Vascular Medicine最新文献

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have demonstrated cardiovascular benefits in patients with type 2 diabetes mellitus (T2DM), but their effect on the risk of cardiovascular events and amputation in patients with chronic limb-threatening ischemia (CLTI) remains underexplored. This retrospective cohort study evaluated the association between GLP-1RA use and the 5-year risk of major amputation, all-cause mortality, and cardiovascular events in diabetic patients with CLTI.

Methods: The TriNetX real-world clinical data platform was used to identify patients with T2DM and CLTI, categorized by GLP-1RA prescription records. Propensity score matching was applied based on demographics, comorbidities, concurrent medications, and laboratory values. Cox proportional hazards, Kaplan-Meier curves, and the log-rank test were used for analysis.

Results: Among 139,173 patients with T2DM and CLTI, 17,306 patients were GLP-1RA users and 121,867 were non-GLP-1RA users. Following propensity score matching, 15,743 patients remained in each group (91% match rate). The mean age was 65.4 ± 11 years and 58.9% were men. The mean follow-up duration was 753.7 days. GLP-1RA users had a significantly lower rate of major amputation (hazard ratio [HR]: 0.745; 95% CI: 0.679-0.816; log-rank p < 0.001), all-cause mortality (HR: 0.7; 95% CI: 0.663-0.738; log-rank p < 0.001), and myocardial infarction (MI) (HR: 0.838; 95% CI: 0.792-0.886; log-rank p < 0.001). There was no difference in the risk of ischemic stroke (HR: 0.969; 95% CI: 0.906-1.036; log-rank p = 0.353).

Conclusion: The use of GLP-1RA medications is associated with a significant decrease in the 5-year risk of major amputations, all-cause mortality, and MI in diabetic patients with CLTI.

Background: In-stent occlusion (ISO) remains a significant challenge in postthrombotic syndrome (PTS), with limited histopathologic characterization.

Methods: Between January 2022 and November 2024, 19 patients with PTS (12 men; mean age 44.3 ± 12.4 years) presenting with 20 iliofemoral venous ISO underwent thrombectomy using the RevCore system. Histopathology was performed on retrieved materials from 16 limbs. Technical success, stent patency, and Villalta score were assessed. Kaplan-Meier and Cox regression identified predictors of restenosis/occlusion.

Results: Technical success was 95% (19/20 limbs). In venous stent occlusions < 3 months duration (n = 12), retrieved materials contained more fresh thrombus (40.4%, p = 0.058) and old thrombus (41.3%, p = 0.040) than in occlusions ⩾ 3 months duration (n = 4), where diffuse intimal thickening (DIT) was predominant (73.8%, p = 0.008). Severe restenosis/occlusion occurred in 60% (12/20) of limbs during a median 209.5-day follow up, with median patency of 144.5 days. Villalta scores improved from 14.8 ± 7.1 to 9.4 ± 6.8 at 1 month (p = 0.002) and 9.5 ± 6.8 at the final follow up (p = 0.001). Retrieved materials containing > 50% old thrombus had a higher restenosis/occlusion risk (p = 0.026). Common iliac vein (CIV) residual stenosis ⩾ 30% (hazard ratio (HR) = 4.103; p = 0.037) and a restored common femoral vein (CFV) flow diameter < 8.0 mm (HR = 3.871; p = 0.026) predicted severe restenosis/occlusion.

Conclusion: In PTS-related ISO, DIT predominated in occlusion ⩾ 3 months. Old thrombus, CIV residual stenosis ⩾ 30%, and a CFV flow diameter < 8.0 mm predicted restenosis/occlusion. Integrating histopathologic assessment into postthrombectomy evaluation may help tailor and optimize management strategies for iliofemoral ISO.

Background: Peripheral artery disease (PAD) is a global health challenge. Advances in artificial intelligence (AI), such as large language models (LLMs) and chain-of-thought (CoT) reasoning, offer novel approaches for clinical recommendations. This study compared the readability and guideline adherence of responses from physicians and AI for a standardized PAD case.

Methods: This cross-sectional study gathered responses from 30 specialized physicians (11 cardiologists, 19 vascular surgeons) across seven Latin American countries and 13 LLM systems (10 standard, three CoT). Both groups addressed diagnosis, treatment, risks, and prognosis; LLMs responded as vascular specialists. Responses were blindly evaluated with five validated Spanish readability indices and compared to the 2024 ACC/AHA multisocietal PAD guideline. Three experts scored guideline adherence; nonparametric tests were applied.

Results: Guideline adherence did not differ significantly between physicians (median 5.8 [3.4-7.6]) and LLMs (7.3 [4.7-9.7], p = 0.169), though CoT-LLMs achieved the highest scores (9.7 [8.5-11.0]). LLMs more often recommended supervised exercise (84.6% vs 30.0%, p = 0.002) and revascularization for quality of life (69.2% vs 20.0%, p = 0.004), whereas physicians favored cilostazol (60.0% vs 30.8%, p = 0.104). LLM responses had lower Readability μ values (46.9 vs 51.4, p = 0.012). Inter-rater reliability was highest for CoT-LLMs (intraclass correlation coefficient [ICC] = 0.98) versus physicians (ICC = 0.76).

Conclusion: LLM showed comparable guideline adherence to physicians although CoT models achieved the highest scores. The difference in physician and AI treatment preferences suggest the potential of AI as adjunct clinical tools and warrants further study.

