Presence Of Peripheral Vascular Disease Research Articles

1431. Comparison of Treatment Outcomes with Definitive Antibiotic Therapy and Empiric Antibiotic Therapy in Osteomyelitis

BackgroundDefinitive therapy for osteomyelitis (OM) is thought to be superior to empiric antimicrobial therapy; however, identifying causative pathogens is difficult.MethodsThis retrospective cohort study included patients treated with either definitive or empiric antimicrobial therapy for OM at VA St. Louis HCS between 1 January 2010 and 1 January 2018. Definitive antibiotic therapy was defined as a regimen tailored to susceptibilities of an organism(s) cultured from bone or deep tissue. The primary outcome was treatment failure, defined as a need for unplanned surgical intervention or re-initiation of antibiotic therapy for OM of the same anatomical site within 6-months after initial therapy was discontinued. Secondary outcomes included the incidence of acute kidney injury (AKI), Clostridium difficile-associated diarrhea (CDAD), and thrombocytopenia. Surgical intervention as part of initial therapy, presence of peripheral vascular disease (PVD), creatinine clearance < 50 mL/minute at initiation of therapy, receiving antibiotics at an extended care facility, age > 60 years, and receiving definitive antibiotics were included in a univariate analysis with variables with a P < 0.2 included in a multivariate logistic regression.ResultsThere were 301 patients included; 179 in the definitive therapy group and 122 in the empiric therapy group. Baseline characteristics were similar among groups; however, more patients receiving definitive therapy had a bone biopsy compared with those treated with empiric therapy (58.1% (104/179) vs. 36.8% (45/122); P < 0.05). 33 percent (60/179) of patient treated with definitive therapy failed compared with 45% (55/122) treated with empiric therapy (P = 0.109). No significant differences were observed in secondary outcomes; however non-CDAD diarrhea occurred more in the empiric therapy group than definitive therapy group (3.9% (7/179) vs. 8.2% (10/122); P > 0.05). Receiving definitive therapy (OR 1.43, CI 0.89–2.313; P = 0.138) and presence of PVD (OR 1.34; CI 0.823–2.197; P = 0.238) were included in the multivariate logistic regression, but neither were independently associated with failure.ConclusionDefinitive antibiotic therapy was not associated with a significant decrease in treatment failure.Disclosures All authors: No reported disclosures.

Computed Tomography-Determined Muscle Quality Rather Than Muscle Quantity Is a Better Determinant of Prolonged Hospital Length of Stay in Patients Undergoing Transcatheter Aortic Valve Implantation

Computed tomography (CT)-determined skeletal muscle measures have been used for predicting postoperative outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). We investigated the impact of CT-determined muscle quantity (measured as psoas muscle area [PMA] and psoas muscle index [PMI]) and quality (measured as psoas muscle density [PMD]) on hospital length of stay (LOS) after TAVI. We retrospectively identified 182 consecutive patients who underwent TAVI between March 2013 and August 2017 with adequate preprocedural CT imaging. Baseline demographic and clinical data, the Society of Thoracic Surgeons score, the essential frailty toolset (EFT) frailty rating, and precontrast PMD, PMA, and PMI were obtained in all study patients. The primary outcome was prolonged postoperative LOS defined as greater than 14 days. Patients with prolonged LOS had a significantly higher Society of Thoracic Surgeons score (p < 0.001) and significantly lower PMD (p < 0.001) than those with LOS ≤14 days. More patients with prolonged LOS had concomitant peripheral vascular disease (p = 0.001), had undergone percutaneous coronary interventions (p = 0.022), and had an EFT score ≥4 (p < 0.001) compared to those without prolonged LOS. Neither PMA (p = 0.123) nor PMI (p = 0.271) were associated with prolonged LOS. Multivariate analysis identified EFT score ≥4, the presence of peripheral vascular disease, and PMD as independent predictors of prolonged LOS. The precontrast CT-determined muscle quality measurement PMD is a simple and objective predictor of prolonged LOS after TAVI.

Factors Associated with Health-Related Quality of Life among Jordanian Patients with Diabetic Foot Ulcer.

