German guideline on the diagnosis and treatment of peripheral artery                     disease – a comprehensive update 2016

Abstract. The prevalence of peripheral artery disease (PAD) is increasing worldwide and is strongly age-related, affecting about 20 % of Germans over 70 years of age. Recent advances in endovascular and surgical techniques as well as clinical study results on comparative treatment methods strengthened the need for a comprehensive review of the published evidence for diagnosis, management, and prevention of PAD. The interdisciplinary guideline exclusively covers distal aorta and atherosclerotic lower extremity artery disease. A systematic literature review and formal consensus finding process, including delegated members of 22 medical societies and two patient self-support organisations were conducted and supervised by the Association of Scientific Medical Societies in Germany, AWMF. Three levels of recommendation were defined, A = „is recommended/indicated”, B = „should be considered”, C = “may be considered”, means agreement of expert opinions due to lack of evidence. Altogether 294 articles, including 34 systematic reviews and 98 RCTs have been analysed. The key diagnostic tools and treatment basics have been defined. In patients with intermittent claudication endovascular and/or surgical techniques are treatment options depending on appropriate individual morphology and patient preference. In critical limb ischaemia, revascularisation without delay by means of the most appropriate technique is key. If possible and reasonable, endovascular procedures should be applied first. The TASC classification is no longer recommended as the base of therapeutic decision process due to advances in endovascular techniques and new crural therapeutic options. Limited new data on rehabilitation and follow-up therapies have been integrated. The article summarises major new aspects of PAD treatment from the updated German Guidelines for Diagnosis and Treatment of PAD. Limited scientific evidence still calls for randomised clinical trials to close the present gap of evidence.

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Economic model to examine the cost-effectiveness of FlowOx home therapy compared to standard care in patients with peripheral artery disease

PLoS ONE ◽

10.1371/journal.pone.0244851 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0244851

Author(s):

Victory ‘Segun Ezeofor ◽

Nathan Bray ◽

Lucy Bryning ◽

Farina Hashmi ◽

Henrik Hoel ◽

...

Keyword(s):

Cost Effectiveness ◽

Peripheral Artery Disease ◽

Lower Limb ◽

Standard Care ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Peripheral Artery ◽

Artery Disease ◽

The Cost ◽

The Impact

Background Critical limb ischaemia is a severe stage of lower limb peripheral artery disease which can lead to tissue loss, gangrene, amputation and death. FlowOx™ therapy is a novel negative-pressure chamber system intended for home use to increase blood flow, reduce pain and improve wound healing for patients with peripheral artery disease and critical limb ischaemia. Methods A Markov model was constructed to assess the relative cost-effectiveness of FlowOx™ therapy compared to standard care in lower limb peripheral artery disease patients with intermittent claudication or critical limb ischaemia. The model used data from two European trials of FlowOx™ therapy and published evidence on disease progression. From an NHS analysis perspective, various FlowOx™ therapy scenarios were modelled by adjusting the dose of FlowOx™ therapy and the amount of other care received alongside FlowOx™ therapy, in comparison to standard care. Results In the base case analysis, consisting of FlowOx™ therapy plus nominal care, the cost estimates were £12,704 for a single dose of FlowOx™ therapy per annum as compared with £15,523 for standard care. FlowOx™ therapy patients gained 0.27 additional quality adjusted life years compared to standard care patients. This equated to a dominant incremental cost-effectiveness ratio per QALY gained. At the NICE threshold WTP of £20,000 and £30,000 per QALY gained, FlowOx™ therapy in addition to standard care had a 0.80 and 1.00 probability of being cost-effectiveness respectively. Conclusions FlowOx™ therapy delivered as a single annual dose may be a cost-effective treatment for peripheral artery disease. FlowOx™ therapy improved health outcomes and reduced treatment costs in this modelled cohort. The effectiveness and cost-effectiveness of FlowOx™ therapy is susceptible to disease severity, adherence, dose and treatment cost. Research assessing the impact of FlowOx™ therapy on NHS resource use is needed in order to provide a definitive economic evaluation.

