Mean Ankle-brachial Index Research Articles

No false elevation in ankle brachial index in patients with tibial plateau fractures and vascular risk factors

ObjectivesThe ankle brachial index (ABI) is a useful tool in detection of lower extremity vascular injury. However, diabetes mellitus (DM), chronic kidney disease (CKD), and peripheral vascular disease (PVD) may affect extremity perfusion leading to possible false elevation of the ABI value. If true in trauma patients, this can affect initial evaluation, diagnostics, and management. We therefore explored mean ABI values in tibial plateau fractures of patients with vascular risk factors to help determine whether there is a difference. DesignThis is a retrospective chart review of patients sustaining tibial plateau fractures with a specific ABI value recorded in the medical record. Patients were identified as either having vascular risk factors or not and data analysis performed to determine if their ABI differed and whether they were more likely to have a vascular injury. Results282 acute tibial plateau injuries with specific ABI values were identified, 46 of which carried the risk factors in question. The average risk factor group ABI was 0.95 ± 0.15 versus those without risk factors 1.0 ± 0.15 (p = 0.057). No patient with risk factors required a vascular intervention or four-compartment fasciotomy. ConclusionsThis study shows no statistical significance between the presenting ABI of patients with risk factors such as DM, CKD, or PVD and those without those risk factors who sustained acute tibial plateau fractures. Therefore, in general the ABI still holds as a useful screening tool for evaluation of vascular insult in the setting of acute lower extremity trauma.

An assessment of a screening method for peripheral arterial disease of the lower limbs in patients aged at least 65 years at the Yaoundé Central Hospital, Cameroon

The automatic measurement of the Ankle-Brachial Index (ABI) constitutes a reliable, simple, safe, rapid, and inexpensive alternative diagnostic screening test compared with the Doppler method for peripheral arterial disease (PAD). We aimed to compare the diagnostic performance of automatic ABI measurement tests to Doppler ultrasound for PAD in patients aged ≥ 65. This was an experimental comparative study of Doppler ultrasound's performance to the automated ABI test in diagnosing PAD in patients aged ≥ 65 years followed up at the Yaoundé Central Hospital, Cameroon, between January to June 2018. An ABI threshold < 0.90 defined a PAD. We compare the sensitivity, and specificity of the high Ankle-Brachial Index (ABI-HIGH), low Ankle-Brachial Index (ABI-LOW), and the mean Ankle-Brachial Index (ABI-MEAN) for both tests. We included 137 subjects with an average age of 71.7 ± 6.8 years. In the ABI-HIGH mode, the automatic device had a sensitivity of 55% and a specificity of 98.35% with a difference between the two techniques of d = 0.024 ( P = 0.016). In the ABI-MEAN mode, it had a sensitivity of 40.63% and a specificity of 99.15%; d = 0.071 ( P < 0.0001). In the ABI-LOW mode, it had a sensitivity of 30.95% and a specificity of 99.11%; d = 0.119 ( P < 0.0001). Compared to the Doppler method, the ABI-HIGH mode of the automatic measuring device had better diagnostic performance and can thus be used as a screening test for PAD patients aged ≥ 65 years in our context.

Assessment of peripheral artery disease risk in building construction workers by Ankle-Brachial index measurement with automated oscillometric and hand-held Doppler device.

Background:Peripheral arterial disease (PAD) remains underdiagnosed, partly because of the limitations of the Doppler ankle-brachial index (ABI) with regards to equipment, training, and time constraints.Aims:To compare the accuracy and validity of automated oscillometric ABI measurement in detecting PAD in primary care settings against a gold standard Doppler device.Settings and Design:A cross-sectional observational study was conducted at the physiology department, Dr. Ram Manohar Lohia Institute of Medical Sciences (DrRMLIMS), Lucknow.Methods and Material:A total of 200 male building construction workers of all types of age groups between 20 and 40 years were recruited. The ABI measurement was performed using the Watch BP Office and hand-held HI.dop, BT-200 Vascular Doppler device.Statistical Analysis Used:The Bland-Altman plot and receiver operator characteristics (ROC) curve were determined to analyze the agreement between the two methods. For the reliability of the test, Pearson’s correlation with linear regression was done and the intraclass correlation (ICC) coefficient was calculated.Results:The mean ABI (Osc) and ABI (Dop) were 1.13 ± 0.09 and 1.06 ± 0.08, respectively. The ABI (Dop) and ABI (Osc) methods were highly correlated Pearson’s correlation coefficient of 0.96 with 95% confidence interval (CI) ranges between 0.985 and 1.066 (P < 0.001). On linear regression analysis, the ABI (Dop) predicted ABI (Osc) 92.6% correctly. The paired mean difference between the two measuring devices was 0.07 (95% CI = −0.03 to −0.12). At 0.90 cut-off value of diagnosing PAD, the sensitivity is 50%, specificity 100%, positive predictive value 100%, and negative predictive value 97% by an oscillometric automated device.Conclusion:Our finding suggested that ABI measurement by the automated oscillometric device is reliable, free of examiner bias, and less time-consuming.

