Longitudinal Patterns of Ankle-Brachial Index and Their Association With Progression of CKD in Patients With Type 2 Diabetes and Elevated Body Mass Index.

RATIONALE & OBJECTIVE: Ankle-brachial index (ABI) is used to screen for vascular complications in the setting of diabetes. This study sought to examine the relationship of longitudinal ABI data and chronic kidney disease (CKD) progression in patients with type 2 diabetes (T2D) and elevated body mass index (BMI). STUDY DESIGN: A post-hoc analysis of the Look AHEAD trial. SETTING & PARTICIPANTS: This study included 3,631 participants in the Look AHEAD trial with a baseline glomerular filtration rate (eGFR) >60 ml/min/1.73 m2. EXPOSURES: Average ABI and average annual change in ABI were calculated based on annual ABI measurements during the first 4 years of the study. OUTCOME: CKD progression, defined as kidney failure requiring maintenance dialysis or the occurrence of eGFR<60 ml/min/1.73 m2 with a drop of ≥30% at a follow-up visit relative to the first eGFR measurement. ANALYTICAL APPROACH: Restricted cubic spline and Cox proportional hazards models were fit to estimate associations and to explore non-linearity. RESULTS: Over a median follow-up of 10.1 years, 1,051 participants developed CKD progression. There was a reversed J-shaped relationship of CKD progression with average ABI (when ABI <1.17: HR (per SD decrement), 1.23; 95%CI, 1.06-1.42; when ABI ≥ 1.17: HR (per SD increment), 1.10; 95%CI, 1.00-1.22) and average annual change in ABI (when change in ABI <-0.007: HR (per SD decrement), 1.37; 95%CI, 1.12-1.66; when change in ABI ≥-0.007: HR (per SD increment), 1.13; 95%CI, 1.03-1.24). LIMITATIONS: Observational study, potential unmeasured confounding. CONCLUSIONS: Low and high average ABI, even at clinically normal values, as well as decreasing and increasing average annual ABI, were associated a higher risk of CKD progression in patients with T2D and elevated BMI. Monitoring ABI and its changes over time may facilitate CKD risk stratification in patients with T2D.

The ankle-brachial index, gastrocnemius mitochondrial respirometry, and walking performance in people with and without peripheral artery disease.

Background: Mitochondrial abnormalities exist in lower-extremity peripheral artery disease (PAD), yet the association of the ankle-brachial index (ABI) with mitochondrial respiration in gastrocnemius muscle is unknown. The association of gastrocnemius mitochondrial respiration with 6-minute walk distance in PAD is unknown. Objective: To describe associations of the ABI with mitochondrial respiratory function in gastrocnemius muscle biopsies and associations of gastrocnemius mitochondrial respirometry with 6-minute walk distance in people with and without PAD. Methods: People with (ABI ⩽ 0.90) and without (ABI 1.00-1.40) PAD were enrolled. ABI and 6-minute walk distance were measured. Mitochondrial function of permeabilized myofibers from gastrocnemius biopsies was measured with high-resolution respirometry. Results: A total of 30 people with PAD (71.7 years, mean ABI: 0.64) and 68 without PAD (71.8 years, ABI: 1.17) participated. In non-PAD participants, higher ABI values were associated significantly with better mitochondrial respiration (Pearson correlation for maximal oxidative phosphorylation PCI+II: +0.29, p = 0.016). In PAD, the ABI correlated negatively and not significantly with mitochondrial respiration (Pearson correlation for PCI+II: -0.17, p = 0.38). In people without PAD, better mitochondrial respiration was associated with better 6-minute walk distance (Pearson correlation: +0.51, p < 0.001), but this association was not present in PAD (Pearson correlation: +0.10, p = 0.59). Conclusions: Major differences exist between people with and without PAD in the association of gastrocnemius mitochondrial respiration with ABI and 6-minute walk distance. Among people without PAD, ABI and walking performance were positively associated with mitochondrial respiratory function. These associations were not observed in PAD.

Associations Between Flavonoid Intake and Subclinical Atherosclerosis: The MESA.

