Management Of Peripheral Vascular Disease Research Articles

Assessing the Prevalence Rate of Gangrene Among Patients With Peripheral Vascular Disease in a Tertiary Care Hospital in Central India.

Background Peripheral vascular disease (PVD) includes peripheral arterial disease (PAD) and venous disease. PAD is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion. PAD typically affects the abdominal aorta, iliac arteries, lower limbs,andoccasionally theupper extremities. Assessing the prevalence of gangrene among PVD patients is crucial for understanding the burden of this condition and informing clinical management strategies. This study aimed to estimate the prevalence rate of gangrene among patients diagnosed with peripheral vascular disease. Methods This case-control study was conducted at the General Surgery department of Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Wardha, India. Patients diagnosed with PVD who presented with gangrene of the lower limb were included. Detailed demographic data were collected, and clinical examinationsand diagnostic tests were performed to assess the severity and extent of gangrene. Statistical analysis was conducted to estimate the prevalence of gangrene among PVD patients. Results Among the 100 participants, the age distribution ranged from 21 to over 70 years, with a mean age of 52.89. Gender distribution showed that 30% of the participants were female and 70% were male. The prevalence of gangrene among PVD patients was found to be 35%, with 65% patients not presenting with gangrene. Conclusion The findings of this study highlight the significant prevalence of gangrene among patients diagnosed with peripheral vascular disease. The implications of these findings for clinical practice and management strategies are discussed further, along with potential avenues for further research. The study provides valuable insights into the burden of gangrene among PVD patients. Early detection and appropriate management of PVD are crucial for preventing the development of gangrene and improving patient outcomes.

Abstract 18548: Racial Disparities in the In-Hospital Outcomes of Patients Undergoing Percutaneous Peripheral Endovascular Procedures

Introduction: Endovascular revascularization is becoming the mainstay management of peripheral vascular disease (PVD). Our study seeks to find out the impact of racial disparity on the outcome of this procedure. Methods: We queried the National Inpatient Sample (NIS) database from 2016 to 2019. The NIS is the largest all-payer inpatient healthcare database in the United States. The NIS was searched for hospitalization of adult patients with PVD who had endovascular revascularization, using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Following Propensity score matching, we assessed for a primary outcome of inpatient mortality. The secondary results were acute kidney injury (AKI), amputation, cardiac arrest, cardiogenic shock, total hospital charge (THC), and length of stay (LOS). Results: About 395,510 patients with PVD had endovascular revascularization; 322,015 patients who had the procedure were either White (n=254,840, 79.1%) or Black (n=67,175, 20.9%). White patients had a mean age of 69.2±0.1 years compared to 64.9±0.1 years in Black patients (males: 61.1% versus 53.4%; females: 38.9% versus 46.6%). Compared to White patients, Blacks had significantly lower in-hospital mortality (2.2% versus 2.6%; p=0.005) and cardiogenic shock (0.9% vs 1.2%; p=0.004); however, they had significantly higher AKI (21.6% vs 19.0% p-value 0.015), amputations (7.6% vs 4.4% p-value <0.001), and LOS (10.1 vs 7.5; p-value <0.001) compared to Whites. Conclusions: This study showed that compared to Whites, Black patients were more predisposed to amputations, AKI, and higher LOS despite having a lower mortality rate after endovascular revascularization.

Use of Suture-Mediated Closure Devices for Closure of Punctures in Prosthetic Patches or Grafts is Associated With High Rates of Technical Success and Low Complication Rates.

