Claudication Pain Research Articles

Gait variability is affected more by peripheral artery disease than by vascular occlusion.

BackgroundPatients with peripheral artery disease with intermittent claudication (PAD-IC) have altered gait variability from the first step they take, well before the onset of claudication pain. The mechanisms underlying these gait alterations are poorly understood.AimsTo determine the effect of reduced blood flow on gait variability by comparing healthy older controls and patients with PAD-IC. We also determined the diagnostic value of gait variability parameters to identify the presence of PAD.MethodsA cross-sectional cohort design was used. Thirty healthy older controls and thirty patients with PAD-IC walked on a treadmill at their self-selected speed in pain free walking (normal walking for healthy older controls; prior to claudication onset for PAD) and reduced blood flow (post vascular occlusion with thigh tourniquet for healthy older controls; pain for PAD) conditions. Gait variability was assessed using the largest Lyapunov exponent, approximate entropy, standard deviation, and coefficient of variation of ankle, knee, and hip joints range of motion. Receiver operating characteristics curve analyses of the pain free walking condition were performed to determine the optimal cut-off values for separating individuals with PAD-IC from those without PAD-IC.Results and discussionPatients with PAD-IC have increased amount of variability for knee and hip ranges of motion compared with the healthy older control group. Regarding the main effect of condition, reduced blood flow demonstrated increased amount of variability compared with pain free walking. Significant interactions between group and condition at the ankle show increased values for temporal structure of variability, but a similar amount of variability in the reduced blood flow condition. This demonstrates subtle interactions in the movement patterns remain distinct between PAD-IC versus healthy older controls during the reduced blood flow condition. A combination of gait variability parameters correctly identifies PAD-IC disease 70% of the time or more.ConclusionsGait variability is affected both by PAD and by the mechanical induction of reduced blood flow. Gait variability parameters have potential diagnostic ability, as some measures had 90.0% probability of correctly identifying patients with PAD-IC.

An Observational Study to Analyze Outcome of Omentopexy in Buerger’s Disease in Tertiary Care Center

Thromboangiitis obliterans (TAO) or Buerger’s disease (BD) is a non-atherosclerotic, segmental occlusive inflammatory disease that commonly affects small and medium arteries and veins in the upper and lower limbs. Our purpose of this study was to evaluate outcome of lumbar sympathectomy and omentopexy in patients with Buerger’s disease by assessing neovascularization and good clinical recovery. Thirty consecutive patients underwent omentopexy for Buerger’s disease of lower limb from June 2019 to June 2020 in our institute. Patients were followed up for 3 months postoperatively for relief of intermittent claudication and rest pain. The ulcer and amputation site healing were assessed. The oxygen saturation level was also measured and postoperative complication was noted. The mean age was 45 ± 5.5 years and male to female ratio was 29:1. Out of 30 patients, 26 (86.7%) patients had omentopexy up to below knee level, 3 (10%) patients at ankle level, and 1 (3.3%) patient up to above knee level. All patients had relief of rest pain and 25 (83.3%) patients had relief of intermittent claudication on 3rd month. Three patients who had non-healing ulcers showed ulcer healing and 27 patients who had gangrene showed healing at amputation site at 3rd month. Omentopexy improve oxygen saturation and temperature of the affected limb and helps in clinical recovery in terms of relief in intermittent claudication, rest pain, and ulcer healing. Thus, it can be considered as an effective modality for the management of Buerger’s disease as limb salvage procedure.

Effects of Exercise Mode on Arterial Stiffness in Symptomatic Peripheral Artery Disease Patients: A Randomized Crossover Clinical Trial

Exercise program has been recommended for the treatment of symptomatic peripheral artery disease (PAD) patients. However, whether exercise promotes reduction in arterial stiffness in these patients, who exhibit high arterial stiffness, is poor known. To analyze the effects of a single session of resistance, walking, and combined exercises on arterial stiffness in symptomatic PAD patients and to describe individual responses and identify clinical predictors of arterial stiffness responses after exercises. Twelve patients with symptomatic PAD underwent four experimental sessions in random order: walking exercise (W - 10 bouts of 2-min walking at the speed corresponding to the onset of claudication pain with 2-min interval among sets), resistance exercise (R - 2 sets of 10 reps in eight resistance exercises), combined exercise (CO - 1 set of 10 reps in eight resistance exercises + 5 bouts of 2-min walking with 2-min interval between) and control session (C - resting in exercise room). Ambulatory arterial stiffness index (AASI) was obtained during ambulatory period after each session. Body mass index, ankle brachial index, sex and age also were evaluated. AASI was lower in R compared to other sessions (R - 0.52 ± 0.05; W - 0.59 ± 0.05; CO - 0.64 ± 0.05; C - 0.60 ± 0.05, P < 0.001), with 75% of patients presenting lower AASI after R session. No difference was found between W, CO and C sessions (P> 0.05). Ankle brachial index was negatively correlated with R and W sessions net effect (r = -0.618 and -0.750, respectively; P< 0.05 for both), no correlation was found with CO. A single bout of resistance exercise acutely reduces arterial stiffness in symptomatic PAD, while walking and combined exercise did not alter this variable. This response is more likely to occur in individuals with less severe disease.

