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Annals of Vascular Surgery May 2024Intravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear...
BACKGROUND
Intravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear if IVUS use improves clinical outcomes of peripheral vascular interventions (PVIs) for peripheral arterial disease. This study aimed to evaluate the impact of IVUS on 1-year outcomes of PVI in the vascular quality initiative (VQI).
METHODS
The VQI-PVI modules were reviewed (2016-2020). All patients with available 1-year follow-up after lower extremity PVI were included and grouped as IVUS-PVI or non-IVUS PVI based on use of IVUS. Propensity matching (1:1) was performed using demographics and comorbidities. One-year major amputation and patency rates were compared. A generalized estimating equation model was used to identify predictors of 1-year outcomes. Subgroup analysis based on Trans-Atlantic Intersociety Consensus (TASC) classification, treatment length and treatment modalities were performed using same modeling approaches.
RESULTS
There were 56,633 procedures (non-IVUS PVI = 55,302 vs. IVUS-PVI = 1,331) in 44,042 patients. Propensity matching yielded a total cohort of 1,854 patients matched (1:1), with no baseline differences. Lower extremity revascularization for claudication was performed in 60.4%, while one-third (33.9%) had chronic limb threatening ischemia (CLTI). IVUS was more commonly used for lesions >15 cm in length (46.6% vs. 43.3%) and for aortoiliac disease (31.8% vs. 27.2%). Rates of atherectomy and stenting were significantly higher with IVUS-PVI (21.1% vs. 16.8%), while balloon angioplasty was less common (13.5% vs. 24.4%). One-year patency was better with IVUS-PVI (97.7% vs. 95.2%, P = 0.004). On subgroup analysis, IVUS (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.29-3.75) was associated with improved patency in CLTI patients, TASC C or D lesions, and treatment length >15 cm. Adjunctive IVUS use during PVI did not significantly impact 1-year amputation (OR 1.7, 95% CI 0.78-3.91). On multivariable regression, adjunctive use of IVUS (OR 2.46 95% CI 1.43-4.25) and aortoiliac interventions (OR 2.91, 95% CI 1.09-7.75) were independent predictors of patency. Treatment modalities such as atherectomy, stenting or balloon angioplasty did not significantly impact patency at 1-year.
CONCLUSIONS
IVUS during lower extremity PVI is associated with improved 1-year patency, when compared to angiography alone. Certain subgroups, such as CLTI patients, lesions>15 cm, and TASC C or D lesions might benefit from adjunctive use of IVUS.
PubMed: 38810722
DOI: 10.1016/j.avsg.2024.03.008 -
Giornale Italiano Di Cardiologia (2006) Jun 2024Mortality for cardiogenic shock is still high despite optimal pharmacological therapy. Therefore, active mechanical circulatory support devices are increasingly used;... (Review)
Review
Mortality for cardiogenic shock is still high despite optimal pharmacological therapy. Therefore, active mechanical circulatory support devices are increasingly used; venoarterial extracorporeal membrane oxygenation (VA-ECMO) enables full circulatory and respiratory support. However, recent data show that in patients with infarct-related shock unselected early use of VA-ECMO does not improve survival and is associated with major bleeding and peripheral ischemic complications. Nowadays, waiting for the results of definitive randomized controlled trials, the main indication for ECMO utilization is in selected patients with cardiac arrest, in those with shock for advanced heart failure refractory to conventional therapy, in those with fulminant myocarditis, in patients candidate for heart transplant or ventricular assistance, especially in presence of respiratory insufficiency and severe biventricular dysfunction. An important recommendation is its utilization in specialized, high-volume centers in the setting of hub and spoke hospitals.
Topics: Humans; Extracorporeal Membrane Oxygenation; Shock, Cardiogenic; Evidence-Based Medicine; Heart Failure; Myocarditis; Heart Arrest
PubMed: 38808937
DOI: 10.1714/4269.42465 -
Journal of Biomedical Research May 2024Macrophages mediated inflammatory response is crucial for the recovery of skeletal muscle following ischemia. Thus, it's necessary to exploit macrophages based...
