Ankle-brachial Systolic Pressure Index Research Articles

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.

Frequency of Peripheral Artery Disease in association with Coronary Artery Disease: a cross-sectional monocentric study in eastern Algeria

Introduction. Patients with both Coronary Artery Disease (CAD) and Peripheral Artery Disease (PAD) have a worse cardiovascular prognosis. It therefore seems interesting to detect this association, in particular by measuring the ankle-brachial systolic pressure index (ABI) which is a simple, inexpensive, and non-invasive way with a significant diagnostic input that can detect silent but threatening lesions. It can also identify a subgroup of patients with coronary artery disease at a higher cardiovascular risk requiring a more specific management. Aims. Estimate the frequency of peripheral artery disease (PAD) in patients with Coronary Artery Disease CAD who were recruited at the department of cardiology at the university hospital of Constantine. This the study also aims to detect the risk factors of this association. Patients and methods. Our study is descriptive, cross-sectional, single-centered in cardiovascular exploration units of the regional military university hospital of Constantine. The included subjects had at least one significant coronary lesion in a major coronary artery using radial Coronary angiography. Guided medical history and a cardiovascular clinical examination preceded the measurement of the ABI for each patient. PAD was defined by an ABI of less than 0.90 in one of the four distal arteries of the two lower limbs. Data were analyzed and processed by Epi-Info Statistics V7. Results. 300 coronary patients, the average age of 61 years, mostly males, took part in the study. The frequency of the combination of PAD and coronary artery disease was 34.7% using the ABI, asymptomatic in 18% of cases. independent factors of the association were : Age≥ 65 [aOR 3,67, P <0,0001], tobacco [aOR 4,10, P<0,002], diabetes [aOR 3,48, P<0,0001] , AHT [aOR 3,30, P<0,0001], dyslipidemia [aOR 2.32, P<0,009], inactivity [aOR 2,14, P<0,015] , stroke [aOR 6,4, P<0,015] and severe coronary impairment [aOR 2,36, P<0,015]. Conclusion. ABI, in addition to being an early detection tool for PAD, its dissemination in medical practice would help in the approach and refinement of vascular risk in coronary heart patients.

Tibial artery velocities in the diagnosis and follow-up of peripheral arterial disease

Physiologic assessment of lower limb peripheral artery occlusive disease is based on indirect physiologic measurement of ankle-brachial systolic pressure index (ABI) and recording ultrasound tibial artery waveforms. Duplex ultrasound testing affords direct tibial artery imaging and assessment of pulsed-Doppler tibial artery waveforms, which is more accurate then measurement of ABI for peripheral artery occlusive disease severity assessment. Tibial artery peak systolic velocity (PSV) is of particular value in the evaluation of patients with incompressible tibial arteries producing a falsely elevated ABI. Calculation of the ankle-profunda index (average tibial artery PSV/proximal profunda femoris artery PSV) also correlates with ABI reduction and can be used as an additional measure of peripheral artery occlusive disease. Tibial artery PSVs can be used to supplement ABI as an objective outcome measure after peripheral arterial interventions, and this aspect of duplex scanning warrants further clinical research.

Relationship between symptomatic lower limb peripheral artery disease and calcified carotid artery plaque detected on panoramic images of neurologically asymptomatic males.

