Mild Peripheral Arterial Disease Research Articles

Association of lower extremity peripheral arterial disease with quantitative muscle features from computed tomography angiography

ObjectivesTo explore the association between lower extremity muscle features from CTA and peripheral arterial disease (PAD) severity using digital subtraction angiography (DSA) as reference standard.MethodsInformed consent was waived for this Institutional Review Board approved retrospective study. PAD patients were recruited from July 2016 to September 2020. Two radiologists evaluated PAD severity on DSA and CTA using runoff score. The patients were divided into two groups: mild PAD (DSA score ≤ 7) vs. severe PAD (DSA score > 7). After segmenting lower extremity muscles from CTA, 95 features were extracted for univariable analysis, logistic regression model (LRM) analysis, and sub-dataset analysis (PAD prediction based on only part of the images). AUC of CTA score and LRMs for PAD prediction were calculated. Features were analyzed using Student’s t test and chi-squared test. p < 0.05 was considered statistically significant.ResultsA total of 56 patients (69 ± 11 years; 38 men) with 56 lower legs were enrolled in this study. The lower leg muscles of mild PAD group (36 patients) showed higher CT values (44.6 vs. 39.5, p < 0.001) with smaller dispersion (35.6 vs. 41.0, p < 0.001) than the severe group (20 patients). The AUC of CTA score, LRM-I (constructed with muscle features), and LRM-II (constructed with muscle features and CTA score) for PAD severity prediction were 0.81, 0.84, and 0.89, respectively. The highest predictive performance was observed in the image subset of the middle and inferior segments of lower extremity (LRM-I, 0.83; LRM-II, 0.90).ConclusionsLower extremity muscle features are associated with PAD severity and can be used for PAD prediction.Critical relevance statementQuantitative image features of lower extremity muscles are associated with the degree of lower leg arterial stenosis/occlusion and can be a beneficial supplement to the current imaging methods of vascular stenosis evaluation for the prediction of peripheral arterial disease severity.Key points• Compared with severe PAD, lower leg muscles of mild PAD showed higher CT values (39.5 vs. 44.6, p < 0.001).• Models developed with muscle CT features had AUC = 0.89 for predicting PAD.• PAD severity prediction can be realized through the middle and inferior segment of images (AUC = 0.90).Graphical

Mitochondrial respiration in peripheral arterial disease depends on stage severity.

Peripheral arterial disease (PAD) is an increasing cause of morbidity and its severity is graded based on clinical manifestation. To investigate the influence of the different stages on myopathy of ischemic muscle we analysed severity-dependent effects of mitochondrial respiration in PAD. Eighteen patients with severe PAD, defined as chronic limb-threatening ischemia, 47 patients with intermittent claudication (IC) and 22 non-ischemic controls were analysed. High-resolution respirometry (HRR) was performed on muscle biopsies of gastrocnemius and vastus lateralis muscle of patients in different PAD stages to investigate different respiratory states. Results from HRR are given as median and interquartile range and were normalized to citrate synthase activity (CSA), a marker for mitochondrial content. In order to account for inter-individual differences between patients and controls, we calculated the ratio of O₂-flux in gastrocnemius muscle over vastus muscle ('GV ratio'). CSA of the gastrocnemius muscle as a proxy for mitochondrial content was significantly lower in critical ischemia compared to controls. Mitochondrial respiration normalized to CSA was higher in IC compared to controls. Likewise, the GV ratio was significantly higher in IC compared to control. Mitochondrial respiration and CSA of PAD patients showed stage-dependent modifications with greater changes in the mild PAD stage group (IC).

Correlation of Coronary Artery Disease in Patients with Peripheral Artery Disease: Cross-Sectional Study

Background Peripheral Artery Disease (PAD) and Coronary Artery Disease (CAD) represent two facets of atherosclerotic cardiovascular disease, significantly impacting global health. Despite their high morbidity and mortality rates, the epidemiological and clinical nexus between PAD and CAD remains underexplored. Understanding the interrelation of these conditions is paramount for optimizing diagnostic and therapeutic strategies. Objective This study aimed to delineate the incidence and clinical correlation of CAD in patients diagnosed with PAD, thereby providing insights into the epidemiological characteristics and enhancing the clinical management of these conditions. Methods A cross-sectional analysis was conducted at Afridi Medical Complex's departments of vascular surgery and cardiology from 2021 to 2023. One hundred PAD patients referred for peripheral angiography were enrolled. Demographic data, Ankle Brachial Index (ABI) readings, ejection fraction percentages, and the presence of multivessel disease were evaluated. Statistical analyses were performed using SPSS version 25, focusing on mean, median, range, and significance levels to elucidate the prevalence of CAD among PAD patients. Results The study revealed a median age of 58 years among participants, with a significant male predominance (84%). ABI analysis showed that 74% and 108% of patients had mild and moderate PAD severity, respectively. The incidence of CAD in the PAD population was 56%, with angiographic assessments indicating single, double, and triple vessel disease in 23.21%, 39.29%, and 37.5% of patients, respectively. Notably, diabetes and dyslipidemia were prominent predictors of CAD presence in PAD patients. Conclusion The high prevalence of CAD in PAD patients underscores the critical need for comprehensive cardiovascular risk assessment and suggests the potential benefit of routine coronary angiography in symptomatic PAD cases, particularly among those with diabetes and dyslipidemia. This study reinforces the intertwined nature of PAD and CAD, advocating for an integrated approach to the diagnosis and management of these atherosclerotic conditions.

