Undergoing Revascularization Procedures Research Articles

ELEVATED ILIAC CALCIUM SCORE AS A MARKER OF CORONARY CALCIFICATION AND OVERALL ATHEROSCLEROTIC RISK

BackgroundThe initial assessment of cardiovascular risk in patients undergoing lower limb revascularization surgery is crucial to minimize complications and improve outcomes. This study aims to determine if the iliac calcium score (ICS) serves as a cardiologic risk marker by examining its correlation with the coronary calcium score (CCS) in these patients. MethodsThis prospective observational single-center study included 248 patients with critical limb ischemia undergoing revascularization procedures from January 2022 to June 2023. Baseline characteristics such as age, gender, smoking status, comorbidities, and clinical status were recorded. CCS and ICS were calculated using preoperative computed tomography angiography. Multiple linear regression identified significant predictors of ICS, including CCS, iliac intima-media thickness (i-IMT), coronary artery disease (CAD), diabetes, chronic kidney disease (CKD), hypertension, dyslipidemia, and smoking. ResultsThe study population had a mean age of 74.4 years, 83.86% male. Significant correlations were found between ICS and CCS (Pearson r=0.34, p<0.001) and between ICS and i-IMT (Pearson r=0.35, p<0.001). Regression analysis revealed significant predictors for ICS, including CCS (coefficient=1.808, p<0.0001), i-IMT (coefficient=3.11, p<0.0001), CAD (coefficient=11.94, p=0.042), diabetes (coefficient=19.59, p=0.002), CKD (coefficient=11.79, p<0.0001), and hypertension (coefficient=22.10, p=0.001). Dyslipidemia and smoking did not show significant associations with ICS. ConclusionsThe iliac calcium score shows a statistically significant association with the coronary calcium score and iliac intima-media thickness in patients undergoing lower limb revascularization surgery. This correlation suggests that iliac calcium score reflects vascular calcification patterns like those observed in coronary arteries. Further studies are needed to explore this relationship in diverse patient populations and under varying clinical conditions

Impact of coronary CT angiography on the hospital outcome among patients admitted with AMI undergoing revascularization procedures in theUS

Abstract Background Coronary CT angiography (CCTA) is gaining popularity as a diagnostic modality for risk stratification among patients hospitalized with acute myocardial infarction (AMI). However, its impact on the hospital outcomes among this population of patients remains to be determined. Methods Using national inpatient sample database, admission cases with a diagnosis of AMI who underwent revascularization procedures were identified from 2016-2020. The prevalence of CCTA was determined among the patient population and stratified based on the type of AMI (STEMI vs. NSTEMI) and revascularization procedure (PCI vs. CABG). Hospital outcomes were compared among the study strata. Results A total of 862,064 admission cases for STEMI and 3,586,944 admission cases for NSTEMI were identified out of which 661,958 cases underwent revascularization procedures. The utilization of CCTA was roughly 10 times higher among AMI cases undergoing PCI than those undergoing CABG (0.5% vs. 0.06%, p&amp;lt;0.0001). Prior CCTA increased the odds of receiving PCI by 79.3 times and the odds of undergoing CABG by 2.8 times. Among STEMI patients undergoing PCI, prior CCTA was associated with a lower mortality rate and non-home disposition (13.8% vs. 21.2%, p&amp;lt;0.0001) compared to no CCTA (3% vs. 5.5%, p=0.01). For NSTEMI patients undergoing PCI, CCTA was associated with a lower non-home disposition (16.5% vs. 20.6%, p=0.003) but not a significantly lower mortality rate. CCTA did not demonstrate any statistically significant differences for AMI patients undergoing CABG. On the other hand, CCTA increased the cost of hospitalization by $15,130.7 for STEMI patients undergoing PCI, length of stay (9 days) and hospital cost for STEMI patients undergoing CABG ($302,802), and total hospital cost for NSTEMI patients undergoing PCI by $8,705. Conclusions Using CCTA helps in risk stratifying AMI patients for revascularization procedures, allocating PCI to those admitted with STEMI and CABG to those with NSTEMI. Although CCTA reduces the risk of death and non-home disposition among STEMI patients undergoing PCI, it also increases hospital charges for patients receiving revascularization procedures.

Sex-differences in the clinical features, managements and outcomes of early-onset atherosclerotic coronary artery disease in China

Abstract Background/Introduction There is an alarming rise in the incidence of atherosclerotic coronary artery disease (CAD) among young adults, particularly in young women. Sex disparities of early-onset CAD in the context of contemporary cardiovascular practice are not well understood. Purpose We aimed to delineate the differences in clinical profiles and prognosis between young men and women with established early-onset CAD. Methods This is a nationwide, hospital-based, longitudinal prospective cohort study. Young patients (aged ≥18 years and ≤ 45 years) with angiographically confirmed severe atherosclerotic obstructive coronary arteries (luminal narrowing ≥ 70%) were included from 38 hospitals across China between May 2017 and May 2020. Coronary risk factors, clinical features and treatments were compared between men and women at baseline. Participants were followed for 3 years. The outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, non-fatal myocardial infarction (MI), unplanned revascularization, and ischemic stroke. The Cox regression analyses were used to estimate hazard ratios (HR) with 95% confidence intervals (CIs) for outcome. Results There were 1524 patients (female: 4.4%) included in this study. The female patients were older than the male patients (41.1±4.0 years for females vs. 39.6±4.4 years for males, p=0.006). They showed a lower prevalence of hypertension, lipid disorders, and smoking or drinking (all p&amp;lt;0.01). The female patients were less likely to have at least 1 modifiable risk factors (female: n=45 (67.2%) vs. male: n=1382 [94.6 %], p&amp;lt;0.001); they showed more favorable laboratory results at baseline, including lipids, serum creatinine and uric acid (all p&amp;lt;0.05) as compared to male patients. Besides, young females presented more often with stable angina on admission, whereas young males tended to present with acute MI (p&amp;lt;0.001). There was no significant sex difference in Gensini Score (p=0.15). Female patients were less likely to undergo revascularization procedures than male patients (73.1% vs. 85.3%, p=0.01). During the 3 years of follow-up, female patients were at a significantly higher risk of MACE compared to their male counterparts (13.4% vs. 5.8%, adjusted HR: 3.07, 95% CI:1.36–6.94, p=0.007) after adjusting for age, smoking, drinking, body mass index, hypertension, diabetes, dyslipidemia, diagnosis and revascularization. Conclusions Distinct sex disparities, unfavorable to young females, were documented among patients with early-onset CAD, with the largest gaps noted in the treatment and prognosis. Despite more favorable baseline profiles, young female patients had insufficient care and 3-fold greater risk for MACE compared to young males. These results highlight the need for strengthening the treatment strategies for this vulnerable disease entity.Figure 1

Examining Psychological Factors in Peripheral Artery Disease: Affective Temperament, Anxiety, and Depression in Patients Undergoing Revascularization Procedures.

This study aimed to assess the prevalence of depressive and anxiety symptoms in peripheral artery disease (PAD) patients, correlating these symptoms with clinical parameters and examining affective temperaments within the study group. A total of 159 PAD patients, predominantly male, admitted for vascular surgery due to lower limb atherosclerosis, participated in this cross-sectional study. Various assessments were conducted, including the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A) for affective temperaments, the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression symptoms, and the Numerical Rating Scale (NRS) for pain intensity. Additionally, the Ankle-Brachial Index (ABI) was measured to assess circulation in the legs. The findings revealed a higher prevalence of depressive and anxiety symptoms in the PAD patient group compared to the control group. Notably, depressive and anxiety symptoms correlated with the severity of PAD, as indicated by lower ABI values in the operated leg. Patients undergoing surgical revascularizations exhibited higher depressive symptoms than those undergoing endovascular procedures. Furthermore, correlations were observed between depressive symptoms and the number of previous vascular procedures and amputations, alongside increased pain levels at admission. Clinical factors such as diabetes, hypertension, heart failure, ischemic heart disease, previous revascularization procedures, amputations, and the intensity of affective temperaments did not correlate with HADS scores. The study highlighted the intricate relationship between mood disorders and PAD severity, emphasizing the potential prognostic implications of untreated depression and anxiety in PAD patients. These findings suggest the importance of closely monitoring and addressing psychological well-being in PAD management. However, the study encountered limitations such as varying assessment timing and sample size discrepancies among comorbidities, impacting the observation of associations between mood disorders and certain conditions. In conclusion, depressive and anxiety symptoms are often in PAD. Further research is needed to explore therapeutic interventions targeting mental health and pain management to improve the course and outcomes of PAD.

Long-term patient-reported outcomes among patients undergoing revascularization vs medical therapy for intermittent claudication

ObjectiveSociety for Vascular Surgery guidelines recommend revascularization for patients with intermittent claudication (IC) if it can improve patient function and quality of life. However, it is still unclear if patients with IC achieve a significant functional benefit from surgery compared with medical management alone. This study examines the relationship between IC treatment modality (operative vs nonoperative optimal medical management) and patient-reported outcomes for physical function (PROMIS-PF) and satisfaction in social roles and activities (PROMIS-SA). MethodsWe identified patients with IC who presented for index evaluation in a vascular surgery clinic at an academic medical center between 2016 and 2021. Patients were stratified based on whether they underwent a revascularization procedure during follow-up vs continued nonoperative management with medication and recommended exercise therapy. We used linear mixed-effect models to assess the relationship between treatment modality and PROMIS-PF, PROMIS-SA, and ankle-brachial index (ABI) over time, clustering among repeat patient observations. Models were adjusted for age, sex, diabetes, Charlson Comorbidity Index, Clinical Frailty Score, tobacco use, and index ABI. ResultsA total of 225 patients with IC were identified, of which 40% (n = 89) underwent revascularization procedures (42% bypass; 58% peripheral vascular intervention) and 60% (n = 136) continued nonoperative management. Patients were followed up to 6.9 years, with an average follow-up of 5.2 ± 1.6 years. Patients who underwent revascularization were more likely to be clinically frail (P = .03), have a lower index ABI (0.55 ± 0.24 vs 0.72 ± 0.28; P < .001), and lower baseline PROMIS-PF score (36.72 ± 8.2 vs 40.40 ± 6.73; P = .01). There were no differences in patient demographics or medications between treatment groups. Examining patient-reported outcome trends over time; there were no significant differences in PROMIS-PF between groups, trends over time, or group differences over time after adjusting for covariates (P = .07, P = .13, and P =.08, respectively). However, all patients with IC significantly increased their PROMIS-SA over time (adjusted P = .019), with patients managed nonoperatively more likely to have an improvement in PROMIS-SA over time than those who underwent revascularization (adjusted P = .045). ConclusionsPatient-reported outcomes associated with functional status and satisfaction in activities are similar for patients with IC for up to 7 years, irrespective of whether they undergo treatment with revascularization or continue nonoperative management. These findings support conservative long-term management for patients with IC.