Epidemiology of Peripheral Vascular Disease in the Long Life Family Study (LLFS)

Atherosclerotic occlusion of peripheral arteries is a major contributor to morbidity and mortality in older adults. Our aim was to describe the epidemiology of peripheral artery disease (PAD) and other peripheral vascular disease (OPD) in the LLFS. 3248 individuals from 509 families (1182 probands, mean age 89; 2066 offspring, mean age 60) had doppler ankle-brachial index (ABI) assessment. Measures were performed twice for each posterior tibial artery and minimum of the mean ABI was used. PAD was defined as any ABI<0.9. OPD was defined as any ABI >1.4 or ≥1 non-compressible artery. Stepwise linear or logistic regression determined significant independent clinical and demographic predictors (P<0.05) after adjustment for age, sex, study center, and familial relatedness. Overall, ABI had a median of 1.2 with 7.4% PAD (18.1% probands, 1.2% offspring; P<0.001). OPD prevalence was 10.6% and was more common than PAD in offspring (8.1%). Age-adjusted OPD was higher in men (13.3%) than women (8.3%, P<0.001), while age-adjusted PAD did not did not differ by sex (P=0.45). Predictors of PAD included greater age and systolic blood pressure, lower diastolic blood pressure, prevalent kidney disease, antihypertensive use, and current smoking. Predictors of OPD included greater age, male sex, and current smoking. In these exceptionally long-lived families, PAD was low compared to other epidemiologic studies. However, OPD including non-compressible arteries, a marker of arterial stiffness, was more prevalent than PAD. These findings in long-lived families highlight a need for more epidemiologic research in other peripheral vascular disease in adults from the general population.

OR6. Ankle-brachial index is associated with carotid intima-media thickness in type 2 diabetes mellitus patients

Abstract Background and Aims Atherosclerosis and its complications occur more rapidly in diabetes mellitus. Early detection remains a challenge. Carotid intima-media thickness (CIMT) has been used widely and validated marker for detecting subclinical atherosclerosis. The limitation of this examination is operator dependence. Meanwhile, ankle-brachial index (ABI) examination is easier and widely available. This study is aimed to evaluate correlation ABI and CIMT in type 2 diabetes mellitus patients. Method and Results We conducted cross-sectional study in vascular outpatient clinic of Dr. Sardjito Hospital. Fifty-one patients were taken by purposive sampling. An interview, hematological parameters, lipid profiles, anthropometric, ABI, and CIMT measurement were performed. ABI was measured by doppler ultrasound, meanwhile an ultrasound examination of both common carotid artery was done to obtain the CIMT. Subjects were 49.02% females and 50.98% males, with mean age 59.22 ± 8.8 years old. The percentages of hypertension, dyslipidemia, smoking, obesity, metabolic syndrome, coronary artery disease, congestive heart failure, and chronic kidney disease were 60.8%, 51%, 27.5%, 52.9%, 72.5%, 31.4%, 9.8%, and 9.8%, respectively. Bivariate analysis showed mean ABI in the presence of mean CIMT ≥1mm and/or carotid plaque were lower (1.05±0.17 vs 1.16±0.08, p = 0.016). Proportions mean and maximum CIMT ≥1mm were 15.7% and 33.3%, respectively. Pearson’s correlation showed ABI was negatively correlated with mean CIMT and maximum CIMT (r=-0.334, p = 0.017; r=-0.299, p = 0.033). Conclusion Ankle-brachial index is negatively correlated with carotid intima-media thickness. Therefore, in limited facility, ABI examination might be performed for predicting subclinical atherosclerosis.

A Novel Angiography Scoring System Predicts Improvement After Isolated Common Femoral Endarterectomy With Profundaplasty

