Endovascular Revascularization Procedures Research Articles

US of the Penis: Beyond Erectile Dysfunction.

High-frequency US, with a linear transducer and gray-scale, color, and spectral Doppler US techniques, is the primary imaging modality for evaluation of the penis. It can allow delineation of anatomy and assessment of dynamic blood flow; it is easily available and noninvasive or minimally invasive; it is cost effective; and it is well tolerated by patients. US assessment after pharmacologic induction of erection is an additional tool in assessing patients with suspected vasculogenic impotence, and also in selected patients with penile trauma and suspected Peyronie disease. Penile injuries, life-threatening infections, and vascular conditions such as priapism warrant rapid diagnosis to prevent long-term morbidities due to clinical misdiagnosis or delayed treatment. US can facilitate a timely diagnosis in these emergency conditions, even at the point of care such as the emergency department, which can facilitate timely treatment. In addition, color and spectral Doppler US are valuable applications in the follow-up of patients treated with endovascular revascularization procedures for vasculogenic erectile dysfunction. Image optimization and attention to meticulous techniques including Doppler US is vital to improve diagnostic accuracy. Radiologists should be familiar with the detailed US anatomy, pathophysiologic characteristics, scanning techniques, potential pitfalls, and US manifestations of a wide spectrum of vascular and nonvascular penile conditions to suggest an accurate diagnosis and direct further management. The authors review a range of common and uncommon abnormalities of the penis, highlight their key US features, discuss differential diagnosis considerations, and briefly review management. ©RSNA, 2024 Supplemental material is available for this article.

Factors associated with 90-day reintervention following lower extremity revascularization

ObjectivePeripheral artery disease (PAD) represents a high-volume, high-cost burden on the health care system. The Centers for Medicare and Medicaid Services has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders. MethodsWe conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and Centers for Medicare and Medicaid Services-linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010, and December 31, 2018. Procedures for acute limb ischemia and aneurysms were excluded. The primary outcome was 90-day reintervention. Reintervention at 30 days was a secondary outcome. Covariates of interest included demographics, comorbidities, and patient- and facility-level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions. ResultsAmong 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median age was 74 years (interquartile range, 69-80 years), 57.9% were male, and 84.3% were White. Chronic limb-threatening ischemia was the operative indication in 40.4% of the procedures. Overall, 42.8% were completed in the outpatient setting (40.3% outpatient, 2.5% office-based lab). Over 70% of procedures for chronic limb-threatening ischemia were completed as inpatient, whereas 60% of the claudication interventions were done as outpatient. The 90-day reintervention rate was 14.5%, and the 30-day reintervention rate was 5.5%. Compared with inpatient procedures, PAD interventions completed in the outpatient or office-based lab setting had significantly higher 90- and 30-day reintervention rates (reference, inpatient; outpatient 90-day reintervention: hazard ratio [HR], 1.41; 95% confidence interval [CI] 1.25-1.60; outpatient 30-day reintervention: HR, 1.90; 95% CI, 1.62-2.24; office-based lab 90-day reintervention: HR, 2.09; 95% CI, 1.82-2.41; office-based lab 30-day reintervention: HR, 3.54; 95% CI, 3.17-3.94). Open and hybrid approaches demonstrated lower risk of reintervention compared with endovascular procedures at 30 and 90 days and, compared with aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention, but no difference was noted at 30 days. ConclusionsAlthough outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.

Poor Limb Prognosis of Patients with Chronic Limb-Threatening Ischemia on Hemodialysis: A Retrospective Observational Study Based on the Global Limb Anatomic Staging System

The Global Limb Anatomic Staging System (GLASS) has been widely used to evaluate patients with chronic limb-threatening ischemia (CLTI). As end-stage kidney disease (ESKD) is a well-known CLTI risk factor, we aimed to determine whether patients on hemodialysis (HD) have a worse limb prognosis than those without ESKD, considering the same GLASS background. The data of 445 patients who underwent surgical and/or endovascular revascularization procedures for lower extremity ischemia were retrospectively collected in our division between 2005 and 2018. The major amputation rate and amputation-free survival (AFS) were compared between HD and non-HD patients. Among the 215 (48%) patients receiving HD, 58 limbs required major amputation (27% limb loss rate). Among the non-HD group, the limb loss rate was 13% (P<0.0001). The overall AFS was significantly worse in patients receiving HD than those not (P<0.0001). The AFS was significantly worse in HD patients when comparing GLASS-standardized subgroups. Patients with CLTI who were receiving HD had a worse limb prognosis than those not receiving, even when considering the same GLASS classification. Furthermore, there is a need for an ideal guideline focused on ESKD-directed peripheral artery disease.