Patients with failed femoropopliteal covered stents are more likely to present with acute limb ischemia than those with failed femoropopliteal bare metal stents

ObjectiveCovered stents (CS) to treat superficial femoral artery (SFA) occlusive disease have become more common. However, concerns about patients presenting with acute limb ischemia (ALI) after failure due to coverage of important collaterals have been raised. Herein, we determine if CS are associated with ALI after failure. MethodsVascular Quality Initiative peripheral vascular intervention and infrainguinal bypass datasets were queried from 2010 to 2020 for patients who underwent SFA stenting with a bare metal stent (BMS) or CS and who also had a subsequent ipsilateral SFA endovascular reintervention or bypass recorded in the Vascular Quality Initiative. The initial SFA stenting procedure will be referred to as the index procedure and the subsequent procedure will be referred to as the reintervention. Patients with aneurysmal pathology, prior infrainguinal bypass, and ALI at the index procedure were excluded. Patients with pre-index inflow/outflow procedures were not excluded. The primary outcome was ALI at reintervention. Other outcomes included higher degree of ischemia (claudication vs rest pain vs tissue loss vs ALI) and reoperative factors. Predictors of the primary outcome were determined with multivariable logistic regression. The index treatment length and pre-index ankle-brachial index were forced into the model. ResultsThere were 3721 patients: 3338 with index BMS, 383 with index CS. The mean patients age was 66.3 ± 11.0 years and 59.2% were male. Baseline covariates were similar between the groups; during the index procedure, more patients with BMS underwent plain balloon angioplasty (68.7% vs 62.1%; P = .001) and had shorter total index treatment length (median, 15.0 cm [interquartile range, 10.0-25.0 cm] vs 20.0 cm [interquartile range, 12.0-30.0 cm]; P < .001). At reintervention, ALI was the presenting symptom for 12.0% of the CS cohort vs 6.3% of the BMS cohort (P < .001). More patients with an index CS underwent major amputation at the time of reintervention (2.6% vs 1.0%; P = .006). Reinterventions for the patients with a CS more often used bypass, pharmacologic thrombolysis, and mechanical thrombolysis. CS at the index procedure was a predictor of ALI at reintervention (odds ratio, 1.87; 95% confidence interval, 1.31-2.65; P = .001) while controlling for age, time difference between procedures, body mass index, chronic obstructive pulmonary disorder, preoperative anticoagulation and antiplatelet, prior carotid intervention and major amputation, index procedure fluoroscopy time and treatment length, and pre-index ankle-brachial index. ConclusionsIn patients undergoing reintervention for failed SFA stents, CS are more likely to present with ALI than those with failed SFA BMS.

Efficacy of Rotational Atherectomy Followed by Drug-coated Balloon Angioplasty for the Treatment of Femoropopliteal Lesions—Comparison with Sole Drug–coated Balloon Revascularization: Two-year Outcomes

