Risk of amputation under diuretics in patients with- or at risk of lower-extremity artery disease: A systematic review

SummaryLower extremity artery disease (LEAD) is a sign of wide spread atherosclerosis also affecting coronary, cerebral and renal arteries and is associated with increased risk of cardiovascular events. Many economic evaluations have been published for LEAD due to its clinical, social and economic importance. The aim of this systematic review was to assess modelling methods used in published economic evaluations in the field of LEAD. Our review appraised and compared the general characteristics, model structure and methodological quality of published models. Electronic databases MEDLINE and EMBASE were searched until February 2013 via OVID interface. Cochrane database of systematic reviews, Health Technology Assessment database hosted by National Institute for Health research and National Health Services Economic Evaluation Database (NHSEED) were also searched. The methodological quality of the included studies was assessed by using the Philips’ checklist. Sixteen model-based economic evaluations were identified and included. Eleven models compared therapeutic health technologies; three models compared diagnostic tests and two models compared a combination of diagnostic and therapeutic options for LEAD. Results of this systematic review revealed an acceptable to low methodological quality of the included studies. Methodological diversity and insufficient information posed a challenge for valid comparison of the included studies. In conclusion, there is a need for transparent, methodologically comparable and scientifically credible modelbased economic evaluations in the field of LEAD. Future modelling studies should include clinically and economically important cardiovascular outcomes to reflect the wider impact of LEAD on individual patients and on the society.

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Antithrombotic Therapy in Lower Extremity Artery Disease

Current Vascular Pharmacology ◽

10.2174/1570161117666190206230516 ◽

2020 ◽

Vol 18 (3) ◽

pp. 215-222 ◽

Cited By ~ 1

Author(s):

Mislav Vrsalovic ◽

Victor Aboyans

Keyword(s):

Lower Extremity ◽

Antiplatelet Therapy ◽

Antithrombotic Therapy ◽

Cardiovascular Events ◽

Cardiovascular Outcomes ◽

Lower Limbs ◽

Stent Type ◽

Increased Risk ◽

Artery Disease ◽

Lower Extremity Artery Disease

Lower extremity artery disease (LEAD) is a marker of a more advanced atherosclerotic process often affecting multiple vascular beds beyond the lower limbs, with a consequent increased risk for all-cause and cardiovascular mortality. Antithrombotic therapy is the cornerstone of management of these patients to prevent ischaemic cardiovascular and limb events and death. In patients with symptomatic LEAD, the efficacy of aspirin has been established long ago for the prevention of cardiovascular events. In the current guidelines, clopidogrel may be preferred over aspirin following its incremental ability to prevent cardiovascular events, while ticagrelor is not superior to clopidogrel in reducing cardiovascular outcomes. Dual antiplatelet therapy (DAPT, aspirin with clopidogrel) is currently recommended for at least 1 month after endovascular interventions irrespective of the stent type. Antiplatelet monotherapy is recommended after infra-inguinal bypass surgery, and DAPT may be considered in below-the-knee bypass with a prosthetic graft. In symptomatic LEAD, the addition of anticoagulant (vitamin K antagonists) to antiplatelet therapy increased the risk of major and life-threatening bleeding without benefit regarding cardiovascular outcomes. In a recent trial, low dose of direct oral anticoagulant rivaroxaban plus aspirin showed promising results, not only to reduce death and major cardiovascular events, but also major limb events including amputation. Yet, this option should be considered especially in very high risk patients, after considering also the bleeding risk. Despite all the evidence accumulated since >40 years, many patients with LEAD remain undertreated and deserve close attention and implementation of guidelines advocating the use of antithrombotic therapies, tailored according to their level of risk.

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Impact of left ventricular diastolic dysfunction on long-term outcome in patients with lower extremity artery disease

Journal of Cardiology ◽

10.1016/j.jjcc.2019.12.011 ◽

2020 ◽

Vol 75 (6) ◽

pp. 659-664

Author(s):

Koji Yanaka ◽

Hirokuni Akahori ◽

Takahiro Imanaka ◽

Kojiro Miki ◽

Nagataka Yoshihara ◽

...

Keyword(s):

Lower Extremity ◽

Diastolic Dysfunction ◽

Left Ventricular Diastolic Dysfunction ◽

Left Ventricular ◽

Term Outcome ◽

Long Term Outcome ◽

Ventricular Diastolic Dysfunction ◽

Artery Disease ◽

Lower Extremity Artery Disease

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Molecular Mechanisms Associated with ROS-Dependent Angiogenesis in Lower Extremity Artery Disease

Antioxidants ◽

10.3390/antiox10050735 ◽

2021 ◽

Vol 10 (5) ◽

pp. 735

Author(s):

Greg Hutchings ◽

Łukasz Kruszyna ◽

Mariusz J. Nawrocki ◽

Ewa Strauss ◽

Rut Bryl ◽

...

