Symptomatic Peripheral Vascular Disease Research Articles

O012 Elevated sGP130 characterises dysregulated chronic inflammation in diabetic peripheral vascular disease

Abstract Introduction Chronic systemic inflammation is integral to the pathophysiology of cardiovascular disease and diabetes mellitus. Interleukin 6 (IL-6) is a cytokine which may stimulate either pro- or anti-inflammatory activity depending cell population. Classical IL-6 signalling only occurs in cells expressing membrane-bound IL-6 receptor, and results in anti-inflammatory JAK/STAT3 pathway activation. Trans-signalling, by contrast, involves soluble IL-6 receptor α and soluble glycoprotein 130 (sGP130), and therefore may affect any cell regardless of membrane receptor expression. We designed a study to characterise Interleukin-6 (IL-6) trans-signalling in a diabetic cohort receiving treatment for symptomatic peripheral vascular disease and identify whether IL-6 signalling is correlated to outcomes in this patient group. Methods A single-centre, prospective cohort study of patients with DM undergoing infra-inguinal revascularization was conducted. Pre-operative serum was obtained from patients, who were then followed and observed for major amputation, death, and need for re-intervention as primary outcomes. Quantitative serum assays for IL-6, sIL-6rα, and sGP130 were performed. Results 40 patients (20 controls) were included in the study. Diabetic peripheral vascular disease patients had significantly higher serum IL-6 (p=0.0038), as well as higher serum sGP130 (p=0.0119) at baseline. Significant correlation was found between serum IL-6 and C-reactive Protein (p= 0.02), and serum IL-6 and sGP130 (p=0.02) in the disease group, but not in controls. sGP130 was higher in patients who reached primary outcomes (p=0.0196). Conclusion Systemic IL-6 trans-signalling is dysregulated in diabetic peripheral vascular disease and may be a future therapeutic target or adjunct to surgical management. Elevated sGP130 may be a prognostically-relevant biomarker in this population.

(567) Symptomatic Peripheral Vascular Disease Increases Long Term Mortality after Heart Transplantation

(567) Symptomatic Peripheral Vascular Disease Increases Long Term Mortality after Heart Transplantation

Comparison of Percutaneous Peripheral Intervention Performed in a Dedicated Hybrid Operating Theatre vs. Cardiac Catheterization Laboratory

Objective: Percutaneous Peripheral Intervention (PPI) has emerged as the treatment-of-choice for patients with symptomatic peripheral vascular occlusive disease. The procedure may be performed in a variety of clinical settings including a standard operating theatre, interventional radiology suite, hybrid operating theatre (hybrid room), or cardiac catheterization laboratory (cath lab). The purpose of this retrospective clinical study was to test the hypothesis that PPI could be performed safely by vascular surgery specialists in a cath lab at a reduced cost as compared to a hybrid theatre. Methods: Consecutive PPI procedures performed by three dedicated vascular surgeons were retrospectively analyzed. The choice of venue was primarily related to facility availability although patients with high medical risk were preferentially treated in the hybrid suite. Demographic characteristics, peri-procedural outcomes and cost were tabulated and compared. Results: A total of 146 PPI procedures performed either in the hybrid room (n=97) or the cath lab (n=49) was reviewed. Patient indications and comorbidities including coronary artery disease, hypertension, dialysis-dependence, critical limb ischemia, in-patient status, diagnostic vs. therapeutic procedure, operative time and anatomic level of intervention were similar for the two groups. Patients undergoing PPI in the hybrid room had a higher incidence of prior peripheral revascularization (46% vs. 29%; p=0.049), were more likely to require general anesthesia (18% vs. 0%, p<0.05), were more likely to require open femoral access (9.3% vs. 0%; p=0.03), were accessed with larger sheaths (61% vs. 35%; p<0.01) and were imaged with less contrast dye (73 ± 38 mL vs. 117 ± 57 mL; p<0.01). Major complications including retroperitoneal hematoma (0% vs. 2%; p=0.34), acute limb ischemia (1% vs. 0%; p=1) and/or acute kidney injury (1% vs. 0%; p=1) were rare in both groups. Patients treated in the cath lab were more likely to experience transient hypotension (10% vs. 22%; p=0.08) and/or transient postprocedure creatinine elevation (2.0 ± 2.1 vs. 3.0 ± 3.0; p=0.05). Surprisingly, both hospital charges and hospital costs were significantly less for patients treated in the hybrid room as compared to the cath lab (total charges $18714 ± 9633 vs. $26902 ± 19753; p<0.01, total direct and indirect costs $7174 ± 3847 vs. $9659 ± 7064; p=0.01). Medical supplies indirect cost and room services total direct and indirect costs were also higher in the cath lab (medical supplies indirect $336 ± 557 vs. $836 ± 1893; p=0.02; room services $3183 ± 2068 vs. $5169 ± 3314; p<0.01). Conclusions: PPI can be safely performed in either a hybrid surgical suite or cardiac catheterization laboratory although treatment in a hybrid suite utilizes less hospital resources.