Objective This study is aimed at determining factors associated with the quality of life among Jordanian diabetic patients with foot ulcers. Methods 144 consecutive patients with diabetic foot ulcers aged ≥ 18 years who were attending the diabetic foot clinic at a diabetes-specialized center were included in this study. Health-related quality of life was assessed using two self-administered questionnaires: Diabetic Foot Scale-Short Form (DFS-SF) and Short Form-8 (SF-8). Results Patients with diabetic foot ulcer had low mean DFS-SF score and low mean scores on physical and mental component summary scales (PCS8 and MCS8). Males had significantly higher DFS-SF score indicating better health-related quality of life than females (P value 0.038). A patient with stressful life events had significantly lower health-related quality of life using DFS-SF scale and SF-8 summary scales. Patients with peripheral vascular disease (PVD) and patients with obesity had lower DFS-SF and PCS8 quality of life. Conclusion Patients with diabetic foot ulcer had low quality of life. Female gender, obesity, presence of PVD, and stressful life events were the most important factors associated with lower quality of life in patients with diabetic foot ulcer.

Self-Care Peritoneal Dialysis Patients with Cognitive Impairment Have a Higher Risk of Peritonitis in the Second Year.

Cognitive impairment is common among patients on peritoneal dialysis (PD). We hypothesize that cognitive impairment has a negative impact on the outcome of patients on PD, especially with regard to peritonitis. This was a single-center 2-year prospective cohort study involving 206 patients at 1 PD unit. Cognitive impairment was defined by the latest Hong Kong Montreal Cognitive Assessment Score (HK-MoCA) multiple cut-offs as determined by age and years of education. Eighty percent of patients had come back for interval HK-MoCA. The HK-MoCA was performed at baseline and after 1 year on PD. Potential risk factors for cognitive impairment and peritonitis were studied separately for the first and second year. For cognitive impairment at baseline, multivariate analyses showed that age (odds ratio [OR] 1.003, 95% confidence interval [CI] 1.003 - 1.065, p = 0.03), female sex (OR 3.57, 95% CI 1.60 - 7.97, p = 0.002), peripheral vascular disease (PVD) (OR 3.46, 95% CI 1.33 - 9.01, p = 0.01), and hemoglobin level (OR 0.60, 95% CI 0.43 - 0.84, p = 0.003) were statistically significant factors. For cognitive impairment at 1 year, multivariate analyses showed that age (OR 1.07, 95% CI 1.02 - 1.012, p = 0.007), female sex (OR 5.87, 95% CI 1.86 - 18.5, p = 0.003), and PVD (OR 3.68, 95% CI 1.07 - 12.84, p = 0.04) were statistically significant independent factors for cognitive impairment at 1 year.For self-care PD patients in the second year, patients with cognitive impairment had a higher rate of peritonitis and proportionately more patients suffered from both peritonitis and exit-site infection than non-cognitively impaired patients in the second year (0.50 vs 0.27 episodes per year, p = 0.048; 25% vs 7.2%, p = 0.049). Logistic regression showed that only HK-MoCA-defined cognitive impairment and HK-MoCA scores at 1 year were factors predicting peritonitis (risk ratio [RR] 3.2 [95% CI 1.03 - 9.95], p = 0.04 and RR 0.92 [95% CI 0.86 - 0.995], p = 0.04 respectively). In summary, increasing age, female sex, anemia, and presence of PVD are risk factors for cognitive impairment in PD patients. Self-care PD with cognitive impairment at 1 year has a higher risk for PD-related peritonitis in the second year. Interval HK-MoCA assessment is recommended to detect cognitive impairment in our local PD patients.

