There is a paucity of data on direct comparison of clinical measures in patients with abdominal aortic aneurysm (AAA) and those with peripheral arterial disease (PAD). Here, we examine the risk factors and outcomes between these 2 conditions.

Group differences were examined by Fisher's exact tests with Bonferroni correction, postoperative complications (including delirium and pneumonia) and LOS by logistic regression, and mortality by Cox regression, adjusted for age, sex, smoking, co-morbidities and medications.

In total, 160 men and 33 women aged 74.5years (SD = 9.4) were referred for preoperative cardiac assessment for AAA (n = 70) and PAD (n = 123). Vascular surgery was performed in 148 patients (70% of AAA; 80.5% of PAD). Myocardial infarct was more prevalent in AAA, and diabetes more in PAD, whilst atrial fibrillation, stroke, congestive heart failure and hypertension did not differ between groups. Compared to patients with PAD, there were higher proportions of patients with AAA prescribed with cardiovascular medications, and developed post-operative complications in hospital: odds ratio = 7.34 (95% CI, 2.26-23.84, P < .001), and stayed in hospital >1week: odds ratio = 2.60 (95% CI, 1.15-5.85, P = .021). Compared to those with AAA, patients with PAD were at greater risk of death in the entire sample: hazard ratio = 3.34 (95% CI, 1.64-6.79), and in those who underwent vascular surgery: hazard ratio = 4.90 (95% CI, 1.88-12.79). Left ventricular function did not relate to outcomes.

Differences between AAA and PAD in risk profile and management which may have a bearing on higher risk of death associated with PAD. More intensive cardiovascular management may help improve their outcomes.

Ankle-brachial index (ABI) and carotid-femoral pulse-wave velocity (cfPWV) are well-established surrogate markers of overall cardiovascular risk. However, their prognostic value towards short- and long-term mortality in an emergency medicine setting is yet unknown.

Acutely ill medical patients systematically underwent cfPWV and ABI measurements at the emergency department of a tertiary care hospital. Patients' survival was analysed in relation to their ABI and cfPWV values at initial presentation. In total, 1080 individuals (43.7% females; 59.6 ± 17.4 years old) were enrolled. Over a median follow-up period of 24.4 months, 112 (10%) deaths were observed. 30-day mortality was 4.9% in patients with a pathological ABI and 1.4% with a normal ABI (p = .003). There was also a significant difference over the entire observational period regarding cumulative mortality (p < .001). Thirty-day mortality was 2.4% in patients with a cfPWV ≥10 m/s and .7% with a cfPWV <10 m/s (p = .025), and cumulative mortality over the whole period differed between a cfPWV ≥10 m/s and <10 m/s as well (p < .001).

In acutely ill medical patients, the noninvasive ABI and cfPWV assessment at triage level facilitates initial risk stratification in the emergency setting for short- and long-term mortality. Patients with pathological ABI and cfPWV values could thus be seen as a proxy of a sicker cohort with an overall worse polyvascular situation.

Lowering lipid to reach guideline-indicated goals significantly reduces cardiovascular outcomes in very-high-risk (VHR) patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (DM2). How well VHR patients currently achieve these goals in community practice is unknown.

VHR patients with ASCVD and DM2 were identified across 14 US healthcare systems using electronic health records between 1/1/2021-12/31/2022. Achievement of guideline-based lipid goals was determined according to the 2018 AHA/ACC/Multisociety guideline, defined as either having a low-density lipoprotein-cholesterol <70 mg/dL or receiving maximal lipid-lowering therapy (i.e., on a PCSK9i monoclonal antibody). Multivariable logistic regression was used to evaluate factors associated with the achievement of these goals.

Among 213,380 eligible patients (median age 71.0 years, 42 % women), 51.8 % achieved guideline-based lipid goals. Female sex (odds ratio [OR], 0.64; 95 % confidence interval [CI], 0.61-0.66), Black race (OR, 0.67; 95 % CI, 0.63-0.72 vs white race), and those on Medicaid (OR, 0.92; 95 % CI, 0.86-0.97 vs Medicare) were associated with a lower likelihood of achieving guideline-based lipid goals. Overall, 76.0 % of patients were on statin, 40.5 % were on a high-intensity statin and only 5.8 % were on a statin in combination with ezetimibe or a PCSK9i monoclonal antibody.

Almost half of all VHR patients with ASCVD and DM2 do not achieve current guideline lipid goals. Women, Black individuals, and those on Medicaid were significantly less likely to achieve these goals relative to their counterparts. Further targeted quality improvement interventions are needed to improve the equitable achievement of guideline-based lipid goals.

Peripheral artery disease (PAD) is one of the most prevalent forms of cardiovascular (CV) disease, with many progressing to CV morbidity/death. Adherence to guideline-directed optimal medical therapy (OMT) in PAD is vital. This study evaluated provider adherence to OMT patients with PAD.

A retrospective cohort study of 3,471 patients with PAD undergoing vascular laboratory imaging between 2017 and 2022 at a single large, academic, tertiary referral center. OMT was defined by 2016 AHA guidelines. Adherence to guidelines was denoted by active prescriptions for antiplatelet and statin. Presence of high-intensity OMT (HIOMT) was defined as prescriptions for an antiplatelet and high-intensity statin. Prevalence and incidence (change to OMT/HIOMT within 60 days of index ABI) were evaluated. Multivariable models were created evaluating predictors of OMT and HIOMT prevalence and incidence.

OMT prevalence was 45.3% while HIOMT prevalence was 23.6% at the time of index vascular laboratory. Incident OMT was 24.3% while incident HIOMT was 11.2% within 60 days. Age, min/max ABI, insurance status, smoking status, and comorbidities were associated with prevalent OMT/HIOMT. Age, gender, min/max ABI, smoking status, and HgbA1c were associated with incident HIOMT. In multivariable models, incident HIOMT was less common for females (OR 0.7; 0.52-0.91) whereas lower ABIs were predictive of HIOMT (OR 0.6; 0.51-0.72).

Despite clear guidelines regarding OMT for patients with atherosclerotic cardiovascular disease, in this real-world study of guideline directed management of PAD, adherence to OMT remains low, especially for HIOMT. Predictors of appropriate HIOMT prescription include lower ABI and non-female sex. Given the high prevalence of PAD, the heterogeneity of caregivers, and the widespread availability of screening, this population should be targeted for better adherence to HIOMT to prevent CV morbidity and death.

Although brachial access (BA) has become increasingly used in percutaneous endovascular procedures, results from head-to-head comparisons between open brachial access (OBA) and ultrasound-guided percutaneous brachial access (PBA) are limited in the literature. The objective of our multicenter, prospective, noninterventional ARCHIv BrachiAL study was to compare the safety and efficacy of OBA and PBA to perform peripheral arterial interventions.

From July 2019 to January 2021, all patients needing peripheral endovascular procedures with brachial artery access were consecutively included in the study by 15 surgeons in 14 centers. Procedures were done with 4F-8F (French gauge) introducer sheaths. Arterial closure was done by conventional arterial sutures for OBA and compression or vascular closure devices for PBA. The primary endpoint was the rate of access site complications occurring up to 30 days postoperatively. Secondary endpoints were the occurrence of adverse events and the overall rates of clinical success of BA cannulation and technical success.