Despite the increasing use of endovascular techniques in the management of peripheral vascular disease, there is little data on the safety of percutaneous closure devices in punctures of synthetic vascular material. Our paper sought to address this paucity in the literature by reviewing the incidence of complications occurring in patients in whom the ProGlide device was utilised to achieve haemostasis post-percutaneous puncture of vascular patches and graft materials. A retrospective review of patient records was conducted at a tertiary referral centre. Patients who had undergone percutaneous punctures of prosthetic bypass grafts or patch angioplasties between January 2011 and December 2020 were identified from a prospectively collected database. Medical records and post-procedural imaging were reviewed to assess the occurrence of post-procedural complications such as pseudoaneurysms, puncture site stenosis and further interventions for access complications. A total of 73 punctures of prosthetic material were performed in 42 patients, of which 39 utilised ProGlides. Median age of included patients was 72years. There was male predominance in the cohort (69.8%), and most punctures (87.3%) were through polyurethane patches. Device success rate was 95%, and no patients required open repair. There was a low incidence of complications, with no patients developing pseudoaneurysms, arteriovenous fistulas, ischaemic limbs or > 50% stenosis when either manual pressure or the ProGlide device was used to achieve haemostasis. Furthermore, there were no returns to theatre or further interventions performed for access site complications. The use of the ProGlide closure device has a low incidence of complications and its safety appears to be equivalent to manual compression when used to achieve haemostasis in percutaneous punctures of synthetic vascular material in select patients. To our knowledge, this is the only article to date to assess the safety of the ProGlide in this setting.

Two-year outcomes in patients undergoing rotational atherectomy and drug coated balloon therapy for chronic total occluded peripheral arterial diseases: A retrospective cohort study

Background/Aim: Atherectomy is a minimally invasive endovascular surgery technique for removing atherosclerotic plaques in stenosed arteries. It seems to increase the success of angioplasty in the treatment of peripheral artery disease. We aimed to evaluate the outcomes of patients who underwent rotational atherectomy and drug-coated balloon therapy. Methods: In this retrospective cohort study, thirty-four patients who underwent rotational atherectomy and drug-coated balloon angioplasty between August 2016 and January 2019 were evaluated. The Rotablator System (Boston Scientific Corporation; Scimed, Plymouth, MN, USA) was used in all cases. Drug-coated balloons were used in the femoropopliteal section in all patients. Results: The mean age of patients was 65.55 (8.36) years. Seventeen had diabetes mellitus, for which 12 were using oral antidiabetic drugs and 5 were using insulin. At the 3rd postprocedural month, 94.1% of patients (n=32) had no clinical symptoms (P<0.01), two patients needed additional procedures such as balloon angioplasty and stenting due to decreased blood flow and severe stenosis of the superficial femoral artery. At the 1-year follow-up, while 2 patients needed surgery, one needed stenting to the superficial femoral artery. Within 2 years, 27 patients (79.4%) were clinically stable without any symptoms and 2 patients had undergone surgery. Conclusion: Atherectomy devices have become a major tool in the management of peripheral vascular disease. Opening the natural lumen of the arteries gives the patient more time before open vascular surgery.

Heat shock protein A12B gene therapy improves perfusion, promotes neovascularization, and decreases fibrosis in a murine model of hind limb ischemia

BackgroundHeat shock protein A12B expressed in endothelial cells is important and required for angiogenesis to form functional vessels in ischemic tissue. We have previously shown the cardioprotective effects of heat shock protein A12B overexpression in a rat model of diabetic myocardial infarction. In this study, we aim to explore the role of heat shock protein A12B in a surgically-induced murine hind-limb ischemia model. Materials and MethodsAdult 8- to 12-week-old C57BL/6J mice were divided into 2 groups: treated with Adeno.LacZ (control group) and with Adeno.HSPA12B (experimental group) and, with both groups subjected to right femoral artery ligation. Immediately after surgery, mice in both groups received either Adeno.HSPA12B or Adeno.LacZ (1 × 109 plaque forming units) in both the semimembranosus and gastrocnemius muscles of the right limb. The left limb served as the internal control. Both groups underwent serial laser Doppler imaging preoperatively, and again postoperatively until 28 days. Immunohistochemical analysis was performed 3 and 28 days post-surgery. ResultsMice in the Adeno.HSPA12B gene therapy group showed improved motor function and a significantly higher blood perfusion ratio on postoperative days 21 and 28, along with better motor function. Immunohistochemical analysis showed increased expression of vascular endothelial growth factor, thioredoxin-1, heme oxygenase, and hypoxia-inducible factor 1α, along with a decreased expression of A-kinase-anchoring protein 12 and thioredoxin-interacting protein levels. The Adeno.HSPA12B-treated group also showed increased capillary and arteriolar density and an increased capillary-myocyte ratio, along with reduced fibrosis compared to the Adeno.LacZ group. ConclusionOur study demonstrates that targeted Adeno.HSPA12B gene delivery into ischemic muscle enhances perfusion and angiogenic protein expression. This molecule shows promise for the management of peripheral vascular disease as a potential target for clinical trials and subsequent drug therapy.