We aimed to evaluate the results of the combined use of rotational atherectomy (RA) followed by drug-coated balloon (DCB) treatment against DCB angioplasty alone in patients who had significantly calcified and symptomatic femoropopliteal peripheral arterial disease. Patients presented to the clinic with symptoms of chronic limb ischemia of femoropopliteal segment such as moderate or severe claudication and rest pain, who received endovascular therapy between January 2016 and January 2018 in our hospital comprised the study cohort and investigated, retrospectively. Patients with minor or major tissue loss were excluded from the study. We evaluated the effect of RA system followed by DCB with DCB alone in 121 patients and a total of 226 significantly calcified and symptomatic femoropopliteal lesions. Fifty-eight patients and 112 (49.5%) lesions were treated with RA+DCB, whereas 63 patients and 114 (50.5%) lesions were treated with DCB only. The mean age was 61.2±9.7years. Primary patency is evaluated with duplex ultrasound/angiography at 6, 12, and 24months and with angiography on 12 and 24months. Patients were followed up for 24months to assign clinically driven target lesion revascularization (TLR). Overall survival rates were 96.5% (56/58) in RA+DCB group and 93.6% (59/63) in DCB alone group both at one-year and two-year follow-up. Amputation-free survival rates of RA+DCB and DCB-only groups are 96.5% (56/58) to 87.3% (55/63) at one year, and 94.8% (55/58) to 82.5% (52/63) at two years, respectively. Baseline characteristics of groups were similar. The lesions were longer in the RA+DCB group than the DCB alone group (14.4±5.2cm vs. 10.2±3.1cm; P=0.05). The technical success rate in the RA+DCB group was superior to that of DCB-only group (95.4% vs. 84.8%, P=0.006). The 12-month and 24-month patency rates with angiography in the RA-DCB group were similar to those in the DCB-only group (85.7% vs. 74.6% and 73.2% vs. 62.7%, respectively). The rates of bailout stenting were significantly lower among patients treated with RA+DCB (n=3; 5.1% vs. n=13; 20.6%, P<0.001). The rates of flow-limiting dissections and vessel recoils after procedures were significantly in RA+DCB group (n=2; 3.4% vs. n=8; 12.6%, P<0.001) than DCB only (n=1; 1.7% vs. n=4; 6.3%, P<0.002). The freedom from TLR rate was significantly increased in the RA+DCB group at 12months (95.2% vs. 76.3%, P=0.002) and 24months (93.4% vs. 63.7%, P=0.002). The mean ankle brachial index at discharge in the RA-DCB group improved by 0.35±0.24, and in the DCB-only group, it was 0.30±0.23 (P=0.683). Combined use of RA and DCB treatment is an effective, safe, and durable method for the treatment of the complex femoropopliteal lesions. Combination of RA and DCB angioplasty reveals increased technical success, fewer flow-limiting dissections, significantly reduced TLR, and bailout stenting rates compared with sole DCB angioplasty.

Long Term Results of Stem Cell Therapy in Patients with Peripheral Arterial Disease (PAD)

Peripheral Arterial Disease (PAD) is still a challenging condition affecting millions of people and leading to amputation or death. In patients with non reconstructable disease or failed revascularization, stem cell therapy (SCT) could help in promoting angiogenesis and limb salvage. However, there is limited data about the long-term benefits of SCT in such patients. Aim of this study is to evaluate the long-term survival and clinical outcomes in PAD patients who underwent stem cell therapy. All patients who underwent stem cell therapy using intramuscular injections of autologous bone-marrow mononuclear cells (BM-MNCs) for the treatment of PAD between January 2011 and November 2020 were include in the study. Electronic medical records (EMRs) and Telephonic phone follow up was used to get baseline clinical characteristics and follow up data. Out of 3627 PAD patient, 41 patients underwent stem cell therapy procedure between January 2011 to November 2020. Mean age was 48 years (range, 21 to 75 years) and 37 patients (90.24%) were males. The median follow-up period was 4.66 years (range, 6 months – 9.9 years). Indication for SCT was rest pain, gangrene or non-healing ulcer due to either non reconstructable disease or failed revascularization. All patients were given antiplatelets and statin therapy. Out of 41 PAD patients, 7 patients were lost to follow up. In the remaining, 34 patients, 29 (70.73%) patients were alive, and 5 patients were dead. Overall, 10 (24.39%) patients underwent ipsilateral amputation and 4 patients had persistent claudication pain. In the remaining patients’ ulcers healed and has no residual pain. Amputation free survival was 75.61%. The benefits of Autologous BM-MNCs stem cell therapy are sustained even in the long term with overall survival rate was 85.29% and the amputation free survival was 75.61% and should be considered for all CLI patients irrespective of age.

Validating Effect of Sulodexide in Treatment of Claudication Pain and Chronic Limb-Threatening Ischemia

Background: Peripheral arterial disease is a chronical disease which can lead to a sever quality of life reduction and in certain cases there is no indication or even possibility for revascularization and these patients are reliant on conservative therapy such as Sulodexide medication. Objective: In the retrospective study we evaluated effect of newly administrated Sulodexide therapy for patients with peripheral arterial disease both in cases of claudication pain and patients with chronic limb-threatening ischemia (CLTI). Methods: During a three year period we started Sulodexide therapy in 34 claudication and 38 CLTI cases with no contemporary revascularization procedure. Patients were followed for 4 and 8 months with claudication interval, Rutherford classification and CLTI evaluation. Results: We observed overall positive effect of Sulodexide in both groups. In claudication group there was a prolongation of average pain-free walking distance (PFWD) from 144 m at the baseline to 376 m at 4 months and 430 m at 8 months. In the second group all 38 patients started with CLTI symptoms, after 4 months 6 patients remained with CLTI and after 8 months 3 more had recurrence of CLTI. Conclusion: We observed a significant improvement both in PFWD in claudication sub-group and even in a clinical status of majority of the patients in CLTI sub-group. This effect of Sulodexide on CLTI patients was not yet thoroughly described in any available literature. According to our observations, Sulodexide seem to be a potent auxiliary therapy for patient with peripheral arterial disease even in the case CLTI.