Safety and Effectiveness of Passeo-18 Lux Drug-Coated Balloon Catheter in Infrainguinal Endovascular Revascularization in the Korean Population: A Multicenter Post-Market Surveillance Study.

To evaluate the safety and clinical outcomes of the Passeo-18 Lux drug-coated balloon (DCB) in endovascular revascularization procedures under real-world conditions in a Korean population with atherosclerotic disease of the infrainguinal arteries, including below-the-knee (BTK) arteries. Eight institutions in the Republic of Korea participated in this prospective, multicenter, single-arm, post-market surveillance study. Two hundred patients with Rutherford class 2-5 peripheral arterial disease and infrainguinal lesions suitable for endovascular treatment were competitively enrolled. Data were collected at baseline, the time of intervention, discharge, and 1-, 6-, 12-, and 24-month follow-up visits. The primary safety endpoint was freedom from major adverse events (MAE) within 6 months (except when limiting the time frame for procedure- or device-related mortality to within 30 days), and the primary effectiveness endpoint was freedom from clinically driven target lesion revascularization (CD-TLR) within 12 months after the procedure. A total of 197 patients with 332 target lesions were analyzed. Two-thirds of the patients had diabetes mellitus, and 41.6% had chronic limb-threatening ischemia. The median target lesion length was 100 mm (interquartile range: 56-133 mm). Of the target lesions, 35.2% were occlusions, and 14.8% were located in the BTK arteries. Rate of freedom from MAE was 97.9% at 6 months, and the rate of freedom from CD-TLR was 95.0% and 92.2% at 12 and 24 months, respectively. Subgroup analysis of 43 patients and 49 target lesions involving the BTK arteries showed rate of freedom from MAE of 92.8% at 6 months and rates of freedom from CD-TLR of 88.8% and 84.4% at 12 and 24 months, respectively. The results of the present study, including the BTK subgroup analysis, showed outcomes comparable to those of other DCB studies, confirming the safety and effectiveness of Passeo-18 Lux DCB in the Korean population.

The CathPilot: Performance Validation and Preclinical Safety and Feasibility Assessment.

Peripheral endovascular revascularization procedures often fail due to technical limitations of guidewire support, steering, and visualization. The novel CathPilot catheter aims to address these challenges. This study assesses the safety and feasibility of the CathPilot and compares its performance to conventional catheters for peripheral vascular interventions. The study compared the CathPilot to non-steerable and steerable catheters. The success rates and access times for a relevant target inside a tortuous vessel phantom model were assessed. The reachable workspace within the vessel and the guidewire's force delivery capabilities were also evaluated. To validate the technology, chronic total occlusion tissue samples were used ex vivo to compare crossing success rates with conventional catheters. Finally, in vivo experiments in a porcine aorta were conducted to evaluate safety and feasibility. The success rates for reaching the set targets were 31%, 69%, and 100% with the non-steerable catheter, the steerable catheter, and the CathPilot, respectively. CathPilot had a significantly larger reachable workspace, and allowed for up to four times higher force delivery and pushability. In crossing of chronic total occlusion samples, the CathPilot achieved a success rate of 83% and 100%, for fresh and fixed lesions respectively, which was also significantly higher than conventional catheters. The device was fully functional in the in vivo study, and there were no signs of coagulation or damage to the vessel wall. This study shows the safety and feasibility of the CathPilot system and its potential to reduce failure and complication rates in peripheral vascular interventions. The novel catheter outperformed conventional catheters in all defined metrics. This technology can potentially improve the success rate and outcome of peripheral endovascular revascularization procedures.

Arterial leg ulcers-Bacterial patterns, antimicrobial resistance and clinical characteristics, a retrospective single-centre cohort, 2012-2021.

