Chronic Limb Ischemia Research Articles

A Modified Run-Off Resistance Score from Cross-Sectional Imaging Discriminates Chronic Critical Limb Ischemia from Intermittent Claudication in Peripheral Arterial Disease.

Atherosclerotic peripheral arterial disease (PAD) leads to intermittent claudication (IC) and may progress into chronic limb-threatening ischemia (CLTI). Scoring systems to determine the atherosclerotic burden of a diseased extremity have been developed. This study aimed to evaluate a modification of the run-off resistance (mROR) score for its usability in cross-sectional imaging. The mROR was determined from preoperative imaging of patients undergoing revascularization for PAD. A total of 20 patients with IC and 20 patients with CLTI were consecutively included. A subgroup analysis for diabetic patients was conducted. The mROR was evaluated for its correlation with disease severity and clinical covariates. Patients with CLTI were older; cardiovascular risk factors, diabetes, and ASA 4 were more frequent. The mROR scores were higher in CLTI than in IC. In diabetic patients, no difference was detected between CLTI and IC. In CLTI, non-diabetic patients had a higher mROR. The mROR score is positively correlated with the severity of PAD and can discriminate CLTI from IC. In diabetic patients with CLTI, the mROR is lower than in non-diabetic patients. The mROR score can be determined from cross-sectional imaging angiographies. It may be useful for clinicians helping with vascular case planning, as well as for scientific purposes.

Abstract 9928: Risk Stratification for Amputation in Patients With Symptomatic Peripheral Artery Disease After Lower Extremity Revascularization: Insights From VOYAGER PAD

Introduction: Amputation is a severe consequence of peripheral artery disease (PAD), and systems for risk stratification have been developed. The performance of these systems in trials of PAD patients after successful lower extremity revascularization (LER) and receiving modern medical therapies has not been well described. Hypothesis: Risk of amputation is associated with the Rutherford Chronic Limb Ischemia class as well as the wound, ischemia, and foot infection (WIfI) grade in patients with PAD after LER. Methods: Patients in the VOYAGER PAD trial were assigned a Rutherford class at baseline and follow up. A WIfI score was assigned by 2 vascular specialists blinded to outcome and treatment allocation. Incidence of the composite of first major or minor amputation through 3 years were calculated by risk group. Results: Of 6,564 randomized, Rutherford was available in 6543 and WIfI in 6471. Due to the trial’s inclusion criteria, no Rutherford 6/WIfI high risk were included. Despite successful LER, there was a stepwise increase in the risk of amputation (p<.001) with increasing baseline Rutherford classification (Figure 1A) with incidence at 3 years of 22.4% in Rutherford 5. Risk was also associated with WIfI (Figure 1B); however, those classified as “very low” risk still a 15% incidence of amputation. When stratified by diabetes mellitus (DM), those with DM were at higher risk in all WIfI classes. Those with DM classified as "very low" risk had a higher incidence of amputation than patients without DM stratified as “moderate risk”. Conclusions: In a large clinical trial of patients with symptomatic PAD post successful LER, high incidences of amputation were observed despite contemporary medical therapies. In patients eligible for the study, Rutherford and WIfI both stratify risk; however, those with WIfI “very low” risk still had high incidences of amputation. Risk in those with DM was higher in each WIfI class suggesting that this could be considered in risk stratification.

Contemporary view on chronic limb ischemia

Chronic limb ischemia is a progressive and life threatening disease which in turn effects on quality of life. Up to date several studies have been conducted to timely identify and manage of the disease. Timely identification, diagnosis and treatment of this pathological condition will play crucial role to reduce burden in healthcare associated with this disorder. In this article latest data are shown on chronic limb ischemia, its pathophysiology, and treatment and prevention measurements together with general information on this disorder. Furthermore, latest clinical trials and studies are summarized in order in depth understand the exact mechanisms of the disease.