Among the 251 included patients (mean age, 69.9 years; males 70.5%), 122 (48.6%) had an OBA and 129 (51.4%) had a PBA, without significant differences in baseline demographic and clinical characteristics. 38.6% of the patients had the procedure for more than one indication. Clinical success was achieved in all patients and technical success in 244 patients (97.2%). No death, cerebral, cardiac, or embolic complications were reported. Access site complications (primarily hematomas) were significantly (P = 0.02) more frequent in the PBA (8/129; 6.2%) than the OBA group (1/122; 0.8%) or when using introducer sheaths >6F for OBA or vascular closure devices for PBA.

Our prospective study confirmed the safety and effectiveness of BA and showed the benefit in terms of safety of OBA versus PBA even when PBA was ultrasound-guided and performed by trained surgeons. It encourages the use of OBA and ultrasound guidance when using PBA. Large and/or randomized studies should be performed to support these results.

Atherosclerotic peripheral artery disease (PAD), that is, arteriosclerosis obliterans, is pathologically rooted in atherosclerosis, similar to other cardiovascular diseases. In addition to smoking, hypertension, and dyslipidemia, diabetes mellitus is a major risk factor. People with diabetes mellitus have an elevated risk of developing PAD. PAD in turn increases the risk of diabetic foot ulcers and gangrene in the population. Rest pain, nonhealing ulcers, and gangrene associated with chronic ischemia are known as chronic limb-threatening ischemia (CLTI). This article gives an overview of the link between atherosclerotic PAD, particularly CLTI, and diabetes mellitus. First, the clinical impact of CLTI among patients with diabetes mellitus is presented. Second, its clinical features, including prognosis, comorbidity, occurrence, and seasonality, are mentioned. The clinical management of CLTI is also discussed. Diabetes mellitus has notable clinical impact on CLTI and vice versa. CLTI has different clinical features from those of other atherosclerotic cardiovascular diseases. Its clinical profile also differs between individuals with both diabetes mellitus and CLTI and general people with diabetes mellitus. There is considerable room for improvement in CLTI treatment and management. Clinical measures taken before revascularization, including CLTI risk assessment, prompt diagnosis, and expedited referral to vascular specialists, may enhance CLTI outcomes. Further research is warranted to obtain more evidence.

Approximately 1.4 vascular surgeons/100,000 persons are estimated to fulfill current patient needs in the United States (US), but an ongoing shortage exists. The aims of this study are to provide an updated nationwide state-by-state workforce analysis and compare the distribution of practicing vascular surgeons and training opportunities.

Vascular surgeons in the US were identified using the National Provider Identifier registry in 2023. Only board-certified and actively licensed vascular surgeons were included. To estimate the number of vascular surgery graduates per year in each state, integrated residency and fellowship-matched positions (trainees) were ascertained from the National Resident Matching Program website. Surgeons and trainees were totaled by state, and densities were calculated using the 2020 U.S. Census Bureau state populations. These 2 cohorts were also examined together using simple linear regression and geographic mapping.

This study included 3,399 board-certified vascular surgeons and 228 newly matched trainees. The average densities of vascular surgeons and trainees in the US are 1/100,000 persons and 0.06/100,000 persons, respectively. The 5 states with the lowest densities of vascular surgeons are AR, ND, NV, OK, and WY, averaging 0.4/100,000 persons. 8 states (AK, ID, KS, ND, NM, NV, RI, WY) had 0 training programs offering positions in 2023 and ranked in the lowest quartile for the number of practicing vascular surgeons. Simple linear regression demonstrated a statistically significant correlation between state rates of vascular surgeons and trainees (P < 0.001).

States with 0 training positions also have the fewest vascular surgeons per capita. Statewide attention to expanding vascular surgery training opportunities targeted in these areas could positively impact the current maldistribution and shortage of vascular surgeons.

Several studies reported an increased cancer risk related to lower-extremity peripheral artery disease (PAD) but had important caveats: not accounting for key confounders like smoking, follow-up <10 years, or no race-specific results. To assess the long-term independent association of PAD with cancer incidence in a bi-racial community-based cohort.

We categorized 13,106 ARIC participants without cancer at baseline (mean age 54.0 [SD 5.7] years, 45.7 % male, and 26.1 % Black) into symptomatic PAD (clinical history or intermittent claudication), asymptomatic PAD (ankle-brachial index [ABI] ≤0.9), and five ABI categories (0.1-interval between 0.9 and 1.3 and > 1.3). We used cancer registries and medical records to ascertain cancer cases and ran multivariable Cox models.

During the median follow-up of 25.3 years, there were 4143 incident cancer cases. 25-year cumulative incidence was 37.2 % in symptomatic PAD, 32.3 % in asymptomatic PAD, and 28.0-31.0 % in the other categories. Symptomatic and asymptomatic PAD remained significantly associated with cancer incidence after adjusting for potential confounders, including smoking and diabetes (hazard ratio [HR] 1.42 [1.05-1.92] and 1.24 [1.05-1.46], respectively). When stratified by smoking status, we observed a robust association of PAD (symptomatic and asymptomatic combined) vs. no PAD with cancer risk in ever smokers (HR 1.42 [1.21-1.67]) but not in never smokers. The results were most evident for lung cancer (HR 2.16 (95 %CI 1.65-2.83) for PAD vs. no PAD within ever smokers).

Symptomatic and asymptomatic PAD conferred cancer risk, particularly among ever smokers and for lung cancer. Patients with PAD should receive evidence-based cancer prevention and screening.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Peripheral artery disease (PAD) remains underdiagnosed in patients with coronary artery disease (CAD) and barriers persist to measure screening PAD in routine clinical practice. We assessed the prevalence of PAD in patients with CAD in Italian primary care setting using an easy automatic instrument to measure ankle brachial pressure index (ABI). A multicenter, observational study was conducted with 32 General Practitioners (GPs). Prevalence of PAD was calculated dividing the number of patients with abnormal ABI value, or with symptoms associated with PAD or history of lower limb revascularization procedures, over the total number of patients included in the study. Incidence of major CV clinical events and all-cause death was also evaluated at 12 months in both CAD and CAD + PAD groups. In total, 713 CAD patients were included in the study, 148 (20.8%) patients had also PAD, asymptomatic in nearly 15% of them (106). The 35.4% of patients had ABI value ≤ 0.9 and 46.0% > 1.3 ABI. A significantly higher incidence of major CV events and all-cause death was seen in patients with PAD than in those without. Over 80% of patients received the therapy for secondary CV prevention and difference was seen between groups. Our findings showed that the use of an easy automatic instrument to measure ABI, easily managed by nurses, allowed to detect PAD in a relevant proportion of CAD patients who otherwise would not have been recognized. This encourages performing PAD screening in primary care setting to optimize the management of major CV risk factors associated with PAD. NCTumber: NCT03921905.

Optimal medical therapy (OMT) for peripheral artery disease (PAD) is associated with decreased major amputation and mortality. OMT has several components, including antiplatelet and high-intensity statin therapy, blood pressure control, etc. While there are disparities in receipt of OMT among PAD patients, it is unknown if patients from disadvantaged neighborhoods, measured by the area deprivation index (ADI), are less likely to be on OMT.