Severe wound infections in patients with peripheral artery disease (PAD) are common, potentially life- and limb-threatening, and difficult to treat. Evidence on patients with infected leg ulcers in PAD is scarce. This study aims to provide insight into the microbiological patterns and antimicrobial resistance (AMR) of specific pathogens in patients with arterial leg ulcers. In this retrospective, consecutive, single-centre study 16,553 patients underwent an endovascular revascularization procedure between 2012 and 2021. Of these, 1,142 patients had PAD Rutherford category 5 or 6 with infected leg ulcers. Logistic regression was used to identify risk factors for Staphylococcus aureus-associated infections. A total of 3,431 bacterial isolates were detected, of which 2,335 (68.1%) bacterial isolates were gram-positive and 1,096 (31.9%) were gram-negative species. The most prevalent bacteria were S. aureus (18.6%), Enterococcus faecalis (9.1%) and S. epidermidis (7.8%). Pseudomonas aeruginosa (5.6%), Proteus mirabilis (3.7%) and Escherichia coli (3.4%). The resistance of S. aureus isolates to clindamycin was 11.0%. Resistance to oxacillin was rare (1.5%). P. aeruginosa is frequently resistant to ciprofloxacin (14.4%) whilst intrinsically resistant to trimethoprim/sulfamethoxazole. P. mirabilis and E. coli were frequently resistant to both ciprofloxacin (7.3; 20.7%) and trimethoprim/sulfamethoxazole (24.6; 22.6%), respectively. Resistance to amoxicillin/clavulanic acid was high among E. coli isolates (36.8%). Multi-drug resistance (MDR) was rare among S. aureus and P. aeruginosa isolates. In contrast, the proportion of MDR was high in E. coli isolates. End-stage renal disease was independently positively associated with S. aureus identification (p = .042). S. aureus was the most common pathogen in arterial leg ulcers with end-stage renal disease being an independent risk factor. Clindamycin resistance was common, making empirical therapy likely to fail. Isolated E. coli species had a high proportion of MDR.

Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management

Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.

Specialty Balloons for Vessel Preparation During Infrainguinal Endovascular Revascularization Procedures: A Review of Literature.

Balloon angioplasty with/without utilizing drug eluting technology or stenting constitutes the treatment of choice for a significant percentage of patients with peripheral artery disease requiring an intervention. However, in cases of diffuse disease and plaque complexity, angioplasty may lead to dissection, recoil, and/or early restenosis, making vessel preparation a key component for successful and durable endovascular revascularization outcome. This review of literature aims to present contemporary data for several commercially available specialty balloons that have been designed to minimize the arterial wall stress of conventional balloon angioplasty and facilitate technical success, as well as long-term patency.

Popliteal access for endovascular procedures in femoropopliteal artery occlusive disease.

Even though it has been reported that femoropopliteal artery endovascular revascularization is often performed with antegrade femoral artery interventions, which are technically relatively challenging, having the advantage of better control, it has also been reported that recanalization failure may occur in approximately 20% of patients and some materials have been developed for this reason. To evaluate the safety of retrograde popliteal artery intervention and our procedural success rate for symptomatic femoropopliteal artery occlusive disease. A total of 95 endovascular revascularization procedures were performed for treating symptomatic occlusive peripheral artery disease in the study period. Inclusion criteria were defined as patients who underwent endovascular revascularization procedures for symptomatic femoropopliteal artery occlusive disease. Patients who underwent a percutaneous endovascular procedure for iliac artery or below-knee arterial occlusive disease in the same session and patients who had previously undergone peripheral arterial bypass grafting or endovascular treatment for existing femoropopliteal artery disease were excluded. We evaluated 45 peripheral endovascular procedures performed on 39 patients with a mean age of 62.49 ±11.38 years in our hospital for chronic femoropopliteal artery occlusive disease. Twelve (26.7%) of the endovascular treatment procedures were performed with retrograde access through the popliteal artery (Group 2). In neither group were any complications of arterial rupture, distal embolism, early thrombosis, or pseudoaneurysms observed. We are of the opinion that the retrograde popliteal artery technique is an effective and safe intervention option in endovascular revascularization, particularly in the revascularization of the long segment and complex femoropopliteal artery occlusions.

Machine Learning Approach to Predict In-Hospital Mortality in Patients Admitted for Peripheral Artery Disease in the United States.