Outcomes of Wound Healing and Limb Loss After Transmetatarsal Amputation in the Presence of Peripheral Vascular Disease

Transmetatarsal amputation (TMA) is the procedure of choice in treating forefoot gangrene and infection. Foot and ankle and vascular surgeons work closely together in limb salvage, but little is known about the timing of vascular intervention to achieve a healed amputation site. This study retrospectively looked at 153 patients with peripheral vascular disease who underwent TMA with a minimum of a 3-year follow-up. A total of 102 patients received vascular intervention: 79 endovascular and 23 open bypass. The primary focus of this study was to look at the timing of vascular intervention, incidence of wound healing, and incidence of limb loss. There was an overall 44% rate of limb loss. Patients who underwent open bypass did better than those who underwent endovascular intervention with a lower incidence of limb loss (87% compared with 51%), and quicker time to wound healing. The timing of vascular intervention, performed either before or after TMA, had no association with wound healing or limb loss. Similarly, the time interval between vascular intervention and TMA had no association with wound healing or limb loss. Comorbidities, including end-stage renal disease on hemodialysis, hyperlipidemia, and congestive heart failure, showed a significant association with TMA stump nonhealing and limb loss. Body mass index ≥30, end-stage renal disease on hemodialysis, and hyperlipidemia were all risk factors for limb loss.

Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience.

Contrasting results of recent randomized controlled trials (RCTs) comparing off-pump and on-pump coronary artery bypass graft (CABG) surgery, as well as the lack of evidence for any survival benefit of bilateral internal thoracic artery (ITA) grafting over single ITA use, has intensified the debate about the role of the off-pump technique and bilateral ITA use in CABG surgery. We therefore investigated our 15-year experience in off-pump CABG with bilateral ITA grafting and evaluated temporal trends in preoperative characteristics and postoperative outcomes. Demographic, intra-operative, and outcome data of 1,199 consecutive patients undergoing off-pump CABG with bilateral ITA grafting was prospectively collected in a computerized database. Patients who underwent on-pump cardiac procedures and other extra-cardiac procedures were excluded from this study. Assessment of changes in perioperative characteristics and parameters with time was performed by dividing the whole cohort into three groups (2003-2007, 2008-2012, and 2013-2017) based on the year of surgery. The overall 30-day mortality was 0.6%, with no differences observed between the three time cohorts (0.6%, 0.7%, 0.5%; P=0.8). The perioperative stroke rate for whole cohort was 0.6% and demonstrated a significant reduction in the last two time cohorts (1%, 0.5%, 0.5%; P<0.0001). The overall incidence of deep sternal wound infections was 0.7%, but was marginally higher in the last time-cohort (0.6%, 0.5%, 0.9%; P=0.7). Overall survival for the entire cohort was 92.9%±1% and 78.9%±4% at 5 and 10 years follow-up, respectively. Older age at surgery and presence of peripheral vascular disease were the only predictors of late mortality. Off-pump CABG with bilateral skeletonized ITAs is a safe operation and is associated with a low mortality and morbidity, which can be maintained in high volume center unit over a long period of time. The long-term survival of patients undergoing such an operation is excellent.

