Lower Limb Peripheral Arterial Disease Research Articles

Patient-specific, multiscale modelling of neointimal hyperplasia in lower-limb vein grafts using readily available clinical data

The prediction of neointimal hyperplasia (NIH) growth, leading to vein graft failure in lower-limb peripheral arterial disease (PAD), is hindered by the multifactorial and multiscale mechanobiological mechanisms underlying the vascular remodelling process. Multiscale in silico models, linking patients’ hemodynamics to NIH pathobiological mechanisms, can serve as a clinical support tool to monitor disease progression. Here, we propose a new computational pipeline for simulating NIH growth, carefully balancing model complexity/inclusion of mechanisms and readily available clinical data, and we use it to predict NIH growth for an entire vein graft. To this end, three different fittings to published in vitro data of time-averaged wall shear stress (TAWSS) vs nitric oxide (NO) production were tested for predicting long-term graft response (10-month follow-up) on a single patient. Additionally, the sensitivity of the model’s predictions to different inflow boundary conditions (BCs) was assessed. The main findings indicate that: (i) a TAWSS-NO hyperbolic relationship best predicts long-term graft response; (ii) the model is insensitive to the inflow BCs if the waveform shape and the systolic acceleration time are comparable with the one acquired at the same time as the computed-tomography scan. This proof-of-concept study demonstrates the potential of using multiscale, computational techniques to predict NIH growth in lower-limb vein grafts, considering the routine clinical scenario of non-standardised data collection and sparse, incomplete datasets.

Meta-Analysis of Randomised Controlled Trials Comparing Bypass and Endovascular Revascularisation for Peripheral Artery Disease.

Peripheral artery disease affects approximately 250 million people globally. Multiple randomised controlled trials have compared bypass and endovascular interventions but the optimum revascularisation approach remains unclear. The recently published BEST-CLI and BASIL-2 trials provide current and robust data addressing this question, however their findings are not concordant. This systematic review and meta-analysis provides an overview of the worldwide randomised evidence comparing bypass surgery and endovascular revascularisation in lower limb peripheral artery disease. A comprehensive literature search of MEDLINE, Embase and CENTRAL databases was performed of all time periods up to 7 May 2023 to identify randomised controlled trials comparing bypass and endovascular revascularisation for treating lower limb peripheral artery disease. The primary outcome was major amputation. Secondary outcomes were mortality, re-intervention, 30-day adverse events and 30-day mortality. Odds ratios were calculated and pooled using the random-effects model. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Fourteen cohorts were identified across thirteen studies, enrolling 3840 patients. There was no significant difference in major amputation (OR 1.12; 95% CI 0.80-1.57) or mortality (OR 0.96; 95% CI 0.79-1.17) between the bypass and endovascular groups. Bypass was associated with a significant reduction in re-intervention compared with endovascular treatment (OR 0.57, 95% CI 0.40-0.82). These findings suggest that rates of major amputation and mortality are similar following bypass and endovascular interventions. Patients who undergo bypass surgery have a significantly lower re-intervention rate post-operatively.

Impact of SGLT2 inhibitors on lower limb complications: a mendelian randomization perspective.

While Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective in managing diabetes and reducing cardiovascular risk, concerns about their association with lower limb complications, including, osteomyelitis, ulcers, and peripheral artery disease (PAD), persist. This study employs Mendelian Randomization (MR) to assess the causal relationship between SGLT2 inhibitors and these lower limb safety outcomes. A two-sample drug-target MR approach was used, complemented by a one-sample MR and genetic association analysis. Six SNPs were selected as instrumental variables to proxy the effect of SGLT2 inhibition. Primary outcomes were major limb safety outcomes, including osteomyelitis, lower limb ulcers, PAD, and cellulitis. The primary analytical method was the generalized inverse variance-weighted (IVW) approach, along with several sensitivity analyses. The MR analysis indicated no significant causal association between genetically proxied SGLT2 inhibition and most of the studied lower limb safety outcomes. However, a significant association with PAD was observed, necessitating careful interpretation due to discrepancies between IVW and MR-Egger results. Sensitivity analyses supported these findings, showing little evidence of heterogeneity or directional pleiotropy. This study suggests that SGLT2 inhibitors may not be significantly associated with an increased risk of most lower limb safety outcomes, including osteomyelitis, lower limb ulcers, and cellulitis, in patients with type 2 diabetes. However, the complex relationship with PAD highlights the need for further research. These findings contribute to the understanding of the safety profile of SGLT2 inhibitors, supporting their continued use in diabetes management while underlining the importance of continuous safety monitoring.