Complementary Gene Therapy after Revascularization with the Saphenous Vein in Diabetic Foot Syndrome.

Diabetic foot syndrome (DFS) is one of the most serious macroangiopathic complications of diabetes. The primary treatment option is revascularization, but complementary therapies are still being sought. The study group consisted of 18 patients diagnosed with ischemic ulcerative and necrotic lesions in DFS. Patients underwent revascularization procedures and, due to unsatisfactory healing of the lesions, were randomly allocated to two groups: a group in which bicistronic VEGF165/HGF plasmid was administered and a control group in which saline placebo was administered. Before gene therapy administration and after 7, 30, 90, and 180 days, color duplex ultrasonography (CDU) was performed, the ankle-brachial index (ABI) and transcutaneous oxygen pressure (TcPO2) were measured, and DFS changes were described and documented photographically. In the gene therapy group, four out of eight patients (50%) healed their DFS lesions before 12 weeks. During this time, the ABI increased by an average of 0.25 and TcPO2 by 30.4 mmHg. In the control group, healing of the lesions by week 12 occurred in six out of nine patients (66.67%), and the ABI increased by an average of 0.14 and TcPO2 by 27.1 mmHg. One major amputation occurred in each group. Gene therapy may be an attractive option for complementary treatment in DFS.

Frequency, Risk Factors, and Outcomes of Intracranial Atherosclerotic Stenosis in Stroke Patients From the Southern Region of Saudi Arabia.

Background Intracranial Atherosclerotic Stenosis (ICAS) represents a noteworthy cerebrovascular pathology linked to ischemic stroke, contributing to a considerable burden of morbidity and mortality on a global scale. The present study was undertaken with the primary objective of investigating the frequency, risk factors, and outcomes of ICAS in stroke patients within the Southern Region of Saudi Arabia. Methods This was a descriptive cross-sectional study conducted at a tertiary care hospital located in the southern region of Saudi Arabia, from June 2022 to December 2022. The study population consisted of patients aged 18 years and above who were diagnosed with acute ischemic stroke during the designated research period. Patients with hemorrhagic stroke, transient ischemic attack (TIA), or incomplete medical records were excluded from the analysis. Data pertaining to the patients were retrieved from their respective medical records. Results Out of 201 patients admitted with stroke, 92 (45.77%) were found to have intracranial stenosis. The majority of patients were female (52.2%) and aged over 55 years (60.9%). The presence of hypertension exhibited a statistically significant correlation with varying degrees of stenosis (p=0.02), as did ischemic heart disease and obesity (p=0.04) and active smoking (p=0.01). Hypertension displayed a marginal association with intracranial stenosis, with an odds ratio of 1.01 (95% CI: 0.25, 4.11) and a p-value of 0.02. Similarly, dyslipidemia showed a potential correlation, with an odds ratio of 1.16 (95% CI: 0.44, 3.03) and a p-value of 0.014. On the other hand, obesity showed a stronger association, with an odds ratio of 4.53 (95% CI: 1.05, 19.51) and a p-value of 0.04. Among the patients, 25 (27.17%) underwent revascularization procedures, while 44 (47.83%) were not eligible for such intervention. During the three-month follow-up, 4 (16%) experienced an ipsilateral stroke, and 3 (12%) suffered from a contralateral transient ischemic attack (TIA). Encouragingly, 18 (72%) of the treated patients showed no recurrence during the follow-up period. Conclusion This study concludes that approximately half (45.77%) of stroke patients had intracranial stenosis, and significant associations were found between varying degrees of stenosis and hypertension, ischemic heart disease, obesity, and active smoking. Hypertension demonstrated a marginal correlation, while obesity exhibited a stronger association with intracranial stenosis.

Mast cell activation and degranulation in acute artery injury: A target for post-operative therapy.

The increasing incidence of cardiovascular disease (CVD) has led to a significant ongoing need to address this surgically through coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI). From this, there continues to be a substantial burden of mortality and morbidity due to complications arising from endothelial damage, resulting in restenosis. Whilst mast cells (MC) have been shown to have a causative role in atherosclerosis and other vascular diseases, including restenosis due to vein engraftment; here, we demonstrate their rapid response to arterial wire injury, recapitulating the endothelial damage seen in PCI procedures. Using wild-type mice, we demonstrate accumulation of MC in the femoral artery post-acute wire injury, with rapid activation and degranulation, resulting in neointimal hyperplasia, which was not observed in MC-deficient KitW-sh/W-sh mice. Furthermore, neutrophils, macrophages, and T cells were abundant in the wild-type mice area of injury but reduced in the KitW-sh/W-sh mice. Following bone-marrow-derived MC (BMMC) transplantation into KitW-sh/W-sh mice, not only was the neointimal hyperplasia induced, but the neutrophil, macrophage, and T-cell populations were also present in these transplanted mice. To demonstrate the utility of MC as a target for therapy, we administered the MC stabilizing drug, disodium cromoglycate (DSCG) immediately following arterial injury and were able to show a reduction in neointimal hyperplasia in wild-type mice. These studies suggest a critical role for MC in inducing the conditions and coordinating the detrimental inflammatory response seen post-endothelial injury in arteries undergoing revascularization procedures, and by targeting the rapid MC degranulation immediately post-surgery with DSCG, this restenosis may become a preventable clinical complication.