Keyword(s):

Quality Of Life ◽

Blood Vessel ◽

Lower Extremity ◽

Molecular Mechanisms ◽

Lower Extremities ◽

Tissue Response ◽

Peripheral Arteries ◽

Artery Disease ◽

Lower Extremity Artery Disease

Currently, atherosclerosis, which affects the vascular bed of all vital organs and tissues, is considered as a leading cause of death. Most commonly, atherosclerosis involves coronary and peripheral arteries, which results in acute (e.g., myocardial infarction, lower extremities ischemia) or chronic (persistent ischemia leading to severe heart failure) consequences. All of them have a marked unfavorable impact on the quality of life and are associated with increased mortality and morbidity in human populations. Lower extremity artery disease (LEAD, also defined as peripheral artery disease, PAD) refers to atherosclerotic occlusive disease of the lower extremities, where partial or complete obstruction of peripheral arteries is observed. Decreased perfusion can result in ischemic pain, non-healing wounds, and ischemic ulcers, and significantly reduce the quality of life. However, the progressive atherosclerotic changes cause stimulation of tissue response processes, like vessel wall remodeling and neovascularization. These mechanisms of adapting the vascular network to pathological conditions seem to play a key role in reducing the impact of the changes limiting the flow of blood. Neovascularization as a response to ischemia induces sprouting and expansion of the endothelium to repair and grow the vessels of the circulatory system. Neovascularization consists of three different biological processes: vasculogenesis, angiogenesis, and arteriogenesis. Both molecular and environmental factors that may affect the process of development and growth of blood vessels were analyzed. Particular attention was paid to the changes taking place during LEAD. It is important to consider the molecular mechanisms underpinning vessel growth. These mechanisms will also be examined in the context of diseases commonly affecting blood vessel function, or those treatable in part by manipulation of angiogenesis. Furthermore, it may be possible to induce the process of blood vessel development and growth to treat peripheral vascular disease and wound healing. Reactive oxygen species (ROS) play an important role in regulation of essential cellular signaling pathways such as cell differentiation, proliferation, migration and apoptosis. With regard to the repair processes taking place during diseases such as LEAD, prospective therapeutic methods have been described that could significantly improve the treatment of vessel diseases in the future. Summarizing, regenerative medicine holds the potential to transform the therapeutic methods in heart and vessel diseases treatment.

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Are hypertensive patients with history of coronary artery disease at risk for silent lower extremity artery disease?

Journal of Basic and Clinical Physiology and Pharmacology ◽

10.1515/jbcpp-2021-0235 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Eka Prasetya Budi Mulia ◽

Kevin Yuwono ◽

Raden Mohammad Budiarto

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Lower Extremity ◽

Pearson Correlation ◽

Ankle Brachial Index ◽

Chi Square ◽

Hypertensive Patients ◽

History Of ◽

Artery Disease ◽

Lower Extremity Artery Disease

Abstract Objectives We aimed to investigate the association between hypertension and asymptomatic lower extremity artery disease (LEAD) in outpatients with known history of coronary artery disease (CAD). Methods Patients with known history of CAD who have been undergone coronary angiography and have significant coronary artery stenosis (more than 60%) were included. LEAD was defined as ankle-brachial index (ABI) < 0.9 in either leg. The risk of LEAD in hypertensive group was analyzed using chi-square test, and correlation between blood pressure (BP) and ABI was analyzed using Pearson correlation test in SPSS v.25. Results One hundred and four patients were included. 82.7% of patients were male. Mean age was 57.05 ± 7.97. The prevalence of hypertension was 35.6%, and the prevalence of LEAD was 16.3%. A higher proportion of LEAD was found in hypertensive (18.9%) compared to non-hypertensive (14.9%), although not statistically significant (OR: 1.33; 95% CI: 0.46 to 3.85; p=0.598). There was an association between ABI and systolic BP (p=0.016), but not with diastolic BP (p=0.102). Conclusions Our study showed that the prevalence of LEAD in hypertension, especially in the CAD population, is relatively high. There was no association between hypertension and LEAD, but a higher prevalence of LEAD was found in hypertensive patients. Nevertheless, LEAD screening is still recommended in hypertensive patients, especially in the CAD population, given the fact that outcomes of health and mortality are worse for those with concomitants of these diseases.

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Osteoid Metaplasia in Femoral Artery Plaques Is Associated With the Clinical Severity of Lower Extremity Artery Disease in Men

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2020.594192 ◽

2020 ◽

Vol 7 ◽

Author(s):

Mirjami Laivuori ◽

Johanna Tolva ◽

A. Inkeri Lokki ◽

Nina Linder ◽

Johan Lundin ◽

...

Keyword(s):

Image Analysis ◽

Deep Learning ◽

Lower Extremity ◽

Femoral Artery ◽

Analysis Algorithm ◽

Image Analysis Algorithm ◽

Artery Disease ◽

Area Percentage ◽

Lower Extremity Artery Disease ◽

Whole Slide Images

Lamellar metaplastic bone, osteoid metaplasia (OM), is found in atherosclerotic plaques, especially in the femoral arteries. In the carotid arteries, OM has been documented to be associated with plaque stability. This study investigated the clinical impact of OM load in femoral artery plaques of patients with lower extremity artery disease (LEAD) by using a deep learning-based image analysis algorithm. Plaques from 90 patients undergoing endarterectomy of the common femoral artery were collected and analyzed. After decalcification and fixation, 4-μm-thick longitudinal sections were stained with hematoxylin and eosin, digitized, and uploaded as whole-slide images on a cloud-based platform. A deep learning-based image analysis algorithm was trained to analyze the area percentage of OM in whole-slide images. Clinical data were extracted from electronic patient records, and the association with OM was analyzed. Fifty-one (56.7%) sections had OM. Females with diabetes had a higher area percentage of OM than females without diabetes. In male patients, the area percentage of OM inversely correlated with toe pressure and was significantly associated with severe symptoms of LEAD including rest pain, ulcer, or gangrene. According to our results, OM is a typical feature of femoral artery plaques and can be quantified using a deep learning-based image analysis method. The association of OM load with clinical features of LEAD appears to differ between male and female patients, highlighting the need for a gender-specific approach in the study of the mechanisms of atherosclerotic disease. In addition, the role of plaque characteristics in the treatment of atherosclerotic lesions warrants further consideration in the future.

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