Treatment Of Peripheral Arterial Disease Research Articles

Association of Health Care Utilization and Access to Care With Vascular Assessment Before Major Lower Extremity Amputation Among US Veterans

Patient-level characteristics alone do not account for variation in care among US veterans with peripheral artery disease (PAD). Presently, the extent to which health care utilization and regional practice variation are associated with veterans receiving vascular assessment prior to major lower extremity amputation (LEA) is unknown. To assess whether demographics, comorbidities, distance to primary care, the number of ambulatory clinic visits (primary and medical specialty care), and geographic region are associated with receipt of vascular assessment prior to LEA. This national cohort study used US Department of Veterans Affairs' Corporate Data Warehouse data from March 1, 2010, to February 28, 2020, for veterans aged 18 or older who underwent major LEA and who received care at Veterans Affairs facilities. The number of ambulatory clinic visits (primary and medical specialty care) in the year prior to LEA, geographic region of residence, and distance to primary care. The main outcome was receipt of a vascular assessment (vascular imaging study or revascularization procedure) in the year prior to LEA. Among 19 396 veterans, the mean (SD) age was 66.78 (10.20) years and 98.5% were male. In the year prior to LEA, 8.0% had no primary care visits and 30.1% did not have a vascular assessment. Compared with veterans with 4 to 11 primary care clinic visits, those with fewer visits were less likely to receive vascular assessment in the year prior to LEA (1-3 visits: adjusted odds ratio [aOR], 0.90; 95% CI, 0.82-0.99). Compared with veterans who lived less than 13 miles from the closest primary care facility, those who lived 13 miles or more from the facility were less likely to receive vascular assessment (aOR, 0.88; 95% CI, 0.80-0.95). Veterans who resided in the Midwest were most likely to undergo vascular assessment in the year prior to LEA than were those living in other regions. In this cohort study, health care utilization, distance to primary care, and geographic region were associated with intensity of PAD treatment before LEA, suggesting that some veterans may be at greater risk of suboptimal PAD care practices. Development of clinical programs, such as remote patient monitoring and management, may represent potential opportunities to improve limb preservation rates and the overall quality of vascular care for veterans.

Extravascular Ultrasound (EVUS) to Assess the Results of Peripheral Endovascular Procedures

Contrast arteriography (CA) is considered the gold standard to evaluate any phase in peripheral arterial disease (PAD) interventions, from diagnostics to final results. Nevertheless, duplex ultrasonography (DUS) mostly used for the pre/postoperative phase and follow-up control, could be a potential intraoperative adjunctive imaging tool to assess the effects of endovascular revascularization in patients with iliac and femoropopliteal lesions. The PAD "duplex-assisted" protocol includes a preoperative DUS control followed by an intraoperative and a postoperative control. The most important parameters are pulsed doppler spectral analysis and waveform changes, which are impossible to detect with intravascular ultrasound (IVUS). By using a similar acronym, the intraoperative DUS has been previously described as extravascular ultrasound (EVUS). B-mode imaging, color flow, and peak systolic velocity (PSV) are considered. EVUS could be very useful to evaluate the effects of endovascular treatment, mainly in cases of unclear CAs, severe calcifications and/or dissections. In the context of the "leaving nothing behind" strategy, EVUS can drive the physician to evaluate the absence of flow-limiting dissections and decide which target lesion should be treated with antirestenotic therapy, further vessel preparation, or stenting. The EVUS protocol could be a safe and feasible option to improve the completion assessment of endovascular PAD treatment. A better ultrasound waveform is a sign of improved luminal gain and compliance, which is extremely important to finalize the results of new peripheral device technology, such as intravascular lithotripsy.

Basics of Guidewire Technology and Peripheral Artery Disease.

Guidewire technology has advanced significantly over the last several decades. As more components are incorporated providing valuable features, deciding which guidewire to use during peripheral artery disease (PAD) interventions has become more complex. The challenge for both the beginner and expert is not only understanding which components offer the best characteristics in a guidewire but choosing the optimal wire for an intervention. Manufacturers have attempted to optimize components to provide physicians with routinely available guidewires needed in everyday practice. Yet selecting the best guidewire for a particular situation during an intervention is still challenging. This article provides a basic overview of guidewire components and what benefits they offer during PAD interventions.