Socioeconomic Status Not Associated With Worse Outcomes After Open Lower Extremity Revascularization

Prior research has shown that socioeconomic status (SES) is correlated with higher rates of diabetes, peripheral vascular disease, and amputation. We sought to determine whether socioeconomic status or insurance type increases the risk of mortality, major adverse limb event (MALE), or hospital length of stay following open lower extremity revascularization. We conducted a retrospective analysis of a prospectively maintained database of patients who underwent open lower extremity revascularization at a single tertiary care center from January 2011 to March 2017 (n = 542). Socioeconomic status was determined using state area deprivation index (ADI), a validated metric determined by income, education, employment, and housing quality by census block group. In patients undergoing revascularization procedures on both limbs, each limb was treated individually for analysis. We performed a multivariate analysis of the association between ADI and insurance type with mortality, MALE, and hospital length of stay using Cox proportional hazard models, including confounding variables such as age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes. The cohort with an ADI of 1, meaning least deprived, and the Medicare cohort were used for reference. P values of <.05 were considered statistically significant. Of 542 patients reviewed, 245 patients undergoing surgery had complete data and were included. Controlling for age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes, SES was not an independent predictor of mortality (Table I) (P = .974), MALE (P = .989), or hospital length of stay (P = .325). Controlling for the same confounders, insurance type was not independently correlated with mortality (Table II) (P = .164) or MALE (P = .743). Private insurance was associated with significantly longer hospital stays (P = .004). This study suggests that SES does not correlate with increased risk of mortality or MALE in patients undergoing open lower extremity revascularization. While insurance type did not impact risk of mortality or MALE, those with private insurance may have longer hospital stays following surgery. These findings suggest that individuals undergoing open lower extremity revascularization at this single tertiary care center received similar care, regardless of their SES or insurance type. Further study is warranted to determine the factors that led to these findings, including whether individuals with lower SES may be presenting too late for revascularization and instead undergo primary amputation.Table IMultivariate analysis of the association between socioeconomic status and postoperative outcomes using an area deprivation index (ADI) of 1 as the reference groupMultivariate hazard ratio [95% CI]P valueMortality ADI 20.97 [0.32-2.92].952 ADI 31.02 [0.36-2.89].969 ADI 40.91 [0.28-2.96].871 ADI 50.48 [0.17-1.33].159 ADI 60.51 [0.18-1.47].212 ADI 70.71 [0.24-2.10].541 ADI 81.04 [0.34-3.12].950 ADI 91.33 [0.30-5.97].707 ADI 100.98 [0.32-3.03].974 Age1.05 [1.03-1.08]<.001 Gender (male)1.28 [0.76-2.15].361 Smoking (yes vs no)0.79 [0.50-1.24].307 BMI0.99 [0.95-1.02].437 Hyperlipidemia (yes vs no)1.06 [0.57-1.98].844 Hypertension (yes vs no)1.39 [0.53-3.64].509 Diabetes (yes vs no)1.34 [0.86-2.11].201MALE ADI 20.56 [0.12-2.62].462 ADI 31.67 [0.43-6.46].459 ADI 41.12 [0.28-4.53].872 ADI 51.33 [0.35-5.04].677 ADI 61.16 [0.32-4.21].825 ADI 71.30 [0.36-4.75].690 ADI 82.33 [0.62-8.77].212 ADI 92.79 [0.67-11.59].159 ADI 101.01 [0.25-4.08].989 Age0.98 [0.96-1.00].097 Gender (male)0.89 [0.55-1.43].640 Smoking (yes vs no)1.13 [0.71-1.81].607 BMI1.00 [0.96-1.04].943 Hyperlipidemia (yes vs no)0.56 [0.33-0.95].033 Hypertension (yes vs no)2.99 [1.23-7.27].016 Diabetes (yes vs no)1.09 [0.69-1.72].711Hospital length of stay, days ADI 20.66 [0.23-1.91].444 ADI 30.67 [0.24-1.88].446 ADI 40.63 [0.21-1.91].411 ADI 50.73 [0.26-2.01].543 ADI 60.73 [0.27-1.99].532 ADI 70.55 [0.20-1.53].252 ADI 80.48 [0.16-1.41].183 ADI 90.57 [0.14-2.36].434 ADI 100.58 [0.19-1.73].325 Age1.03 [1.01-1.05].014 Gender (male)1.06 [0.66-1.70].821 Smoking (yes vs no)1.47 [0.91-2.35].113 BMI0.99 [0.96-1.03].674 Hyperlipidemia (yes vs no)1.28 [0.68-2.42].446 Hypertension (yes vs no)1.45 [0.53-3.92].469 Diabetes (yes vs no)1.07 [0.69-1.65].773BMI, Body mass index; CI, confidence interval; MALE, major adverse limb events. Open table in a new tab Table IIMultivariate analysis of the association between insurance type and postoperative outcomes using Medicare as the reference groupMultivariate hazard ratio [95% CI]P valueMortality Private1.55 [0.84-2.87].164 Medicaid1.60 [0.68-3.77].283 Self-pay2.46 [0.74-8.25].144 Age1.06 [1.03-1.08]<.0001 Gender (male)1.40 [ 0.88-2.22].150 Smoking (yes vs no)0.83 [0.53-1.30].404 BMI0.98 [0.94-1.01].186 Hyperlipidemia (yes vs no)1.06 [0.57-1.96].862 Hypertension (yes vs no)1.22 [0.47-3.17].679 Diabetes (yes vs no)1.37 [0.89-2.11].157MALE Private1.10 [0.61-1.99].743 Medicaid1.57 [0.75-3.28].236 Self-pay2.16 [0.83-5.61].114 Age0.99 [0.96-1.01].211 Gender (male)0.94 [0.60-1.47].775 Smoking (yes vs no)1.12 [0.71-1.75].625 BMI1.00 [0.96-1.04].914 Hyperlipidemia (yes vs no)0.62 [0.37-1.03].067 Hypertension (yes vs no)2.85 [1.18-6.91].020 Diabetes (yes vs no)1.04 [0.67-1.62].850Hospital length of stay, days Private1.79 [0.91-3.53].090 Medicaid1.28 [0.56-2.93].563 Self-pay1.84 [0.53-6.42].340 Age1.04 [1.02-1.06].001 Gender (male)1.07 [0.68-1.71].765 Smoking (yes vs no)1.56 [0.97-2.51].067 BMI0.99 [0.96-1.03].750 Hyperlipidemia (yes vs no)1.31 [0.69-2.50].415 Hypertension (yes vs no)1.40 [0.54-3.67].488 Diabetes (yes vs no)1.07 [0.69-1.65].757BMI, Body mass index; CI, confidence interval; MALE, major adverse limb events.Boldface entries indicate statistical significance. 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Skeletal Muscle Bioenergetics in Critical Limb Ischemia and Diabetes

