Association between corrected QT interval and long-term cardiovascular outcomes in elderly patients who had undergone endovascular therapy for lower extremity arterial disease.

Background: Population-based studies have reported the association between prolonged corrected QT (QTc) intervals and an increased risk of adverse cardiovascular events. Data regarding the association between longer QTc intervals and incident cardiovascular outcomes in patients with lower extremity arterial disease (LEAD) are scarce. Objective: To examine the impact of QTc interval on long-term cardiovascular outcomes in elderly patients with symptomatic LEAD. Methods: This cohort study extracted data from the Tzu-chi Registry of ENDovascular Intervention for Peripheral Artery Disease (TRENDPAD) and enrolled 504 patients aged ≥ 70 treated with endovascular therapy for atherosclerotic LEAD from July 1, 2005, to December 31, 2019. The main outcomes of interest were all-cause mortality and major adverse cardiovascular events (MACE). Multivariate analysis was conducted using the Cox proportional hazard model to determine independent variables. We performed interaction analysis between corrected QT and other covariates and Kaplan-Meier analysis to compare the outcome of interest among the groups stratified by the tercile of QTc intervals. Results: A total of 504 patients [235 men (46.6%); mean age, 79.9 ± 6.2 years; mean QTc interval, 459 ± 33 msec] entered the final data analysis. We categorized the baseline patient characteristics according to terciles of QTc intervals. During the median follow-up time of 3.15 (interquartile ranges, 1.65-5.42) years, we noted 264 deaths and 145 MACEs. The 5-year rates of freedom from all-cause mortality (71% vs. 57% vs. 31%, P < 0.001) and MACEs (83% vs. 67% vs. 46%, P < 0.001) were significantly different among the tercile groups. Multivariate analysis showed that a 1-SD increase in the QTc interval increased the risk of all-cause mortality [hazard ratio (HR) 1.49, P < 0.001] and MACEs (HR 1.59, P < 0.001) after adjusting for other covariates. The interaction analysis showed that QTc interval and C-reactive protein levels were most strongly associated with death (HR = 4.88, 95% CI 3.09-7.73, interaction P < 0.001) and MACEs (HR = 7.83, 95% CI 4.14-14.79, interaction P < 0.001). Conclusions: In elderly patients with symptomatic atherosclerotic LEAD, a prolonged QTc interval is associated with advanced limb ischemia, multiple medical comorbidities, increased risk of MACEs, and all-cause mortality.

Repetition of Paclitaxel-Coated Devices for the Treatment of Lower Extremity Artery Disease: Mortality Outcomes and Predictors.

Background: A recent meta-analysis reported late excess mortality in patients treated with paclitaxel-coated devices (PCDs) for symptomatic femoropopliteal disease. However, this finding is controversial. Objectives: To investigate the impact on mortality and predictors of repeat exposure to PCDs in patients with lower extremity peripheral arterial disease (LE-PAD). Methods: We analyzed registry patient-level data from two centers. A total of 214 patients were enrolled, and stratified based on terciles of cumulative dose of paclitaxel. We treated 134 patients with a single PCD exposure and 80 with multiple PCD exposures. We used the follow-up index (FUI) in Kaplan-Meier survival estimates to minimize potential selection bias. We used Cox proportional hazard and splines models to determine the predictors of mortality and assess their relationships with mortality. Results: The mean cumulative dose of paclitaxel was significantly different among groups (6.40 mg vs. 15.06 mg vs. 38.57 mg, p < 0.001). The 5-year FUI (0.93 ± 0.19 vs. 0.94 ± 0.18 vs. 0.95 ± 0.15, p = 0.836) and survival rates were not different (65.4% vs. 51.9% vs. 72.0%, p = 0.148). There was no dose-response association between paclitaxel dosage and death (p = 0.297). The predictors of death were congestive heart failure, stroke, dialysis dependence, neutrophil-lymphocyte ratio (NLR) > 3, age > 71 years, and body mass index (BMI) < 20 kg/m2. Spline model analysis validated the non-linear associations between mortality, age, BMI, and NLR. Conclusions: Repeated PCD exposure for LE-PAD did not result in excess late mortality. Predictors of mortality might change over time, and continuous variables had non-linear relationships with death.

Pleiotropic Effects of APOB Variants on Lipid Profiles, Metabolic Syndrome, and the Risk of Diabetes Mellitus.