Through-knee amputation is a feasible alternative to above-knee amputation

ObjectiveThrough-knee amputation (TKA) is a rare amputation performed in <2% of all major lower extremity amputations in the United States. Despite biomechanical benefits and improved rehabilitation compared with above-knee amputation (AKA), TKA has largely been abandoned by vascular surgeons because of concerns for poor wound healing. The purpose of this study was to evaluate surgical outcomes of TKA. MethodsThe American College of Surgeons National Surgical Quality Improvement Program between 2005 and 2012 was queried using Current Procedural Terminology codes indicating AKA and TKA. Baseline characteristics were reviewed, and logistic regression analysis was performed to identify predictors of 30-day mortality. Propensity score matching was used to balance comorbidities between AKA and TKA. Operative variables and postoperative complications were compared between the groups. ResultsA total of 7469 AKA and 251 TKA patients were identified among 15,932 major lower extremity amputations. Baseline characteristics were examined. White race, chronic obstructive pulmonary disease, dyspnea, emergent operation, steroid use, myocardial infarction, congestive heart failure, high American Society of Anesthesiologists score, old age, preoperative sepsis or septic shock, and dialysis dependency were associated with increased 30-day mortality. Independent lifestyle and smoking (within 1 year) were protective against early death. Baseline comorbidities were not statistically significant after 1:1 propensity score matching. Operative outcomes were similar in both groups (AKA vs TKA). Wound infection (7.2% vs 11.2%; P = .16), dehiscence rate (1.2% vs 0.8%; P = 1.0), and 30-day mortality (9.6% vs 11.2%; P = .66) were comparable. Other outcome parameters, including cardiopulmonary and genitourinary complications, were similar except for a higher likelihood of return to the operating room in the TKA group (27.9% vs 12.4%; P < .01). Postoperative mortality was not associated with TKA (P = .77) or reoperation (P = .42), but it was associated with the patients' physiologic conditions (dyspnea, sepsis, emergent operation, high American Society of Anesthesiologists score, and dependent lifestyle). Predictors of reoperation were contaminated wound (hazard ratio [HR], 2.19; confidence interval [CI], 1.17-3.23; P = .015), sepsis or septic shock (HR, 2.63; CI, 1.37-5.05; P = .004), chronic obstructive pulmonary disease (HR, 2.81; CI, 1.23-6.42; P = .014), and wound infection (HR, 4.91; CI, 2.06-11.70; P < .001). Presence of peripheral vascular disease was not associated with post-TKA reoperation (P = .073). ConclusionsTKA demonstrated similar postoperative morbidity and mortality compared with AKA. Wound infection and risk of dehiscence were equivalent. TKA did demonstrate a higher rate of reoperation; however, neither TKA nor reoperation predicted postoperative mortality. Patients in stable physiologic condition without active infection can safely undergo elective TKA to maximize rehabilitation potential.

IMPACT OF PERIPHERAL VASCULAR DISEASE AND RACE ON OUTCOMES IN PATIENTS WITH CARDIAC ARREST

Peripheral Vascular Disease(PVD) is an independent predictor of elevated risk of myocardial infarction, stroke and death. However, no prior studies have looked into the impact of PVD on outcomes of patients with cardiac arrest. The aim of this study was to assess that if presence of PVD was an

Factors associated to adherence to blood glucose self-monitoring in patients with diabetes treated with insulin. The dapa study

ObjectiveTo assess adherence to self-monitoring of blood glucose and the main factors associated with it, particularly those related to self-perception of glycemia, in patients with diabetes on insulin therapy. Patients and methodsAn epidemiological, observational, prospective, multicenter study conducted in standard clinical practice in primary care, outpatient centers, and hospitals from different Spanish regions. Sociodemographic, clinical and treatment data were collected. Patients were considered adherent to self-monitoring if they performed the minimum number of controls recommended by the Spanish Society of Diabetes (SED). ResultsAdherence was shown in 61.6% of patients. Factors associated to adherence included treatment with less than three insulin injections daily (OR 2.678; 95% CI 2.048–3.5029; p<0.001), presence of peripheral vascular disease (OR 1.529; 95% CI 1.077–2.171; p=0.018), alcohol abstinence (OR 1.442; 95% CI 1.118–1.858; p=0.005), and collection of the glucose test strips from the pharmacy (OR 1.275; 95% CI 1.026–1.584; p=0.028). Adequate self-perception of glycemia was found in 21.4% of patients. ConclusionsOur results show a suboptimal adherence to the recommended protocol for blood glucose self-monitoring in patients with diabetes on insulin therapy. Independent variables associated to good adherence were treatment with less than three insulin injections daily, presence of peripheral vascular disease, alcohol abstinence, and collection of glucose test strips from the pharmacy.