Numerous angiography-based peripheral arterial disease classification schemes have been developed to stratify severity of preoperative patient disease, but few studies have correlated angiography-based anatomic classification schemes to postoperative outcomes. This study examined whether a proposed pre-operative angiography scoring system was predictive of outcomes after isolated common femoral endarterectomy with profundaplasty (CFEP). A retrospective review was conducted of patients treated with isolated CFEP for claudication and/or rest pain at a single institution from 2016-19. Pre-operative angiograms were assessed quantitatively by 4 blinded surgeons across 3 domains: profunda stenosis, profunda disease length, and outflow disease severity. Table I describes the proposed angiography scoring system. Internal consistency reliability of rater scores was calculated using Cronbach alpha. Outcomes included clinical improvement, further interventions, major amputations, mortality, and mean increase in ankle-brachial index (ABI) at 30 days, and 6 months. McNemar tests, between-group t-tests, Pearson correlations, and linear regression were used. Clinical Outcomes 88% of patients (n=22) had clinical improvement at 30 days; the remaining 12% of patients (n=3) required further interventions. One patient (4%) required major amputation between 30 days and 6 months for recurrence of rest pain that had initially resolved after isolated CFEP. There was 0% mortality during the study period. Mean ABI increased by 0.15 ± 0.21 at 30 days, and by 0.06 ± 0.21 at 6 months. Angiography Scoring System Profunda stenosis score was associated with clinical improvement at 6 months (P = 0.04). A profunda stenosis score of ≥2.6 was strongly associated with 6-month clinical improvement (64% of those ≥ 2.6 improved, versus 15% of those <2.6, P = 0.15). Profunda stenosis score was associated with ABI improvement at 30 days (r=0.73, P = 0.01) and 6 months (r=0.82, P = 0.007). Profunda disease length score was associated with clinical improvement at 30 days (P = 0.002). 100% of patients with a profunda disease length score of ≥1.5 clinically improved at 30 days, versus 67% of those with <1.5 (P = 0.04). Angiography scores were not found to be associated with further intervention, major amputation, or mortality. Cronbach alpha for profunda stenosis, profunda disease length, and outflow severity scores were 0.90, 0.90, and 0.79, respectively, indicating strong internal consistency. This institutional angiography scoring system successfully predicts clinical improvement following CFEP. Higher profunda stenosis and profunda disease length scores were most predictive of operative success within 6 months.Future validation studies will investigate these outcomes in a larger population, and over a longer period.

General and Disease-Specific Factors Associated with Health Related Quality of Life Among Patients With Peripheral Artery Disease to Inform Treatment Selection in the Era of Patient-Reported Outcomes

<h3>Introduction and Objective</h3> Patient-reported outcomes (PRO) have been championed for assessment of peripheral artery disease (PAD) severity and treatment outcomes. Limited evidence exists regarding factors associated with PRO that may affect their sensitivity to change with PAD interventions. We performed a prospective, cross-sectional study to evaluate how patient-level factors are associated with a validated PAD-specific health related quality of life (QOL) instrument, the VascuQol-6. <h3>Methods</h3> Patients were recruited from a diagnostic vascular unit based on referral for ankle brachial index (ABI) testing. All participants were assessed for PAD symptoms using the San Diego Claudication Questionnaire and tested for neuropathy using the Michigan Neuropathy Screening Instrument (MNSI). PAD-specific QOL was assessed using the VascuQol-6. Clinical data was collected from the medical record and patient-self report. Factors associated with QOL were evaluated using ANOVA, confidence intervals, and linear models. <h3>Results</h3> 70 patients were recruited and participated. Mean age was 67.8±11.7 years (Figure 1Figure 1Plot of age versus VascuQOI-6 summary score (P=0.011).Figure 1); 41% of participants were women and 87.1% were white, and 29% were current smokers. Comorbid conditions included diabetes (23.2%) and peripheral neuropathy (44.3%). Mean ABI was 0.77±0.29 and mean TBI was 0.48±0.23. PAD symptoms were classified as claudication in 48.6%, CLTI in 31.4%, and asymptomatic in 20%. Among symptomatic patients, 21 had multi-level symptoms, 13 had calf symptoms only, 4 had buttock symptoms only, and 3 had thigh symptoms (Figure 2Figure 2Distribution of Vascuqol-6 summary scores by anatomic symptom distribution (P=0.025).Figure 2). Symptoms were bilateral in 55 patients (78.6%). Patients with multi-level disease had lower QOL scores (13.8±4.0; 90% CI 12.3-15.3) versus those with no symptoms (17.6±4.8; 90% CI 16.1-19.2), calf symptoms (17.8±3.1; 90% CI 16.2-19.3) (P=0.024). In multivariable models QOL was associated with minimum ABI (P=0.020), symptom anatomic level (P=0.002) and age (P=0.001); a trend was also observed for symptom category (P=0.121). No associations between QOL and smoking status, diabetes, neuropathy, or bilateral versus unilateral symptoms were observed. <h3>Conclusions</h3> PAD-specific QOL assessments are associated with factors related and unrelated to PAD. Higher QOL scores among older participants was unanticipated and may impart ceiling effects that limit potential for improvement through PAD interventions in this subgroup, while patients with multi-level symptoms may have greater potential gains from PAD treatment. Future work following this cohort will explore changes in QOL over time and associations with treatment interventions, adverse events, and patient-level factors.