Apolipoprotein B (ApoB) plays a crucial role in lipid and lipoprotein metabolism. The effects of APOB locus variants on lipid profiles, metabolic syndrome, and the risk of diabetes mellitus (DM) in Asian populations are unclear. We included 1478 Taiwan Biobank participants with whole-genome sequence (WGS) data and 115,088 TWB participants with Axiom genome-wide CHB array data and subjected them to genotype-phenotype analyses using APOB locus variants. Five APOB nonsynonymous mutations, including Asian-specific rs144467873 and rs13306194 variants, were selected from participants with the WGS data. Using a combination of regional association studies, a linkage disequilibrium map, and multivariate analysis, we revealed that the APOB locus variants rs144467873, rs13306194, and rs1367117 were independently associated with total, low-density lipoprotein (LDL), and non-high-density lipoprotein (non-HDL) cholesterol levels; rs1318006 was associated with HDL cholesterol levels; rs13306194 and rs35131127 were associated with serum triglyceride levels; rs144467873, rs13306194, rs56213756, and rs679899 were associated with remnant cholesterol levels; and rs144467873 and rs4665709 were associated with metabolic syndrome. Mendelian randomization (MR) analyses conducted using weighted genetic risk scores from three or two LDL-cholesterol-level-associated APOB variants revealed significant association with prevalent DM (p = 0.0029 and 8.2 × 10-5, respectively), which became insignificant after adjustment for LDL-C levels. In conclusion, these results indicate that common and rare APOB variants are independently associated with various lipid levels and metabolic syndrome in Taiwanese individuals. MR analyses supported APOB variants associated with the risk of DM through their associations with LDL cholesterol levels.

Association Rule Mining and Prognostic Stratification of 2-Year Longevity in Octogenarians Undergoing Endovascular Therapy for Lower Extremity Arterial Disease: Observational Cohort Study.

BACKGROUND: Two-year longevity is a crucial consideration in revascularization strategies for patients with symptomatic lower extremity arterial disease (LEAD). However, factors associated with 2-year longevity and risk stratification in octogenarians or nonagenarians have been underreported. OBJECTIVE: This paper aims to investigate the associated variables and stratify the 2-year prognosis in older patients with LEAD. METHODS: We performed logistic regression and association rule mining based on the Apriori algorithm to discover independent variables and validate their associations with 2-year longevity. Malnutrition, inflammation, and stroke factors were identified. C statistics and Kaplan-Meier analysis were used to assess the impact of different numbers of malnutrition, inflammation, and stroke factors on 2-year longevity. RESULTS: We recruited a total of 232 octogenarians or nonagenarians (mean age 85 years, SD 4.2 years) treated with endovascular therapy. During the study period, 81 patients died, and 27 of those (33%) died from a cardiac origin within 2 years. Association rules analysis showed the interrelationships between 2-year longevity and the neutrophil-lymphocyte ratio (NLR) and nutritional status as determined by the Controlling Nutritional Status (CONUT) score or Geriatric Nutritional Risk Index (GNRI). The cut-off values of NLR, GNRI, and CONUT were ≥3.89, ≤90.3, and >3, respectively. The C statistics for the predictive power for 2-year longevity were similar between the CONUT score and the GNRI-based models (0.773 vs 0.760; P=.57). The Kaplan-Meier analysis showed that 2-year longevity was worse as the number of malnutrition, inflammation, and stroke factors increased from 0 to 3 in both the GNRI-based model (92% vs 68% vs 46% vs 12%, respectively; P<.001) and the CONUT score model (87% vs 75% vs 49% vs 10%, respectively; P<.001). The hazard ratio between those with 3 factors and those without was 18.2 (95% CI 7.0-47.2; P<.001) in the GNRI and 13.6 (95% CI 5.9-31.5; P<.001) in the CONUT score model. CONCLUSIONS: This study demonstrated the association and crucial role of malnutrition, inflammation, and stroke factors in assessing 2-year longevity in older patients with LEAD. Using this simple risk score might assist clinicians in selecting the appropriate treatment.

Contemporary cardiovascular outcomes in Taiwanese patients undergoing endovascular therapy for symptomatic lower extremity peripheral arterial disease.

