Lower Extremity Peripheral Arterial Disease Research Articles

Exercise Therapy for Peripheral Artery Disease.

To summarize evidence regarding exercise treatments for lower extremity peripheral artery disease (PAD). Supervised walking exercise is recommended by practice guidelines for PAD. Supervised treadmill exercise improves treadmill walking distance by approximately 180m and 6-min walk distance by 30-35m, compared to control. The Centers for Medicaid and Medicare Services covers 12weeks of supervised exercise, but most people with PAD do not participate. Home-based walking exercise may be more convenient and accessible than supervised exercise. In randomized clinical trials, home-based walking exercise interventions incorporating behavioral methods, such as accountability to a coach, goal-setting, and self-monitoring, improved 6-min walk distance by 40-54m, compared to control. Arm and leg ergometry also improved walking endurance for people with PAD, but efficacy compared to walking exercise remains unclear. Walking exercise is first-line therapy for PAD-related walking impairment and can be effective in either a supervised or a structured home-based setting.

Medical Therapy for Peripheral Artery Disease.

Patients with lower extremity peripheral artery disease (PAD) are at high risk for major adverse cardiovascular events (MACE) and major adverse limb events (MALE). This manuscript will review the current evidence for medical therapy in patients with PAD according to different clinical features and the overall cardiovascular (CV) risk. The management of PAD encompasses non-pharmacologic strategies, including lifestyle modification such as smoking cessation, supervised exercise, Mediterranean diet and weight loss as well as pharmacologic interventions, particularly for high risk patients. Benefits for reduction of CV and limb outcomes have been demonstrated for new therapies, including antithrombotic therapy (i.e., low-dose rivaroxaban plus aspirin), lipid lowering therapy (i.e., proprotein convertase subtilisin/kexin type 9inhibitors), and glucose lowering therapy (i.e., sodium-glucose cotransporter-2inhibitors and glucagon-like peptide-1receptor agonists). However, the adoption of these therapies in PAD remains suboptimal in practice. Implementation science studies have recently shown promising results in PAD patients. Comprehensive medical and non-medical management of PAD patients is crucial to improving patient outcomes, mitigating symptoms, and reducing the risk of MACE and MALE. A personalized approach, considering the patient's overall risk profile and preference, is essential for optimizing medical management of PAD.

Impact of Early Intervention on Health Status Outcomes in Peripheral Artery Disease Patients with Chronic Total Occlusion Lesions Using the PORTRAIT Registry

To analyze the impact of non-invasive and early invasive treatments on health status in patients with lower extremity peripheral arterial disease (PAD) without and with chronic total occlusions (CTO) after 12 months of follow-up. Using the international (U.S., Netherlands, and Australia) observational longitudinal PORTRAIT registry, we included patients with recent PAD symptoms between June 2011 and December 2015. We assessed the PAD-specific health status at initial visit, 3-, 6- and 12-month follow-up using the Peripheral Arterial Questionnaire (PAQ). On a propensity matched-weighted cohort, we compared patients' characteristics by CTO status and treatment groups as early invasive (revascularization in the 3 months) vs. non-invasive (exercise, medical therapies, or smoking cessation). We then assessed the health status trajectory over 12 months, as 3-way interaction between CTO status, and treatment groups, and months, using a multilevel generalized linear regression model for repeated measures adjusted for baseline health status with random effects at sites- and patients-level. We included 581 participants, with mean age of 66.62±9.33 years, 34.3% female, and 90.8% White, of whom 353 (60.8%) without and 228 (39.2%) with a CTO lesion. Respectively, 96 (27.2%) and 70 (30.7%) patients underwent early invasive treatment (d=0.07). While patients with CTO were more likely to have lower resting ABI, multilevel disease, and to experience severe claudication vs. their counterparts (|d|≥0.20); the patients' health status at baseline with CTO was not different from those without CTO, with mean Summary scores of 45.14±20.26 vs. 45.90±21.24 (d=0.04), respectively. The trajectory did not differ by CTO status (interaction CTO status*month: p=0.517) and was higher in early invasive vs. non-invasive treatment (treatment*month: p<0.001), regardless of CTO status (CTO status*treatment: p=0.981 and CTO status*treatment*month: p=0.264). The score increased over time with the largest improvement occurring at 3 months in both non-invasive (non-CTO: +7.82 95%CI 4.03;11.60 and CTO: +9.27 95%CI 4.45;14.09) and early invasive (non-CTO: +26.17 95%CI 20.06; 32.28 and CTO: +24.52 95%CI 17.40;31.64) groups. The mean score in CTO vs. non-CTO did not differ at each timepoint, with the 12-month mean score of 70.26 (95%CI 67.87; 74.65) vs. 71.17 (95% CI 65.91; 76.44) (p=0.99) in the non-invasive treatment and 84.93 (95%CI 78.90;90.97) vs. 79.20 (95%CI 72.77;86.14) (p=0.31) in the early invasive treatment. Patients with symptomatic PAD undergoing early revascularization exhibited higher health status over time vs. those undergoing non-invasive treatment strategy, irrespective of the presence of CTOs. The degree of the improvement was greater in the 3 months following the initial visit, especially in patients undergoing early revascularization.

