Brachial Pressure Index Research Articles

Fatness and Fluctuating Body Weight: Effect on Central Vasculature.

Weight Cycling (WC) is a prevalent behavior associated with adverse cardiovascular (CV) health. However, a 2010 review on the effects of WC and blood pressure (BP) determined that there was not enough evidence to draw definitive conclusions. Central BP is the principal predictor of CV risk compared to peripheral BP. The influence that WC may have specifically on central BP is unknown. Cross-sectional observation of self-reported history of WC on measures of CV health was undertaken. Seventy-five women completed a Weight and Lifestyle Inventory questionnaire, which is considered a reliable index of WC (r = 0.87, p < 0.001). Measures of visceral fat, BP, arterial stiffness, and VO2peak were taken. Regression equations were used to assess primary predictors of these outcomes. Seventy-five middle aged (39 ± 11 years), obese (32 ± 7 kg/m2), and relatively unfit (24 ± 8 ml·kg−1 min−1) women completed the study. Visceral fat was the strongest predictor of brachial systolic blood pressure (SBP; r2 = 0.283), brachial diastolic blood pressure (DBP; r2 = 0.176), central SBP (r2 = 0.375), and augmentation index (AIx; r2 = 0.535, all p < 0.001). VO2peak was the strongest predictor of central DBP (r2 = 0.062, p = 0.036) and augmentation pressure (AP; r2 = 0.491, p < 0.001). Weight cycling index was associated with visceral fat (r = 0.521, p < 0.001). Visceral fat was a mediator between WC and central SBP (confidence interval [CI] = 0.0053–0.0602), AP (CI = 0.0507–0.4915), AIx (CI = 0.0025–0.0699), and carotid-femoral pulse wave velocity (CI = 0.0115–0.1227; all p < 0.05). WC may increase visceral fat accumulation, which was associated with increased central SBP and measures of arterial stiffness.

Clinical, Etiological, Anatomical, and Bacteriological Study of "Diabetic Foot" Patients: Results of a Single Center Study.

Objective: To examine the clinical pattern of foot-related complications in type 2 diabetes patients.Material and methods: A cross-sectional study was conducted among indoor, adult type 2 diabetes patients with risk factors for diabetic foot complications. The diabetic neuropathy symptom score (DNSS), Doppler scanning, ankle brachial pressure index (ABPI) assessment, neuropathy assessment, neuropathic disability score (NDS), biothesiometry evaluation, and bacteriological examination was performed. Diabetic foot risk stratification was done using the NICE risk stratification system. Foot ulcer severity was assessed with the Lipsky severity grading system.Results: Ninety-one patients (mean age 59 years; male 65.9%) were included, of which 20 (22%) had a history of ulcer and 40 (44%) were smokers. Seventy-seven (83.5%) patients had a neuropathy symptom score between 4 and 9. Biothesiometry vibration perception threshold (VPT) was “severe” in 55 (60.4%) patients. Doppler assessment showed triphasic flow in 53 patients (58.2%). Out of 52 patients (57.1%) with neuropathy, 30 (57.7%) had a severe problem. Diabetic foot ulcer, cellulitis, and callus were present in 44 (48.3%), 29 (31.5%), and 11 (12.4%) patients, respectively. Foot ulcers were present on 21 (38%) metatarsal heads, 11 (20%) toes, 10 (18%) heels, 08 (15%) ankles, and 05 (09%) lateral foot borders. Of the 55 patients who underwent culture examination, 30 (33.3%) showed the presence of Staphylococcus aureus. As per NICE risk stratification, 55 patients (60%) were at “very high risk.”Conclusion: A foot ulcer is the commonest complication in diabetic patients followed by cellulitis. Standardized simple noninvasive testing methods should be used to identify patients at risk for the diabetic foot. Multidisciplinary diabetic foot care could be useful to prevent diabetes-related amputation of the lower extremities.

Lumbar sympathectomy versus prostanoids for critical limb ischaemia due to non-reconstructable peripheral arterial disease.

Lumbar sympathectomy versus prostanoids for critical limb ischaemia due to non-reconstructable peripheral arterial disease.

