Management Of Peripheral Arterial Disease Research Articles

Considerations for Patients With Peripheral Artery Disease During the COVID-19 Pandemic

New York City was one of the epicenters of the COVID-19 pandemic. The management of peripheral artery disease (PAD) during this time has been a major challenge for health care systems and medical personnel. This document is based on the experiences of experts from various medical fields involved in the treatment of patients with PAD practicing in hospitals across New York City during the outbreak. The recommendations are based on certain aspects including the COVID-19 infection status as well as the clinical PAD presentation of the patient. Our case-based algorithm aims at guiding the treatment of patients with PAD during the pandemic in a safe and efficient way.

Individual Differences in Response to Supervised Exercise Therapy for Peripheral Artery Disease.

Nonresponse to exercise has been extensively examined in young athletes but is seldom reported in studies of aerobic exercise interventions in older adults. This study examined the prevalence of nonresponse and poor response to exercise in functional and quality of life outcomes and response patterns between and among older adults undergoing 12-weeks of supervised exercise therapy for the management of peripheral artery disease (N = 44, mean age 72.3 years, 47.7% female). The prevalence of nonresponse (no change/decline in performance) in walking distance was 31.8%. The prevalence of poor response (lack of a clinically meaningful improvement) was 43.2%. Similar patterns of response were observed in both objective and patient-reported measures of physical function. All participants improved in at least one outcome; only two participants improved in all measured outcomes. Additional research should examine modifiable predictors of response to inform programming and maximize an individual's potential benefit from exercise therapy.

Deteksi Dini Penyakit Arteri Perifer pada Pasien Diabetes Melitus di Kota Mataram

Diabetes mellitus is currently becoming a major public health problem in the world. The prevalence of diabetes mellitus globally in 2019 is estimated at 9.3% and will increase to 10.9% in 2040. Peripheral artery disease is one of the important complications of diabetes mellitus. Patients with diabetes mellitus accompanied by peripheral artery disease have high morbidity and. Therefore, early detection of peripheral artery disease in diabetic patients is important. This event is carried out with the aim of early detection of peripheral artery disease in diabetes mellitus sufferers in Mataram. A total of 183 diabetes mellitus patients at the Siti Hajar Hospital, Mataram, were participated in this event, with an average age of 57 years and 67.8% of them were women. Most of the patients (75.4%) had poor blood glucose control. Of these, 26.8% of patients had peripheral artery disease. Patients and/or caregivers showed high enthusiasm during the education regarding the detection results of the peripheral artery disease. This event was very useful in increasing the knowledge of diabetic patients, especially in terms of blood sugar control, prevention, and management of peripheral artery disease.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease.

Nonpharmacological Management of Diabetic Foot Ulcers: An Update.

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus that is associated with increased morbidity and mortality, as well as substantial economic burden for the health care system. The standard of care for DFUs includes pressure off-loading, sharp debridement, and wound moisture balance, along with infection control and management of peripheral arterial disease. A variety of advanced modalities that target distinct pathophysiological aspects of impaired wound healing in diabetes are being studied as possible adjunct therapies for difficult to heal ulcers. These modalities include growth factors, stem cells, cultured fibroblasts and keratinocytes, bioengineered skin substitutes, acellular bioproducts, human amniotic membranes, oxygen therapy, negative pressure wound therapy, and energy therapies. Additionally, the use of advanced biomaterials and gene delivery systems is being investigated as a method of effective delivery of substances to the wound bed. In the present narrative review, we outline the latest advances in the nonpharmacological management of DFUs and summarize the efficacy of various standard and advanced treatment modalities.

Vessel Preparation Is Essential to Optimize Endovascular Therapy of Infrainguinal Lesions.

Symptomatic peripheral arterial disease management involves medical treatment and interventional procedures. Intermittent claudication and critical limb threatened ischemia (CLTI) should be individually considered with specific outcomes and procedures. When intervention is required, an endovascular approach is usually the first-line option. Plain balloon angioplasty was previously used to dilate clinically significant femoropopliteal lesions with variable results. However, over recent years, the use of self-expanding nitinol stents has enabled treatment of long lesions, yielding significantly improved clinical results. Drug-eluting technology has also exhibited a capacity to limit in-stent restenosis and to drive target revascularization. Nevertheless, calcifications and elastic recoil of the arterial wall remain risk factors for early restenosis and failure. Therefore, vessel preparation using specific devices is required to modify vessel compliance and debulk obstructive calcification. In this short review, we provide an overview of the options for gaining lumen before stenting or dilation using drug-coated balloons.

Missed Opportunities for Timely Recognition of Chronic Limb Threatening Ischaemia in Patients Undergoing a Major Amputation: A Population Based Cohort Study Using the UK's Clinical Practice Research Datalink

Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care. This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days). In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p=.003), with higher systolic (p=.008) and diastolic (p=.001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p=.003) and ethnicity (p=.006). Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.