Smoking as a risk factor for lower extremity peripheral artery disease in women compared to men: A systematic review and meta-analysis.

To investigate whether the relationship between smoking and peripheral artery disease (PAD) differs by sex (PROSPERO CRD42022352318). PubMed, EMBASE, and CINAHL were searched (3 March 2024) for studies reporting associations between smoking and PAD in both sexes, at least adjusted for age. Data were pooled using random effects. Between-study heterogeneity was examined using I2 statistic and Cochran's Q test. Newcastle-Ottowa Scale was adopted for quality assessment. Four cohort studies (n = 2,117,860, 54.4% women) and thirteen cross-sectional studies (n = 230,436, 59.9% women) were included. In cohort studies, former and current smokers had higher risk of PAD than never smokers. Compared to those who never or previously smoked, women current smokers (relative risk (RR) 5.30 (95% confidence interval 3.17, 8.87)) had higher excess risk of PAD than men (RR 3.30 (2.46, 4.42)), women-to-men ratio of RR 1.45 (1.30, 1.62)(I2 = 0%, p = 0.328). In cross-sectional studies, risk of PAD was higher among former and current compared to never smokers, more so in men, women-to-men ratios of odds ratio: 0.64 (0.46, 0.90)(I2 = 30%, p = 0.192), 0.63 (0.50, 0.79)(I2 = 0%, p = 0.594), respectively. For both sexes, risk of PAD was higher among current smokers compared to those who were not currently smoking. Cohort studies and five cross-sectional studies were of good quality, scoring 6 to 8 of a possible maximum 9 points. Eight cross-sectional studies scored 2 to 5. Further research is required to elucidate sex differences in the relationships between smoking and PAD, as the current evidence is limited and mixed. Tobacco-control programs should consider both sexes.

Retrospective Evaluation of the Effect of Lumbar Sympathetic Blockade on Pain Scores, Fontaine Classification, and Collateral Perfusion Status in Patients with Lower Extremity Peripheral Arterial Disease

Background and Objectives: The aim of this retrospective study was to evaluate the effect of lumbar sympathetic block (LSB) on pain scores, Fontaine Classification, and collateral perfusion status in patients with lower extremity peripheral artery disease (PAD), in whom revascularization is impossible. Material and Methods: Medical records of 21 patients with PAD who underwent LSB with a combination of local anesthetics, steroids, and patient follow-up forms containing six-month follow-ups between January 2020 and March 2021 were retrospectively reviewed. Numeric Rating Scale (NRS), Pain Detect Questionnaire (PDQ) scores, Fontaine Classification Stages, and collateral perfusion status (collateral diameter and/or development of neovascularization) evaluated by arterial color Doppler Ultrasound (US) from the medical records and follow-up forms of the patients were reviewed. Results: NRS and PDQ scores were significantly lower, and regression of the Fontaine Classification Stages was significantly better after the procedure at the first, third, and sixth month than at the baseline values (p &lt; 0.001). Only four patients (19%) had collaterals before the procedure. An increase in the collateral diameter after LSB was noted in three out of four patients. Before the procedure, 17 patients had no prominent collateral. However, in thirteen of these patients, after LSB, neovascularization was detected during the six-month follow-up period (three patients in the first month, seven patients in the third month, and thirteen patients in the sixth month). The number of patients evolving neovascularization after LSB was found to be statistically significant at the third and sixth months compared to the initial examination (p &lt; 0.001). Conclusions: LSB with the use of local anesthetic and steroids in patients with lower extremity PAD not only led to lower NRS and PDQ scores, but also resulted in regressed Fontaine Classification Stages and better collateral perfusion status.

