Lower Limb Peripheral Arterial Disease Research Articles

Association of apolipoprotein levels with peripheral arterial disease: a meta-analysis of literature studies.

Lower limb peripheral artery disease (PAD) is a leading cause of atherosclerotic cardiovascular disease (ASCVD). Discordant data are available on the association between apolipoprotein and PAD. We performed a meta-analyses on the association between apolipoprotein (apo)B, apoA-I, and apoB/apoA-I ratio with PAD. PubMed, Web of Science, Scopus databases were systematically searched. Studies providing data about apoB, apoA-I, apoB/apoA-I ratio in PAD subjects and non-PAD controls were included. Differences between PAD and non-PAD subjects were expressed as mean difference (MD) with pertinent 95% confidence intervals (95%CI). Twenty-two studies were included. Peripheral artery disease subjects showed higher apoB (MD: 12.5 mg/dL, 95%CI: 2.14, 22.87) and lower apoA-I levels (MD: -7.11 mg/dL, 95%CI: -11.94, -2.28) than non-PAD controls. Accordingly, ApoB/ApoA-I ratio resulted higher in PAD subjects than non-PAD controls (MD: 0.11, 95% CI: 0.00, 0.21). Non-HDL-C showed a direct association with the difference in apoB (z-value: 4.72, P < 0.001) and an inverse association with the difference of apoA-I (z-value: -2.43, P = 0.015) between PAD subjects and non-PAD controls. An increasing BMI was associated with an increasing difference in apoA-I values between PAD subjects and non-PAD controls (z-value: 1.98, P = 0.047). Our meta-analysis suggests that PAD subjects exhibit increased apoB and reduced apoA-I levels, accompanied by an increased apoB/apoA-I ratio as compared with non-PAD controls.

Association of gout with major adverse cardiovascular events and all-cause mortality in patients with peripheral artery disease

Background and aimsPrior epidemiological studies have suggested that individuals with gout are at greater risk of cardiovascular events, but there have been no studies in people with peripheral artery disease (PAD). The aim of this study was to investigate the relationship between gout and major adverse cardiovascular events (MACE) and all-cause mortality in people with PAD. MethodsParticipants with a range of PAD presentations, including carotid artery disease, aortic or peripheral aneurysm and lower limb PAD, were prospectively recruited from outpatient vascular departments within Australia. MACE (myocardial infarction, stroke or cardiovascular death) and all-cause mortality were identified through out-patient follow-up and linked medical records. Propensity-score matching was undertaken to generate a matched cohort of patients with and without a history of gout. Kaplan-Meier survival analysis and Cox-proportional hazard analysis were used to examine the association of gout with MACE and all-cause mortality. ResultsA total of 4308 people with PAD, of whom 334 had a history of gout, were included and followed for a median (inter-quartile range) of 2.1 (0.1–5.9) years. In the unadjusted analyses, participants with gout were at increased risk of MACE (hazard ratio, HR 1.37, 95% confidence intervals, CI 1.09–1.71, p = 0.006) and all-cause mortality (HR 1.38, 95% 1.13–1.68, p = 0.002), however, the associations were lost in the adjusted analyses. In the propensity-score matched cohort, gout was not significantly associated with an increased risk for MACE or all-cause mortality. ConclusionsGout was not independently associated with increased cardiovascular events in PAD patients.

Dysregulation of ghrelin in diabetes impairs the vascular reparative response to hindlimb ischemia in a mouse model; clinical relevance to peripheral artery disease