BACKGROUND: Flavonoids may play a role in mitigating atherosclerotic cardiovascular diseases, with evidence suggesting effects may differ between vascular beds. Studies examining associations with subclinical markers of atherosclerosis between subpopulations with different underlying risks of atherosclerosis are lacking. METHODS: Among 5599 participants from the MESA (Multi-Ethnic Study of Atherosclerosis), associations between dietary flavonoid intakes (estimated from a food frequency questionnaire) and subclinical measures of atherosclerosis (ankle-brachial index, carotid plaques and intima-media thickness, and coronary artery calcification) were examined using repeated measures models. Exposures and outcomes were measured at exam 1 (2000-2002) and exam 5 (2010-2011). Stratified analyses and interaction terms were used to explore effect modification by time, sex, race/ethnicity, and smoking status. RESULTS: In the analytic population, at baseline, ≈46% were males with a median age of 62 (interquartile range, 53-70) years and total flavonoid intakes of 182 (interquartile range, 98-308) mg/d. After multivariable adjustments, participants with the highest (quartile 4) versus lowest (quartile 1) total flavonoid intakes had 26% lower odds of having an ankle-brachial index <1 (odds ratio, 0.74 [95% CI, 0.60-0.92]) and 18% lower odds of having a carotid plaque (odds ratio, 0.82 [95% CI, 0.69-0.99]), averaged over exams 1 and 5. Moderate (quartile 3) to high (quartile 4) intakes of flavonols, flavanol monomers, and anthocyanins were associated with 19% to 34% lower odds of having an ankle-brachial index <1 and 18% to 20% lower odds of having carotid plaque. Participants with the highest intakes of anthocyanins (quartile 4) at baseline had a marginally slower rate of carotid plaque progression than those with moderate intakes (quartiles 2 and 3). There were no significant associations with intima-media thickness or coronary artery calcification. Observed associations did not differ by sex, race/ethnicity, or smoking status. CONCLUSIONS: In this multi-ethnic population, higher dietary flavonoid intakes were associated with lower odds of peripheral and carotid artery atherosclerosis. Increasing intakes of healthy, flavonoid-rich foods may protect against atherosclerosis in the peripheral and carotid arteries.

Correlation between serum 25-hydroxyvitamin D level and peripheral arterial disease in patients with type 2 diabetes mellitus: a single-center retrospective study.

OBJECTIVE: To investigate the association between serum 25-hydroxyvitamin D (25(OH)D) level and peripheral arterial disease (PAD) in patients with type 2 diabetes mellitus (T2DM). METHODS: This retrospective study analyzed data from 752 T2DM patients treated at Shaoyang Central Hospital between September 2020 and September 2023. Patients were divided into two groups: those with T2DM alone and those with T2DM and PAD. We compared demographic data, biochemical indices, and ankle-brachial index (ABI) values. Pearson correlation and multivariate logistic regression with a forward likelihood ratio method assessed the relationship and risk factors. The predictive value of serum 25(OH)D levels for PAD was evaluated using receiver operating characteristic (ROC) analysis. RESULTS: The T2DM+PAD group was older and had a longer duration of diabetes compared to the T2DM group. This group also had lower BMI, diastolic blood pressure, and ABI values, but higher levels of low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC) (all P<0.05). Serum 25(OH)D levels were significantly lower in the T2DM+PAD group (P<0.05). ABI negatively correlated with age, diabetes duration, LDL-C, and TC, and positively with BMI and 25(OH)D levels (all P<0.05). Older age, lower BMI, higher LDL-C, and lower 25(OH)D levels were independent risk factors for PAD (ORs: 1.060, 0.781, 1.083, and 0.959, respectively; all P<0.05). The risk of PAD was significantly higher in the 25(OH)D deficiency group (P<0.05). The AUC for serum 25(OH)D in predicting PAD occurrence was 0.629. CONCLUSION: Lower serum 25(OH)D levels are associated with higher risk of PAD in patients with T2DM. Early identification and management of 25(OH)D deficiency may be crucial for preventing PAD in this population.

Peripheral artery disease and risk of kidney outcomes: The Atherosclerosis Risk in Communities (ARIC) study.