Near-infrared spectroscopy with a provocative maneuver to detect the presence of severe peripheral arterial disease

Current assessment standards for peripheral arterial disease (PAD), such as the ankle brachial index, are limited in their utility and portability. Near-infrared spectroscopy (NIRS) has shown some promise in diagnosing PAD when used in conjunction with a provocative maneuver. The purpose of this study was to assess the viability of NIRS in conjunction with a transient leg elevation provocative maneuver for detecting severe PAD. This retrospective observational cross-sectional study assessed 57 limbs in 34 patients receiving routine vascular screening for PAD at Madigan Army Medical Center. The patient limbs were stratified into normal (n = 17), mild (n = 9), moderate (n = 16), and severe (n = 15) PAD groups based on the clinician assessments. Additionally, the patients were assessed with NIRS measurements taken with the patient in the supine position at rest and using a provocative leg raise maneuver of transient leg elevation of 45° for 60 seconds. The resting tissue oxygen saturation (StO2) and the change in StO2 (ΔStO2) from rest to elevation were recorded and compared between the PAD severity groups via independent measures analysis of variance with the Tukey honest significant difference post hoc test. The supine resting StO2 was not different between the normal (77.5% ± 7.7%), mild (72.5% ± 7.4%), moderate (72.0% ± 10.3%), and severe (74.2% ± 5.4%) PAD groups (P = .23). However, the ΔStO2 with transient leg elevation was significantly greater in the severe PAD group (−17.2% ± 6.0%) compared with the normal (−3.9% ± 4.8%), mild (−6.9% ± 4.7%), and moderate (−9.7% ± 5.2%) PAD groups (P < .002 for all). Similar results were observed in the changes in oxyhemoglobin and deoxyhemoglobin. The leg elevation protocol was also used for two patients before and after lower limb revascularization, which demonstrated that the ΔStO2 corresponded with the clinical assessment of PAD severity. Resting supine NIRS images were unable to detect any differences among normal and limbs with different PAD severity. However, NIRS imaging with 45° leg elevation for 60 seconds showed a significant difference between severe PAD compared healthy patients and those with mild to moderate PAD in a fast, precise, and accurate manner. These preliminary data support the use of NIRS and transient leg elevation as a tool to diagnose severe PAD but do not support the use of NIRS alone as a screening test for PAD. NIRS measurements with leg elevation might be a viable noninvasive, noncontact, and portable method of assessing severe PAD for home monitoring, in rural communities, and/or in standard clinical practice.

Ultrasonographic assessment and clinical outcomes after deployment of a suture-mediated femoral vascular closure device.

Data regarding changes in the arterial vascular wall after the deployment of suture-mediated vascular closure devices (VCD) at the femoral site in patients undergoing percutaneous coronary angiography (CAG) or percutaneous coronary intervention (PCI) are sparse. This study investigated the occurrence of structural vascular changes or adverse vascular complications at the access site in the short term after the deployment of a suture-mediated intravascular VCD. Ninety-three patients (72% males) with a mean age of 62 ± 11 years were enrolled. Duplex sonography was conducted at the access site at baseline, 24 hours and 30 days after femoral puncture in patients with successful VCD deployment. Vessel diameter, flow velocities, the severity of atherosclerosis, and the intravascular or perivascular tissue alterations in both the right common femoral artery (RCFA) and right external iliac artery (REILA) were assessed. Vascular complications were documented. There were no significant changes regarding the diameter of the RCFA in the transverse and longitudinal view, peak systolic velocity (PSV) of the RCFA, PSV ratio of the RCFA to REILA, the resistive index of the RFCA and the severity of arterial wall abnormalities before femoral puncture, the day following VCD deployment and 30 days after (p = NS for all) in the general population and in patients with diabetes mellitus, on oral anticoagulants or with mild peripheral artery disease (p = NS for all markers). Device failure was observed in four cases. Few (4.4%) patients had vascular complications, which included exclusively major or minor haematomas, most of which did not persist at the 30-day follow up. The use of a suture-mediated VCD was safe and was not associated with adverse vascular wall changes at the femoral access site 30 days after deployment in patients undergoing CAG and/or PCI.