We performed a retrospective review of patients that underwent major lower extremity amputation between 2015 and 2019 at 2 large academic healthcare systems. Primary exposure was high ADI, defined as ADI ≥60th percentile, and secondary exposure was non-Hispanic Black (NHB) race. For each analysis, the primary outcome of interest was receipt of OMT, defined here as at least one antiplatelet agent and a high-intensity statin. The exposure outcome relationship was assessed using multivariable logistic regression.

Among 354 patients with median age of 66 (interquartile range [IQR] 58-74), 267 (75.4%) were male, 219 (61.9%) identified as NHB and 116 (32.8%) as non-Hispanic White (NHW). Overall, 91 (25.7%) patients were on OMT at time of amputation despite 57.3% of the cohort being established with a vascular surgeon. Compared to those with low ADI, the category high ADI had a higher proportion of NHB patients (48.1% vs 70.3%, P = 0.001) and patients were more often hospitalized at the University-affiliated facilities (47.4% vs 63.0%, P = 0.004). High ADI was not associated with receipt of OMT prior to major amputation (adjusted odds ratio [aOR] 0.72, 95% confidence interval [CI] 0.42-1.24). In secondary analysis, NHB race was not associated with receipt of OMT. Stratification by facility type (Veterans Affairs and University-affiliated facilities) also showed no association between high ADI or race and receipt of OMT.

Neighborhood economic well-being is not associated with receipt of OMT prior to major amputation. While the absence of socioeconomic disparities is notable, the proportion of patients on OMT is suboptimal. Care processes should be critically evaluated and quality measures potentially created to improve the rate of receipt of OMT among patients at risk for amputation.

Older patients may be denied endovascular revascularization of the superficial femoral artery (SFA) for peripheral artery disease (PAD) due to concerns of worse limb outcomes than younger patients.

We assessed adverse outcomes in patients after an index revascularization stratified by age (age < 65, 65-75 years, and > 75 years) from two centers between 2003 and 2011 and followed a median 9 (25 %-75 %: 7, 11) years. Outcomes included major adverse limb events (MALE) or minor repeat revascularization, death, and major adverse cardiac and cerebrovascular events (MACCE). We used cause-specific and competing-risks analyses with clustering by patient to determine the hazard ratios (HR), sub-hazard ratios (SHR), 95 % confidence intervals (95%CI) for outcomes according to older age.

There were 253 limbs revascularized in 202 patients with a high use of lipid lowering therapy (91 %) and aspirin anti-platelet therapy (96 %). In oldest age group (>75 years), 71 limbs were revascularized and patients were less likely to be active smokers and had poorer tibial runoff than younger patients. In competing risks multivariable models, patients >75 years old had similar risks over 10 years of MALE or minor revascularization (SHR = 0.92, 95%CI = 0.53, 1.62) and MACCE (SHR = 1.12, 95%CI = 0.58, 2.18) to younger patients. All-cause death was more common in older patients (HR = 1.99, 95%CI = 1.25, 3.17).

After adjusting for the competing risk of death, patients >75 years had similar incidence of adverse limb outcomes and MACCE to younger patients after endovascular revascularization of the femoral artery. Consequently, older patients should be considered for endovascular revascularization when indicated.

Lower extremity peripheral arterial disease (PAD) presents a substantial disease burden, yet lifetime estimates remain scant. This nationwide study quantified the lifetime risk of PAD and its clinical outcomes in Denmark.

This cohort study included 4 275 631 individuals in Denmark aged 40-99 years between 1998 and 2018. We estimated the lifetime risk using a modified survival analysis method, considering death as a competing risk event.

Over a median 15.5-year follow-up, 151 846 individuals were diagnosed with PAD (median age at diagnosis 71.5 years, interquartile range 63.1-79.2). The overall lifetime risk of PAD from age 40 was 11.6% (95% confidence interval 11.6%-11.7%), decreasing from 12.9% in 1998-2002 to 10.7% in 2013-18. Males had a higher lifetime risk than females (12.8% vs. 10.5%). Socioeconomic disparities were evident, with higher risks for those with lower educational levels (risk difference 3.4%, 95% confidence interval 3.2%-3.6%) and lower income (risk difference 0.4%, 95% confidence interval 0.2%-0.5%). One year after PAD diagnosis, 21.4% had undergone lower limb revascularization, 8.0% had experienced a major amputation, and 16.2% had died. At 5 years, the corresponding proportions were 26.4%, 10.8%, and 40.8%, respectively. The risk of lower limb revascularization showed little variation by sex and socioeconomic status, whereas there was a strong socioeconomic gradient for major amputation and all-cause death.

More than one in 10 Danish individuals are diagnosed with symptomatic PAD during their lifetime. Peripheral arterial disease diagnosis is associated with high morbidity and mortality at 1 and 5 years.

The aim of this study was to determine if there is an association between statin-use and prosthetic mobility and long-term survival in patients receiving rehabilitation after major amputation for lower limb arterial disease.

A retrospective analysis of prospectively maintained data (2008-2020) from a centre for rehabilitation was performed. Patients were grouped by statin-use status and sub-grouped by the combination of statin and antithrombotic drugs (antiplatelets or anticoagulants). Outcomes were prosthetic mobility (SIGAM score, timed-up-go and 2-min walking distance) and long-term survival. Regression, Kaplan-Meier and Cox-proportional hazard analyses were performed to test associations adjusted to confounders.

Of 771 patients, 499 (64.7%) were on a statin before amputation or prescribed a statin peri-operatively. Rate of statin-use was significantly lower among female (53.3%) compared to male (68.2%) patients, P < 0.001. Statin-use was associated with significantly better prosthetic independence (53.1% vs 44.1%, P = 0.017), timed-up-go (mean difference of 4 s, P = 0.04) and long-term survival HR 0.59 (0.48-0.72, P < 0.001). Significance persisted after adjusting for confounding factors and in subgroup analyses. The combination of statin with antiplatelet was associated with the most superior survival, HR 0.51 (0.40-0.65, P < 0.001). Sensitivity analysis (exclusion of non-users of prosthesis) showed that statin-use remained a significant indicator of longer survival, maximally when combined with antiplatelet use HR 0.52 (0.39-0.68, P < 0.001).

Statin-use is associated with better mobility and long-term survival in rehabilitees after limb loss, particularly when used in combination with antiplatelets. Significantly lower rates of statin-use were observed in female patients. Further research is warranted on gender disparities in statin-use and causality in their association with improved mobility and survival.

Background: Peripheral arterial disease (PAD) is a complex, heterogeneous condition that has become a leading health concern globally. Peripheral arterial disease often co-exists with other vascular disease states, including cerebrovascular and cardiovascular disease. Optimal therapy for managing symptoms and progression of disease employs non-pharmacological, pharmacological, and contemporary revascularisation techniques to improve clinical outcomes and quality of life. However, large well-designed randomised control trials (RCT) and corresponding evidence-based guidelines for management of PAD are lacking, with current practice standards often extrapolated from evidence in coronary artery disease. Purpose: This review article aims to discuss currently accepted best pharmacological practice for PAD. Method: Relevant articles were searched between May 2023 and January 2024 through PubMed, Cochrane Library, Google Scholar and international guidelines, focusing on pharmacological management for PAD. Results: This narrative review discusses holistic pharmacological treatments for PAD.