Urinary vanin-1 as a novel biomarker for survival in peripheral artery disease.

Chronic kidney disease is associated with increased rates of incidence, morbidity, and mortality in lower-extremity peripheral artery disease (PAD). No specific marker for a functional risk assessment of kidney disease in PAD is known, especially at the early stages. Thus, we speculated that urinary vanin-1 (uVNN1), a marker of oxidative stress even in early kidney injury, could further stratify outcome assessment in patients with PAD. Patients with stable PAD (n = 304) of the Vienna medical cohort were followed up for up to 10 years and the outcome was assessed by central death database queries. uVNN1 was measured by enzyme-linked immunosorbent assay (ELISA) at study inclusion and normalized to urinary creatinine (uVNN1/Cr). During the observation time (9.3, 7.0-9.8 years), 104 patients died, 54.8% of which were due to cardiovascular causes. uVNN1/Cr was associated with a urine albumin-creatinine ratio (UACR) (R = 0.166, p = 0.004) but not with an estimated glomerular filtration rate (R = 0.102, p = 0.077). Levels of uVNN1/Cr did not differ between asymptomatic and symptomatic PAD (p = 0.406). Kaplan-Meier curves showed a clear-cut association with higher all-cause (log-rank p = 0.034) and cardiovascular mortality (log-rank p = 0.032) with higher uVNN1/Cr levels. Similarly, significant associations for all-cause (hazard ratio [HR] 1.34, 95% CI [1.08-1.67], p = 0.009) and cardiovascular mortality (HR 1.45, 95% CI [1.06-1.99], p = 0.020) could be seen in multivariable Cox regression models. uVNN1/Cr showed an independent association with both all-cause and cardiovascular mortality in patients with PAD and was associated with early kidney disease. Thus, uVNN1 could be a useful marker for risk stratification of kidney disease in PAD.

Sex Differences in Mortality Risk after the First Hospitalisation due to Lower Extremity Peripheral Arterial Disease

Lower extremity peripheral arterial disease (PAD) is a severe condition that increases the risk of major adverse cardiovascular events, major adverse limb events, and all cause mortality. This study aimed to investigate the mortality risk among females and males hospitalised for the first time due to lower extremity PAD. Three cohorts of patients who were admitted for the first time due to lower extremity PAD in 2007 - 2010, 2011 - 2014, and 2015 - 2018 were constructed. For the 2007 - 2010 and 2011 - 2014 cohorts, the 28 day, one year, and five year mortality were calculated, assessing survival time from date of hospital admission until date of death, end of study period, or censoring. For the 2015 - 2018 cohort, only 28 day and one year mortality were investigated due to lack of follow up data. Mortality of these cohorts was compared with the general population using standardised mortality rates (SMRs), and the risk of mortality between sexes was evaluated using Cox proportional hazards models. Cox models were adjusted for age, cardiovascular disease, and diabetes mellitus to account for potential confounding factors. In total, 7 950, 9 670, and 13 522 patients were included in the 2007 - 2010, 2011 - 2014, and 2015 - 2018 cohorts, respectively. Over 60% of individuals in each cohort were male. Mortality rates at 28 day and one year remained stable across all cohorts, while the five year mortality rate increased both for males and females in the 2011 - 2014 cohort. The SMRs both of females and males with PAD were significantly higher than in the general population. Multivariable regression analyses found no significant differences in mortality risk between sexes at 28 days and one year. However, the five year mortality risk was lower in females, with a hazard ratio of 0.89 (95% confidence interval [CI] 0.83 - 0.97) in the 2007 - 2010 cohort and 0.88 (95% CI 0.82 - 0.94) in the 2011 - 2014 cohort. The five year mortality risk has increased, and females face a lower mortality risk than males. Lower extremity PAD still carries unfavourable long term consequences compared with the general population.