Macrophages mediated inflammatory response is crucial for the recovery of skeletal muscle following ischemia. Thus, it's necessary to exploit macrophages based therapeutic targets for ischemic disease. Here, we found mRNA level of SR-A1 was elevated in patients with critical limb ischemia by analysis of gene expression omnibus (GEO) database. Then we investigated the role and the underlined mechanisms of macrophage SR-A1 in a mouse HLI model. Compared with the SR-A1 mice, the Lyz /SR-A1 (SR-A1 ) mice showed significantly lower laser doppler blood flow in the ischemic limb at day 7 after HLI. Consistently, histological analysis exhibited that ischemic limb of SR-A1 mice displayed more sever and sustained necrotic morphology, inflammation and fibrosis, decreased vessel density and regeneration rate, compared with which of control SR-A1 mice. Furthermore, restoration of wild-type myeloid cells to SR-A1 knock-out mice effectively relieved the doppler perfusion in the ischemic limb and restrained skeletal muscle damage 7 days post HLI. In line with findings, when co-cultivating macrophages with the mouse myoblast line C2C12, SR-A1 bone marrow macrophage significantly inhibited myoblast differentiation . Mechanically, SR-A1 enhanced skeletal muscle regeneration response to HLI by inhibiting the oncostatin M (OSM) production via suppressed NF-κB signaling activation. These results indicates that SR-A1 is a promising candidate molecule to improve tissue repair and regeneration in peripheral ischemic arterial disease.
PubMed: 38807379
DOI: 10.7555/JBR.38.20240117 -
Korean Journal of Radiology Jun 2024To evaluate the safety and clinical outcomes of the Passeo-18 Lux drug-coated balloon (DCB) in endovascular revascularization procedures under real-world conditions in a...
Safety and Effectiveness of Passeo-18 Lux Drug-Coated Balloon Catheter in Infrainguinal Endovascular Revascularization in the Korean Population: A Multicenter Post-Market Surveillance Study.
OBJECTIVE
To evaluate the safety and clinical outcomes of the Passeo-18 Lux drug-coated balloon (DCB) in endovascular revascularization procedures under real-world conditions in a Korean population with atherosclerotic disease of the infrainguinal arteries, including below-the-knee (BTK) arteries.
MATERIALS AND METHODS
Eight institutions in the Republic of Korea participated in this prospective, multicenter, single-arm, post-market surveillance study. Two hundred patients with Rutherford class 2-5 peripheral arterial disease and infrainguinal lesions suitable for endovascular treatment were competitively enrolled. Data were collected at baseline, the time of intervention, discharge, and 1-, 6-, 12-, and 24-month follow-up visits. The primary safety endpoint was freedom from major adverse events (MAE) within 6 months (except when limiting the time frame for procedure- or device-related mortality to within 30 days), and the primary effectiveness endpoint was freedom from clinically driven target lesion revascularization (CD-TLR) within 12 months after the procedure.
RESULTS
A total of 197 patients with 332 target lesions were analyzed. Two-thirds of the patients had diabetes mellitus, and 41.6% had chronic limb-threatening ischemia. The median target lesion length was 100 mm (interquartile range: 56-133 mm). Of the target lesions, 35.2% were occlusions, and 14.8% were located in the BTK arteries. Rate of freedom from MAE was 97.9% at 6 months, and the rate of freedom from CD-TLR was 95.0% and 92.2% at 12 and 24 months, respectively. Subgroup analysis of 43 patients and 49 target lesions involving the BTK arteries showed rate of freedom from MAE of 92.8% at 6 months and rates of freedom from CD-TLR of 88.8% and 84.4% at 12 and 24 months, respectively.
CONCLUSION
The results of the present study, including the BTK subgroup analysis, showed outcomes comparable to those of other DCB studies, confirming the safety and effectiveness of Passeo-18 Lux DCB in the Korean population.
Topics: Humans; Male; Female; Aged; Prospective Studies; Peripheral Arterial Disease; Product Surveillance, Postmarketing; Republic of Korea; Angioplasty, Balloon; Middle Aged; Treatment Outcome; Coated Materials, Biocompatible; Endovascular Procedures; Aged, 80 and over
PubMed: 38807338
DOI: 10.3348/kjr.2024.0099 -
European Journal of Vascular and... May 2024There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences...
