Lower All-Cause Mortality Risk in Females and Males with Peripheral Artery Disease following Pain-Free Home-Based Exercise: A 7-Year Observational Study.

We evaluated the sex-specific difference in response upon participation in an exercise program with respect to the risk of adverse clinical outcomes among patients with peripheral artery disease (PAD) and claudication. The records of 400 PAD patients were assessed between 2012 and 2015. Two hundred of them were addressed to a walking program prescribed at the hospital and executed at home at symptom-free walking speed (Ex), while the remaining 200 acted as a control group (Co). The number and date of deaths, all-cause hospitalizations, and amputations for a 7-year period were collected from the regional registry. At baseline, no differences were observed (MEXn = 138; FEXn = 62; MCOn = 149; FCOn = 51). The 7-year survival rate was significantly higher in FEX (90%) than in MEX (82% hazard ratio, HR: 0.542 95% CI 0.331-0.885), FCO (45%, HR: 0.164 95% CI 0.088-0.305), and MCO (44%; HR: 0.157 95% CI 0.096-0.256). A significantly lower rate of hospitalization (p < 0.001) and amputations (p = 0.016) was observed for the Ex group compared to the Co group, without differences by sex. In conclusion, in PAD patients, active participation in a home-based pain-free exercise program was associated with a lower rate of death and better long-term clinical outcomes, particularly among women.

SARS-COV-2 Pandemic for Patients with Chronic Obstructive Peripheral Arterial Disease: Impact of Interruption to Access According to Gender in a Single Center Experience.

BACKGROUND: This retrospective study aims to evaluate the impact of interrupted services for peripheral arterial disease (PAD) patients and especially women in a single north-eastern Italian center over a period of 3 months prior to the pandemic, during the first (2020) and the second (2021) wave of contagion in northern Italy. METHODS: Patients with PAD at Rutherford stages 3 to 6 that required revascularization between March 2019 and March 2021 were classified into 3 groups, according to the period of treatment: the prepandemic period, the pandemic-20 period, and the pandemic-21 period. RESULTS: Twenty-eight patients were treated in the prepandemic period, 21 in the pandemic-20 period, and 39 in the pandemic-21 period. It was observed that in the both pandemic periods patients presented with more severe stages of limb ischemia, Rutherford 5 and 6 stages. During pandemic-20, patients underwent mostly open surgery, followed by hybrid procedures. No differences were observed between the 3 groups in major amputations, length of hospital stay, type of discharge, limb salvage and mortality. During long-term follow-up, limb salvage appeared to be significantly better in the pandemic-21 group. The gender analysis revealed a significantly reduced female proportion of overall treated patients in 2020 and 2021 compared to the prepandemic period. In the pandemic-20 this difference appears even more evident since treatments on females represented 19% of the total while in the same period of the previous year the male/female percentage was comparable (54% vs. 46%). The women admitted presented higher stages of disease and tended to have a longer hospital stay than men. At 12-month follow-up, limb salvage was similar between the 2 genders but was slightly worse in women. CONCLUSIONS: An efficient reorganization of the vascular surgery services during the pandemic period guaranteed the quality and standard of treatment offered in the preceding periods. Among patients suffering from PAD the impact of the pandemic was greater for the female gender. It is therefore important that in addition to a reorganization of hospital services to provide adequate care for patients with ACOP in the pandemic period, greater information and awareness of women.

Biomarkers of Muscle Metabolism in Peripheral Artery Disease: A Dynamic NIRS-Assisted Study to Detect Adaptations Following Revascularization and Exercise Training.

We assessed whether muscle metabolism biomarkers (MMb) identified by near-infrared spectroscopy (NIRS) are valid for determining adaptations following revascularization or exercise training in peripheral artery disease (PAD). Eighteen patients (males n = 13; 69 ± 7 years) were randomized to receive revascularization (Rev = 6) or pain-free home-based exercise (Ex = 12). MMb were safely collected via a NIRS-assisted treadmill test as area-under-curve for the spectra of oxygenated (-oxy), deoxygenated (-deoxy), differential (-diff) and total (-tot) hemoglobin traces. MMb, ankle-brachial index (ABI), pain-free (PFWD) and 6-minute (6MWD) walking distances were assessed at baseline and after four months. MMb were correlated at baseline with ABI (MMb-oxy r = 0.46) and 6MWD (MMb-tot r = 0.51). After treatments, MMb-oxy showed an expected increase, which was more relevant for Rev group than the Ex (56% vs. 20%), with trends towards normalization for the other MMb. These changes were significantly correlated with variations in ABI (MMb-oxy r = 0.71; p = 0.002) and 6MWD (MMb-tot r = 0.58; p = 0.003). The MMb-diff in Rev group and MMb-deoxy in Ex group at baseline predicted clinical outcomes being correlated with PFWD improvements after 4-month (r=-0.94; p = 0.005 and r = -0.57; p = 0.05, respectively). A noninvasive NIRS-based test, feasible in a clinical setting, identified muscle metabolism biomarkers in PAD. The novel MMb were associated with validated outcome measures, selectively modified after different interventions and able to predict long-term functional improvements after surgery or exercise training.

Changes in exercise capacity and risk of all-cause mortality in patients with peripheral artery disease: a 10-year retrospective cohort study.