Liver Disease is Associated with Increased Mortality and Major Morbidity After Infra-Inguinal Bypass but not After Endovascular Intervention

Liver disease increases mortality after abdominal surgery, including endovascular aortic aneurysm repair. However, its effect on mortality and morbidity after endovascular and open management of peripheral vascular disease has not been widely evaluated. The National Surgical Quality Improvement Program was used to evaluate patients undergoing infra-inguinal bypass and endovascular intervention (2005 - 2016). Aspartate aminotransferase to platelet ratio (APRI score) is a non-invasive tool recommended by the World Health Organisation to identify liver disease and was calculated for all patients. A ratio of > 0.5 was used to identify patients with liver fibrosis. Demographics, comorbidities, and 30 day outcomes were evaluated for patients with and without liver fibrosis. A subgroup analysis was completed in patients with APRI scores > 0.5, to evaluate the effect of increasing Model for End-Stage Liver Disease (MELD) scores on outcomes. Multivariable regression was used to account for differences in baseline factors. In total, 17 603 patients underwent infra-inguinal bypasses. Fibrosis was associated with higher mortality (3.8% vs. 2.4%; p < .001), major complications (23% vs. 20%; p= .020), pulmonary (5.1% vs. 2.9%; p < .001), and renal complications (1.9% vs. 1.1%; p= .007) after bypass. These differences persisted following multivariable adjustment. Altogether, 7 830 patients underwent endovascular intervention. Fibrosis was also associated with higher mortality (4.7% vs. 2.2%; p < .001), pulmonary (3.9% vs. 2.5%; p= .022), and renal complications (1.9% vs. 0.8%; p= .003) after endovascular intervention. After adjustment, only renal complications persisted. In a subgroup analysis of patients with liver fibrosis, morbidity (31% vs. 17%; p < .001) and mortality (7.2% vs. 1.8%; p < .001) increased after bypass among those with MELD scores > 15 but not after endovascular intervention. Liver fibrosis was associated with higher 30 day mortality and major complications after infra-inguinal bypass, with outcomes worsening as MELD scores increased. Surgeons may consider an endovascular first approach in managing peripheral arterial disease among those with liver fibrosis.

Transtibial Osseointegration for Patients with Peripheral Vascular Disease: A Case Series of 6 Patients with Minimum 3-Year Follow-up.

Background:The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI).Methods:Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded.Results:All patients’ mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis.Conclusions:All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient’s death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Endovascular stents––boon or bane? A case report of spondylodiscitis following aorto-illiac stent insertion

Spondylodiscitis after aorto-illiac stent insertion for the management of peripheral vascular disease is a rare but serious complication. We report the first case that we encountered as it provided insight into the device-related infections and the treatment dilemma that we went through. Within a week following insertion, a 43-year-old patient developed symptoms of infection. Imaging, laboratory cultures, and inflammatory markers were sought. The patient was treated with antibiotics for over six months to achieve a complete cure. Acute stent-graft infections require prompt and aggressive management. Centers specialized in carrying out endovascular stent insertions should monitor this device-related infection as a health-care-associated infection. The case may be looked on as a learning experience for the spine surgeons, vascular surgeons, microbiologists, and the infection control team of the hospital.

