 at a willingness to pay threshold of €50,000 per QALY. Conclusions Our study showed that FRS and ABI combination is a potentially cost-effective CV risk classification approach in female population. Our results can help the healthcare decision makers in implementing better strategies for primary CV diseases prevention in Italy. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): ASST Niguarda Cà Granda Hospital, University of Milano-Bicocca, Milan, Italy

Early Ankle Brachial Index Testing Is Associated With Decreased Risk of Amputation for Patients With Lower Extremity Ulcers

Patients with lower extremity wounds from diabetes mellitus or peripheral artery disease have a risk of amputation as high as 25%. In patients with arterial disease, revascularization decreases the risk of amputation. We aimed to determine whether early assessment of arterial perfusion would correlate with amputation rates. We retrospectively reviewed the data from patients referred to the vascular clinic over 18 months with lower extremity wounds to determine when a complete pulse examination and diagnostic studies to evaluate perfusion were performed. Kaplan-Meier analysis was used to determine whether the timing affected the outcomes for treatment and the risk of amputation. Eighty-nine patients with lower extremity wounds were identified. Of the 89 patients, 52 (58%) had not had a pulse examination performed by their primary care provider when the wound was identified (Table). The patients were classified by when they had undergone ankle brachial index (ABI) testing to assess arterial perfusion. Of the 89 patients, 18 had had early ABI (<30 days) testing and 71 had had late ABI testing. The patients in the early ABI group were more likely to have undergone a pulse examination by their primary care provider than those in the late ABI group (n = 12; 67%; vs n = 25; 34.7%; P = .03). The early ABI group also had had a shorter interval to vascular referral (15 days vs 125 days; P < .001) and a shorter time to wound healing (119 days vs 313 days; P < .001) compared with the ABI late group. Finally, the patients in the early ABI group were less likely to have required amputation (Fig), although the difference was not statistically significant (P = .06). Early ABI testing expedites specialty referral and shortens the time to revascularization. It can also decrease the time to wound healing. Larger cohort studies are required to determine the overall effect of early ABI testing to decrease amputation rates.TablePatient characteristicsCharacteristicPulse examinationP valueNo (n = 52)Yes (n = 37)Age, years68.368.8.84Male gender, no.3128.18Diabetes, no.3827.73Coronary artery disease, no.2615.7COPD, no.104.7Median time to vascular referral, days3661.17Median time to revascularization, days8287.67Median time to wound healing, days217300.77COPD, Chronic obstructive pulmonary disease. Open table in a new tab

A summary of data of screening of the lower limb peripheral arterial diseases in the region of Northern Hungary

The screening tool for diagnosing lower extremity arterial disease (LEAD) is the assessment of the ankle-brachial index (ABI). In patients at risk for LEAD, the purpose of screening is to avoid major adverse limb events, such as amputation. However, resting ABI can easily produce a false negative result. In light of this, our goal was to test the usefulness of an easily performed, fast and cost-effective screening method and to determine the proportion of subjects without definitive diagnoses among patients screened in general practice (with special attention to groups having negative ABI with symptoms and patients with non-compressible arteries). 680 patients were screened from the region of Northern Hungary. We used the Edinburgh Questionnaire, recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing. 34% complained about lower extremity claudication; 23% had abnormal ABI values; 14% of the patients within the normal ABI range had complaints of dysbasia; 12% were in the non-compressible artery group. The ABI-negative symptomatic group's risk factor profile showed a close similarity to the clear LEAD-positive and non-compressible artery groups. The percentage of LEAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups. When screening purposely for LEAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is a high clinical suspicion of LEAD in spite of normal ABI values, further assessment may be considered. Orv Hetil. 2020; 161(33): 1381-1389.

Tissue-type plasminogen activator and plasminogen activator inhibitor type 1 in patients with symptomatic lower extremity artery disease.

Background Lower extremity artery disease (LEAD) involves progressive arterial narrowing manifested by intermittent claudication (IC). LEAD entails endothelial dysfunction and fibrinolytic disorders. In the current study, we analyze the selected parameters of the fibrinolytic system in the blood of patients with symptomatic LEAD depending on clinical parameters. Methods The test group was comprised of 80 patients with diagnosis of LEAD based on Ankle-Brachial Index (ABI) test (27 female/53 male) with an average age of 63.5±9 years. The control group included 30 healthy, non-smoking volunteers (10 female/20 male), with the median age of 56±6 years. The research material - venous blood - was sampled to determine the concentrations of tissue-type plasminogen activator (t-PA Ag), plasminogen activator inhibitor type 1 (PAI-1 Ag), D-dimer, fibrinogen, and platelet count (PLT). Results We found elevated concentrations of t-PA Ag, PAI-1 Ag, D-dimer, and fibrinogen in the plasma of subjects with symptomatic LEAD. Various stages of the Fontaine classification demonstrated a gradual, statistically significant increase in the concentrations of fibrinogen and PLT count as the disease progressed. More so, in the subgroup of LEAD patients aged ≥65 years, we observed significantly higher levels of D-dimer than in the group of younger subjects. In addition to that, the LEAD group demonstrated negative correlations of IC distance, fibrinogen concentrations, and PLT count, negative correlations of ABI at rest and concentrations of D-dimer and PLT count, as well as positive correlations between age and D-dimer levels. Conclusions High t-PA Ag concentrations in LEAD patients suggest damage to the endothelium which comprises the main source of this factor. With high PAI-1 Ag levels, inactive fibrinolytic t-PA-PAI-1 complexes are formed. Increasing fibrinogen concentrations at the subsequent stages in accordance with the Fontaine classification, indicate increasing inflammation. Moreover, heightened values of D-dimer reflect an increased secondary fibrinolysis activation as patients get older and impaired extremity vascularization, manifested by the decreasing ABI, progresses.