Rationale and Design of the Latin-American Registry of Peripheral Interventions: Insights From SOLACI Peripheral

BackgroundChronic limb-threatening ischemia represents the most advanced stage of lower extremity peripheral artery disease (PAD); the improvement in revascularization strategies has successfully reduced the number of patients who were previously deemed untreatable. The aim of this manuscript was to provide an overview of the demographic and clinical characteristics of patients with lower-limb peripheral artery disease, as well as the procedural and technical aspects of peripheral endovascular interventions in Latin America. MethodsThe Latin-American Society of Interventional Cardiology peripheral registry is a prospective, multicenter, observational, and hospital-based registry of patients with lower-limb PAD, who are treated with endovascular interventions across Latin-American countries. ResultsA total of 1057 independent procedures (997 patients) were analyzed in this report. The most common clinical presentation was chronic limb-threatening ischemia (61.2%): an advanced stage of the disease was common, and the symptomatic classification was predominately Rutherford V (minor tissue loss) in 37.6%, followed by Rutherford III (severe claudication [30.9%]). Of the patients, 14.8% had previous amputations, 22.2% had previous endovascular revascularizations, and 5.9% had previous surgical revascularizations. Index endovascular procedures mainly treated femoral-popliteal and infrapopliteal regions. Disease extending across multiple vascular territories was common and 27.6% of patients underwent angioplasty of multiple regions during the same procedure. There was a high prevalence of cardiovascular risk factors and concomitant comorbidities: hypertension (84.5%), dyslipidemia 67.4%), diabetes mellitus (64.7%), myocardial infarction (17%), and stroke (8.4%). Major adverse events during hospitalization included death from any cause (1.3%), cardiovascular death (0.7 %), myocardial infarction (0.4%), stroke (0.1%), and BARC ≥3a bleeding (0.8%). ConclusionsReal-world data on lower-limb PAD in Latin-American countries will help us identify unmet needs and generate evidence-based recommendations to facilitate the development of more effective preventive and treatment strategies according to each country’s necessities and resources.

The Management of Aneurysmal Degeneration of Lower Extremity Cryopreserved Saphenous Vein Bypass Grafts

Objective/BackgroundThe use of cryopreserved saphenous veins (CSVs) for the treatment of lower extremity peripheral arterial disease is an attractive option when there is no available autogenous vein. Prior studies found CSVs are at risk for aneurysmal degeneration requiring reoperation. As the management of these complications and patient outcomes is not well described, the objective of this case series is to describe the open and endovascular management of degenerative CSVs at a tertiary community center. MethodsAll CSVs implanted for lower extremity bypass at our institution between 2001 and 2021 were retrospectively reviewed. All CSVs with evidence of aneurysmal change were included in this study. CSVs with evidence of active infection were excluded. The decision to intervene was left to the discretion of the operating surgeon. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. Study endpoints included limb salvage and continued patency. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. ResultsSeventeen bypasses were identified to have aneurysmal degeneration in thirteen patients in the absence of infection between 2001 and 2021. Nine of the thirteen patients were male, and the average age and BMI during the index procedure were 72 and 28 respectively. Indications for the index bypass included acute limb ischemia (ALI) (9), popliteal aneurysm (2), and CLTI with Rutherford's class IV (5) and V (1).The mean time between the index procedure and first graft revision due to aneurysmal changes was 4 years. Most of the aneurysms did not occur at the site of anastomosis with 13 occurring in the body of the graft. Thirteen grafts were managed with open surgery and three were managed with endovascular techniques. All endovascular repairs were managed via covered stenting.Patients were followed for an average duration of 7 years from the initial bypass and 2 years from their last aneurysmal repair. Limb salvage in this cohort was 87% with 2 limbs requiring amputation, all of whom underwent open reconstruction. The mortality rate in this series was 54% and no patients died due to complications from their graft. Continued patency on Kaplan Meier survival curve analysis was 79% at 6 months, 65% at one year, 54% at three years, and 27% at 5 years. ConclusionIn our experience, aneurysmal degeneration of CSV grafts were mostly managed with standard open surgical techniques, although endovascular therapy also proved acceptable. Limb salvage rates and continued patency of repair at one year in this cohort were acceptable. This case series highlights the importance of diligent surveillance for patients with CSVs.