Angioplasty (versus non surgical management) for intermittent claudication

Intermittent claudication is pain in the legs due to muscle ischaemia associated with arterial stenosis or occlusion. Angioplasty is a technique that involves dilatation and recanalisation of a stenosed or occluded artery. The objective of this review was to determine the effects of angioplasty of arteries in the leg when compared with non surgical therapy, or no therapy, for people with mild to moderate intermittent claudication. Sources searched include the Cochrane Peripheral Vascular Diseases Group's Specialized Trials Register (August 2006), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2006) and reference lists of relevant articles. The review authors also contacted investigators in the field and handsearched relevant conference proceedings (August 2006). Randomised trials of angioplasty for mild or moderate intermittent claudication. The contact author selected suitable trials and this was checked by the other review author. Both review authors assessed trial quality independently. The contact author extracted data and this was cross checked by the other review author. Two trials with a total of 98 participants were included. The average age was 62 years old with 20 women and 78 men. Participants were followed for two years in one trial and six years in the other.At six months follow up, mean ankle brachial pressure indices were higher in the angioplasty groups than control groups (mean difference 0.17; 95% confidence interval (CI) 0.11 to 0.24). In one trial, walking distances were greater in the angioplasty group, but in the other trial, in which controls underwent an exercise programme, walking distances did not show a greater improvement in the angioplasty group. At two years follow up in one trial, the angioplasty group were more likely to have a patent artery (odds ratio 5.5; 95% CI 1.8 to 17.0) but not a significantly better walking distance or quality of life. In the other trial, long term follow up at six years demonstrated no significant differences in outcome between the angioplasty and control groups. These limited results suggest that angioplasty may have had a short term benefit, but this may not have been sustained.

The importance of accurate methodology in ABPI calculation when assessing lower limb wounds.

Recent health economic publications have highlighted the cost of wound care and demonstrated the important role played by community and practice nurses in delivering care. Leg ulcers form a significant proportion of the wounds managed in the community. Data indicates that many patients are managed with no specific diagnosis or without calculation of the ankle brachial pressure index (ABPI), despite care guidelines emphasising the importance of a full assessment including Doppler ABPI calculation in patient management. This article highlights the important role Doppler ABPI plays in patient assessment and describes the methodology, focusing on the importance of correct application of the technique if reliable reproducible results are to be obtained. The rationale for obtaining blood pressure readings from both arms is discussed, and the possible error resulting from reliance on single upper limb blood pressure measurement for both manual and automated ABPI calculation is highlighted and its impact on ABPI calculation illustrated.

Multicenter, randomized controlled, observer-blinded study of a nitric oxide generating treatment in foot ulcers of patients with diabetes-ProNOx1 study.

The aim of this multicenter, prospective, observer-blinded, parallel group, randomized controlled trial was to assess the safety and efficacy of EDX110, a nitric oxide generating medical device, in the treatment of diabetic foot ulcers in a patient group reflecting "real world" clinical practice compared against optimal standard care. Participants were recruited from ten hospital sites in multidisciplinary foot ulcer clinics. The ulcers were full thickness, with an area of 25-2,500 mm2 and either a palpable pedal pulse or ankle brachial pressure index > 0.5. Infected ulcers were included. Treatment lasted 12 weeks, or until healed, with a 12-week follow-up period. Both arms were given optimal debridement, offloading and antimicrobial treatment, the only difference being the fixed used of EDX110 as the wound dressing in the EDX110 group. 135 participants were recruited with 148 ulcers (EDX110-75; Control-73), 30% of which were clinically infected at baseline. EDX110 achieved its primary endpoint by attaining a median Percentage Area Reduction of 88.6% compared to 46.9% for the control group (p = 0.016) at 12 weeks in the intention-to-treat population. There was no significant difference between wound size reduction achieved by EDX110 after 4 weeks and the wound size reduction achieved in the control group after 12 weeks. EDX110 was well tolerated. Thirty serious adverse events were reported (12 in the EDX110 group, of which 4 were related to the ulcer; 18 in the control group, of which 10 were related and 1 possibly related to the ulcer), with significant reduction in serious adverse events related to the ulcer in EDX group. There was no significant difference in adverse events. This study, in a real world clinical foot ulcer population, demonstrates the ability of EDX110 to improve healing, as measured by significantly reducing the ulcer area, compared to current best clinical practice.

Opportunities for better value wound care: a multiservice, cross-sectional survey of complex wounds and their care in a UK community population

BackgroundComplex wounds impose a substantial health economic burden worldwide. As wound care is managed across multiple settings by a range of healthcare professionals with varying levels of expertise, the actual...