Type 2 diabetes is a prominent risk factor for peripheral artery disease (PAD). Yet, the mechanistic link between diabetes and PAD remains unclear. This study proposes that dysregulation of the endogenous hormone ghrelin, a potent modulator of vascular function, underpins the causal link between diabetes and PAD. Moreover, this study aimed to demonstrate the therapeutic potential of exogenous ghrelin in a diabetic mouse model of PAD. Standard ELISA analysis was used to quantify and compare circulating levels of ghrelin between (i) human diabetic patients with or without PAD (clinic) and (ii) db/db diabetic and non-diabetic mice (lab). Db/db mice underwent unilateral hindlimb ischaemia (HLI) for 14 days and treated with or without exogenous ghrelin (150 µg/kg/day.) Subsequently vascular reparation, angiogenesis, hindlimb perfusion, structure and function were assessed using laser Doppler imaging, micro-CT, microangiography, and protein and micro-RNA (miRNA) analysis. We further examined hindlimb perfusion recovery of ghrelin KO mice to determine whether an impaired vascular response to HLI is linked to ghrelin dysregulation in diabetes. Patients with PAD, with or without diabetes, had significantly lower circulating levels of endogenous ghrelin, compared to healthy individuals. Diabetic db/db mice had ghrelin levels that were only 7% of non-diabetic mice. The vascular reparative capacity of diabetic db/db mice in response to HLI was impaired compared to non-diabetic mice and, importantly, comparable to ghrelin KO mice. Daily therapeutic treatment of db/db mice with ghrelin for 14 days post HLI, stimulated angiogenesis, and improved skeletal muscle architecture and cell survival, which was associated with an increase in pro-angiogenic miRNAs-126 and -132. These findings unmask an important role for endogenous ghrelin in vascular repair following limb ischemia, which appears to be downregulated in diabetic patients. Moreover, these results implicate exogenous ghrelin as a potential novel therapy to enhance perfusion in patients with lower limb PAD, especially in diabetics.

CT Angiography in Patients with Peripheral Arterial Disease

Background: Peripheral arterial disease is one of the most important causes of morbidity. Non-invasive characterization of peripheral arterial disease is possible by using CT angiography. The aim of this research is to evaluate CT angiographic findings in patients with peripheral arterial disease, to characterize lesion, risk factors and site of lesion.&#x0D; Methods: This hospital based prospective study was conducted in 40 consecutive patients with lower limb peripheral arterial disease who underwent CT angiography in the Department of Radiodiagnosis College of Medical Sciences-Teaching Hospital from January 2018 to Jan 2019.&#x0D; Results: Atherosclerotic peripheral disease was most common in elderly male patient with history of smoking, hypertension, diabetes or dyslipidemia and usually presents in the late stages with single or multiple arterial segmental involvement including the abdominal aorta. However, non- atherosclerosis peripheral arterial disease was seen in younger patients and presents with vascular thrombosis.&#x0D; Conclusions: CT angiography is a reliable non-invasive imaging modality for evaluating patients with peripheral arterial disease and lesion characterization.&#x0D; Keywords: CTA; Peripheral arterial disease.&#x0D;

Peripheral artery disease in the lower limbs: The importance of secondary risk prevention for improved long-term prognosis.

Patients with lower limb peripheral artery disease (PAD) are at high risk ofcardiovascular mortality and morbidityalong with limb loss. PAD isunderdiagnosed in the community andpresents a missed opportunity to prescribe evidence-based secondary prevention therapy. The aim of this article is tosummarise key updates in the management of patients with PAD, withparticular reference to newly published guidelines. PAD continues to be a major contributor to the mortality and morbidity of patients with atherosclerosis in Australia. For patients with chronic limb-threatening ischaemia, revascularisation remains the mainstay of limb salvage, and expedited access to vascular surgery assessment isnecessary. Both prescription of, and adherence to, evidence-based secondary prevention therapy is low. A greater emphasis on cardiovascular risk factor modification for all patients with PAD is required to improve long-term outcomes. General practitioners and vascular surgeons can work collaboratively to provide patient-centred, effective care topatients with PAD.

The omental free flap and flow-through flap: pre-operative evaluation of right gastro-omental artery on multidetector computed tomography.