Peripheral artery disease (PAD) is a well-described risk factor for mortality, but few studies have examined secular trends in mortality over time for patients with PAD. We characterized trends in mortality in patients with PAD in recent years among Medicare patients.

We used Medicare claims to identify patients with a new diagnosis code for PAD between January 1, 2006 and December 31, 2018 using International Classification of Diseases (ICD) diagnosis codes. The primary outcome of interest was the 1-year all-cause age-adjusted mortality rate. Our secondary outcome was the 5-year all-cause mortality rate. Multivariable regression was used to identify factors which predict mortality at 1 year.

We identified 4,373,644 patients with a new diagnosis code for PAD during the study period. Between 2006 and 2018, 1-year all-cause age-adjusted mortality declined from 12.6% to 9.9% (p < 0.001). One-year crude all-cause mortality also declined from 14.6% to 9.5% (p < 0.001). Similar results were observed for 5-year age-adjusted mortality rates (40.9% to 35.2%, p < 0.001). Factors associated with increased risk of death at 1 year included age ⩾ 85 years (hazard ratio [HR] 3.030; 95% CI 3.008-3.053) and congestive heart failure (HR 1.86; 95% CI 1.85-1.88). Patients who were regularly dispensed statins, ace-inhibitors, beta-blockers, antithrombotic agents, and anticoagulants all had lower mortality (range OR 0.36; CI 0.35-0.37 for statins to OR 0.60; CI 0.59-0.61 for anticoagulants; all p < 0.001).

Among US Medicare patients diagnosed with PAD between 2006 and 2019, 1-year age-adjusted mortality declined by 2.7%. This decline in mortality among patients with PAD occurred in the context of a younger mean age of diagnosis of PAD and improved cardiovascular prevention therapy.

Postoperative complications after major surgery, especially vascular procedures, are associated with a significant increase in costs and mortality. Previous studies evaluating general anesthesia versus regional or neuraxial anesthesia for infrainguinal bypass have produced conflicting results. The main aim of the present study is to review current evidence on the application of regional or general anesthesia in patients undergoing infrainguinal bypass surgery and its potential favorable effects on postoperative outcomes.

Patients undergoing vascular surgery often have multiple comorbidities, and it is important to outline both benefits and risks of regional anesthesia techniques. Neuraxial anesthesia in vascular surgery allows overall avoidance of general anesthesia and does provide short-term benefits beyond analgesia. Previous observational studies suggest that neuraxial anesthesia for lower limb revascularization may reduce morbidity and length of stay. However, evidence of long-term benefits is lacking in most procedures and further work is still warranted.

Neuraxial anesthesia is usually an effective anesthesia technique for infrainguinal bypass surgery. Elderly patients and those with underlying respiratory problems may display some benefit from neuraxial anesthesia. Further evaluation within institutions should be performed to identify which patients would most benefit from regional techniques. Notably, systemic antithrombotic and anticoagulation therapy is common among this population and may affect anesthetic choices.

This prospective study from October 2016 to September 2020 aimed to identify the factors associated with non-revascularization and mortality rates in patients who underwent endovascular interventions for Trans-Atlantic Inter-Society Consensus (TASC) II A/B iliac artery occlusions at the Department of Vascular Surgery.

Patients with TASC II A/B iliac artery occlusions who underwent endovascular intervention, including balloon angioplasty and stent placement, were included. The primary outcomes were factors associated with non-revascularization and mortality rate.

A total of 133 patients were enrolled in this study. Univariable analysis revealed significant associations between non-revascularization and diabetes (hazard ratio [HR]=2.61, 95% confidence interval [CI], p=0.03), chronic kidney disease (HR=16.2, 95% CI, p=0.01), and severe calcifications (HR=8.56, 95% CI, p<0.001). Subsequent multivariable analysis confirmed the significance of these factors, showing HRs of 3.04 (95% CI, p=0.02), 13.12 (95% CI, p=0.03), and 8.62 (95% CI, p<0.001), respectively. The overall mortality rate observed was 20.3%. Severe calcifications emerged as a significant risk factor for mortality in both univariable (HR=2.47, 95% CI, p=0.02) and multivariable (HR=3.01, 95% CI, p<0.001) analyses.

Severe calcifications correlate with non-revascularization and mortality, while comorbidities like diabetes mellitus and chronic kidney disease are also associated with non-revascularization. Recognizing these identified factors holds substantial promise in enhancing patient selection and procedural approaches, potentially bolstering the success rates of endovascular interventions. However, further research aimed at comprehending the underlying mechanisms and devising strategies to mitigate these risks is imperative for continued improvement in patient outcomes.

The study provides valuable insights into patient selection and procedural planning for endovascular interventions in TASC II A/B iliac artery occlusions. Identifying severe calcifications, diabetes, and chronic kidney disease as key risk factors for non-revascularization and mortality equips clinicians with essential predictive tools, potentially improving outcomes by tailoring treatment approaches. The innovation lies in highlighting the impact of comorbidities and calcification severity, offering a pathway to refine patient eligibility criteria and optimize procedural decisions. This underscores the importance of further research to develop strategies that mitigate these risk factors and enhance intervention success rates.

Inflammation is involved in the pathomechanism of vascular diseases. Pro-inflammatory cytokines are important in perioperative monitoring. The aim of the study was the perioperative assessment of biochemical tests and inflammatory markers in patients with vasculopathy, focusing on the identification of subjects prone to complications. The study was performed between 2020 and 2023 at the Clinical County Hospital in Târgu Mureș on enrolled diabetic and non-diabetic patients with vasculopathy and lower limb surgery (amputation or necrectomy). Pre- and postoperative inflammatory markers, biochemical, and hematological tests (n = 62) were performed. Positive correlation was found between preoperative C-reactive protein (CRP) and interleukin-6 (IL-6) levels, and between preoperative triglyceridemia and glycemia/cholesterolemia. Positive correlation was present between pre- and postoperative values of IL-6, tumor necrosis factor-alfa (TNF-α), CRP, and fibrinogen. Preoperative TNF-α values positively correlated with malondialdehyde (MDA) levels, postoperative TNF-α values with transaminase enzymes. Diabetic patients presented higher IL-6 results compared to non-diabetic subjects. We can conclude that dynamic assessment of inflammatory markers is appropriate for monitoring perioperative course. Half of the subjects presented moderately increased preoperative IL-6 levels, and one quarter had critically high values, which might predict prolonged hospitalization. The assessment of oxidative stress, inflammatory markers and biochemical parameters enables the identification of patients prone to complications, so they can benefit from more complex management.

Peripheral arterial disease (PAD) has been associated with suboptimal treatment, high mortality, and high amputation rates. It is unclear how the COVID-19 (coronavirus disease 2019) pandemic affected this development in a long term context.