Complete Lower Extremity Revascularization via a Hybrid Procedure for Patients with Critical Limb Ischemia.

Complete revascularization, achieving inline flow to the foot through at least 1 patent tibioperoneal artery, is considered to be desirable for treating critical limb ischemia (CLI). Hybrid procedure, combined femoral endarterectomy and endovascular treatment, is commonly performed on patients with CLI because they often present with complicated lower extremity lesions involving the common femoral artery. This study aimed to investigate the efficacy of complete revascularization (CR) achieved by hybrid procedure on limb salvage in patients with CLI. Between February 2010 and January 2016, 95 limbs (82 patients) were treated by lower extremity hybrid procedure; of these 95 procedures, 61 were for patients with CLI. We defined CR as achieving inline flow to the foot through at least 1 patent tibioperoneal artery. Complete revascularization was performed on 37 limbs, and incomplete revascularization (IR) was performed on 24 limbs. Specific variables, including patient age, male-female ratio, Rutherford classification, preoperative and postoperative ankle-brachial pressure indices (ABIs), follow-up duration (months), primary patency rate, assisted primary patency rate, secondary patency rate, and major amputation rate, were analyzed. The mean age was similar between the groups 67.2 years in the CR group and 70.7 years in the IR group ( P = .11). Limb ischemia severity was significantly higher in the CR group: 63% of the patients scored Rutherford 5 in the CR group, compared to 30% in the IR group ( P = .027). Mean postoperative ABI was significantly higher in the CR group (CR: 0.87, IR: 0.53; P = .0001). Major amputation rate was higher in the IR group (CR: 2.7%, IR: 13%; P = .29), and major amputation-free survival rate at 3 years after the index procedure was higher in the CR group (CR: 97%, IR: 81%; P = .054). Complete lower extremity revascularization was beneficial for patients with CLI, avoiding major amputation.

AB040. 69. The use of oscillometric measurement of ankle-brachial pressure indices as a screening tool for peripheral arterial disease

: Ankle brachial pressure indices (ABPIs) are useful in community and primary care settings in screening for significant peripheral vascular disease (PVD) but require training, expertise and are operator dependent. We compared the reliability of a novel automated (operator independent) affordable device that uses oscillometric analysis to measure ABPI with conventional Doppler measurement in a vascular laboratory environment. ABPIs were measured on a series of patients referred for assessment with no known history of vascular disease using a standard Doppler technique (ELCAT, Sword Medical, Dublin) and a novel oscillometric device (MESI, MedEarly Healthcare, Nenagh, Co.Tipperary). The ABPI readings were recorded and patients were categorised as having “Normal” (ABPI >0.9) or “Abnormal” (ABPI <0.9 or incompressible using MELCAT versus “Error” or “no normal value obtained” using MESI) based on lowest values in either leg. A total of 12 patients were studied included. Among the 6 patients with normal ABPI (MELCAT), all had normal readings on MESI. 5/5 of those with ABPI <0.9 using MELCAT also had abnormal results using MESI (mainly error results). One patient categorised as having incompressible vessels (MELCAT) had normal results using MESI and had normal (0.6) toe pressure indices. MESI identifies patients with abnormal ABPI with a specificity of 100% and sensitivity of 83.3%. The positive and negative predictive values of MESI were 100% and 87.5% respectively. Despite small numbers in this pilot study we have identified the potential use of the MESI device as a screening tool in a community/primary care setting with potential for reducing demand for vascular lab and vascular OPD. Further evaluation is indicated required in a clinically appropriate setting.

Nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus and its association with cardiovascular disease

IntroductionNon-alcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of liver disease that ranges from hepatic steatosis to non-alcoholic steatohepatitis. Obesity and diabetes mellitus are the prime risk factors for NAFLD. The aim of this study was to find out the prevalence of NAFLD among patients with type 2 diabetes mellitus and to detect the association of NAFLD with cardiovascular disease in them. Study designProspective observational study. Material and methodsThe study was conducted on 300 patients with type 2 diabetes mellitus attending the outpatient department of a tertiary care teaching hospital. All patients underwent hepatic ultrasonography to look for hepatic steatosis. Among the 300 patients, 124 were divided into NAFLD and non-NAFLD groups based on the ultrasound findings. These patients were subjected to electrocardiogram, 2D echocardiogram, carotid intima media thickness (CIMT) measurement and ankle brachial pressure index measurement along with measurement of markers of oxidative stress. ResultsHepatic steatosis was present in 61% of diabetic patients in this study. Cardiovascular disease was not found to be significantly associated in diabetic patients with NAFLD. However, cardiovascular risk factors like CIMT, high sensitivity c-reactive protein (hs-CRP) and malondialdehyde (MDA) were elevated in these patients. hs-CRP and MDA levels were found to be significantly associated with the severity of NAFLD. ConclusionThere is a high prevalence of NAFLD in type 2 diabetic patients. No correlation was detected between the presence of NAFLD and cardiovascular disease in them; although there was an association between cardiovascular risk factors and NAFLD.