PENGARUH BUERGER ALLEN EXERCISE TERHADAP NILAI ANKLE BRACHIAL INDEX PADA PASIEN DIABETES MELITUS

Diabetes mellitus is a disorder of the endocrine system characterized by increased levels of glucose in the blood. The purpose of this study was to assess the effect of Buerger's Allen exercise on the value of the ankle brachial index (ABI) in patients with diabetes mellitus. The research design was a quasi-experimental pretest and posttest without a control. The study was conducted from March to May 2021 at Grandmed Lubuk Pakam Hospital with 48 respondents, with consecutive sampling technique. Data were analyzed using the Wilcoxon test. The Buergers Allen exercise intervention was performed twice a day, for three weeks. The procedure is performed by lifting the lower extremities up at an angle of 45-90 degrees for 2-3 minutes, then the patient sits at the bedside with the legs hanging down, accompanied by flexion, extension, pronation and supination movements for 5-10 minutes, and the patient lies down. with both feet resting for 10 minutes. There was a significant effect between the mean ABI value before intervention 0.83 and after intervention 0.95, p=0.00. The difference in mean ABI p=0.000, p&lt;0.05. The results of the study concluded that there was an effect of buerger allen exercise on the ABI value before and after the intervention where the ABI value was getting better. It is recommended for nurses to make Buergers Allen exercise one of the independent nursing interventions in providing nursing care to patients with diabetes mellitus.

Mathematical Modeling of Blood Flow to Evaluate the Hemodynamic Significance of Peripheral Vascular Lesions

Background: Evaluating the severity of peripheral artery lesions is challenging. Image-based blood flow modeling from peripheral Computed Tomographic Angiography (pCTA) may provide a non-invasive method to determine the hemodynamic significance of lesions. This pilot study evaluates the performance of pCTA-based blood flow modeling in diagnosing functionally significant peripheral lesions in comparison with Digital Subtraction Angiography (DSA). Methods: Ten patients undergoing DSA and pCTA were included. The peripheral arteries were divided into 8 segments per extremity and stenosis severity was graded by visual estimation from DSA. Each segment was graded 0 to IV (normal, mildly-stenotic, moderately-stenotic, severely-stenotic, occluded) or non-evaluable. Independent from DSA review, a Resting Pressure Drop (RPD) and an Exercise Pressure Drop (ExPD) for each segment was calculated from pCTA-based blood flow modeling. A functionally significant (FS) lesion was defined as grade III or IV by DSA and RPD &gt; 5 mmHg from pCTA-based modeling. Analysis was repeated with an ExPD &gt; 20 mmHg. Sensitivity, specificity and accuracy were calculated for RPD &gt; 5 mmHg and ExPD &gt; 20 mmHg using DSA as the standard. Results: Mean age was 52±16 years, 4 patients were male, 8 patients presented with critical limb ischemia, mean ankle brachial index was 0.60±0.29, and 66 arterial segments were available for both assessment methods. Twenty-two segments had FS lesions by DSA. Using an RPD &gt; 5 mmHg, sensitivity was 80%, specificity was 85% and accuracy was 79%. Using an ExPD &gt; 20 mmHg, sensitivity was 84%, specificity was 89% and accuracy was 88%. Conclusion: Use of a resting pressure drop &gt; 5 mmHg and an exercise pressure drop &gt; 20 mmHg, measured by blood flow modeling from CT angiography, can accurately identify functionally significant stenosis in patients with peripheral vascular disease. This information motivates the need for a larger-scale prospective imaging trial to further validate this novel non-invasive approach.

Artificial Intelligence Identifies an Urgent Need for Peripheral Vascular Intervention by Multiplexing Standard Clinical Parameters.

Background: Peripheral artery disease (PAD) is a significant burden, particularly among patients with severe disease requiring invasive treatment. We applied a general Machine Learning (ML) workflow and investigated if a multi-dimensional marker set of standard clinical parameters can identify patients in need of vascular intervention without specialized intra–hospital diagnostics. Methods: This is a retrospective study involving patients with stable PAD (sPAD, Fontaine Class I and II, n = 38) and unstable PAD (unPAD, Fontaine Class III and IV, n = 18) in need of invasive therapeutic measures. ML algorithms such as Random Forest were utilized to evaluate a matrix consisting of multiple routinely clinically available parameters (age, complete blood count, inflammation, lipid, iron metabolism). Results: ML has enabled a generation of an Artificial Intelligence (AI) PAD score (AI-PAD) that successfully divided sPAD from unPAD patients (high AI-PAD in sPAD, low AI-PAD in unPAD, cutoff at 50 AI-PAD units). Furthermore, the probability score positively coincided with gold-standard intra-hospital mean ankle-brachial index (ABI). Conclusion: AI-based tools may be promising to enable the correct identification of patients with unstable PAD by using existing clinical information, thus supplementing clinical decision making. Additional studies in larger prospective cohorts are necessary to determine the usefulness of this approach in comparison to standard diagnostic measures.

Surgical 5-year Outcomes of Extra-Anatomical Bypass for Middle Aortic Syndrome: A Case Series.

