Peripheral Artery Stenosis Research Articles

Ultrasound-based prevalence of polyvascular disease and its association with adverse outcome in patients undergoing coronary artery bypass grafting.

Objective: Polyvascular disease (polyVD) often coexists with coronary artery disease (CAD). We aim to investigate the prevalence of polyVD using the method of ultrasound and find its association with adverse outcomes in coronary artery bypass grafting (CABG) patients. Methods: This retrospective and cross-sectional study included 1344 patients with a mean age of 61.4 years. Presence of peripheral artery atherosclerotic plaque and stenosis was assessed using the method of ultrasound. Receiver operating characteristic (ROC) analysis and multivariate logistic regression analysis were performed to investigate the association of polyVD with in-hospital all-cause death. Results: 52.1% of the patients had polyVD and among which 31.9% had one additional arterial bed involvement and 20.2% had two or three additional arterial beds involvement. Patients with two or three involved arterial beds had worse baseline characteristics. In-hospital all-cause death rate increased with the number of involved arterial beds (1.1% in patients with only CAD vs 3.7% in patients with two or three involved arterial beds), and this trend was more prominent in elderly patients. Multivariate logistic regression analysis confirmed that polyVD patients with two or three involved arterial beds had about three times the risk for all-cause death. Conclusions: Prevalence of polyVD assessed by ultrasound was high in CABG patients and it was significantly associated with in-hospital all-cause death. Our study may provide additive information for preoperative risk stratification in CABG patients.

APOC1 rs445925 and rs4420638 polymorphic variants as genetic predictors of occlusive peripheral arterial disease of lower extremities

Aim. To study the involvement of APOC1 rs445925 and rs4420638 single nucleotide polymorphisms (SNP) in the development of occlusive peripheral arterial disease (PAD) of lower extremities.Material and methods. The study included 1278 people, including 630 patients with occlusive PAD and 648 relatively healthy individuals. Genotyping of APOC1 rs445925 and rs4420638 SNPs was performed using the MassARRAY-4 genomic mass spectrometer. The analysis of the association of alleles, genotypes, haplotypes and diplotypes with the risk of occlusive PAD was performed using the statistical programs SNPStats, PLINK, v1.9 and STATISTICA 13.3. The adaptive permutation test was used to assess statistical significance of associations (Pperm).Results. The rs445925-A (Pperm=1,0×10-6) and rs4420638-G (Pperm=0,006) alleles, as well as the rs445925-G/A-A/A (Pperm=1,0×10-6) and rs4420638-A/G-G/G (Pperm=0,006) genotypes were associated with an increased risk of occlusive PAD. The rs445925 polymorphism was also associated with the blood cholesterol level in patients with occlusive PAD (Pperm=0,04). The rs445925A-rs4420638A and rs445925A-rs4420638G haplotypes, as well as three APOC1 diplotypes, showed a pronounced relationship with a predisposition to occlusive PAD. In particular, the rs445925G/A×rs4420638A/A (odds ratio (OR) 6,59, 95% confidence interval (CI) 4,20-10,35, P=2,4×10-19) and rs445925G/A×rs4420638A/G (OR 4,24, 95% CI 2,23-8,03, P=2,0×10-6) diplotypes were associated with an increased risk of occlusive PAD. The rs445925G/G×rs4420638A/A diplotype had a protective effect on the disease development (OR 0,26, 95% CI 0,20-0,35, P=1,3×10-20). Associations of haplotypes with the severity of peripheral arterial stenosis of various locations were also revealed (P<0,05).Conclusion. The study results established for the first time that APOC1 rs445925 and rs4420638 polymorphic variants are part of a genetic predisposition to occlusive PAD and have a significant effect on the severity of peripheral arterial stenosis. The molecular mechanisms underlying the identified genotypic associations can affect not only lipid metabolism disorders, but also the proliferation of immunocompetent cells, platelet activation and aggregation processes, inflammation and apoptosis.

Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses

Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses

Lipoprotein(a) and cardiovascular disease: sifting the evidence to guide future research.