IntroductionMitochondrial dysfunction is implicated in the metabolic myopathy accompanying peripheral artery disease (PAD) and critical limb ischemia (CLI). Type-2 diabetes mellitus (T2DM) is a major risk factor for PAD development and progression to CLI and may also independently be related to mitochondrial dysfunction. We set out to determine the effect of T2DM in the relationship between CLI and muscle mitochondrial respiratory capacity and coupling control. MethodsWe studied CLI patients undergoing revascularization procedures or amputation, and non-CLI patients with or without T2DM of similar age. Mitochondrial respiratory capacity and function were determined in lower limb permeabilized myofibers by high-resolution respirometry. ResultsFourteen CLI patients (65 ± 10y) were stratified into CLI patients with (n = 8) or without (n = 6) T2DM and were compared to non-CLI patients with (n = 18; 69 ± 5y) or without (n = 19; 71 ± 6y) T2DM. Presence of CLI but not T2DM had a marked impact on all mitochondrial respiratory states in skeletal muscle, adjusted for the effects of sex. Leak respiration (State 2, P < 0.025 and State 4o, P < 0.01), phosphorylating respiration (P < 0.001), and maximal respiration in the uncoupled state (P < 0.001), were all suppressed in CLI patients, independent of T2DM. T2DM had no significant effect on mitochondrial respiratory capacity and function in adults without CLI. ConclusionsSkeletal muscle mitochondrial respiratory capacity was blunted by ∼35% in patients with CLI. T2DM was not associated with muscle oxidative capacity and did not moderate the relationship between muscle mitochondrial respiratory capacity and CLI.

Hypertriglyceridemia and Atherosclerotic Carotid Artery Stenosis.

Both fasting and non-fasting hypertriglyceridemia have emerged as residual risk factors for atherosclerotic disease. However, it is unclear whether hypertriglyceridemia increases the risks of the progression of carotid artery stenosis. Statins are well known to prevent carotid plaque progression and improve carotid plaque instability. In addition, statin therapy is also known to reduce cerebrovascular events in patients with carotid artery stenosis and to improve clinical outcomes in patients undergoing revascularization procedures. On the other hand, there have been no randomized controlled trials showing that the combination of non-statin lipid-lowering drugs with statins has additional beneficial effects over statin monotherapy to prevent cerebrovascular events and stenosis progression in patients with carotid artery stenosis. In this article, the authors demonstrate the mechanisms of atherosclerosis formation associated with hypertriglyceridemia and the potential role of lipid-lowering drugs on carotid artery stenosis. The authors also review the articles reporting the relationships between hypertriglyceridemia and carotid artery stenosis.