Pathologic Disparities Between Peripheral Artery Disease and Coronary Artery Disease.

Atherosclerosis is a systemic disease that involves multiple vascular beds. The pathological characteristics and clinical presentation, however, vary among the different vascular territories. Acute coronary syndrome is a relatively common manifestation of coronary atherosclerotic disease, wherein the thrombosis occurs secondary to disruption (65%-75%) and erosion (25%-35%) of the fibrous caps of atheromatous plaques. The plaques associated with plaque rupture have large necrotic cores and thin and inflamed fibrous caps. However, the pathological manifestations of peripheral artery disease result from thrombosis regardless of the extent of atherosclerosis. Approximately 75% of peripheral arteries with significant stenosis demonstrate presence of thrombi, of which two-thirds have thrombi associated with insignificant atherosclerosis. The presence of obliterative thrombi in peripheral arteries of patients with critical limb ischemia in the absence of coronary artery-like lesions suggests a locally thrombogenic or remotely embolic basis of disease. Extensive calcification of the medial vascular layer is commonly observed. In this review, we have described and compared the pathological basis of coronary and peripheral artery disease in patients with acute coronary syndrome and critical limb ischemia. It is expected that pathogenetic characterization would allow for definition of strategic targets for superior management of peripheral artery disease.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease:A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee.

Background: Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.Objectives: The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.Methodology: A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.Results: A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD—3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

Racial Disparity in Major Amputation in Patients With Critical Limb Ischemia

Several prior reports have shown that black patients with critical limb ischemia are substantially more likely than white patients to undergo major amputation. However, data available on the scope of this issue in the contemporary era of peripheral arterial disease management is scarce. Thus, the aim of this study was to determine whether racial disparities in lower extremity amputation continue to exist and whether differences in attempts at limb salvage contribute to this disparity.

Recent advances in endovascular treatment of peripheral arterial disease.

As associated co-morbidities have transformed over time, the evaluation and management of peripheral arterial disease have evolved as well. New classification systems have been created to better understand the severity of a patient’s condition and the risk of amputation. These classifications include the Wound, Ischemia, and Foot Infection (WIfI) and Global Anatomic Staging System (GLASS) classification systems. Through the utility of these systems, a patient’s disease can be appropriately staged and managed with medical, endovascular, or surgical therapies or a combination of these. Endovascular therapies specifically have grown with the explosion of new technologies. There are numerous options for patients with disease amenable to endovascular therapy. In this review article, we discuss a number of these different endovascular therapies as well as the new classification systems.

Underrepresentation of Vascular Surgery In Twitter-based Clinical Discussions On The Management Of Peripheral Arterial Disease

Underrepresentation of Vascular Surgery In Twitter-based Clinical Discussions On The Management Of Peripheral Arterial Disease

Evidence-Based Medical Management of Peripheral Artery Disease.

Peripheral artery disease is an atherosclerotic disease of the lower extremities associated with high cardiovascular mortality. Management of this condition may include lifestyle modifications, medical management, endovascular repair, or surgery. The medical approach to peripheral artery disease is multifaceted and includes cholesterol reduction, antiplatelet therapy, anticoagulation, peripheral vasodilators, blood pressure management, exercise therapy, and smoking cessation. Adherence to this regimen can reduce limb-related complications like critical limb ischemia and amputation, as well as systemic complications of atherosclerosis like stroke and myocardial infarction. Relative to coronary artery disease, peripheral artery disease is an undertreated condition. In this article, we explore the evidence behind medical therapies for the management of peripheral artery disease.

Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.

Interpretation of 2019 International Working Group on Diabetic Foot guidelines on the prevention and management of diabetic foot disease

The 8th World International Symposium on the Diabetic Foot (ISDF) Conference which was sponsored by the International Working Group on Diabetic Foot (IWGDF) was held in the Hague between May 22nd and May 25th, 2019. The conference issued the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease. The update to the 2015 edition of the guidelines involves the following 6 chapters: prevention of foot ulcers in patients with diabetes; offloading foot ulcers in patients with diabetes; diagnosis, prognosis, and management of peripheral arterial disease in patients with a foot ulcer and diabetes; diagnosis and treatment of foot infection in patients with diabetes; interventions to enhance healing of foot ulcers in patients with diabetes; classification of diabetic foot ulcers. This guideline has been changed more than the previous edition. In this paper, the guidelines will be interpreted to provide cutting-edge information for domestic diabetic foot researchers.

Antithrombotic therapy for postinterventional management of peripheral arterial disease.