Lipoprotein(a) (Lp(a)) is a genetically determined causal risk factor for cardiovascular disease including coronary heart disease, peripheral arterial disease, ischaemic stroke, and calcific aortic valve stenosis. Clinical trials of specific and potent Lp(a)-lowering drugs are currently underway. However, in clinical practice, widespread assessment of Lp(a) is still lacking despite several guideline recommendations to measure Lp(a) at least once in a lifetime in all adults to identify those at high or very high risk due to elevated levels. The present review provides an overview of key findings from observational and genetic Lp(a) studies, highlights the main challenges in observational Lp(a) studies, and proposes a minimum set of requirements to enhance the quality and harmonize the collection of Lp(a)-related data. Adherence to the recommendations set forth in the present manuscript is intended to enhance the quality of future observational Lp(a) studies, to better define thresholds for increased risk, and to better inform clinical trial design. The recommendations can also potentially assist in the interpretation and generalization of clinical trial findings, to improve care of patients with elevated Lp(a) and optimize treatment and prevention of cardiovascular disease.

Clinical Practice Recommendations for Antithrombotic Management of Peripheral Artery Disease: An Indian Perspective

Abstract Currently, there are no guidelines or consensus recommendations on the antithrombotic management of peripheral artery disease (PAD) from an Indian perspective. In this article, we have summarized clinical practice recommendations on antithrombotic management of (i) asymptomatic chronic PAD (cPAD), (ii) symptomatic cPAD (intermittent claudication [IC] and chronic limb-threatening ischemia [CLTI]), and (iii) after revascularization (endovascular and surgical). An electronic search of the PubMed database was undertaken to identify relevant articles. Various combinations of keywords such as PAD, chronic peripheral arterial disease, asymptomatic chronic peripheral arterial disease, symptomatic chronic peripheral arterial disease, dual antiplatelet therapy, single antiplatelet therapy, dual pathway inhibition, antithrombotic, revascularization, endovascular, and surgical were used. Randomized controlled trials, case reports, practice guidelines, systematic literature reviews, and meta-analyses were screened and assessed. A roundtable meeting of experts (n = 13) was conducted to arrive at clinical practice recommendations. Experts made their decisions based on the evidence and guideline recommendations. In patients with asymptomatic cPAD and significant peripheral artery stenosis (PAS), long-term single antiplatelet therapy may be considered at the discretion of the clinician. There is no clear evidence in favor of long-term dual antiplatelet therapy in symptomatic cPAD. Experts agreed that low-dose rivaroxaban plus aspirin should be considered in patients with asymptomatic cPAD with >50% PAS and conditions such as diabetes and polyvascular disease. This combination was also suggested in patients with IC, CLTI, postendovascular (stent based/nonstent), and surgical revascularization to reduce cardiovascular and limb ischemic risk, including major amputation in the absence of high bleeding risk or other contraindications.

Adult-onset idiopathic peripheral pulmonary artery stenosis.

Peripheral pulmonary artery stenosis (PPS) refers to stenosis of the pulmonary artery from the trunk to the peripheral arteries. Although paediatric PPS is well described, the clinical characteristics of adult-onset idiopathic PPS have not been established. Our objectives in this study were to characterise the disease profile of adult-onset PPS. We collected data in Japanese centres. This cohort included patients who underwent pulmonary angiography (PAG) and excluded patients with chronic thromboembolic pulmonary hypertension or Takayasu arteritis. Patient backgrounds, right heart catheterisation (RHC) findings, imaging findings and treatment profiles were collected. 44 patients (median (interquartile range) age 39 (29-57) years; 29 females (65.9%)) with PPS were enrolled from 20 centres. In PAG, stenosis of segmental and peripheral pulmonary arteries was observed in 41 (93.2%) and 36 patients (81.8%), respectively. 35 patients (79.5%) received medications approved for pulmonary arterial hypertension (PAH) and 22 patients (50.0%) received combination therapy. 25 patients (56.8%) underwent transcatheter pulmonary angioplasty. RHC data showed improvements in both mean pulmonary arterial pressure (44 versus 40 mmHg; p<0.001) and pulmonary vascular resistance (760 versus 514 dyn·s·cm-5; p<0.001) from baseline to final follow-up. The 3-, 5- and 10-year survival rates of patients with PPS were 97.5% (95% CI 83.5-99.6%), 89.0% (95% CI 68.9-96.4%) and 67.0% (95% CI 41.4-83.3%), respectively. In this study, patients with adult-onset idiopathic PPS presented with segmental and peripheral pulmonary artery stenosis. Although patients had severe pulmonary hypertension at baseline, they showed a favourable treatment response to PAH drugs combined with transcatheter pulmonary angioplasty.

Novel Peripheral Perfusion Dynamics Indices for Detecting and Grading Arterial Stenosis.