BACKGROUND AND AIMS: The potential impact of peripheral artery disease (PAD) on kidney outcomes is not well understood. The aim of this study was to explore the association between PAD and end-stage kidney disease (ESKD) and chronic kidney disease (CKD). METHODS: Among 14,051 participants (mean age 54 [SD 6 years]) from the Atherosclerosis Risk in Communities study, we categorized PAD status as symptomatic PAD (intermittent claudication or leg revascularization), asymptomatic PAD (ankle-brachial index [ABI] ≤0.90 without clinical history of symptoms), and ABI 0.91-1.00, 1.01-1.10, 1.11-1.20 (reference), 1.21-1.30, and >1.30. We evaluated their associations with two kidney outcomes: ESKD (the need of renal replacement therapy or death due to kidney disease) and CKD (ESKD cases or an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 with a ≥25 % decline from the baseline) using multivariable Cox proportional hazards models. RESULTS: Over ∼30 years of follow-up, there were 598 cases of incident ESKD and 4686 cases of incident CKD. After adjusting for potential confounders, both symptomatic PAD and asymptomatic PAD conferred a significantly elevated risk of ESKD (hazard ratio 2.28 [95 % confidence interval 1.23-4.22] and 1.75 [1.19-2.57], respectively). Corresponding estimates for CKD were 1.54 (1.14-2.09) and 1.63 (1.38-1.93). Borderline low ABI 0.91-1.00 also showed elevated risk of adverse kidney outcomes after adjustment for demographic variables. Largely consistent results were observed across demographic and clinical subgroups. CONCLUSIONS: Symptomatic PAD and asymptomatic PAD were independently associated with an elevated risk of ESKD and CKD. These results highlight the importance of monitoring kidney function in persons with PAD, even when symptoms are absent.

Impact of Abnormal Ankle Brachial Index on Sepsis Survival: One-Year Prospective Study Results.

Background: Lower extremity peripheral artery disease (LE-PAD) has been linked to unfavorable cardiovascular outcomes. The impact of potentially undiagnosed LE-PAD, suspected by abnormal ankle-brachial index (ABI), on the survival of sepsis patients admitted to the intensive care unit (ICU) remains uncertain. Methods: We conducted a prospective cohort study and recruited adult patients admitted to the ICU with a primary diagnosis of sepsis (defined by a quick Sepsis-Related Organ Failure Assessment score of ≥ 2) between November 23, 2017 and July 22, 2018. ABI measurements were obtained within 24 hours of admission. The study compared the 30-day and 1-year all-cause mortality rates as well as the incidence of major adverse cardiovascular events (MACEs) between the groups with normal and abnormal ABI values. Results: Of the 102 sepsis patients admitted to the ICU, 38 (37%) were diagnosed with LE-PAD based on their ABI measurements. The overall 30-day mortality rate was 30.0% in patients with LE-PAD and 25.8% in those with normal ABI (p = 0.56). At 1 year, the overall mortality rate was 52.6% in the patients with abnormal ABI and 40.6% in those with normal ABI (p = 0.24). Additionally, the incidence of MACEs was significantly higher in the patients with abnormal ABI compared to those with normal ABI at 1-year follow-up (21.1% vs. 3.1%, respectively; p = 0.003). Conclusions: The patients with abnormal ABI had a higher incidence of MACEs within one year following hospital discharge. Future studies are needed to improve cardiovascular outcomes among sepsis survivors (ClinicalTrials.gov number, NCT03372330).

Diagnostic Potential of Combined Photoplethysmography and Ankle-Brachial Index in Peripheral Arterial Disease: A Duplex Ultrasonography-Based Comparative Study.

BACKGROUND: Although ankle-brachial index (ABI) and photoplethysmography (PPG) have also shown adequate sensitivity in detecting peripheral arterial disease, their diagnostic performance is less reliable in asymptomatic cases or those with high atherosclerotic cardiovascular risks. METHODS AND RESULTS: We evaluated 130 participants using ABI, PPG, and duplex ultrasonography, diagnosing 65 with peripheral arterial disease. From the PPG, we derived 2 parameters: PPG amplitude ratio of the lower-to-upper extremities (PPGratio) and the PPG amplitude of the lower extremity (PPGamp). Sensitivity, specificity, accuracy, and the area under receiver operating characteristic (ROC) curve were calculated for PPG parameters and ABI, and their combination of both methods. Univariate and multivariate logistic regression assessed the prognostic potential of these parameters. ROC analysis revealed optimal cutoff values in diagnosing peripheral arterial disease were 0.417 for PPGratio and "58" for PPGamp. Both PPGratio and PPGamp demonstrated significantly higher sensitivities, 78.4% and 75.7%, respectively, compared with 55.9% for ABI <0.9 (P<0.05). The areas under the ROC curves of combination models, including model 1 (ABI <0.9 and PPGratio), model 2 (ABI <0.9 and PPGamp), and model 3 (ABI <0.9, PPGratio, and PPGamp), exhibited improved performance with areas under the ROC curves of 0.922, 0.922, and 0.931 (all P<0.01) compared with ABI alone (area under the ROC curve, 0.822). Additionally, the PPG parameters, both alone and combined with ABI, were associated with major adverse cardiac events and all-cause mortality after adjusting for other relevant factors. CONCLUSIONS: On the basis of duplex ultrasonography, combining ABI and PPG markedly improves peripheral arterial disease diagnosis in high-risk individuals compared with either method alone and provides crucial insights into major adverse cardiac events and all-cause mortality risks.