The gastro-omental artery (GOA) and the greater omentum are nowadays commonly used in many reconstructive surgeries, including cardiac, vascular, and plastic surgery. There are cases in which the GOA is found to be unsuitable only after partial harvesting following an upper laparotomy, and an improved method of pre-operative evaluation is required to eliminate the need for intraoperative small laparotomy. Multidetector computed tomography was performed for 30 consecutive patients admitted for lower limb ischemia in a routine pre-operative evaluation of lower limb peripheral arterial disease (PAD). The origin of the GOA was checked on coronal and sagittal slices, its pathway was identified on the three-dimensional rendering. We assessed length and mean diameter of the distal and proximal right GOA, and the mean distances between the origins of GOA and the omental branches. Finally, we report one case of omental flow-through flap. 30 patients were included in our study. Routine pre-operative MDCT during lower limb PAD workup enabled identification of GOA in all cases. The mean internal diameter of the GOA at its origin was 3.3mm (± 3.3). The mean internal diameter of the distal GOA was 1.26mm (± 0.3). At least one omental descending branch was detected in every case and in 63% (19 patients) at least two branches were visualized. Routine pre-operative angio-MDCT imaging is an effective tool to assess precisely the different anatomical properties of the GOA. This exam could be useful for both diagnosis of lower limb PAD and evaluation of the GOA suitability for flow-through flap lower limb revascularisation.

Multiple Peri-Operative Complications are Associated with Reduced Long Term Amputation Free Survival Following Revascularisation for Lower Limb Peripheral Artery Disease: A Population Based Linked Data Study

Multiple Peri-Operative Complications are Associated with Reduced Long Term Amputation Free Survival Following Revascularisation for Lower Limb Peripheral Artery Disease: A Population Based Linked Data Study

UNEXPECTED COMPLICATION FROM SHOCKWAVE INTRAVASCULAR LITHOTRIPSY

Lower limb peripheral artery disease (PAD) affects 20% of population over 65 years. Shockwave peripheral intravascular lithotripsy has emerged as a safe and feasible treatment option for those patients. A 42-year old woman with history of PAD presented with severe claudication that did not improve

Multiple Peri-Operative Complications are Associated with Reduced Long Term Amputation Free Survival Following Revascularisation for Lower Limb Peripheral Artery Disease: A Population Based Linked Data Study

To determine, in a population based linked data study, the relationship between peri-operative multiple complications and longer term outcomes, specifically the combined outcome of two year amputation or death, after lower limb revascularisation for peripheral artery disease (PAD). State wide health administrative data and death records were probabilistically linked for all patients who had lower limb artery surgery between 2010 and 2012 in New South Wales, Australia. Multivariable Cox regression modelled the impact of medical and surgical complications on the combined outcome of amputation or death two years after discharge. Open surgery was performed on 3004 patients (26.7%), and endovascular on 8263 (73.3%). Of the 10971 patients discharged alive, 3747 (34.1%) experienced at least one complication, and 2113 (19.3%) had multiple complications. Older patients, those with high comorbidity scores, or those with chronic limb threatening ischaemia were at increased risk of multiple complications. After adjusting for procedure type, patients with multiple complications experienced more than three times the hazard ratio (HR) of amputation or death two years after the procedure than those without complications (adjusted HR 3.4, 95% confidence interval 3.1-3.7), and increasing complications progressively multiplied the risk. In particular, non-surgical complications such as stroke, acute renal failure, delirium, and cardiac events were associated with the highest rates of two year amputation or death. Multiple complications after surgery for lower limb PAD carried a compounding risk of reduced long term amputation free survival. Patients experiencing at least one complication form a high risk group that requires increased attention to prevent the potential development of further complications.

C-Reactive Protein and Infrainguinal Autologous Bypass Treatment of Lower Limb Peripheral Artery Disease: An Independent Prognostic Factor