This is a registry based, retrospective, nationwide cohort study including patients hospitalised with PAD as a main or secondary diagnosis and amputation surgery between 2012 - 2021 in Germany. Primary endpoints were population wide major and minor amputation rates, in hospital death, and in hospital mortality rates. Secondary endpoints were same admission revascularisations and in hospital death in the event of complications, i.e., failure to rescue (FTR). Pre-pandemic and pandemic trends, focusing on lockdown periods, were analysed.

A total of 365 926 patient records with PAD and amputation surgery were analysed. The median patient age was 75 years and 28.8% were female. Overall population wide amputation and in hospital mortality rates (monthly decrease -0.002/100 000, p < .001, and -0.001/100 000, p< .001, respectively) and in hospital mortality rate (8.0% for 2012 - 2014 vs. 6.5% for 2020 - 2021; p < .001) declined between 2012 and 2020. Concurrently, same admission revascularisations increased (41.0% for 2012 - 2014 vs. 47.0% for 2020 - 2021; p < .001), while FTR decreased in a subset of complications (acute ischaemia, major bleeding, compartment syndrome, and mesenterial ischaemia). In the first pandemic lockdown, there was a temporary trend change to higher major amputations rates (+0.02/100 000; p < .001) and higher in hospital mortality rates (+0.007/100 000; p < .001), which changed to a decrease as of the second lockdown (-0.03/100 000, p = .034, and -0.010/100 000, p < .001, respectively) in an interrupted time series analysis. There was no statistically significant change in observed amputation rates during lockdowns, while observed in hospital mortality rates decreased by 12.0% in the first lockdown (0.22/100 000 vs. 0.25/100 000; p = .005) compared with reference periods of the two previous years.

Between 2012 and 2021, pre-pandemic trends toward decreasing population wide overall amputation rates, fewer major amputations, more amputation related revascularisation procedures, and lower in hospital mortality were maintained despite a temporary trend to increased major amputations and in hospital mortality during the first COVID-19 related lockdown in Germany.

Background: Peripheral artery disease (PAD) is still the least studied and evaluated form in clinical practice among atherosclerotic pathologies, despite the increased mortality and comorbidities related to it. The relationship between steatotic liver disease and an increased risk of cardiovascular disease has been extensively documented. Methods: The purpose of this work is to perform a review of the evidence linking NAFLD or MASLD to PAD, and examine possible clinical scenarios that arise from this new terminology. Results: The new definition of metabolic dysfunction-associated steatotic liver disease (MASLD) includes the presence of cardiometabolic risk factors and hepatic steatosis without any other underlying causes of hepatic steatosis; this terminology, coined in the hepatological field, could generate confusion, especially in the initial stages of its diffusion and among different medical specialists. Conclusions: Some recent data in the literature have strengthened the evidence of a pathological link between hepatic metabolic alteration (NAFLD or MAFLD) and PAD.

Peripheral arterial disease (PAD) of the lower limbs is caused by atherosclerotic occlusive disease in which narrowing of arteries reduces blood flow to the lower limbs. PAD is common; it is estimated to affect 236 million individuals worldwide. Advanced age, smoking, hypertension, diabetes and concomitant cardiovascular disease are common factors associated with increased risk of PAD. Complications of PAD can include claudication pain, rest pain, wounds, gangrene, amputation and increased cardiovascular morbidity and mortality. It is therefore clinically important to use diagnostic tests that accurately identify PAD. Accurate and timely detection of PAD allows clinicians to implement appropriate risk management strategies to prevent complications, slow progression or intervene when indicated. Toe-brachial index (TBI) and toe systolic blood pressure (TSBP) are amongst a suite of non-invasive bedside tests used to detect PAD. Both TBI and TSBP are commonly utilised by a variety of clinicians in different settings, therefore a systematic review and meta-analysis of their diagnostic accuracy is warranted and highly relevant to inform clinical practice.

To (1) estimate the accuracy of TSBP and TBI for the diagnosis of PAD in the lower extremities at different cut-off values for test positivity in populations at risk of PAD, and (2) compare the accuracy of TBI and TSBP for the diagnosis of PAD in the lower extremities. Secondary objectives were to investigate several possible sources of heterogeneity in test accuracy, including the following: patient group tested (people with type 1 or type 2 diabetes, people with renal disease and general population), type of equipment used, positivity threshold and type of reference standard.

The Cochrane Vascular Information Specialist searched the MEDLINE, Embase, CINAHL, Web of Science, LILACS, Zetoc and DARE databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 27 February 2024.

We included diagnostic case-control, cross-sectional, prospective and retrospective studies in which all participants had either a TSBP or TBI measurement plus a validated method of vascular diagnostic imaging for PAD. We needed to be able to cross-tabulate (2 x 2 table) results of the index test and the reference standard to include a study. To be included, study populations had to be adults aged 18 years and over. We included studies of symptomatic and asymptomatic participants. Studies had to use TSBP and TBI (also called toe-brachial pressure index (TBPI)), either individually, or in addition to other non-invasive tests as index tests to diagnose PAD in individuals with suspected disease. We included data collected by photoplethysmography, laser Doppler, continuous wave Doppler, sphygmomanometers (both manual and aneroid) and manual or automated digital equipment.

Two review authors independently completed data extraction using a standardised form. We extracted data to populate 2 x 2 contingency tables when available (true positives, true negatives, false positives, false negatives). Where data were not available to enable statistical analysis, we contacted study authors directly. Two review authors working independently undertook quality assessment using QUADAS-2, with disagreements resolved by a third review author. We incorporated two additional questions into the quality appraisal to aid our understanding of the conduct of studies and make appropriate judgements about risk of bias and applicability.

Eighteen studies met the inclusion criteria; 13 evaluated TBI only, one evaluated TSBP only and four evaluated both TBI and TSBP. Thirteen of the studies used colour duplex ultrasound (CDU) as a reference standard, two used computed tomography angiography (CTA), one used multi-detector row tomography (MDCT), one used angiography and one used a combination of CDU, CTA and angiography. TBI was investigated in 1927 participants and 2550 limbs. TSBP was investigated in 701 participants, of which 701 limbs had TSBP measured. Studies were generally of low methodological quality, with poor reporting of participant recruitment in regard to consecutive or random sampling, and poor reporting of blinding between index test and reference standard, as well as timing between index test and reference standard. The certainty of evidence according to GRADE for most studies was very low.

Whilst a small number of diagnostic test accuracy studies have been completed for TBI and TSBP to identify PAD, the overall methodological quality was low, with most studies providing a very low certainty of evidence. The evidence base to support the use of TBI and TSBP to identify PAD is therefore limited. Whilst both TBI and TSBP are used extensively clinically, the overall diagnostic performance of these tests remains uncertain. Future research using robust methods and clear reporting is warranted to comprehensively determine the diagnostic test accuracy of the TBI and TSBP for identification of PAD with greater certainty. However, conducting such research where some of the reference tests are invasive and only clinically indicated in populations with known PAD is challenging.