TcPO2 Value Can Predict Wound Healing Time in Clinical Practice of CLTI Patients

Transcutaneous oxygen pressure (TcPO2) is a noninvasive, nonradiological test to measure local oxygen released from capillaries through the skin. Since it reflects the metabolic state of the lower limb, it can predict wound healing in patients with critical limb threatening ischemia (CLTI). The purpose of this study was to determine the effectiveness of TcPO2 test in evaluating wound healing potential of patients with CLTI. This was a retrospective, single-center, nonrandomized, and observational study. A prospectively registered database of patients who visited Vascular Surgery Department of St. Mary's Hospital for CLTI and underwent TcPO2 tests from October 1, 2015 to July 1, 2021 was reviewed. Patients were divided into 2 groups: (1) those who had amputation only; and (2) those who underwent revascularization procedures. Patients whose wound healing status could not be determined were excluded. The clinical characteristics of patients, patient characteristics related to lower TcPO2 value, treatment success rate, and time for the wound to be healed were analyzed. A total of 84 patients were included in this study. There was no difference in background patient characteristics between the 2 groups despite better survival within 12months and shorter healing time in the revascularization group. A total of 76 patients survived 12months after surgery, and 63 patients were healed. Higher HbA1c, higher serum creatinine, history of stroke, and history of coronary artery disease were related to lower TcPO2 value on multiple linear regression. The cutoff value of TcPO2 was determined to be 40mm Hg for predicting wound healing. This value was similar to those of previous studies. In addition, there was a negative correlation between TcPO2 and wound healing time. Correlations among the anklebrachial index (ABI), toe-brachial index (TBI), and TcPO2 were not determined because ABI and TBI for some patients could not be obtained due to wound condition. The TcPO2 value can predict the wound healing process of ischemic lower extremity injury.

Impact of socioeconomic disparities on major lower extremity revascularization complications.

Low socioeconomic status (SES), distance lived from hospital, and insurance status are well documented in the literature to increase the risk of post-operative morbidity and mortality for some disease processes however there is a paucity of data regarding how this association impacts patients with peripheral artery disease (PAD). This study aimed to evaluate if SES, distance lived from hospital, and insurance status increased the risk of developing major graft failure in patients undergoing revascularization procedures for symptomatic PAD in a prospective, observation study. In this prospective, observational study, all patients undergoing lower extremity revascularization (endovascular or open) were included from December 2020 to February 2022. Demographic factors, insurance status, operative details, and median income and distance from hospital were documented through chart review. Complications were defined as thrombosis/occlusion of the revascularized vessel or bypass graft or infection of the distal wound or surgical incision wound. Univariate and multivariate analysis were performed comparing patients that developed complications and those that did not. This project was undertaken at the Massachusetts General Hospital and was governed by the Institutional Review Board (IRB: 2020P000263) all patients agreed to participation via informed written consent prior to enrollment in the study. A total of 108 patients were enrolled in the study of which 94 underwent successful revascularization procedures. Of those 94 patients, 38 (40.4%) underwent open bypass, 39 (41.5%) underwent endovascular revascularization, and 17 (18.1%) underwent a hybrid approach. There were no significant differences in post-operative outcomes between operative approaches. Twenty-five patients (28.7%) experienced major revascularization complications as defined as re-occlusion of the treated vessel/thrombosis of the bypass graft (n = 13) or development of post-operative infection (n = 12). There was no significant difference in median income ($75,295 vs $87,757, p = NS), distance lived from hospital, (27.4 miles vs. 29.7 miles, p = NS), or type of insurance (private 24% vs 26%, government 76% vs 73%, p = NS between patients that experienced complications versus those that did not have complications. These findings suggest the risk of major graft failure is independent of a patient's socioeconomic status, distance lived from hospital, or insurance type in patients undergoing revascularization procedures for PAD. While socioeconomic factors impact access to and have a known association with negative outcomes, complications in patients with PAD appear to be independent of these factors. To mitigate the negative outcomes in patients with peripheral artery disease, a focus should be on patient risk factors and modifiable medical factors that contribute to adverse outcomes.

Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample.

Disparities in acute coronary syndrome (ACS) outcomes exist between racial and ethnic groups. We aimed to evaluate disparities in resource utilization and inpatient outcomes across multiple ethnic and racial groups using contemporary data. We identified hospital discharges for ACS in the United States using the National Inpatient Sample from 2015 to 2018. The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify variables of interest. The primary outcomes were in-hospital complications, length of stay, and total hospital charge. Statistical analysis was performed using STATA version 17. Our analysis included 1,911,869 ACS discharges. Our sample was made up of 78.6% White, 12.1% Black, and 9.3% Hispanic patients. Hispanic and Black patients presenting with ACS were younger and had more cardiometabolic comorbidities than their White counterparts, especially hypertension, diabetes mellitus, and obesity. Despite social determinants of health being more likely to be unfavorable for Hispanics than their White counterparts, they were more likely to incur higher total hospital charges than their White counterparts. Black patients were the least likely to undergo revascularization procedures. Despite these differences, White patients had higher in-hospital mortality rates than Black and Hispanic patients. In this nationally representative study, despite having higher cardiometabolic comorbidity burden, lower socioeconomic status, and percutaneous intervention, Black and Hispanic patients experienced lower mortality rates than their White counterparts. Hispanic patients incurred the highest amount of total hospital charges for an ACS admission.

Risk Factors Associated 90-Day Readmission among Patients with Peripheral Artery Disease Undergoing Revascularization Procedures