Introduction - Research has shown that inflammatory processes are involved in the onset and progression of peripheral artery disease (PAD). In particular, high-sensitivity C-reactive protein (hsCRP), a surrogate of systemic inflammation, is a promising marker of this atherosclerotic manifestation. Nevertheless, although recent evidence shows association between high baseline hsCRP levels and worse prognosis after revascularization, especially in endovascular therapy [1], there is scarce evidence about revascularization with open bypass surgery. The aim of this study was to determine if hsCRP can predict the outcome of infrainguinal autologous bypass surgery in patients with PAD and to calculate a cutoff value that may be useful in identifying patients with a higher long-term risk of failure. Methods - In this prospective single-center cohort study, 95 patients (78 men; mean age 69±6 years) undergoing bypass surgery of lower limb were enrolled as a derivation set in a 12-month period. In the subsequent 6 months, 40 patients (31 men; mean age 72±4 years) were enrolled as the validation set. Blood samples were collected before intervention from both sets of patients to measure hsCRP levels. The cohorts were followed for 2 years and data on reinterventions was recorded. An hsCRP cutoff value was calculated with the highest sensitivity and specificity for bypass permeability and amputation free survival based on receiver operator characteristic (ROC) curve analysis. The cutoff value was confirmed as well in the validation set. Cox proportional hazards analyses were performed to evaluate the independent contribution of hsCRP levels and other variables to the risk of reintervention; results are given as the hazard ratio (HR) and 95% confidence interval (CI). Results - The area under the ROC curve relating preprocedure hsCRP levels to 2-year reintervention was 0.59 ± 0.06. The highest likelihood ratio corresponded to a pre-surgery hsCRP value of 6.0 mg/L. hsCRP levels lower than 6.0 mg/L were associated to a greater primary patency (HR= 1.8; 95%CI 1.02 - 3.2, p= 0.045); assisted primary patency (HR= 2.19, 95%CI 1.04 - 4.63, p= 0.039); and secondary patency (HR= 2.11, 95%CI 1.01 - 4.46, p= 0.05); as well as a greater amputation-free survival (HR= 2.57, 95%CI 1.18 - 5.58, p= 0.018). These results were confirmed in the validation set: Primary patency (HR= 1.7, 95%CI 1.03 - 2.9, p= 0.04); assisted primary patency (HR= 1.99, 95%CI 1.1 - 3.9, p= 0.03); secondary patency (HR= 2.3, 95%CI 1.04 - 5.1, p= 0.045); and amputation-free survival (HR= 2.8, 95%CI 1.13 - 6.01, p= 0.02). Conclusion - hsCRP values may be used as an independent marker of autologous infrainguinal bypass surgery outcome. Baseline hsCRP levels <6.0 mg/L are associated to a greater long-term patency and greater amputation-free survival.

Giant cell arteritis-related aortitis with positive or negative temporal artery biopsy: a French multicentre study

Objective: To compare the clinical presentation and outcome of giant cell arteritis (GCA)-related aortitis according to the results of temporal artery biopsy (TAB).Method: Patients with GCA-related aortitis diagnosed between 2000 and 2017, who underwent TAB, were retrospectively included from a French multicentre database. They all met at least three American College of Rheumatology criteria for the diagnosis of GCA. Aortitis was defined by aortic wall thickening > 2 mm on computed tomography scan and/or an aortic aneurysm, associated with an inflammatory syndrome. Patients were divided into two groups [positive and negative TAB (TAB+, TAB−)], which were compared regarding aortic imaging characteristics and aortic events, at aortitis diagnosis and during follow-up.Results: We included 56 patients with TAB+ (70%) and 24 with TAB− (30%). At aortitis diagnosis, patients with TAB− were significantly younger than those with TAB+ (67.7 ± 9 vs 72.3 ± 7 years, p = 0.022). Initial clinical signs of GCA, inflammatory parameters, and glucocorticoid therapy were similar in both groups. Coronary artery disease and/or lower limb peripheral arterial disease was more frequent in TAB− patients (25% vs 5.3%, p = 0.018). Aortic wall thickness and type of aortic involvement were not significantly different between groups. Diffuse arterial involvement from the aortic arch was more frequent in TAB− patients (29.1 vs 8.9%, p = 0.03). There were no differences between the groups regarding overall, aneurism-free, relapse-free, and aortic event-free survival.Conclusion: Among patients with GCA-related aortitis, those with TAB− are characterized by younger age and increased frequency of diffuse arterial involvement from the aortic arch compared to those with TAB+, without significant differences in terms of prognosis.