A clinico-radiological study of Peripheral Arterial Disease in patients with type 2 Diabetes Mellitus using ankle-brachial index and peripheral arterial doppler

Background: Peripheral Arterial Disease (PAD) is an important complication of Diabetes Mellitus (DM). PAD is a part of systemic illness caused by atherosclerosis, resulting in arterial narrowing. Hence PAD is a marker of atherosclerosis in other parts of the vascular system, especially in the arteries supplying the brain and heart. Over two - third of the patients with PAD are asymptomatic, resulting in inadequate treatment of their risk factors. There is a need to screen every DM patient for effective treatment of PAD and the risk factors. Ankle-brachial Index (ABI) is a useful test for the same. Objective: The objective of the study was to find out the incidence of PAD in DM and the factors affecting it. Materials and Methods: It was a hospital-based prospective observational study. In all, 200 diabetic patients from tertiary care hospital (outpatient and indoor) were screened for PAD using ABI, and those showing ABI < 0.9 were further confirmed using Duplex Ultrasonography (DUS). Smokers and patients with a previous history of lower limb surgery, vasculopathy, or trauma were excluded from the study. Factors affecting the incidence of PAD were also studied. Results: Overall incidence of PAD was 10% using ABI as a screening test, confirmed with DUS. Male gender, aging, obesity, duration of DM, poor control of DM, hypertension, coronary artery disease, cerebrovascular disease, hyperlipidemia, and presence of retinopathy were found to be adversely affecting risk factors for PAD. Conclusion: ABI is a bedside, simple, reliable, non-invasive, and cost-effective clinical test for diagnosing PAD, a marker of atherosclerosis in the body. There is a need to screen for PAD, even in asymptomatic patients, for its early detection and management of risk factors.

Tongxinluo promotes endothelium-dependent arteriogenesis to attenuate diabetic peripheral arterial disease.

Peripheral arterial disease (PAD) has become one of the leading causes of disa-bility and death in diabetic patients. Restoring blood supply to the hindlimbs, especially by promoting arteriogenesis, is currently the most effective strategy, in which endothelial cells play an important role. Tongxinluo (TXL) has been widely used for the treatment of cardio-cerebrovascular diseases and extended for diabetes-related vascular disease. To investigate the effect of TXL on diabetic PAD and its underlying mechanisms. An animal model of diabetic PAD was established by ligating the femoral artery of db/db mice. Laser Doppler imaging and micro-computed tomography (micro-CT) were performed to assess the recovery of blood flow and arteriogenesis. Endothelial cell function related to arteriogenesis and cellular pyroptosis was assessed using histopathology, Western blot analysis, enzyme-linked immuno-sorbent assay and real-time polymerase chain reaction assays. In vitro, human vascular endothelial cells (HUVECs) and human vascular smooth muscle cells (VSMCs) were pretreated with TXL for 4 h, followed by incubation in high glucose and hypoxia conditions to induce cell injury. Then, indicators of HUVEC pyroptosis and function, HUVEC-VSMC interactions and the migration of VSMCs were measured. Laser Doppler imaging and micro-CT showed that TXL restored blood flow to the hindlimbs and enhanced arteriogenesis. TXL also inhibited endothelial cell pyroptosis via the reactive oxygen species/nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3/Caspase-1/GSDMD signaling pathway. In addition, TXL restored endothelial cell functions, including maintaining the balance of vasodilation, acting as a barrier to reduce inflammation, and enhancing endothelial-smooth muscle cell interactions through the Jagged-1/Notch-1/ephrin-B2 signaling pathway. Similar results were observed in vitro. TXL has a pro-arteriogenic effect in the treatment of diabetic PAD, and the mechanism may be related to the inhibition of endothelial cell pyroptosis, restoration of endothelial cell function and promotion of endothelial cell-smooth muscle cell interactions.