Factores asociados a la adherencia al autoanálisis de la glucemia capilar en personas con diabetes en tratamiento con insulina. Estudio dapa

ObjectiveTo assess adherence to self-monitoring of blood glucose and the main factors associated with it, particularly those related to self-perception of glycemia, in patients with diabetes on insulin therapy. Patients and methodsAn epidemiological, observational, prospective, multicenter study conducted in standard clinical practice in primary care, outpatient centers, and hospitals from different Spanish regions. Sociodemographic, clinical and treatment data were collected. Patients were considered adherent to self-monitoring if they performed the minimum number of controls recommended by the Spanish Society of Diabetes (SED). ResultsAdherence was shown in 61.6% of patients. Factors associated to adherence included treatment with less than three insulin injections daily (OR 2.678; 95% CI 2.048– 3.5029; p <0.001), presence of peripheral vascular disease (OR 1.529; 95% CI 1.077 – 2.171; p=0.018), alcohol abstinence (OR 1.442; 95% CI 1.118 – 1.858; p=0.005), and collection of the glucose test strips from the pharmacy (OR 1.275; 95% CI 1.026 – 1.584; p=0.028). Adequate self-perception of glycemia was found in 21.4% of patients. ConclusionsOur results show a suboptimal adherence to the recommended protocol for blood glucose self-monitoring in patients with diabetes on insulin therapy. Independent variables associated to good adherence were treatment with less than three insulin injections dailyu, presence of peripheral vascular disease, alcohol abstinence, and collection of glucose test strips from the pharmacy.

Effect of systemic insulin treatment on diabetic wound healing.

This study investigates if different diabetic treatment regimens affect diabetic foot ulcer healing. From January 2013 to December 2014, 107 diabetic foot ulcers in 85 patients were followed until wound healing, amputation or development of a nonhealing ulcer at the last follow-up visit. Demographic data, diabetic treatment regimens, presence of peripheral vascular disease, wound characteristics, and outcome were collected. Nonhealing wound was defined as major or minor amputation or those who did not have complete healing until the last observation. Median age was 60.0 years (range: 31.1-90.1 years) and 58 cases (68.2%) were males. Twenty-four cases reached a complete healing (healing rate: 22.4%). The median follow-up period in subjects with classified as having chronic wounds was 6.0 months (range: 0.7-21.8 months). Insulin treatment was a part of diabetes management in 52 (61.2%) cases. Insulin therapy significantly increased the wound healing rate (30.3% [20/66 ulcers] vs. 9.8% [4/41 ulcers]) (p = 0.013). In multivariate random-effect logistic regression model, adjusting for age, gender, smoking status, type of diabetes, hypertension, chronic kidney disease, peripheral arterial disease, oral hypoglycemic use, wound infection, involved side, presence of Charcot's deformity, gangrene, osteomyelitis on x-ray, and serum hemoglobin A1C levels, insulin treatment was associated with a higher chance of complete healing (beta ± SE: 15.2 ± 6.1, p = 0.013). Systemic insulin treatment can improve wound healing in diabetic ulcers after adjusting for multiple confounding covariates.

Can vascular pathology in cerebral and coronary fields predict peripheral artery disease in a cohort of diabetic patients?

Objective: To find out whether peripheral artery disease followed the same pattern, set of risk factors and indicators as macro vascular disease in the coronary arteries and cerebral arteries disease. Study design: This was a randomized cross sectional retrospective analysis. Place and duration: Study was carried out at The Diabetes Management Center at The Services Hospital Lahore, during June 1999 to June 2001. Patients and methods: A total of 580 patients were selected from the diabetic data base that had absent pulsations in the any of the four arteries of the lower limbs. Another set of 580 diabetics with presence of pulsations in all the arteries of the lower and upper limbs was randomly selected to match the cases. Results: Diabetics with peripheral vascular disease had a significant positive history of past CVA and past MI. Conclusion: Presence of peripheral vascular disease is significantly associated with presence of history of past CVA and past MI, raised systolic BP, diastolic BP, and mean BP and increased proteinurea.