Males with peripheral arterial disease (PAD) are at high risk of ischaemic stroke given that atherogenic risk factors for both diseases are similar. We hypothesized that neurologically asymptomatic males diagnosed with PAD would demonstrate calcified carotid artery plaques (CCAP) on panoramic images (PI) significantly more often than similarly aged males not having PAD. Investigators implemented a retrospective cross-sectional study. Subjects were male patients over age 50 diagnosed with PAD by ankle-brachial systolic pressure index results of 0.9. Controls negative for PAD had an ankle-brachial systolic pressure index > 0.9. Predictor variable was a diagnosis of PAD and outcome variable was presence of CCAP. Prevalence of CCAP amongst the PAD+ patients was compared to prevalence of CCAP among PAD- patients. Descriptive and bivariate statistics were computed and p-value was set at 0.05. Final sample size consisted of 234 males (mean age 72.68 ± 9.09); 116 subjects and 118 controls. Among the PAD+ cohort, CCAP+ prevalence rate (57.76%) was significantly (p = 0.001) greater than the CCAP+ rate (36.44%) of the PAD- (control). There was no significant difference in atherogenic "risk factors" in the PAD+ cohort between CCAP+ and CCAP- subjects. We demonstrated that CCAP, a "risk factor" for future stroke and "risk indicator" of future myocardial infarction is seen significantly more often detected on the PIs of older male patients with PAD than among those without. Dentists treating patients with PAD must be uniquely vigilant for the presence of CCAPs on their patients' PI.

Relationships of Age and Gender with Ankle-brachial Systolic Pressure Index and Cardio-ankle Vascular Index in Patients with Diabetes Mellitus

Summary Background Cardio-ankle vascular index (CAVI) and ankle-brachial systolic pressure index (ABI) are used as indicators of atherosclerotic progression, which is more prominent in the elderly than in the young. The relationships of age and gender with these indicators were investigated in patients with diabetes mellitus. Methods Subjects were outpatients with type 2 diabetes (113 men and 53 women). CAVI and ABI were simultaneously measured at rest. ABI was also measured after leg exercise. Patients with ABI higher than 1.3 were excluded from the subjects. Results CAVI and ABI were significantly higher in men than in women, while % decrease in ABI after exercise was not significantly different in men and women. Both in men and women, CAVI was not significantly correlated with ABI and % decrease in ABI. Both in men and women, there were significant correlations between age and CAVI (men, r = 0.497 [p Conclusion In male and female patients with diabetes, ABI was not associated with CAVI. Age was related more strongly with CAVI than with ABI. Thus, CAVI is thought to be a more reliable marker than ABI for atherosclerotic progression in patients with diabetes.

The importance of community screening of asymptomatic elderly for peripheral arterial disease by Doppler ultrasound and ankle-brachial index.

BackgroundPeripheral arterial disease is an atherosclerotic disease characterized by an increase in morbidity and mortality. For these reasons early diagnosis of peripheral arterial disease is important. Ankle-brachial systolic pressure index measurement is frequently used in screening studies. Evaluating waveforms of distal lower extremities with Doppler ultrasound can be used as a screening program and provides more accurate information on peripheral arterial disease.AimWe investigate the prevalence of peripheral arterial disease, compare the efficacy of Doppler ultrasound evaluation of distal lower extremity waveforms and ankle-brachial systolic pressure index measurement in screening programs, and discuss the importance of early diagnosis of asymptomatic cases.Material and methodsA total of 457 patients over the age of 65 (between 65 and 94, mean age: 71.4) including 270 males and 187 females were examined with Doppler ultrasound, had ankle-brachial systolic pressure index measurement taken and were screened for peripheral arterial disease. The correlation between Doppler ultrasound findings and ankle-brachial systolic pressure index was examined.ResultsAccording to the Doppler ultrasound findings, in the aortoiliac (r = 0.648) and femoropopliteal (r = 0.564) area, there is a medium level of correlation between severe stenosis and occlusions and a low ankle-brachial systolic pressure index value, and a low level of correlation between such abnormalities in the tibioperoneal region (r = 0.116) and a low ankle-brachial systolic pressure index value. Therefore, while the sensitivity of ankle-brachial systolic pressure index increases in proximal stenosis, it decreases in distal stenosis.ConclusionDespite the fact that ankle-brachial systolic pressure index is a diagnostic test commonly used in screening studies, evaluation of distal arteries by means of Doppler ultrasound provides more accurate information in terms of the identification of peripheral arterial disease.