Background Peripheral artery disease (PAD) affects >10million people in the United States. PAD is associated with poor outcomes, including premature death. Machine learning (ML) has been increasingly used on big data to predict clinical outcomes. This study aims to develop ML models to predict in-hospital mortality in patients hospitalized for PAD based on a national database. Methods and Results Inpatient hospitalization data were obtained from the 2016 to 2019 National Inpatient Sample. A total of 150 921 inpatients were identified with a primary diagnosis of PAD and PAD-related procedures using codes of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). Four ML models, including logistic regression, random forest, light gradient boosting, and extreme gradient boosting models, were trained to predict the risk of in-hospital death based on a selection of variables, including patient characteristics, comorbidities, procedures, and hospital-related factors. In-hospital mortality occurred in 1.8% of patients. The performance of the 4 models was comparable, with the area under the receiver operating characteristic curve ranging from 0.83 to 0.85, sensitivity of 77% to 82%, and specificity of 72% to 75%. These results suggest adequate predictability for clinical decision-making. In all 4 models, the total number of diagnoses and procedures, age, endovascular revascularization procedure, congestive heart failure, diabetes, and diabetes with complications were critical predictors of in-hospital mortality. Conclusions This study demonstrates the feasibility of ML in predicting in-hospital mortality in patients with a primary PAD diagnosis. Findings highlight the potential of ML models in identifying high-risk patients for poor outcomes and guiding personalized intervention.

Performance Of The Emergency Surgery Score (ESS) For Non-elective Aortoiliac Endovascular Reconstructions

The Emergency Surgery Score (ESS) has been previously validated as a reliable tool to predict postoperative outcomes in emergency general surgeries and some vascular surgeries. The objective of this study was to assess the performance of the ESS for endovascular aortoiliac revascularization procedures in the nonelective setting (neAERs).

Measurement of Revascularization Effect Using Near Infrared Spectroscopy in Below the Knee Arteries

Objectives: Current methods evaluating tissue ischemia are based mainly on evaluating blood flow and not tissue perfusion. However, diabetes mainly affects small vessels and blood flow evaluation is insufficient. The aim of the trial was to evaluate the feasibility of NIRS in measuring perfusion changes during chronic total occlusion (CTO) revascularization in below the knee (BTK) arteries. Methods and Material: A prospective observational study was performed. During the endovascular revascularization procedure, tissue oxygenation changes were measured using three NIRS sensors. Postoperative angiographies and 30 days wound healing was evaluated. Results: The study enrolled 30 patients with chronic limb threatening ischemia, occluded below the knee arteries, Rutherford 5. Mean age 74.7 ± 11.2 years, 16 (53%) of the patients had diabetes mellitus, 10 (33%) had end-stage renal disease. A statistically significant NIRS rSO2 increase was observed on sensors near the wound after the revascularization, p = 0.001. Thirty days follow-up visits included 27 patients, because 3 patients had died. Comparing good wound healing group with poor wound healing group intraoperative NIRS rSO2 increase difference was statistically significant, p = 0.017. Conclusions: The study confirmed tissue perfusion increase could be detected using NIRS during revascularization of below the knee arteries. An intraoperative increase of NIRS rSO2 proved to predict wound healing results.

Reintervention Following Outpatient Peripheral Artery Disease Procedures: Trading Convenience for Value?