BACKGROUND/PURPOSE: To investigate contemporary cardiovascular (CV) outcomes in Taiwanese patients with symptomatic low extremity peripheral artery disease treated with endovascular therapy. METHODS: An observational cohort study with up to 155 months of follow-up was conducted using a single-center registry database between July 2005 and June 2017. Long-term outcomes and predictors of future CV events were analyzed in 936 patients with 1246 affected legs. RESULTS: This study cohort comprised 21% claudicants and 79% critical limb ischemia (CLI) patients. Compared with claudicants, CLI patients had higher rates of medical comorbidities, tissue inflammation, and lesion complexities. During the study period, 349 patients died (130 CV deaths and 219 non-CV deaths), 306 had non-fatal CV events. The rates of 5-year freedom from all-cause mortality, major CV events (MACEs), and non-fatal CV events were 54.9%, 67.1%, and 56.6% respectively. For CLI patients, independent factors for all-cause mortality were age (odds ratio [OR] 1.03), atrial fibrillation (OR 1.79), albumin (OR 0.62), hematocrit (OR 0.96), body mass index (OR 0.94), C-reactive protein (OR 1.18), dialysis (OR 2.16), and non-ambulance (OR 2.05). Congestive heart failure, dialysis, and non-ambulance independently predicted the MACEs (OR 2.04, 1.93, and 1.67, respectively). For claudicants, coronary artery disease (CAD) was the essential factor for all-cause mortality (OR 2.24), MACE (OR 2.76) and non-fatal CV events (OR 1.82). CONCLUSION: Long-term survival and MACE-free rates were significantly worse in CLI patients than in claudicants. Malnutrition and inflammation were associated with long-term survival. CAD, low hematocrit, dialysis, CHF, and ambulatory status predicted future CV events.

Risk stratification for low extremity amputation in critical limb ischemia patients who have undergone endovascular revascularization: A survival tree analysis.

Patients with peripheral artery disease (PAD) are a heterogeneous population and differ in risk of mortality and low extremity amputation (LEA), which complicates clinical decision-making. This study aimed to develop a simple risk scale using decision tree methodology to guide physicians in managing critical limb ischemia (CLI) patients who will benefit from endovascular therapy (EVT).A total of 736 patients with CLI, Rutherford classification (RC) stage ≥4, and prior successful EVT were included. Variables significantly associated with LEA by univariate analysis (P < .05) were selected and put into classification tree analysis using the Classification and Regression Tree (CART) model with a dependent variable, amputation, and depth of tree = 3. Four risk groups were generated according to the order of amputation rate. The amputation-free survival (AFS) times between groups were compared using the Kaplan-Meier curve with the log-rank test.Patients were classified as high risk for amputation (G4) (WBC counts ≥10,000/µl, and platelet-lymphocyte ratio (PLR) ≥130.337); intermediate risk group 1 (G3) (WBC < 10,000/µl and RC stage before EVT > 5); intermediate risk group 2 (G2) (WBC count ≥ 10,000/µl, and PLR < 130.337) and low-risk group (G1) (WBC < 10,000/µl, RC before EVT ≤ 5). G2, G3, and G4 risk groups had shorter AFS time (range, 58.7 to 65.5 months) than the G1 risk group (100 months) (P < .05). Risk of LEA was significantly higher in the G4, G3, and G2 groups than in the G1 group (P ≤ .05). The G4 group had the highest risk of amputation (odds ratio = 6.84, P < .001).This simple risk scale model can help healthcare professionals more easily identify and appropriately treat patients with CLI who are at different levels of risk for LEA following endovascular revascularization.

Feasibility and Mid-Term Outcomes of Drug-Coated Balloon Angioplasty Between Intermittent Claudication and Critical Limb Ischemia in Patients with Femoropopliteal Disease.

BACKGROUND: The efficacy of drug-coated balloons (DCBs) in critical limb ischemia (CLI) is unclear. To investigate the clinical characteristics and outcomes of DCBs in symptomatic femoropopliteal disease between patients with intermittent claudication (IC) and CLI. METHODS: Data were retrospectively collected from three centers in Taiwan on patients who received DCBs for femoropopliteal lesions between March 2013 and June 2017. We compared the clinical characteristics and outcomes regarding binary restenosis, amputation-free survival (AFS), and major adverse limb events (MALEs) between groups. Cox proportional hazards analysis was used to identify predictors of outcome endpoints. RESULTS: We enrolled a total of 200 affected limbs in 174 patients, including 83 limbs in 71 patients with IC and 117 limbs in 103 patients with CLI. Compared to the patients with claudication, those with CLI were older and had higher proportions of medical comorbidities, tissue inflammation, poor runoff, and vessel calcification. The 3-year rates of freedom from binary restenosis (57% vs. 59%, p = 0.781), and MALEs (77% vs. 67%, p = 0.507) were similar between the two groups. However, the 3-year AFS was significantly higher in the IC group compared to the CLI group (91% vs. 73%, p = 0.001). Lesion length and severe calcification independently predicted binary restenosis, and restenotic lesion predicted MALEs. Age, congestive heart failure, and dialysis were independently associated with AFS. CONCLUSIONS: Despite advanced limb ischemia and comorbidities, the mid-term outcomes in surviving CLI patients were similar to those in the IC patients after treatment with DCBs for femoropopliteal disease.