Cost-effectiveness of diagnostic imaging modalities in symptomatic patients with lower limb peripheral arterial disease: discrete event simulation model.

Lower limb peripheral arterial disease in the symptomatic stage has a significant effect on patients´ functional disability. Before an intervention, an imaging diagnostic examination is necessary to determine the extent of the disability. This study evaluates cost-effectiveness of duplex ultrasonography (DUS), digital subtraction angiography (DSA), computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in the diagnostics of symptomatic patients with lower limb peripheral arterial disease indicated for endovascular or surgical intervention. Discrete event simulation was used to capture lifetime costs and effects. Costs were calculated from the perspective of the health care payer, and the effects were calculated as quality-adjusted life year's (QALY's). The cost-effectiveness analysis was performed to pairwise compare CTA, MRA and DSA with DUS as the baseline diagnostic modality. A scenario analysis and probabilistic sensitivity analysis were carried out to evaluate the robustness of the results. In the basic case, the DUS diagnostic was the least expensive modality, at a cost of EUR 10,778, compared with EUR 10,804 for CTA, EUR 11,184 for MRA, and EUR 11,460 for DSA. The effects of DUS were estimated at 5.542 QALYs compared with 5.554 QALYs for both CTA and MRA, and 5.562 QALYs for DSA. The final incremental cost-effectiveness ratio (ICER) value of all evaluated modalities was below the cost-effectiveness threshold whereas CTA has the lowest ICER of EUR 2,167 per QALY. However, the results were associated with a large degree of uncertainty, because iterations were spread across all cost-effectiveness quadrants in the probabilistic sensitivity analysis. For imaging diagnosis of symptomatic patients with lower limb peripheral arterial disease, CTA examination appears to be the most cost-effective strategy with the best ICER value. Baseline diagnostics of the DUS modality has the lowest costs, but also the lowest effects. DSA achieves the highest QALYs, but it is associated with the highest costs.

Drug-eluting devices for lower limb peripheral arterial disease.

Peripheral arterial disease is the third leading cause of cardiovascular morbidity after coronary artery disease and stroke. Lower limb peripheral arterial disease commonly involves infrainguinal arteries, may impair walking ability (intermittent claudication) and may confer a significant risk of limb loss (chronic limb-threatening ischaemia), depending on the severity of ischaemia. Endovascular treatment has become the mainstay revascularisation option in both the femoropopliteal and the below-the-knee arterial segments. After crossing and preparing the lesion, treatment results in these arterial segments can be enhanced by using drug-coated devices (drug-eluting stents and drug-coated balloons) that mitigate the occurrence of restenosis. As for other medical devices, the use of drug-eluting devices is based on their demonstrated safety and efficacy profiles when applied in the distinct segments of the lower limb vasculature. In this state-of-the-art narrative review we provide an overview of the safety and efficacy of drug-coated devices when used in the femoropopliteal and below-the-knee arterial segments.

In-silico trial emulation to predict the cardiovascular protection of new lipid-lowering drugs: an illustration through the design of the SIRIUS programme.