Peripheral artery disease (PAD) represents a high volume, high-cost burden on the healthcare system. The Centers for Medicare and Medicaid Services has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services to be administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders. We conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and Centers for Medicare and Medicaid Services linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010, and December 31, 2018. Procedures for acute limb ischemia and aneurysm indications were excluded. The primary outcome was 90-day reintervention and 30-day reintervention was a secondary outcome. Covariates of interest included demographic, comorbidities, and patient and facility level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions. Among 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median (interquartile range) age was 74 years (interquartile range, 69-80 years), 58.9% were male, and 84.3% were White. Chronic limb-threatening ischemia was the operative indication in 56.4%; 42.8% of the procedures were completed in the outpatient setting (40.3% outpatient, 2.5% office-based laboratory). More than 70% of procedures for chronic limb-threatening ischemia were completed as an inpatient, while 60% of the claudication interventions were done as an outpatient. The 30-day reintervention rate was 5.5% and the 90-day reintervention rate was 14.5%. Compared with inpatient procedures, PAD interventions completed in the outpatient or office-based laboratory setting had significantly higher 30- and 90-day reintervention rates (ref, inpatient; outpatient 30-day reintervention: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.62-2.24]; outpatient 90-day reintervention: HR, 1.41; 95% CI, 1.25-1.60); office-based laboratory 30-day reintervention: HR, 3.54; 95% CI, 3.17-3.94]; office-based laboratory 90-day reintervention, HR, 2.09; 95% CI, 1.82-2.41) Open and hybrid approaches demonstrated lower risk of reintervention compared with endovascular procedures at 30 and 90 days and, compared with aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention but no difference was noted at 30 days (Table). Although outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent 30- and 90-day reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.TableMultivariable analysis of factors associated with 30- and 90-day reinterventionsCovariate30-Day reintervention90-Day reinterventionAdjusted hazard ratio95% confidence intervalAdjusted hazard ratio95% confidence intervalStandard demographics Age 70-74 vs 65-690.950.891.020.990.951.04 Age 75-79 vs 65-690.950.841.090.950.881.03 Age 80-84 vs 65-691.000.841.190.950.861.05 Age ≥85 vs 65-690.990.911.080.880.820.94 Female vs male0.760.690.830.870.820.92 Non-White vs White1.050.931.191.050.971.14Comorbidities BMI ≥30 vs BMI <300.950.871.030.930.890.98 Coronary artery disease0.990.881.121.101.041.15 Congestive heart failure0.990.891.090.940.890.99 Chronic obstructive pulmonary disease1.040.971.131.081.011.16 Diabetes mellitus1.030.941.141.050.991.10 ESRD on dialysis1.461.311.631.381.261.50 Hypertension1.070.931.241.090.981.22 Microvascular disease1.010.901.141.010.921.11 Current smoker vs nonsmoker1.130.991.300.980.911.06 Prior smoker vs nonsmoker1.080.971.201.010.941.08Patient-level characteristics Ischemic rest pain vs claudication1.171.011.361.101.001.20 Tissue loss vs claudication1.110.991.241.070.991.15 Femoropopliteal vs aortoiliac1.050.911.211.241.151.35 Tibial vs aortoiliac0.930.771.111.311.191.45 Aortoiliac + any outflow vs aortoiliac1.140.961.351.381.251.51 Femoropopliteal + tibial vs aortoiliac1.030.821.301.341.171.54 Prior LER0.930.851.020.990.941.04 Ambulation with assistance vs ambulatory1.121.011.241.080.981.18 Wheelchair/bedridden vs ambulatory0.880.731.060.870.790.96 Homeless vs home0.000.000.000.430.111.67 Nursing home vs home0.880.681.140.820.730.91Facility-level or operative characteristics Office/clinic vs inpatient3.543.173.942.091.822.41 Outpatient vs inpatient1.901.612.241.411.251.60 Hybrid vs endovascular0.440.340.580.740.650.85 Open vs endovascular0.460.380.560.780.690.89 Year of procedure 2013-2015 vs 2010-20121.020.781.321.120.981.27 Year of procedure 2016-2018 vs 2010-20120.930.671.291.040.901.20 Distance to care 5-10 miles vs <5 miles1.030.941.131.020.951.11 Distance to care >10-20 miles vs <5 miles1.000.881.140.980.901.07 Distance to care >20-40 miles vs <5 miles1.070.921.251.040.941.15 Distance to care >40-60 miles vs <5 miles1.070.911.271.050.941.18 Distance to care >60 miles vs <5 miles0.860.661.120.960.841.11BMI, body mass index; LER, lower extremity revascularization; ESRD, end stage renal disease.All variables in the table are included in the model. 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Tissue Perfusion Changes after Direct and Indirect Angiosome Revascularization in Critical Limb Ischemia