Isolated deep femoral artery plasty in the management of peripheral arterial disease

In chronic lower limb ischemia, the deep femoral artery plays a significant role in compensating for blood circulation due to the developed collateral branches providing the blood supply to the entire limb when a superficial femoral artery occluded. Surgical plasty of the deep femoral artery, profundaplasty, has been established as a technique having long-term patency results, significantly superior to bypass operations on the femoral-popliteal-tibial segment, as well as endovascular operations. However, the clinical effectiveness of isolated deep femoral artery is often questioned, especially in patients with critical ischemia. Nowadays there are no instrumental methods to reliably assess the quality of collaterals preoperatively. The article provides an overview of published data concerning different methods of profundaplasty improving effectiveness of surgical strategy through various technical modifications. Also it is introduced the role of the plain balloon angioplasty and stenting of the deep femoral artery. It also describes existing methods for isolated profundoplasty effectiveness preoperative evaluation.

Long-Term Results of the Treatment of Patients With Chronic Ischemia of the Lower Limbs in Combination With Ischemic Heart Disease.

Aim To compare long-term outcomes of x-ray endovascular (percutaneous coronary intervention, PCI, and lower limb angioplasty with stent placement, LLA; group 1) and combination treatments (PCI and open LLA surgery; group 2) in patients with chronic lower limb ischemia (CLLI) associated with ischemic heart disease (IHD).Material and methods This retrospective study has been conducted in the Vishnevsky National Medical Research Center of Surgery since 2019. The study includes 92 patients with stage 2B CLLI associated with IHD who were managed from January 1, 2017 through December 31, 2020. Long-term outcomes were evaluated in 76 (82.6 %) patients. The endpoint was severe cardiovascular complications (CVC), including death, myocardial infarction, and acute cerebrovascular disease (ACVD).Results In group 1 during the long-term period, 1 (2.7%) fatal outcome due to pneumonia was observed. In group 2, 4 (10 %) patients died: 1 (2.5 %) patient due to ACVD, 1 (2.5 %) patient due to progression of oncological process, and 2 2 (5 %) patients due to COVID-19. Also, 2 (5.5 %) and 1 (2.5 %) cases of acute coronary syndrome (ACS) were observed in groups 1 and 2, respectively (p=0.61).Conclusion In the x-ray endovascular (group1) and the combination (group 2) intervention groups, lethal outcomes due to myocardial infarction were absent. This fact confirms the importance of PCI in patients with CLLI for prevention of possible ACS in the long-term. Both therapeutic tactics in managing CLLI patients with IHD demonstrated high safety and clinical efficacy during the hospital and long-term periods and can be extensively used in routine clinical practice.

Effectiveness of cell and gene therapy in treatment of obliterating diseases of the arteries in the lower extremities: a review

The lack of significant progress in improving the results of treatment for patients with chronic lower limb ischemia (CLLI) determines a necessity to search new approaches to solve this problem. One of the promising methods for treatment of patients with CLLI is therapeutic angiogenesis. Gene and cell therapy clinical trials for this pathology have been carried out in the world for more than 20 years and showed conflicting results. It is extremely difficult to produce a drug based on cellular material, therefore the development of gene-based therapies is more promising. In most of the analyzed studies, patients with critical limb ischemia, i.e with initially with a high risk for major amputation, were included. Since the process of neoangiogenesis takes several months, it seems more logical to use that option for treatment in the earlier stages of the disease.
 VEGF-165 is the most studied angiogenic agent. Only VEGF-165 is registered as a drug for treatment of patients with CLLI. There are publications on the effectiveness of treatment with a plasmid VEGF-165-gene therapy in patients with stages II and III of CLLI according to the FontaineA.V. Pokrovsky classification in a five-year follow-up study.

Simplification of ankle-brachial-index measurement using Doppler-waveform classification in symptomatic patients suspected of lower extremity artery disease.