The Relationship Between Fibrinogen and Glycated Hemoglobin (HbA1c) in Diabetic Foot Ulcers.

INTRODUCTION:  Diabetic foot ulcers (DFUs) are a common complication of diabetes that affects patients' quality and prognosis of life. The study aims to assess the correlation between fibrinogen and glycated hemoglobin (HbA1c) in DFUs at the first and sixth months and to compare fibrinogen levels with Wagner classification in DFU patients. METHODS:  This observational study was conducted at SRM Medical College Hospital and Research Centre from January 2021 to July 2022. Fifty diabetes patients with DFUs were selected, and informed consent was obtained before the study started. Blood samples were collected from all the participants for HbA1C, serum fibrinogen, hemoglobin, and white blood cells. In this study, data were entered into MS Excel (Microsoft Corporation, Redmond, WA) and analyzed using SPSS version 24 (IBM Corp., Armonk, NY). ANOVA and Pearson's correlation were used to examine the relationships between serum fibrinogen levels and clinical parameters. RESULTS:  Among 50 patients, the females were 16 (32%), and the males were 34 (68%). Most patients (34%) were in the 56-60 age group. Twenty patients had diabetes for 10 years, and 24 were diabetic for 11-15 years. The ankle-brachial index (ABI score) was mild in 14 patients (28%), moderate in 28 patients (56%), and normal in eight patients (16%). There is a significant difference in comparison between the Wagner classification and ABI. A significant difference was observed in fibrinogen at the first and sixth months between HbA1c first, third, and sixth months. Significant differences were also observed in fibrinogen and ABI in the first and sixth months. CONCLUSION:  Key findings include significant differences between fibrinogen and HbA1c levels (p < 0.0001) and a strong association between fibrinogen levels and ABI scores (p < 0.0001), underscoring fibrinogen's potential as an early marker for glycemic control and peripheral arterial disease in DFU patients. We concluded that simple fibrinogen estimation helps predict glycemic control in diabetic patients with DFUs.

Relationship of proteins and subclinical cardiovascular traits in the population-based LIFE-Adult study.

BACKGROUND AND AIMS: Understanding molecular processes of the early phase of atherosclerotic cardiovascular disease conditions is of utmost importance for early prediction and intervention measures. METHODS: We measured 92 cardiovascular-disease-related proteins (Olink, Cardiovascular III) in 2024 elderly participants of the population-based LIFE-Adult study. We analysed the impact of 27 covariables on these proteins including blood counts, cardiovascular risk factors and life-style-related parameters. We also analysed protein associations with 13 subclinical cardiovascular traits comprising carotid intima media thickness, plaque burden, three modes of Vicorder-based pulse-wave velocities, ankle-brachial index and ECLIA-based N-terminal prohormone of brain natriuretic peptide (NT-proBNP). RESULTS: Estimated glomerular filtration rate, triglycerides and sex where the most relevant covariables explaining more than 1 % variance of 49, 22 and 20 proteins, respectively. A total of 43 proteins were significantly associated with at least one of the analysed subclinical cardiovascular traits. NT-pro-BNP, brachial-ankle pulse-wave velocity (baPWV) and parameters of carotid plaque burden accounted for the largest number of associations. Association overlaps were relatively sparse. Only growth/differentiation factor 15, low density lipoprotein receptor and interleukin-1 receptor type 2 are associated with these three different cardiovascular traits. We confirmed several literature findings and found yet unreported associations for carotid plaque presence (von-Willebrand factor, galectin 4), carotid intima-media thickness (carboxypeptidase A1 andB1), baPWV (cathepsin D) and NT-proBNP (cathepsin Z, low density lipoprotein receptor, neurogenic locus homolog protein 3, trem-like transcript 2). Sex-interaction effects were observed, e.g. for spondin-1 and growth/differentiation factor 15 likely regulated by androgen response elements. CONCLUSIONS: We extend the catalogue of proteome biomarkers possibly involved in early stages of cardiovascular disease pathologies providing targets for early risk prediction or intervention strategies.

Relationship of Thyroid Volume and Function with Ankle-Brachial Index, Toe-Brachial Index, and Toe Pressure in Euthyroid People Aged 18-65.