Modern approaches and innovations in the diagnosis and treatment of peripheral vascular diseases.

Amongst the three major vascular beds (coronary, cerebrovascular, and peripheral), peripheral vascular disease (PVD) has traditionally received the least attention, despite its growing global burden. The aging population has led to the increased prevalence of PVD, thereby increasing visibility to its various diagnostic and treatment modalities. In the past decade, research and development of innovations in the management of PVD has exploded. Modern advances in imaging, molecular technology, medical devices, and surgical techniques have reduced the morbidity and mortality of PVD. However, many challenges still remain due to the debilitating and progressive nature of this disease. In this article, we will introduce some common vascular diseases, the state of art in diagnosis and treatment, the limitations of modern technology, and our vision for this field over the next decade.

Abstract 15314: Gene Therapy With Pellino1 Improves Perfusion and Decreases Tissue Loss in an Flk-1 Heterozygous Murine Limb Ischemia Model But Fails in Mapkapkinase 2 Knockout Mice

Introduction: Peripheral vascular disease (PVD) is a major cause of morbidity in the US. Vascular endothelial growth factor (VEGF) induces angiogenesis through Fetal-Liver Kinase-1 (Flk-1 or VEGFR-2), an endothelial tyrosine kinase receptor which activates a downstream signaling cascade involving MAPKAPKinase2 (MK2). We have demonstrated poorer recovery in hind limb ischemia models using Flk-1 +/- and MK2 -/- knockout mice compared to wild type mice. We also demonstrated overespression of Pellino1 (Peli1), an E3 Ligase, can attenuate ischemic damage and increase neovascularization and survivability of ischemic myocardium and skin flaps. Therefore, in this study we aim to show if Peli1 gene therapy can help rescue function in Flk-1 +/- and MK2 -/- after femoral artery ligation. Methods: 8-12 week-old Flk-1 +/- and MK2 -/- mice were subjected to femoral artery ligation of the right hind limb and treated with either adenovirus carrying Peli1 (Ad.Peli1) or LacZ (Ad.LacZ), for a total of 4 groups: Flk-1 +/- Ad.LacZ, Flk-1 +/- Ad.Peli1, MK2 -/- Ad.LacZ and MK2 -/- Ad.Peli1. Perfusion was assessed with laser Doppler imaging preop and on days 0, 3, 7, 14, 21 and 28. Extent of limb ischemia was also quantified using a standardized scoring scale (0 = no ischemia, to 8 = full limb amputation). Results: Perfusion was significantly higher in the Flk-1 +/- Ad.Peli1 group compared to Flk-1 +/- Ad.LacZ on days 7 (0.19±0.03 vs 0.08±0.02), 14 (0.41±0.07 vs 0.09±0.03), 21 (0.33±0.05 vs 0.14±0.05) and 28 (0.31±0.05 vs 0.15±0.02) (n=9-15, p&lt;0.05). The level of ischemia (ischemic score) was significantly lower in the Flk-1 +/- Ad.Peli1 group when compared to Flk-1 +/- Ad.LacZ on days 3 (1.89±0.56 vs 4.88±0.85), 7 (2.11±0.54 vs 5.69±0.92), 14 (2.18±0.52 vs 6.31±1.02), 21 (1.83±0.58 vs 6.50±1.05) and 28 (1.67±0.62 vs 6.50±1.05) (n=8-9, p&lt;0.05). There was no difference in perfusion or ischemic score between the MK2 -/- Ad.Peli1 and MK2 -/- Ad.LacZ groups. Values are mean +/- SEM. Conclusions: Treatment with Ad.Peli1 resulted in improved perfusion and decreased tissue ischemia in Flk-1 +/- mice. These results were not paralleled in MK2 -/- mice suggesting that Peli1 acts upstream to MK2 but downstream of VEGF/Flk-1. Overall, Peli1 gene therapy is a promising candidate in the management of PVD.

Peripheral Vascular Disease and Implication of Nursing Practice: A Brief Literature Review.