Introduction: The CMS Bundled Payments for Care Improvement-Advanced program provides a single payment for all anticipated care within 90-days of surgery. Readmission are an important driver of healthcare cost, however, factors associated with 90-day readmission after peripheral artery disease (PAD) intervention are not well-described. Methods: National cohort of adults over 65 in the Vascular Quality Initiative-CMS linked dataset who underwent open, endovascular, or hybrid procedures for PAD between 2010 and 2018. The primary outcome was 90-day readmission. Multivariable Cox regression analysis was used to evaluate associations between patient- and facility-level characteristics and 90-day readmission. Results: 42,429 patients over age 65 underwent revascularization for PAD during the study period. The median age was 74(69-80), 58.9% were male and 84.3% were White. Over two-thirds of revascularizations were performed via endovascular method and over half had revascularization for chronic limb threatening ischemia (CLTI). The 90-day readmission rate was 30.9%. Patient-level factors such as advanced age, CLTI upon presentation, poor functional status, and most comorbidities of interest were associated with higher 90-day readmission. Those who had an outpatient index revascularization were less likely to have subsequent readmission (ref - inpatient; outpatient [HR 0.60 (95% CI 0.56-0.64)]; office-based lab [HR 0.61 (95% CI 0.51-0.72)]). Conclusion: Patient (e.g., age, comorbidity, severity of PAD upon presentation) and facility (e.g., site of index procedure) characteristics are associated with increased risk for 90-day readmission in PAD patients undergoing revascularization. This data may be used to guide novel intervention that will improve this quality metric among patients undergoing PAD intervention.

Impact of impaired renal function on outcomes of chronic total occlusion undergoing revascularization: a systemic review and meta-analysis.

Patients with chronic kidney disease (CKD) have an associated burden of coronary artery disease, including chronic total occlusions (CTO). It is unclear how the presence of CKD affects the outcomes of CTO revascularization. Previous reviews have not taken into account all relevant published studies that examined the association of CKD with outcomes of CTO revascularization. A systematic search was conducted using PubMed, Scopus, and Google Scholar databases for studies investigating patients with or without CKD who also had coronary chronic total occlusion undergoing revascularization procedures Statistical analysis was performed using STATA software. Effect sizes were reported as pooled relative risk (RR). A total of 13 studies were included. CKD patients showed elevated risk of in-hospital mortality (RR 4.25, 95% CI 2.64, 6.82) and mortality at latest follow-up (RR 3.24, 95% CI 2.56, 4.11), elevated risk of major cardio or cerebrovascular events (RR 1.65, 95% CI 1.38, 1.98), major bleeding (RR 2.85, 95% CI 1.96, 4.13), and contrast-induced acute kidney injury (RR 3.06, 95% CI 1.70, 5.52). CKD patients also showed lower chances of technical success (RR 0.95, 95% CI 0.91, 1.00). The presence of CKD increases the risk of mortality, complications and adversely affects the success of CTO revascularization. Patients with CKD undergoing revascularization should have their kidney function comprehensively evaluated and these patients should be carefully monitored.

Long-term outcomes of coronary artery bypass graft surgery in patients with widespread atherosclerotic lesions of the coronary and peripheral vascular basins (based on the REGATA long-term antithrombotic therapy registry)

Introduction . Multifocal atherosclerosis (MFA) in patients with CHD is a key risk factor for thrombotic complications (TC). There are little data on the long-term prognosis in patients with multivessel CHD combined with carotid artery lesions. Objective . To assess prognostic negative outcomes (thrombosis and bleeding) in patients with CHD and MFA undergoing revascularization procedures – coronary artery bypass graft surgery and, in case of high risk of ischemic stroke, carotid endarterectomy. Materials and methods . A total of 189 patients with stable multivessel coronary artery disease who successfully underwent coronary bypass graft surgery and had concomitant atherosclerosis of the carotid arteries ≥50% were included in the study. The exclusion criterion was chronic use of oral anticoagulants. The choice of antithrombotic therapy after the surgical intervention was determined by the attending physicians. The efficacy endpoint was defined as the sum of TC including cardiovascular death, acute coronary syndrome, ischemic stroke, acute lower limb ischemia, and the need for emergency revascularization of the carotid or coronary basins. BARC bleeding types 2-5 were considered as a safety endpoint. Results . The median follow-up period was 37 months. [MR 25.0; 45.0]. The cumulative incidence of TC was 11.1%, BARC 2-5 bleeding was 4.8%. One or two antiplatelet agents were prescribed at discharge in 87.3% of cases, and in 12.7% – a combination of acetylsalicylic acid (ASA) and oral anticoagulant (OAC) for up to 6 months. The incidence of thrombotic complications was not significantly different in the mono- or dual antiplatelet therapy groups. The combination therapy group (OAC + ASA) was characterized by the highest number of comorbidities. When analyzing the TC for the first 6 months. (before anticoagulant withdrawal) there was no significant difference between the groups of antiplatelet therapy and the combination of ASA and OAC (Log-Rank, p = 0.4669). The proportion of patients who survived the entire follow-up period without developing TC was significantly higher in the group compared to the initial combination therapy group: 0.83 versus 0.50 (Log-Rank, p = 0.0101). Conclusion . Despite complete revascularization, the incidence of TC during the two years of follow-up was high. In the combination therapy group, anticoagulant withdrawal led to an increased incidence of TC.