OBJECTIVE
There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand.
METHODS
After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength.
RESULTS
A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared with angioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with over a third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) or moderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban.
CONCLUSION
This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisions by procedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.
PubMed: 38802038
DOI: 10.1016/j.ejvs.2024.05.034 -
Radiography (London, England : 1995) Jul 2024Information on tissue perfusion in the foot is important when treating patients with chronic limb-threatening ischemia. This study aims to test the reliability of...
INTRODUCTION
Information on tissue perfusion in the foot is important when treating patients with chronic limb-threatening ischemia. This study aims to test the reliability of different magnetic resonance sequences when measuring perfusion in the foot.
METHODS
Sixteen healthy volunteers had their right foot scanned in a test/retest study with six different magnetic resonance sequences (BOLD, multi-echo gradient echo (mGRE), 2D and 3D pCASL, PASL FAIR, and DWI with intravoxel incoherent motion (IVIM) with quantitative measurements of perfusion. For five sequences, cuff-induced ischemia followed by a hyperactive response was measured. Images of the feet were segmented into angiosomes and perfusion data were extracted from the five angiosomes.
RESULTS
BOLD, PASL FAIR, mGRE, and DWI with IVIM had low mean differences between the first and second scans, while the results of 2D and 3D pCASL had the highest differences. Based on a paired t-test, BOLD, and FAIR were able to distinguish between perfusion and no perfusion in all angiosomes with p-values below 0.01. This was not the case with 2D and 3D pCASL with p-values above 0.05 in all angiosomes. The mGRE could not distinguish between perfusion and no perfusion in the lateral side of the foot.
CONCLUSION
BOLD, mGRE, pASL FAIR, and DWI with IVIM seem to give more robust results compared to 2D and 3D pCASL. Further studies on patients with peripheral artery disease should explore if the sequences can have clinical relevance when assessing tissue ischemia and results of revascularization.
IMPLICATIONS FOR PRACTICE
This study provides knowledge that could be used to improve the diagnosis of patient with chronic limb-threatening ischemia to explore tissue perfusion.
Topics: Humans; Peripheral Arterial Disease; Foot; Male; Female; Adult; Reproducibility of Results; Magnetic Resonance Imaging; Middle Aged; Healthy Volunteers; Ischemia; Magnetic Resonance Angiography
PubMed: 38797044
DOI: 10.1016/j.radi.2024.05.007 -
Medicina (Kaunas, Lithuania) May 2024: Lower limb skeletal muscle ischemia-reperfusion (IR) injury is associated with increased morbidity and mortality, and it is common in several clinical situations such...
: Lower limb skeletal muscle ischemia-reperfusion (IR) injury is associated with increased morbidity and mortality, and it is common in several clinical situations such as aortic aneurysms repairment, peripheral arterial surgery, vascular injury repairment, and shock. Although it is generally accepted that oxidative stress mediators have a significant role in IR injury, its precise mechanism is still unknown. Anecdotally, it is sustained not only by structural and functional changes in the organ it affects but also by damage to distant organs. The purpose of this report is to illustrate the effect of proanthocyanidin on IR injury. : In our study, 18 male Wistar albino rats were used. The subjects were divided into three groups containing six mice each (control, C; ischemia-reperfusion, IR; ischemia-reperfusion and proanthocyanidin; IR-PRO). Intraperitoneal proanthocyanidin was given to the IR and proanthocyanidin groups 30 min before laparotomy, and 1 h ischemia led to these two groups. After one hour, reperfusion started. Muscle atrophy-hypertrophy, muscle degeneration-congestion, fragmentation-hyalinization, muscle oval-central nucleus ratio, leukocyte cell infiltration, catalase enzyme activity, and TBARS were all examined in lower-limb muscle samples after one hour of reperfusion. : When skeletal muscle samples were evaluated histopathologically, it was discovered that muscle atrophy-hypertrophy, muscle degeneration-congestion, fragmentation-hyalinization, and leukocyte cell infiltration with oval-central nucleus standardization were significantly higher in the IR group than in the C and IR-P groups. Oval-central nucleus standardization was significantly higher in the IR and IR-PRO groups than in the control group. TBARS levels were significantly higher in the IR group than in the control and IR-PRO groups, while catalase enzyme activity was found to be significantly lower in the IR group than in the control and IR-PRO groups. : As a consequence of our research, we discovered that proanthocyanidins administered before IR have a protective impact on skeletal muscle in rats. Further research in this area is required.