Background. Blood flow restore in critical limb ischemia according to angiosomes is becoming very popular. This method allows to restore blood flow precisely to the artery supplying the ischemic zone, based on the angiosome concept. However, angiosome revascularization is not a gold standard because of the lack of evidence supporting this approach. The aim of this study was to compare tissue oxygenation changes in ischemic zone during endovascular revascularization procedure either following angiosome concept or performing indirect revascularization. Methods. A prospective observational study was performed. Patients with critical limb ischemia and tissue loss due to chronic total occlusion of below the knee arteries were included. Endovascular revascularization was performed in all cases. Tissue oxygen saturation was observed intraoperatively using near-infrared spectroscopy. Tissue oxygenation changes near the ischemic wound were compared between direct and indirect revascularization groups. Results. This clinical trial included 30 patients with critical limb ischemia (Rutherford 5) and occluded below the knee arteries intended to treat. In 15 patients the procedure was performed according to angiosome, while the other half underwent indirect revascularization. Tissue oxygenation near the wound was monitored during the intervention. Greater oxygen saturation increase was observed in the group with direct revascularization (29% and 23% accordingly), however the difference between groups was not statistically significant (t-test for independent group, p = 0,544). Conclusions. The increase in tissue oxygen saturation differed very slightly in direct and indirect revascularization groups and the difference was statistically insignificant.

LOWER EXTREMITY PHERIPHERALARTERIAL DISEASE - AN UPDATE

Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthful to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patient and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.

Incident cardiovascular events and early mortality in patients with revascularized critical limb ischemia.

Patients with critical limb ischemia (CLI) present a high risk of cardiovascular events and death. This study aimed to investigate the incidence of major adverse cardiovascular events (MACE) and one-year mortality in patients undergoing percutaneous revascularization procedure for CLI. This investigation is a retrospective analysis of an ongoing cohort study in patients with CLI undergoing endovascular revascularization, hospitalized in the vascular medicine department from November 2013 to December 2018. Major cardiovascular events were collected during the first year after revascularization procedure and were defined as heart failure, acute coronary syndrome, ischemic stroke and sudden death. Mortality and major limb amputations, defined as above-the-ankle amputation, were determined during the one-year follow-up period. Multivariate logistic regression analyses were performed to identify factors independently associated with the occurrence of MACE and one-year mortality after revascularization procedure. A P≤0.05 was considered as statistically significant. The study included 285 consecutive patients, 157 men (55%) and 128 women (45%), with a mean age of 77.8±12 years. Treated hypertension was present in 222 (78%) patients; diabetes was present in 137 (48%) patients; 112 (39%) patients had known coronary heart disease and 20 (7%) patients were dialysis dependent. During the one-year follow-up after revascularization procedure, 75 (26.3%) patients presented an incident cardiovascular event, of whom 19 (6.7%) patients in the perioperative period. Cumulative mortality rate was 26.7% (76 patients) mostly from cardiovascular causes. Twenty-five patients (8.8%) experienced major amputation. In multivariate analysis, the occurrence of MACE was associated with an increased mortality risk (HR 6.96 (2.99-16.94), P<0.001). Other variables associated with an increased mortality were living in a nursing home and malnutrition. Decompensated heart failure and coronary heart disease were both associated with incident MACE in multivariate analysis, independently of confounders. In the present study population, incident MACE were prevalent in the year following endovascular revascularization procedure in patients with CLI and were associated with an increased risk of mortality. Coronary heart disease and decompensated heart failure are important contributors for the occurrence of MACE. In this elderly patient population with CLI, these results should be taken into account during the multidisciplinary team meeting before consideration of revascularization procedure.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia

The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI). This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan-Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement. Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford's category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different (p = .006). Group 1 had significantly lower amputation rate at 36 months (p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40-36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02-0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07-16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02-0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015-29.95, p = .002) were the significant independent predictors of LCI. The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

A comparison of revascularization methods for peripheral arterial disease in diabetics: Changing trends in lower extremity revascularization from 2008 to 2014