Background and Objectives: The interrelationship between thyroid function and the state of the cardiovascular system has been investigated both in preclinical and human studies. However, it remains unclear whether there is any association between thyroid hormones and features of subclinical cardiovascular dysfunction in euthyroid patients. Material and Methods: This study involved 45 people (females: 57.8%) with no thyroid disease who, during planned hospitalization, underwent thyroid ultrasound, determination of biochemical parameters of thyroid function, and measurement of ankle-brachial index (ABI) and toe-brachial index (TBI). People with signs of acute illness or a deterioration of their health were excluded. Results: Significant correlations were found between free triiodothyronine (FT3) and several parameters of both ABI (R = 0.347; p = 0.019 for the mean ABI taken from right side and left side values) and TBI (R = 0.396; p = 0.007 for the mean TBI taken from right side and left side values), as well as the maximal toe pressure (TP) taken from right side and left side values (R = 0.304; p = 0.045). Thyrotropin (TSH) was shown to be significantly correlated only with the maximal TBI value (taken from right side and left side values) (R = 0.318; p = 0.033), whereas free thyroxin (FT4) was shown to be significantly correlated only with the minimal TBI value (taken from right side and left side values) (R = 0.381; p = 0.01). Thyroid volume (TV) was shown to be correlated with TP (R = 0.4; p = 0.008 for the mean TP taken from right side and left side values) and some parameters of TBI value (R = 0.332; p = 0.028 for the mean TBI taken from right side and left side values), but no significant correlations were found between TVand ABI parameters. Patients with a mean ABI value ≤ 1.0 or a mean TBI value ≤ 0.75 have lower TSH, FT3, FT4, and TV than the rest of the study population, but the difference was statistically significant only for FT3. Conclusions: Even in a population of euthyroid patients with no diagnosed thyroid disease, there are some significant correlations between the volume and function of the thyroid gland and the selected features of subclinical cardiovascular dysfunction such as ABI and TBI.

The Association between Percentage of Mean Arterial Pressure and Long-Term Mortality in Acute Myocardial Infarction Patients: An Observational Cohort Study.

Background: Acute myocardial infarction (AMI) is a critical cardiovascular disease with high morbidity and mortality. Identifying practical parameters for predicting long-term mortality is crucial in this patient group. The percentage of mean arterial pressure (%MAP) is a useful parameter used to assess peripheral artery disease. It can be easily calculated from ankle pulse volume recording. Previous studies have shown that %MAP is a useful predictor of all-cause mortality in specific populations, but its relationship with mortality in AMI patients is unclear. Methods: In this observational cohort study, 191 AMI patients were enrolled between November 2003 and September 2004. Ankle-brachial index (ABI) and %MAP were measured using an ABI-form device. All-cause and cardiovascular mortality data were collected from a national registry until December 2018. Cox proportional hazards model and Kaplan-Meier survival plot were used to analyze the association between %MAP and long-term mortality in AMI patients. Results: The median follow-up to mortality was 65 months. There were 130 overall and 36 cardiovascular deaths. High %MAP was associated with increased overall mortality after multivariable analysis (HR = 1.062; 95% CI: 1.017-1.109; p =0.006). However, high % MAP was only associated with cardiovascular mortality in the univariable analysis but became insignificant after the multivariable analysis. Conclusions: In conclusion, this study is the first to evaluate the usefulness of %MAP in predicting long-term mortality in AMI patients. Our study shows that %MAP might be an independent predictor of long-term overall mortality in AMI patients and has better predictive power than ABI.

Ankle-brachial index and carotid ultrasound as surrogates for coronary artery disease diagnosis.

INTRODUCTION: Cardiovascular disease represents the foremost cause of death among chronic and non-transmissible diseases. Diagnostic tools commonly used for peripheral and carotid atherosclerosis, such as ankle-brachial index (ABI) and carotid ultrasonography (CU), may contribute as surrogates for the diagnosis of coronary arterial disease (CAD). MATERIAL AND METHODS: We report a cross-sectional study of 50 patients referred to elective invasive coronary angiography (ICA). Patients were submitted to ABI and CU-for carotid intima-media thickness (CIMT) and carotid atherosclerotic plaque screening (CAPS). Clinical and demographic variables were also evaluated. CAD was defined as greater than 50% stenosis in at least one coronary artery. RESULTS: In logistic regression analysis, only CAPS showed a statistically significant area under the curve (AUC) for CAD prediction: 0.812 (95% CI, p <0.001). ABI and CIMT did not show statistically significant performance. For multivariate logistic regression analysis, the model including variables "gender," "dyslipidemia," "smoking," "pack-years," and CAPS predicted CAD better. The AUC for this model was 0.912 (95% CI, p = 0.002). CONCLUSION: The screening for carotid atherosclerotic plaques may enhance traditional risk stratification strategies for CAD. Longitudinal studies and bigger samples of subject are needed to allow extrapolation of our findings.