Although the ankle-brachial index (ABI) presents overall satisfactory accuracy, its sensitivity in the context of screening strategies does not ensure the detection of all individuals with peripheral arterial disease (PAD), especially in clinical situations where there is calcification of the arterial media layer. This study evaluated the accuracy of ABI in screening PAD among individuals with diabetes mellitus (DM) in a community setting. An observational study included only individuals with DM. ABI measurement was performed, and the lower limb duplex ultrasound (DU) was used as the reference standard for PAD diagnosis. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR+ and LR-) of ABI were assessed. The analysis included 194 limbs from 99 participants, with a PAD prevalence identified by DU of 15.98%. ABI demonstrated an accuracy of 87.63%, with a sensitivity of 35.48%, specificity of 97.55%, PPV of 73.33%, NPV of 89.83%, LR+ of 14.46, and LR- of 0.66. ABI showed high specificity but limited sensitivity in detecting PAD among individuals with DM in a community setting. An LR- of 0.66 suggests that a normal ABI result reduces but does not eliminate the possibility of PAD, highlighting the importance of complementary diagnostic approaches to enhance accuracy in identifying PAD in high-risk patients, such as those with DM. Incorporating additional diagnostic methods may be necessary to improve the effectiveness of PAD screening in this group.

Peripheral artery disease (PAD) is a growing global epidemic. Women with PAD are at elevated risk of experiencing psychosocial stressors that influence the diagnosis, management, and course of their illness due to unique sex- and gender-based factors.

We review existing evidence for increased psychosocial risk in women with PAD with a focus on mood disorders, chronic stress, pain experiences, substance use disorders, health behaviors and illness perceptions, and healthcare access. We discuss how these factors exacerbate PAD symptomatology and lead to adverse outcomes. Existing gaps in women's vascular care are reviewed and potential solutions to bridge these gaps through psychosocial care integration are proposed. Current care paradigms for women's vascular care do not adequately screen for and address psychosocial comorbidities. Clinician education, integration of evidence-based psychological care strategies, implementation of workflows for the management of individuals with PAD and mental health comorbidities, reform to reimbursement structures, and further advocacy are needed in this space. This review provides a construct for integrated behavioral health care for women with PAD and advocates for further integration of care.

Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.

Frailty is common among cardiac patients; however, frailty assessment data from patients with peripheral arterial disease (PAD) are limited. The purpose of this observational study was to identify the prevalence and factors related to frailty in addition to unique frailty marker groupings in a cohort of sedentary adults with PAD. We grouped three PAD-relevant frailty characteristics using Fried's frailty phenotype -1) exhaustion, (2) weakness, and (3) slowness-and observed the prevalence of pre-frailty (1-2 characteristics) and frailty (3 characteristics) in the PAD cohort. Of the 106 participants, 34.9% were robust/non-frail, 53.8% were pre-frail, and 2.8% were frail. Exhaustion (33.3%) was the most occurring characteristic followed by weakness (20.0%) and slowness (5.0%). The grouping of weakness + slowness (10.0%) was the most prevalent followed by exhaustion + weakness (8.3%) and exhaustion + slowness (5.0%). Among pre-frail participants, ankle brachial index was correlated with a reduction in gait speed.

Peripheral artery disease is a major atherosclerotic disease that is associated with poor outcomes such as limb loss, cardiovascular morbidity, and death. Artificial intelligence (AI) has seen increasing integration in medicine, and its various applications can optimize the care of peripheral artery disease (PAD) patients in diagnosis, predicting patient outcomes, and imaging interpretation. In this review, we introduce various AI applications such as natural language processing, supervised machine learning, and deep learning, and we analyze the current literature in which these algorithms have been applied to PAD.

Aortoiliac occlusive disease (AIOD) has traditionally been repaired with open surgery. However, with advancements in endovascular devices and techniques, many have adopted endovascular first approach, even for complex lesions. Stenting is the fundamental technique for endovascular treatment of AIOD, has been proven to be effective and safe. However, different types of stents may have different outcomes based on patient anatomy, lesion characteristics, and location. Intravascular lithotripsy is another device which may provide value in the setting of AIOD. This paper summaries current evidence and literature on outcomes of aortoiliac stenting and use of IVL in the treatment of AIOD.

Although ankle-brachial index (ABI) and photoplethysmography (PPG) have also shown adequate sensitivity in detecting peripheral arterial disease, their diagnostic performance is less reliable in asymptomatic cases or those with high atherosclerotic cardiovascular risks.

We evaluated 130 participants using ABI, PPG, and duplex ultrasonography, diagnosing 65 with peripheral arterial disease. From the PPG, we derived 2 parameters: PPG amplitude ratio of the lower-to-upper extremities (PPGratio) and the PPG amplitude of the lower extremity (PPGamp). Sensitivity, specificity, accuracy, and the area under receiver operating characteristic (ROC) curve were calculated for PPG parameters and ABI, and their combination of both methods. Univariate and multivariate logistic regression assessed the prognostic potential of these parameters. ROC analysis revealed optimal cutoff values in diagnosing peripheral arterial disease were 0.417 for PPGratio and "58" for PPGamp. Both PPGratio and PPGamp demonstrated significantly higher sensitivities, 78.4% and 75.7%, respectively, compared with 55.9% for ABI <0.9 (P<0.05). The areas under the ROC curves of combination models, including model 1 (ABI <0.9 and PPGratio), model 2 (ABI <0.9 and PPGamp), and model 3 (ABI <0.9, PPGratio, and PPGamp), exhibited improved performance with areas under the ROC curves of 0.922, 0.922, and 0.931 (all P<0.01) compared with ABI alone (area under the ROC curve, 0.822). Additionally, the PPG parameters, both alone and combined with ABI, were associated with major adverse cardiac events and all-cause mortality after adjusting for other relevant factors.

On the basis of duplex ultrasonography, combining ABI and PPG markedly improves peripheral arterial disease diagnosis in high-risk individuals compared with either method alone and provides crucial insights into major adverse cardiac events and all-cause mortality risks.

Cancer therapy is considered to cause accelerated ischemia. Ankle-Brachial Index (ABI) measurement is an inexpensive, simple, available test for the early diagnosis of peripheral artery disease (PAD); however, it is not performed routinely. We aimed to evaluate the role of routine ABI measurement for the diagnosis of PAD among patients diagnosed with cancer and whether it correlates with left ventricular (LV) dysfunction.

A retrospective, single-center study including patients diagnosed with cancer at Tel Aviv Sourasky Medical Center. The cohort included patients performing routine ABI and LV global longitudinal strain (GLS) echocardiography. The primary endpoint was the prevalence of PAD and whether it correlates with LV dysfunction, defined by LV GLS absolute value < 19%. The secondary composite endpoint evaluated the association between reduced ABI to LV dysfunction and all-cause mortality.

Among 226 patients, PAD was diagnosed in 14 patients (6%). We revealed a positive correlation between ABI and LV GLS (r = 0.22, p < 0.01) with a reduced mean ABI score among patients with reduced LV GLS. A reduced mean ABI was observed among the positive composite endpoint group; however, it was not statistically significant (p = 0.35).

We report, for the first time to our knowledge, the routine use of ABI testing among patients diagnosed with cancer. ABI showed a significant correlation to LV GLS, implying a potential tool in the early diagnosis of atherosclerosis and cardiotoxicity. Considering its low cost and availability, future prospective trials are needed to integrate its role in routine assessment.