Preoperative Sizing to Lower In-Stent Restenosis in Peripheral Arterial Occlusive Disease

ObjectivesThe primary treatment for lower extremity peripheral arterial occlusive disease (PAOD) is angioplasty-stenting. Its main complication is in-stent restenosis. Poor selection of stent dimensions has been identified as a factor contributing to early in-stent restenosis. The aim of this study is to determine whether the implantation of stents, selected based on arterial morphological reconstruction using sizing software, reduces the occurrence of in-stent restenosis. The study also aims to evaluate the potential benefits of routine preoperative sizing. MethodsBetween January 2016 and December 2020, all patients treated for PAOD through scheduled angioplasty-stenting in our department were included in the study. Using systematic preoperative Computed Tomography Angiography (CTA), precise reconstruction and sizing were performed to select the ideal length and diameter of stents, resulting in the selection of a so-called IDEAL stent. During the procedure, the surgeon implanted either the IDEAL stent or a different one, named the ACTUAL stent, based on intraoperative data and/or availability. We compared the in-stent restenosis rate between IDEAL and ACTUAL stents. ResultsThere were no significant differences in the overall characteristics between the IDEAL and ACTUAL stent groups. The in-stent restenosis rate at one year was 13% (N=28/212, P=0.994) in the IDEAL group and 17% (N=25/149, P=0.994) in the ACTUAL group. Among the ACTUAL stents, a total of 19.6% of stents with a diameter mismatch when chosen based on arteriography showed a significantly higher restenosis rate during the first year of follow-up (P=0.02). ConclusionsOur study did not demonstrate a significant difference in 1-year restenosis rate between the IDEAL and the ACTUAL stents groups. It specifically revealed the significant impact of diameter selection on the intrastent restenosis rate during the first year of follow-up. Stents chosen based on arteriographic criteria, which exhibited diameter discordance, compared to the IDEAL stents group selected using sizing reconstructions, could be either oversized or undersized. This led to a significantly higher restenosis rate at 1 year postoperative.

23 AHA’s Essential Eight: Opportunities for Preventive Care among Adults with Peripheral Arterial Disease

OBJECTIVES/GOALS: The objective was to examine the American Heart Association’s (AHA) Essential Eight metrics of cardiovascular (CV) health among Black and White adults with peripheral arterial disease (PAD) collected via validated surveys and medical records. Each metric was examined in association with available social determinants of health (SDoH) factors. METHODS/STUDY POPULATION: This observational study completed data collection through surveys and medical record review. Validated surveys were used to collect Essential Eight metrics of diet, physical activity, sleep, and smoking status. Medical records were used to collect data on body mass index, blood lipids, blood glucose, and blood pressure. Participants with a diagnosis of lower extremity PAD, ability to complete surveys, and provided informed written consent were eligible. Equal numbers of Black and White participants were enrolled. Essential Eight metrics were used to calculate CV health scores for each participant. Scores were examined for association with SDoH factors and by race using Student’s T-test or ANOVA for continuous variables or Chi-Square tests for categorical variables. RESULTS/ANTICIPATED RESULTS: A total of 50 participants will be enrolled, with the expected majority being men and half self-reporting as Black individuals. Worse SDoH is expected to be associated with lower CV health metrics, including lower levels of physical activity and higher levels of saturated fatty food consumption. Higher levels of blood lipids, blood glucose, and blood pressure are expected to be associated with worse SDoH factors. We expect this association to be attenuated by rates of CV medications, such as statin therapy, antiglycemic medications, and antihypertensive medications. No effect modification by rurality is expected, although our projected sample size is small and may impact the ability to examine this interaction. DISCUSSION/SIGNIFICANCE: Black Americans, particularly in the Deep South, are at elevated risk for PAD and critical limb ischemic events, such as amputation. Understanding CV health metrics and SDoH characteristics among adults with PAD is essential to reduce disparities in care and provide valuable information for those at highest risk for complications.