Non-Contact Assessment of Peripheral Artery Haemodynamics Using Infrared Video Thermography

Skin temperature has long been used as a natural indicator of vascular diseases in the extremities. Considerable correlation between oscillations in skin surface temperature and oscillations of skin blood flow has previously been demonstrated. We hypothesised that the impairment of blood flow in stenotic (subcutaneous) peripheral arteries would influence cutaneous temperature such that, by measuring gradients in the temperature distribution over skin surfaces, one may be able to diagnose or quantify the progression of vascular conditions in whose pathogenesis a reduction in subcutaneous blood perfusion plays a critical role (e.g. peripheral artery disease). As proof of principle, this study investigates the local changes in the skin temperature of healthy humans (15 male, [Formula: see text] years old, BMI [Formula: see text]kg/m 2) undergoing two physical challenges designed to vary their haemodynamic status. Skin temperature was measured in four central regions (forehead, neck, chest, and left shoulder) and four peripheral regions (left upper arm, forearm, wrist, and hand) using an infrared thermal camera. We compare inter-region patterns. Median temperature over the peripheral regions decreased from baseline after both challenges (maximum decrease: [Formula: see text]°C at 60s after exercise; [Formula: see text] and [Formula: see text]°C at 180s of cold-water immersion; [Formula: see text]). Median temperature over the central regions showed no significant changes. Our results show that the non-contact measurement of perfusion-related changes in peripheral temperature from infrared video data is feasible. Further research will be directed towards the thermographic study of patients with symptomatic peripheral vascular disease.

TCT-557 Clinical Outcomes of Atherectomy Use for the Treatment of Symptomatic Peripheral Vascular Disease

Current endovascular treatment for peripheral arterial disease (PAD) involves percutaneous transluminal angioplasty using plain balloon followed by drug-eluting stent (DES) or drug-coated balloon (DCB). Lesion preparation using atherectomy might improve clinical outcomes. We did a meta-analysis

Total Adiponectin and Risk of Symptomatic Lower Extremity Peripheral Vascular Disease in Type 2 Diabetes Mellitus

Total Adiponectin and Risk of Symptomatic Lower Extremity Peripheral Vascular Disease in Type 2 Diabetes Mellitus

TCTAP A-120 Management of Silent Coronary Ischemia in Patients with Symptomatic Peripheral Vascular Disease Who Require Surgery

Complications of coronary artery disease (CAD) are the major causes of postoperative major adverse cardiac events (MACE) in patients undergoing peripheral vascular surgery (PVS). Pre-operative invasive angiography (ICA) before PVS is recommended only for patients with proven myocardial ischemia or

Comorbid conditions responsible for the higher complications and poorer outcome in cardiac and vascular surgery: Time to reconsider hyperhomocysteinemia and its repercussions

Background: Plasma homocysteine is a perceived risk factor for the cardiovascular diseases. Many studies confirmed its remarkably high level with severity of the disease. There are no studies to correlate plasma homocysteine level and outcome of surgery in patients suffering from cardiovascular diseases. Objective: The purpose of our clinical study is to analyze the correlation of plasma Homocysteine levels in patients undergoing coronary artery bypass grafting (CABG) and various peripheral vascular surgeries regarding various patient variables such as age, sex, and also the severity of disease and outcome of surgery. Materials and Methods: The plasma homocysteine levels of 200 patients undergoing CABG and various vascular surgeries, between January 2016 and January 2018 were analyzed. This was a prospective study, data about patient variables obtained from questionnaires handed out to the patients during the preoperative period. All peripheral arterial diseases patients were symptomatic and belong to Rutherford stage 3, 4, 5, and 6. The severity of disease was evaluated based on coronary angiogram (CAG), who was undergoing CABG and computed tomography (CT) angiograms for patients presenting with peripheral vascular disease (PVD) and peroperative findings. A total of 178 CAG and 100 CT peripheral angiograms assessed. Homocysteine levels were determined by CLIA method and levels of >13 mmol/L taken as hyperhomocysteinemia. All patients had surgical vascular intervention in the form of CABG, peripheral vascular bypass, and thromboembolectomy. The results and complications evaluated postoperatively. Result: Higher homocysteine levels associated with a higher number of triple vessel coronary disease and symptomatic PVD. They had greater severity of the disease. It is also associated with poorer target vessels with an increased morbidity and postoperative fatality. Conclusion: Homocysteine level is one of the independent risk factors for severity of CAD. It can have predictive value in CABG, peripheral vascular surgery, and poor postoperative outcome.