Peripheral artery disease (PAD) is an atherosclerotic occlusive disease of the lower extremities and is associated with an increased risk of amputation and cardiovascular events. The interplay between diabetes and PAD is complex, influenced by shared risk factors such as hypertension, dyslipidemia, and smoking. High rates of undiagnosed diabetes, coupled with barriers to accessing care, contribute to the complexity of managing PAD. Unique to the Sub-Sahara region is associations with communicable diseases such as human immunodeficiency virus and tuberculosis which further complicates the epidemiological landscape. Comprehensive management strategies, including lifestyle modifications, pharmacological interventions, and revascularization procedures, are essential. However, the region faces challenges such as inadequate healthcare infrastructure and high costs of treatment. This narrative review highlights the epidemiology of PAD in people with diabetes, the risk factors associated with PAD, the impact of PAD on the morbidity and mortality of individuals with diabetes, as well as the management of PAD in individuals with diabetes, with attention geared toward Sub-Saharan Africa These insights are critical for developing effective strategies to mitigate the burden of PAD in diabetes, especially in Sub-Saharan Africa. Further research is essential to understand the associations between diabetes and other diseases in the region.

Antiplatelets and statins therapies are associated with improved cardiovascular outcomes following major vascular intervention. Many vascular surgery institutions are reporting improved prescribing rates for aspirin (ASA), P2Y12 antagonists, and statins. Nevertheless, there remains limited publication describing rates and patient-perceived barriers for postoperative adherence. The purpose of this study is to investigate patient nonadherence to antiplatelet and statin therapies following major vascular intervention.

A retrospective review of patients who underwent major vascular intervention at a single academic center was performed. The prescribing rates of ASA, P2Y12 antagonists, and statins were reviewed. Postoperative adherence, defined as consistent intake as prescribed, was evaluated at 1, 3, 6, 9, and 12 months using electronic documentation of both follow-up clinic appointments and phone call assessments, then corroborated with pharmacy fulfilment records. Patient-reported barriers to medication adherence were also examined.

A total of 101 subjects underwent major vascular intervention between January 2020 and July 2020, 98% of whom were discharged on at least 1 antiplatelet or statin agent. Approximately 90% of patients were discharged with ASA, 32% with a P2Y12 antagonist, and 96% with a statin. All patients who maintained adherence up to 6 months continued to report adherence at 9 and 12 months. Consistent adherence at 12 months was documented in 76% of patients on ASA, 81% on P2Y12 antagonism therapy, and 73% on statins. New adverse drug reactions represented the most common barrier to achieving adherence (37% [n = 20]). Preoperative therapy with ASA, P2Y12 antagonists, and statins were all independently predictive of postoperative adherence to the same regimen (P ≤ 0.001). The female gender was also associated with higher rates of adherence to postoperative P2Y12 antagonism therapy (P ≤ 0.05).

The current prescribing rates for antiplatelet and statin agents are promising, but postoperative nonadherence remains a multifaceted issue.

There is a dearth of research on immunophenotyping in peripheral artery disease (PAD). This study aimed to describe the baseline characteristics, immunophenotypic profile, and quality of life (QoL) of participants with PAD in the Project Baseline Health Study (PBHS).

The PBHS study is a prospective, multicenter, longitudinal cohort study that collected clinical, molecular, and biometric data from participants recruited between 2017 and 2018. In this analysis, baseline demographic, clinical, mobility, QoL, and flow cytometry data were stratified by the presence of PAD (ankle brachial index [ABI] ≤0.90).

Of 2,209 participants, 58 (2.6%) had lower-extremity PAD, and only 2 (3.4%) had pre-existing PAD diagnosed prior to enrollment. Comorbid smoking (29.3% vs 14%, P < .001), hypertension (54% vs 30%, P < .001), diabetes (25% vs 14%, P = .031), and at least moderate coronary calcifications (Agatston score >100: 32% vs 17%, P = .01) were significantly higher in participants with PAD than in those with normal ABIs, as were high-sensitivity C-reactive protein levels (5.86 vs 2.83, P < .001). After adjusting for demographic and risk factors, participants with PAD had significantly fewer circulating CD56-high natural killer cells, IgM+ memory B cells, and CD10/CD27 double-positive B cells (P < .05 for all).

This study reinforces existing evidence that a large proportion of PAD without claudication may be underdiagnosed, particularly in female and Black or African American participants. We describe a novel immunophenotypic profile of participants with PAD that could represent a potential future screening or diagnostic tool to facilitate earlier diagnosis of PAD.

NCT03154346, https://clinicaltrials.gov/ct2/show/NCT03154346.

Peripheral arterial disease (PAD) indicates generalised atherosclerotic disease but is often asymptomatic. The prevalence and potential risk factors of PAD were studied in ECHORN cohort study participants.

Representative samples of community-dwelling people ≥40 years of age residing in Barbados, Puerto Rico, Trinidad, and the USVI were recruited. The survey included questions on diabetes, hypertension, heart disease and smoking status. Body Mass Index, HbA1c, blood glucose and lipids were determined. Ankle brachial index (ABI) was evaluated in one leg. An oscillometric device measured arm and leg systolic BP simultaneously. ABI classifications were PAD ≤0.90, borderline 0.91 to 0.99, normal 1.00 to 1.40, and non-compressible >0.40. Multivariable logistic regression tested associations of potential risk factors with PAD.

Of 2772 participants (mean age 57.3, 65.2% female), 35.8% were overweight, 38.1% obese, 32.4% had diabetes, 60% hypertension, and 15.4% reported heart. ABI prevalence (95% CI) by category was PAD 4.4% (3.6%, 5.1%), borderline 5.2% (4.4%, 6.1%), normal 87.0% (85.8%, 88.3%) and noncompressible 3.4% (2.7%, 4.0%). Female sex (OR 1.72, 95% CI 1.07 to 2.77), diabetes (OR 2.23, 95% CI 1.47 to 3.4), heart disease history (OR 1.74, 95% CI 1.07 to 2.83) and less than high school education vs having a university degree (OR 2.49, 95% CI 1.19 to 5.22) were independently associated with PAD.

Testing one leg only would underestimate PAD prevalence. Increasing the ABI cutoff for identifying PAD to <1.0 when using oscillometric devices is suggested by some studies but would more than double the estimated prevalence. Guidelines need to address this issue. Female sex and lower educational attainment are important considerations when screening. While diabetes and a history of heart disease were confirmed as risk factors, the lack of association of increasing age and cigarette smoking with PAD was unexpected.

Peripheral artery disease is a common condition caused by narrowing/blockage of the arteries, resulting in reduced blood supply. Peripheral artery disease is associated with an increased risk of vascular complications, but early treatment reduces mortality and morbidity. Leg ulcers are long-lasting wounds, usually treated by compression therapy. Compression therapy is not suitable for people with peripheral artery disease, as it can affect the arterial blood supply. In clinical practice, people with peripheral artery disease are identified by measurement of the ankle-brachial pressure index using a sphygmomanometer and manual Doppler device. However, this method can be uncomfortable for people with leg ulcers and automated devices have been proposed as a more acceptable alternative. The objective of this appraisal was to summarise the clinical and cost-effectiveness evidence on the use of automated devices to detect peripheral artery disease in people with leg ulcers.