Surgical treatment of patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis using minimally invasive bilateral decompression

Objective. To analyze clinical and radiological outcomes of minimally invasive bilateral decompression through a unilateral approach in the treatment of patients with degenerative grade I spondylolisthesis combined with lumbar spinal stenosis. Material and Methods. A total of 28 patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis at one or several levels with clinical manifestations of neurogenic intermittent claudication and low back pain were operated on using the method of bilateral microsurgical decompression through a unilateral approach. The minimum follow-up period was 1 year. Clinical outcomes was assessed using VAS, Oswestry and MacNab questionnaires. Central stenosis of the spinal canal was graded according to Shizas classification based on MRI data, and the degree of segment stability according to Hanley and progression of spondylolisthesis in a neutral position were assessed by a functional lumbar spondylograms before surgery and in the long-term period. Results. The average hospital stay was 3.07 ± 0.26 days. The average duration of the operation was 145.07 ± 44.67 minutes. When assessing pain by VAS questionnaire, a significant decrease in the median value of the intensity of pain was noted: in the leg – from 7.0 [7.0; 8.0] to 1.0 [1.0; 2.0], in the back – from 5.0 [4.0; 5.0] to 1.0 [1.0; 2.0]. The ODI questionnaire showed a decrease in the median indicator of disability from 60.0 [56.0; 64.0] to 15.0 [12.0; 19.0]. Assessment of radiological outcomes showed a slight increase in the parameters of anteroposterior translation (on average +0.42 mm) and segmental rotation (on average +1.03 degrees) of the operated segment during functional tests, and a slight increase in spondylolisthesis (on average by 1.42 %), which in general did not affect clinical outcomes. Conclusion. Retrospective analysis of minimally invasive bilateral decompression through unilateral approach in patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis without segmental instability provided the evidence of significant clinical efficacy of the method with a low risk of iatrogenic segment instability in the late postoperative period.

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass

The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8kg/m2 vs. 28kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P<0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P<0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P<0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P>0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P>0.05). Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.

Investigation of Roll-Over Characteristics in Healthy Old Individuals and Patients With Peripheral Artery Disease

Atherosclerotic blockages in the leg arteries, cause leg pain with ambulation (called claudication), impair gait and substantially reduce the walking ability of patients with peripheral artery disease (PAD). Ankle-foot orthoses are being developed and applied so patients can walk more and with less pain. Roll-over shape (ROS) is a potential design objective for such assistive devices. In the proposed work, we study roll-over characteristics in patients with PAD and healthy older subjects. Gait data of ten healthy older individuals (Age: 72.8 ± 5.5 years) and twenty patients with PAD (Age: 64.1 ± 6.6 years) were collected at self-selected walking speed. In patients with PAD, gait data were collected before the onset of pain and after claudication pain was induced. To generate ROS, the center of pressure data was transformed to the shank-based coordinate system and circular arcs were fit using an optimization program in MATLAB. Independent t-tests with Bonferroni corrections were used to separately compare roll-over radius differences (p<0.05) between healthy older to both walking conditions in patients with PAD. The mean roll-over radius was not significantly different between healthy older vs PAD pain-free (p=0.468) or PAD pain-induced (p=0.289) walking conditions. Our results indicate invariance of ROS radius in patients with PAD, which is consistent with previous literature showing general invariance of ROS in healthy young individuals. Previous biomechanical studies show gait kinematics and kinetics are more affected by PAD than by age. Future studies should focus on the potential adaptive mechanisms in patients with PAD achieving invariant ROS.