Abstract No. 546 - CTA versus angiography for evaluation of symptomatic peripheral vascular disease

Abstract No. 546 - CTA versus angiography for evaluation of symptomatic peripheral vascular disease

Abstract 14339: Nonalcoholic Fatty Liver Disease and the Risk of Clinical Cardiovascular Events: A Meta-Analysis

Background: Numerous studies have assessed the association of Nonalcoholic fatty liver disease (NAFLD) withcardiovascular disease (CVD). However, results have been conflicting due to variability in definitionsof NAFLD and ascertainment of CVD, often combining clinical and surrogate endpoints. We therefore systematically reviewed published literature to assess the association between NAFLD and clinical cardiovascular events. Methods: We searched Medline, Cochrane, google scholar, CINAHL, and Web of Sciencedatabasesusing terms “nonalcoholic fatty liver disease”, “cardiovascular disease”, and their combinations to identify studies published through March 2015. Data from selected studies was extracted and meta-analysis was then performed using Random effects model following the PRISMA guidelines. Publication bias and heterogeneity wereassessed. The main outcome measure was Odds ratio (OR) with 95% CI. Clinical CVD was defined as symptomatic coronary artery disease, myocardial infarction, coronary or peripheral intervention, ischemic stroke, and symptomatic peripheral vascular disease. Results: A total of 7 studies with 14634 patients (NAFLD: 4204; controls: 10430) were included in the final analysis. 3 studies were cross- sectional reporting prevalence, while 4 studies were prospective cohort studies reporting incidence. Patients with NAFLD had a significantly higher risk of clinical CVD compared to controls [OR: 3.17; 95% CI: 1.89-5.30, P&lt;0.01) (figure 1A). There was significant heterogeneity (I2=93%). Funnel plot and Begg’s test did not reveal significant publication bias. Separate analyses of the cohort and cross sectional studies and exclusion sensitivity analysis did not alter the findings (figure 1B). Conclusion: NAFLD is associated with a three fold increase in the risk of clinical CVD compared to controls without NAFLD. These results need to be conformed in large prospective studies.

Temporal changes in the prevalence and associates of foot ulceration in type 2 diabetes: The Fremantle Diabetes Study

AimsTo assess temporal changes in foot ulceration and its risk factors in community-based people with type 2 diabetes. MethodsBaseline data from the longitudinal observational Fremantle Diabetes Study collected from 1993 to 1996 (Phase I) and 2008 to 2011 (Phase II) were analyzed. Generalized linear modeling was used to examine changes in foot ulcer prevalence and its associates between phases. Multiple logistic regression was used to determine associates of prevalent foot ulceration in individual and pooled phases. ResultsThere were 16 foot ulcers among 1296 patients in Phase I (1.2%) and 23 in 1509 Phase II patients (1.5%; P=0.86 after age, sex and race/ethnicity adjustment). Glycemic and non-glycemic cardiovascular risk factors were better in Phase II, but diabetes duration was longer, peripheral sensory neuropathy (PSN) was more prevalent and more patients were Aboriginal (P<0.001) than in Phase I. In multivariable analysis of both phases and pooled data, diabetes duration and peripheral sensory neuropathy (PSN) were independent associates of foot ulceration (P≤0.026). Prior hospitalization for ulcer, intermittent claudication, any absent pedal pulse and Aboriginality were also significant in the pooled model (P≤0.009). ConclusionsStrong associations between foot ulcer and diabetes duration, PSN, symptomatic and clinically-detectable peripheral vascular disease were observed. Aboriginality also proved an independent risk factor. Since all these risk factors apart from intermittent claudication and impalpable foot pulses were more prevalent in Phase II, improved community- and hospital-based foot care between phases are likely to have attenuated the risk of foot ulcers in Phase II patients.