The PodPAD project: a podiatry-led integrated pathway for people with peripheral arterial disease in the UK \u2013 a pilot study

BackgroundPeripheral arterial disease affects the lower limb and is associated with diabetes, high cholesterol, smoking and obesity. It increases the risk of cardiovascular morbidity and mortality. It can be symptomatic causing intermittent claudication, but often there are few clinical signs. Podiatrists are able to detect the presence of peripheral arterial disease as part of their lower limb assessment and are well placed to give advice on lifestyle changes to help reduce disease progression. This is important to improve health outcomes and is offered as a prevention/public health intervention.MethodWe describe the clinical and patient-centred outcomes of patients attending a podiatry-led integrated care pathway in a multi-use clinic situated in a venue supported by the National Centre for Sports and Exercise Medicine in the UK. At the baseline appointment, patients were given a full assessment where symptoms of intermittent claudication using the Edinburgh Intermittent Claudication Questionnaire, foot pulses, Doppler sounds, Ankle Brachial Pressure Indices, glycated haemoglobin (HbA1c) and cholesterol levels, and smoking status were recorded. A tailored treatment plan was devised, including referral to an exercise referral service, smoking cessation programmes (if applicable) and each participant was also seen by a dietician for nutritional advice. Participants were followed up at 3 and 6 months to assess any improvement in vascular status and with each completing the EQ-5D quality of life questionnaire and a simple satisfaction questionnaire at the end of the study. As this was a complex intervention a pilot study design was adopted to evaluate if the method and outcomes were suitable and acceptable to participants the results of which will then inform the design of a larger study.ResultsData was collected on 21 individuals; 15 men (71.4%) and 6 women (28.6%) across the 6-month study period. Eleven participants were referred onto the exercise referral service; 16 participants saw the dietician for nutritional advice at baseline and had one-to-one or telephone follow-up at 3 months. Five out of 14 participants had reduced scores from baseline of intermittent claudication during the study period. No evidence for substantive changes in Doppler sounds or ABPI measurements was revealed. Quality of life scores with the EQ-5D improved in 15 participants; this was statistically significant (p = 0.007) with 14 participants who completed the simple satisfaction questionnaire expressing a positive view of the programme. Of the four people who were smokers, two stopped smoking cigarettes and moved to e-cigarettes as part of smoking cessation advice.ConclusionAs this was a pilot study the sample size was low, but some statistically significant improvements with some measures were observed over the 6-month study. Podiatrists are able to provide a comprehensive vascular assessment of the lower limb and accompanying tailored advice on lifestyle changes including smoking cessation and exercise. Locating clinics in National Centres for Sports and Exercise Medicine enables easy access to exercise facilities to encourage the adoption of increased activity levels, though the long term sustainability of exercise programmes still requires evaluation.This study was reviewed and approved by London Brent Ethics Committee IRAS ID 204611 and received research governance approval from the sponsor, Sheffield Teaching Hospitals NHS Foundation Trust Research and Innovation Office STH19410.

Outcomes of Open Surgery for Popliteal Artery Aneurysms: An 18-Year Experience in a Single Institution in Japan