Profile of Peripheral Arterial Disease in Type 2 Diabetes Mellitus - A Hospital-based observational study in Coastal Karnataka

Introduction: Ankle Brachial Index (ABI) is one of the common non-invasive diagnostic tools available for diagnosing Peripheral Arterial Disease (PAD). However, it has been observed that for an individual diagnosed with both PAD and Type 2 Diabetes Mellitus (T2DM), ABI tends to give false diagnostic value because of the calcification of the major lower limb arteries. Therefore, the health care professionals are at times misled for the diagnosis of PAD. To overcome this another diagnostic tool Toe Brachial Index (TBI) was suggested to perform. However, there is limited literature on performing both ABI and TBI in the given population in a single study.Aim:The main focus of this study is to report the profile of ABI and TBI along with classical symptoms like claudication pain, palpation of pulse and history of T2DM for the screening and diagnosis of PAD in T2DM.Materials And Methods: In this cross-sectional observational study, a total of 121 participants diagnosed with T2DM were recruited for the study as per the inclusion criteria. Detailed demographic details of the participants were noted. Diagnostic tool including both ABI and TBI were performed for all the participants and the data was analysed.Results:Among 121 participants, only 3 participants had both ABI and TBI positive indicating positive diagnostic test for PAD and 106 participants had both ABI and TBI negative. However, in the remaining 12 participants, 10 showed TBI positive but ABI negative and 2 had ABI positive but TBI negative.Conclusions: Based on our study we have reported the profile of PAD in T2DM individuals, which is found to be 10.75.%. Therefore, it can be concluded that ABI and TBI both should be performed to rule out any complication. This will be beneficial in early screening and detection of neuro ischemic changes in foot and subsequently to prevent amputation.

Lumbar degenerative spondylolisthesis: factors associated with the decision to fuse

BACKGROUND CONTEXTThe indication to perform a fusion and decompression surgery as opposed to decompression alone for lumbar degenerative spondylolisthesis (LDS) remains controversial. A variety of factors are considered when deciding on whether to fuse, including patient demographics, radiographic parameters, and symptom presentation. Likely surgeon preference has an important influence as well. PURPOSEThe aim of this study was to assess factors associated with the decision of a Canadian academic spine surgeon to perform a fusion for LDS. STUDY DESIGN/SETTINGThis study is a retrospective analysis of patients prospectively enrolled in a multicenter Canadian study that was designed to evaluate the assessment and surgical management of LDS. PATIENT SAMPLEInclusion criteria were patients with: radiographic evidence of LDS and neurogenic claudication or radicular pain, undergoing posterior decompression alone or posterior decompression and fusion, performed in one of seven, participating academic centers from 2015 to 2019. OUTCOME MEASURESPatient demographics, patient-rated outcome measures (Oswestry Disability Index [ODI], numberical rating scale back pain and leg pain, SF-12), and imaging parameters were recorded in the Canadian Spine Outcomes Research Network (CSORN) database. Surgeon factors were retrieved by survey of each participating surgeon and then linked to their specific patients within the database. METHODSUnivariate analysis was used to compare patient characteristics, imaging measures, and surgeon variables between those that had a fusion and those that had decompression alone. Multivariate backward logistic regression was used to identify the best combination of factors associated with the decision to perform a fusion. RESULTSThis study includes 241 consecutively enrolled patients receiving surgery from 11 surgeons at 7 sites. Patients that had a fusion were younger (65.3±8.3 vs. 68.6±9.7 years, p=.012), had worse ODI scores (45.9±14.7 vs. 40.2±13.5, p=.007), a smaller average disc height (6.1±2.7 vs. 8.0±7.3 mm, p=.005), were more likely to have grade II spondylolisthesis (31% vs. 14%, p=.008), facet distraction (34% vs. 60%, p=.034), and a nonlordotic disc angle (26% vs. 17%, p=.038). The rate of fusion varied by individual surgeon and practice location (p<.001, respectively). Surgeons that were fellowship trained in Canada more frequently fused than those who fellowship trained outside of Canada (76% vs. 57%, p=.027). Surgeons on salary fused more frequently than surgeons remunerated by fee-for-service (80% vs. 64%, p=.004). In the multivariate analysis the clinical factors associated with an increased odds of fusion were decreasing age, decreasing disc height, and increasing ODI score; the radiographic factors were grade II spondylolisthesis and neutral or kyphotic standing disc type; and the surgeon factors were fellowship location, renumeration type and practice region. The odds of having a fusion surgery was more than two times greater for patients with a grade II spondylolisthesis or neutral and/or kyphotic standing disc type (opposed to lordotic standing disc type). Patients whose surgeon completed their fellowship in Canada, or whose surgeon was salaried (opposed to fee-for-service), or whose surgeon practiced in western Canada had twice the odds of having fusion surgery. CONCLUSIONSThe decision to perform a fusion in addition to decompression for LDS is multifactorial. Although patient and radiographic parameters are important in the decision-making process, multiple surgeon factors are associated with the preference of a Canadian spine surgeon to perform a fusion for LDS. Future work is necessary to decrease treatment variability between surgeons and help facilitate the implementation of evidence-based decision making.