Inclisiran, an siRNA targeting hepatic PCSK9 mRNA, administered twice-yearly (after initial and 3-month doses), substantially and sustainably reduced LDL-cholesterol (LDL-C) in Phase III trials. Whether lowering LDL-C with inclisiran translates into a reduced risk of major adverse cardiovascular events (MACE) is not yet established. In-silico trials applying a disease computational model to virtual patients receiving new treatments allow to emulate large scale long-term clinical trials. The SIRIUS in-silico trial programme aims to predict the efficacy of inclisiran on CV events in individuals with established atherosclerotic cardiovascular disease (ASCVD). A knowledge-based mechanistic model of ASCVD was built, calibrated, and validated to conduct the SIRIUS programme (NCT05974345) aiming to predict the effect of inclisiran on CV outcomes. The SIRIUS Virtual Population included patients with established ASCVD (previous myocardial infarction (MI), previous ischemic stroke (IS), previous symptomatic lower limb peripheral arterial disease (PAD) defined as either intermittent claudication with ankle-brachial index <0.85, prior peripheral arterial revascularization procedure, or vascular amputation) and fasting LDL-C ≥ 70 mg/dL, despite stable (≥4 weeks) well-tolerated lipid-lowering therapies.SIRIUS is an in-silico multi-arm trial programme. It follows an idealized crossover design where each virtual patient is its own control, comparing inclisiran to (i) placebo as adjunct to high-intensity statin therapy with or without ezetimibe, (ii) ezetimibe as adjunct to high-intensity statin therapy, (iii) evolocumab as adjunct to high-intensity statin therapy and ezetimibe.The co-primary efficacy outcomes are based on the time to the first occurrence of any component of 3P-MACE (composite of CV death, nonfatal MI, or nonfatal IS) and time to occurrence of CV death over 5 years. The SIRIUS in-silico trial programme will provide early insights regarding potential effect of inclisiran on MACE in ASCVD patients, several years before the availability of the results from ongoing CV outcomes trials (ORION-4 and VICTORION-2-P). Clinicaltrials.gov identifier: NCT05974345.

Major Adverse Limb Events in Patients Undergoing Revascularisation for Lower Limb Peripheral Arterial Disease: A Nationwide Observational Study

Major adverse limb events (MALEs) are frequent in patients with lower extremity peripheral arterial disease (PAD). However, routine care MALE rate estimations after revascularisation are scarce. This study aimed to determine post-procedural MALE rates in revascularised patients with PAD and identify predictors for post-procedural MALEs. This was a population based observational study on merged national registry data. Patients with PAD undergoing lower limb revascularisation between 2008 and 2016 were retrieved from the Swedish National Registry for Vascular Surgery. Information on comorbidities, medications, and post-procedural MALE endpoints were identified in national healthcare registries. Primary outcomes of interest were categorised as 2 - 4 point MALE composites that included limb amputation, acute lower limb ischaemia, progression to or relapse of chronic limb threatening ischaemia (CLTI), and ipsilateral re-interventions regardless of indication. Patients with intermittent claudication (IC) and CLTI were analysed separately using Kaplan-Meier estimates. Stepwise Cox proportional hazard models were used for predictor candidate analysis. Overall, 28 021 revascularised patients with PAD were analysed (IC, n = 10 506, 37.5%; CLTI, n = 17 515, 62.5%). During a mean follow up ± standard deviation of 3.2 ± 2.4 years, 5 226 (18.7%), 9 423 (33.6%), and 12 696 (45.3%) patients experienced a 2, 3, and 4 point MALE, respectively. The estimated one year 4 point MALE rates were 21.4% (95% confidence interval [CI] 20.6 - 22.2%) in IC and 46.9% (95% CI 46.1 - 47.7%) in CLTI. Adjusted predictors for experiencing a 4 point MALE in IC were chronic kidney disease (CKD) (hazard ratio [HR] 1.33, 95% CI 1.12 - 1.59) and previous lower limb revascularisation (HR 1.29, 95% CI 1.19 - 1.40). In CLTI, previous contralateral lower limb amputation (HR 1.60, 95% CI 1.47 - 1.73) and CKD (HR 1.25, 95% CI 1.17 - 1.34) were adjusted predictors. This study emphasises the very high MALE rates in revascularised patients with lower limb PAD, especially in CLTI. Prior lower limb revascularisation correlated with increased MALE rates in IC patients, while prior lower limb amputation was linked to subsequent MALEs in CLTI. In both IC and CLTI, CKD was associated with poorer outcomes, regardless of applied MALE definition.

Advances in Vascular Imaging: A Comparative Analysis of Doppler Ultrasound and Multidetector CT for Lower Limb Peripheral Arterial Disease Diagnosis.