Effects of Remote Ischaemic Preconditioning on Arterial Stiffness in Patients Undergoing Lower Limb Angiographic Procedures: A Randomised Clinical Trial

Remote ischaemic preconditioning (RIPC) is a phenomenon that promotes protection of tissues and organs against ischaemia reperfusion injury. RIPC has been shown to reduce myocardial and renal injury but its effect on arterial stiffness in patients undergoing lower limb digital subtraction angiography (DSA) is unknown. The aim of this study was to evaluate the effect of RIPC on arterial stiffness in patients with peripheral arterial disease (PAD) undergoing lower limb DSA. In the RIPC intervention, the blood pressure cuff on the arm was inflated to 200mmHg or to 20mmHg above systolic pressure, and in the sham intervention to 20mmHg. For both, the procedure was repeated for four five minute cycles at five minute intervals between the cycles. Changes in heart rate corrected augmentation index (AIx@75), augmentation index (AIx), carotid femoral pulse wave velocity (PWV), and haemodynamic parameters were measured before and 24h after DSA. 111 (RIPC 54, sham 57) patients with symptomatic lower limb PAD scheduled for DSA were randomised. 102 patients (RIPC 47, sham 55) were included in final analysis. RIPC significantly improved AIx (-5.46% in RIPC and-1.45% in sham group; p=.05), but not AIx@75 (-4.88% in RIPC and-1.38% in sham group; p=.07) or PWV (-0.41m/s in RIPC and-0.27m/s in sham group; p=.74). In the RIPC group a significant reduction in AIx (p=.002) and AIx@75 (p=.003) was noted after stenting when compared with the sham intervention. AIx (p=.001), AIx@75 (p=.002), mean arterial (p=.01), peripheral (p=.02), and central systolic blood pressure (p=.006) were significantly reduced only in the RIPC group 24h after DSA. This study evaluates for the first time the effects of RIPC on arterial stiffness parameters in patients with symptomatic PAD following DSA. RIPC may modulate arterial stiffness following a DSA procedure and is more pronounced in patients after stent placement.

Mortality Risk Following Application of a Paclitaxel-Coated Stent in Femoropopliteal Lesions

Purpose: To examine if endovascular therapy (EVT) with paclitaxel-coated stents increases the mortality risk in patients with symptomatic lower limb peripheral artery disease (PAD). Materials and Methods: A retrospective analysis was conducted of paclitaxel-coated stent use in the femoropopliteal segment of 1535 symptomatic (Rutherford category 2 to 4) patients treated between January 2010 and December 2016 at 4 hospitals in Japan. The risk of all-cause mortality was examined between the 285 patients (mean age 73±8 years; 213 men) treated with a paclitaxel-coated stent (PTX-coated group) and 1250 patients (mean age 73±9 years; 872 men) not exposed to a paclitaxel-coated device (PTX-free group) during EVT. Propensity score matching was employed to balance baseline characteristics. Cox proportional hazards models stratified on the quintiles of the propensity score were used to investigate paclitaxel-coated stent use and mortality risk as well as interactions among baseline variables and the main outcome. Interactions between a PXT-coated stent and subgroups of the PTX-free group (bare stent and angioplasty) were also investigated, as was the impact of paclitaxel dose on mortality risk. The results of regression analysis are reported as the hazard ratio (HR) and 95% confidence interval (CI). Results: The 3-year overall survival estimates were 86.4% in the PTX-coated group vs 87.7% in the PTX-free group; the corresponding 5-year estimates were 77.5% vs 73.7%, respectively. There was no significant difference in all-cause mortality between the 2 groups (HR 0.89, 95% CI 0.66 to 1.19, p=0.41). The cause of death also showed no remarkable difference between the groups. Chronic renal failure (p=0.044) and arterial calcification (p=0.022) demonstrated a significant interaction effect on the association of the use of a PTX-coated stent with all-cause mortality. No subgroup demonstrated that the use of a paclitaxel-coated stent was associated with an increased risk of all-cause mortality. A dose dependency was not evident. Conclusion: Mortality risk following application of a PTX-coated stent did not increase over 5 years, irrespective of the dose. A PTX-coated stent for femoropopliteal lesions in PAD patients is a safe treatment option.