Tissue-type plasminogen activator and plasminogen activator inhibitor type 1 in patients with symptomatic lower extremity artery disease.

Lower extremity artery disease (LEAD) involves progressive arterial narrowing manifested by intermittent claudication (IC). LEAD entails endothelial dysfunction and fibrinolytic disorders. In the current study, we analyze the selected parameters of the fibrinolytic system in the blood of patients with symptomatic LEAD depending on clinical parameters. The test group was comprised of 80 patients with diagnosis of LEAD based on Ankle-Brachial Index (ABI) test (27 female/53 male) with an average age of 63.5±9 years. The control group included 30 healthy, non-smoking volunteers (10 female/20 male), with the median age of 56±6 years. The research material - venous blood - was sampled to determine the concentrations of tissue-type plasminogen activator (t-PA Ag), plasminogen activator inhibitor type 1 (PAI-1 Ag), D-dimer, fibrinogen, and platelet count (PLT). We found elevated concentrations of t-PA Ag, PAI-1 Ag, D-dimer, and fibrinogen in the plasma of subjects with symptomatic LEAD. Various stages of the Fontaine classification demonstrated a gradual, statistically significant increase in the concentrations of fibrinogen and PLT count as the disease progressed. More so, in the subgroup of LEAD patients aged ≥65 years, we observed significantly higher levels of D-dimer than in the group of younger subjects. In addition to that, the LEAD group demonstrated negative correlations of IC distance, fibrinogen concentrations, and PLT count, negative correlations of ABI at rest and concentrations of D-dimer and PLT count, as well as positive correlations between age and D-dimer levels. High t-PA Ag concentrations in LEAD patients suggest damage to the endothelium which comprises the main source of this factor. With high PAI-1 Ag levels, inactive fibrinolytic t-PA-PAI-1 complexes are formed. Increasing fibrinogen concentrations at the subsequent stages in accordance with the Fontaine classification, indicate increasing inflammation. Moreover, heightened values of D-dimer reflect an increased secondary fibrinolysis activation as patients get older and impaired extremity vascularization, manifested by the decreasing ABI, progresses.

Cost-effectiveness Analysis of Ankle-Brachial Index Screening in Patients With Coronary Artery Disease to Optimize Medical Management

Currently, screening for peripheral artery disease (PAD) with the ankle-brachial index (ABI) test is not recommended in the general population; however previous studies advocate screening in high risk populations. Although providers may be hesitant to prescribe patients low dose rivaroxaban in patients with coronary artery disease (CAD) we hypothesize that screening patients for PAD may provide additional evidence to prescribe rivaroxaban given the additional benefits of reducing cardiovascular events and death. We sought to describe the cost-effectiveness of screening for PAD in patients with CAD to optimizing medical management of these patients. We used a Markov model to evaluate the ABI test in patients with CAD. We assume that all patients screened would be candidates for low dose rivaroxaban. We assessed the cost of ABI screening at $100 per patient and added additional costs for physician visits ($100) and cost of rivaroxaban ($470). We used a 30-day cycle and performed analysis over 30 years. We evaluated quality-adjusted life-years (QALYs) from previous studies and determined the incremental cost effectiveness ration (ICER) according to our model. We performed sensitivity analysis of variables with uncertainty and report them in a Tornado diagram showing the variables with the greatest effect on the ICER. Our model estimates screening with ABI costs $109,382 compared with $99,607 without screening (difference $9775). The QALYs gained from screening was 0.075 generating an ICER of 130,897/QALY. Factors affecting the ICER was the cost of rivaroxaban and the reduction in cardiovascular events with rivaroxaban (Figure). If rivaroxaban cost less than $100 per 30 days this would reduce the ICER to $31,000/QALY and would make PAD screening with the ABI cost effective. According to our model, screening patients with CAD for PAD to start low dose rivaroxaban is not currently cost effective due to the cost of medication. However, vascular surgeons vascular surgeons have a unique opportunity to prescribe or advocate for low dose rivaroxaban in patients with PAD to help improve cardiovascular outcomes.