Management of carotid atherosclerosis in stroke.

Internal carotid artery atherosclerosis is a major risk factor for stroke, accounting for 15-20% of ischaemic strokes. Revascularisation procedures-either carotid endarterectomy or carotid artery stenting-can reduce the risk of stroke for those with significant (>50%) luminal stenosis but particularly for those with more severe (70-99%) stenosis. However, advances in medical pharmacotherapy have implications for the relative benefit from surgery for symptomatic carotid atherosclerosis, as well as our approach to asymptomatic disease. This review considers the evidence underpinning the current medical and surgical management of symptomatic carotid atherosclerosis, the importance of factors beyond the degree of luminal stenosis, and developments in therapeutic strategies. We also discuss the importance of non-stenotic but high-risk carotid atherosclerotic plaques on the cause of stroke, and their implications for clinical practice.

Adherence to vascular care guidelines for emergency revascularization of chronic limb-threatening ischemia.

Objective: In 2022, the National Health Service Commissioning for Quality and Innovation (CQUIN) indicator for vascular surgery, with its pay-for-performance incentive for timely (5-day) revascularization of chronic limb-threatening ischemia (CLTI), was introduced. We sought to assess its effects in terms of (1) changes in the care pathway process measures relating to timing and patient outcomes; and (2) adherence to the Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF) guidelines for patients admitted with CLTI. Methods: A retrospective before-and-after cohort study was performed from January to June 2022 of nonelective admissions for CLTI who underwent revascularization (open, endovascular, or hybrid) at Cambridge University Hospitals National Health Service Foundation Trust, a regional vascular "hub." The diagnostic and treatment pathway timing-related process measures recommended in the PAD-QIF were compared between two 3-month cohorts-before vs after introduction of the CQUIN. Results: For the two cohorts (before vs after CQUIN), 17 of 223 and 17 of 219 total admissions met the inclusion criteria, respectively. After introduction of financial incentives, the percentage of patients meeting the 5-day targets for revascularization increased from 41.2% to 58.8% (P = .049). Improvements were also realized in the attainment of PAD-QIF targets for a referral-to-admission time of ≤2 days (from 82.4% to 88.8%; P = .525) and admission-to-specialist-review time of ≤14 hours (from 58.8% to 76.5%; P = .139). An increase also occurred in the percentage of patients receiving imaging studies within 2 days of referral (from 58.8% to 70.6%; P = .324). The reasons for delay included operating list pressures and unsuitability for intervention (eg, active COVID-19 [coronavirus disease 2019] infection). No statistically significant changes to patient outcomes were observed between the two cohorts in terms of complications (pre-CQUIN, 23.5%; post-CQUIN, 41.2%; P = .086), length of stay (pre-QUIN, 12.0 ± 12.0 days; post-QUIN, 15.0 ± 21.0 days; P = .178), and in-hospital mortality (pre-QUIN, 0%; post-QUIN, 5.9%). Other PAD-QIF targets relating to delivery of care were poorly documented for both cohorts. These included documented staging of limb threat severity with the WIfI (wound, ischemia, foot infection) score (2.9% of patients; target >80%), documented shared decision-making (47.1%; target >80%), documented issuance of written information to patient (5.9%; target 100%), and geriatric assessment (6.3%; target >80%). Conclusions: The pay-for-performance incentive CQUIN indicators appear to have raised the profile for the need for early revascularization to treat CLTI, engaging senior hospital management, and reducing the time to revascularization in our cohort. Further data collection is required to detect any resultant changes in patient outcomes. Documentation of guideline targets for delivery of care was often poor and should be improved.

The risk of harm whilst waiting for varicose veins procedure.

INTRODUCTION: Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention. OBJECTIVE: This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year. METHODS: This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison. RESULTS: 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease (p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life.

Comparing the Benefit of Duplex Ultrasound Surveillance Following Both Infrainguinal Bypass Surgery and Stenting for Femoro-Popliteal Disease.

OBJECTIVE: Duplex ultrasound surveillance (DUS) is commonly used following infrainguinal vein bypass. The role of DUS following endovascular revascularisation is as yet unclear. This study focuses on the role of DUS in a contemporary group of patients undergoing infrainguinal bypass or stent insertion. METHODS: All patients undergoing either an infrainguinal vein graft bypass or stent insertion into the femoro-popliteal segment (November 2014 - January 2017) were identified. Patients were followed up for 2 years. Data on entry into DUS, pre-operative characteristics, adjunctive pharmacotherapy and reintervention were collated. The primary outcomes were major lower limb amputation and mortality at 2 years post revascularisation. RESULTS: One hundred and thirty-five patients underwent infrainguinal vein bypass and 100 patients underwent stent insertion. 107 patients in the bypass cohort and 58 patients in the stent cohort entered DUS. For the bypass cohort, entering DUS was associated with a lower mortality rate (P = .003) but was not associated with an improvement in amputation rates. The odds ratio of major amputation or mortality was greater in the no surveillance group (4.58, 95% CI: 1.855 - 11.364). In the stent cohort, DUS was not associated with a significant improvement in either major amputation or death (odds ratio 2.13 (95% CI 0.903 - 5.051; P = .081). CONCLUSION: DUS was associated with improved survival rates in patients undergoing lower limb bypass but had no benefit in those patients undergoing stent insertion. The role of DUS following stent insertion in the femoropopliteal segment needs to be better defined.

Effects of Statin Therapy and Dose on Cardiovascular and Limb Outcomes in Peripheral Arterial Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: Statin therapy is indicated in patients with peripheral arterial disease (PAD). National Institute for Health and Care Excellence guidelines suggest the use of "high intensity" statins, although evidence with PAD specific data are lacking. The effect of statin therapy and dose on outcomes in PAD is investigated. DATA SOURCES: Studies measuring statin use in PAD patients and outcomes were identified based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The EMBASE and MEDLINE databases were interrogated from January 1957 until February 2020. Twenty-two observational cohort studies and two randomised control trials were included (n = 268 611). REVIEW METHODS: Pooled estimates of dichotomous outcome data were calculated using the odds/hazard ratios (OR/HR) and 95% confidence interval (CI). