Vasa-european Journal of Vascular Medicine最新文献

Background: Dual-pathway inhibition (DPI) with aspirin and rivaroxaban exhibited a net clinical benefit for patients with cardiovascular disease in the randomized COMPASS trial. The non-observational, international XATOA registry showed that the COMPASS results can be reproduced in clinical practice in patients with coronary artery disease (CAD) and peripheral artery disease (PAD). Here we report patient characteristics and clinical outcomes for the subgroup of German PAD patients of the XATOA registry and compare them to COMPASS PAD patients. Patients and methods: XATOA was an international prospective registry of patients receiving DPI with a mean follow-up period of 15 months. The subgroup of German patients with PAD in XATOA comprised 1,819 patients, of which 925 patients (50.9%) had only PAD and 894 patients (49.1%) had both CAD and PAD. Patient characteristics such as prior medical history and prior medications as well as clinical outcomes such as incidences of major adverse limb events (MALE), major adverse cardiovascular events (MACE) and major bleeding events were assessed. Results: DPI was well-tolerated in clinical practice. Patient characteristics and clinical outcomes especially for patients with only PAD differed from characteristics and outcomes of the overall German XATOA population as well as the PAD subgroup of COMPASS. Patients with only PAD were markedly less supplied with lipid-lowering agents and betablockers. Incidences of MALE were high in German PAD patients of XATOA (9.0%) and markedly higher than in the PAD subgroup of COMPASS (1.2%). Incidences of MACE and major bleeding events were lower in German PAD patients of XATOA (MACE: 2.9%, major bleeding: 1.4%) than in PAD patients of COMPASS (MACE: 5.1%, major bleeding: 3.1%). Conclusions: DPI with rivaroxaban and aspirin is well-tolerated by PAD patients in German clinical practice. PAD patients in Germany exhibit different characteristics and show a different clinical outcome profile than PAD patients in COMPASS.

Background: Intermittent negative pressure is an emerging treatment for lower limb vascular disease but the specific physiological effects, particularly upon large artery haemodynamics are unclear. This study examined the influence of intermittent negative pressure upon popliteal artery shear rate during both supine and sitting postures. Participants and methods: Eleven healthy participants (5 female; age: 28.3 ± 5.8 y; weight: 69.6 ± 9.8 kg, height: 1.75 ± 0.07 m) received intermittent negative pressure (-37 mmHg; 9.5-sec on, 7.5-sec off), upon the lower leg during both supine and sitting postures. Popliteal artery blood flow and shear rate were recorded (duplex ultrasound), accompanied by heart rate (3-lead ECG) and blood pressure (volume clamp method). Results: Compared to sitting, a supine posture led to greater mean shear rate during baseline (supine: 21[9]; sitting: 17[13] sec^-1; all median [IQR]) and negative pressure phases (supine: 24[15]; sitting: 17[14] sec^-1; both p<0.05). While supine, negative pressure raised mean shear rate above baseline levels (p<0.05) and reduced it upon return to atmospheric pressure (p < 0.05). In sitting, mean shear rate only differed from baseline at the points of peak and minimum shear (peak:18[17]; minimum: 10[9] sec^-1; both p<0.05). Shear pattern (oscillatory shear index) showed changes from baseline during both postures (p<0.05), but was not different between postures. Conclusions: Intermittent negative pressure influenced lower limb popliteal artery shear rate during both the supine and sitting postures, the effect was greater while supine. Fluctuation in shear pattern seen during both positions may account for positive clinical effects observed following intermittent negative pressure treatment. These findings are framed against previous work investigating clinical populations. Future work should investigate any differences in lower limb haemodynamics and markers of endothelial function among patients with vascular disease.

Background: Infrapopliteal endovascular interventions (EVT) strategies in diabetic patients are still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this all-comers study was to analyse the outcome of two different infrapopliteal EVT strategies (Group I: angiosome-based direct revascularization - DR vs. Group II: complete (direct + indirect) revascularization strategy - CR) in diabetic patients with chronic limb-threatening ischemia (CLTI) in 2 time-periods. Furthermore we analysed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA). Patients and methods: The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts. 24 female, 44 male, mean age 73±10 years) between 2013-2016 and 2017-2022. Positive clinical outcome was defined as wound healing with or w/o minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test. Results: Successful DR (59%) and successful CR (47%) strategy demonstrated a similar positive clinical outcome (92.6% vs. 90.5%; p=0.594). Indirect revascularization (Group I: 26%; Group II: 44%) showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33.3% vs. 92.6%, p=0.0003; 40% vs 90.5%, p=0.001). IR outcome improved by the presence of collaterals (66.7% vs. 30.8%). Conclusions: In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch on the clinical outcome are important in patients in whom only IR was possible.