Evidence on the use of antithrombotic pharmacotherapy in patients undergoing revascularization of lower extremities for symptomatic peripheral arterial disease (PAD) is reviewed. Individuals with PAD can experience leg pain, intermittent claudication, critical limb ischemia, and acute limb ischemia. In such patients, revascularization may be indicated to improve the quality of life and to prevent amputations. Antithrombotic therapy is often intensified in the postrevascularization period to prevent restenosis of the index artery and to counteract the prothrombotic state induced by the intervention. Therapeutic modalities include dual antiplatelet therapy (DAPT), anticoagulation, a combination of antiplatelet and anticoagulation therapy, and addition of cilostazol to single antiplatelet therapy. Subgroup analyses of data from randomized clinical trials provided low-quality evidence for the use of DAPT in patients with a below-knee prosthetic bypass graft and anticoagulation for those with a venous bypass graft. Cilostazol, when added to aspirin therapy, has been shown to prevent index vessel reocclusion after an endovascular intervention in patients at low risk for thrombosis in several small randomized trials. There is a considerable paucity of high-quality evidence on the optimal antithrombotic regimen for patients undergoing lower extremity revascularization, with no particular therapy shown to consistently improve patient outcomes. The decision to initiate intensified antithrombotic therapy should include a close examination of its risk-benefit profile. The demonstrated benefit of such treatment is restricted to the prevention of index artery reocclusion, while an increased risk of bleeding may lead to significant morbidity and mortality.

Exercise therapy in routine management of peripheral arterial disease and intermittent claudication: a scoping review.

Background:Little is known about the extent to which routine care management of peripheral arterial disease (PAD) and intermittent claudication (IC) align with best practice recommendations on exercise therapy. We conducted a scoping review to examine the published literature on the availability and workings of exercise therapy in the routine management of patients with PAD and IC, and the attitude and practice of health professionals and patients.Methods:A systematic search was conducted in February 2018. The Cumulative Index of Nursing and Allied Health Literature, Ovid MEDLINE, Allied and Complementary Medicine Database, ScienceDirect, Web of Science and the Directory of Open Access Repositories were searched. Hand searching of reference lists of identified studies was also performed. Inclusion criteria were based on study aim, and included studies that reported on the perceptions, practices, and workings of routine exercise programs for patients with IC, their availability, access, and perceived barriers.Results:Eight studies met the eligibility criteria and were included in the review. Studies conducted within Europe were included. Findings indicated that vascular surgeons in parts of Europe generally recognize supervised exercise therapy as a best practice treatment for IC, but do not often refer their patients for supervised exercise therapy due to the unavailability of, or lack of access to supervised exercise therapy programs. Available supervised exercise therapy programs do not implement best practice recommendations, and in the majority, patients only undergo one session per week. Some challenges were cited as the cause of the suboptimal program implementation. These included issues related to patients’ engagement and adherence as well as resource constraints.Conclusion:There is a dearth of published research on exercise therapy in the routine management of PAD and IC. Available data from a few countries within Europe indicated that supervised exercise is underutilized despite health professionals recognizing the benefits. Research is needed to understand how to improve the availability, access, uptake, and adherence to the best exercise recommendations in the routine management of people with PAD and IC.

Синдром Леріша як тривалий часовий континуум судинного ураження: від початкових клінічних проявів до можливого фатального завершення (актуальність міждисциплінарної співпраці за власними клінічними спостереженнями)

Leriche syndrome typical signs include incapability for erection maintaining, fatigue feeling originating from both lower limbs, bilateral claudication with ischemic pain and lack or reduction of peripheral pulse (starting from femoral segment) combined with paleness or coldness of both lower limbs. The disease commonly affects men, and risk factors include hypertension, diabetes mellitus, hyperlipidemia and smoking. Currently the disorder is referred to type D aortoiliac injuries according to Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Data on psychiatric morbidity in Leriche syndrome is scarce. Some publications are dedicated in such a state to depressive disorder and erectile dysfunction, which were observed in psychiatric outpatient department. These may have several reasons, such as obesity, hypertension, diabetes mellitus, hypercholesterolemia and lower urinary tract symptoms. Moreover, erectile dysfunction is believed to be a strong predictor of general and coronary atherosclerosis. Leriche syndrome and penis arteries obstructive disease are considered to be two main reasons of impotence. Other reasons of Leriche syndrome may be lifestyle factors which are common with atherosclerosis: insufficient physical exercises, imbalanced diet and smoking. Statistics on psychiatric morbidity in Leriche syndrome is hard to receive because of multiple risk factors, partially because of atherosclerosis, which is the risk for vascular depression. The article represents historical data about prominent doctors in the history of vascular surgery who touched upon the problems of Leriche syndrome. The authors describe their own clinical observations of acute patient with prolonged development of full clinical manifestation with fatal outcome.

Game changers in vascular and endovascular surgery

Game changers in vascular and endovascular surgery

ESC/EASD guideline sheds light on diabetes and cardiovascular disease management

ESC/EASD guideline sheds light on diabetes and cardiovascular disease management