Clinicopathological Features of Smoking Patients with Multivessel Coronary Artery Disease According to the Frailty Registry

Aim. To analyse clinicopathological features of smoking patients with multivessel coronary artery disease.Material and Methods. We analysed the data from the FRAILTY registry which includes patients with coronary artery disease. In addition to clinical features, we assessed echocardiography data and lipid metabolism levels (total cholesterol, triglycerides, low- and high-density lipoproteins, and high-sensitive C-reactive protein).Results. Of the 381 CAD patients, 178 (46.7%) have smoked at some point (107 (60.1%) current smokers and 71 (39.1%) smoking quitters), whereas 203 (53.3%) patients have never smoked. These groups were comparable in age and cardiovascular disease prevalence. Smokers or smoking quitters’ group had higher proportion of males (78.1 vs. 69%; p = 0.045), higher prevalence of myocardial infarction (61.8 vs. 55.2%; p = 0.047), chronic obstructive pulmonary disease (6.4 vs. 2.3%; p = 0.045), and lower extremity peripheral artery disease (47.8 vs. 31.5%; p = 0.041). There were no differences between the groups regarding the risk of death after cardiac surgery. The level of total cholesterol was 1.8-fold higher in smokers and smoking quitters as compared with patients who never smoked (5.5 (3.7; 6.7) vs. 3.0 (2.2; 4.0) mmol/L; p = 0.01). Similar pattern was discovered regarding to the level of C-reactive protein (5.1 (2.4; 5.3) vs. 3.9 (2.2; 4.2) mg/L in smokers/smoking quitters and never smokers, respectively; p = 0.041). The analysis of echocardiography parameters did not reveal statistically significant differences.Conclusion. Smoking frequently accompanies coronary artery disease. Current smokers and smoking quitters were characterized by higher frequency of myocardial infarction, chronic obstructive pulmonary disease, and lower extremity peripheral artery disease Further, current smokers and smoking quitters had higher serum total cholesterol and C-reactive protein.

Association of lower extremity peripheral arterial disease with quantitative muscle features from computed tomography angiography

ObjectivesTo explore the association between lower extremity muscle features from CTA and peripheral arterial disease (PAD) severity using digital subtraction angiography (DSA) as reference standard.MethodsInformed consent was waived for this Institutional Review Board approved retrospective study. PAD patients were recruited from July 2016 to September 2020. Two radiologists evaluated PAD severity on DSA and CTA using runoff score. The patients were divided into two groups: mild PAD (DSA score ≤ 7) vs. severe PAD (DSA score > 7). After segmenting lower extremity muscles from CTA, 95 features were extracted for univariable analysis, logistic regression model (LRM) analysis, and sub-dataset analysis (PAD prediction based on only part of the images). AUC of CTA score and LRMs for PAD prediction were calculated. Features were analyzed using Student’s t test and chi-squared test. p < 0.05 was considered statistically significant.ResultsA total of 56 patients (69 ± 11 years; 38 men) with 56 lower legs were enrolled in this study. The lower leg muscles of mild PAD group (36 patients) showed higher CT values (44.6 vs. 39.5, p < 0.001) with smaller dispersion (35.6 vs. 41.0, p < 0.001) than the severe group (20 patients). The AUC of CTA score, LRM-I (constructed with muscle features), and LRM-II (constructed with muscle features and CTA score) for PAD severity prediction were 0.81, 0.84, and 0.89, respectively. The highest predictive performance was observed in the image subset of the middle and inferior segments of lower extremity (LRM-I, 0.83; LRM-II, 0.90).ConclusionsLower extremity muscle features are associated with PAD severity and can be used for PAD prediction.Critical relevance statementQuantitative image features of lower extremity muscles are associated with the degree of lower leg arterial stenosis/occlusion and can be a beneficial supplement to the current imaging methods of vascular stenosis evaluation for the prediction of peripheral arterial disease severity.Key points• Compared with severe PAD, lower leg muscles of mild PAD showed higher CT values (39.5 vs. 44.6, p < 0.001).• Models developed with muscle CT features had AUC = 0.89 for predicting PAD.• PAD severity prediction can be realized through the middle and inferior segment of images (AUC = 0.90).Graphical

Exercise therapy for chronic symptomatic peripheral artery disease.