Background: To evaluate the impact of polypharmacy, defined as the concurrent use of five or more medications, on the clinical outcomes of patients undergoing revascularisation for symptomatic peripheral arterial disease (PAD). Patients and methods: This is a retrospective analysis of consecutive PAD patients treated by surgical, endovascular or hybrid therapy in a tertiary center between January 2017 and December 2017. The composite of amputation and/or death (amputation-free survival; AFS) was the primary endpoint. Mortality, major limb amputation, risk for Major Cardio-Cerobro-vascular Events (MACCE) and re-intervention during follow-up were additionally analyzed. Results: A total of 560 patients (369 male, 66%) were included. Mean age was 72.43 ± 38.67, while the main indication for treatment was lifestyle limiting claudication (330 patients, 59%). Most patients (434, 78%) were treated with endovascular means, and the commonest anatomical site of intervention was the femoropopliteal arterial segment (449 patients, 80%). A total of 409 (73%) met the criteria for polypharmacy. Cox regression analysis showed that polypharmacy was an independent predictor of death (exp: 4.72, p=0.008), MACCE (exp: 2.82, p=0.001), re-intervention (exp 1.51, p=0.0016) and of the composite outcome of AFS (exp: 3.46, p=0.021) but not of major amputation (exp: 1.26, p=0.686). Propensity-score matching analysis showed that even when controlling for comorbidity and procedural characteristics, polypharmacy is associated with a higher risk of cardiovascular death (p<0.001), MACCE (p<0.001), and re-intervention (p=0.001). Conclusions: In this study, polypharmacy was associated with unfavourable clinical outcomes for patients undergoing revascularisation for symptomatic PAD, without influencing the risk for major limb amputation.

Background: Thromboangiitis obliterans (TAO) is a rare but threatening disease associated with significant morbidity and mortality. The pathophysiology is poorly understood, the diagnosis is often obscure and causal treatment options are limited. In the current study, we aimed to identify distinct TAO patient clusters that differed in clinical presentation and prognosis. Patients and methods: We retrospectively analysed a cohort of 48 patients with the working diagnosis TAO who were assessed for clinical presentation at hospital admission. We applied hierarchical clustering to divide patients into clinically meaningful subgroups. Results: Patients were followed-up for a median of 95 months. We found that cluster analyses including a variety of demographic and diagnostic parameters were valuable to identify patient subgroups with similar clinical presentation, but with different clinical course of the disease, including the individual risk for mortality and major amputation. Patients treated with statins showed a significantly better survival, which may allow us to hypothesize that a conventional secondary prevention strategy, which is recommended for atherosclerotic artery diseases, may be of benefit also in patients that present with TAO. Conclusions: The current data may help to develop strategies to identify high-risk TAO patients. Furthermore, statins may serve as a readily available therapeutic option to this rare but serious disease.

Background: The OAC³-PAD bleeding risk score was developed to assess the bleeding risk in patients with peripheral arterial disease (PAD), however its performance in patients treated exclusively with endovascular revascularisation has not yet been tested. We aimed to externally validate the bleeding risk score for this patient cohort. Patients and methods: A retrospective observational study, analysing the data of all PAD patients successfully treated with endovascular revascularisation in a single centre within a five-year period. The performance of the Cox proportional hazards (CPH) model, upon which the OAC³-PAD bleeding risk score is based, was tested using calibration methods, discrimination, and a scaled Brier score for overall performance. The OAC³-PAD bleeding risk score was calculated for all patients, classifying them into the four respective risk groups. Kaplan-Meier curves were plotted for all risk groups and discrimination was tested using log-rank tests. Results: While discrimination of the CPH model was adequate, calibration of the model was poor and the scaled Brier score was 3.27% (95% CI 0.65%-4.40%). Of the 1,434 patients, 33 (2.3%) experienced a major bleeding event. The frequency of bleeding was 0.4% in the low risk group (3/736 patients), 0.8% in the low-to-moderate risk group (2/243 patients), 5.8% in the moderate-to-high risk group (15/258 patients), and 6.6% in the high risk group (13/197 patients). The OAC³-PAD score successfully discriminated each of the two lower bleeding risk groups from one of the two higher risk groups, but failed to discriminate among the two lower risk groups and the two higher risk groups, respectively. Conclusions: Although the OAC³-PAD score did not stratify patients into the four respective risk groups, it allowed discrimination between the low risk patients and the high risk patients. It could therefore become a useful tool for predicting major bleeding events in patients with PAD after endovascular revascularisation.