Objective: To elucidate the outcomes of open surgery for popliteal artery aneurysm (PAA) in a single Japanese institution. Materials and Methods: Between 1999 and 2016, 35 patients (44 PAAs) underwent open surgery in our department. The first-line surgical strategy involved the medial approach, with excision of the aneurysm sac and autologous vein bypass grafting. Associations between the outcomes and 1) the surgical management of the aneurysmal sac (aneurysmectomy vs. ligation with bypass) and 2) the preoperative clinical symptoms were evaluated. Results: There were no aneurysm-related deaths during the follow-up period (mean, 4 years; range, 1 - 17.6 years). The 5-year primary, primary-assisted, and secondary patency rates were 67.9%, 72.7%, and 94.5%, respectively. Re-intervention was required for 19 PAAs (14 patients), including two PAAs in patients with suspected Behçet’s disease. Patency rates did not differ between the aneurysmectomy and ligation groups. Remnant sac enlargement occurred in 3 cases. Among asymptomatic patients, clinical symptoms did not deteriorate; however, the ankle brachial pressure index decreased ≥0.15 in patients with artery-graft mismatching. Conclusion: Patency rates were good, and our modified ligation with bypass procedure, which involves excising the sac as much as possible, exhibited less risk in terms of remnant sac enlargement compared to that in previous studies.

Long-term follow-up of patients with Buerger's disease after autologous stem cell therapy.

Objective:We investigated the long-term results of autologous bone marrow mononuclear cells (ABMMNCs) implantation in patients with Buerger’s disease (BD).Methods:Twenty-eight patients (25 males and 3 females) who had BD and critical unilateral limb ischemia were investigated between April 2003 and August 2005. The patients were administered multiple injections of CD34+ and CD45+ positive ABMMNCs into the gastrocnemius muscle, the intermetatarsal region, and the dorsum of the foot (n=26) or forearm (n=2) and saline injection into the contralateral limb.Results:The mean follow-up time was 139.6±10.5 months. No complication related to stem cell therapy was observed during the follow-up. The ankle–brachial pressure index evaluated at 6 months and 120 months was compared to the baseline scores (p<0.001 and p=0.021, respectively). Digital subtraction angiography (DSA) was performed for all patients at baseline, 6 months, and 120 months. The angiographic improvement was 78.5% and 57.1% at 6 and 120 months, respectively. Patients demonstrated a significant improvement in the quality of life parameters at 6 months compared to baseline (p=0.008) and 120 months compared to the baseline (p=0.009). The 10-year amputation-free rate was 96% (95% CI=0.71-1) in ABMMNC-implanted limbs and 93% (95% CI=0.33–0.94) in saline-injected limbs (p=1).Conclusion:Autologous stem cell therapy could be an alternative therapeutic method for BD at long-term follow-up.

Venous leg ulcer management in clinical practice in the UK: costs and outcomes.

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to managing venous leg ulcers (VLUs) in clinical practice by the UK's National Health Service (NHS) and the associated costs of patient management. This was a retrospective cohort analysis of the records of 505 patients in The Health Improvement Network (THIN) Database. Patients' characteristics, wound-related health outcomes and health care resource use were quantified, and the total NHS cost of patient management was estimated at 2015/2016 prices. Overall, 53% of all VLUs healed within 12 months, and the mean time to healing was 3·0 months. 13% of patients were never prescribed any recognised compression system, and 78% of their wounds healed. Of the 87% who were prescribed a recognised compression system, 52% of wounds healed. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 30% of all the VLUs may have been clinically infected at the time of presentation, and only 22% of patients had an ankle brachial pressure index documented in their records. The mean NHS cost of wound care over 12 months was an estimated £7600 per VLU. However, the cost of managing an unhealed VLU was 4·5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU). This study provides important insights into a number of aspects of VLU management in clinical practice that have been difficult to ascertain from other studies and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.

Ankle-brachial pressure index as a predictor of the 2-year outcome after transcatheter aortic valve replacement: data from the Japanese OCEAN-TAVI Registry.