LOX-1 rs1050283 TT genotype is associated with the severity of peripheral artery disease: a cross-sectional study in Mataram, Indonesia

Background: Peripheral arterial disease (PAD) is an important consequence of atherosclerosis commonly determined based on the results of ankle-brachial index (ABI) measurements. Due to its limitations, the search for potential predictors of PAD severity is ongoing. Serum soluble Lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) levels and LOX-1 polymorphism rs1050283 are candidates for predictors of PAD severity. This study aimed to investigate the association between the LOX-1 rs1050283 TT genotype and the severity of PAD. Methods: This cross-sectional study involved PAD patients recruited consecutively. The patients were genotyped for rs1050283 (3’ UTR C&gt;T) LOX-1 single nucleotide polymorphism using the sequencing method. Serum sLOX-1 levels were measured using ELISA. Data on ABI were collected, and the patients were categorized into mild and moderate to severe PAD groups. Results: A total of 66 PAD patients with a mean age of 58.9 years participated in this study, which consisted of 45 patients with mild PAD and 21 patients with moderate to severe PAD. Multivariate logistic regression analysis showed that the TT genotype was associated with PAD severity compared to those with the CC genotype (odds ratio (OR): 15.0, 95% confidence intervals (CI): 1.1 – 209.0), while higher serum sLOX-1 levels were not. PAD severity was also associated with increasing age (OR: 5.7, 95% CI: 1.3 – 25.7) and male gender (OR: 6.0, 95% CI: 1.1 – 32.2). Conclusion: TT genotype of LOX-1 rs1050283 polymorphism was associated with PAD severity, whereas higher serum sLOX-1 levels were not. In addition, increasing age and male gender were also associated with PAD severity.

Mitochondrial Complex Abundance, Mitophagy Proteins, and Physical Performance in People With and Without Peripheral Artery Disease.

Background Mitochondrial abnormalities exist in gastrocnemius muscle of people with peripheral artery disease (PAD). Whether abnormalities in mitochondrial biogenesis and autophagy are associated with greater ischemia or walking impairment in PAD is unknown. Methods and Results Protein markers of mitochondrial biogenesis and autophagy and the abundance of mitochondrial electron transport chain complexes were quantified in gastrocnemius muscle biopsies from people with and without PAD. Their 6-minute walk distance and 4-m gait speed were measured. Sixty-seven participants (mean age 65.0 years [±6.8], 16 [23.9%] women, 48 [71.6%] Black) were enrolled, including 15 with moderate to severe PAD (ankle brachial index [ABI] <0.60), 29 with mild PAD (ABI 0.60-0.90), and 23 without PAD (ABI 1.00-1.40). Abundance of all electron transport chain complexes was significantly higher in participants with lower ABI (eg, complex I: 0.66, 0.45, 0.48 arbitrary units [AU], respectively, P trend=0.043). Lower ABI values were associated with a higher LC3A/B II-to-LC3A/B I (microtubule-associated protein 1A/1B-light chain 3) ratio (2.54, 2.31, 2.15 AU, respectively, P trend=0.017) and reduced abundance of the autophagy receptor p62 (0.71, 0.69, 0.80 AU, respectively, P trend=0.033). The abundance of each electron transport chain complex was positively and significantly associated with 6-minute walk distance and 4-m gait speed at usual and fast pace only among participants without PAD (eg, complex I: r=0.541, P=0.008; r=0.477, P=0.021; r=0.628, P=0.001, respectively). Conclusions These results suggest that accumulation of electron transport chain complexes in gastrocnemius muscle of people with PAD may be because of impaired mitophagy in the setting of ischemia. Findings are descriptive, and further study in larger sample sizes is needed.