Middle aortic syndrome is a rare disease. Several surgical treatments are available; however, the optimal treatment strategy and long-term outcomes remain unelucidated. We herein report the 5-year outcomes of six patients treated with extra-anatomical bypass surgery for middle aortic syndrome. Between 2013 and 2016, six patients underwent extra-anatomical bypass for middle aortic syndrome at our institute: three had Takayasu's arteritis, one had vessel vasculitis, and two had middle aortic hypoplastic syndrome of unknown origin. The patients included five women and one man, with a mean age of 59.7years. Four patients had uncontrolled hypertension and were receiving antihypertensive medications. The mean ankle-brachial pressure index was .61. The three patients with Takayasu's arteritis were hospitalized for congestive heart failure. These patients underwent bypass surgery from the descending aorta to the infrarenal abdominal aorta, and one also underwent concomitant heart surgery. The patient with microscopic polyangiitis underwent Y-grafting with an aortic aneurysmectomy. Subsequently, bypass surgery was performed from the descending aorta to the graft via the diaphragm. The two patients with unknown causes underwent bypass surgery from the proximal descending aorta to the distal descending thoracic aorta. There were no early or late deaths at the 5-year follow-up. We did not observe any changes in anastomotic site stenosis or new aneurysmal changes during the follow-up period. The number of antihypertensive medications was reduced in all cases, and critical symptoms, including headache, severe abdominal pain, claudication, and heart failure, improved in all patients. The ankle-brachial pressure index increased to 1.11 and did not change for five years. Renal function remained stable, and the brain natriuretic peptide level decreased from 302.8 to 74.5pg/mL at follow-up. Extra-anatomical bypass for middle aortic syndrome is safe and effective, and can help prevent renal failure, and relieve critical ischemic symptoms.

Evaluation of foot hypoperfusion and estimation of percutaneous transluminal angioplasty outcome in patients with critical limb ischemia using intravoxel incoherent motion microperfusion MRI.

To emerge hypoperfusion of lower limbs in patients with critical limb ischemia (CLI) using Intravoxel Incoherent Motion microperfusion magnetic resonance imaging (IVIM-MRI). Moreover to examine the ability of IVIM-MRI to differentiate patients with severe peripheral arterial disease (PAD) from normal subjects and evaluate the percutaneous transluminal angioplasty (PTA) results in patients with CLI. Eight patients who presented with CLI and six healthy volunteers were examined. The patients underwent IVIM-MRI of lower extremity before and following PTA. The imaging protocol included sagittal diffusion-weighted (DW) sequences. DW images were analyzed and color parametric maps of the micro-circulation of blood inside the capillary network (D*) were constructed. The studies were evaluated by two observers to define interobserver reproducibility. Technical success was achieved in all patients (8/8). The mean ankle-brachial index increased from 0.35 ± 0.2 to 0.76 ± 0.25 (p < 0.05). Successful revascularization improved IVIM microperfusion. Mean D* increased from 279.88 ± 13.47 10-5 mm2/s to 331.51 ± 31 10-5 mm2/s, following PTA, p < 0.05. Moreover, PAD patients presented lower D* values as compared to healthy individuals (279.88 ± 13.47 10-5 mm2/s vs 332.47 ± 22.95 10-5 mm2/s, p < 0.05, respectively). Good interobserver agreement was obtained with an ICC = 0.84 (95% CI 0.64-0.93). IVIM-MRI can detect differences in microperfusion between patients with PAD and healthy individuals. Moreover, significant restitution of IVIM microperfusion is found following successful PTA. IVIM-MRI is a safe, reproducible and effective modality for evaluation of lower limb hypoperfusion in patients with PAD. It seems also to be a helpful tool to detect changes of tissue perfusion in patients with CLI following revascularization.

Long-term results of the Japanese multicenter Viabahn trial of heparin bonded endovascular stent grafts for long and complex lesions in the superficial femoral artery