Nowadays nurse practitioners are working in several acute hospital settings in different specialized departments. For decades, studies have shown the implications of nurse practice in peripheral vascular disease (PVD) and peripheral vascular intervention (PVI) to have several major benefits. However, there are very limited studies and data on this particular aspect. In this literature review, we briefly discuss the implication of nursing practice in PVD/PVI. This review briefly shows that nursing practice has a major contribution and implication in the treatment of patients with PVD or PVI, especially in patients with diabetes mellitus. From available research, we briefly discuss the implication of nursing practice pre- and postoperatively for PVI. Nurses also contribute significantly in catheter-directed thrombolytic therapy, in smoking cessation programs organized for patients with PVD, and in screening patients for PVD. The vascular nurse practitioners are also involved in providing healthcare advice in order to reduce the risk of disease progression. The major lack of research in this particular field should further inspire scientists to develop and carry out research to further investigate and demonstrate the contribution of nurses in the treatment and management of PVD or PVI, which is gradually becoming a major issue.

Cilostazol alleviate nicotine induced cardiomyocytes hypertrophy through modulation of autophagy by CTSB/ROS/p38MAPK/JNK feedback loop.

Nicotine is proved to be an important factor for cardiac hypertrophy. Autophagy is important cell recycling system involved in the regulation of cardiac hypertrophy. Cilostazol, which is often used in the management of peripheral vascular disease. However, the effects of cilostazol on nicotine induced autophagy and cardiac hypertrophy are unclear. Here, we aim to determine the role and molecular mechanism of cilostazol in alleviating nicotine-induced cardiomyocytes hypertrophy through modulating autophagy and the underlying mechanisms. Our results clarified that nicotine stimulation caused cardiomyocytes hypertrophy and autophagy flux impairment significantly in neonatal rat ventricular myocytes (NRVMs), which were evidenced by augments of LC3-II and p62 levels, and impaired autophagosomes clearance. Interestingly, cathepsin B (CTSB) activity decreased dramatically after stimulation with nicotine in NRVMs, which was crucial for substrate degradation in the late stage of autophagy process, and cilostazol could reverse this effect dramatically. Intracellular ROS levels were increased significantly after nicotine exposure. Meanwhile, p38MAPK and JNK were activated after nicotine treatment. By using ROS scavenger N-acetyl-cysteine (NAC) could reverse the effects of nicotine by down-regulation the phosphorylation of p38MAPK and JNK pathways, and pretreatment of specific inhibitors of p38MAPK and JNK could restore the autophagy impairment and cardiomyocytes hypertrophy induced by nicotine. Moreover, CTSB activity of lysosome regained after the treatment with cilostazol. Cilostazol also inhibited the ROS accumulation and the activation of p38MAPK and JNK, which providing novel connection between lysosome CTSB and ROS/p38MAPK/JNK related oxidative stress pathway. This is the first demonstration that cilostazol could alleviate nicotine induced cardiomyocytes hypertrophy through restoration of autophagy flux by activation of CTSB and inhibiting ROS/p38/JNK pathway, exhibiting a feedback loop on regulation of autophagy and cardiomyocytes hypertrophy.

MON-136 MANAGEMENT AND OUTCOMES OF LIMB-THREATENING ISCHAEMIA IN DIALYSIS-DEPENDENT PATIENTS: EXPERIENCE IN A LARGE NEW ZEALAND RENAL SERVICE