Background This study explores the comparison between Doppler ultrasound and multidetector CT angiography (MDCTA) in diagnosing peripheral arterial disease (PAD), emphasizing the urgent need for precise and minimally invasive methodologies in vascular medicine. PAD, stemming from atherosclerosis, manifests as reduced blood flow and symptoms, such as claudication, requiring timely and accurate diagnosis for optimal treatment outcomes. Doppler ultrasound emerges as an option, offering a non-invasive and cost-effective approach. Conversely, MDCTA provides intricate images, albeit with associated risks, such as radiation exposure and potential complications from contrast agents. This research rigorously evaluates the efficacy, safety, and cost-efficiency of these modalities, aiming to provide clinicians with valuable insights for informed decision-making, ultimately enhancing standards of patient care. Methodology In this prospective study conducted at Saveetha Medical College, Chennai, 34 patients diagnosed with PAD were enrolled to compare the efficacy of duplex ultrasound and MDCTA in identifying arterial lesions. Statistical analysis comprised kappa statistics and contingency tables to evaluate the concordance between the modalities, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) being calculated. Exclusions were made for patients with contraindications to MDCTA, those under 18 years of age, severe renal impairment, and allergies to contrast agents. This research examined the diagnostic accuracy of both imaging techniques, aiming to provide valuable insights into their effectiveness in identifying arterial lesions associated with PAD. Statistical analysis This investigation studied the efficacy of Doppler ultrasound and MDCTA in diagnosing PAD, with a particular focus on comparing the accuracy of Doppler ultrasonography (DUS) against MDCTA using sensitivity, specificity, and Cohen's kappa coefficient. Through segmental analysis, valuable insights were garnered into the diagnostic precision of DUS across various arterial segments. The results underscored the significance of DUS as a safe, cost-effective, and non-invasive alternative that complements the utility of MDCTA. This comprehensive assessment sheds light on the comparative strengths of both modalities, offering invaluable guidance for clinicians in selecting optimal diagnostic approaches for PAD assessment. Statistical analysis was conducted using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 24.0, Armonk, NY). Results The sensitivity of ultrasonography (USG) arterial Doppler in evaluating the supra-inguinal, femoropopliteal segments, and infrapopliteal segments was 87.5%, 100%, and 75.32%, respectively. The specificity in evaluating supra-inguinal, femoropopliteal segments, and infrapopliteal segments was 100%, 96.01%, and 83.06%, respectively. The agreement between the two modalities (USG arterial Doppler and CT angiography) obtained by Cohen's kappa analysis with respect to the aortoiliac region and femoropopliteal region was very good (0.91). For infrapopliteal vessels, it was only moderate (0.76). Conclusion Duplex ultrasound emerges as an indispensable tool in the investigation of PAD, offering safety, affordability, and non-invasiveness alongside high diagnostic accuracy and substantial concordance with MDCTA.

Patient Factors Influencing Prescription of Antithrombotic Medication After Lower Limb Endovascular Intervention

There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand. After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength. A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared withangioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with overa third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) ormoderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban. This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisionsbyprocedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.

Modelling lower-limb peripheral arterial disease using clinically available datasets: impact of inflow boundary conditions on hemodynamic indices for restenosis prediction

Background and ObjectivesThe integration of hemodynamic markers as risk factors in restenosis prediction models for lower-limb peripheral arteries is hindered by fragmented clinical datasets. Computed tomography (CT) scans enable vessel geometry reconstruction and can be obtained at different times than the Doppler ultrasound (DUS) images, which provide information on blood flow velocity. Computational fluid dynamics (CFD) simulations allow the computation of near-wall hemodynamic indices, whose accuracy depends on the prescribed inlet boundary condition (BC), derived from the DUS images. This study aims to: (i) investigate the impact of different DUS-derived velocity waveforms on CFD results; (ii) test whether the same vessel areas, subjected to altered hemodynamics, can be detected independently of the applied inlet BC; (iii) suggest suitable DUS images to obtain reliable CFD results. MethodsCFD simulations were conducted on three patients treated with bypass surgery, using patient-specific DUS-derived inlet BCs recorded at either the same or different time points than the CT scan. The impact of the chosen inflow condition on bypass hemodynamics was assessed in terms of wall shear stress (WSS)-derived quantities. Patient-specific critical thresholds for the hemodynamic indices were applied to identify critical luminal areas and compare the results with a reference obtained with a DUS image acquired in close temporal proximity to the CT scan. ResultsThe main findings indicate that: (i) DUS-derived inlet velocity waveforms acquired at different time points than the CT scan led to statistically significantly different CFD results (p<0.001); (ii) the same luminal surface areas, exposed to low time-averaged WSS, could be identified independently of the applied inlet BCs; (iii) similar outcomes were observed for the other hemodynamic indices if the prescribed inlet velocity waveform had the same shape and comparable systolic acceleration time to the one recorded in close temporal proximity to the CT scan. ConclusionsDespite a lack of standardised data collection for diseased lower-limb peripheral arteries, an accurate estimation of luminal areas subjected to altered near-wall hemodynamics is possible independently of the applied inlet BC. This holds if the applied inlet waveform shares some characteristics – derivable from the DUS report – as one matching the acquisition time of the CT scan.