ObjectivesAnkle-brachial index (ABI) is commonly used for screening lower extremity peripheral artery disease (PAD) according to the international guidelines. Arterial Doppler waveform recordings is a tool to diagnose and assess PAD severity. We hypothesized that ABI measurement could be simplified by measuring only the pressure where the best arterial flow is recorded. The aim of this study was to evaluate the concordance between ABI performed according to the American Heart Association guidelines (AHA-ABI) and ABI measured according to best arterial waveform (FLOW-ABI).DesignThis was a monocentric cross-sectional study.MethodsWe included patients with exertional limb symptoms suspected of PAD. Arterial Doppler waveforms and ABI were acquired on both lower extremities at the pedis and tibial posterior arteries. Each arterial waveform was classified using the Saint-Bonnet classification. Concordances were analyzed with the kappa coefficient (confidence interval 95%). Exercise PAD study was registered n° NCT03186391.ResultsIn total, one hundred and eighty-eight patients (62+/−12 years and 26.8+/−4.5 kg/m2) with exertional limb symptoms were included from May 2016 to June 2019. On each extremity, FLOW-ABI had excellent concordance for the diagnosis of PAD with the AHA-ABI with a kappa of 0.95 (95% CI: 0.90, 0.99) in the right extremity and 0.91 (95% CI: 0.86, 0.97) in the left extremity.ConclusionThere is almost perfect concordance between AHA-ABI and FLOW-ABI. Thus, ABI can be simplified into five pressure measurements instead of seven in patient suspected of PAD with exertional limb symptoms. The question remains in patients with chronic limb ischemia.

Topical and intravenous administration of human umbilical cord mesenchymal stem cells in patients with diabetic foot ulcer and peripheral arterial disease: a phase I pilot study with a 3-year follow-up

BackgroundDiabetic foot ulcer (DFU) is a serious chronic complication of diabetes mellitus that contributes to 85% of nontraumatic lower extremity amputations in diabetic patients. Preliminary clinical benefits have been shown in treatments based on mesenchymal stem cells for patients with DFU or peripheral arterial disease (PAD). However, the long-term safety and benefits are unclear for patients with both DFU and PAD who are not amenable to surgical revascularization.MethodsIn this phase I pilot study, 14 patients with PAD and incurable DFU were enrolled to assess the safety and efficacy of human umbilical cord mesenchymal stem cell (hUC-MSC) administration based on conservative treatments. All patients received topical and intravenous administrations of hUC-MSCs at a dosage of 2 × 105 cells/kg with an upper limit of 1 × 107 cells for each dose. The adverse events during treatment and follow-up were documented for safety assessments. The therapeutic efficacy was assessed by ulcer healing status, recurrence rate, and 3-year amputation-free rate in the follow-up phase.ResultsThe safety profiles were favorable. Only 2 cases of transient fever were observed within 3 days after transfusion and considered possibly related to hUC-MSC administration intravenously. Ulcer disclosure was achieved for more than 95% of the lesion area for all patients within 1.5 months after treatment. The symptoms of chronic limb ischaemia were alleviated along with a decrease in Wagner scores, Rutherford grades, and visual analogue scale scores. No direct evidence was observed to indicate the alleviation of the obstruction in the main vessels of target limbs based on computed tomography angiography. The duration of rehospitalization for DFU was 2.0 ± 0.6 years. All of the patients survived without amputation due to the recurrence of DFU within 3 years after treatments.ConclusionsBased on the current pilot study, the preliminary clinical benefits of hUC-MSCs on DFU healing were shown, including good tolerance, a shortened healing time to 1.5 months and a favorable 3-year amputation-free survival rate. The clinical evidence in the current study suggested a further phase I/II study with a larger patient population and a more rigorous design to explore the efficacy and mechanism of hUC-MSCs on DFU healing.Trial registration: The current study was registered retrospectively on 22 Jan 2022 with the Chinese Clinical Trial Registry (ChiCTR2200055885), http://www.chictr.org.cn/showproj.aspx?proj=135888Graphical

Frailty predicts poor longer-term outcomes in patients following lower limb open surgical revascularization.