Patients With Failed Femoropopliteal Covered Stents Are More Likely to Present With Acute Limb Ischemia Than Those With Failed Femoropopliteal Bare-Metal Stents

Abstract Objective Covered stents (CS) to treat superficial femoral artery (SFA) occlusive disease have become more common. However, concerns about patients presenting with acute limb ischemia (ALI) after failure due to coverage of important collaterals have been raised. Herein, we determine if CS are associated with ALI after failure. Methods Vascular Quality Initiative peripheral vascular intervention and infrainguinal bypass datasets were queried from 2010 to 2020 for patients who underwent SFA stenting with a bare metal stent (BMS) or CS and who also had a subsequent ipsilateral SFA endovascular reintervention or bypass recorded in the Vascular Quality Initiative. The initial SFA stenting procedure will be referred to as the index procedure and the subsequent procedure will be referred to as the reintervention. Patients with aneurysmal pathology, prior infrainguinal bypass, and ALI at the index procedure were excluded. Patients with pre-index inflow/outflow procedures were not excluded. The primary outcome was ALI at reintervention. Other outcomes included higher degree of ischemia (claudication vs rest pain vs tissue loss vs ALI) and reoperative factors. Predictors of the primary outcome were determined with multivariable logistic regression. The index treatment length and pre-index ankle-brachial index were forced into the model. Results There were 3721 patients: 3338 with index BMS, 383 with index CS. The mean patients age was 66.3 ± 11.0 years and 59.2% were male. Baseline covariates were similar between the groups; during the index procedure, more patients with BMS underwent plain balloon angioplasty (68.7% vs 62.1%; P = .001) and had shorter total index treatment length (median, 15.0 cm [interquartile range, 10.0-25.0 cm] vs 20.0 cm [interquartile range, 12.0-30.0 cm]; P Conclusions In patients undergoing reintervention for failed SFA stents, CS are more likely to present with ALI than those with failed SFA BMS.

Heparin-Bonded Stent-Graft for the Treatment of TASC II C and D Femoropopliteal Lesions: 36-Month Results of the Viabahn 25 cm Trial

Purpose: To evaluate the 36-month technical and clinical outcome after implantation of the 25-cm Viabahn endoprosthesis with Propaten bioactive surface in TransAtlantic Inter-Society Consensus II C and D lesions of the superficial femoral and proximal popliteal arteries. Materials and Methods: This prospective, multicenter, single-arm trial (ClinicalTrials.gov; identifier NCT01263665) enrolled 71 patients (mean age 66.7±8.3 years; 50 men) with lifestyle-limiting claudication or rest pain (Rutherford category 2–4) and long (>20-cm) lesions of the superficial femoral and proximal popliteal arteries. Primary endpoint was primary patency at 36 months. Secondary endpoints included primary assisted patency; secondary patency; freedom from target lesion revascularization (TLR); freedom from a composite of death, target vessel revascularization (TVR), and amputation; clinical success; and freedom from device fracture. Results: Primary patency estimated by Kaplan-Meier analysis was 40.6% at 36 months. Primary assisted patency and secondary patency estimates were 53.0% and 96.9%, respectively. Within 36 months, 27 patients had to undergo a TLR. Twenty-five patients (35.2%) had a TVR. Freedom from the composite of death, TVR, and amputation endpoint was 44.5%. The estimate of the sustained clinical success with stable or improved Rutherford category was 58.5%. No stent fracture was detected during follow-up. Conclusion: The primary patency rate without reintervention after treatment of long femoropopliteal lesions is low. However, secondary patency after implantation of a Viabahn endoprosthesis is high and seems to be superior to the use of other revascularization techniques, resulting in persistent clinical improvement.

The Prevalence of Back and Leg Pain and the Cross-sectional Association With Adverse Health Outcomes in Community Dwelling Older Adults in England.