Endovascular interventions for peripheral arterial disease in patients with pre-existing endovascular aortic repair utilizing mother-and-child sheath system.

Peripheral interventions for Peripheral arterial occlusive disease involving the lower extremity vessels have been a challenge in patients who have undergone prior Endovascular Aneurysm repair. To provide a solution to the above-mentioned challenge. Practical use of existing articulating sheath and catheter and wires to achieve the objective. Successful accomplishment of objective. Endovascular interventions for Peripheral arterial disease in patients with pre-existing Endovascular Aortic Repair utilizing mother-and-child sheath system have conferred success. This could be a useful technique in the armamentarium of the interventionist.

Abstract P626: Associations of Supervised and Home-Based Exercise With Serious Adverse Event Rates During Exercise Interventions for Peripheral Artery Disease: A Meta-Analysis of Five Randomized Clinical Trials

Background: Supervised or home-based walking exercise therapy (ET) are guideline recommended to improve walking performance in people with peripheral artery disease (PAD). This study compared serious adverse event (SAE) rates associated with home-based compared to supervised exercise in people randomized into clinical trials of ET for PAD. Methods: Data from five randomized clinical trials of ET for PAD were combined. In three trials (GOALS, HONOR, and LITE), participants were randomized to home-based ET or control. In two trials (PROPEL and TELEX), participants were randomized to supervised ET or control. The primary outcome in all trials was change in six-minute walk. SAEs consisted of hospitalization or death and were identified from participants, family members, and medical records. In post-hoc analyses, a meta-analysis compared associations of supervised ET and home-based ET on odds of a SAE or death. Control groups from the trials of supervised and home-based ET were not combined. Results: 867 unique participants were included (mean age + SD: 69 ±10 years, 47% female, 57 % Black, mean + SD ABI 0.66 ±0.15). Results are shown in the Table. Conclusion: In clinical trials of home-based ET, rates of coronary revascularizations and cardiovascular events were significantly higher in participants randomized to exercise, compared to control. However, there were no significant differences in rates of coronary revascularizations or cardiovascular events between participants randomized to home-based, compared to supervised ET. Improved walking performance from home-based exercise may precipitate symptoms from underlying coronary artery disease in people with PAD.

Implementation and Evaluation of a Comprehensive Simulation Curriculum for the IR/DR Integrated Residency

Endovascular simulation is a validated training method, allowing residents to improve technical skills with interventional equipment in a risk-free environment. The purpose of this study was to assess the utility and efficacy of supplementing the IR/DR Integrated Residency training program with a dedicated 2-year endovascular simulation curriculum. Trainees participated in a 2-year curriculum that included the completion of 8 modules using a high-fidelity endovascular simulator (Mentice AB, Gothenberg, Sweden). Procedural modules included IVC filter placement, transarterial chemoembolization, trauma embolization, uterine artery embolization, prostate artery embolization, and peripheral arterial disease interventions. Each quarter, two trainees were filmed while completing an assigned module. Sessions led by IR faculty were held with film footage review and didactics on the assigned topic. Pre- and postcase surveys were collected to evaluate trainee comfort and confidence and assess the validity of the simulation. At the conclusion of the 2-year period, a postcurriculum survey was sent to all trainees to determine how residents viewed the utility of the simulation sessions. Eight residents participated in the pre- and postcase surveys. The simulation curriculum significantly increased trainee confidence for these 8 residents. A separate postcurriculum survey was completed by all 16 IR/DR residents. All 16 residents felt that simulation was a helpful addition to their education. A total of 87.5% of all residents felt that the sessions improved their confidence in the IR procedure room. A total of 75% of all residents believe that the simulation curriculum should be incorporated into the IR residency program. Adoption of a 2-year simulation curriculum can be considered for existing IR/DR training programs with access to high-fidelity endovascular simulators using the described approach.