Frailty in vascular surgery patients is increasingly recognized as a marker of poor outcome. This provides particular challenges for patients with lower limb peripheral arterial disease who require surgical revascularization. This study aimed to assess the impact of frailty on short- and long-term outcome in this specific patient group using a specialty specific frailty score. Patients undergoing open surgical revascularization for chronic limb ischemia (January 2015-December 2016) were assessed. Demographics, mode of admission, diagnosis, and site of surgery were recorded alongside a variety of frailty-specific characteristics. We calculated the previously validated Addenbrookes Vascular Frailty Score (AVFS) and Long AVFS (LAVFS). Primary outcome was 3-year mortality. Two hundred and sixty-one patients (75% men, median age 69 years) were studied. The median length of stay was 6 days with a 3-year mortality of 23%. The predictive power of vascular frailty scores showed that for 3-year mortality, area under the receiver operator curve values (AUROC) were specific for both the AVFS score (AUROC: 0.724, 95% CI: 0.654-0.794) and LAVFS Score (AUROC: 0.741, 95%CI: 0.670-0.813). Furthermore, the cumulative AVFS and LAVFS scores both predicted mortality over the follow-up period (P=0.0001) with increased mortality among patients with higher scores. Incremental worsening of frailty, determined using a specialty specific frailty score, predicts mortality risk in patients undergoing lower limb surgical revascularization.

A Study of the Peripheral Vessels in Patients With Type 2 Diabetes Mellitus With or Without Foot Involvement.

Peripheral vascular disease (PVD) is chronic limb ischemia caused by atherosclerosis of the peripheral arteries. Diabetes mellitus (DM) is a risk factor for this disease. The probability of a diabetic foot ulcer (DFU) is higher in a patient with DM and PVD than in a patient without DM. Ankle-brachial-pressure index (ABPI) allows the measurement of blood flow towards the distal extremities, which could help timely diagnosis, initiate brief therapy, and minimize the risk of critical limb ischemia and loss. This study aims to determine the prevalence of peripheral vascular disease and assess its association with intima-media thickness (IMT) in diabetic patients with and without foot ulcers in India. In the present study, we included all type 2 DM patients. The assessment was conducted clinically by measuring Ankle Brachial Pressure Index (ABPI) radiologically by Duplex Ultrasonography (Samsung HS 70A machine), and Doppler (Linear probe- LA3 - 12A) and IMT were detected. In healthy adults, IMT ranges from 0.25 to 1.5mm, and values above 1.0mm are often considered abnormal and linked with atherosclerosis and significantly increased cardiovascular disease (CVD). In this study, 72 patients with DM were enrolled over the study period; 52 patients presented with DFU, and 20 presented without DFU. The prevalence of PVD was higher in males compared to females; 40% of the patient population in the age range of 40-49 years was with PVD, and 62.5% of patients with PVD showed an IMT value more than 1.0mm, whereas only 5% patients without PVD shows IMT value more than 1.0mm. In conclusion, among type 2 diabetic subjects, the prevalence of PVD is 72.2%, and IMT is strongly associated with PVD.

CYP2C19 genotype-guided antithrombotic treatment versus conventional clopidogrel therapy in peripheral arterial disease: study design of a randomized controlled trial (GENPAD)