5 RISK FACTORS OF PERIPHERAL ARTERY DISEASE IN THE HYPERTENSIVE CHRONIC KIDNEY DISEASE PATIENTS ON HEMODIALYSIS

Background: Hypertensive chronic kidney disease (CKD) patients have increased risk of having peripheral artery disease (PAD), especially when combined with traditional PAD risk factors. Prevalence of PAD among CKD patients were variably reported. Objective: To analyze the risk factors of PAD in the hypertensive CKD patients on hemodialysis. Method: Cross-sectional study was conducted in December 2021 in Prof. dr. R. D. Kandou Hospital, Manado. Patients aged 18 years-old on hemodialysis at least twice a week for three months and taking anti- hypertension were included. Patients that refused and unable to be performed Ankle Brachial Index (ABI) due to physical limitation were excluded. Smoking, hemodialysis duration, anti-hypertension, alcohol intake history was taken. Laboratory (ureum-creatinine, albumin, lipid-profile, fasting-blood-glucose [FBG], hemoglobin, leukocyte, phosphate, calcium, uric acid, calcium-phosphate-product) and ABI examination was performed one day before patient's regular hemodialysis schedule. Result: On this study, among 30 patients, PAD prevalence was 50% with median age 55.5 (IQR 13) and 56.7% was male. Among those with PAD, 66.7% had PAD on both legs, 86.7% with mild PAD and 13.3% with moderate. All of them were asymptomatic. Diabetes mellitus (p=0,025), elevated FBG (p=0.006), and low-density-lipoprotein (LDL) level (p=0.017) were associated with PAD in this study. Other risk factors were not significant. Conclusion: PAD prevalence among hypertensive CKD patients on hemodialysis was high and all of them were asymptomatic. Diabetes mellitus, elevated FBG and LDL level were associated with PAD risk factors. Screening and management of PAD should be employed for those with risk factors.

Clinical Effect of Revascularization Strategies and Pharmacologic Treatment on Long-Term Results in Patients with Advanced Peripheral Artery Disease with TASC C and D Femoropopliteal Lesions.

Background This study was to assess the clinical outcome and associated parameters of endovascular therapy (EVT group) and bypass surgery (bypass group) in patients with long femoropopliteal TransAtlantic Inter-Society Consensus II (TASC II) C and D peripheral artery disease (PAD). Methods 187 patients who underwent successful EVT or bypass surgery were assessed. The endpoints included the events of cardiovascular disease (CVD) and lower-extremity amputation (LEA), 3-year primary patency, and 3-year amputation-free survival (AFS). Results The 3-year primary and secondary patency rates were better in the bypass group (P=0.007 and P=0.039, respectively), while the incidences of LEA, new CVD events, and mortality were comparable between groups. Weighted multivariate Cox analyses showed that cilostazol treatment (hazard ratio (HR): 0.46, 95% confidence interval (CI): 0.3–0.72, P=0.001), statin treatment (HR: 0.54, 95% CI: 0.33–0.9, P=0.014), and direct revascularization (DR) (HR: 0.47, 95% CI: 0.29–0.74, P=0.001) were predictive factors of 3-year primary patency. Kaplan–Meier curve analyses of time-to-primary cumulative AFS showed that nondiabetes mellitus, mild PAD, and cilostazol and statin treatment were correlated with a superior 3-year AFS (log rank test, P=0.001, P < 0.001, P=0.009, and P=0.044, respectively). Conclusions Endovascular stenting based on the angiosome concept and bypass surgery provide comparable benefits for the treatment of long, advanced femoropopliteal lesions after a short follow-up period, whereas cilostazol therapy for more than 3 months, aggressive treatment of dyslipidemia, and surgical revascularization were associated with higher primary patency.

Utility of Ankle Brachial Index in the Diagnosis of Peripheral Arterial Disease in a Resource Limited Setting

Background: Peripheral arterial disease (PAD) constitutes a significant healthcare problem with immense health and economic implications. Owing to ill-equipped healthcare systems in poor countries the diagnosis of PAD demands the availability of a reasonably reliable and inexpensive diagnostic test. Ankle brachial index (ABI) is a simple, inexpensive office-based test for the diagnosis of PAD. The study was aimed to evaluate the reliability of ABI for the diagnosis of PAD using Doppler ultrasound (DUS) as the gold standard. Methods: The ABI of patients suspected of having lower limb PAD was measured followed by DUS examination. The sensitivity and specificity of ABI for the diagnosis of PAD was calculated by comparing it with DUS which was used as the reference or standard diagnostic test. Results: The ABI of a total of 200 limbs from 100 patients was recorded followed by DUS examination. One hundred and thirty-two limbs (66%) had PAD on DUS which was graded as mild, moderate, and severe in 45.5%, 27.2% and 30.3% respectively. Out of 132 patients who had PAD on Doppler, 96/132 (72.8%) were correctly labelled as PAD on ABI, whereas 36/132 (27.2%) received an erroneous diagnosis of normal on ABI. Conversely, only 6/60 (10%) patients who were labelled as PAD on ABI had a normal arterial system on DUS. The ABI yielded a low overall sensitivity of 72.7% and a high specificity of 90%. The sensitivity was relatively low for mild PAD (52.7%), however, for moderate and severe PAD, ABI demonstrated a high sensitivity of 88.9% and 100% respectively. Overall agreement between ABI and DUS for the diagnosis of PAD was good (k = 0.67). Conclusion: ABI demonstrated a good sensitivity and specificity for the diagnosis of PAD especially in patients with moderate-severe PAD. Combined with the advantages of ready availability, low cost, and technical feasibility the use of ABI should be maximized in routine clinical practice to clinch the diagnosis of PAD in suspected individuals.