Immediate post-procedure bridging with unfractioned heparin versus low molecular weight heparin in patients undergoing radiofrequency ablation for atrial fibrillation with an interrupted oral anticoagulation strategy

Many centers perform catheter ablation for atrial fibrillation (AF) with periprocedural interruption of oral vitamin K antagonists. In this scenario, the optimal post-procedural anticoagulation strategy is still under debate. We sought to compare the incidence of major complications associated with post-procedural use of low molecular weight heparin (LMWH) versus unfractioned heparin (UFH) as a bridge to reinitiation of oral anticoagulation after an AF ablation procedure. We retrospectively reviewed medical history data of all patients undergoing catheter ablation for AF at three Spanish referral centers between January 2009 and January 2014. A total of 702 patients were included in the analysis. We compared the incidence of major complications (a combination of major bleeding and thromboembolic events) between patients receiving UFH (291) and those receiving LMWH (411) after the procedure. The overall incidence of major complications was 4.1%, including five thromboembolic events (0.7%) and 24 major bleeding events (3.4%), with no significant differences in patients treated with LMWH vs. UFH (2.9 vs. 4.1%; P = NS). The presence of peripheral vascular disease emerged as the only independent predictor of major complications (adjusted odds ratio (OR) 9.1; confidence interval (CI) 95% 1.7-49.3; P < 0.01). Immediate post-procedural bridging with UFH or with LMWH are equally safe strategies in patients undergoing catheter ablation for AF in whom oral anticoagulation is interrupted for the procedure. Due to its greater simplicity of use, LMWH may be the preferred option. The presence of peripheral vascular disease is a potent predictor of major post-procedural complications.

Comparison of colour Doppler ultrasound and ankle-brachial pressure index measurements in peripheral vascular disease in type 2 diabetic patients with foot infection

Background: Peripheral vascular disease is diagnosed by definitive history of intermittent claudication or if one or more of peripheral pulses are absent in one or both lower limbs. Diagnostic testing for peripheral vascular disease must be accurate, inexpensive, widely accessible, easy to perform and preferably non-invasive. A variety of non-invasive techniques are available to detect the presence of peripheral vascular disease as well as to localize areas of stenosis, assess severity of disease and follow patients for disease progression or response to therapy. In this study we compare the specificity and sensitivity of ankle brachial pressure index with colour Doppler ultrasound for diagnosis of peripheral vascular disease in type 2 diabetes. Methods: This prospective study was carried out in the department of General surgery, GMCH, Udaipur, Rajasthan, India, from September 2014 to February 2016 after taking the permission from institutional ethical committee. A total of 50 patients were selected. The selected patients were evaluated by detailed clinical history, physical examination, local examination, ankle brachial pressure index (ABPI), colour doppler study and other relevant investigations. The ABPI ratio was calculated in every patient and an ABPI less than 0.9 in either foot was defined to have PVD. Colour duplex ultrasound was done in all selected patients. Imaging of peripheral arteries of the lower limbs was done using high resolution colour duplex ultrasound. PVD was diagnosed if the stenosis in the artery was greater than 50% or presence of occlusion. Results: Total 50 patients having type 2 diabetes mellitus with foot infection were included and most of the patients were between 40-60 years of age (68%) with males preponderance. In our study 12 (24%) patients had normal ABPI of 1.0 to 1.29 and 22 (44%) patients were in the range of mild to moderate PVD with ABPI between 0.41 to 0.90. Colour doppler was used as a standard diagnostic test for PVD & out of 50 patients, 36 (72%) showed involvement of arteries and among them both anterior and posterior tibial arteries were involved in 12 (24%) patients. In our study colour doppler ultrasound was used as standard diagnostic method for PVD. The sensitivity, specificity, positive predictive value and negative predictive value of ABPI against colour duplex ultrasound were calculated. Conclusions: In our study it’s concluded that ABPI is a good initial screening tool for peripheral vascular disease, but some patients with significant stenosis or in whom collaterals have developed in lower extremity would be missed, if ABPI measurement alone is used for diagnosis of peripheral vascular disease.