Integrating Toe Brachial Index and longitudinal strain echocardiography for detecting coronary artery disease in patients with diabetic foot syndrome.

Coronary artery disease (CAD) is a common problem amongst diabetic foot syndrome (DFS) patients, associated with peripheral arterial disease. This analytic cross-sectional study investigates the diagnostic efficacy of the Toe Brachial Index (TBI) in the detection of CAD in 62 DFS patients. The presence of CAD was assessed by longitudinal strain echocardiography, a sensitive method that provides a more accurate measure of intrinsic left ventricular contractility than left ventricular ejection fraction, especially in diabetic patients. Univariate and multivariate logistic regression identified CAD-associated factors. Receiver operating characteristic curve evaluated TBI and toe pressure's diagnostic performance for CAD. p-Values < 0.05 were considered significant. There was a significant association between TBI and CAD, with each 0.01 increase in TBI associated with a 15% decrease in the odds of CAD development (odds ratio = 0.85, 95% CI: 0.72-0.99, p = 0.039). TBI demonstrated an area under the curve of 0.854, a sensitivity of 80.0% and a specificity of 66.7% at a cut-off of 0.69. Additionally, toe pressure exhibited an area under the curve of 0.845, sensitivity of 74.0% and specificity of 75.0% at a cut-off of 68.0 mmHg. Overall accuracy for TBI and toe pressure was 77.4% and 74.2%, respectively, indicating their potential for CAD risk stratification in the DFS population. This study highlights a significant association between low TBI and the presence of CAD in DFS patients. Consequently, TBI emerges as a valuable screening tool for identifying CAD within this population.

Vascular Injuries in Multiligament Knee Injuries (MLKIs).

Purpose: Vascular injuries are rarely associated with severe knee injuries; nonetheless, it is imperative to efficiently detect this condition and plan for either immediate or definitive treatment at later stages. The diagnosis and management of multiligament knee injuries still present unresolved issues, particularly in the early detection of vascular issues and the sequential stabilisation of ligaments. High-energy trauma is a frequently encountered cause, however, even low-energy trauma in those who are morbidly obese might pose a significant risk. Advancements in detection and management methods have greatly decreased the occurrence of vascular complications and amputation rates over time. MLKIs after transient knee dislocations are frequently misdiagnosed for vascular injuries, underscoring the necessity for improved diagnostic techniques to avoid avoidable amputations. Methods: This article is a new conceptual review of vascular injuries associated with MLKIs. It provides a full overview of these conditions and includes a review of the most recent literature. We have included pertinent citations from the literature, together with suggestions derived from the latest studies. This review article had additional evaluation by proficient specialists with commendable outcomes and more than a decade of expertise in surgical techniques. Results: This article offers a detailed overview of orthopaedic management, including new definitions and summaries of the causes, evaluation of patients, clinical assessment, identification of vascular injuries, and initial management in patients with vascular impairment following major limb and joint injuries (MLKIs). Conclusion: MLKIs (patients with lower limb ischaemia) who have vascular damage necessitate meticulous physical assessment and sophisticated treatments in order to decrease amputation rates. Prompt identification and timely treatment of vascular lesions, namely in the popliteal artery, can substantially reduce the occurrence of amputations. Emerging research suggests that there is a heightened risk in low-energy situations, particularly amongst individuals who are extremely obese. Progress in vascular intervention has led to a reduction in amputation rates, whilst the implementation of new guidelines has enhanced identification. Thorough patient assessment is essential, utilising physical examinations and imaging techniques such as Computed tomography angiography, magnetic resonance angiography (CTA or MRA) to guide treatment decisions. MRA, in particular, is capable of identifying both vascular and knee structural damage. Level of Evidence: Level IV, Literature reviews.

Prospective evaluation of automated vascular analysis for ilio-femoral artery lesions before and after percutaneous endovascular aortic repair.