ObjectiveWe assessed the long-term safety and efficacy of endovascular stent grafting to treat long, complex lesions in the superficial femoral artery (SFA). MethodsThe present prospective, multicenter study at 15 Japanese hospitals assessed heparin-bonded stent grafts used to treat long SFA lesions in patients with symptomatic peripheral arterial disease. The inclusion criteria were Rutherford category 2 to 5 symptoms (grade 5 without active infection), an ankle brachial index of ≤0.9, and SFA lesions ≥10 cm long with ≥50% stenosis. The key efficacy and safety outcomes were primary-assisted patency and adverse events through 24 months, respectively. The secondary outcomes included primary patency, secondary patency, freedom from target lesion revascularization (fTLR), and Vascular Quality of Life questionnaire score. ResultsOf the 103 patients (mean age, 74.2 ± 7.0 years; 82.5% male), 100 (97.1%) had intermittent claudication. The average lesion length was 21.8 ± 5.8 cm; 87 lesions (84.5%) were TASC (Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease) C or D (65.7% chronic total occlusions). Of the 103 patients, 92 and 61 were evaluable through 24 and 60 months, respectively. At 24 months, the Kaplan-Meier–estimated primary-assisted patency, primary patency, and secondary patency rate was 85.7% (95% confidence interval [CI], 76.3%-91.5%), 78.8% (95% CI, 68.8%-85.9%), and 92.0% (95% CI, 82.4%-96.5%), respectively. The mean ankle brachial index was 0.64 ± 0.12 at baseline and 0.94 ± 0.19 at 24 months (P < .0001). At 24 and 60 months, the fTLR was 87.2% (95% CI, 78.9%-92.3%) and 79.1% (95% CI, 67.9%-86.8%), respectively. No device- or procedure-related life- or limb-threatening critical events or acute limb ischemia cases were observed through 5 years. No stent fractures were detected on the annually scheduled follow-up radiographs. The vascular quality of life questionnaire and walking impairment questionnaire scores were significantly increased at 1 through 24 months compared with the baseline scores (P < .0001 for both). One patient had required conversion to open bypass during the 5-year follow-up period. ConclusionsStent grafting of long and complex SFA lesions in patients with claudication is safe and effective through long-term follow-up, with 79.1% fTLR and no leg amputation, acute limb ischemia, or stent fractures through 5 years.

Two-year single centre results with covered endovascular reconstruction of aortic bifurcation (CERAB) in the treatment of extensive aorto-iliac occlusive disease.

To report the results of a single-centre in the treatment of extensive aorto-iliac occlusive disease (AIOD) by the covered endovascular reconstruction of aortic bifurcation (CERAB) technique. A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients treated with CERAB technique for AIOD between January 2016 and December 2019 in San Giovanni-Addolorata Hospital (Rome, Italy). Clinical examination, duplex ultrasound with ankle-brachial index measurement and contrast-enhanced computed tomography angiography were performed preoperatively. A clinical and ultrasound follow-up was carried out at one month and then half yearly after the intervention to evaluate patients' clinical status, limb salvage, target lesion revascularization rate, primary and secondary patency rate. During the study period, 24 patients (14 men, 58.3%; 10 women, 41.7%; median age 59 years, range 37-79 years) underwent CERAB for AIOD (TASC II C 29.2%, TASC II D 70.8%). Indications for treatment were: intermittent claudication in 18 patients (75%) and critical limb ischemia in 6 (25%). Technical success was achieved in all cases. Perioperative minor complications occurred in three cases (12.5%). One patient reported an intraoperative iliac rupture requiring adjunctive covered stenting. Median hospital length of stay was two days (range 1-9). No patient died perioperatively nor at the last follow-up. At a median follow-up of 18 months (range 6-48 months), mean ankle-brachial index increased significantly (from 0.62 ± 0.15 before the procedure to 0.84 ± 0.18) (P < 0.001) and target lesion revascularization rate was 12.5%. At two years, the limb salvage rate was 100%, and primary and secondary patency rates were 87.5% and 100%, respectively. CERAB technique demonstrated to be effective at the mid-term follow-up with low rate of complications and short length of stay. Long-term results and more robust data are needed to affirm this technique as the first-line treatment for extensive AIOD. However, it could become the preferred option especially in fragile patients and during contemporary COVID-19 pandemic due to the current limitations in vascular and critical care bed capacity.

Safety and Efficacy of Vacuum Assisted Thrombo-Aspiration in Patients with Acute Lower Limb Ischaemia: The INDIAN Trial

The aim was to evaluate the short term safety and effectiveness of the Penumbra/Indigo aspiration thrombectomy Systems (Penumbra Inc.) in patients with acute lower limb ischaemia. (ALLI). Recently, endovascular vacuum assisted thrombectomy devices, similar to those used in the management of acute ischaemic stroke, have become available for peripheral arteries, but data are still scarce. To assess vessel patency, a modified Thrombolysis in Myocardial Infarction (TIMI) classification, called TIPI (Thrombo-aspiration In Peripheral Ischaemia), is proposed. The TIPI flow is assessed at presentation, immediately after treatment with the study device, and after all adjuvant procedures. The primary outcome is the technical success of the thrombo-aspiration with the investigative system, defined as near complete or complete revascularisation TIPI 2 – 3. Safety and clinical success rate were collected at one month. One hundred and fifty patients were enrolled. The mean age was 72.4 years and 73.3% were male. Rutherford grade on enrolment was I in 16%, IIa in 40.7%, and IIb in 43.3% with a mean ankle brachial index of 0.19. Primary technical success (TIPI 2 – 3 flow) was achieved in 88.7% of patients. Adjunctive procedures included angioplasty/stenting of chronic atherosclerotic lesions (n = 39), thrombolysis (n = 31), covered stenting (n = 15), and supplementary Fogarty embolectomy (n = 6). After all interventions, assisted primary technical success was 95.3% (TIPI 2 – 3 in 143/150). No systemic bleeding complications or device related serious adverse events were reported. At one month follow up, one death, and one below the knee amputation were recorded. Primary patency was 92% (138/150), and the re-intervention rate was 7.33%, resulting in an assisted primary and secondary patency of 94% and 99.33%, respectively. Results from the INDIAN registry reveal that mechanical thrombectomy using the Indigo system is safe and effective for revascularisation of ALLI as a primary therapy.