Limb-threating ischaemia (LTI) is highly prevalent in dialysis patients worldwide and associated with high mortality and morbidity. Risk factors include diabetes, smoking and also kidney failure-associated factors such as diffuse medial vascular calcification. The rate of lower limb amputation in dialysis populations is 2-5% per annum. Current KDOQI guidelines for the management of peripheral vascular disease are extrapolated from studies in the general population, in whom primary revascularisation is recommended unless they have poor physical function or infection. This may not be the optimal approach for dialysis patients with a higher burden of diffuse vascular disease, catabolic state and complications. Aim: To compare outcomes in chronic dialysis patients receiving primary amputation (PA) versus primary revascularisation (PRV) for LTI at Waikato Hospital, New Zealand. This was a retrospective cohort study. Patients on chronic dialysis aged ≥18 years presenting with their first LTI episode (defined according to consensus guidelines) between 01/01/2008 to 31/12/2015 were included. Their outcomes were followed until 31/12/2017. We excluded patients with previous treatment for peripheral vascular disease prior to the study period, patients managed conservatively, patients declining or deferring amputation, admissions with simultaneous bilateral lower limb ischaemia, non-ischaemic ulcers, and calciphylaxis. Data collected included baseline demographics, cause of end-stage kidney disease (ESKD), co-morbidities, dialysis characteristics and body-mass index. We recorded data on the index admission with LTI, concurrent infection, imaging, treatment(s) and readmissions. Outcomes included major adverse limb events (MALE), patient survival and hospital length of stay. 41 index admissions were identified with 40 patients in total. Patient characteristics were as follows: mean age-60.9 years, Male-61%, Maori-80.5%, diabetic nephropathy as cause of ESKD-85.43%, mean dialysis vintage-34.2 months, dialysis modality-HD-73.2% and PD-26.8%, mean comorbidity index score-7.0, mean BMI-31.2 kg/m2 and mean PTH-68.2 pmol/L. There were 23 PRVs and 18 PAs. After accounting for patient survival, there were 8 index admissions with >1 MALE/year in the PRV group and 1 index admission in the PA group with >1 MALE/year. Median survival was 11.7 months in the PRV group versus 21.4 months in the PA group. Median length of stay for the index admission was 14.9 days in the PRV group versus 17.3 days in the PA group. Early amputation is associated with lower MALE and mortality but increased hospital length of stay, in dialysis dependent patients presenting with limb-threatening ischemia. Larger, prospective observational studies are needed to confirm this association and help develop future guidelines.

Clinical profile and management of peripheral vascular disease

Clinical profile and management of peripheral vascular disease

A study of association of Diabetic Foot Ulcers and Peripheral Vascular Disease

Background: Diabetic foot ulcers (DFU) are a common, costly, complex, and disabling complication of diabetes resulting in lower-extremity amputations. Diabetes Mellitus (DM) is associated with an increase in the incidence of peripheral vascular disease (PVD) compared to non-diabetic subjects. DFU are divided into two types: neuropathic ulcers (NPU) and neuro-ischemic ulcers (NIU). PVD in association with neuropathy leads to neuro-ischemic ulcers (NIU).Methods: A cross-sectional observational study was conducted for eighteen months period from October 2016 to March 2018, on 120 type-2 DM patients presenting with DFU at tertiary centre in central India. Informed written consent, detailed history was obtained from the patients including duration of diabetes, history of hypertension, smoking, presenting symptoms and other complications related to diabetes. Examination of foot and evaluation for peripheral pulses, ankle brachial pressure index (ABI), neuropathy and blood pressure were done. Laboratory tests for HbA1C, lipid profile, blood urea, serum creatinine and urine albumin creatine ratio (urine ACR) were done. Statistical analysis used: t test, fisher exact test and univariate analysis.Results: In our study, 1594 patients with T2DM were studied, out of which 120 patients presented with new DFU. Mean age of the patients was 61.5years with an M: F ratio of 1.78:1. NIU was present in 36 and NPU in 84 out of 120 DFU patients. Neuro-ischemic ulcers (NIU) were more common among males (28/78 males vs 8/42 females). NIU was found to have significant association with smoking (25/36 patients), hypertension (28/38 patients) and longer duration of diabetes (13.1 vs 9.2years). Other diabetic complications, retinopathy (26/36 patients) and nephropathy (18/36 patients) were more prevalent in patients with NIU. Dyslipidemia was also found in 58.33% (21/36) patients with NIU however the association was insignificant.Conclusions: Diabetic foot ulcers are very debilitating complication of diabetes, and a leading cause of amputations all over the world. Because of increased association of peripheral vascular disease with diabetic foot ulcers there is a rise in prevalence of neuro-ischaemic ulcers. Early management of peripheral vascular disease is important to prevent development of neuro-ischaemic ulcers.