Clopidogrel is recommended in international guidelines to prevent arterial thrombotic events in patients with peripheral arterial disease (PAD). Clopidogrel itself is inactive and metabolism is dependent on the CYP2C19 enzyme. About 30% of Caucasian PAD patients receiving clopidogrel carry 1 or 2 CYP2C19 loss-of-function allele(s) and do not or to a limited extent convert the prodrug into its active metabolite. As a result, platelet inhibition may be inadequate which could lead to an increased risk of adverse clinical events related to arterial thrombosis. A CYP2C19 genotype-guided antithrombotic treatment might be beneficial for PAD patients. GENPAD is a multicenter randomized controlled trial involving 2,276 PAD patients with an indication for clopidogrel monotherapy. Patients with a separate indication for dual antiplatelet therapy or stronger antithrombotic therapy are not eligible for study participation. Patients randomized to the control group will receive clopidogrel 75 mg once daily without pharmacogenetic guidance. Patients randomized to the intervention group will be tested for carriage of CYP2C19 *2 and *3 loss-of-function alleles, followed by a genotype-guided antithrombotic treatment with either clopidogrel 75 mg once daily for normal metabolizers, clopidogrel 150 mg once daily for intermediate metabolizers, or acetylsalicylic acid 80 mg once daily plus rivaroxaban 2.5 mg twice daily for poor metabolizers. The primary outcome is a composite of myocardial infarction, ischemic stroke, cardiovascular death, acute or chronic limb ischemia, peripheral vascular interventions, or death. The secondary outcomes are the individual elements of the primary composite outcome and clinically relevant bleeding complications. The aim of the GENPAD study is to evaluate the efficacy, safety, and cost-effectiveness of a genotype-guided antithrombotic treatment strategy compared to conventional clopidogrel treatment in PAD patients.

Composite Grafts as an Alternative Conduit to Prosthetic Grafts in Below Knee Femoro-popliteal Bypass in Patients of Chronic Lower Limb Ischemia

Composite Grafts as an Alternative Conduit to Prosthetic Grafts in Below Knee Femoro-popliteal Bypass in Patients of Chronic Lower Limb Ischemia

Predictors of Long-Term Complications of Femoropopliteal Bypass with Autovenous Graft

INTRODUCTION: Atherosclerotic lesion of lower limb arteries often occurs with the development of chronic and later with critical ischemia of the lower limbs. Revascularization in these conditions has always been at the center of attention of vascular surgeons worldwide.
 AIM: To analyze long-term complications after femoropopliteal bypass (FPB) with the autovenous graft.
 MATERIALS AND METHODS: This retrospective open study was conducted in Scientific the Research Institute Regional Clinical Hospital No. 1 named after Professor S. V. Ochapovsky (Krasnodar) in the period from January 10, 2016, to December 25, 2019, and included 464 patients who underwent FPB with venous autograft. The following autovenous conduits were used: n = 266, reverse vein (great saphenous vein (GSV)); n = 59, autovein (GSV) prepared in situ; n = 66, autovein (GSV) prepared ex situ; and n = 73, veins of an upper limb. The long-term follow-up period was 16.6 10.3 months.
 RESULTS: During the postoperative hospital period, single cases of lethal outcome and myocardial infarction were noted. No ischemic strokes were recorded. Shunt thrombosis developed in 4.5% of the patients, and 2.1% required limb amputation. Postoperative wound revision caused by bleeding was performed in 1.7% of the cases. In the remote follow-up period, adverse cardiovascular events were noted in every fifth patient (21.8%). Shunt thrombosis was diagnosed in 17.4% of cases, and limb amputation was performed in 5.1% of the cases. To identify the factors for poor prognosis, the whole sample was divided to two groups: group 1 (n = 366) included those without long-term complications and group 2 (n = 99) comprised patients with long-term complications. Using the odds ratio (OR), the following predictors of adverse cardiovascular events were identified: degree I obesity (р 0.0001; OR = 3.24; 95% confidence interval (CI) = 1.935.43), degree II obesity (р = 0.0005; ОR = 4.84; 95% CI = 1.7113.67), and stage IIB chronic lower limb ischemia (CLLI) (р = 0.0006; ОR = 2.24; 95% CI = 1.423.52). Protective factors were postinfarction cardiosclerosis (р = 0.04; ОR = 0.51; 95% CI = 0.270.95), excessive body mass (р = 0.01; ОR = 0.56; 95% CI = 0.350.88), and stage IV CLLI (р = 0.01; ОR = 0.53; 95% CI = 0.320.86).
 CONCLUSIONS: FPB with venous autograft is characterized by a low frequency of complications in the hospital and long-term follow-up periods, making this technique a method of choice for the open surgical treatment of patients with extended atherosclerotic lesion of the superficial femoral artery. Predictors of adverse cardiovascular events in the long-term period are degree I obesity, degree II obesity, and stage IIB CLLI. Protective factors against the development of long-term surgical complications are postinfarction cardiosclerosis, overweight, and stage IV CLLI. The presented results should be considered when constructing stratification risk scales for adverse cardiovascular events in patients who underwent FPB. Precision management of patients with identified predictors of complications will allow the reduction of the risks for the development of these conditions and increase long-term survival free from shunt thrombosis and limb amputation.