Background: Bifemoral arterial access is common in patients undergoing transcatheter aortic valve implantation (TAVI), with a primary treatment access (TAVI access) and a secondary non-TAVI access. Pseudoaneurysm (PSA) is an important complication of femoral arterial puncture. Major vascular complications after TAVI are well described, but little is known about PSA. Patients and methods: A total of 2063 patients underwent transfemoral TAVI between January 2014 and January 2020. Vascular ultrasound of the common femoral artery was assessed before and after TAVI. We compared patient characteristics, periprocedural risk scores, procedural characteristics, and access site bleeding events according to Valve Academic Research Consortium 3 (VARC-3) criteria, length of stay (LOS), and all-cause mortality at one year between patients with (46) and without (2017) PSA. Results: The incidence of PSA after TAVI was 2.2% (46/2063). All PSA were successfully treated with ultrasound-guided manual compression (UGMC) or thrombin injection (UGTI) without complications. Patients with PSA had lower platelet counts (210×1000/μl vs. 234×1000/μl; p<0.05), more heart failure symptoms on admission (91% vs. 25%; p<0.05), were more often treated with (N)OACs for atrial fibrillation (AF; 54% vs. 38%; p <0.05), and were less often treated with aspirin (35% vs. 51%; p<0.03). Multivariate analysis identified secondary access site (odds ratio [OR] 8.11; p<0.001) and (N)OAC therapy (OR 1.31; p = 0.037) as risk factors for PSA development. PSA is associated with VARC-3 type 1-3 access site bleeding and longer LOS (15.2 ± 11.3 d vs. 11.6 ± 8.9 d; p<0.01), but this did not affect one year mortality (17% vs. 14%; p = 0.53). Conclusions: Pseudoaneurysms are an important complication after TAVI and are associated with access site bleeding and prolonged hospital stay. (N)OAC therapy and secondary access are important risk factors. Pseudoaneurysms can be safely and effectively treated with thrombin injection and do not affect one-year mortality.

Background: Walking rehabilitation is the cornerstone of patients with peripheral arterial disease (PAD) treatment. In order to propose a personalised walking rehabilitation program to each patient, it is important to know the PAD-patients walking characteristics. Such data are lacking in the literature. The aim of this study was to analyse the spontaneous walking characteristics of PAD patients. Patients and methods: This study was conducted between May 2016 and March 2018. Walking characteristics (cadence, stride, number of daily walking episodes, duration of an episode, distance covered during an episode, daily total walking duration and distance, walking speed) were recorded by Withings Pulse O2® activity trackers for one week in patients with asymptomatic or symptomatic PAD. Walking intensity was classified as ambling pace (<2 METs), slow walking (2-3 METs) and active walking (>3 METs). Study protocol has been approved by an independent ethics committee. Results: Eighty-seven patients were included (males 87%, mean age 66 ± 9 years, intermittent claudication 86%, right ankle brachial index (ABI) = 0.80 ± 0.19 and left ABI = 0.79 ± 0.15). The mean recording duration was 8 ± 1.2 days. Most of the steps were shuffling pace (shuffling pace 55.7%, active walking 32.8%, slow walking 11.5%). There was no significant difference between weekdays and weekend days nor for cadence, stride, episode duration, distance covered during an episode, number of daily walking episodes, daily total walking duration and distance. The average duration of active walking episodes was 3 minutes. Duration of active walking was less than 3 minutes in 66% of patients with a mean duration of 1 minute and 55 seconds. Conclusion: Analysis of PAD patients spontaneous walking characteristics with an activity tracker can get the maximum active walking duration achieved by each patient and be useful to offer a personalised walking rehabilitation program.