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Stem cell and progenitor cell therapy in peripheral artery disease

Thrombosis and Haemostasis ◽

10.1160/th09-10-0688 ◽

2010 ◽

Vol 103 (04) ◽

pp. 696-709 ◽

Cited By ~ 117

Author(s):

Peter Bramlage ◽

Berthold Amann ◽

Holger Lawall

Keyword(s):

Stem Cell ◽

Cell Therapy ◽

Peripheral Artery Disease ◽

Mononuclear Cells ◽

Ankle Brachial Index ◽

Tissue Loss ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Peripheral Artery ◽

Artery Disease

SummaryAtherosclerotic peripheral artery disease (PAD) is a common manifestation of atherosclerosis. The occlusion of large limb arteries leads to ischaemia with claudication which can progress to critical limb ischaemia (CLI) with pain at rest, and to tissue loss. At present, common therapy for CLI is either surgical or endovascular revascularisation aimed at improving blood flow to the affected extremity. However, major amputation and death are still frequent complications. Exploring new strategies for revascularisation of ischaemic limbs is thus of major importance. Bone marrow (BM)-derived stem and progenitor cells have been identified as a potential new therapeutic option to induce therapeutic angiogenesis. Encouraging results of preclinical studies have rapidly led to several small clinical trials, in which BM-derived mononuclear cells were administered to patients with limb ischaemia. Clinical benefits were reported from these trials including improvement of ankle-brachial index (ABI), transcutaneous partial pressure of oxygen (TcPO2), re-duction of pain, and decreased need for amputation. Nonetheless, large randomised, placebo-controlled, double-blind studies are necessary and currently ongoing (BONMOT-CLI, JUVENTUS and NCT00498069). Further research relates to the optimal cell type and dosage, the isolation method, the role of colony-stimulating factors, administration route, and the supportive stimulation of cells with reduced functioning due to advanced PAD. Autologous stem cell therapy for ischaemic peripheral disease seems to be a promising new tool for the treatment of severe limb ischaemia. Preliminary evidence has established its safety, feasibility and effectiveness on several important endpoints. Several large endpoints studies are underway to further consolidate this evidence.

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The Role of Atherectomy in Peripheral Artery Disease: Current Evidence and Future Perspectives

Vascular and Endovascular Review ◽

10.15420/ver.2018.16.2 ◽

2019 ◽

Vol 2 (1) ◽

pp. 12-18 ◽

Cited By ~ 1

Author(s):

Grigorios Korosoglou ◽

Sorin Giusca ◽

Martin Andrassy ◽

Michael Lichtenberg

Keyword(s):

Endovascular Treatment ◽

Peripheral Artery Disease ◽

Critical Limb Ischaemia ◽

Current Evidence ◽

Limb Ischaemia ◽

Ageing Population ◽

Peripheral Artery ◽

Directional Atherectomy ◽

First Choice ◽

Artery Disease

An ageing population and the increasing prevalence of cardiovascular risk factors have aggravated the burden of peripheral artery disease (PAD). Despite advances in the pharmacological treatment of atherosclerosis, many patients with symptomatic PAD require invasive procedures to reduce the symptoms of claudication, salvage tissue and prevent amputation and subsequent disability in those with critical limb ischaemia. After significant advances in endovascular treatment over the past two decades, these techniques are widely accepted as first-choice treatment in the majority of patients with PAD. However, in patients with severely calcified lesions, standard endovascular treatment such as plain or drug-coated balloon (DCB) angioplasty may fail due to vessel recoil or severe dissection in the acute setting, and intimal hyperplasia in the long term. With the use of percutaneous plaque modification and debulking techniques based on atherectomy, such calcified lesions can be tackled more easily after removal or fragmentation of atherosclerotic plaque. More homogeneous balloon expansion at lower pressures can be achieved after atherectomy, which reduces barotrauma while allowing better drug delivery to the vessel wall during DCB angioplasty avoids the need for stent placement. There are four principal methods of direct atherectomy available at the present time: directional atherectomy, rotational atherectomy, orbital atherectomy and hybrid atherectomy. In this article, we provide a short overview of these techniques and the current evidence from clinical trials to support their use.

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Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with infrapopliteal peripheral artery disease

British Journal of Surgery ◽

10.1002/bjs.10292 ◽

2016 ◽

Vol 103 (13) ◽

pp. 1815-1822 ◽

Cited By ~ 21

Author(s):

S. D. Patel ◽

L. Biasi ◽

I. Paraskevopoulos ◽

J. Silickas ◽

T. Lea ◽

...

Keyword(s):

Peripheral Artery Disease ◽

Bypass Surgery ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Peripheral Artery ◽

Artery Disease

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Prognostic value of myeloperoxidase in patients with peripheral artery disease

Vascular ◽

10.1177/1708538120957491 ◽

2020 ◽

pp. 170853812095749

Author(s):

Nadjib Schahab ◽

Seyid Mansuroglu ◽

Christian Schaefer ◽

Rolf Fimmers ◽

Georg Nickenig ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Vascular Disease ◽