Approach to peripheral arterial disease in the elderly

The prevalence of peripheral arterial disease, which usually develops on the basis of atherosclerosis and develops as a result of chronic arterial occlusive pathology, increases with age. Peripheral artery disease in the elderly patient population may be asymptomatic due to restrictive conditions associated with immobilization. Concurrent cerebrovascular disease and coronary artery disease risk and mortality rates are higher in elderly patients with peripheral artery disease. The life expectancy in patients with peripheral arterial disease is worse than in prostate cancer patients. Leading risk factors include advanced age, smoking, diabetes mellitus, hypertension, hyperlipidemia, hyperhomocysteinemia and hypothyroidism. The most important physical examination component is the palpation of the entire peripheral pulses. The cases in which the ankle-brachial systolic pressure index measurement for clinical diagnosis is below 0.9 are defined as peripheral arterial disease. It is aimed to completely correct or improve the existing clinical symptoms and to increase the survival rates of the patients. The existing risk factors are modified as the first step of the treatment. Smoking cessation, treatment of hypertension primarily with angiotensin-converting enzyme inhibitors, lowering of hemoglobin A1c levels below 7%, anti-hyperlipidemic treatment primarily with statin, antiaggregant therapy primarily with clopidogrel, cilostazol therapy, good foot care, controlled exercise program, if necessary, interventional or operational revascularization, amputation in the presence of irreversible effects are the main treatment components. Indications for major revascularization include the presence of resting pain in the limb and / or open and long-lasting unhealed wound in the extremity and / or severe complaints of intermittant claudication that will result in limitation in daily activities. It should not be forgotten that, all the clinical decisions to be taken in the treatment of elderly patients with peripheral arterial disease are determined by the patient's physical condition, current clinical condition and the expectation level of the patient.

Association between cardiometabolic index and atherosclerotic progression in patients with peripheral arterial disease

BackgroundCardiometabolic index (CMI), calculated as a product of waist-to-height ratio and triglycerides-to-HDL cholesterol ratio, is a new index for discriminating diabetes mellitus. Patients with peripheral arterial disease (PAD) are prone to have other atherosclerotic diseases such as coronary artery disease and stroke. The purpose of this study was to clarify the relationships between CMI and indicators of atherosclerotic progression in patients with PAD. MethodsThe subjects were 63 outpatients with PAD. Relationships of CMI with variables related to atherosclerotic progression were investigated using multivariate linear regression analysis and analysis of covariance with adjustment for age, sex and histories of smoking and alcohol drinking. ResultsLog-transformed CMI was significantly correlated with mean intima-media thickness of the common carotid artery (IMT) (standardized regression coefficient: 0.350, p<0.01) and % decrease in ankle-brachial systolic pressure index (ABI) after treadmill exercise (standardized regression coefficient: 0.365, p<0.01). Mean IMT and % decrease in ABI by treadmill exercise were significantly higher (p<0.01) in the group of the 3rd tertile for CMI than in the group of its 1st tertile (mean±SE: mean IMT (mm), 0.94±0.06 (1st tertile) vs. 0.94±0.06 (2nd tertile) vs. 1.19±0.06 (3rd tertile); % decrease in ABI, 14.1±3.4 [1st tertile] vs. 26.0±3.5 [2nd tertile] vs. 30.0±3.5 [3rd tertile]). ConclusionCMI was shown to be associated with the degrees of atherosclerosis in the common carotid artery and ischemia in leg arteries and is therefore a useful discriminator of atherosclerotic progression in patients with PAD.