The use of ABI in screening for diabetes-related lower limb peripheral arterial disease in IDF middle- and low-income countries: a scoping review

The burden of disease from diabetic foot ulcers linked to peripheral arterial disease (PAD) is complicated by limited resources in low- to middle-income countries (LMIC). This precludes the widespread use of sophisticated imaging methods. Screening for PAD can include the use of low-cost tests such as the ankle brachial index (ABI). A scoping review was performed to identify what is known about the use of ABI in screening for diabetes-related PAD in LMIC. LMIC were defined as per the International Diabetes Federation Atlas. The following databases were searched using a comprehensive search term: Cochrane Library, EbscoHost, PubMed, Web of Science, Science Direct, Scopus, and Google Scholar. A total of 400 records were gleaned. The publication abstracts were screened through several rounds to select only those in which ABI was used in the context of screening for PAD to prevent diabetic foot disease. Twenty publications were included, from MLIC countries such as Brazil, Nigeria, Kenya, Uganda, South Africa, India, China, Singapore, Korea, Taiwan, Hong Kong, Indonesia, Thailand, and the Philippines. Ten ancilliary publications were identified. The widespread reporting and large scale use of ABI in PAD screening in Asia are evident, compared to fewer reports from Africa and South America. Many Asian publications report using faster, automated ABI equipment in conjunction with handheld Doppler evaluation of flow signals. Despite concerns regarding the potential for false elevations secondary to vessel calcification and non-compressibility, ABI remains a useful first encounter test in screening for PAD. Asian publications endorse and report the use of ABI firmly within the core clinical examination and consideration of other risk factors for PAD. No publications were found on large-scale use of automated ABI in the South African or greater African context of diabetic foot screening.

Combined percutaneous direct puncture of occluded artery - antegrade intervention for recanalization of below the knee arteries.

We aimed to assess the technical success of the combined percutaneous direct puncture of occluded artery - antegrade intervention technique, as well as the clinical effectiveness of treatment, on the basis of changes in the Rutherford classification. Between June 2015 and July 2018, 441 patients underwent endovascular recanalization due to lower limb peripheral arterial disease at our center. Of these, 18 patients (4%; 15 males, 3 females; mean age, 63.2 years) had failed antegrade recanalization and percutaneous retrograde access because of long segment occlusion, arterial rupture or dissection. Combined percutaneous direct puncture of occluded artery and antegrade approach was applied to these patients. Clinical follow-up examinations were performed at 1 month, 3 months, 6 months, and annually thereafter. The mean follow-up period was 22.8±10.9 months. The mean procedure time was 93.6±28.2 min. Technical success was achieved in 14 patients (78%). Complete restoration of arterial flow in the punctured vessel could not be achieved in 4 patients (22%). Minor complications occurred in 4 of 18 procedures (22%). Amputation-free survival and limb salvage rates (83.3% and 100%, respectively) were the same for 12 and 24 months. Technical success in lower limb peripheral arterial disease may be improved with the use of a combined percutaneous direct puncture of occluded artery - antegrade intervention, particularly for patients in whom other techniques are not a viable option.

The position of Polish experts on conservative management in patients with artery diseases of lower limbs