BACKGROUND: This study was conducted to evaluate the differences between pre- and postoperative access conditions in percutaneous endovascular aortic repair (PEVAR). METHODS: Between December 2021 and October 2023, PEVAR was performed on 61 patients using the Perclose ProStyle (Abbott Vascular). Enhanced computed tomography and ankle-brachial index tests were performed preoperatively and postoperatively. The inner diameter and area of the iliofemoral artery were automatically measured, and the pre- and postoperative values were compared (114 legs). The same analysis was performed on 12 legs with previous groin operations; open surgical EVAR was performed in 9 legs, an endarterectomy of the femoral artery in 1, and a femoropopliteal bypass in the other leg. RESULTS: All patients were discharged without surgical site infections, lymphatic fistulas, or retroperitoneal haematomas. There were no significant differences between the pre-and postoperative inner diameter and inner area of the external iliac artery and common femoral artery. There were no significant differences between the preoperative and postoperative ankle-brachial index tests. In 12 legs with a previous groin operation, the postoperative ankle-brachial index tests and inner diameter and area of the external iliac artery and common femoral artery were statistically equal to the preoperative values. CONCLUSIONS: This study can support the safety of percutaneous endovascular aortic repair, even in patients with redo groin operations.

Vascular complications after a multiligament knee reconstruction: A case report highlighting the role of preoperative imaging.

Vascular injuries are serious complications of multiligament knee injuries and can result in catastrophic outcomes. These injuries can range from intimal flaps with no compromise of the distal perfusion to a complete occlusion or transection requiring emergent vascular intervention. Several diagnostic tests, including the measurement of the ankle-brachial index (ABI), conventional angiography, and computed tomography angiography (CTA), are commonly used as diagnostic tools to identify vascular injuries in the context of a multiligament knee injury. In this report, the authors discuss the case of a patient with a normal ABI and palpable distal pulses on physical examination who developed limb ischemia after a multiligament knee reconstruction under tourniquet. The patient underwent emergent embolectomy and had a favorable postoperative outcome. During vascular exploration, there was no evidence of injury to the popliteal artery. The two working diagnoses were that either the patient had an intimal flap complicated by the development of a thrombus during surgery or that the initial vascular injury was not detected by ABI and clinical examination. Therefore, intimal flaps in multiligament knee injuries can lead to limb threatening ischemia in the context of reconstructive knee surgery and are likely underdiagnosed with ABI assessment. The utilization of preoperative CTA may help identify these injuries in patients indicated for reconstructive surgeries.

Hypertension in Patients With Peripheral Artery Disease: An Updated Literature Review.

Peripheral artery disease (PAD), a condition where there is reduced blood flow due to narrowing or blockage of the arteries of the peripheral vasculature, is an epidemic that currently affects eight million people in the United States alone and is a major risk equivalent to having active coronary artery disease (CAD). However, it is commonly underdiagnosed in the general population. Hypertension is a common cardiovascular condition characterized by elevated blood pressure levels. There are several mitigating risk factors that can reduce the risk of complications of PAD, with hypertension playing a major role. This literature review aims to explore the relationship between hypertension and PAD, including their shared risk factors, pathophysiological mechanisms, and management strategies. In addition, we will analyze how this impacts major cardiovascular outcomes, such as critical limb ischemia, vascular amputation, myocardial infarction (MI), ischemic stroke, and cardiovascular-related death by examining relevant studies, current guidelines, and evidence. This literature review is intended to guide practitioners on ideal blood pressure parameters and evidence-based anti-hypertensives that provide overall cardiovascular benefit in both the primary care and hospital-based setting. By understanding the association between hypertension and PAD and the underlying pathophysiological mechanisms, healthcare professionals can improve diagnosis, treatment, and management strategies for affected individuals.

Nutritional habits in patients with peripheral arterial disease: Adherence to the mediterranean diet. / Hábitos nutricionales en los pacientes con enfermedad arterial periférica: adherencia a la dieta mediterránea.