Ankle-Brachial Index and Brachial-Ankle Pulse Wave Velocity in a Mexican Population of Healthy Individuals: A Reproducibility Research Study

Background: Ankle-brachial systolic pressure index, reflect arterial hemodynamics in lower extremity and therefore indicates the presence of peripheral arterial disease. On the other hand, an emerging method for assessing arterial stiffness is brachial-ankle pulse wave velocity. Automated devices, such as the “Vascular Profiler 1000” (VP1000) (Omron®, Kyoto, Japan), are currently available for measuring not only the brachial-ankle pulse wave velocity but also the ankle-brachial index, proving their utility in the diagnosis of peripheral arterial disease. Objective: This study assessed the agreement and reproducibility of non-invasive measurement of brachialankle pulse wave velocity (baPWV) and the ankle-brachial index (ABI) with the OMRON® VP1000 device, in a Mexican population of healthy individuals. Methods: The cross-sectional study was carried out in 36 healthy subjects (20 men and 16 women; average age was 20.6 ± 1.6 years, average BMI 23.5 ± 3.5 kg/m2, average waist circumference 82.5 ± 9.3 cm kg/m2) from Guadalajara, Mexico. The baPWV and ABI were measured with the VP1000 device, and all values were expressed as the average ± SD. The correlation between the first and second measurements was analyzed using Pearson’s correlation coefficient and the Bland Altman method. All p-values were two-tailed, and p<0.05 was accepted as significant. Results: The right and left baPWV showed good correlation between the first and second measurements (r2Pearson=0.810, p<0.001 and r2 Pearson=0.831, p<0.001). The arterial ABI also showed good correlation between the first and second measurement (r2 Pearson=0.730, p<0.001 and r2 Pearson=0.599, p<0.001). The Bland-Altman plot of the first and second baPWV and ABI measurements demonstrated good agreement (mean difference -4.3 ± 39.43 cm/s and -0.0071 ± 0.43, respectively). Conclusion: The results obtained with the OMRON® VP1000 device, demonstrate high and significant correlation, as well as good agreement, between the first and second baPWV arterial stiffness and ABI values.

Association of diabetes and hemodialysis with ankle pressure and ankle-brachial index in Japanese patients with critical limb ischemia.

OBJECTIVETo investigate whether diabetes and regular hemodialysis are associated with false elevation of ankle systolic blood pressure and ankle-brachial systolic pressure index (ABI) because of their arterial calcification in patients with critical limb ischemia (CLI).RESEARCH DESIGN AND METHODSWe recruited 269 Japanese patients who underwent endovascular therapy for CLI. Ankle systolic blood pressure and ABI were assessed before endovascular therapy. Arterial stenosis and calcification were evaluated angiographically. We investigated the associations among clinical comorbidities, arterial calcification, and measurements of ankle systolic blood pressure and ABI.RESULTSAnkle systolic blood pressure was 85 ± 56 mmHg, and ABI was 0.59 ± 0.37. Arterial calcification was observed in 69% of the patients. The prevalence of diabetes and regular hemodialysis was 71 and 47%. Diabetes and regular hemodialysis were both significantly associated with the presence of arterial calcification; their adjusted odds ratios were 2.33 (P = 0.01) and 7.40 (P < 0.01), respectively. However, there was no significant difference in ankle systolic blood pressure or ABI level between those with and without these comorbidities. Furthermore, the presence of arterial calcification was not associated with ankle systolic blood pressure or ABI level, whereas arterial stenoses of all segments in the lower body had independent associations with reduced ankle systolic blood pressure and ABI level.CONCLUSIONSDiabetes and regular hemodialysis were significantly associated with arterial calcification, but not with elevated measurements of ankle systolic blood pressure or ABI, in CLI patients.

Diastolic Ankle-Brachial Indices as a Complementary Measure to Screen for Peripheral Arterial Disease in Diabetic Patients