Cardiovascular Parameters Associated With Troponin I as Indicators for 14-Day Mortality in Patients With Septic Shock.

BACKGROUND: Troponin I is better than other troponin isoforms for monitoring cardiocyte damage, and correlates with sepsis-related mortality. However, hemodynamic factors possibly interact with cardiac function to affect mortality in sepsis. Thus, this study used parameters from pulse-induced contour cardiac output (PiCCO) to investigate the possibility. METHODS: Patients with troponin I tests and sequential organ failure assessment score ≥2 were selected and divided into survivors and nonsurvivors groups and blood troponin I levels between them were compared. Additionally, 65 patients with septic shock and PiCCO records were selected and divided into high cardiac function index (CFI) and low CFI groups and their cardiac function associated with troponin I levels was checked. Furthermore, the patients were classified into 4 subgroups based on CFI and another hemodynamical parameter of PiCCO for identifying if any interaction between CFI and the parameter existed. RESULTS: High blood troponin I levels correlated with high mortality, and with low cardiac function (CFI < 4.5) alone or with low CFI combined with high stroke volume variation (SVV), but did not correlate with global end-diastolic index (GEDI), or systemic vascular resistance index. However, only the subgroup with low CFI and high SVV (CFI < 4.5 and SVV > 10) increased mortality. CONCLUSIONS: Our data give an insight into interactions between cardiac and hemodynamic factors to cause cardiocyte damage and suggest that multiple factors (i.e., low CFI and high SVV) should be considered together to evaluate cardiocyte damage and mortality in sepsis.

Drug-Coated Balloon vs. Conventional Balloon Angioplasty in Dialysis Patients With Symptomatic Femoropopliteal Disease　- A Matched Comparison.

BACKGROUND: Recent randomized trials have shown the treatment benefits of use of a drug-coated balloon (DCB) over conventional percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal disease. However, the effectiveness and safety of DCB for dialysis patients remain unclear.Methods and Results:Consecutive dialysis patients, who underwent PTA or DCB for femoropopliteal disease, were assessed retrospectively via 2:1 propensity score matching. Effectiveness and safety endpoints, including binary restenosis, clinically driven target lesion revascularization (CD-TLR), amputations, major adverse cardiac events (MACE), and deaths, were compared between groups. A total of 278 dialysis patients with 339 limbs were eligible for matching: 84 limbs from 77 patients treated with PTA and 46 limbs from 37 patients treated with DCB were compared after matching. Baseline patient and lesion characteristics were not different between groups. Patients treated with DCB had significantly higher rates of freedom from binary restenosis (52.4% vs. 18.6%, P<0.001) and CD-TLR (56.4% vs. 25.9%, P=0.001) at 2 years compared with patients treated with PTA. Both groups had similar outcomes for amputation, MACE, and death. Cox proportional analysis showed that treatment with DCB was independently associated with a reduction of binary restenosis (hazard ratio [HR] 0.368, P=0.001) and CD-TLR (HR 0.390, P=0.004). CONCLUSIONS: This study suggested superior 2-year outcomes using DCB compared with PTA and similar safety profiles in dialysis patients with femoropopliteal disease.

Failure mode and bimodal restenosis of drug-coated balloon in femoropopliteal intervention.