Peripheral artery disease causes severe morbidity, especially in diabetics and the elderly. There is a need for accurate noninvasive detection of peripheral arterial stenosis. The study has tested the hypothesis that arterial stenosis and the associated adaptation of the downstream circulation yield characteristic changes in the leg perfusion dynamics that enable early diagnosis, utilizing impedance plethysmography. The arterial perfusion dynamic was derived from impedance plethysmography (IPG). Two degrees of arterial stenosis were emulated by inflating a blood-pressure cuff around the thigh to 45 and 90mmHg, in healthy volunteers (n = 30). IPG signals were acquired continuously throughout the experiment. Ankle and brachial blood pressures were measured at the beginning of each experiment and at the end of each emulated stenosis phase. Thigh compressions did not affect the pulse-transit time, but prolonged the time to the peak perfusion wave. Segmentation of the perfusion upstroke into two phases, at the time point of maximum acceleration (MAT), revealed that arterial compression prolonged only the initial slow phase duration (SPd). The MAT and SPd were proportional to the emulated stenosis severity and detected the arterial stenosis with high sensitivity (>93%) and specificity (100%). The SPd increased from 46.4 ± 21.2ms at baseline to 75.4 ± 38.5ms and 145 ± 39ms under 45mmHg and 90mmHg compressions (p < 0.001), without affecting the pulse-transit time. The novel method and indices can identify and grade the emulated arterial stenosis with high accuracy and may assist in differentiating between focal arterial stenosis and widespread arterial hardening.

Characteristics in patients with adult-onset idiopathic peripheral pulmonary artery stenosis

Abstract Background Peripheral pulmonary artery stenosis (PPS) refers to the obstruction of the pulmonary artery from the pulmonary artery trunk to the peripheral arteries. Although pediatric PPS is well described, the clinical characteristics of adult-onset idiopathic PPS have not been established. Purpose To establish the disease profile of adult-onset PPS, we characterized the clinical background, laboratory and imaging findings, treatment, and prognosis. Methods The nationwide survey in Japan, supported by the government, retrospectively collected clinical data on patients with idiopathic PPS from multiple centers. This cohort comprised individuals aged 15 years and above who had pulmonary arterial stenosis confirmed through pulmonary angiography, indeed patients with chronic thromboembolic pulmonary hypertension or Takayasu arteritis were excluded. Patient backgrounds, imaging findings, treatment profiles, right heart catheterization findings, and long-term prognosis were collected. A comparison was made between the data obtained from prior-treatment and post-treatment right heart catheterization. Results Forty-five patients (median age at diagnosis: 38 years [Q1–Q3:28–56]; 29 males [64.4%]) with idiopathic PPS were enrolled from 21 centers. The median period between diagnosis of PPS and the final follow-up was 60 months [Q1–Q3: 24–114 months]. Eight patients (17.8%) were associated with moyamoya disease. Pulmonary angiography was performed in all patients for a definite diagnosis, and stenosis of segmental and peripheral pulmonary arteries was observed in 41 (91.1%) and 36 patients (80.0%), respectively. Thirty-six patients (80.0%) received treatment with pulmonary arterial hypertension (PAH)-specific drugs, 23 patients (51.1%) received combination therapy, and 25 patients (55.6%) received transcatheter pulmonary angioplasty. Right heart catheterization data showed improvements in both the mean pulmonary artery pressure (46 vs. 41 mmHg; p&amp;lt;0.001) and pulmonary vascular resistance (738 vs. 506 dyn.s.cm-5; p&amp;lt;0.001) from baseline to the final follow-up. The 3-, 5-, and 10-year survival rates of patients with idiopathic PPS were 97.6% (95% confidence interval [CI]:83.9–99.7), 89.7% [95% CI:69.9–96.6), and 68.6% (95% CI:43.9–84.2), respectively. Conclusion In this study, the patients with adult-onset idiopathic PPS presented with segmental and peripheral pulmonary artery stenosis. Although patients had severe pulmonary hypertension at baseline, they showed a favorable treatment response to the PAH-specific drugs combined with transcatheter pulmonary angioplasty.

TCT-432 Imaging-Based Evaluation and Differentiation of Vessel Preparation Technologies in a Porcine Model of Peripheral Artery Stenosis

TCT-432 Imaging-Based Evaluation and Differentiation of Vessel Preparation Technologies in a Porcine Model of Peripheral Artery Stenosis

Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses

Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (Pd/Pa) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting Pd/Pa was not influenced by the degree of stenosis (p= .074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p= .019). An FFR of <0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75- 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 - 0.89), eABPI (0.72;0.57 - 0.83), and PSVR (0.65; 0.51 - 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p< .001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13±0.09; p= .009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 - 1.00). This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation.

Transplantation of endothelial progenitor cells overexpressing mir-126-3p improves vascular repair in a diabetic rat model.

Transplantation of endothelial progenitor cells overexpressing mir-126-3p improves vascular repair in a diabetic rat model.

Towards noninvasive early detection and classification of peripheral arterial disease stenosis severity by perfusion dynamics and artificial intelligence

Abstract Introduction Recent guidelines suggest Ankle-Brachial Index (ABI) measurement for assessing and reducing cardiovascular risk. PAD patients suffer from generalized arterial stiffening (arteriosclerosis) and develop threatening arterial stenosis foci. ABI cannot differentiate between the two, and detecting focal stenosis is especially challenging in the elderly and diabetics suffering from severe arteriosclerosis. Thus, better diagnostic tools are required for early detection of severe arterial stenosis in order to improve patient management reduce atherosclerotic cardiovascular risk and amputation rates. Purpose We hypothesized that quantifying the peripheral perfusion dynamics would provide more sensitive indices for monitoring atherosclerotic disease severity. Thus, we compared the utility of ABI, impedance-plethysmography (IPG), and photoplethysmography (PPG) in detecting and classifying arterial-stenosis using machine learning and artificial intelligence. Methods Arterial stenosis was emulated in supine lying healthy consenting volunteers (n=31) by inflating a blood-pressure cuff around their thigh to 45 and 90 mmHg for six minutes. We quantified the perfusion dynamics by IPG and PPG signal analyses in the time-frequency domain. The induced stenosis levels were classified by artificial intelligence using novel indices. Results Hallux O2-saturation remained intact (96±3%, p=0.4) even during 90 mmHg thigh-cuff compression. The baseline ABI (1.19±0.01) remained unchanged during 45 mmHg compression, slightly declined (1.12±0.02) upon 90 mmHg compression; but, all ABI values were above the 0.9 threshold. The pulse transit time, a well-established index of arteriosclerosis, remained unchanged. Conversely, upon stenosis emulation (compression), the IPG immediately recorded a significant proportional phase delay between the compressed and contralateral legs and a significant proportional correlation decline. At baseline, the IPG phase-difference between legs over the 2–4 Hz band was 1.79±0.48° and grew to 29.5±2.4° and 71.2±1.8° upon 45 and 90 mmHg compression (p&amp;lt;0.001). The IPG inter leg correlation at the 4–6 Hz band declined from 0.962±0.005 at baseline to 0.857±0.012 and 0.676±0.015 during 45 and 90 mmHg compression (p&amp;lt;0.001). The PPG phase difference grew significantly and proportionally upon compression (p&amp;lt;0.001, n=28) but without a significant correlation decline. A neural-network classifier achieved 100% accuracy in classifying baseline and each compression level based on the IPG phase and correlation. The best classifier achieved only 81.25% accuracy, 83.33% sensitivity, and 90% Specificity based on the PPG. Conclusion Our perfusion-dynamic indices outperformed the ABI, and the IPG outperformed the PPG in detecting and classifying emulated stenosis. Differentiation between arteriosclerosis and arterial stenosis may be of immense clinical merit. Therefore, this simple, noninvasive method merits clinical evaluation. Funding Acknowledgement Type of funding sources: None.

Development, characterisation, and modelling of processability of nitinol stents using laser powder bed fusion

Additive manufacturing (AM) of customised vascular or peripheral stents is of great potential for surgeons and patients, enabling the patients to have customised stents and achieving better outcomes from stenting procedures, with further advantages of having a resource efficient manufacturing process. In this study, the potential for AM of superelastic NiTi-based shape memory alloy (Nitinol) stents was investigated. Two stent designs, which are used for the treatment of complex peripheral artery stenosis in the lower limbs, were studied. Laser Powder Bed Fusion (LPBF) of two stent designs was studied to investigate the impact of the process parameters on the stent geometry, strut size, structural integrity and the phase transformations. The study demonstrated the successful manufacture of Nitinol stents via LPBF, with strut sizes in the range between 250 µm and ≈ 560 µm. The elastic modulus of the stents was between 56 and 73 GPa, which matches well with the elastic modulus of standard austenitic Nitinol. Chemical etching was used to reduce the strut diameter and to remove the partially melted particles. It was shown that the laser energy input has a vital role in controlling the Ni-evaporation and the subsequent changes in the transformation temperatures, as well as the morphology of the stents. The lower energy input results in a reduced Ni-evaporation, maintaining the austenite finish temperature at the expected range, in addition to generating a good build morphology.