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

BackgroundChronic limb-threatening ischemia (CLTI) represents the most advanced stage of lower extremity peripheral artery disease (PAD). The aim of this manuscript is 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 SOLACI peripheral registry is a prospective, multi-center, 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 CLTI (61.2%): Advanced stage of the disease was common, and the symptomatic classification was predominately Rutherford V (minor tissue loss) in 37.6%. 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 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.

A Systematic Review and Meta-Analysis of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Below-The-Knee Femoral Bypass Surgery

Heparin-bonded expanded polytetrafluoroethylene (hb-ePTFE) synthetic grafts are an alternative to autologous vein grafts (AVG) for surgical bypass interventions in lower limb peripheral arterial disease (LLPAD). However, the clinical benefits of hb-ePTFE grafts have not been reviewed systematically for patients undergoing below-the-knee (BK) surgical bypass. This study aimed to meta-analyze available data on the utility of hb-ePTFE in patients undergoing BK surgical bypass. Medline, Embase, and Cochrane databases were searched, restricted to material in English with no date restriction. In addition, proceedings from relevant congresses were screened going back 2years. The search was performed in December 2021. Eligible studies included prospective or retrospective comparative studies or prospective single-arm cohorts with an hb-ePTFE arm. Methodological quality was assessed with the ROBINS-I criteria. Outcomes included primary patency, amputation/limb salvage, and overall survival. Clinical outcomes were expressed as event rates. Studies were compared using meta-analysis to generate a standardized mean event rate for each outcome, with its 95% confidence interval (95% CI), using a random-effects model. Following deduplication, 10,263 records were identified and 261 were assessed as full texts. No prospective comparative studies were identified. The level of evidence was uniformly low. Seventeen publications describing data from 9 individual patient cohorts met the inclusion criteria. These cohorts included a total of 1,452 patients undergoing BK surgical bypass with hb-ePTFE. The primary patency rate was 78.9% [95% CI: 72.2-85.7%] at 1year, 68.2% [95% CI: 62.8-73.6%] at 2years, decreasing to 48.0% [95% CI: 27.3-68.7%] at 5years. The secondary patency rate was 84.8% [95% CI: 77.0-92.5%] at 1year and 68.9% [95% CI: 43.0-94.9%] at 3years; the 1-year limb salvage rate was 88.3% [95% CI: 79.6-97.1%] at 1year and 79.0% [95% CI: 56.7-100%] at 3years. In patients undergoing BK bypass surgery, hb-ePTFE synthetic grafts, compared to uncoated grafts, perform well for patency and limb salvage. However, the quality of the evidence is low, and well-performed randomized clinical trials are needed to inform clinical decision-making on the choice of synthetic graft.

Spectrum of Findings in Lower Limb Doppler Ultrasonography in UBTH, Benin City

Objectives: Doppler ultrasonography (USS) is a relatively new radiological procedure in our environment but gradually gaining recognition in assessment of lower limb pathologies. This study aims to assess the pattern of referrals for lower limb Doppler USS and the outcome of the procedure at the University of Benin teaching hospital&#x0D; Materials and Methods: This was a retrospective study carried out at the University of Benin teaching hospital, between January 2018 and June 2019. The request forms and Doppler scan results of patients done within this period were retrieved and relevant information were obtained and analyzed using statistical package for social sciences, version 23.&#x0D; Results: A total of 204 patients comprising of 125 females (61.3%) and 79 males (38.7%) were analyzed in this study. Mean age of study population was 55.25±17.02 years. The commonest indication for lower limb Doppler scan was leg swelling (70, 22.8%) while the least was peripheral arterial disease (PAD) (14, 4.6%) The commonest Doppler ultrasound finding was PAD (74, 44.3%), followed by DVT (39, 23.4%). The least findings on Doppler ultrasound of the lower limb was arterio-venous malformation (AV) malformation (1, 0.6%). Arterial wall calcification (100%) was the commonest Doppler finding in patients with PAD. DVT occurred more in the left lower limb (67.7%) than right limb (32.3%) and superficial femoral vein (27.8%) was most affected.&#x0D; Conclusion: This study has shown that Doppler scan is quite relevant in lower limb pathologies and peripheral artery disease is the commonest diagnosis in the lower limb.