All guidelines worldwide strongly recommend exercise as a pillar of the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended for clinicians to promote and assist for the set-up of comprehensive exercise programmes to best advice in patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are narratively described based on the current best evidence. The document ends by highlighting disparities in access to supervised exercise programmes across Europe and the series of gaps for evidence requiring further research.

Exercise therapy for chronic symptomatic peripheral artery disease.

All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.

Enhancing walking performance in patients with peripheral arterial disease: An intervention with ankle-foot orthosis

Lower extremity peripheral artery disease (PAD) is a cardiovascular condition manifesting from narrowed or blocked arteries supplying the legs. Gait is impaired in patients with PAD. Recent evidence suggests that walking with carbon fiber ankle foot orthoses (AFOs) can improve patient mobility and delay claudication time. This study aimed to employ advanced biomechanical gait analysis to evaluate the impact of AFO intervention on gait performance among patients with PAD. Patients with claudication had hip, knee, and ankle joint kinetics and kinematics assessed using a cross-over intervention design. Participants walked over the force platforms with and without AFOs while kinematic data was recorded with motion analysis cameras. Kinetics and kinematics were combined to quantify torques and powers during the stance period of the gait cycle. The AFOs effectively reduced the excessive ankle plantar flexion and knee extension angles, bringing the patients' joint motions closer to those observed in healthy individuals. After 3 months of the AFO intervention, the hip range of motion decreased, likely due to changes occurring within the ankle chain. With the assistance of the AFOs, the biological power generation required from the ankle and hip during the push-off phase of walking decreased. Wearing AFOs resulted in increased knee flexor torque during the loading response phase of the gait. Based on this study, AFOs may allow patients with PAD to maintain or improve gait performance. More investigation is needed to fully understand and improve the potential benefits of ankle assistive devices.

Exercise Therapy for Chronic Symptomatic Peripheral Artery Disease: AClinical Consensus Document of the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases in Collaboration With the European Society of Vascular Medicine and the European Society for Vascular Surgery.

All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.

Association between macro- and microvascular damage and sarcopenia index in individuals with type 2 diabetes mellitus.

Sarcopenia was recently reported to be relevant to an increased macro-and microvascular disease risk. Sarcopenia index (SI) has been identified as a surrogate marker for sarcopenia. The aim of the present study was to investigate the association between macro- and microvascular disease and SI in patients with type 2 diabetes mellitus (T2DM). A total of 783 patients with T2DM were enrolled in this cross-sectional study. The SI was calculated by (serum creatinine [mg/dL]/cystatin C [mg/L])×100. The subjects were divided into three groups according to SI tertiles: T1 (41.27-81.37), T2 (81.38- 99.55), and T3 (99.56-192.31). Parameters of macro- and microvascular complications, including diabetic retinopathy (DR), micro- and macroalbuminuria (MAU), diabetic peripheral neuropathy (DPN), and lower extremity peripheral artery disease (LEAD) were evaluated. Multivariate logistic regression analysis revealed that when taking the top tertile of SI as a reference, an increasing trend of the prevalence of DR, MAU, DPN, and LEAD were presented (all P for trend <0.05), where the OR (95% CI) for DR prevalence was 1.967 (1.252-3.090) in T2, 2.195 (1.278-3.769) in T1, for MAU was 1.805 (1.149-2.837) in T2, 2.537 (1.490-4.320) in T1, for DPN was 2.244 (1.485-3.391) in T2, 3.172 (1.884-5.341) in T1, and for LEAD was 2.017 (1.002-4.057) in T2, 2.405 (1.107-5.225) in T1 (all P<0.05). Patients with lower SI were more inclined to have an increased risk of macro- and microvascular damage in T2DM population, which may be related to sarcopenia.