Evaluation of Perfusion Index as a Screening Tool for Developing Critical Limb Ischemia.

Objective: The perfusion index (PI) is a physiological marker for evaluating the peripheral circulation. We explored the possibility of using PI as a screening tool for development of critical limb ischemia in peripheral artery disease (PAD).Method: We measured the PI in 79 limbs of 70 PAD patients. Data were analyzed to find a correlation between the PI and PAD severity.Result: The PI tended to be lower as PAD became severer. Especially, there were significant differences between the Fontaine 1 and Fontaine 4 groups in average PI and minimum PI, and between Fontaine 1 and two other groups (Fontaine 2 and Fontaine 4 groups) in maximum PI. A mild correlation was found between PI and the ankle brachial index. These data were used to calculate an average PI of 0.27 as a cut-off value for critical limb ischemia (CLI). In 65 asymptomatic PAD patients and claudication, significantly more patients with a PI value greater than the cut-off value developed CLI than those with a PI lower than the cut-off.Conclusion: The PI can be a useful tool for evaluating the development of CLI in mild PAD patients, and patients tended not to progress to CLI when their average PI was higher than 0.27. (This is a translation of Jpn J Vasc Surg 2020; 29: 103–108.)

Peripheral artery disease and physical function in women with and without HIV.

Peripheral artery disease (PAD) is associated with decreased physical function and increased mortality in the general population. We previously found that PAD is common in middle-aged women with and without HIV infection, but its association with functional decline is unclear. We examine the contribution of PAD to functional decline in the Women's Interagency HIV Study, controlling for traditional cardiovascular risk factors and HIV-related factors. Analysis included 1839 participants (72% with HIV) with measured ankle-brachial index (ABI) and 4 m gait speed. ABI values categorized PAD severity. Linear models with repeated measures estimated the association of PAD severity with log-transformed gait speed after controlling for demographic, behavioral, and metabolic risk factors, and HIV/hepatitis C virus status. Median age was 50 years and more than 70% were Black. Compared with normal ABI, there was a dose-response relationship between increasing PAD severity and slower gait speed in univariable analyses: 6% slower gait speed for low-normal ABI [95% confidence interval (CI): 4-9%], 10% for borderline PAD (95% CI: 6-13%), 14% for mild PAD (95% CI: 9-18%), and 16% for moderate-severe PAD (95% CI: 5-25%). PAD severity remained associated with slower gait speed in multivariable analyses. HIV/hepatitis C virus co-infection was independently associated with 9% (95% CI: 4-14%) slower gait speed compared with those with neither infection. Among women with HIV, neither CD4+ cell count nor HIV-RNA level was associated with gait speed. In middle-aged women with and without HIV infection, greater PAD severity is associated with progressively slower gait speed. Early detection of subclinical PAD may decrease the risk of lower extremity functional impairment and its long-term health consequences.

The Impact of Peripheral Artery Disease (PAD) on Lower Limb Kinematics in Type 2 Diabetes Mellitus.

BACKGROUNDPeripheral artery disease (PAD) and diabetes mellitus are factors known to influence gait characteristics. However, there is a lack of knowledge on the extent to which type 2 diabetes mellitus (T2D) and PAD as comorbidities cause limb and gait complications.AIMThe purpose of this study was to investigate the impact of PAD as a complication of T2D on ankle joint dorsiflexion and knee joint flexion angles using an optoelectronic motion analysis system and to find out whether these alterations are complications secondary to neuropathy or reduced blood perfusion.METHODSNinety participants were recruited in this quantitative study which applied a prospective, comparative, non-experimental approach. Participants with T2D and PAD (n = 60), categorized according to the severity of PAD (mild and severe group), were compared with a control group consisting of patients with T2D alone. An optoelectronic motion capture system was used to record mean maximum flexion angles of the knee joint and maximum mean dorsiflexion angles of the ankle joint during gait.RESULTS180 limbs were analyzed. Both mild and severe PAD participants exhibited a significant increase in mean maximum ankle joint dorsiflexion angles (p = 0.001) and a significant decrease in mean maximum flexion of the knee joint compared with the control subjects (p = 0.001).CONCLUSIONSThis study shows that T2D and PAD alter ankle joint and knee joint kinematics. This research provides biomechanical understanding of limb and gait alterations in this specific patient population which may contribute to an improved understanding of gait alterations and clinical management. The findings suggest that the reduction in ankle joint dorsiflexion commonly attributed to glycosylation in diabetes may be secondary to neuropathy and not to reduced blood perfusion.