BACKGROUND: Pattern of DCB restenosis and associated outcomes in facing complex femoropopliteal lesions remain uncertain. METHODS: Data were retrospectively collected from dual centers in Taiwan on patients who underwent treatment with DCBs for femoropopliteal lesions between 2013 and 2016. The restenosis pattern was categorized by the index-treated length. Clinical outcomes and time to DCB restenosis were retrospectively analyzed. Cox proportional hazards model identified restenosis predictors. RESULTS: We recruited a total of 164 patients (91 men; median age 73 years) into the final analysis. The mean lesion length was 204.0 ±â€¯109.2 mm. Of them, 45% total occlusions, 28% severe calcification and 15% in-stent restenosis were treated. Fifty-five patients have DCB restenosis (28 focal and 27 diffuse-occlusive patterns) over a 55-month follow-up. The median restenosis time emerged as a bimodal pattern with a significant difference between the diffuse-occlusive and focal restenosis group (225 vs. 484 days, P = 0.01). The 1-year patency rate after reintervention for DCB restenosis also was different between both restenosis group (29% vs. 65%, P = 0.017). The anticipated timing of escape for diffuse-occlusive or focal restenosis was 687 and 1068 days, respectively. Independent factors were lesion length (P = 0.049) for diffuse-occlusive restenosis and lumen gain of the popliteal artery for focal restenosis (P = 0.034). CONCLUSIONS: This study demonstrated time to DCB failure emerged as a bimodal pattern of distribution and associations of restenosis pattern to subsequent outcomes after the repeated intervention. Exemption from late catchup restenosis required 3-year observation instead of the 1-year mark for conventional treatment.

Clinical Outcomes of Repetition of Drug-Coated Balloon for Femoropopliteal Restenosis After Drug-Coated Balloon Treatment.

BACKGROUND: To compare the clinical outcomes of patients undergoing repeated drug-coated balloon (DCB) treatment for femoropopliteal (FP) DCB restenosis with those of patients without repetition-DCB.Methods and Results:From March 2013 to September 2014, 102 patients (118 affected legs) underwent DCB for symptomatic FP disease; 47 patients had restenosis, and 37 underwent reintervention over a 45-month follow-up. We compared the outcomes of repetition-DCB for DCB restenosis with those of patients without repetition. The baseline patient and lesion characteristics were similar between groups. The mean lesion length was 200.8±113.1 and 195.2±134.6 mm, P=0.894, respectively. In addition, the procedural and follow-up outcomes were not different. The rates of freedom from binary restenosis (70% vs. 14%, P=0.001) and clinically driven target lesion revascularization (CD-TLR) (78% vs. 38%, P=0.026) at 1 year were statistically different between groups. Cox regression analysis showed that repetition of DCB was the only predictor for freedom from binary restenosis (hazard ratio [HR]: 6.15, 95% confidence interval (CI) 1.60 to 23.6, P=0.008) and CD-TLR (HR: 5.37, 95% CI 1.32-22.0, P=0.019). CONCLUSIONS: For FP DCB restenosis, repetition of DCB can potentially improve vessel patency and significantly reduce the need for reintervention compared with conventional treatment. However, these observations require further confirmation in larger scale studies.

Predictors of Left Ventricle Remodeling: Combined Plasma B-type Natriuretic Peptide Decreasing Ratio and Peak Creatine Kinase-MB.

Background: Previous studies reported that patients who had an acute myocardial infarction (AMI) have found that measuring B-type natriuretic peptide (BNP) during the subacute phase of left ventricular (LV) remodeling can predict the possible course of LV remodeling. This study assessed the use of serial BNP serum levels combined with early creatine kinase-MB (CK-MB) to predict the development of significant LV remodeling in AMI patients. Methods: Nighty-seven patients with new onset AMI were assessed using serial echocardiographic studies and serial measurements of BNP levels, both performed on day-2 (BNP1), day-7 (BNP2), day-90 (BNP3), and day-180 (BNP4) after admission. LV remodeling was defined as >20% increase in biplane LV end-diastolic volume on day-180 compared to baseline (day-2). Results: Patients were divided into LV remodeling [LVR(+)] and non LV remodeling [LVR(-)] groups. No first-week BNP level was found to predict remodeling. However, the two groups had significantly different day-90 BNP level (208.1 ± 263.7 pg/ml vs. 82.4 ± 153.7 pg/ml, P = 0.039) and significantly different 3-month BNP decrease ratios ( R BNP13) (14.4 ± 92.2% vs. 69.4 ± 25.9%, P < 0.001). The appropriate cut-off value for R BNP13 was 53.2% (AUC = 0.764, P < 0.001). Early peak CK-MB (cut-off 48.2 ng/ml; AUC = 0.672; P = 0.014) was another independent predictor of remodeling. Additionally, combining peak CK-MB and R BNP13 offered an excellent discrimination for half-year remodeling when assessed by ROC curve (AUC = 0.818, P < 0.001). Conclusion: R BNP13 is a significant independent predictor of 6-month LV remodeling. The early peak CK-MB additionally offered an incremental power to the predictions derived from serial BNP examinations.