Cross-sectional analysis of the Oxford Pain, Activity and Lifestyle (OPAL) Cohort Study. The aim of this study was to assess the prevalence of back pain (BP) and leg pain and determine their relationship with adverse health states among older adults in England. Epidemiological data describing the prevalence of BP and leg pain in older adults in England is lacking. A total of 5304 community-dwelling adults (aged 65-100 years) enrolled in the OPAL cohort study who provided data on BP and leg pain were included. Participants were classified into four groups based on reports of back and leg pain: no BP, BP only, BP and leg pain which was likely to be neurogenic claudication (NC), and BP and leg pain which was not NC. Adverse health states were frailty, falls, mobility decline, low walking confidence, poor sleep quality, and urinary incontinence. We collected demographic and socioeconomic information, health-related quality of life, and existing health conditions, and estimated the association between BP presentations and adverse health states using regression analysis. Thirty-four percent of participants (1786/5304) reported BP only, 11.2% (n = 594/5304) reported BP and NC and 8.3% (n = 441/5304) reported BP and non-NC leg pain. Participants with BP had worse quality of life compared to those without BP. All BP presentations were significantly associated with adverse health states. Those with NC were most affected. In particular, there was greater relative risk (RR) of low walking confidence (RR 3.11, 95% confidence interval [CI] 2.56-3.78), frailty (RR 1.88, 95% CI 1.67-2.11), and mobility decline (RR 1.74, 95% CI 1.54-1.97) compared to no BP. Back and leg pain is a common problem for older adults and associated with reduced quality of life and adverse health states. Findings suggest a need to develop more effective treatment for older adults with BP especially for those with neurogenic claudication. 2.

Hydration may reverse most symptoms of lower extremity intermittent claudication or rest pain

BackgroundMedical treatment of severe intermittent claudication or critical limb-threatening ischemia causing rest pain frequently achieves only partial relief or is not effective at all. MethodsPatients with severe intermittent claudication or rest pain of the lower extremities who did not improve after control of risk factors, supervised exercises, and cilostazol medication were included in this study. All patients were treated with hydration. They were asked to drink 2500 mL of fluids (water, soup, milk) during a 24-hour period and to ingest 0.6 g/kg of albumin a day, as egg white or albumin powder. Total salt administered daily was 3.5 g. Symptoms, skin temperature, ankle-brachial index, albumin concentration in serum, and time and distance to claudication were recorded before treatment, at 6 weeks, and at 6 months. Electrolytes were measured monthly. No additional treatment was used during the study. Walking was encouraged but not supervised. The trial has continued indefinitely. For statistical analysis, SPSS software (IBM Corp, Armonk, NY) was used. The Ethical Committee approved the protocol, and an informed consent was signed by all patients. ResultsThere were 132 patients (94 male, 38 female) included in the study. Median age was 72.5 years (range, 67-77 years); all had severe claudication of a mean of 100 meters or rest pain. Symptoms had been present for >5 months in all patients; 22 (16.8%) had rest pain. Proper hydration, determined as drinking at least 2000 mL of water during 24 hours for a period of 6 months, was achieved in 131 compliant patients. Only one patient failed to drink 2000 mL of water or more. Ankle-brachial index in 131 compliant patients improved from 0.6 to 0.75 (P < .0001) after 6 months. Skin temperature of the feet increased from 29.4°C to 31.7°C (P = .009). Distance to claudication using the treadmill improved from 100 meters to 535 meters (P < .0001) at 6 weeks and remained stable at 6 month in 65.83% of the patients; in 34.17% of them, distance to claudication increased further by 200 (100-500) meters and time to claudication improved from 1.3 to 6.3 minutes (P < .0001) at 6 weeks, but the same group of patients (34.17%) that increased the distance to claudication further prolonged the time to claudication by 2.49 (1.24-6.23) minutes. All 131 compliant patients improved their status related to lower extremity ischemia; the noncompliant patient did not have any variation of symptoms, skin temperature, ankle-brachial index, or time and distance to claudication. All patients survived the initial 6 months of treatment; afterward, three patients abandoned the treatment and four died of unrelated causes. After the 6-month control, 49% of the patients continued to improve the time and distance to claudication as well as the ankle-brachial index. The rest of the patients conserved the initial improvement. Five patients who had significantly improved the time and distance to claudication were asked to decrease water intake for 3 days. No changes in time and distance to claudication were detected. Hydration was reinitiated. ConclusionsThis study suggests that proper hydration by drinking ≥2000 mL of water daily and albumin complement orally to reach 4 g/dL in serum could be included in the armamentarium of physicians treating patients with disabling claudication or rest pain caused by peripheral artery disease. Further comparative studies to assess the benefit of hydration and increasing the serum oncotic pressure are warranted.