CHRONIC LIMB ISCHEMIA

Background: The Ankle brachial index (ABI) measurements are commonlyused inscreening and management of Peripheral Vascular Disease. In recent studies, Anklebrachial index (ABI) is utilized as a predictor of future atherosclerotic vascular disease andall-cause mortality. Purpose: The purpose of this study was to investigate utility of pre andpost peripheral vascular intervention ankle-brachial index (ABI) assessmentinpatientswith thechronic limb ischemia. Study Design: Quasi experimental study. Setting: National Instituteof Cardio-Vascular Disease (NICVD), Karachi, Pakistan. Period: January 2013 to June 2014.Methodology: The study included 23 patients hospitalized. According to study inclusion/exclusion criteria, patients of chronic limb ischemia on clinical ground and the vascular lesionsof lower limb according toTrans-Atlantic Inter-Society Consensus (TASC scoreclassification II)were evaluated and recruited. The lesions were further classified into three types, Aortoilliac,Femoropopliteal andTibioperoneal. Ankle brachial index (ABI) was classified according toAmerican Diabetic Association. The study was approved by the ethical committee of NICVD.Data was analyzed using SPSS 20. Inc. Results: The mean age of the enrolled patients was57.86±6.56 years. Majority of the patients were male 18(78.3%). The commonly found peripherallesion was femoropopliteal in 9(39%), TASC grade A was commonwith 8 (62%) of cases. ABIscore done pre and post procedure showed a significant difference with a (p-value&lt;0.05) andthere was an improvement of ABI scores in all the lesions after peripheral vascular intervention.Conclusion: The study results concluded that there was animprovement in ABI score afterintervention of peripheral vascular surgery for lower limb segment and recommended its utilityfor the assessment in Peripheral Vascular Disease intervention.

Modulatory Effects of a Nutraceutical Supplement on Saos-2 Cells Reveal Its Phlebotonic Activity

ABSTRACTObjective: Herbal extract compositions are largely used to manage vein diseases. We prepared a new composition of herbs, named FLEBO OK™, that, when administered as a nutraceutical to patients affected by peripheral vascular diseases, was able to improve their health conditions. We analyzed the effects of this nutraceutical composition on in vitro cultured cells with the aim to obtain information about its mechanisms of action.Methods: A culture of human osteoblast cell line Saos-2 was stimulated with tumor necrosis factor (TNF)-α or interleukin (IL)-1β to induce the expression of some chemokines and matrix metalloproteases (MMPs). This cell culture was then exposed to the prepared composition and the amount of expression of the genes coding for the monocyte chemotactic protein (MCP)-1, IL-8, IL-1β, MMP-2, MMP-3, MMP-9 proteins was measured by real-time polymerase chain reaction (RT-PCR). The experiments were repeated exposing the cells to the same amount of the well-known micronized purified flavonoid fraction. Moreover, we describe the effects of the administration of nutraceutical composition to 20 patients affected by peripheral vascular diseases and 20 healthy individuals.Results: The RT-PCR analyses showed that the new composition induces the expression of MMP-3 and MMP-9 and downregulates MMP-2 in cell cultures stimulated with IL-1β, whereas it induces the expression of IL-8 and represses the expression of IL-1β and MCP-1 in cell cultures stimulated with TNF-α. The induction of the expression of MMP-3 and the downregulation of MCP-1 might result in an antiplatelet activity that was not observed for the micronized purified flavonoid fraction. Interviewed patients reported an improvement in their conditions after 1 month of FLEBO OK treatment.Conclusion: These findings could provide a hypothesis for the high efficiency of the identified nutraceutical composition to management of peripheral vascular diseases.