Mid-term outcomes of endovascular treatment and risk factors for recurrence in patients with Trans-Atlantic-Inter-Society II C/D femoropopliteal lesions.

The purpose of this study was to determine the efficacy of interventional endovascular treatment (EVT) and the risk factors for postoperative restenosis in patients with Trans-Atlantic Inter-Society Consensus (TASC) II C/D femoropopliteal lesions. A total of 55 patients who received EVT for TASC II C/D femoropopliteal lesions (64 affected limbs) from October 2014 to September 2017 were examined. The mean lesion length was 19.6±5.3 (range, 15.5-26.4 cm). The femoropopliteal lesions were classified as TASC II C and TASC II D in 39 and 16 cases, respectively. The ankle-brachial index (ABI), primary patency rate, secondary patency rate, and limb salvage rate were monitored in follow-up evaluations for up to 24 months. A Cox regression model was used to evaluate the correlation between each of these factors and the restenosis rate after EVT. Patent TASC II C/D femoropopliteal lesions were present in 59 of the 64 limbs. The mean ABI values for the dorsal pedal artery and posterior tibial artery increased 1 month after treatment from a baseline level of 0.35±0.12 to 0.89±0.10 and from 0.43±0.15 to 0.90±0.13, respectively (P<0.01). The mean follow-up time was 19.3 (range, 6-24) months. The cumulative primary patency rates at 1, 3, 6, 12, 18, and 24 months were 98.3%, 91.5%, 84.3%, 61.1%, 53.1%, and 31.1%, respectively. The secondary patency rates at 12 and 24 months were 70.4% and 60.0%, respectively. Factors with a high hazard ratio included male sex, TASC II D, smoking, and diabetes mellitus (DM). EVT had a safe and satisfactory mid-term therapeutic effect on TASC II C/D femoropopliteal lesions. Male sex, TASC II D (compared to TASC II C), smoking, and DM were risk factors for restenosis. EVT has a secondary patency rate comparable to that of open surgery and can be considered a first-line treatment for TASC II C/D femoropopliteal lesions.

CORRELATION OF ANKLE-BRACHIAL INDEX WITH SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS HOSPITALIZED FOR ACUTE MYOCARDIAL INFARCTION

Objective: Ankle-brachial index (ABI) is an stablished predictor of cardiovascular events in different clinical setting including hypertension Purpose: To assess the usefulness of ABI evaluation for identifying multivessel CAD in patients with acute myocardial infraction (AMI). Design and method: We studied 101 patients [77.2% male; mean age 60.9 years; 63.4% hypertensives; 24.8% with diabetes mellitus (DM)] who were hospitalized because of ST-elevation MI (STEMI, 51.5%) and Non-ST–elevation MI (NSTEMI). All patients underwent baseline estimation of clinical and laboratory parameters during their hospitalization. The ABI was measured according to established methodology using a certified automated device and abnormal ABI was defined as a value &lt;0.9. Severity of CAD was estimated by the number of affected main vessels. Results: In the entire population, mean ABI was 1.11 ± 0.17, while 15.8% of patients had abnormal ABI. NSTEMI patients compared to those with STEMI demonstrated a trend forlower ABI (1.07 ± 0.18 vs 1.12 ± 0.16; p = 0.144) and more often abnormal ABI (22.4% vs 9.6%; p = 0.103). Using univariate analysis in the entire population, severity of CAD was correlated with age (r = 0.133; p = 0.053), history of DM (r = 0.225; p = 0.01), ABI value (r = 0.214; p = 0.029) and abnormal ABI (r = 0.242; p = 0.015). In multivariate regression models, both ABI value (b = 0.258; p = 0.014) and abnormal ABI (b = 0.218; p = 0.036) remained significant predictors of CAD severity independently of gender, age, DM, smoking, low density lipoprotein (LDL-C), 24-h systolic blood pressure and the type of MI. Conclusions: An impaired ABI is associated with greater risk of multivessel CAD in patients with AMI. This finding in patients with acute coronary syndromes may thusraise the suspicion of advanced disease, alerting to the need for moreaggressive diagnostic and therapeutic strategies.

Can ankle-brachial index be used as a predictor for carotid artery shunt application during carotid endarterectomy?