Preoperative evaluation of basal free triiodothyronine in patients undergoing coronary artery bypass grafting surgery. Does it help?

noBackground &amp; Objectives: The postoperative Low T3 syndrome has been considered as a possible source of reduced myocardial contractility, resulting in increased mortality after CABG. Effect of preoperative Low T3 has not been well studied in patients undergoing CABG surgery. Aim of our study is to evaluate effect of preoperative Low T3 syndrome in patients undergoing CABG surgery.Materials &amp; Methods: Six hundred and six patients undergoing CABG were included in this prospective study. The impact of the base-line FT3 concentration and of preoperative low T3 syndrome on the risk of postoperative low cardiac output and hospital death was analyzed.Results: Fifteen patients (2.3%) postoperatively and 159 (26.2%) developed major complications. At univariate analysis a reduced EF, the presence of peripheral vascular disease, the NYHA class, the surgical urgency, the aortic cross-clamp time, the CPB time and the FT3 concentration at admission were significantly associated with low CO and higher mortality. At multivariate analysis, the CPB time, an emergency procedure, a reduced LVEF, and the fT3 concentration were independently related to the development of low CO. However, in multivariate analysis low EF, and the fT3 concentration were the only predictors of hospital death.Conclusion: We conclude that preoperative low EF and low T3 syndrome independently causes low cardiac output and higher mortality in patients undergoing CABG. Therefore, all patients undergoing CABG should be evaluated for low T3 syndrome and patients with low T3 syndrome should be considered at increased risk. Appropriate preoperative T3 replacement therapy could decrease the postoperative complications in patients undergoing CABG.JCMS Nepal. 2015; 11(2):1-7

The role of molecular imaging in the evaluation of myocardial and peripheral angiogenesis.

Angiogenesis, or the formation of new microvasculature, is a physiological process that may occur in the setting of chronic tissue ischemia and can play an important role in improving tissue perfusion and blood flow following myocardial infarction or in the presence of peripheral vascular disease (PVD). Molecular imaging of angiogenesis within the cardiovascular system is a developing field of study. Targeted imaging of angiogenesis has the potential for non-invasive assessment of the underlying molecular signaling events associated with the angiogenic process and, when applied in conjunction with physiological perfusion imaging, may be utilized to predict and evaluate clinical outcomes in the setting of ischemic heart disease or PVD. This review discusses the developing radiotracer-based imaging techniques and technology currently in use that possess potential for clinical translation, with specific focus on PET and SPECT imaging of myocardial and peripheral angiogenesis.

Effect of Peripheral Vascular Disease on Mortality in Cardiac Transplant Recipients (from the United Network of Organ Sharing Database)

Peripheral vascular disease (PVD) portends increased morbidity and mortality in patients with heart failure. In those with advanced heart failure, heart transplantation (HT) is the only causative therapy to increase survival. However, little is known about the impact of symptomatic PVD on survival of HT recipients in large multicenter cohorts. The aim of this study was to investigate an association between recipient symptomatic PVD and survival after HT. We analyzed 20,297 patients from the United Network of Organ Sharing data set. Survival analysis using a control cohort established by propensity matching was performed. There was an increased prevalence of traditional cardiovascular risk factors in 711 patients with symptomatic PVD compared with 19,586 patients without PVD. Patients with pretransplant symptomatic PVD had increased post-transplant mortality compared with those without PVD (1-, 5- and 10-year survival rate 91.5% vs 94.9%, 74.8% vs 82.6%, 48.6% vs 54.7%, respectively, log-rank p<0.001). On multivariate analysis based on the propensity matching, factors associated with a lower survival rate were presence of PVD (hazard ratio 1.20, 95% confidential interval 1.02 to 1.42, p=0.030), and female gender (hazard ratio 1.22, 95% confidence interval 1.02 to 1.47, p=0.034). In conclusion, patients with symptomatic PVD have a lower survival rate after HT. Symptomatic PVD should be considered an independent risk factor for poor prognosis in patients undergoing HT evaluation.

The Influence of Comorbidity On Graft and Patient Survival After Kidney Transplantation.