3:54 PMAbstract No. 154 - Retrograde popliteal arterial access for recanalization of lower extremity chronic total occlusion (CTO)

Traditionally, lower extremity arterial lesions are addressed through a retrograde approach via the contralateral common femoral artery, otherwise known as the “up-and-over” technique. However, this approach may not be feasible in patients with difficult contralateral access with failure rates up to 20%. Patients with occluded contralateral arteries or aorto-iliac grafts may also be precluded from this approach. For these cases, retrograde popliteal access provides an alternative to traditional approaches. The goal of this study is to demonstrate the efficacy and safety of retrograde popliteal access as a suitable alternative to traditional access techniques for addressing lower extremity chronic total occlusion (CTO). 13 cases of patients with superficial femoral artery (SFA) occlusions underwent percutaneous recanalization via retrograde popliteal artery access. Patients were primarily selected for previously failed or unfeasible contralateral retrograde femoral approaches. Ultrasound-guided popliteal access was obtained in prone position, followed by recanalization. Hemostasis was achieved through ultrasound-guided compression. Follow-up ultrasonography determined post-procedural vessel patency. Popliteal arterial access was successfully obtained in all cases. Successful recanalization was achieved in 84.6% (11/13) cases via popliteal intervention. Failures were due to inability to fully traverse SFA lesions. Complications included two instances of distal embolization; one resolved without intervention, while the other resolved following thrombolysis. Post-procedural ultrasound follow-up demonstrated one occlusion (10 months) and one stenosis (11 days) but otherwise patent vessels were seen. No complications associated with access site bleeding. Our study demonstrates that ultrasound-guided popliteal arterial access can be safely and effectively used to recanalize the SFA. Retrograde popliteal access should be a tool for interventionalists in the management of peripheral vascular disease.

Cost-effectiveness of medical, endovascular and surgical management of peripheral vascular disease.

Peripheral arterial disease (PAD) is responsible for 20% of all US hospital admissions. Management of PAD has evolved over time to include many medical and transcatheter interventions in addition to the traditional surgical approach. Non-invasive interventions including supervised exercise programs and antiplatelets use are economically attractive therapies that should be considered in all patients at risk. While surgery offers so far a clinically and economically appropriate option, the improvement of percutaneous transluminal angioplasty (PTA) technique with the addition of drug-coated balloons offers a reasonably clinically and economically attractive alternative that will continue to evolve in the future.

Short‐term outcomes of excisional atherectomy in lower limb arterial disease

Endovascular interventions are increasingly utilized in managing occlusive peripheral vascular disease. Angioplasty and stenting remain the mainstay of endovascular management; however, newer treatment modalities such as excisional atherectomy provide the clinician with additional treatment options. While demonstrating promising results in available trials, a paucity of data exist regarding peripheral atherectomy. The purpose of this retrospective clinical study was to assess the efficacy and safety of excisional atherectomy with the TurboHawk atherectomy device (Covidien/ev3, Plymouth, MN, USA) in the treatment of lower limb peripheral vascular disease and to evaluate the learning curve involved in the institution of a new treatment modality. A retrospective analysis was performed on all patients undergoing atherectomy for symptomatic lower limb peripheral vascular disease by a single clinician between November 2011 and June 2013. Forty-seven vessels on 28 legs in 24 patients were treated during the period. Atherectomy was possible in 98% of cases. The 6- and 12-month primary patency was 72.6 and 58.9%, respectively. The primary-assisted patency was 93.2% at 6 months and 74.6% at 12 months. There were significantly greater patency rates in the TransAtlantic Inter-Society Consensus A + B lesions and a non-significant trend towards improved patency rates in claudicants versus critical limb ischaemia. There were four instances of embolization and four cases of dissection. Excisional atherectomy provides a further option for the minimally invasive management of peripheral vascular disease. It has similar patency rates to established endovascular therapies and should be considered among the treatment options in patients with favourable pathology.