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To identify reports of relevant studies, we searched major electronic databases and scrutinised the information supplied by the manufacturers of the automated devices under investigation. Due to the lack of evidence on people with leg ulcers, we considered evidence from studies of any design assessing automated devices versus an acceptable reference device in any population receiving ankle-brachial pressure index assessment. We summarised information on diagnostic accuracy of the automated devices and level of agreement with the reference device. For each device, when data permit, we pooled data across studies by conducting random-effects meta-analyses using a Hierarchical Summary Receiving Operating Characteristics model.

An economic model comprising a decision tree (24 weeks) and Markov models to capture lifetime costs and quality-adjusted life-years associated with venous, arterial and mixed aetiology disease in leg ulcer patients. Analyses were conducted from a United Kingdom National Health Service and Personal Social Services perspective. Costs and quality-adjusted life-years were discounted at 3.5% per year. Deterministic and several probabilistic analyses were used to capture uncertainty surrounding a range of optimistic and pessimistic assumptions about the impact of automated tests on health outcomes (ulcer healing and requirement for invasive management of arterial disease).

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From the 116 records retrieved by the electronic searches, we included 24 studies evaluating five devices (BlueDop Vascular Expert, BOSO ABI-System 100, Dopplex Ability, MESI ankle-brachial pressure index MD and WatchBP Office ABI). Two studies assessing people with leg ulcers found that automated devices often gave higher ankle-brachial pressure index readings than manual Doppler (underestimation of arterial disease). In the 22 studies involving people without leg ulcers, automated devices generally demonstrated good specificity and moderate specificity. Meta-analysis of 12 studies showed a pooled sensitivity of 64% (95% confidence interval 57% to 71%) and a pooled specificity of 96% (95% confidence interval 92% to 98%) for detection of peripheral artery disease.

Automated devices cost less than manual Doppler to deliver. However, increased risks of invasive treatment requirements for inappropriately compressed arterial/mixed ulcers due to false-negative results, and increased healing times due to delayed compression of false-positive test results mean that in most scenarios manual Doppler was less costly and had slightly higher quality-adjusted life-years than automated devices. Results are highly uncertain, dependent on many assumptions and should be interpreted cautiously.

The limited evidence identified for each automated device, especially in people with leg ulcers, and its clinical heterogeneity precludes any firm conclusions on the diagnostic performance and cost-effectiveness of these devices in clinical practice.

This study is registered as PROSPERO CRD42022327588.

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135478) and is published in full in Health Technology Assessment; Vol. 28, No. 37. See the NIHR Funding and Awards website for further award information.

Lower extremity peripheral artery disease (PAD) is a cardiovascular condition manifesting from narrowed or blocked arteries supplying the legs. Gait is impaired in patients with PAD. Recent evidence suggests that walking with carbon fiber ankle foot orthoses (AFOs) can improve patient mobility and delay claudication time. This study aimed to employ advanced biomechanical gait analysis to evaluate the impact of AFO intervention on gait performance among patients with PAD. Patients with claudication had hip, knee, and ankle joint kinetics and kinematics assessed using a cross-over intervention design. Participants walked over the force platforms with and without AFOs while kinematic data was recorded with motion analysis cameras. Kinetics and kinematics were combined to quantify torques and powers during the stance period of the gait cycle. The AFOs effectively reduced the excessive ankle plantar flexion and knee extension angles, bringing the patients' joint motions closer to those observed in healthy individuals. After 3 months of the AFO intervention, the hip range of motion decreased, likely due to changes occurring within the ankle chain. With the assistance of the AFOs, the biological power generation required from the ankle and hip during the push-off phase of walking decreased. Wearing AFOs resulted in increased knee flexor torque during the loading response phase of the gait. Based on this study, AFOs may allow patients with PAD to maintain or improve gait performance. More investigation is needed to fully understand and improve the potential benefits of ankle assistive devices.

Although the correlation between hyperuricemia and cardiovascular disease (CVD) is well known, there have been limited data regarding the impact of hyperuricemia on long-term clinical outcomes in patients with peripheral arterial disease (PAD) after percutaneous transluminal angioplasty (PTA).

A total of 718 patients who underwent PTA for PAD were enrolled. The patients were divided into the hyperuricemia group (N = 168) and the normal group (N = 550). Hyperuricemia was defined as a uric acid level ≥ 7.0 mg/dL in men, and ≥ 6.5 mg/dL in women. The primary endpoint was major adverse cerebral and cardiovascular event (MACCE), including death, myocardial infarction (MI), any coronary revascularization, and stroke, up to 5 years. The secondary endpoint was major adverse limb event (MALE), including any repeated PTA, and target extremity surgery (TES). Inverse probability weighting (IPTW) analysis, derived from the logistic regression model, was performed to adjust potential confounders.

After IPTW matching analysis, compared to the normal group, the hyperuricemia group was not associated with increased MACCE but was associated with an increased incidence of MI (2.6 % vs. 0.5 %, p = 0.001), and coronary revascularization (6.7 % vs. 3.9 %, p = 0.018). Also, the hyperuricemia group was associated with a higher incidence of MALE (45.3 % vs. 28.9 %, p < 0.001), including target extremity revascularization (TER; 25.1 % vs. 15.9 %, p < 0.001), non-TER (11.5 % vs. 5.6 %, p < 0.001), and TES (22.8 % vs. 16.2 %, p = 0.002).

In the present study, hyperuricemia was associated with worse clinical outcomes in PAD patients following PTA during 5-year clinical follow-up. Further investigations should be made regarding the clinical benefit of controlling hyperuricemia on clinical outcomes.

Patients with diabetes mellitus (DM) are at increased risk for peripheral artery disease (PAD) and its complications. Arterial calcification and non-compressibility may limit test interpretation in this population. Developing tools capable of identifying PAD and predicting major adverse cardiac event (MACE) and limb event (MALE) outcomes among patients with DM would be clinically useful. Deep neural network analysis of resting Doppler arterial waveforms was used to detect PAD among patients with DM and to identify those at greatest risk for major adverse outcome events.

Consecutive patients with DM undergoing lower limb arterial testing (April 1, 2015-December 30, 2020) were randomly allocated to training, validation, and testing subsets (60%, 20%, and 20%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict all-cause mortality, MACE, and MALE at 5 years using quartiles based on the distribution of the prediction score.

Among 11,384 total patients, 4211 patients with DM met study criteria (mean age, 68.6 ± 11.9 years; 32.0% female). After allocating the training and validation subsets, the final test subset included 856 patients. During follow-up, there were 262 deaths, 319 MACE, and 99 MALE. Patients in the upper quartile of prediction based on deep neural network analysis of the posterior tibial artery waveform provided independent prediction of death (hazard ratio [HR], 3.58; 95% confidence interval [CI], 2.31-5.56), MACE (HR, 2.06; 95% CI, 1.49-2.91), and MALE (HR, 13.50; 95% CI, 5.83-31.27).

An artificial intelligence enabled analysis of a resting Doppler arterial waveform permits identification of major adverse outcomes including all-cause mortality, MACE, and MALE among patients with DM.