Vascular Medicine最新文献

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Background: Preclinical studies have demonstrated that therapeutic ultrasound (TUS) increases perfusion in peripheral artery disease (PAD). This pilot study assessed the safety and effectiveness of a noninvasive TUS device in patients with advanced PAD.

Methods: A phased array of TUS transducers was fabricated on a wearable sleeve, designed to sonicate the posterior and anterior tibial arteries (and their collaterals) at the calf level. Twelve patients with PAD (Rutherford classes 3-5) were enrolled in a single-arm study in which they underwent 30-40 daily 90-minute TUS sessions to the diseased limb. Changes in pedal flow and tissue oxygenation (StO₂) were measured by laser speckle and spatial frequency domain imaging, respectively. A subset of five patients underwent evaluation by laser Doppler, transcutaneous oximetry (TcPO₂), and quality of life questionnaires (Vascular Quality of Life Questionnaire [VascuQoL] and the Walking Impairment Questionnaire [WIQ]).

Results: Eleven out of 12 enrolled patients completed the study. During 90-minute TUS sessions pedal flow improved by 180% (p < 0.001) on laser speckle imaging, and 18% (p = 0.12) on laser Doppler. Tissue oxygenation improved by 18% (p = 0.43) on TcPO₂ and by 6% (p = 0.097) on StO₂. After all sessions, tissue oxygenation improved by 17% (p = 0.020) on StO₂, without significant changes in laser Doppler (+39%, p = 0.41) or TcPO₂ (-3%, p = 0.70), which was largely in the normal range (56 ± 15 mmHg) at baseline. VascuQoL improved by 2.4 points (14%, p = 0.080) and WIQ improved by 8.2 points (11%, p = 0.053).

Conclusions: TUS for patients with symptomatic PAD was safe and well tolerated. Most metrics of tissue perfusion and oxygenation improved, but future sham-controlled studies are needed and planned.

Introduction: As the role of social determinants in carotid artery stenting (CAS) outcomes remains unclear, we investigated the association between the Distressed Community Index (DCI) (zip-code based) and post-CAS mortality/stroke outcomes.

Methods: We analyzed patients undergoing CAS from 2015 to 2019 using the Medicare claims-linked Vascular Quality Initiative database. Patients were grouped based on high (DCI ⩾ 60) and low (DCI < 60) community distress. We analyzed 36-month mortality using Kaplan-Meier survival curves and hierarchical Cox regression, and 36-month stroke using cumulative incidence function curves and Fine-Gray models.

Results: The final cohort included 8717 patients (3032 DCI ⩾ 60), with a mean DCI score of 46.2 (± 28.5) and mean age of 74.7 (± 7.8) years. Most participants were men (64.3%), White (92.7%), and non-Hispanic/Latino (97.7%). There was no significant difference in the 36-month mortality incidence between high and low community distress groups (25.6% vs 23.5%, p = 0.22), and no significant association between high community distress and mortality (unadjusted HR: 1.04; 95% CI 0.90-1.21; adjusted HR: 1.02; 95% CI 0.89-1.17). The high community distress group experienced an elevated 36-month stroke incidence (26.8% vs 22.4%, p = 0.048), but no significant association with stroke was observed (unadjusted sub-HR: 1.12; 95% CI 1.00-1.24; adjusted sub-HR: 1.03; 95% CI 0.92-1.16).

Conclusion: Our cohort showed underrepresentation in terms of sex, race, and ethnicity, with a skewed DCI distribution towards lower community distress. Contrary to what we know about community distress, no independent association between higher community distress and post-CAS stroke/mortality risk was found. Future work must examine whether accessibility barriers and selective CAS allocation explain our results.

Introduction: ¹⁸F-sodium fluoride (NaF) positron-emission tomography (PET) is increasingly being used to measure microcalcification in atherosclerotic disease in vivo. Correlations have been drawn between sodium fluoride uptake and the presence of high-risk plaque features, as well as its association with clinical atherosclerotic sequelae. The aim of this study was to perform a meta-analysis of NaF uptake on PET imaging and its relation to symptomatic and asymptomatic disease.

Methods: A systematic review was performed according to PRISMA guidelines, via searching the Ovid MEDLINE, Ovid Embase, Cochrane Library, PubMed, Scopus, and Web of Science Core Collection databases up to May 2024. The search strategy included the terms 'NaF', 'PET', and 'plaque', and all studies with data regarding the degree of microcalcification, as measured by ¹⁸F-NaF uptake in symptomatic and asymptomatic atherosclerotic plaques, were included. Analysis involved calculating mean differences between uptake values and comparison using a random-effects model.

Results: A total of 16 articles, involving 423 participants, were included in the meta-analysis (10 carotid artery studies, five coronary artery studies, and one in peripheral vascular disease). Comparing ¹⁸F-NaF uptake in symptomatic versus asymptomatic atherosclerotic plaques, a mean difference of 0.43 (95% CI 0.29 to 0.57; p < 0.0001, I² = 65%) was noted in studies comparing symptomatic and asymptomatic plaques in the same participant, with a significant difference in effect based on arterial territory studied (χ² = 12.68, p = 0.0018). In studies of participants with and without symptomatic disease, there was no significant difference between symptomatic and asymptomatic plaques (mean difference 0.27, 95% CI -0.26 to 0.80, p = 0.28, I² = 85%).