Topics: Animals; Reperfusion Injury; Male; Muscle, Skeletal; Rats, Wistar; Rats; Proanthocyanidins; Oxidative Stress; Disease Models, Animal
PubMed: 38792987
DOI: 10.3390/medicina60050804 -
Journal of Clinical Medicine May 2024: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to...
: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to assess the safety, feasibility, and technical success of this access route for infrainguinal endovascular recanalizations. : We retrospectively analyzed 186 consecutive patients treated over a 7-year period (May 2014-August 2021) who underwent endovascular recanalization of infra-inguinal lesions using a PA access route. In all cases, retrograde PA access was obtained following a failed attempt to cross the occlusion via the antegrade route. : Among the 186 patients, 120 were males (60.5%) and the mean age was 76.8 ± 10.7 years old (44-94 years). One hundred and thirteen patients (60.7%) suffered from chronic limb threatening ischemia (CLTI). All patients presented with chronic total occlusions (CTO) and a failed conventional antegrade recanalization attempt. Retrograde access was performed under angiographic guidance in 185 cases (99.5%). It was successfully established in 171 cases (91.9%). The total rate of retrograde puncture-related complications was 2.1% (two puncture site bleedings of which one necessitated fasciotomy and two cases of arteriovenous fistulas managed conservatively). The Major Adverse Event (MAE) rate at 30 days was 1.6% (3/186). : Retrograde recanalization of challenging infra-inguinal lesions via PA is safe and effective in experienced hands.
PubMed: 38792312
DOI: 10.3390/jcm13102770 -
Vascular May 2024There is a risk of distal embolization lower extremity endovascular interventions. Possibly a drug-coating embolism caused by coating detachment from intravascular... (Review)
Review
INTRODUCTION
There is a risk of distal embolization lower extremity endovascular interventions. Possibly a drug-coating embolism caused by coating detachment from intravascular devices.
METHODS
This review focuses on providing updated information on distal embolism in endovascular revascularization of lower extremity arteries, including the use of drug-coated balloons.
RESULTS
Drug-coating embolism is a special case of distal embolization during recanalization of the arteries of the lower extremities. Preclinical studies have demonstrated embolization of drug-coated balloons during angioplasty of lower extremity arteries. However, the clinical role of drug-coating embolism is not completely clear. A 2020 meta-analysis found an increased risk of major lower extremity amputation after drug-coated balloon angioplasty in patients with critical limb ischemia. But long-term research is emerging to support the safety of using these devices. Perhaps a more thorough assessment of the quality of life and the degree of compensation of lower limb ischemia with an intraoperative assessment of the frequency of peripheral embolizations using ultrasound emboli detection, as well as microcirculation with transcutaneous oximetry and laser Doppler flowmetry of the operated lower limb will allow a more detailed study of the phenomenon of drug-coating embolism and its impact on long-term clinical outcomes.
CONCLUSION
According to the results of preclinical studies, the use of paclitaxel-coated balloons leads to an increase in the concentration of paclitaxel in distal skeletal muscles. However, paclitaxel concentration in skeletal muscle was significantly higher in first-generation DCBs. The non-target effects of drug-coating balloon are not fully understood and require further study. Understanding the phenomenon of drug-coating embolism can help physicians to better assess the patient risk and to minimize complications.
PubMed: 38790137
DOI: 10.1177/17085381241256534 -
The Journal of Emergency Medicine Jul 2024Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously,... (Review)
Review
BACKGROUND
Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access.
OBJECTIVES OF THE REVIEW
This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock.
DISCUSSION
Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause.
CONCLUSION
Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
Topics: Humans; Vasoconstrictor Agents; Shock; Emergency Medicine; Norepinephrine; Hypotension; Blood Pressure; Shock, Cardiogenic
PubMed: 38789351
DOI: 10.1016/j.jemermed.2024.03.004