Introduction Ankle-brachial systolic pressure ratio or Index (ABI or ABI-S) has influenced cardiovascular screening for decades. Total or partial rigidity (i.e. calcification) of tibial arteries has hampered Doppler ABI-S measurements in patients with diabetes. Diastolic pressures are measurable with the oscillometric technique. The authors of a previous study demonstrated that ABI-D (ankle-brachial index based on diastolic pressure ratio) was less sensitive than ABI-S, but partial or total incompressibility of tibial arteries was suspected if ABI-D &lt; ABI-S. This study examined whether ABI-D added information to screen for peripheral arterial disease (PAD) in patients with diabetes. Methods An “eye-to-foot” screening/educational program was performed at the city of Arapiraca, state of Alagoas, northeast of Brazil. A vascular surgeon, an expert on the diabetic foot, selected subjects with decreased pulse and/or older age. Bilateral arm and ankle pressures were performed in 71 diabetic patients: 47 (66%) women and 24 (34%) men, 68 ± 10 years (range, 46–86). ABI-S and ABI-D were calculated on the basis of bilateral brachial and ankle oscillometric pressures. Screening for PAD was compared on the basis of the prevalence of ABI &lt; 0.90. Results ABI-S, ABI-D, or either ABI &lt; 0.90 were detected in 36 (51%), 48 (68%), and 55 (77%) diabetics, respectively. ABI-S and ABI-D, only ABI-S, or only ABI-D were &lt;0.90 in 53% (n = 29), 13% (n = 7), and 35% (n = 19) of the 55 diabetics with ABI &lt; 0.90. The increase in frequency of ABI &lt; 0.90 was significant if ABI-D complemented ABI-S ( p &lt; 0.001 by chi-square). ABI-D and ABI-S were 0.83 ± 0.06 (0.68–0.895) versus 1.01 ± 0.10 (0.92–1.30) in the only ABI-D &lt; 0.90 group. Conclusions Diastolic ankle pressures were estimated successfully by use of the oscillometric technique. Diastolic ABI correlated with expert physician assessment and contributed to quantitative screening for PAD in diabetic patients with apparently falsely elevated systolic ABI caused by partial incompressibility of tibial arteries.

Ultrafiltration intensification for achievement of dry weight and hypertension control is not always the therapeutic gold standard

Extracellular volume excess is an important factor in the pathogenesis of arterial hypertension, and control of volume status by ultrafiltration and achievement of dry weight is considered as an essential therapeutical approach. In the present issue of the Journal of Nephrology, Curatola and coworkers present challenging data indicating that ultrafiltration intensification improves hypertension control but increases the risks for cardiovascular events, with peripheral arteriopathy as the principal complication. This is another challenge for determination of dry weight on the basis of blood pressure (BP) measurement. The reference BP is brachial blood pressure. Brachial blood pressure is lower than limb BP. In normal conditions, lower-limb BP (ankle blood pressure) is higher than brachial BP, and the so-called ankle-brachial systolic pressure index is between 0.9 and 1.3. An ankle-brachial index <0.90 indicates the presence of lower-limb arteriopathy, and it should be measured systematically in end-stage renal disease (ESRD) patients because a large proportion of these patients present asymptomatic peripheral arteriopathies. In these conditions, taking into account brachial BP to determine dry weight and BP control can lead to a decline in the perfusion pressure of the lower limbs, with dramatic clinical consequences. The study by Curatola et al (J Nephrol, 2011, present issue) illustrates that the therapeutic approach to cardiovascular risk and hypertension in ESRD patients is still challenging. It underlines the necessity of considering the pathophysiology and mechanisms associated with cardiovascular risk, instead of systematically applying a generally accepted "gold standard" approach.

The Metabolic syndrome is associated with subclinical atherosclerosis independent of insulin resistance: the Guangzhou Biobank Cohort Study‐CVD