Short‐term outcomes of excisional atherectomy in lower limb arterial disease

Endovascular interventions are increasingly utilized in managing occlusive peripheral vascular disease. Angioplasty and stenting remain the mainstay of endovascular management; however, newer treatment modalities such as excisional atherectomy provide the clinician with additional treatment options. While demonstrating promising results in available trials, a paucity of data exist regarding peripheral atherectomy. The purpose of this retrospective clinical study was to assess the efficacy and safety of excisional atherectomy with the TurboHawk atherectomy device (Covidien/ev3, Plymouth, MN, USA) in the treatment of lower limb peripheral vascular disease and to evaluate the learning curve involved in the institution of a new treatment modality. A retrospective analysis was performed on all patients undergoing atherectomy for symptomatic lower limb peripheral vascular disease by a single clinician between November 2011 and June 2013. Forty-seven vessels on 28 legs in 24 patients were treated during the period. Atherectomy was possible in 98% of cases. The 6- and 12-month primary patency was 72.6 and 58.9%, respectively. The primary-assisted patency was 93.2% at 6 months and 74.6% at 12 months. There were significantly greater patency rates in the TransAtlantic Inter-Society Consensus A + B lesions and a non-significant trend towards improved patency rates in claudicants versus critical limb ischaemia. There were four instances of embolization and four cases of dissection. Excisional atherectomy provides a further option for the minimally invasive management of peripheral vascular disease. It has similar patency rates to established endovascular therapies and should be considered among the treatment options in patients with favourable pathology.

Spermatocytic variant of classic seminoma: a report of five cases and a brief review of the literature.

BackgroundSpermatocytic seminoma is a rare testicular malignancy, appearing in the adult population. It has a good prognosis and a low rate of metastatic potential.ObjectivesWe present five cases diagnosed and treated with radiotherapy at Rambam Health Care Campus in Haifa, Israel.MethodsBetween 1974 and 1996, five patients with stage I spermatocytic seminoma were referred post-orchiectomy to the Northern Israel Oncology Center. All five patients presented with the typical pathological features of the spermatocytic variant of classic seminoma, and all were staged clinically and radiologically.ResultsMean age at diagnosis was 44 years (range 30–58 years). Main symptoms included a palpable testicular mass and/or testicular enlargement. Mean duration of symptoms was 9 months (range 0.5–24 months). Three patients were irradiated to the para-aortic/ipsilateral iliacal lymph nodes (mean total dose 2,500 cGy), one patient with 4,000 cGy. One patient was irradiated to the bilateral iliacal lymph nodes (2,600 cGy). With a median follow-up of 15 years, four patients are alive with no evidence of disease or severe late side effects. One patient developed severe lymphedema and symptomatic peripheral vascular disease, stage IIA prostate carcinoma (hormonal and brachytherapy treatment) and a non-secretory hypophyseal adenoma (surgically removed); he died at the age of 75 due to severe peripheral vascular and coronary heart disease with no evidence of his first or second primaries.ConclusionsPrognosis is excellent and does not differ from classic seminoma. As in the accumulated experience in early-stage, low-risk classic seminoma, we suggest surveillance as the preferred policy.

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.

Assessment of self-expanding nitinol stent deformation after chronic implantation into the femoropopliteal arteries

The purpose of this prospective clinical investigation was to quantify the degree and range of compressive and bending deformations sustained by self-expanding nitinol stents when implanted into the femoropopliteal arteries of patients with symptomatic peripheral vascular disease (PVD). Twenty-three nitinol self-expanding stents (Absolute; Abbott Vascular, Santa Clara, CA, USA) with diameters ranging from 5-10 mm and lengths ranging from 40-100 mm were implanted in 19 lesions in 18 extremities of 17 patients. Two days following implantation, in vivo stent compression and bending were assessed by measurement of stent length and deflection angle via lateral view radiographs. The results showed that leg flexion was associated with significant stent bending; popliteal stents bent almost 90° while SFA stents bent only minimally. Leg flexion was also associated with stent shortening (compression), the greatest amount being observed for stents implanted into the popliteal artery (popliteal 8.5% ± 3.2%; SFA/prox pop 5.3% ± 0.5%; SFA 3.1% ± 1.8%). After a mean follow-up of 7.1 ± 1.3 months, the degree of stent deformation during leg flexion was essentially unchanged as compared to immediate post-procedure levels. Indwelling nitinol stents are routinely bent and compressed during leg flexion, with most bending observed in stents implanted near the popliteal artery. The degree of deformation observed immediately after implantation appears to be predictive of the chronic state, as repeat measurements obtained after a mean of seven months were essentially unchanged from baseline.