Identification of coronary artery lesions and tactics of surgical treatment in patients with chronic lower limb ischemia

Introduction. Ischemic heart disease is undoubtedly the main factor that significantly aggravates the condition of patients with chronic lower limb ischemia in the perioperative period.Aim. To establish the expediency of mandatory performance of selective polypositional coronary angiography in patients with chronic ischemia of the lower extremities to determine the stages of surgical intervention and prevent cardiac complications.Materials and methods. The study included 285 patients, treated to the Department of arterial pathology surgery of the Bakulev National Medical Research Center of Cardiovascular Surgery with a diagnosis of chronic lower limb ischemia. The patients were divided into 2 groups. The main group included 139 patients admitted in 2016. The control group – 146 patients admitted in 1989. In the main group, all patients underwent coronary angiography. In the control group, coronary angiography was performed only in patients with a clinical picture of coronary artery disease or in asymptomatic patients after positive stress tests.Results and discussion. After analysis of coronary angiograms in patients of the main group, out of 139 patients included in the study, 124 (89.2%) had a lesion of at least 1 coronary artery >50%; and in 101 (72.7%) patients, at least 1 coronary artery was affected >70%. In the main group, cardiac complications were noted in 6 (4.32%) patients, while in the control group they were detected in 21 (14.4%) cases. These complications appeared due to the underestimation of the state of the coronary bed, based only on the results of stress tests.Conclusions. Selective polypositional coronary angiography is the main method for detecting asymptomatic significant coronary artery disease in patients with CLCI, which improves the immediate results of surgical treatment by reducing the incidence of cardiac complications.

The clinic surgeon as the main link in the treatment of patients with chronic ischemia of the lower extremities of atherosclerotic genesis

Introduction. An alternative way in the treatment of intermittent claudication is the use of genetic engineering technologies that lead to the stimulation of their own vasculogenesis in ischemic limbs. Treatment is carried out on an outpatient basis.Purpose: to present the results of complex conservative treatment using a drug based on a plasmid with the VEGF165 gene in patients with grade II CINI according to the Fontaine – A.V. Pokrovsky classification for 7 years after one course of gene therapy.Materials and methods. From 2009 to 2015, 50 patients were treated. Men – 41, women – 9. Average age 64.3 ± 10.5 years. All patients received basic therapy for atherosclerosis. In addition, a 1.2 mg gene preparation was injected twice into the muscles of the ischemic limb. The preservation of the limb, the survival rate of patients, the change in the distance of painless walking according to the treadmill test were assessed.Results and discussion. The safety of the limb after 7 years was 94%, the survival rate was 80%. Significant and moderate clinical improvement was noted in 68% of cases, satisfactory result – 6%, deterioration – 2% of patients. Only in 6% of cases there was an unfavorable outcome associated with the progression of chronic limb ischemia. All patients showed good tolerance to the drug and no side effects. Continuous conservative treatment of patients with peripheral atherosclerosis is the key factor preventing rapid progression of the disease. There is high requirement for the development of new areas of the combination treatment, which would lead to compensation of blood circulation in the extremities in peripheral atherosclerosis. The provided innovative treatment method with widespread introduction into outpatient practice will improve the quality of life of patients with intermittent claudication.Conclusions. Long-term results of treatment of patients with grade II CINI using gene therapy have been demonstrating high efficiency for 7 years. The presented innovative method of treatment, with its widespread introduction into outpatient practice, will improve the quality of life of patients with intermittent claudication by increasing the passable distance without pain in the legs, reduce the risk of ischemia progression, and minimize the burden on the healthcare system.