Peripheral artery disease plays a pivotal role for access site selection in transcatheter aortic valve replacement (TAVR). Abnormal ankle-brachial index (ABI) is a generalized mortality marker in many cardiovascular scenarios. However, the long-term outcomes in high-risk TAVR populations remain unclear. We investigated the association between low ABI and 2-year outcome after TAVR. Of 1613 patients enrolled in the OCEAN-TAVI registry, 1458 (90.4%) who underwent ABI before TAVR were divided into groups: patients with (1) ABI≥0.9 in both legs and (2) ABI<0.9 in either leg. Primary endpoint was all-cause death within 2years. ABI<0.9 was noted in 304 patients (20.8%). ABI<0.9-group had more frequent and severe comorbidities. Primary endpoint in ABI<0.9-group was significantly higher than that in ABI≥0.9-group (15.8 vs. 8.7%, p<0.001). This trend continued in the transfemoral (TF)-approach (14.9 vs. 7.5%, p<0.001), but not in the alternative approach (17.2 vs. 15.8%, p=0.815). Within 30days, ABI<0.9-group had a higher cardiac death rate (3.1 vs. 1.0%, p=0.033), whereas between 31days and 2years, non-cardiovascular death was more frequently observed (9.2 vs. 5.1%, p=0.003). In ABI<0.9-group, in-hospital vascular complications (11.9 vs. 4.9%, p<0.001) and acute kidney injury (10.8 vs, 5.7%, p=0.009) were more frequently found when using the transfemoral-approach. In multivariate analysis, ABI<0.9 was an independent predictor of 2-year mortality (adjusted hazard ratio 1.495, 95% CI 1.007-2.220, p=0.046). Pre-procedure ABI<0.9 is a useful prognostic marker for all-cause mortality, even in high-risk TAVR populations.

Comparison of ankle brachial pressure index to arterial doppler USG in the diagnosis of peripheral vascular disease in diabetes mellitus

Background: Peripheral artery disease(PAD) is a major macrovascular complication of diabetes mellitus. Patients with diabetes mellitus have an increased prevalence of PAD. However, due to associated neuropathy, common symptoms such as claudication are often masked and such patients often diagnosed late when limb threatening ischemia has already set in. Arterial colour doppler ultrasonography and ankle brachial pressure index are easy, non- invasive and often underutilised tools for diagnosis of PAD.Methods: In the present study, 100 diabetic patients were enrolled to study the comparison of Ankle Brachial Pressure Index to arterial doppler USG in diagnosis of peripheral artery disease.Results: Colour duplex ultrasonography (CDU) was taken as gold standard. Ankle brachial index (ABI) was compared with it. Sensitivity of ABI was 92.50%, Specificity was 88.33%, Positive Predictive Value was 84.09% and Negative Predictive Value was 94.64% respectively.Conclusions: Peripheral arterial disease (PAD) is very common in patients with diabetes. ABI is a simple and very sensitive test to detect PAD early in these patients.

The burden and characteristics of peripheral arterial disease in patients undergoing amputation in Korle Bu Teaching Hospital, Accra, Ghana.

To determine the prevalence of Peripheral Arterial Disease (PAD) and associated risk factors in patients undergoing amputation at the Korle Bu Teaching Hospital (KBTH), Accra, Ghana. A cross- sectional study of all patients undergoing lower extremity amputation at the Department of Surgery, KBTH. A coded questionnaire was used to ascertain risk factors for PAD. The Edinburgh Claudication Questionnaire was used to determine symptomatic PAD and a 5 mmHz hand held Summit® Doppler together with an Accoson ® sphygmomanometer was used to determine PAD and its severity. Clinical diagnosis of symptomatic PAD was made using a symptom-based questionnaire and signs of PAD determined by measuring the ankle brachial pressure index (ABPI) by means of a handheld Doppler and sphygmomanometer. Risk factors were determined using the coded questionnaire and related to the occurrence and severity of PAD. The prevalence of PAD among recruited participants was 71%. Twenty-eight per cent of participants with PAD in the index limb also showed signs of PAD in the other limb. The diagnosis of PAD was made in 71%, using ABPI, and 13%, using ECQ. Twenty-seven per cent of patient with hypertension, seventeen per cent with diabetes and all patients with hypercholesterolemia were not on any form of medication. There is a high prevalence of PAD among patients undergoing lower extremity amputation at the KBTH. The majority of PAD patients presented with moderate to severe PAD. Instituting measures to identify and control risk factors of PAD may reduce this high burden. Not declared. Authors funded the study.

Could botulinum toxin be a treatment for functional popliteal artery entrapment syndrome? A preliminary study