Abstract 14374: Peripheral Artery Disease and Gait Speed in Women With and at Risk for HIV

Introduction: Peripheral artery disease (PAD) is associated with decreased physical function and increased mortality in the general population. PAD is common in women with and at risk for HIV infection, but its association with functional decline is unclear. We examined the contribution of PAD to gait speed in the Women’s Interagency HIV Study, controlling for traditional cardiovascular risk factors and HIV-related factors. Methods: 1,839 participants (72% HIV+) with measured ankle-brachial index (ABI) and 4-meter gait speed were included in analysis. ABI scores were categorized as: &lt;0.7, moderate-severe PAD; 0.7-&lt;0.9, mild PAD; 0.9-&lt;1.0, borderline PAD; 1.0-&lt;1.1, low-normal; 1.1-1.4, normal. Longitudinal regression models with repeated measures were used to examine the association of PAD category with log-transformed gait speed after controlling for demographic, behavioral, and cardiovascular disease risk factors, and HIV and HCV status. Coefficients represented percentage differences. Results: Median age was 50 years, &gt;70% were Black. Figure 1 shows median gait speed by PAD group. In univariate analysis, compared to normal ABI, each category of PAD severity was associated with slower gait speed: 6% slower for low-normal (95% confidence interval [CI]:4%, 9%), 10% for borderline (95% CI:6%, 13%), 14% for mild (95% CI:9%, 18%), and 16% for moderate-severe (95% CI:5%, 25%). In multivariate analysis, PAD severity remained associated with 6% (95% CI:4%, 9%), 10% (95%CI:7%, 14%), 12% (95%CI:8%, 17%), and 11% (95%CI: -1%, 22%) slower gait speed, respectively. HIV/HCV coinfection reduced gait speed by 9% (95%CI:4%, 14%). Among HIV+ women, neither CD4 count nor HIV viral load was associated with gait speed. Conclusions: In middle-aged women with and at risk for HIV, greater PAD severity is associated with progressively slower gait speed. ABI measurement may be a simple and clinically useful tool for early assessment of functional declines.

The influence of peripheral arterial disease on lower limb surface myoelectric signals in patients living with type II diabetes mellitus

BackgroundThe aim of this study was to evaluate whether there are any significant differences in muscle activity between individuals living with type II diabetes mellitus (T2DM) and individuals living with T2DM and peripheral arterial disease (PAD), during gait at a self-selected speed. The influence of different stages of PAD on muscle activity during gait was also assessed with the use of surface electromyography (EMG). Research questionDoes PAD affect lower limb muscle activity during gait in the presence of T2DM? MethodsThis quantitative study involves a prospective, comparative, non-experimental subject design. Ninety participants were divided into three groups namely Group A (thirty participants living with T2DM), Group B(i) (thirty participants living with T2DM and mild PAD) and Group B(ii) (thirty participants living with T2DM and severe PAD). Surface electrode sensors were placed according to SENIAM guidelines, on six main lower limb muscles on both limbs. Muscle activity was recorded using a wireless system, where participants were instructed to walk at a self-selected speed on a 10-m walkway. Average Burst RMS was performed and the amplitude (mV) and the duration of muscle activation (s) was analysed. ResultsThere was a significant increase in muscle amplitude and duration of activation in the presence of lower limb ischaemia during gait. The largest significant difference (p = <0.05) in EMG amplitude and duration of activation when looking at the twelve muscles in general was found between participants living with T2DM and participants living with T2DM and severe PAD. SignificanceThe increase in muscle activity indicates that there are musculoskeletal and biomechanical changes in the lower limb musculature with increasing severity of PAD. Higher muscle exertion demands are required during gait which may result in earlier fatigue. EMG tests would be beneficial for detecting muscle dysfunction objectively and non-invasively in T2DM and PAD.