INTRODUCTION: Adherence to the Mediterranean diet (Dietmed) exerts protective effects on cardiovascular disease (CVD). In the Lower Extremity Peripheral Arterial Disease (PAD) there are fewer studies that analyze these data. OBJECTIVE: To determine adherence to Dietmed and dietary habits in patients with PAD, according to a history of CVD (coronary and/or cerebral ischaemic pathology) and according to the ankle-brachial index (ABI ≥ or <0,5). MATERIAL AND METHODS: Cross-sectional analytical study carried out in a tertiary hospital. The sample was collected consecutively. Sociodemographic and clinical history, ankle-brachial index (ABI) and a 14-point Dietmed adherence dietary questionnaire were included. The analysis of categorical variables was carried out using the Pearson's Chi-Square test, the T-Student's statistic test for independent samples was used for parametric variables and the U. Mann-Whitney test for non-parametric variables. RESULTS: Of the 97 patients, 87,6% had low adherence to Dietmed, with no differences according to the severity of PAD. However, when we analysed the data according to whether or not they had a history of CVD, we observed a high adherence to some items included in Dietmed, specifically, in the CVD group, the consumption of lean meat (95,5% vs 64%; P=.004). In addition, we observed a significant difference in the consumption in the group without a history of CVD (32% vs 9,1%; P=.033). CONCLUSION: In our population, patients with PAD, regardless of the stage of the disease and whether they had associated coronary or cerebral ischaemic pathology, had low adherence to Dietmed. Therefore, it is important to implement nutritional education programmes in patients with PAD in all stages, as well as in those patients who have already suffered a vascular event, so that they maintain adherence to healthy dietary habits in the long term.

Difference in right and left cardio-ankle vascular index as a useful marker for evaluation of leg ischemia in patients with lower extremity arterial disease.

OBJECTIVES: Cardio-ankle vascular index (CAVI) is a blood pressure-independent measure of heart-ankle pulse wave velocity and is used as an indicator of arterial stiffness. However, there is a paradox that CAVI is inversely associated with leg ischemia in patients with lower extremity arterial disease (LEAD). The aim of this study was to clarify the significance of the absolute value of left and right difference in CAVI (diff-CAVI). METHODS: The subjects were 165 patients with LEAD who had received medication therapy. Relationships between diff-CAVI and leg ischemia were investigated. Leg ischemia was evaluated by decrease in leg arterial flow using ankle-brachial index (ABI) and by symptoms using the Rutherford classification. RESULTS: There was a significant inverse correlation between diff-CAVI and ABI. The odds ratio for low ABI of the 3rd versus 1st tertile groups of diff-CAVI was 7.03 with a 95% confidence interval of 2.71 ∼ 18.22. In ROC analysis, the cutoff value of diff-CAVI for low ABI was 1.05 with a sensitivity of 61.1% and a specificity of 87.1%. The median of diff-CAVI was significantly higher in subjects with grade 2 of the Rutherford classification than in subjects with its grade 1. CONCLUSIONS: diff-CAVI showed an inverse association with ABI and a positive association with symptoms of leg ischemia. Thus, diff-CAVI is thought to be a useful indicator of leg ischemia in LEAD patients.

Clinical evolution of patients with lower extremity peripheral artery disease during the COVID-19 pandemic (the COVID-PAD study).

Background: The COVID-19 pandemic has led to significant disruptions in chronic disease care and forced people to stay at home. The effects of such issues on outpatients with lower extremity peripheral artery disease (PAD) remain unknown. Patients and methods: Single-centre, retrospective-prospective study conducted in a Swiss University Hospital. Patients with PAD were included between May 1 and July 31, 2020, with a follow-up visit at 12 months. Upon both visits, the Leriche-Fontaine PAD stage was recorded, and study participants underwent ankle-brachial index (ABI) calculation to assess limb perfusion. Functional capacities were assessed through the 6-minute walking and treadmill tests. Major adverse cardiovascular (MACE) and limb events (MALE) were recorded. Data collected during the pandemic were compared with the pre-pandemic period (January 1, 2019-April 30, 2020). Results: Overall, 259 patients were included. Mean age was 69 years and male sex was prevalent (69.1%). Odds of experiencing a degradation in PAD stage were lower during the pandemic than before (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21-0.87; p = 0.018). No significant difference was found between periods in terms of ABI trends. Both pain-free walking time at treadmill test (p = 0.003) and maximal pain intensity at 6-minute walking test (p = 0.001) significantly improved during the pandemic. Compared with the pre-pandemic period, during the pandemic patients were hospitalized less frequently (p = 0.028) and were less likely to undergo elective limb revascularization (p<0.001). No significant difference was found between periods in terms of MALE (p = 0.311), whereas non-fatal strokes were less frequently reported during the pandemic (p = 0.043). Conclusion: In a cohort of outpatients with PAD, we found no evidence of clinical deterioration during the pandemic compared with the pre-pandemic period, though rates of adverse events were nonnegligible in both periods. In case of future pandemics, patients with PAD should be encouraged to maintain an active lifestyle while being closely monitored to avoid clinical worsening.