Background Nowadays patients with a large variety of comorbidities are referred for transplantation. Acceptance criteria for kidney transplantation are continuously being eased. We questioned to what extent increasing severity and number of comorbidities interfere with graft and patient survival. Methods In our center, 1728 patients were transplanted between January 1, 2000 and December 31, 2012. Four pre-transplant comorbidity categories were defined: cardiovascular disease, peripheral vascular disease, cerebrovascular accident, and diabetes mellitus. A total comorbidity score was computed adding one point for each comorbidity category. Kaplan Meier analysis and various multivariable Cox proportional hazards analyses corrected for variables with a known significant influence were performed. Original disease was divided into diabetes mellitus and other. Results 309 graft failures and 202 deaths were noted. Total comorbidity point scores were 0 (n=1057), 1 (n=459), 2 (n=157) and 3 (3 or 4 points, n=44) with 11 missing values. Kaplan Meier analysis showed 5-year patient survival of 0, 1, 2, and 3 scores of 93%, 84%, 80%, and 68% respectively (p<0.001). The difference between the comorbidity scores was not significant for graft survival (p=0.97). Table 1 shows all survival percentages 5 and 10 years after transplantation.Table: No Caption available.In Cox analysis graft failure censored for death was significantly influenced by peripheral vascular disease (p=0.005) and by the known variables, e.g. donor type. The total comorbidity score was not significant. Patient death was significantly influenced by cardiovascular disease (p<0.001) and the total comorbidity score (p<0.001). There was no interaction between donor type and comorbidity in these analyses. Conclusion Graft survival is influenced by the presence of peripheral vascular disease, but not by the presence of other comorbidities analyzed. Patient survival on the other hand is influenced by the presence of comorbidities, but patient survival after transplantation in the population with comorbidity is very good. This means that even patients with comorbidities should be enabled to be selected for transplantation.

Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm

Repair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort. Of 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n = 93), hybrid (n = 11), or TEVAR (n = 33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n = 53) or fusiform (n = 30) aneurysms or dissection (n = 15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n = 30), arch (n = 40), descending (n = 24), or abdominal (n = 9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias. Early mortality was seen in nine patients (7%). Morbidity included stroke (n = 9), paraplegia (n = 1), and need for dialysis (n = 5) or tracheostomy (n = 10). A composite outcome of death and stroke was independently predicted by advancing age (P= .055) and performance of a hybrid procedure (P= .012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P< .05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P=.018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P= .017) and anendovascular or hybrid procedure (P= .001) independently predicted late aortic rupture or need for reintervention. Isolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches.

Predictors of high‐risk angiographic findings in patients with non‐ST‐segment elevation acute coronary syndrome

Current risk assessment of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) may fail to identify some patients with severe coronary artery disease (CAD). We aimed to identify predictors of the angiographic extent and severity of CAD in patients with NSTE-ACS undergoing early angiography and to evaluate its impact on prognosis. We evaluated 923 patients with NSTE-ACS who underwent coronary angiography. High-risk coronary anatomy (HRCA) was defined as left main disease > 50%, proximal LAD lesion > 70%, or 2- to 3-vessel disease involving the LAD. Clinical characteristics, in-hospital, and 30-day outcome and 1-year mortality were compared between the high-risk (N = 370) and the low-risk groups (N = 553). Proportion of patients with elevated cardiac biomarkers was similar in both groups. The presence of peripheral vascular disease (OR = 1.88, 95% confidence interval [CI] = 1.62-5.80, P < 0.001) and a GRACE score of >140 (OR = 1.88, 95% CI = 1.29-2.75, P < 0.001) were the strongest predictors of HRCA. Patients with HRCA were prone to more complications during hospitalization and at 30 days (11.9% vs. 6%, P < 0.01) and increased 1-year mortality (6.7% vs. 0.9%, P < 0.001). HRCA was the strongest predictor for 30-day MACCE (OR = 2.32, 95% CI = 1.42-3.79, P < 0.001). HRCA (OR = 8.36, 95% CI = 1.01-69.4, P = 0.049; OR = 3.64, 95% CI = 1.2-11.07, P = 0.02) and GRACE score of >140 (OR = 6.86, 95% CI = 1.68-27.9, P = 0.007; OR = 4.84, 95% CI = 1.74-13.5, P = 0.002) were significant predictors of 30-day and 1-year mortality, respectively. HRCA is predicted by clinical parameters and was not associated with elevated cardiac biomarkers. These patients fared worse when compared with those with low-risk anatomy. We suggest that HRCA predictors should be included in the risk stratification of patients with NSTE-ACS.