We retrospectively studied the association between changes in exercise capacity at discharge from a home-based exercise program and the risk of all-cause mortality among patients with peripheral artery disease (PAD) and claudication. The records of 1076 consecutive PAD patients were assessed between 2003 and 2013. The exercise program was prescribed during a few visits and executed at home at symptom-free walking speed. Ankle-Brachial Index (ABI) and maximal speed (Smax) on an incremental treadmill test were recorded at baseline and discharge. The number and date of deaths and hospitalizations for a 10-year period were collected from the regional registry. A total of 865 PAD patients completed the program (completers), while 221 left the program for health reasons (n = 128, diseased) or for nonhealth reasons (n = 83, quitters). Among the completers, the mortality rate (27%) was significantly lower (p < 0.001) than that of both the diseased (49 deaths, 38%) and the quitters (45 deaths, 54%). The completers (71 ± 9 years; 88% exercise sessions completed) showed significant improvements in the lowest ABI (from 0.62 ± 0.18 to 0.67 ± 0.19) and Smax (from 3.3 ± 1.1 to 3.8 ± 1.1 km h-1) at discharge. The completers who reached the clinically important difference of Smax ≥ 0.4 km h-1 at follow-up showed a significantly lower mortality risk (25% vs. 30%; HR 0.72; 95% CI 0.55-0.93) as well a lower rate of hospitalizations (p < 0.001). In conclusion, in PAD patients, active participation in a home-based exercise program was associated with a lower rate of death and better long-term clinical outcomes, particularly for those who attained a moderate increase in exercise capacity.

The effect of an Enhanced Recovery Program in elective retroperitoneal abdominal aortic aneurysm repair.

OBJECTIVE: Enhanced Recovery Programs (ERPs) have been introduced to accelerate postoperative recovery and are mainly focused on decreasing the surgical stress response. Limited data are available regarding the implementation of ERPs in patients who undergo abdominal aortic aneurysm (AAA) repair using the retroperitoneal approach. The aims of this study were: (1) to evaluate the implementation of an ERP in patients who underwent elective retroperitoneal AAA repair; and (2) to define independent predictors of prolonged hospital length of stay (LOS) in these patients. METHODS: This was a retrospective cohort study on 221 patients who underwent elective AAA repair via a retroperitoneal approach from 2005 through 2013 at an Italian university hospital. Patients who received surgery from 2008 through 2013 and enrolled in an ERP (n = 130) were compared with those who received surgery from 2005 through 2007 and managed with traditional perioperative care (n = 91). RESULTS: Patient characteristics were comparable between groups. Intensive care unit admissions were prevalent among patients who received traditional care vs patients in the ERP (P < .01). ERP patients had fewer major (P < .01) and minor (P = .019) complications, and mortality was similar between groups. Complete functional recovery was achieved earlier in ERP patients vs controls (P < .01). Patients in the ERP group left the hospital earlier than controls (P < .01). No readmission ≤30 days were reported in the ERP group. Age ≥65 years and being in a conventional care protocol were found to be independent predictors of prolonged hospital LOS. CONCLUSIONS: The implementation of an ERP after elective AAA repair using a retroperitoneal approach reduced postoperative intensive care unit admission, accelerated functional recovery, and decreased morbidity and LOS with no readmission ≤30 days. Age ≥65 years and conventional perioperative care were the only independent predictors of prolonged LOS.

Retroperitoneal access for abdominal aortic aneurysms: a single center experience.

BACKGROUND: Abdominal aortic aneurysms (AAA) may be treated through different surgical techniques. In this endovascular era, surgery remains a mainstay in the management of this disease, especially in patients unsuitable for EVAR. The purpose of this study was to compare retrospectively the postoperative outcomes and survival rates of the transperitoneal and the retroperitoneal approach for the abdominal aortic aneurysm repair in our Unit. METHODS: A retrospective analysis of 840 consecutive patients affected by AAA who were electively admitted in our unit from 1996 to 2011 was performed. Five hundred and sixty patients underwent surgical treatment, 193 through a transperitoneal approach (TP group) and 367 by a retroperitoneal approach (RP group). Short and long-term postoperative outcomes were compared in the two groups. RESULTS: The RP group was characterized by significantly fewer ICU admissions and fewer respiratory and cardiac postoperative complications. Canalization and oral feeding occurred earlier and the mean length of hospital stay for the RP group was shorter compared with that for the TP group. Twelve months survival rate in the RP group was significantly higher comparing with the TP group. Similarly higher survival rates were also observed at 180 months follow-up. CONCLUSIONS: In our study the repair of AAA through a retroperitoneal approach was associated with positive outcomes particularly in high-risk patients. It represents a valid therapeutic option especially in subjects not suitable for endovascular procedures. Surgical training and competence should be maintained to ensure the selection of the appropriate therapy for each patient.

Heparin surface stent-graft for the treatment of a carotid pseudoaneurysm.

Carotid pseudoaneurysms are a rare consequence of carotid surgery, trauma, and infection. Historically, carotid aneurysms and pseudoaneurysms were treated surgically. However, endovascular techniques have recently become a valid alternative for the treatment of carotid pseudoaneurysms. The case of a 57-year-old male patient with a pseudoaneurysm of the right internal carotid artery is described. The patient came to our unit with a painless and pulsatile mass in the neck, which was growing slowly. Five years earlier, he had undergone surgery on a saccular aneurysm located on the distal extracranial segment of the right internal carotid artery. The pseudoaneurysm was successfully treated with a heparin surface Viabahn stent-graft system (Gore AL, Flagstaff, AZ). Heparin surface stent-grafts can be used for the treatment of carotid lesions and may offer protection against intimal hyperplasia and thrombosis. Further studies are needed to evaluate the long-term results.