Effectiveness and safety of anticoagulant versus antiplatelet therapy in patients after endovascular revascularisation of the lower limb

Background. Patients with peripheral arterial disease (PAD) are routinely prescribed antiplatelet treatment (APT) after revascularisation. An exception are patients who receive anticoagulant treatment (ACT) due to comorbidity. We set out to determine possible differences in the effectiveness and safety between ACT and APT in patients who underwent endovascular revascularisation of the lower limb arteries.
 
 Methods. In a single-centre retrospective study, we analysed the data of 1,587 consecutive patients with PAD who underwent successful endovascular revascularisation of the lower limb arteries due to disabling intermittent claudication or chronic critical limb ischemia in a 5-year period. Patients were divided in the ACT and APT group based on their prescribed treatment. After balancing both groups' baseline characteristics and cardiovascular risk factors with propensity score matching (PSM), we compared the effectiveness and safety of both treatment regimens in the first year afterrevascularisation.
 
 Results. Compared to patients with APT, patients with ACT were older, more often reported arterial hypertension, diabetes, chronic kidney disease, congestive heart failure, ischaemic heart disease, and a history of stroke or transient ischaemic attack. After PSM, the odds ratio (OR) for an effective outcome with ACT versus APT was 0.78 (95% CI 0.39–1.59; p=0.502), while the OR for a safe outcome with ACT versus APT was 4.12 (95% CI 0.82–20.73; p=0.085).
 
 Conclusions. Patients who required ACT were older, had more cardiovascular risk factors, and more advanced PAD than patients with APT. After matching, we found no statistically significant difference in the effectiveness and safety of both treatment regimens.
 

Chronic Limb Ischemia due to Thrombosis of an Aneurysmal Degeneration of the Autogenous Vein Graft: A Case Report.

Nonanastomotic aneurysmal degeneration of a great saphenous vein graft is an unusual condition, despite the common use of this conduit in arterial reconstructions. Vein grafts are at risk of degenerative changes, but the real cause remains unknown. Postoperative graft surveillance with duplex ultrasound scanning is important for maintaining patency of the venous graft. We present a rare case of chronic limb ischemia due to partial thrombosis of an aneurysm of the great saphenous vein graft.

Factors Affecting Mortality of Critical Limb Ischemia 1 Year after Endovascular Revascularization in Patients with Type 2 Diabetes Mellitus.

BACKGROUNDChronic limb ischemia (CLI) is strongly associated with increased mortality in diabetes patients.OBJECTIVEThe aim of this study was to evaluate factors affecting mortality within 1 year after endovascular revascularization in CLI patients.METHODSThis retrospective cohort study was based on medical records from the Integrated Cardiovascular Centre of Dr. Cipto Mangunkusumo National General Hospital, a tertiary care hospital in Jakarta, Indonesia. The study included 199 CLI patients with type 2 diabetes mellitus (T2DM) who underwent endovascular revascularization from January 2008 to June 2018. The patients were followed up for 1 year after endovascular revascularization. Kaplan-Meier and Cox proportional hazard analysis was used to analyze the data.RESULTS1-year survival probability was 58.8%. Cox proportional hazard analysis showed that duration of diabetes (HR 3.52; 95% CI 1.34-9.22), anemia (HR 2.59; 95% CI 1.47-4.56), and smoking (HR 2.49; 95% CI 1.46-4.27) were significantly associated with mortality within 1 year after endovascular revascularization.CONCLUSIONSIn T2DM patients with CLI, duration of diabetes, anemia and smoking were associated with a higher risk of mortality within 1 year post endovascular revascularization

Abstract P039: Low-density Lipoprotein Management In Patients With Peripheral Artery Disease With And Without Severe Hypercholesterolemia In A Largely Rural Population