VALUE OF MULTI-DETECTOR CT ANGIOGRAPHY IN CHRONIC ISCHEMIA OF LOWER LIMBS IN COMPARISON WITH THE DOPPLER ULTRASOUND

Background: Peripheral arterial disease (PAD) is one of the most common cardiovascular diseases in developed countries and is an emerging problem in developing countries. Duplex ultrasonography (DUS) has been used as the initial imaging modality in mild symptomatic PAD. Multi-slice helical CT angiography of arteries of the thigh represents a reliable means for the detection of relevant stenoses in patients with peripheral occlusive artery disease. Objective: To assess value of multi-detector computed tomography angiography (MDCTA) and to compare it with DUS to diagnose chronic ischemia of lower limbs. Methods: A prospective comparative study was conducted on 30 patients with chronic lower limbs ischemia of both limbs during the period from September 2015 to September 2016 at the Department of Diagnostic Radiology of Al-Imamein Al-Kadhimein Medical City, Baghdad, Iraq. DUS was done for all the patients and then MDCTA was done. Results: Thirty patients (20 males and 10 females) with a mean age of 57.1 ± 8.5 (range: 33 –80) years were included in this study. MDCTA detects 69 lesions (41 occluded segments and 28 stenotic segments) and DUS detects 58 lesions (35 occluded segments and 43 stenotic segments). In MDCTA, 8 patients (26.7%) had lesion in only one arterial segment, 13 patients (43.3%) had two segment lesions, 3 patients (10%) had three segment lesions, 4 patients (13.3%) with four lesions and only two patients (6.7%) had lesions in five arterial segments. Regarding the findings of the DUS one segment lesion was detected in 13 patients (43.3%), two segment lesions in 11 (36.7%), three segment lesions in 2 (6.7%), four segment lesions in 3 (10.0%) and only five segment lesions in only one patient (3.3). Furthermore, the measure of agreement between both MDCTA and DUS in the number of lesions detected revealed a good agreement between both tests, (Kappa = 0.81) with a percent agreement of (86.6%). Conclusion: Multi-detector CT angiography is a fast, accurate, safe and a minimally-invasive imaging modality which may be used in cases of PAD for diagnosis, grading and for preoperative assessment of lower limb arterial disease. Keywords: Multi-detector CT Angiography, chronic ischemia of lower limbs, doppler ultrasound Citation: Kadhim MA, Eisa YA, Mohammed SJ. Value of multi-detector CT angiography in chronic ischemia of lower limbs in comparison with the doppler ultrasound. Iraqi JMS. 2018; 16(2): 144-151. doi: 10.22578/IJMS.16.2.5

Improving Lower Extremity Functioning in Peripheral Artery Disease

Lower extremity peripheral artery disease (PAD) now affects approximately 8.5 million adults 40 years and older in the United States and approximately 202 million adults worldwide.1 PAD is atherosclerotic disease of the arteries supplying the legs, resulting in impaired oxygen delivery to leg muscles during walking activities. Most people with PAD will never experience critical limb ischemia, which includes pain at rest, nonhealing leg ulcers, or gangrene. However, even without critical limb ischemia, patients with PAD have significant functional impairment that is manifest as poor walking endurance, poor physical activity, and faster functional decline than people without PAD. Among 666 participants (412 with PAD) in the Walking and Leg Circulation Study, participants with severe PAD were 4.2 times more likely and those with mild PAD were 3.2 times more likely to become unable to walk one-quarter of a mile or walk up 1 flight of stairs without assistance compared with people without PAD at 5-year follow-up, independently of age, comorbidities, and other confounders.2

Impact of betablockers on general and local outcome in patients hospitalized for lower extremity peripheral artery disease: The COPART Registry.

Lower extremity peripheral artery disease (PAD) is one manifestation of atherosclerosis. Patients with PAD have an increased rate of mortality due to concurrent coronary artery disease and hypertension. Betablockers (BB) may, therefore, be prescribed, especially in case of heart failure. However, BB safety in PAD is controversial, because of presumed peripheral hemodynamic consequences of BB that could lead to worsening of symptoms in patients with PAD. In this context, we aimed to determine the impact of BB on all-cause and cardiovascular mortality and amputation rate at 1 year after hospitalization for PAD from the COPART Registry population. This is a prospective multicenter observational study collecting data from consecutive patients hospitalized for PAD in vascular medicine departments of 4 academic hospitals in France. Patients with, either claudication, critical limb ischemia or acute lower limb ischemia related to a documented PAD were included. We compared the outcomes of patients with BB versus those without BB in their prescription list at hospital discharge. The mean age of the study population was 70.9 years, predominantly composed of males (71%). Among the 1267 patients at admission, 28% were treated by BB for hypertension, prior myocardial infarction or heart failure. During their hospital stay, 40% underwent revascularization (including bypass surgery 29% and angioplasty 74%), 17% required an amputation, and 5% died. In a multivariate analysis, only prior myocardial infarction was found associated with BB prescription with an odds ratio (OR) of 3.11, P < 0.001. Conversely, chronic obstructive pulmonary disease or PAD with ulcer impeded BB prescription (OR: 0.57 and 0.64, P = 0.007; P = 0.001, respectively). One-year overall mortality of patients with BB did not differ from those without (23% vs. 23%, P = 0.95). The 1-year amputation rate did not differ either (4% vs. 6%, P = 0.14). Patients hospitalized for PAD with a BB in their prescription did not worsen their outcome at 1 year compared to patients without BB. Based on these safety data, prospective study could be conducted to assess the effect of BB on long-term mortality and amputation rate in patients with mild, moderate, and severe PAD.