Comparison effect of high-intensity interval training and moderate intensity continuous training on vascular function in a mouse model of lower extremity peripheral artery disease

Introduction&#x0D; Lower extremity peripheral artery disease (PAD), due to narrowing of the arteries supplying the legs, represents a major cause of physical disability. Exercise training is an important part of PAD treatment, improving functional capacity. Recent research suggests that exercise training-induced endothelial function improvement is involved in the benefits of exercise in PAD (Lee et al., 2023); however, the underlying molecular mechanisms remain unknown. In addition, the potential vascular benefits of high intensity training in PAD remain unexplored. Therefore, the aim of the study was to compare the effects of moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT) on endurance capacity, vascular endothelial function and expression of genes related to nitric oxide (NO) bioavailability in a mouse model of PAD.&#x0D; Methods&#x0D; PAD disease model was generated in male C57BL/6 mice by ligation of the right iliac artery. Mice with PAD were divided into 3 groups: sedentary control group (SED), MICT (40 min running at 70% of maximal aerobic speed) and HIIT (8 intervals of 2.5 minutes running at 90% of maximal aerobic speed combined with 2.5 minutes of running at 50% of maximal aerobic speed). Mice were exercised three times per week for 8 weeks. Maximal running time was determined by an incremental test until exhaustion. Vascular reactivity was assessed by measuring vasoconstrictor responses to phenylephrine as well as endothelium-dependent and -independent vasodilator responses to acetylcholine and DEA-NONOate, respectively, in isolated aortic rings. Gene expression of antioxidant enzymes (catalase and superoxide dismutase isoforms), prooxidant NADPH oxidase subunits (p22phox and p47phox), enzyme involved in NO production (endothelial NO synthase), vascular smooth muscle cell relaxation (soluble guanylate cyclase) and receptors involved in vascular tone regulation (a1 and b2 adrenergic receptors) was determined in aortic tissue by qPCR.&#x0D; Results&#x0D; Maximal running time was improved in both MICT and HIIT as compared to SED at the end of the study, but with no significant difference between the two exercise groups. Phenylephrine-induced vasoconstriction as well as vasodilator responses to acetylcholine and DEA-NONOate were significantly improved in MICT compared to SED while no significant differences were reported between HIIT and SED. There was no significant difference in gene expression among the three groups.&#x0D; Discussion/Conclusion&#x0D; MICT and HIIT were equally effective at improving endurance capacity in mice with PAD. However, only MICT improved vascular reactivity.&#x0D; References&#x0D; Lee, J., Zarezadehmehrizi, A., LaVoy, E., Markofski, M., &amp; Park, Y. (2023). Exercise training improves brachial artery endothelial function, but does not alter inflammatory biomarkers in patients with peripheral artery disease: A systematic review and meta-analysis. Journal of Cardiovascular Translational Research. Advance online publication. https://doi.org/10.1007/s12265-023-10451-0

Awareness of smoking cessation amongst German vascular surgeons.

Background: Smoking represents the well-known enemy of vascular well-being. Numerous previous studies emphasised the important role of smoking on the development and progression of atherosclerotic cardiovascular disease. The current study aimed to identify hurdles and barriers for an insufficient implementation of secondary prevention in the treatment of lower extremity peripheral arterial disease (PAD). Methods: All members of the German Society for Vascular Surgery and Vascular Medicine (DGG) with valid email addresses were invited to participate in an electronic survey on smoking. Results are descriptively presented. Results: Amongst 2716 invited participants, 327 (12%) submitted complete responses, thereof 33% women and 80% between 30 and 59 years old (87% board certified specialists). 83% were employed by hospitals (56% teaching hospital, 14% university, 13% non-academic) and 16% by outpatient facilities. 6% are active smokers (63% never) while a mean of five medical education activities on smoking cessation were completed during the past five years of practice. Only 27% of the institutions offered smoking cessation programs and 28% of the respondents were aware of local programs while a mean of 46% of their patients were deemed eligible for participation. 63% of the respondents deemed outpatient physicians primarily responsible for smoking cessation, followed by medical insurance (26%). Conclusions: The current nationwide survey of one scientific medical society involved in the care of patients with vascular disease revealed that smoking cessation, although being commonly accepted as important pillar of comprehensive holistic care, is not sufficiently implemented in everyday clinical practice.