Association of Anticoagulation and Major Adverse Limb Events After Index Peripheral Endovascular Intervention

Dual-antiplatelet therapy is commonly prescribed after endovascular intervention for peripheral artery disease. However, it is not known whether therapeutic anticoagulation affects outcomes after peripheral endovascular intervention. We sought to investigate whether therapeutic anticoagulation after peripheral endovascular intervention is associated with lower risk of major adverse limb events (MALEs) and all-cause mortality. We studied patients who underwent index endovascular intervention for peripheral artery disease in the Vascular Study Group of New England (2010 to 2018). The main exposure was anticoagulation at the time of discharge. Outcomes included patency loss (occlusion or target lesion reintervention), MALE (any major amputation or reintervention), and all-cause mortality. We compared outcomes between patients who received anticoagulation on discharge versus those who did not receive anticoagulation using Kaplan-Meier survival analysis and Cox regression. In the cohort of 6,809 patients, 15% were discharged on an anticoagulant (mostly warfarin). These patients had a higher prevalence of acute or chronic limb ischemia than those not receiving an anticoagulant (74% vs 47%, p < 0.001) and were less likely to receive any antiplatelet agent after peripheral endovascular intervention (5% vs 14%, p < 0.001). After risk adjustment, compared with patients not on an anticoagulant, patients receiving therapeutic anticoagulation had a higher risk of 2-year patency loss (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.05 to 1.89), MALE (HR 1.39, 95% CI 1.09 to 1.76), and all-cause mortality (HR 1.24, 95% CI 1.05 to 1.47). In conclusion, anticoagulation after peripheral endovascular intervention was associated with higher risk of adverse events, including patency loss, MALE, and all-cause mortality.

Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labs

BackgroundA recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings. MethodsThe Vascular Quality Initiative database was queried for all elective infrainguinal PVIs for occlusive peripheral arterial disease between January 2016 and December 2021. The primary outcomes were rates of postprocedural hospital admissions, postprocedural medical complications, and access site complications. Secondary outcomes included technical success and intraprocedural details, such as types and number of devices used, amount of contrast, and fluoroscopy time. The χ2 test, analysis of variance, and multivariate logistic regression were used to analyze the outcomes. ResultsA total of 66,101 PVI cases (HOPD, 57,062 [83.33%]; ASC, 4591 [6.95%]; OBL, 4448 [6.73%]) were included in the study. There were 445 cases requiring hospital admission (HOPD, 398 [0.70%]; ASC, 26 [0.57%]; OBL, 21 [0.47%]; P = .126). There were no significant differences in cardiac, pulmonary, or renal complications. Access site complications occurred in less than 1.7% of all cases and were significantly higher in OBLs when compared with ASCs (adjusted odds ratio [aOR], 3.70; 95% confidence interval [CI], 1.70-8.03; P = .001) and significantly lower in ASCs in comparison to HOPDs (aOR, 0.27; 95% CI, 0.18-0.41; P < .001). Technical success occurred in at least 92% of all cases, regardless of setting. There was a 16-fold increase in the use of atherectomy devices in an OBL vs HOPD setting (aOR, 16.79; 95% CI, 11.77-23.95; P < .001) and a five-fold increase in the use of atherectomy devices in an ASC vs HOPD setting (aOR, 5.37; 95% CI, 2.47-11.65; P < .001). There was a five-fold decrease in the use of special balloons in an OBL vs HOPD setting (aOR, 0.20; 95% CI, 0.10-0.39; P < .001) and a four-fold decrease when comparing ASCs with HOPDs (aOR, 0.25; 95% CI, 0.12-0.51; P < .001). ConclusionsElective PVIs performed in any outpatient setting proved to be safe and technically successful. However, there are significant differences in the way PVIs are performed in each setting, such as the greater use of atherectomy devices in OBLs and greater use of special balloons in HOPDs. Long-term studies are needed to evaluate the durability and reintervention outcomes and understand factors associated with practice pattern variability across these different settings.