Increased Prevalence of Moderate and Severe Peripheral Arterial Disease in the American Indian (AI)/Alaskan Native (AN) Population; a Study of 96,000 AI/AN

Peripheral arterial disease (PAD) disproportionally affects racial groups in the United States. Few studies have analyzed the rates of PAD in the American Indian (AI)/Alaskan Native (AN) population. In this article, we compare the prevalence of PAD in the AI/AN as compared with white and nonwhite Americans. The study data were provided by Life Line Screening (Independence, OH). Thecohort consists of self-referred individuals who paid for vascular screening tests. Mild-to-moderate and severe PAD were defined as having an ankle-brachial index (ABI) inat least one extremity of<0.9 and<0.5, respectively. Univariate and multivariate analyses were performed to compare the rates of PAD between AI/AN, Caucasians, and nonwhites. The original sample for which this study was obtained included 3,444,272 people. Of this group there was a predominance of females 64.5% (2,221,555) compared with 35.5% (1,222,716) males. The Native American/AN population was 2.8% of the sample (96,440). In our univariate analysis AI/AN had the highest rates of mild-moderate and severe PAD when compared with whites (odds ratio [OR] 1.78 and 2.14, respectively) and nonwhites (OR 1.52 and 1.82, respectively). We then controlled for atherosclerotic risk factors in our multivariate analysis, and the AI/NA cohort had persistently higher rates of both moderate and severe PAD compared with whites (OR 1.32 and 1.40) but not compared with nonwhites (OR 0.95 and 0.92). Here we present the largest epidemiology study of PAD in AI/AN to date. AI/NA people have disproportionately high rates of both mild to-moderate and severe PAD when compared with whites and nonwhite Americans. After controlling for atherosclerotic risk factors the rates of PAD remain high for AI/NA when compared with whites but not when compared with nonwhites. While it is possible that a combination of diet and lifestyle choices are responsible for the high rates of PAD in this population, genetic factors may be involved as well, and deserve further investigation. Optimal medical management may help to prevent the complications of PAD in this patient population.

Abstract 292: Microparticle-encapsulated miRNAs Are Associated With Peripheral Artery Disease

miRNAs are short, noncoding RNAs that circulate in plasma within membrane-bound vesicles, such as microparticles (MPs), or bound to proteins or lipoproteins. Circulating miRNAs are putative biomarkers for a wide range of diseases, including cardiovascular disease. Our group and others have evidence to suggest MP-encapsulated miRNAs, rather than total plasma miRNAs, may harbor more specific and functionally relevant biomarkers. We tested the hypothesis that MP-encapsulated miRNA levels would differ between patients with mild or severe peripheral artery disease (PAD) and healthy controls matched for age, gender, and race. Banked plasma stored at -80°C was obtained for 5 healthy subjects, 6 patients with mild PAD (ABI 0.8-1.0), and 10 patients with severe PAD (ABI &lt; 0.4). MPs were isolated using a standard differential centrifugation protocol and quantified by flow cytometry. Four miRNAs implicated in vascular disease (miR-126-3p, miR-126-5p, miR-21, and miR-222) were quantified with qRT-PCR. Relative expression for each miRNA (-2ΔCt) was calculated and divided the total number of MPs to determine miRNA expression per MP. There was a non-significant trend towards increased levels of MPs in patients with mild (19,462 MPs/μl ± 5,213) and severe PAD (21,688 MPs/μl ± 7,175) compared to healthy controls (7244 MPs/μl ± 919). MP levels of miR-126-5p were increased among healthy subjects compared to patients with mild and severe PAD (p = 0.003), while MP miR-126-3p levels were significantly lower in healthy subjects (p = 0.002). miR-21 and miR-222 did not differ significantly between groups. None of the four miRNAs distinguished mild versus severe PAD. In conclusion, our data suggests that MP-mediated transport of miR-126-5p and miR-126-3p is dysregulated in the setting of mild and severe vascular disease, and supports the concept that the plasma MP fraction may harbor disease-associated miRNA profiles.