Background: Peripheral vascular interventions (PVI) in chronic limb-threatening ischemia (CLTI) are used to prevent amputation. However, imaging practices following PVI and their correlation with amputation outcomes remain unclear. Methods: Using Medicare-linked Vascular Quality Initiative data (2017-2019), we identified imaging tests (ankle-brachial index [ABI], duplex ultrasound, magnetic resonance angiography, computed tomography angiography) ordered within 1 year post-PVI for CLTI. Site variability was assessed using median odds ratio (MOR) and intraclass correlation coefficient (ICC). The association between post-PVI imaging and 1-year major amputation was examined using competing risk analyses in a propensity-matched cohort. Results: We included 10,006 patients (mean age: 72.1 ± 11.0 years); 25.5% received no imaging. Over 50% of imaging tests were ABI and 83.1% were ordered within 3 months. Significant site variability was noted (none vs ⩾ 1: MOR 1.64, 95% CI 1.50-1.78; ICC 7.6%, 95% CI 5.2-9.9%; per one-unit increase in monthly volume: MOR 1.06, 95% CI 1.05-1.07; ICC 9.4%, 95% CI 7.0-11.8%). Having none versus ⩾ 1 imaging tests post-PVI occurred more in patients with lower 1-year major amputation rates (5.7%, 95% CI 5.0-6.6% vs 8.8%, 95% CI 7.9-9.9%, p < 0.001; subdistribution hazard ratio [SHR] 0.63, 95% CI 0.53-0.76, p < 0.001). More imaging ordered was correlated with a higher rate of major amputation (SHR 1.83, 95% CI 1.52-2.20, p < 0.001). Conclusions: Imaging practices post-PVI for CLTI are highly variable. Imaging tests are more often ordered in patients with higher amputation rates, but causality cannot be inferred. Additional information about symptom status and access to care are necessary. Standardized follow-up imaging protocols need to be developed and studied for improved clinical outcomes.

Introduction: Exercise transcutaneous oxygen pressure measurement (Exercise-TcPO₂) that has been validated with a constant-load treadmill protocol, is useful to assess patients with suspected lower-extremity peripheral artery disease (PAD). To date, nothing is known about its use with a graded protocol. The aim of this study is to compare the Exercise-TcPO₂ results obtained in patients with suspected PAD using a graded Gardner-Skinner (3.2 km/h, 2% grade increase every 2 min) versus a constant modified Strandness (3.2 km/h, 10% grade) treadmill test.

Methods: Patients with suspected PAD were assessed twice on the same day on a treadmill using the modified Strandness (Strand) followed by the Gardner-Skinner (Gard) tests. In both tests, the decrease from resting oxygen pressure (DROP) indexes were measured at the buttock and calf levels as previously validated. A DROP_Strand index ⩽ -15 mmHg was considered positive for the diagnosis of PAD. The relationship between DROP_Gard and DROP_Strand as well as DROP value differences between the two tests and concordances were studied.

Results: This prospective study included 40 patients. Using a linear mixed model, the relationship between DROP_Gard and DROP_Strand was defined as DROP_Gard = 0.647 × DROP_Strand - 1.858. The mean difference between DROP_Gard and DROP_Strand was -4.3 ± 7.3 mmHg. Positive and negative agreements were 78.0% and 86.3%, respectively. The kappa coefficient between DROP_Gard and DROP_Strand was 0.65 [0.54; 0.77].

Conclusion: Exercise-TcPO₂ results using the Gardner-Skinner and modified Strandness treadmill tests were highly correlated. This study suggests the use of a DROP_Gard value ⩽ -12 mmHg to diagnose PAD when performing Exercise-TcPO₂ with a Gardner-Skinner test. However, this cut-off value should be confirmed against an imaging gold standard. ClinicalTrials.gov identifier: NCT03186391.

This systematic review aimed to describe the association between peripheral artery disease (PAD) and cognitive impairment or dementia. We included studies reporting on the association between PAD (defined by ankle-brachial index ⩽ 0.9) and cognitive function in adult populations. MEDLINE, Embase, CINAHL, PsycINFO, and CENTRAL were systematically searched from inception to January 2025. Study quality was assessed using the Risk of Bias In Nonrandomized Studies of Exposure effects (ROBINS-E) tool. A narrative synthesis was undertaken structured by cognitive outcome and study design. Thirty-eight studies were included in the review (58,586 participants). The results provide evidence that PAD is associated with cognitive impairment. Seventeen (81%) cross-sectional studies and four (67%) longitudinal studies reported associations of PAD with poorer cognitive performance or increased risk of cognitive impairment. Impaired memory and processing speed were most frequently associated with PAD. PAD was also associated with increased dementia risk in cross-sectional (odds ratios = 1.50-2.41) and longitudinal studies (hazard ratios = 1.03-2.40), although proportionally fewer longitudinal studies reported significant association of PAD with dementia. Results suggest increased prevalence of cognitive impairment, independent of cardiovascular risk factors and cerebrovascular disease. Awareness of the prevalence of cognitive impairment and its potential impact on treatment adherence and engagement in a healthy lifestyle is important for clinicians treating patients with PAD. Screening for cognitive impairment in those with PAD may aid early diagnosis and management of cognitive impairment in this high-risk population. Further research is required to determine whether screening for and optimal management of PAD has cognitive benefits. (PROSPERO Registration No.: CRD42023399608).