Functional popliteal artery entrapment syndrome (FPAES) is an uncommon cause of exercise-induced leg pain. Contrary to the anatomic type, there is no anatomical abnormality: entrapment is caused by hypertrophic gastrocnemius muscles (GCM). Even though arterial compression is purely functional, a surgical arteriolysis of popliteal artery is often proposed, in order to release the artery from adjacent structures. It is sometimes associated with myotomy. Studies on surgical treatment lack for cases. We hypothesize that botulinum toxin A (BoNT-A) injections in GCM could improve GCM-artery impingement by inducing localized and partial muscular atrophy and hypotonia. This retrospective study included patients with FPAES treated with BoNT-A. Clinical exam, ankle brachial pressure index after exercise, provocative tests in plantar or dorsal flexion of the ankle (Doppler ultrasonography, computed tomography or magnetic resonance angiography) were used for diagnostic. Other causes of leg pain were systematically excluded with further investigations, such as compartment pressure after exercise, low back and leg imagery. BoNT-A was injected in the proximal third of both heads of GCM, in two sites for each head, after location of the muscles by electrical stimulation. Investigations with provocative maneuvers were done after treatment. Eight patients (fourteen limbs) aged between 17 and 54 years old were included. One patient had previously unsuccessfully been treated by surgery. Mean follow up was 22.1 ± 21.2 months (6–74). Five patients had resolution of symptoms, during 70.6 ± 74.3 weeks (17–216). Two patients are currently still asymptomatic. Three patients relapsed. Adverse events were moderate systemic events (two patients) and subjective muscular weakness (two patients). Ankle brachial index, Doppler ultrasonography or tomography angiography improved or normalized in three patients, all successfully treated. Long-lasting resolution of symptoms in five patients could indicate that BoNT-A injections reduce functional compression. However, treatment failed in three patients. Continuation of the study with more patients may indicate whether BoNT-A injections could be a treatment of FPAES, which has no appropriate treatment as of today.

One Year Primary Patency of Infrapopliteal Angioplasty Using Drug- Eluting Balloons: Single Center Experience at King Hussein Medical Center.

Objective:Conventional percutaneous transluminal angioplasty (PTA) for long lesions in the below-the-knee (BTK) arteries in patients presenting with critical limb ischemia (CLI) has high restenosis rates at 1 year. Our goal is to evaluate whether paclitaxel drug-eluting balloons (DEB) have higher 1 year primary patency rates compared to conventional PTA.Methods:This is a single-center, prospective, randomized trial that was conducted from June 2013 to December 2015. The aim of the study was to compare 1 year primary patency rates of DEB and PTA in BTK arteries in CLI patients. Inclusion criteria were patients presenting with CLI (Rutherford class 4 or greater), stenosis or occlusion ≥30 mm of at least one tibial artery, and agreement to 12-month evaluation. Exclusion criteria were life expectancy <1 year, allergy to paclitaxel, and contraindication to combined antiplatelet treatment. Follow-up was performed by clinical assessment, ankle brachial pressure index, Doppler ultrasound imaging, and conventional angiogram if indicated. Primary end point was 1 year primary patency, and secondary end points were target lesion revascularization (TLR) and major amputation. Statistical analysis was performed using Fischer's exact test.Results:Ninety-three patients with 106 lesions in the BTK arteries were enrolled in this study. One year primary patency was achieved in 26 (65%) and seven (17%) in the DEB and PTA groups (P = 0.006), respectively. TLR was performed in nine lesions (23%) and 29 lesions (71%) in DEB and PTA groups (P = 0.009), respectively. Major amputations occurred in one limb (2%) and two limbs (4%) in DEB and PTA groups (P = 0.6), respectively.Conclusion:Paclitaxel DEB has significantly higher 1 year primary patency rate associated with significantly less TLR than conventional PTA, following endovascular recanalization of BTK arteries in patients presenting with CLI.

Endothelial dysfunction in patients with Buerger disease.

We evaluated the endothelial function of patients with Buerger disease using peripheral arterial tonometry test, and examined the factors that are significantly correlated with the endothelial dysfunction in these patients. We performed the peripheral arterial tonometry test in 22 patients with Buerger disease. We recorded the patients’ characteristics, including ankle brachial pressure index and reactive hyperemia index, which reflect the endothelial dysfunction. We divided the patients with Buerger disease into the conservative treatment and lumbar sympathectomy group. While the reactive hyperemia index was not significantly different between these two groups, the ankle brachial pressure index was significantly different (1.12 versus 0.83, P=0.003). Furthermore, the reactive hyperemia index was significantly correlated with the ankle brachial pressure index value in the patients in the lumbar sympathectomy group (ρ=0.848, P=0.005). Given that patients with Buerger disease show impairment of the sympathetic nervous system, we should consider the after-effects of such an impaired system on the condition of these patients. The patients treated with lumbar sympathectomy might be more appropriate to evaluate their endothelial function by a peripheral arterial tonometry test.