We examined whether the association of the metabolic syndrome (MetS) and subclinical atherosclerosis is independent of insulin resistance in a Chinese community sample with no history of type 2 diabetes. Five hundred and ninety-six men and 526 women from a substudy of the Guangzhou Biobank Cohort Study (GBCS-CVD) had carotid intimal-medial thickness (IMT) measured by B-mode ultrasonography, and brachial-ankle pulse wave velocity (PWV) and ankle-brachial systolic blood pressure index (ABI) measured simultaneously by a noninvasive automatic waveform analyser. Fourteen percentage had MetS as defined by the International Diabetes Federation. Obesity indices, systolic and diastolic blood pressure and pulse pressure, lipids, fasting and postload glucose and insulin, homeostatic model assessment of insulin resistance, glycosylated haemoglobin A1c, leptin, high-sensitivity C-reactive protein, IMT and PWV increased and high-density lipoprotein-cholesterol, adiponectin and ABI decreased significantly with increasing number of MetS components after adjusting for age and sex (P for trend from 0.004 to <0.001). After adjusting for traditional cardiovascular risk factors and insulin resistance, the odds ratios [OR (95% CI)] of thicker IMT (> or =1.0 mm), higher PWV (> or =14.0 m/s) and low ABI (< or =1.0) for MetS were significantly increased [2.28 (1.19-4.38), 2.17 (1.36-3.46) and 1.72 (1.14-2.59), respectively, all P < 0.01] but were lower than the adjusted OR for those with three or more MetS components. MetS was associated with subclinical atherosclerosis independent of insulin resistance. The presence of increasing number of MetS risk factors appeared to be more important than the diagnosis of MetS in predicting subclinical atherosclerosis. Early screening for MetS risk factors might identify those at greater cardiovascular risk.

Assessment of low ABSPI among arsenic exposed and non-exposed populations: A pilot study

This cross-sectional study was carried out to assess and compare Ankle Brachial Systolic Pressure Index (ABSPI) amongst 120 arsenic exposed and 120 non-exposed populations of Samta village in Bangladesh. Abnormal ABSPI was more prevalent in arsenic exposed (13.3%) than in non-exposed (2.5%) group. The prevalence of abnormal ABSPI for respondents when adjusted for age, sex, BMI, blood pressure status and diabetic status, the prevalence remain significantly different. The findings suggest that those exposed to arsenic have increased chance of having abnormal ABSP and hence increased chance of peripheral arterial disease in Bangladesh.

Different Ankle Brachial Index Levels in Asymptomatic Hemodialysis Patients

Background. It has been suggested that a resting ankle brachial systolic pressure index (ABI) level of ≤ 0.90 is 95% sensitive in detecting an angiogram-positive peripheral arterial disease (PAD) and that falsely elevated pressures or incompressible arteries at the ankle level and ABI ≥ 1.30 might be caused by mediosclerosis. Methods. In a cross-sectional study on 117 asymptomatic hemodialysis (HD) patients, we evaluated the presence of PAD and mediosclerosis assessed by ABI measurement, and the presence of atherosclerotic lesions in patients with different ABI levels on high resolution B-mode ultrasonography (US) of the common carotid (CCA) and femoral arteries (FA). Finally, we compared various groups of patients according to the ABI levels for a number of clinical and biochemical parameters which might be responsible for those conditions. Results. Our results showed frequent presence of high ABI (33.3%) and low ABI (23.1%) levels in asymptomatic HD patients. The low ABI group of patients were older, presented with more diabetics, lower dialysis adequacy, a higher dose of prescribed calcium carbonate and a number of documented cardiovascular and peripheral arterial diseases, as well as an increased CCA intima media thickness and a higher frequency of atherosclerotic and calcified intimal plaques. The high ABI group characterised by the prevalence of male gender and an increased level of all blood pressure parameters. In addition, patients with high ABI presented with higher internal diameter on CCA and FA. Conclusions. Arterial disease in asymptomatic HD patients is a frequent finding. Screening for atherosclerotic lesions in HD patients could be recommended even if they are symptom free. The participation of a small number of patients in this study needs further confirmation in additional large scale trials.