Peripheral artery disease (PAD) is a common disease, though not very well known and often diagnosed on a very late stage, causing not only typical complications such as intermittent claudication, critical limb ischemia or amputations, but also to cardiovascular mortality. The risk of cardiovascular death can be even 11 times higher in patients with symptomatic PAD than in healthy patients. The risk of heart attack, stroke or cardiovascular death is even higher, reaching almost 4% within one year, nearly equal to the risk for patients with coronary artery disease (CAD). In those patients, the 5-year mortality risk is estimated at 10–15%, with cardiovascular disorders being the most likely cause of death. In patients with critical limb ischemia, the risk of cardiovascular death within one year can be as high as 25% and the risk of amputation — 30%. It is estimated that the global population of patients with PAD is over 120 million. The incidence of the diseases is 3–10%, but in patients aged 70 and more, the incidence increases to 14–29%. In Poland, around 4,000 people are hospitalized every year for PAD of lower limbs. The number of PAD-related amputations is over 9,000 per year. Although the methods of PAD diagnosis (e.g. ABI) are often easy and non-invasive, they are scarcely used in clinical practice. Also, optimal conservative management in the form of quitting smoking, modifying the cardiovascular risk factors and supervised exercise is often overlooked. PAD is a major issue not only for vascular surgery, but also for many other medical specializations, including angiology, general medicine, cardiology, or diabetology. As a result of long waiting times for the next visit and lack of access to patient programmes and reimbursed drugs, patients with PAD often report to the doctor when their condition is very serious. Despite the 2017 ESC guidelines on the diagnosis and treatment of peripheral artery disease, prepared together with ESVS, not all healthcare professionals have access to the latest knowledge on PAD diagnosis and treatment. Unfortunately, though published recently, the ESC’s guidelines do not include some of the recent studies, among them the possibly breakthrough COMPASS trial which has the potential to change the paradigm of management of patients with PAD. We must bear in mind that the population with PAD is a difficult patient group who need new treatment methods and optimization of the existing ones in order to visibly improve diagnosis, treatment and prognosis.

Relationship between symptomatic lower limb peripheral artery disease and calcified carotid artery plaque detected on panoramic images of neurologically asymptomatic males.

Males with peripheral arterial disease (PAD) are at high risk of ischaemic stroke given that atherogenic risk factors for both diseases are similar. We hypothesized that neurologically asymptomatic males diagnosed with PAD would demonstrate calcified carotid artery plaques (CCAP) on panoramic images (PI) significantly more often than similarly aged males not having PAD. Investigators implemented a retrospective cross-sectional study. Subjects were male patients over age 50 diagnosed with PAD by ankle-brachial systolic pressure index results of 0.9. Controls negative for PAD had an ankle-brachial systolic pressure index > 0.9. Predictor variable was a diagnosis of PAD and outcome variable was presence of CCAP. Prevalence of CCAP amongst the PAD+ patients was compared to prevalence of CCAP among PAD- patients. Descriptive and bivariate statistics were computed and p-value was set at 0.05. Final sample size consisted of 234 males (mean age 72.68 ± 9.09); 116 subjects and 118 controls. Among the PAD+ cohort, CCAP+ prevalence rate (57.76%) was significantly (p = 0.001) greater than the CCAP+ rate (36.44%) of the PAD- (control). There was no significant difference in atherogenic "risk factors" in the PAD+ cohort between CCAP+ and CCAP- subjects. We demonstrated that CCAP, a "risk factor" for future stroke and "risk indicator" of future myocardial infarction is seen significantly more often detected on the PIs of older male patients with PAD than among those without. Dentists treating patients with PAD must be uniquely vigilant for the presence of CCAPs on their patients' PI.

Serum Low-Density Lipoprotein Cholesterol Level After Endovascular Therapy in Patients With Claudication