Objectives: This study aims to investigate the possible relationship between low ankle-brachial index (ABI) and shunt requirement during carotid endarterectomy (CEA) operations. Patients and methods: Medical records of a total of 56 patients (40 males, 16 females; mean age: 65.6±8.4 years; range, 48 to 82 years) who underwent CEA between January 2013 and December 2016 were retrospectively reviewed. The ABI was measured in all patients at the time of hospital admission. Peripheral arterial disease was defined as having an ABI of ≤0.90 in either leg. Selective carotid artery shunt strategy was applied to all patients who underwent CEA under regional anesthesia. Results: Forty-eight (85.8%) patients were symptomatic. Peripheral arterial disease was diagnosed in 25 (44.6%) patients with ABI measurements. Eleven (19.6%) patients required shunt placement due to neurological deterioration during the carotid clamping test. The mean ABI of 11 (19.6%) patients was 0.8±0.15, while the ABI was less than 0.90 in 10 (17.8%) patients. There was a statistically significant correlation between perioperative shunt usage and peripheral arterial disease (odds ratio [OR]: 19.68, 95% confidence interval [CI]: 2.3-164.4; p=0.001). Conclusion: Low ABI appears to be related to a higher rate of shunt requirement in patients undergoing CEA under regional anesthesia with a selective shunt strategy in our modest cohort.

Association of Ankle Brachial Index with Clinical Outcomes Following Percutaneous Coronary Intervention in Patients with Aortic Aneurysm.

Objective Since patients with thoracic aortic aneurysm (TAA)/abdominal aortic aneurysm (AAA) are often complicated with coronary artery disease, it is common for those patients to undergo percutaneous coronary intervention (PCI). The ankle brachial index (ABI) is usually measured in patients with TAA/AAA to screen the presence of peripheral arterial disease. The present study investigated the association between the ABI and clinical outcomes following PCI in patients with TAA/AAA. Methods We divided 200 TAA/AAA patients who underwent PCI into a normal ABI group (n=137) and an abnormal ABI group (n=63) according to the ABI cut-off level of 1.00. The primary endpoint was one-year major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, non-fetal myocardial infarction, stroke, target vessel revascularization, and hospitalization for heart failure. Results Mean ABIs in the normal and abnormal ABI groups were 1.12±0.09 and 0.86±0.11, respectively (p<0.01). Kaplan-Meier curves showed MACE were more frequent in the abnormal ABI group than in the normal ABI group (p=0.01). A multivariate Cox hazard analysis revealed that an abnormal ABI was significantly associated with 1-year MACE (vs. ABI ≥1.0: HR 3.02, 95% confidence interval 1.00-9.08, p=0.049). Conclusion Among patients with TAA/AAA who underwent PCI, abnormal ABI was significantly associated with 1-year MACE, suggesting the utility of the ABI measurement in this high-risk population.

Safety and Efficacy of Vacuum Assisted Thrombo-Aspiration in Patients with Acute Lower Limb Ischaemia: The INDIAN Trial

The aim was to evaluate the short term safety and effectiveness of the Penumbra/Indigo aspiration thrombectomy Systems (Penumbra Inc.) in patients with acute lower limb ischaemia. (ALLI). Recently, endovascular vacuum assisted thrombectomy devices, similar to those used in the management of acute ischaemic stroke, have become available for peripheral arteries, but data are still scarce. To assess vessel patency, a modified Thrombolysis in Myocardial Infarction (TIMI) classification, called TIPI (Thrombo-aspiration In Peripheral Ischaemia), is proposed. The TIPI flow is assessed at presentation, immediately after treatment with the study device, and after all adjuvant procedures. The primary outcome is the technical success of the thrombo-aspiration with the investigative system, defined as near complete or complete revascularisation TIPI 2 - 3. Safety and clinical success rate were collected at one month. One hundred and fifty patients were enrolled. The mean age was 72.4 years and 73.3% were male. Rutherford grade on enrolment was I in 16%, IIa in 40.7%, and IIb in 43.3% with a mean ankle brachial index of 0.19. Primary technical success (TIPI 2 - 3 flow) was achieved in 88.7% of patients. Adjunctive procedures included angioplasty/stenting of chronic atherosclerotic lesions (n= 39), thrombolysis (n= 31), covered stenting (n= 15), and supplementary Fogarty embolectomy (n= 6). After all interventions, assisted primary technical success was 95.3% (TIPI 2 - 3 in 143/150). No systemic bleeding complications or device related serious adverse events were reported. At one month follow up, one death, and one below the knee amputation were recorded. Primary patency was 92% (138/150), and the re-intervention rate was 7.33%, resulting in an assisted primary and secondary patency of 94% and 99.33%, respectively. Results from the INDIAN registry reveal that mechanical thrombectomy using the Indigo system is safe and effective for revascularisation of ALLI as a primary therapy.