Preferential Use of Nonreversed Vein Grafts in Above-Knee Femoropopliteal Bypasses for Critical Ischemia: Midterm Outcome

We evaluated nonreversed vein grafts in above-knee bypasses for chronic critical limb ischemia in a retrospective study with intention-to-treat analysis in patients who underwent above-knee bypass grafting. During a 4-year period, 51 patients (men, 32; women, 19; mean age = 66 years) with 53 critically ischemic lower extremities underwent above-knee femoropopliteal bypass grafting. The follow-up evaluation consisted of clinical examination, assessment of the ankle-brachial systolic blood pressure index, and, whenever necessary, duplex scanning. Three (5.7%) deaths occurred within 30 days, two from myocardial infarction and one from an undetermined cause. The 2-year cumulative success rate was 82.5 +/- 9.6% for primary patency, 84.6 +/- 8.9% for secondary patency, 90.1 +/- 7.3% for tertiary patency, 86.9 +/- 7.6% for limb salvage, 77.7 +/- 8.4% for survival, 68.0 +/- 11.1% for composite patency, and 68.4 +/- 9.3% for amputation-free survival; the corresponding estimates for vein grafts alone were 86.6 +/- 9.2%, 88.9 +/- 8.6%, 89.0 +/- 8.5%, 88.1 +/- 8.1%, 81.1 +/- 9.1, 76.8 +/- 11.1%, and 72.6 +/- 10.2%. Three prosthetic grafts failed and were replaced with an arm vein graft. Nonreversed vein bypass grafts in above-knee revascularization of critically ischemic limbs are justified.

PTLA (percutaneous transluminal laser angioplasty) recanalization of femoral artery stenoses/occlusions after Angio-Seal administration

To demonstrate desobliration of Angio-Seal-induced femoral artery stenosis and occlusion by Excimer-laser assisted angioplasty and PTA. The Angio-Seal hemostatic closure device was applied to the puncture site in 1500 patients after diagnostic or therapeutic coronary artery catheterisation. In 5 of 1500 cases symptoms of claudication occurred. Following the determination of the walking distance and ankle-brachial systolic pressure index (ABI) and diagnostic angiography, therapeutic percutaneous transluminal laser angioplasty (PTLA) and PTA was performed. 5 patients with acute symptoms of peripheral artery disease presented with superficial femoral artery occlusions (three cases) and high grade stenoses of the common femoral arteries (two cases). Angiographic and clinical improvement was achieved after PTLA/PTA in all five patients. The mean walking distance increased from 61 meters to 600 meters. The average ankle-brachial systolic pressure index increased from 0.40 to 0.82. PTLA/PTA is a satisfactory therapeutic method for femoral artery occlusion or high-grade stenosis following Angio-Seal application.

Long-term results of a multicenter randomized study on direct versus crossover bypass for unilateral iliac artery occlusive disease

To compare late patency after direct and crossover bypass in good-risk patients with unilateral iliac occlusive disease not amenable to angioplasty. Between May 1986 and March 1991, 143 patients with unilateral iliac artery occlusive disease and disabling claudication were randomized into two surgical treatment groups, ie, crossover bypass (n = 74) or direct bypass (n = 69). The size of the patient population was calculated to allow detection of a possible 20% difference in patency in favor of direct bypass with a one-sided alpha risk of 0.05 and a beta risk of 0.10. Patients underwent yearly follow-up examinations using color flow duplex scanning with ankle-brachial systolic pressure index measurement. Digital angiography was performed if hemodynamic abnormalities were noted. Median follow-up was 7.4 years. Primary endpoints were primary patency and assisted primary patency estimated by the Kaplan-Meier method with 95% confidence interval. Secondary endpoints were secondary patency and postoperative mortality and morbidity. Cardiovascular risk factors, preoperative symptoms, iliac lesions TASC class (C in 87 [61%] patients and D in 56 [39%] patients), and superficial femoral artery (SFA) run-off were comparable in the two treatment groups. One patient in the direct bypass group died postoperatively. Primary patency at 5 years was higher in the direct bypass group than in the crossover bypass group (92.7 +/- 6.1% vs 73.2 +/- 10%, P = .001). Assisted primary patency and secondary patency at 5 years were also higher after direct bypass than crossover bypass (92.7 +/- 6.1% vs 84.3 +/- 8.5%, P = .04 and 97.0 +/- 3.0% vs 89.8 +/- 7.1%, P = .03, respectively). Patency at 5 years after crossover bypass was significantly higher in patients presenting no or low-grade SFA stenosis than in patients presenting high-grade (> or =50%) stenosis or occlusion of the SFA (74.0 +/- 12% vs 62.5 +/- 19%, P = .04). In both treatment groups, patency was comparable using polytetrafluoroethylene (PTFE) and polyester grafts. Overall survival was 59.5 +/- 12% at 10 years. This study showed that late patency was higher after direct bypass than crossover bypass in good-risk patients with unilateral iliac occlusive disease not amenable to angioplasty. Crossover bypass should be reserved for high-risk patients with unilateral iliac occlusion not amenable to percutaneous recanalization.