Purpose: To investigate the association between low-density lipoprotein cholesterol (LDL-C) levels and the 5-year cardiovascular death rate after endovascular therapy (EVT) in patients with lower limb peripheral artery disease (PAD) according to statin therapy status. Methods: From January 2010 to March 2016, 1324 PAD patients (1670 limbs) with claudication (Rutherford category 1–3) underwent EVT. After excluding 389 patients owing to death or missing data, 935 (70.6%) patients (mean age 72.1±8.7 years; 708 men) were included in the analysis. Statin therapy was prescribed to 509 (54.4%) patients at discharge. LDL-C levels at 3 to 6 months after EVT were correlated with the incidence of cardiovascular death (CVD; procedure-related and proximate cardiac, noncoronary vascular, or unknown causes) at 5 years. A stratifying factor of 100 mg/dL was based on the median LDL-C value (94 mg/dL) in the cohort. Predictors of CVD were sought in multivariate analysis; results are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results: Over a median follow-up of 30.7 months (interquartile range 13.7, 47.6), CVD occurred in 83 (8.9%) patients. The incidence of CVD at 5 years was significantly higher in patients with LDL-C ≥100 mg/dL at 3 to 6 months than in those with LDL-C <100 mg/dL (23.5% vs 13.5%, p=0.03). In addition, LDL-C ≥100 mg/dL at 3 to 6 months was associated with a higher incidence of CVD (25.2% vs 10.9%, p=0.02) in 509 (54.4%) patients with statin therapy at discharge. In the multivariate model, LDL-C ≥100 mg/dL at 3 to 6 months after EVT was an independent predictor of CVD (adjusted HR 1.60, 95% CI 1.001 to 2.59, p=0.049). Conclusion: LDL-C ≥100 mg/dL at 3 to 6 months after the EVT for symptomatic lower limb PAD was independently associated with a higher risk of CVD, particularly in patients on statin therapy at discharge. This observation suggests that intensive LDL-C–lowering therapy may be needed to improve clinical outcomes.

Ankle-brachial index in ischemic stroke: risk factor correlation and prognostic value

BackgroundAnkle-brachial index (ABI) is not only a marker of lower limb peripheral arterial disease (PAD), but may also reflect the severity of systemic atherosclerosis.ObjectivesTo study the prevalence of abnormal ABI among the studied patients with ischemic stroke compared to general population, to assess the correlation between the ABI abnormality and different risk factors, and to study the relationship between ABI abnormality and severity of stroke.Materials and methodsA case control observational analytical study for 200 patients, 100 patients with ischemic stroke and 100 patients as control group matched to case group in age and sex excluding patients with cardioembolic stroke, stroke of undetermined etiology, or young patients. We obtained ABI measurement from all participants. Criteria for PAD diagnosis is an ABI of < 0.9. We assessed patients’ group using magnetic resonance imaging, transthoracic echocardiography, electrocardiography, carotid duplex, hemoglobin A1C, and lipid profile. Severity of stroke was assessed by the National Institute of Health Stroke Scale (NIHSS).Results and conclusionAbnormal ABI relative frequency is higher in stroke group compared to controls. The risk factors most frequently associated with abnormal ABI are diabetes mellitus and dyslipidemia with high statistical significance. In our study, no single stroke patient with abnormal ABI who is not diabetic. In stroke patients, abnormal ABI is relatively more associated with carotid stenosis, recurrent stroke, small vessel disease stroke, and mild to moderate stroke severity by the NIHSS yet with no statistical significance for any of them.

Sortilin levels are associated with peripheral arterial disease in type 2 diabetic subjects

BackgroundSortilin is a 95-kDa protein which has recently been linked to circulating cholesterol concentration and lifetime risk of developing significant atherosclerotic disease. Sortilin is found inside different cell types and circulating in blood. Higher circulating sortilin concentration has been found in patients with coronary atherosclerosis compared to control subjects. Sortilin concentration is influenced by statin therapy.MethodsWe enrolled statin-naïve subjects with type 2 diabetes mellitus and we performed a cross-sectional study to evaluate the association between sortilin levels and the presence of clinically significant lower limb peripheral artery disease (PAD) in a population of statin-free diabetic subjects.ResultsOut of the 154 patients enrolled in our study, 80 patients were free from PAD, while 74 had clinically significant PAD. Sortilin concentration was significantly higher in the latter group compared to the former (1.61 ± 0.54 ng/mL versus 0.67 ± 0.30 ng/mL, P < 0.01) and there was a trend toward increased sortilin levels as disease severity increased. The association of sortilin levels with PAD remained after adjusting for major risk factors in a multivariate analysis.ConclusionsWe showed that sortilin is significantly and independently associated with the presence of lower limb PAD in a statin-free diabetic population and it may be a promising marker for clinically significant atherosclerosis of the lower limbs. Further studies are needed to confirm this finding and to evaluate its clinical usefulness.