Three-Year Sustained Clinical Efficacy of Drug-Coated Balloon Angioplasty in a Real-World Cohort

Multicenter, prospective single-arm IN.PACT Global Study from 2012 to 2014 There were 1406 patients with claudication (89%) or rest pain (11%) with complex femoropopliteal occlusive lesions who were treated with IN.PACT Admiral drug-coated balloon (DCB) angioplasty (Medtronic, Dublin, Ireland). Mean lesion length was 12 cm, and a third of the lesions were occluded. The Kaplan-Meier estimate of freedom from clinically driven target lesion revascularization through 36 months was significantly lower in patients with chronic limb-threatening ischemia (68%) compared with claudicants (78%). Predictors of clinically driven target lesion revascularization through 36 months included increased lesion length, reference vessel diameter ≤4.5 mm, in-stent restenosis, and chronic limb-threatening ischemia. DCB angioplasty with the IN.PACT Admiral DCB for femoropopliteal disease to treat complex lesions in a real-world population is associated with sustained clinical efficacy and low rates of reintervention at 3 years after the initial procedure.

Drug-coated balloons used in peripheral artery disease: experience from a single center

ObjectiveThis retrospective single-center study aimed to analyze immediate and follow-up results of using drug-coated balloons (DCBs) for treating peripheral arterial disease.MethodsIn this study, we identified a total of 75 patients who underwent DCB therapy at our institution. The ankle–brachial index (ABI) was measured before and after intervention. Intermittent claudication and whether there was healing of ulcers were determined by telephone.ResultsThe cohort consisted of 56 men and 19 women aged 38 to 87 years (68 ± 12 years). Twenty-three patients had Rutherford grade III, 15 had Rutherford grade IV, and 37 had Rutherford grade V. Seventeen patients had stents and 18 had the Rotarex system used. The postoperative ABI was significantly greater than the preoperative ABI (0.911 ± 0.173 vs 0.686 ± 0.249). Good results for treatment were obtained. Intermittent claudication and rest pain did not occur in subjects with Rutherford grades III and IV during follow-up. The amputation rate was 4.1% among all patients using DCB therapy during follow-up.ConclusionsDCB therapy is safe and effective for treating peripheral arterial disease in real-world patients. Future prospective studies on this issue are recommended.

Impact Of An Ankle-foot Orthosis On Physical Activity In Patients With Peripheral Artery Disease

Patients with peripheral artery disease (PAD) are sedentary due to claudication pain in the lower extremities. Our research has documented an inability of the ankle plantarflexors to generate normal push-off during walking. An ankle-foot orthosis (AFO) to offset push-off deficiency may improve physical activity levels and walking distances in patients with PAD. PURPOSE: To compare step count (SC), peak activity index (PAI), initial claudication distances (ICD), and absolute claudication distances (ACD) before and after an AFO intervention. METHODS: Six patients with PAD (Age: 71.7 ± 9.3 years; Body Mass Index: 27.5 ± 5.5 kg/m2) were enrolled in the study. They underwent measurements of SC and PAI over a week using an accelerometer. ICD and ACD were determined while subjects performed the Gardner treadmill protocol without wearing AFOs. All measures were assessed before and after the three month AFO intervention. Signed Rank tests were performed to determine differences following the intervention. RESULTS: ACD was significantly increased following the AFO intervention (p=0.046). Mean ACD was 312 ± 169 meters at baseline and increased to 364 ± 194 meters after the three month AFO intervention. Measures before and after the AFO intervention of SC (2422 ± 1166 steps/day and 2349 ± 1112 steps/day), PAI (34 ± 13 steps/min and 30 ± 7 steps/min), and ICD (187 ± 111 meters and 173 ± 138 meters) were not significantly different. CONCLUSION: The preliminary results of this study indicated that the AFO intervention improves the ACD in patients with PAD while walking without AFO. Future work should increase the number of subjects and determine whether physical activity intensity levels (light, moderate, and vigorous) changed after AFO intervention. Supported by NIH Grant HD090333-01. We acknowledge Alex Dzewaltowski, Cody Anderson, and Kaeli Samson for supporting this study.

Outcome of ligation of peripheral arterial pseudo aneurysm with or without revascularization in intravenous drug abuser

Background: Current treatment options of pseudo aneurysm in intravenous drug abuser (IVDA) include either excision of pseudo aneurysms sac with only ligation or with routine revascularization. Methods: This is a retrospective study of 53 patients over a period of 14 years done in Bir hospital where we describe the management of the pseudo aneurysm either with ligation only or with revascularization.Results: Out of total 53patients, 43 (81.13%) were male and 10 (18.87%) were female. Ligation of the artery of the pseudo aneurysm in 42 (80.77%) cases and revascularization in 10 (19.23%) cases were done. Post-surgery claudication pain was in 9 (17.31%) cases, thrombosed and infected grafts in 9 (17.31%) cases. However there was no case of amputation and mortality.Conclusion: Ligation and debridement of pseudo aneurysm is a simple, safe and effective procedure with minimal morbidity in IVDA.