Design and Verification of a Novel Perfusion Bioreactor to Evaluate the Performance of a Self-Expanding Stent for Peripheral Artery Applications.

Endovascular stenting presents a promising approach to treat peripheral artery stenosis. However, a significant proportion of patients require secondary interventions due to complications such as in-stent restenosis and late stent thrombosis. Clinical failure of stents is not only attributed to patient factors but also on endothelial cell (EC) injury response, stent deployment techniques, and stent design. Three-dimensional in vitro bioreactor systems provide a valuable testbed for endovascular device assessment in a controlled environment replicating hemodynamic flow conditions found in vivo. To date, very few studies have verified the design of bioreactors based on applied flow conditions and their impact on wall shear stress, which plays a key role in the development of vascular pathologies. In this study, we develop a computationally informed bioreactor capable of capturing responses of human umbilical vein endothelial cells seeded on silicone tubes subjected to hemodynamic flow conditions and deployment of a self-expanding nitinol stents. Verification of bioreactor design through computational fluid dynamics analysis confirmed the application of pulsatile flow with minimum oscillations. EC responses based on morphology, nitric oxide (NO) release, metabolic activity, and cell count on day 1 and day 4 verified the presence of hemodynamic flow conditions. For the first time, it is also demonstrated that the designed bioreactor is capable of capturing EC responses to stent deployment beyond a 24-hour period with this testbed. A temporal investigation of EC responses to stent implantation from day 1 to day 4 showed significantly lower metabolic activity, EC proliferation, no significant changes to NO levels and EC's aligning locally to edges of stent struts, and random orientation in between the struts. These EC responses were indicative of stent-induced disturbances to local hemodynamics and sustained EC injury response contributing to neointimal growth and development of in-stent restenosis. This study presents a novel computationally informed 3D in vitro testbed to evaluate stent performance in presence of hemodynamic flow conditions found in native peripheral arteries and could help to bridge the gap between the current capabilities of 2D in vitro cell culture models and expensive pre-clinical in vivo models.

Role of circulating polyunsaturated fatty acids on cardiovascular diseases risk: analysis using Mendelian randomization and fatty acid genetic association data from over 114,000 UK Biobank participants

BackgroundDespite early interest in the health effects of polyunsaturated fatty acids (PUFA), there is still substantial controversy and uncertainty on the evidence linking PUFA to cardiovascular diseases (CVDs). We investigated the effect of plasma concentration of omega-3 PUFA (i.e. docosahexaenoic acid (DHA) and total omega-3 PUFA) and omega-6 PUFA (i.e. linoleic acid and total omega-6 PUFA) on the risk of CVDs using Mendelian randomization.MethodsWe conducted the largest genome-wide association study (GWAS) of circulating PUFA to date including a sample of 114,999 individuals and incorporated these data in a two-sample Mendelian randomization framework to investigate the involvement of circulating PUFA on a wide range of CVDs in up to 1,153,768 individuals of European ancestry (i.e. coronary artery disease, ischemic stroke, haemorrhagic stroke, heart failure, atrial fibrillation, peripheral arterial disease, aortic aneurysm, venous thromboembolism and aortic valve stenosis).ResultsGWAS identified between 46 and 64 SNPs for the four PUFA traits, explaining 4.8–7.9% of circulating PUFA variance and with mean F statistics >100. Higher genetically predicted DHA (and total omega-3 fatty acids) concentration was related to higher risk of some cardiovascular endpoints; however, these findings did not pass our criteria for multiple testing correction and were attenuated when accounting for LDL-cholesterol through multivariable Mendelian randomization or excluding SNPs in the vicinity of the FADS locus. Estimates for the relation between higher genetically predicted linoleic acid (and total omega-6) concentration were inconsistent across different cardiovascular endpoints and Mendelian randomization methods. There was weak evidence of higher genetically predicted linoleic acid being related to lower risk of ischemic stroke and peripheral artery disease when accounting by LDL-cholesterol.ConclusionsWe have conducted the largest GWAS of circulating PUFA to date and the most comprehensive Mendelian randomization analyses. Overall, our Mendelian randomization findings do not support a protective role of circulating PUFA concentration on the risk of CVDs. However, horizontal pleiotropy via lipoprotein-related traits could be a key source of bias in our analyses.