Conclusions: PET imaging using ¹⁸F-NaF can detect differences in microcalcification between symptomatic and asymptomatic atherosclerotic plaques within, but not between, individuals, and thus, is a marker of symptomatic disease. The standardization of ¹⁸F-NaF PET imaging protocols, and its future use as a risk stratification tool or outcome measure, requires further study. (PROSPERO Registration ID: CRD42023451363).

A carotid web (CaWeb), otherwise known as a carotid bulb diaphragm, is a spur of intimal fibrous tissue extending into the carotid bulb. It is a rare, underdiagnosed cause of ischemic strokes in young people. The purpose of this narrative review was to provide an update on CaWebs, highlighting recent evolutions in their management. We undertook a comprehensive literature search on main electronic databases - MEDLINE/PubMed, Cochrane Library, Web of Science, and EMBASE - using a dedicated equation to include studies up to February 13, 2024. We also searched for the most recent guidelines about carotid disease or stroke including CaWeb management. A CaWeb is found in up to 10% of young patients, particularly young women, with severe anterior stroke due to an arterial-arterial embolism from the intra-nidus thrombus. Most patients with a CaWeb have less than 50% stenosis on duplex ultrasound, and diagnosis is mostly obtained by computed tomography angiography. When applying traditional stenosis criteria for symptomatic disease (> 50% stenosis), this highly morbid condition is easily overlooked, leading to recurrent strokes. Antithrombotic treatment is associated with a high recurrence rate of stroke after the index event. The first-line treatment of symptomatic CaWebs is increasingly based on endarterectomy or stenting. The lack of recommendations before 2021 and recent discordant guidelines make CaWeb management complex. No guidelines are available to manage patients with asymptomatic CaWebs. Results from ongoing multicenter registries will be useful in guiding management decisions.

Introduction: Sex differences exist in risk factors and comorbidities of older adults (aged ⩾ 65 years) with pulmonary embolism (PE). Clinically relevant sex-based treatment disparities for PE have not been adequately addressed. The few existing show conflicting results due to small sample size (type II error) and suboptimal methods (overreliance on p-value, which may detect differences of small clinical relevance).

Methods: We assessed sex differences in anticoagulation and advanced therapies for PE in older adults, utilizing data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a large PE registry with predominant participation from Europe, and data from US Medicare beneficiaries. We prespecified a standardized difference (SRD) > 10% as clinically relevant. RIETE included 33,462 (57.7% female) and Medicare included 102,391 (55.0% female) older adults with PE.

Results: In RIETE, there were no overall sex differences in the use of anticoagulation (median: 181 vs 180 days, SRD < 1%), fibrinolysis (SRD < 3%), thrombectomy (SRD < 2%), or inferior vena cava (IVC) filters (SRD: 4.4%). However, fibrinolytic therapy (systemic or catheter-based) was less often used in female than male patients with intermediate-risk PE (8.0% vs 12.1%, SRD: 13.6%). No sex differences were noted with advanced PE therapies in Medicare beneficiaries. In unadjusted analyses, fibrinolysis and IVC filter placement were more frequent in Medicare than RIETE participants regardless of sex (p < 0.001).

Conclusion: In a predominantly European PE registry and a US study of older adults, there were no overall sex differences in anticoagulation patterns or advanced therapy utilization. Future studies should determine if sex disparities in fibrinolytic therapy for intermediate-risk PE and greater use of advanced therapies in US older adults correlate with clinical outcomes.

Foot ulceration is a significant and growing health problem worldwide, particularly due to rises in diabetes mellitus (DM) and peripheral artery disease. The prediction of ulcer healing remains a major challenge. In patients with foot ulcers, medial arterial calcification (MAC) can be present as a result of concomitant DM or chronic kidney disease and is a prognostic factor for unfavorable outcome. This systematic review aimed to evaluate the prognostic reliability of bedside tests to predict ulcer healing and wound healing after minor amputation in patients prone to MAC, following PRISMA guidelines. Primary endpoints were the positive and negative likelihood ratios for ulcer healing. Methodological quality and risk of bias were assessed using the QUIPS-tool. A total of 35 studies were included, predominantly investigating transcutaneous oxygen pressure (TcPO₂), followed by ankle-brachial index and toe pressure. None of these bedside tests effectively provided an acceptable trade-off between predicting healing and nonhealing. A TcPO₂ below 30 mmHg was most closely associated with nonhealing of an ulcer. The same applied to wound healing after minor amputation, in which none of the bedside tests was able to sufficiently predict healing or nonhealing. To conclude, currently used bedside tests lack acceptable prognostic performance for ulcer healing and healing after minor amputation in patients prone to MAC. Future prospective studies should establish a clear definition of ulcer healing, utilize a standardized wound classification system, and minimize patient heterogeneity. A combined assessment of microvascular and macrovascular perfusion status could improve the prediction of wound healing.