Novel Scaffolds for the Treatment of Below-the-Knee Peripheral Arterial Disease With Chronic Limb Threatening Ischemia: A Review

Below-the-knee (BTK) peripheral arterial disease (PAD) is a significant source of cardiovascular morbidity and mortality. Patients with chronic limb-threatening ischaemia in BTK PAD represent one of the highest-risk cohorts of PAD patients, with little progress having been made regarding long-term patency and mortality over the past four decades. Although conventional balloon angioplasty has long been the standard of care, several novel scaffolds have been introduced over the past decade with promising 1-year patency rates and freedom from clinically driven target limb revascularisation, which may herald a new age of endovascular intervention for BTK PAD. In this review, we present a critical appraisal of the literature surrounding novel scaffolds and drug-eluting technology in the treatment of BTK PAD.

The Relationship Between Peripheral Arterial Disease Severity and Socioeconomic Status

Although socioeconomic disparities in outcomes of peripheral arterial disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship. Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005 - 2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses. There were 765,175 patients identified; 34% in the 1st MHI quartile and 18% in the 4th MHI quartile. Compared to patients in the 1st quartile, those in the 4th quartile were more likely White (69% vs. 42%, P <0.001), more likely ≥65 years old (75% vs. 62%, P <0.001), and were less likely to undergo amputations (25% vs. 34%, P <0.001). After adjusting for patient characteristics, the 4th quartile was associated with more severe disease [Odds ratio: 1.19, 95% CI: 1.11 - 1.27] compared to the 1st quartile.. While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.

A biomechanical perspective on walking in patients with peripheral artery disease.

The most common symptom of peripheral artery disease (PAD) is intermittent claudication, which consists of debilitating leg pain during walking. In clinical settings, the presence of PAD is often noninvasively evaluated using the ankle-brachial index and imaging of the arterial supply. Furthermore, various questionnaires and functional tests are commonly used to measure the severity and negative effect of PAD on quality of life. However, these evaluations only provide information on vascular insufficiency and severity of the disease, but not regarding the complex mechanisms underlying walking impairments in patients with PAD. Biomechanical analyses using motion capture and ground reaction force measurements can provide insight into the underlying mechanisms to walking impairments in PAD. This review analyzes the application of biomechanics tools to identify gait impairments and their clinical implications on rehabilitation of patients with PAD. A total of 18 published journal articles focused on gait biomechanics in patients with PAD were studied. This narriative review shows that the gait of patients with PAD is impaired from the first steps that a patient takes and deteriorates further after the onset of claudication leg pain. These results point toward impaired muscle function across the ankle, knee, and hip joints during walking. Gait analysis helps understand the mechanisms operating in PAD and could also facilitate earlier diagnosis, better treatment, and slower progression of PAD.

Atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease patients: a narrative review.

Vascular calcification (VC) and resulting vascular disease is one of the major causes of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). CKD itself is increasingly recognized as a risk factor for cardiac and peripheral arterial disease (PAD). This paper examines the atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease (ESRD) patients. The literature was reviewed regarding the current status of medical and interventional management arteriosclerotic disease in patients with CKD. Lastly, three representative cases displaying typical endovascular treatment options are provided. A literature search was performed in PubMed covering publications up to September 2021 as well as discussion with experts in the field. The high prevalence of atherosclerotic lesions in patients with chronic renal failure and high (re-)stenosis cause problems in the medium and long term as vascular calcium load represents one of the most widely encountered predictors of failure of endovascular treatment of PAD and future cardiovascular events (e.g., coronary calcium score). Patients with CKD also suffer from a greater risk for major vascular adverse events in general and worse revascularization outcomes following peripheral vascular intervention. A correlation between calcium burden and drug-coated balloon (DCB) performance has been established for PAD necessitating the need for different tools to cope with vascular calcium such as endoprosthesis or braided stents. Patients with CKD are at a higher risk of developing contrast-induced nephropathy (CIN). In addition to recommendations such as the administration of intravenous fluids, carbon dioxide (CO2) angiography is one option to potentially provide an effective and safe alternative both to iodine-based contrast media allergy and to the use of iodine-based contrast media in patients with CKD. Management and endovascular procedures of patients with ESRD are complex. In the course of time, new endovascular therapy methods have been developed such as directional atherectomy (DA) and the so-called "pave-and-crack" technique to deal with high vascular calcium burden. Besides interventional therapy, vascular patients with CKD benefit from aggressive medical management.