Activin A Predicts Left Ventricular Remodeling and Mortality in Patients with ST-Elevation Myocardial Infarction.

BACKGROUND: Activin A levels increase in a variety of heart diseases including ST-elevation myocardial infarction (STEMI). The aim of this study is to investigate whether the level of activin A can be beneficial in predicting left ventricular remodeling, heart failure, and death in patients with ST-elevation myocardial infarction (STEMI). METHODS: We enrolled 278 patients with STEMI who had their activin A levels measured on day 2 of hospitalization. Echocardiographic studies were performed at baseline and were repeated 6 months later. Thereafter, the clinical events of these patients were followed for a maximum of 3 years, including all-cause death and readmission for heart failure. RESULTS: During hospitalization, higher activin A level was associated with higher triglyceride level, lower left ventricular ejection fraction (LVEF), and lower left ventricular end diastolic ventricular volume index (LVEDVI) in multivariable linear regression model. During follow-up, patients with activin A levels > 129 pg/ml had significantly lower LVEF, and higher LVEDVI at 6 months. Kaplan-Meier survival curves showed that activin A level > 129 pg/ml was a predictor of all-cause death (p = 0.022), but not a predictor of heart failure (p = 0.767). CONCLUSIONS: Activin A level > 129 pg/ml predicts worse left ventricular remodeling and all-cause death in STEMI.

Immediate results and long-term cardiovascular outcomes of endovascular therapy in octogenarians and nonoctogenarians with peripheral arterial diseases.

PURPOSE: To investigate the clinical outcomes of endovascular therapy (EVT) in octogenarians and nonoctogenarians with peripheral arterial disease. METHODS: A retrospective analysis of 511 patients (654 affected legs) who underwent EVT between July 2005 and December 2013 was conducted in a prospectively maintained database. Immediate results and long-term vascular outcomes were analyzed and compared between octogenarians and nonoctogenarians. RESULTS: Octogenarians were more likely to be female and have atrial fibrillation (AF), whereas nonoctogenarians had higher rates of obesity, claudication, and medical comorbidities. There were no differences in the rates of EVT success, 30-day major adverse vascular events, and 6-month functional improvement between groups. Over the 10-year follow-up period, the rates of 3-year limb salvage, sustained clinical success, freedom from major cerebrovascular and cardiovascular events, and composite vascular events were similar between groups, but the survival rate was better in nonoctogenarians than in octogenarians (73% vs 63%, respectively, P=0.004). In Cox regression analysis, dependence on dialysis and AF were significant predictors of death (odds ratio [OR] 4.44 in dialyzed and 2.83 in AF patients), major cerebrovascular and cardiovascular events (OR 3.49 and 2.45), and composite vascular events (OR 3.14 and 2.25). CONCLUSION: EVT in octogenarians was feasible, without an increased risk of periprocedural complications. The rates of limb salvage, sustained clinical success, and long-term vascular events were comparable between groups. Dialysis dependence and AF are independent predictors for poor prognosis in patients with peripheral arterial disease. However, these observations require further confirmation in larger scale studies.

Outcomes of Endovascular Therapy With the Controlled Antegrade Retrograde Subintimal Tracking (CART) or Reverse CART Technique for Long Infrainguinal Occlusions.

PURPOSE: To compare the safety, efficacy, and clinical outcomes associated with the controlled antegrade retrograde subintimal tracking (CART) or reverse CART (r-CART) technique to the conventional retrograde approach in the treatment of patients with long infrainguinal occlusions. METHODS: From May 2008 to April 2014, 121 patients failed antegrade recanalization and underwent a retrograde approach to recanalize long infrainguinal occlusions. Patients who underwent successful endovascular therapy (EVT) by the conventional retrograde approach (CRA group) were compared to patients who had successful EVT using the CART/r-CART technique (CART group) after failure of a bidirectional approach. The efficacy, safety, vessel patency, and other clinical outcomes were compared between the groups. RESULTS: Fifty-eight patients (mean age 71.6 ± 12.2 years; 32 men) underwent successful EVT (47.9%, 58/121) using the conventional retrograde approach (CRA group), while 44 patients (mean age 70.8 ± 11.1 years; 31 men) among the 50 patients who underwent the CART/r-CART technique were successfully treated (88.0%, 44/50). Both groups had similar average occlusion lengths and gained 100% immediate hemodynamic success after EVT. There was no significant difference between the groups regarding procedure-related complications. During follow-up, 28 patients died (p=0.380), but there were no differences in the rates of major (p=0.279) or minor amputation (p=0.417) between the groups. There was no difference in the 2-year primary patency (31% vs 24%, p=0.686), assisted primary patency (66% vs 76%, p=0.251), target vessel revascularization (65% vs 54%, p=0.845), or sustained clinical success (52% vs 46%, p=0.995) rates between the CRA and CART groups, respectively. CONCLUSION: Based on acceptable safety, efficacy, and follow-up results in this study, the CART/r-CART technique can salvage patients with long peripheral occlusions after failure of the conventional antegrade or retrograde approach.