This study examined the current demographic and outcome trends regarding endovascular and open revascularization for people with diabetes. The National Inpatient Sample database was utilized to identify diabetic patients who underwent lower extremity revascularization and amputation procedures between 2008 and 2014. International Classification of Diseases 9th edition codes were used to identify the procedures, diagnoses, and comorbidities. We identified 38,143 diabetic patients who underwent endovascular revascularization and 25,415 who underwent open revascularization between 2008 and 2014. The number of endovascular and open revascularization procedures decreased steadily by 17.5% and 12.43% during the study period, respectively. The total charges for the endovascular procedure were greater than the open procedure ($98,761 vs. $80,782, p ≤ 0.001) despite similar median length of stay (5 days (inner quartile range (IQR) = 1-10) vs. 5 days (IQR = 3-10), p ≤ 0.001). Compared to open, the in-patient amputation rate for endovascular patients has been increasing faster for both minor (11.75% vs. 0.37%) and major amputations (3.08% vs. 0.19%). Although the post-procedure amputation rates between endovascular and open procedures were increased for endovascular patients (odds ratio [OR] = 1.71, confidence interval [CI] = 1.35-2.18, p ≤ 0.001) in 2008, by 2014 the risk of major amputation was doubled in endovascular patients (OR = 2.88, CI = 2.27-3.64, p ≤ 0.001). African Americans were more likely to undergo minor amputation than Whites (p ≤ 0.001). Lastly, diabetic patients with uncontrolled diabetes, systemic infection, weight loss, congestive heart failure, gangrene, and end-stage renal disease were more likely to undergo endovascular repair. As more medically complex patients undergo endovascular revascularization, endovascular revascularization for diabetic patients is becoming associated with higher total cost despite similar length of stay, minor amputation, and major amputation rates. Further studies are needed to continuously evaluate the post-procedural outcomes and cost effectiveness of this trend.

Changes in Early Postoperative Toe-Brachial Indices May Reflect Positive or Negative Remodeling

Society for Vascular Surgery guidelines recommend utilization of the ankle-brachial index (ABI) for early postoperative surveillance after infrainguinal revascularizations. However, little guidance exists regarding the ideal timing of the initial postoperative examination. This study sought to investigate the efficacy and optimal timing of these postprocedural noninvasive studies. A retrospective review of all open and endovascular infrainguinal revascularization procedures between July 2014 and November 2019 at a single tertiary referral center was performed. Patient and procedural details as well as preoperative and postoperative ABI and toe-arm indices (TAI) were collected and analyzed. A total of 711 patients underwent infrainguinal revascularization for peripheral arterial disease. Of these, 37.4% (266) did not undergo a postoperative ABI or TAI within 30 days, 0.4% had incompressible ABI and TAI, 2.1% had incompressible ABI with inability to obtain toe pressures, 0.6% had incompressible brachial arteries, and 2.5% were excluded for other reasons. A total of 404 patients had a valid postprocedural ABI or TAI. Locally weighted regression of the TAI values demonstrated early improvement with a steep rise in TAI within the first two days postprocedure followed by continue improvement until a plateau after 20 days (Fig). A small cohort of 36 patients had two studies performed within the initial 30 days from their index procedure. Of these patients, five (13.9%) had a significant decrease (>0.15) in their TAI, 19 (52.8%) had no significant change, and 12 (33.3%) had a significant increase in their TAI. 40% of those with a significant drop in TAI required reintervention within 1 year compared with 30% of those whose TAI increased or did not change. When performed, ABI and TAI are reliable tools to establish baseline arterial perfusion after revascularization, with <5% of studies performed invalidated due to incompressible vessels. Plateau of postprocedural TAI occurs after 20 days, suggesting that immediate baseline studies may not accurately reflect the peak benefit of an intervention, potentially due to ongoing remodeling. However, when serial studies are performed, a decrease in TAI may help to identify patients who require reintervention.

Near-Infrared Spectroscopy Might Help Prevent Onset of Cerebral Hyperperfusion Syndrome.

Cerebral hyperperfusion syndrome (CHS) is a rare but fatal perioperative complication after surgical correction of carotid stenosis. Despite numerous treatment options for preventing CHS, it does occur in some patients. We developed the outlet gate technique (OGT), in which the embolic balloon was deflated gradually in accordance with the ratio of oxygen saturation measured by a brain oximeter of the ipsilateral brain region to that in the contralateral region. Between June 2017 and May 2018, 39 patients with carotid stenosis underwent endovascular carotid revascularization procedures; of these, 20 underwent the procedure with the OGT. CBO was measured five times in those 20 patients: before the procedure, with the embolic protection device (EPD) on, with the EPD off, during the procedure, and after the procedure. Preventive treatment options were used more frequently in these patients, and although their surgical status seemed more complicated, perioperative complications were not increased. There were almost significant differences between CBO values except between those during and after the procedure with the OGT. This showed that the OGT allowed for stabilization of the CBO and thus has the potential to prevent CHS.