The Characteristics of Dialysis Membranes: Benefits of the AN69 Membrane in Hemodialysis Patients.

Patients undergoing hemodialysis (HD) experience serious cardiovascular complications, through malnutrition, inflammation, and atherosclerosis. Amputation for peripheral arterial disease (PAD) is more prevalent in patients undergoing HD than in the general population. In addition, revascularization procedures in dialysis patients are often associated with subsequent amputation and high mortality rates. To improve the prognosis of dialysis patients, malnutrition and inflammation must be properly treated, which necessitates a better understanding of the characteristics of dialysis membranes. Herein, the characteristics of several dialysis membranes were studied, with a special reference to the AN69 membrane, noting several similarities to low-density lipoprotein (LDL)-apheresis, which is also applicable for the treatment of PAD. Both systems (LDL-apheresis and AN69) have anti-inflammatory and anti-thrombogenic effects because they use a negatively charged surface for extracorporeal adsorptive filtration from the blood/plasma, and contact phase activation. The concomitant use of both these therapeutic systems may have additive therapeutic benefits in HD patients. Here, we reviewed the characteristics of dialysis membranes and benefits of the AN69 membrane in dialysis patients.

Variations in Practice Patterns for Peripheral Vascular Interventions Across Clinical Settings

Peripheral vascular interventions (PVI) for lower extremity peripheral artery disease (PAD) have been increasing, particularly in the office-based setting. Our goal was to evaluate practice patterns for PVI by site of service using a contemporary real world dataset. The Vascular Quality Initiative PVI registry was queried from 2010-2021. Site of service was classified as hospital/inpatient, hospital/outpatient, and ambulatory/office based center. Patient demographics, comorbidities, procedural details, and peri-procedural outcomes were analyzed. There were 54,897 hospital/inpatient (43.2%), 64,105 hospital/outpatient (50.4%), and 8179 ambulatory/office based center (6.4%) PVI. When comparing the two outpatient settings, ambulatory/office based center patients were older than hospital/outpatient (mean age 70.7 vs. 68.7 years), more often female sex (41.4% vs 39.1%), never smokers (27.5% vs. 18.5%), primary Medicare (61.6% vs. 55.9%), non-ambulatory (6.5% vs. 4.7%), and less often with coronary artery disease (30.2% vs. 34.1%), chronic obstructive pulmonary disease (18.1% vs. 26.9%), congestive heart failure (13% vs 17.2%), and obesity (30.9% vs. 33.6%), and less often on a statin (71.4% vs. 76.1%), (P<.001). Ambulatory/office based center procedures were more likely for claudication (60.1% vs. 55.8%), more often involved femoro-popliteal (73.1%) vs. 64.6%) and infrapopliteal (36.7% vs. 24.3%), and less often iliac interventions (24.1% vs. 33.6%) (P<.001).Overall, atherectomy was used in 14.2% of hospital/inpatient, 19.4% of hospital/outpatient, and 63.4% of ambulatory/office based center procedures. Stents were used in 41.8% of hospital/inpatient, 45.1% of hospital/outpatient, and 48.8% of ambulatory/office based center procedures. However, stent grafts were used 12.5% of hospital/inpatient, 8.8% of hospital/outpatient, and only 1.3% of ambulatory/office based center procedures. On multivariable analysis, compared with hospital/inpatient, atherectomy use was associated with ambulatory/office based center setting (OR 10.9, 95% CI 10.3 - 11.5, P<.001) and hospital/outpatient setting (OR 1.57, 95% CI 1.51 - 1.62, P<.001). Peri-procedure complications including hematoma requiring intervention (0.3%), any stenosis/occlusion (0.2%), and distal embolization (0.6%) were quite low across all settings. There are substantial variations in both patient populations, procedural indications, and types of interventions undertaken during PVI across different locations. Ambulatory/office-based procedures more commonly treat claudicants, use atherectomy, and less often use stent grafts. Further research is warranted to investigate long-term trends in practice patterns, as well as long-term outcomes, for PVI in the ever-expanding ambulatory/office-based setting.