Blood flow in the lower limb after balloon angioplasty of the superficial femoral artery.

Using duplex ultrasonography lower-limb blood flow measurements were obtained in 20 patients with intermittent claudication. Assessments of flow were made in the common femoral artery, profunda femoris artery (PFA) and superficial femoral artery (SFA) before and after angioplasty for stenoses of short segments of the SFA. Blood flow was measured at rest and after exercise on a cycle ergometer. Collateral flow was calculated using an established mathematical model. Results were compared with the ankle:brachial systolic pressure index (ABPI) after exercise. Although there was no overall increase in resting limb blood flow, an increase in mean(s.d.) SFA flow from 148(79) to 312(94) ml min-1, with a concomitant decrease in PFA flow from 224(84) to 98(43) ml min-1 was noted 1 week after angioplasty (P < 0.05). At rest there was an increase in mean(s.d.) ABPI from 0.62(0.12) to 0.89(0.23) (P < 0.05). Collateral flow was estimated to have decreased from 186(34) to 18(8) ml min-1; the pattern of change in flow was similar after exercise. Angioplasty of the SFA remains controversial because of the risk of restenosis. The above methodology allows assessment of whether patients can re-establish collateral flow or whether limb blood flow will be significantly compromised if restenosis occurs.

Excimer laser-assisted recanalisation of femoral arterial stenosis or occlusion caused by the use of Angio-Seal.

The aim of this study was to demonstrate the effect of excimer laser and balloon angioplasty of femoral artery stenosis and occlusion after use of a haemostatic puncture closure device. A haemostatic puncture closure device (Angio-Seal) was used in 6000 patients after diagnostic or therapeutic artery catheterisation. In 34 of those patients symptoms of peripheral artery disease occurred. Sixteen of those 34 cases were transferred to our clinic for excimer laser angioplasty. All 16 patients presented with symptoms of acute peripheral artery disease within 1-14 days: superficial femoral artery (SFA) occlusions (4 cases); superficial femoral artery stenosis (3 cases); high-grade stenosis of the common femoral artery (CFA; 3 cases); high-grade stenosis of CFA; SFA and profund femoral artery (PFA; 3 cases); and occlusions of CFA, SFA and PFA (3 cases). Before any procedure was performed, informed consent was given by the patient, which included the use of the Angio-Seal closure device. Every patient who had to undergo recanalisation procedures gave additional informed consent which especially included the usage of the excimer laser for recanalisation. A measurement of the walking distance, ankle-brachial systolic pressure index (ABI) and diagnostic angiography was performed in 13 cases before and immediate after as well as 3 and 6 months after therapeutic percutaneous transluminal laser angioplasty followed by balloon angioplasty (PTLA/PTA). In 3 patients the risks of PTLA/PTA was considered too high; those patients underwent surgical repair. Angiographic and clinical improvement was achieved in 13 of 13 patients. The mean walking distance increased from 81 to > 400 m. The average ankle-brachial systolic pressure index (ABI) increased from 0.47 to 0.84. One patient developed a dissection of the SFA, and in 1 case a peripheral embolisation was seen. The PTLA/PTA technique is a successful therapeutic option for patients with femoral artery occlusion or high-grade stenosis after Angio-Seal application.