Mortality in a Nationwide Practice-Based Cohort Receiving Paclitaxel-Coated Devices for Lower Limb Peripheral Artery Disease

BackgroundAccording to a meta-analysis of randomized clinical trials, paclitaxel-coated devices (PCDs) for lower limb endovascular revascularization may be associated with increased risk of late mortality. ObjectivesThe purpose of this study was to determine whether PCDs are associated with all-cause mortality in a real-world setting. MethodsDETECT is a nationwide, exhaustive retrospective cohort study using medico-administrative data from the French National Healthcare System representing >99% of the population. The main selection criterion was the first procedure of interest: endovascular revascularization for lower limb peripheral artery disease involving ≥1 balloon and/or stent performed between October 1, 2011, and December 31, 2019. Patients with or without PCDs were compared for all-cause mortality until December 31, 2021. ResultsA total of 259,137 patients were analyzed, with 20,083 (7.7%) treated with ≥1 PCD. After a median follow-up of 4.1 years (Q1-Q3: 2.3-6.4 years), a total of 5,385 deaths/73,923 person-years (PY) (7.3/100 PY) and 109,844 deaths/1,060,513 PY (10.4/100 PY) were observed in the PCD and control groups, respectively. After adjustment for confounding factors, PCD treatment was associated with a lower risk of mortality in multivariable Cox analyses (HR: 0.86; 95% CI: 0.84-0.89; P < 0.001). Similar results were observed using propensity score matching approaches based on either nearest-neighbor or exact matching. ConclusionsIn a nationwide analysis based on large-scale real-world data, exposure to PCDs was not associated with a higher risk of mortality in patients undergoing endovascular revascularization for lower limb peripheral artery disease. (The DETECT Project; NCT05254106)

Comparative study of arterial doppler with digital subtraction angiography in lower limb peripheral arterial disease: a protocol

Background One of the serious cardiovascular conditions is peripheral arterial disease; in which distinctive feature is diminished blood supply towards the lower extremities, frequently because of atherosclerotic occlusive disease. Methods We will compare arterial Doppler with digital subtraction angiography in peripheral lower limb occlusive arterial sickness; to determine Peripheral Arterial Disease along with its location and stenosis severity on Duplex Ultra-Sonography and Digital Subtraction Angiography; and to determine the segment-to-segment agreement of the arterial tree within Duplex Ultra-Sonography and Digital Subtraction Angiography. Implications This will encourage the participants for periodic investigation and proper use of medications which will improve hospital/facility outcome. It will be helpful for older individuals how are more susceptible to peripheral artery disease. A fair accurate treatment options will be given to patients. Limitations Findings will only be applicable to our organization because the study will be done at one tertiary care hospital, limiting their external validity and generalizability.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication

Screening for Peripheral Artery Disease Using an Automated Four-Limb Blood Pressure Monitor Equipped with Toe-Brachial Index Measurement.

Toe-brachial index (TBI) measurement helps to detect peripheral artery disease (PAD) in patients with incompressible ankle arteries due to medial arterial calcification, which is most frequently associated with diabetes. We aimed to evaluate how an automated four-limb blood pressure monitor equipped with TBI measurement could contribute to PAD screening. In 117 patients (mean age 63.2 ± 12.8 years), ankle-brachial index (ABI) measurement was performed using the Doppler-method and the MESI mTablet. TBI was obtained via photoplethysmography (MESI mTablet, SysToe) and a laser Doppler fluxmeter (PeriFlux 5000). Lower limb PAD lesions were evaluated based on vascular imaging. A significant correlation was found between Doppler and MESI ankle-brachial index values (r = 0.672), which was stronger in non-diabetic (r = 0.744) than in diabetic (r = 0.562) patients. At an ABI cut-off of 0.9, Doppler (AUC = 0.888) showed a sensitivity/specificity of 67.1%/97.4%, MESI (AUC 0.891) exhibited a sensitivity/specificity of 57.0%/100%; at a cut-off of 1.0, MESI demonstrated a sensitivity/specificity of 74.7%/94.8%. The TBI values measured using the three devices did not differ significantly (p = 0.33). At a TBI cut-off of 0.7, MESI (AUC = 0.909) revealed a sensitivity/specificity of 92.1%/67.5%. Combining MESI ABI and TBI measurements recognised 92.4% of PAD limbs. Using an ABI cut-off level of 1.0 and sequential TBI measurement increases the sensitivity of the device in detecting PAD. The precise interpretation of the obtained results requires some expertise.