Examining Care Fragmentation After PAD Interventions: The Readmission Event

Lower extremity revascularization (LER) for peripheral artery disease (PAD) is complicated by the frequent need for readmission either at the same facility or a different one than where the index LER was performed. Prior work using Vascular Quality Initiative data linked to Medicare claims has demonstrated that readmission rates after LER are 18% and 31% at 30 days and 90 days, respectively. It is unclear, however, if readmission at a nonindex LER facility compared with the index LER facility is associated with worse outcomes.

Combined Effect of Dynapenia and Abdominal Obesity on the Prevalence of Peripheral Artery Disease in Older Adults Over 75 Years Old in China.

The objective is to examine the separate and joint effects of dynapenia and abdominal obesity on the prevalence of peripheral artery disease (PAD) in older adults of different ages (60-74 and over 75 years old). This study comprised 1293 community-dwelling Chinese participants recruited from Shanghai, China, who were aged at least 60 years (753 women; mean age: 72.0 ± 5.9 years). Dynapenia was defined as low-grip strength (<28.0 kg for males and <18.0 kg for females) but normal skeletal muscle index (≥7.0 kg/m2 for males and ≥5.7 kg/m2 for females). Abdominal obesity was determined according to waist circumference (≥90 cm for males and ≥85 cm for females), and PAD was diagnosed by an ankle-brachial index ≤ 0.9. Binary logistic regression models were performed to determine associations between dynapenia, abdominal obesity, and the combination of dynapenia and abdominal obesity and PAD. According to dynapenia and abdominal obesity status stratified by age (60-74 or over 75), the patients were divided into 4 groups: normal, dynapenia alone, abdominal obesity alone, and co-occurring groups. A logistic regression showed that the co-occurring groups (odds ratio = 4.63, 95% confidence interval = 1.41-15.21) had a higher prevalence of PAD than the normal group after adjusting for the covariates in older adults over 75 years of age. The combination of dynapenia and abdominal obesity increase the prevalence of PAD in older adults over 75 years. The present findings have important implications for the early identification of older adults with PAD and appropriate interventions should be implemented.

A review of the current state in neointimal hyperplasia development following endovascular intervention and minor emphasis on new horizons in immunotherapy.

Endovascular strategies play a vital role in the treatment of peripheral arterial disease (PAD). However, luminal loss or restenosis after endovascular intervention remains a significant challenge. The main underlying mechanisms are negative vascular remodeling and elastic recoil in balloon angioplasty. During stenting, the main reason for this complex is neointimal proliferation. Endothelial cell injury due to endovascular intervention initiates a series of molecular events, such as overexpression of growth factors, cytokine secretion, and adhesion molecules. These induce platelet activation and inflammatory processes, which trigger the proliferation and migration of vascular smooth muscle cells into the intima, resulting in neointimal hyperplasia. During this process, PAD progression is mainly caused by chronic inflammation, in which macrophages play a central role. Of the current strategies, drug release interventions aim to suppress restenosis using antiproliferative drugs, such as sirolimus and paclitaxel, during drug release. These drugs inhibit vascular reendothelialization and reduce late in-stent restenosis. For this reason, immunotherapy can be considered an important alternative. Interventions that polarize macrophages to the M2 subtype are particularly important, as they shape the immune response in an anti-inflammatory direction and contribute to tissue repair. However, there are several challenges to overcome, such as localizing antiproliferative or polarizing agents only to areas of vascular injury. This review discusses, based on the early study observations, immunotherapeutic approaches to prevent restenosis after endovascular intervention for the treatment of PAD.

The effects of renal impairment on the mid-term clinical outcomes following endovascular intervention for peripheral arterial disease

Peripheral arterial disease (PAD) shares common risk factors with coronary artery disease. Presence of renal impairment might affect the clinical outcomes of PAD patients, possibly due to vascular calcification. Treating calcified peripheral vessels is difficult and rate of re-narrowing and the need for re-intervention is generally higher compared to normal renal function patients.