Predictors of Peripheral Artery Disease Progression. Is there Any Role for Vascular Age?

Predictors of Peripheral Artery Disease Progression. Is there Any Role for Vascular Age?

High prevalence of middle cerebral artery calcification is associated with cardiovascular mortality in hemodialyzed patients: an overlooked part of arterial tree?

We have analyzed markers of accelerated atherosclerosis like large artery stiffness, ankle-brachial index, carotid and vertebral duplex ultrasonography and their possible associations with the incidence of intracranial calcifications, clinical course of hemodialyzed patients, and cardiovascular mortality. A computed tomographic scan of the head was performed for any neurological indication on 100 hemodialyzed patients. Eleven intracranial arteries were analyzed for calcification score, while internal carotid arteries and vertebral arteries were excluded in cerebral artery calcification score. As a control group for assessing intracranial calcifications, we have analyzed computed tomographic scans from diabetic patients who had an acute stroke. Deceased patients had significantly higher values of augmentation index and pulse wave velocity, lower ankle-brachial index, and higher internal carotid arteries peak systolic value than survived patients. Deceased patients had significantly higher number of calcified middle cerebral arteries as well as significantly higher intracranial artery calcification score and cerebral artery calcification score. Hemodialyzed patients had significantly higher both intracranial and cerebral artery calcification scores than diabetic control group. Age and calcified middle cerebral arteries had increased HR of 1.08 and 1.36 for cardiovascular mortality. This study showed that large artery stiffness and not the presence of peripheral arterial disease or carotid artery stenosis have the prognostic role of middle cerebral arteries' calcifications and cardiovascular mortality in hemodialyzed patients. The presence of middle cerebral arteries' calcifications diagnosed by a non-invasive method should be considered a marker of middle-sized conduit arteries atherosclerosis, subclinical brain damage, and future fatal cardiovascular events.

C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension

Abstract Background Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality. Case Description A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered. Discussion Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.

C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension

Abstract Background Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality. Case Description A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered. Discussion Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.

Arterial Preparation by Longitudinal Micro-Incisions Before Balloon Angioplasty of the Superficial Femoral and Popliteal Artery: Acute and 12-Month Results

Purpose: Percutaneous transluminal angioplasty (PTA) with conventional plain old balloon (POBA) and/or drug-coated balloon (DCB) is the primary intervention to treat peripheral artery stenoses. However, acute dissections during the procedure and potential for future target lesion revascularization remain procedural complications. The purpose of this study was to assess the acute and 12-month outcomes in patients who underwent novel vessel preparation with longitudinal, controlled-depth micro-incisions prior to PTA. Materials and Methods: Patients with symptomatic lower extremity peripheral arterial disease with a Rutherford class of 2 to 6 and >70% de novo stenosis of the superficial femoral or popliteal arteries were included in this retrospective study. Patients with thrombotic or embolic lesions, restenosis, or in-stent restenosis were excluded. The FLEX Vessel Prep System (FLEX VP) was used to prepare the vessel prior to PTA by creating micro-incisions at the target lesion. The FLEX VP was followed by POBA or paclitaxel DCB. Results: The study included 65 patients. Lesion characteristics were 90% median stenosis (range = 70%–100%), 75.4% mild-to-severe calcifications, and 33.8% occlusion rate, and median lesion length was 196 (range = 10–480) mm. Following vessel preparation, 82.1% of the patients had low severity dissection or no flow-limiting dissection. The provisional stent rate postprocedure was 16.9%, with a median stent length of 60 mm. The freedom from target lesion revascularization (FFTLR) in 63 evaluable patients at 6 and 12 months was 98.4% and 93.7%, respectively. Freedom from amputation was 100%. Conclusion: In this real-world/all-comers patient population with long, stenotic lesions across the calcification spectrum, vessel preparation with longitudinal micro-incisions prior to PTA was associated with low dissection rate, low dissection severity, low stent implantation, and high FFTLR with the absence of amputation at 12 months relative to published reports in long-lesion cohorts. These results support vessel preparation via micro-incisions.