Sensitivity and Specificity of Pulse Oximetry for Identification of Peripheral Artery Disease: A Systematic Review.

Lower limb peripheral artery disease (PAD) is associated with poor outcomes including ulceration, gangrene, amputations, and mortality. Clinicians therefore routinely perform point-of-care tests in high-risk populations to identify PAD and subsequently implement cardiovascular management and appropriate interventions. Pulse oximetry has been suggested as a useful adjunct test for identifying PAD. The aim of this systematic review was to determine the sensitivity and specificity of pulse oximetry in the lower limb for identifying PAD. MEDLINE, EMBASE, and CINAHL were searched up until January 10, 2023, to identify studies of sensitivity and specificity of pulse oximetry that used criterion standard diagnostic imaging as a reference standard. Two authors screened articles for inclusion and appraised quality of included studies using the Quality Appraisal for Diagnostic Accuracy Studies, version 2. A total of 6371 records were screened, and 4 were included. The included studies had a total of 471 participants, with an age range of 41 to 80.6 years. All studies were cross-sectional and conducted in hospital settings. Sensitivity values for pulse oximetry compared with diagnostic imaging in identifying PAD ranged from 44% to 76%, and specificity values ranged from 85% to 96%. There was no consensus regarding measurement techniques and diagnostic thresholds for pulse oximetry, which precluded meta-analysis. There is currently inadequate evidence to support the use of pulse oximetry for identifying PAD. Current evidence suggests that pulse oximetry has low levels of sensitivity and is therefore likely to miss PAD when it is present.

Antithrombotic drugs for cardiovascular risk reduction in patients with lower limb peripheral arterial disease: protocol for a systematic review and network meta-analysis of randomised controlled trials

IntroductionThe optimal antithrombotic regimen to reduce the risk of vascular events in patients with peripheral arterial disease (PAD) is contentious. This systematic review and network meta-analysis (NMA) aims to define...

Performance of systolic pressure index for lower limb peripheral arterial disease in a group of elderly in sub-Saharan Africa

BackgroundThe automatic measurement of the ankle-brachial index (ABI) constitutes a reliable, simple, safe, rapid, and inexpensive alternative diagnostic screening test compared with the Doppler method for peripheral arterial disease (PAD). We aimed to compare the diagnostic performance of automatic ABI measurement tests to Doppler ultrasound for PAD in a group of patients aged 65 years and above, in Sub-Saharan Africa. MethodsThis was an experimental comparative study of the performance of Doppler ultrasound to the automated ABI test in the diagnosis of PAD in patients aged ≥ 65 years followed-up at the Yaoundé Central Hospital, Cameroon between January to June 2018. An ABI threshold < 0.90 is defined as a PAD. We compare the sensitivity, and specificity of the high ankle-brachial index (ABI-HIGH), low ankle-brachial index (ABI-LOW), and the mean ankle-brachial index (ABI-MEAN) for both tests. ResultsWe included 137 subjects with an average age of 71.7 ± 6.8 years. In the ABI-HIGH mode, the automatic device had a sensitivity of 55% and a specificity of 98.35% with a difference between the two techniques of d = 0.024 (p = 0.016). In the ABI-MEAN mode, it had a sensitivity of 40.63% and a specificity of 99.15%; d = 0.071 (p < 0.0001). In the ABI-LOW mode, it had a sensitivity of 30.95% and a specificity of 99.11%; d = 0.119 (p < 0.0001). ConclusionThe Automatic measurement of systolic pressure index has a better diagnostic performance in the detection of Peripheral Arterial Disease compared to the reference method by continuous Doppler in sub-Saharan African subjects aged ≥ 65 years.