Effect of Peripheral Vascular Disease on Kidney Allograft Outcomes

The U.S. Renal Data System was used to analyze renal allograft outcomes in patients with peripheral vascular disease (PVD) at the time of transplant listing. We used an incident cohort of patients who underwent renal transplantation between June 2004 and September 2009. We defined PVD as symptomatic PVD at wait-listing. Comorbid conditions were diabetes mellitus, ischemic heart disease, cerebrovascular disease, hypertension, and smoking. Chi-square test, Student's t test, and Cox regression were used for statistical associations. The mean graft survival was 55.3±0.40 months in patients with PVD versus 60.8±0.06 months in patients without PVD. There was an increased risk of graft failure with PVD (hazard ratio, 2.01; 95% confidence interval, 1.83-2.21; P=0.0001). After adjusting for other variables, PVD remained an independent risk factor for graft failure. Patients with PVD had lower death-censored graft survival versus patients without PVD at 1 year (93.3% vs. 96.6%), 2 years (89.7% vs. 95%), and 3 years (87.2% vs. 93.7%). All-cause mortality was higher in PVD versus without PVD (6.2% vs. 3.0%). In African Americans, the mean allograft survival was 54.8±0.98, months with PVD versus 59.7±0.135 months without PVD (P=0.0001). In non-African Americans, the mean allograft survival was 55.4±0.44 months with PVD versus 61.1±0.069 months without PVD (P=0.0001). There were no differences in survival between African Americans with PVD and non-African Americans with PVD. Patients with PVD have inferior allograft and patient survival versus those without PVD. Caution should be exercised when placing patients with symptomatic PVD or amputation on the wait-list.

PC-FACS

PC-FACS

Blood transfusion for upper gastrointestinal bleeding: is less more again?

BackgroundThe hemoglobin threshold for transfusion of red blood cells in patients with acute gastrointestinal (GI) bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.MethodsObjective: The objective was to prove that the restrictive threshold for red blood cell transfusion in patients with acute upper GI bleeding (UGIB) was safer and more effective than a liberal transfusion strategy.Design: A single-center, randomized controlled trial was conducted.Setting: Patients with GI bleeding were admitted to the de la Santa Creu i Sant Pau hospital in Barcelona, Spain.Subjects: The subjects were adult intensive care unit patients admitted with high clinical suspicion of UGIB (hematomemesis, melena, or both). Patients were excluded if they had massive exsanguinating bleeding, acute coronary syndrome, symptomatic peripheral vascular disease, stroke/transient ischemic attack, transfusion within the previous 90 days, recent trauma or surgery, lower GI bleeding, or a clinical Rockall score of 0 with hemoglobin higher than 12 g/dL.Intervention: A total of 921 patients with severe acute UGIB were enrolled. Of these, 461 were randomly assigned to a restrictive strategy (transfusion when the hemoglobin level fell to below 7 g/dL) and 460 to a liberal strategy (transfusion when the hemoglobin fell to below 9 g/dL). Random assignment was stratified according to the presence or absence of liver cirrhosis.Outcomes: The primary outcome was rate of death from any cause within the first 45 days. Secondary outcomes were further bleeding, defined as hematemesis or melena with hemodynamic instability or hemoglobin decrease of 2 g/dL or more, and in-hospital complications.ResultsIn total, 225 patients assigned to the restrictive strategy (51%) and 65 assigned to the liberal strategy (15%) did not receive transfusions (P <0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% versus 91%; hazard ratio (HR) for death with restrictive strategy, 0.55; 95% confidence interval (CI) 0.33 to 0.92; P = 0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group and in 16% of the patients in the liberal-strategy group (P = 0.01), and adverse events occurred in 40% and 48%, respectively (P = 0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (HR 0.70, 95% CI 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (HR 0.30, 95% CI 0.11 to 0.85) but not in those with cirrhosis and Child-Pugh class C disease (HR 1.04, 95% CI 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P = 0.03) but not in those assigned to the restrictive strategy.ConclusionsCompared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute UGIB.

The epidemic of pediatric chronic kidney disease: the danger of skepticism

The epidemic of pediatric chronic kidney disease: the danger of skepticism

Is there a role for thoracic aortic calcium to fine-tune cardiovascular risk prediction?

Screening asymptomatic subjects to streamline measures for the prevention of cardiovascular events remains a major challenge. The established primary prevention risk-scoring methods use equations derived from large prospective cohort studies, but further fine-tuning of cardiovascular risk assessment remains important as 25 % of individuals with low estimated risk may experience cardiac events. Independent studies provided evidence that extended risk assessment using coronary artery calcium quantification may improve risk stratification as it can lead to reclassification of persons at increased risk. Particularly in intermediate-risk subjects, coronary artery calcium scoring can help to correctly identify individuals at highest risk. Data on the extent of calcification of the ascending and descending thoracic aorta might be useful for additional cardiovascular risk stratification. Future analyses and studies will be required to answer the question of whether the implementation of such data may allow further fine-tuning of cardiovascular risk prediction in specific subpopulations—for instance in women or men with an increased risk of stroke and/or symptomatic peripheral vascular disease.