Peripheral Artery Disease ◽

Prognostic Value ◽

Target Lesion ◽

Limb Ischaemia ◽

Target Lesion Revascularisation ◽

Peripheral Artery ◽

Artery Disease

Objectives The involvement of myeloperoxidase in the production of dysfunctional high-density lipoproteins and oxidised biomolecules leads to oxidative stress in the blood vessel endothelium. This prospective cohort study aimed to examine the prognostic value of myeloperoxidase in patients with peripheral artery disease in relation to major adverse cardiac events (MACEs), target lesion revascularisation, and major adverse limb events (MALEs) and its association with multi-bed vascular disease, which is defined as any combination of the following: peripheral artery disease and coronary artery disease. Methods Myeloperoxidase levels were measured in patients with peripheral artery disease and coronary artery disease during angiography. A total of 94 patients were analysed and followed up regarding their MACEs, target lesion revascularisation, and MALEs from August 2016 until February 2019. Results Among patients with peripheral artery disease, the rates of MACE and mortality were higher in patients with high myeloperoxidase levels than in those with low myeloperoxidase levels; the myeloperoxidase levels were 3.68 times higher in these patients ( p < 0.0001). Patients with peripheral artery disease and coronary artery disease (multi-bed vascular disease) had higher myeloperoxidase levels than those with only peripheral artery disease and only coronary artery disease (one-bed vascular disease). Peripheral artery disease patients with higher myeloperoxidase levels had significantly higher rates of limb ischaemia, requiring further revascularisation than those with low myeloperoxidase levels. Conclusions High myeloperoxidase levels suggest poor outcomes and are associated with MACE and limb ischaemia. Our findings indicated that myeloperoxidase levels could become a prognostic marker and may be used in conjunction with other methods for risk stratification in patients with peripheral artery disease and multi-bed vascular disease.

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Application of an Integrated Algorithm in the Diagnosis and Treatment of Peripheral Artery Disease in Patients with Diabetes

Cardiologia Croatica ◽

10.15836/ccar2021.133 ◽

2021 ◽

Vol 16 (3-4) ◽

pp. 133-139

Author(s):

Krešimir Gabaldo ◽

Domagoj Vučić ◽

Ivan Bitunjac ◽

Marijana Knežević Praveček ◽

Katica Cvitkušić Lukenda ◽

...

Keyword(s):

Peripheral Artery Disease ◽

Diagnosis And Treatment ◽

Peripheral Artery ◽

Patients With Diabetes ◽

Artery Disease

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Knowledge of peripheral artery disease: What do the public, healthcare practitioners, and trainees know?

Vascular Medicine ◽

10.1177/1358863x19893003 ◽

2020 ◽

Vol 25 (3) ◽

pp. 263-273 ◽

Cited By ~ 1

Author(s):

Bernadeta M Bridgwood ◽

Andrew TO Nickinson ◽

John SM Houghton ◽

Coral J Pepper ◽

Rob D Sayers

Keyword(s):

Vascular Disease ◽

Peripheral Artery Disease ◽

General Public ◽

Medical Professional ◽

Public Healthcare ◽

Limb Ischaemia ◽

Peripheral Artery ◽

Clinical Exposure ◽

Level Of Training ◽

Artery Disease

This systematic review evaluated the knowledge and awareness of peripheral artery disease (PAD) within the general public (including patients with peripheral vascular disease), nonspecialist healthcare professionals (nsHCP), and trainees (medical students and trainee doctors). Relevant articles were identified from electronic databases using key search terms: ‘peripheral artery disease’; ‘limb ischaemia’; ‘intermittent claudication’; ‘knowledge’; ‘understanding’; ‘public’; ‘medical professional’. The heterogeneous results were described narratively. A lack of knowledge and understanding of PAD (disease awareness) were identified in all groups. Among nsHCPs, factors which affect knowledge include the level of training, early clinical exposure and the presence of family members with cardiovascular/vascular disease. Within the general public, knowledge and awareness was improved if a family member/friend had a diagnosis, or following a patient-centred consultation with any HCP. Public campaigns are proven effective in improving disease knowledge/awareness in conditions such as stroke alongside sustained patient education. These may provide future avenues to improve PAD knowledge and awareness, in order to effectively manage risk factors and minimise delayed or missed diagnosis of PAD. (PROSPERO registration number: CRD42018117304)

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Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis

European Heart Journal ◽

10.1093/eurheartj/ehab116 ◽

2021 ◽

Author(s):

Saman L Parvar ◽

Linh Ngo ◽

Joseph Dawson ◽

Stephen J Nicholls ◽

Robert Fitridge ◽

...

Keyword(s):

Propensity Score ◽

Peripheral Artery Disease ◽

Limb Ischaemia ◽

Peripheral Artery ◽

Long Term Outcomes ◽

Surgical Revascularization ◽

Endovascular Revascularization ◽

Acute Limb Ischaemia ◽

Artery Disease

Abstract Aims Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes. Methods and results This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09–1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99–1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98–1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11–1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations. Conclusion Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

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