Background: Elevated low-density lipoprotein cholesterol (LDL) is associated with increased risk for peripheral artery disease (PAD) and major limb or adverse cardiovascular events. We aimed to compare the prevalence and appropriate lipid-lowering treatment of patients diagnosed with PAD with and without prior phenotypic severe hypercholesterolemia (SH) in a large, rural healthcare system. Methods: Retrospective study of ambulatory adults with a lipid panel at Essentia Health clinics obtained between 7/1/2016-6/30/2019 (MN, WI, and ND, USA) with PAD on the problem list (defined based on ICD-9/10 codes). Patients were divided into two groups, PAD only and PAD with SH. Phenotypic SH was defined as any prior LDL ≥ 190 mg/dL. Patients were excluded if they were currently pregnant (n=232) or if they did not have repeat LDL > 30 days apart (n=1684). High-intensity statin was considered atorvastatin 40mg or 80mg or rosuvastatin 20mg or 40mg daily. Results: A total of 10,874 patients were previously diagnosed with PAD (mean age 40.4 + 10.9, 43.3% female (N=4711), 58.1% rural (N=6319). A total of 13.6% (N=1484) had SH. Patients with PAD and SH were more likely to be female, urban, have prior acute limb ischemia, stroke/transient ischemic attack, and were less likely to have diabetes or chronic limb ischemia than patients with PAD only. Patients with PAD and SH were more likely to be on a high intensity statin than those with PAD only (65.8% (N=977) vs. 51.3% (N=4813); p<0.001). Very few patients received no lipid-lowering therapy (PAD with SH 0.7% (N=10) vs. PAD alone 2.1% (N=234). More patients with PAD and SH received PCKS9 inhibitors (2.5% (N=37) vs 0.4% (N=39); p<0.001) and ezetimibe (23.4% (N=347) vs. 8.1% (N=760); p<0.001) than patients with PAD only. Approximately 50% (N=749) of PAD with SH patients achieved a 50% lowering from peak LDL compared to 28.9% (N=2717) with PAD only. Mean LDL in the PAD with SH was 113.9 + 43.4 mg/dL compared to 81.8 + 29.1 mg/dL in patients with PAD without SH. However, fewer patients with PAD and SH achieved a LDL <70 mg/dL compared to those with PAD only (13.3% (N=197) vs 37.1% (N=3487), p< 0.001). Conclusion: One in 10 patients with PAD has a history of SH and majority are not achieving target LDL<70mg/dL. There is an urgent need for more aggressive lipid-lowering therapy for all patients with PAD.

Comparative characteristics of postoperative outcomes of different treatment strategies of patients with intermittent claudication in combination with coronary arteries disease.

Aim To compare in-hospital outcomes (severe cardiovascular complications, CVC) in patients with IIB stage chronic lower limb ischemia (CLLI) in combination with ischemic heart disease (IHD) in the following groups: stepwise percutaneous coronary intervention (PCI) and stenting and angioplasty of lower limb arteries (LLA) (group 1) and combination treatment, including PCI and open surgery on LLA (group 2).Material and methods Since 2019, the A.V. Vishnevsky National Medical Research Center of Surgery has performed a retrospective study that includes patients with stage IIB CLLI in combination with IHD. Patients were divided into 2 groups: group 1 (n=46), stepwise X-ray endovascular treatment (PCI and stenting and angioplasty of LLA); group 2 (n=46), stepwise combination treatment (PCI and open surgery on LLA). The endpoint included severe CVCs (death, acute myocardial infarction, acute cerebrovascular disease) and severe complications in the LLA area (stent thrombosis, repeated intervention on LLA, amputation).Results In 198 surgeries, none of 92 patients had severe CVC, and no fatal outcomes were observed. In group 2, there was one (2.1 %) severe complication on LLA during the early postoperative period, for which a successful additional intervention was performed.Conclusion Individualized approach to care of each patient with LLA pathology in combination with IHD helps avoiding severe CVCs at the hospital stage. It was shown that X-ray endovascular and combination treatments are safe and effective in the absence of fatal outcomes and acute disorders of coronary circulation at the hospital stage.