Role of Wound, Ischemia, and Foot Infection Scores in Predicting Major Limb Loss Despite Appropriate Revascularization

Background: Wound, Ischemia, and foot Infection (WIfI) scores correlate well with amputation risk in patients with peripheral vascular disease. A certain subset will eventually require a major amputation despite revascularization. These patients may be offered the option of an upfront primary amputation and early rehabilitation. We sought to assess the WIfI staging and the novel WIfI composite scoring in identifying this subgroup. Patients and Methods: Patients with lower limb peripheral vascular disease with chronic lower limb extremity wounds who underwent revascularization procedures with the intent of limb salvage were included. Retrospective data of prospectively maintained preoperative WIfI scores, details of vascular intervention and occurrence of major amputation over 1 year from April 2018 to March 2019 was collected. Follow-up data were obtained for 1 year postoperatively. Results: Hundred thirty-seven patients were included. One hundred and one underwent an endovascular procedure, 17 underwent an aortobifemoral bypass, 16 underwent an open bypass procedure, and 3 were hybrid procedures. About 16.5% (23 patients) required a major amputation despite revascularization within 6 months of intervention. The mean total component score (out of 9) in these patients who required amputation was significantly higher (7.73 vs. 5.15, P &lt; 0.05). Higher infection score preoperatively (2.17 vs. 0.88, P &lt; 0.05) and higher wound score (2.7 vs. 1.63, P &lt; 0.05) were significant. Mean ischemia scores were not significantly different between the two groups (2.87 vs. 2.65). The most common cause of amputation was infection (20 out of 23 events), and most of the amputations occurred in the first 1 month following. Three patients died within the 1-year follow-up period. Conclusion: Patients with higher total WIfI scores &gt;7, higher wound, and infection components at presentation may have poor outcomes following revascularization.

Modifiable Risk Factors and Residual Risk Following Coronary Revascularization: Insights From a Regionalized Dedicated Follow-Up Clinic.

ObjectiveTo ensure compliance with optimal secondary prevention strategies and document the residual risk of patients following revascularization, we established a postrevascularization clinic for risk-factor optimization at 1 year, with outcomes recorded in a web-based registry. Although coronary revascularization can reduce ischemia, medical treatment of coronary artery disease (CAD) remains the cornerstone of ongoing risk reduction. While standardized referral pathways and protocols for revascularization are prevalent and well studied, post-revascularization care is often less formalized.Patients and MethodsThe University of Ottawa Heart Institute is a tertiary-care center providing coronary revascularization services. From 2015 to 2019, data were prospectively recorded in the CAPITAL revascularization registry, and patient-level procedural, clinical, and outcome data are collected in the year following revascularization. Major adverse cardiovascular event (MACE) was defined as death, myocardial infarction, unplanned revascularization, or cerebrovascular accident. Kaplan-Meier curves were generated to evaluate time-to-event data for clinical outcomes by risk-factor management, and comparisons were performed using log-rank tests and reported by hazard ratio (HR) and 95% confidence intervals (CIs).ResultsA cohort of 4147 patients completed 1-year follow-up after revascularization procedure that included 3462 undergoing percutaneous coronary intervention (PCI), 589 undergoing coronary artery bypass graft (CABG), and 96 undergoing both PCI and CABG. In the year following revascularization (median follow-up 13.3 months—interquartile range [IQR]: 11.9-16.5) 11% of patients experienced MACE, with female patients being disproportionately at risk. Moreover, 47.7% of patients had ≥2 risk factors (diabetes, dyslipidemia, overweight, active smoker) at the time of follow-up, with 45.0% of patients with diabetes failing to achieve target hemoglobin (Hb) A1c, 54.8% of smokers continuing to smoke, and 27.1% of patients failing to achieve guideline-directed lipid targets.ConclusionPatients who have undergone revascularization procedures remain at elevated risk for MACE, and inadequately controlled risk factors are prevalent in follow-up. This highlights the need for aggressive secondary prevention strategies and implementation of programs to optimize postrevascularization care.

Calcium Score Predicts Mortality After Revascularization in Critical Limb Ischemia

Purpose: The calcium score is a measure of vessel wall calcification and has clinical applications when studied in different vascular beds. The presence of vascular calcification in the arteries of the lower limbs is very common in patients with peripheral arterial disease; however, its relationship with the postoperative outcomes in patients undergoing lower limb revascularization is still poorly studied. The aim of this study is to evaluate association between the calcium score of lower limbs and the postoperative outcomes in patients with peripheral arterial disease undergoing revascularization procedures. Methodology: We retrospectively analyzed 88 lower limb revascularization procedures in 72 patients with critical limb ischemia who had enhanced computed tomography for preoperative evaluation. The calcium score was calculated, from the angiographic phase of preoperative computed tomography, in the segments of the aorta, iliac, femoropopliteal, and infrapopliteal. It was also calculated the calcium score of the operated limb, and the total calcium score using a standardized method. The outcomes evaluated were the occurrence of acute myocardial infarction, amputation, patency, technical success, and death from any cause. Patients were followed up through a 12 month period. Results: Among the 88 procedures performed, 31 (43.1%) lesions were classified as Trans-Atlantic Inter-Society Consensus Document II D. There were 66 (75%) endovascular procedures, 16 (18.2%) open surgery, and 6 (6.8%) hybrid interventions. No statistically significant relationship was found between the calcium score of the segments (aorta, iliac, femoropopliteal, infrapopliteal, the operated limb, and total calcium score) and the outcomes of acute myocardial infarction, amputation, patency, and technical success in any of the periods analyzed. The calcium score of the operated limb was higher in patients who died within 30 days and 6 months (6571 vs 2590.6; p=0.026) and (5227.8 vs 2335.3; p=0.036). Conclusion: A standardized calcium score calculation method with the angiographic phase of the computed tomography is feasible and reproducible. Higher values of the calcifications of the operated limb are related to a greater chance of death in the postoperative period. The calcium score of the operated limb can be considered as a marker of clinical severity and prognosis in this group of patients