Feasibility and Clinical Outcomes of Peripheral Drug-Coated Balloon in High-Risk Patients with Femoropopliteal Disease.

BACKGROUND: Clinical outcomes of the drug-coated balloon (DCB) procedure in high-risk patients with femoropopliteal (FP) disease have not been investigated sufficiently. METHODS: This retrospective, single-center study analyzed 87 patients (39% dialysis) and 97 affected legs (64% critical limb ischemia [CLI]) that underwent DCB for symptomatic FP disease from March 2013 to September 2014. Risk stratification was based on FeDCLIP (female, diabetes, dialysis, CLI, lesion length >150 mm and poor runoff) score. The DCB outcomes among the different risk groups were compared and factors predicting restenosis were analyzed during follow-up. RESULTS: Most of study participants (84%) were moderate to high-risk patients. The procedural success rate was 100% and the 30-day major adverse vascular event rate was 2.1%. The mean lesion length was 178 ± 106 mm and the mean follow-up time was 428 ± 145 (range 50-782) days. The binary restenosis-free and clinically driven target lesion revascularization (CD-TLR)-free rates at 12 months were 77.5% and 84.3%, respectively, for all participants. No significant differences were observed in 1-year binary restenosis and CD-TLR rates in the low-, moderate-, and high-risk groups (60%, 84%, and 73%: p = 0.396; 78%, 89%, and 80%: p = 0.635, respectively). In multivariate analysis, lesion length >150 mm (Hazard ratio [HR]: 8.00, 95% confidence interval (CI) 1.12 to 55.6, p = 0.038) and Rutherford class 6 (HR: 7.09, 95% CI, 1.15 to 43.5, p = 0.034) were identified as independent predictors of binary restenosis. CONCLUSIONS: Despite general comorbidities and advanced limb ischemia, 1-year outcomes of DCB in high-risk patients with FP disease were effective. The DCB procedure holds promise to improve vessel patency; however, lesion length >150 mm and major tissue loss were independent predictors for binary restenosis after the treatment.

Relation of arterial stiffness assessed by brachial-ankle pulse wave velocity to complexity of coronary artery disease.

BACKGROUND: The progression of atherosclerosis leads to increased arterial stiffness. The present study used brachial-ankle pulse wave velocity (baPWV) to evaluate the connection between arterial stiffness in patients with chest pain and the presence and extent of coronary artery disease (CAD). METHODS: On a retrospective basis, we analyzed the data of 703 consecutive patients who had undergone baPWV and an elective coronary angiogram for suspected CAD, between June 2010 and July 2012, at a single cardiovascular center. RESULTS: The baPWV was one of the statistically meaningful predictors of significant CAD (diameter of stenosis >50%) in addition to diabetes and dyslipidemia in a multivariate analysis. When the extent of CAD was classified into nonsignificant or significant CAD (ie, 1-, 2- and 3-vessel disease), there was a significant difference in baPWV between the significant and nonsignificant CAD groups, but there was no difference in baPWV among the 3 significant CAD groups. Linear regression analyses showed that baPWV was significantly associated with the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score. The cutoff value of baPWV at 1735 cm/s had a sensitivity of 55.6%, specificity of 62.4%, and area under receiver operating characteristic curve of 0.612 in predicting CAD. CONCLUSIONS: Arterial stiffness as determined by baPWV is associated independently with significant CAD in patients with angina. Arterial stiffness is related to CAD severity as assessed by the SYNTAX score. As a result, increased arterial stiffness assessed by baPWV is associated with the severity and presence of CAD.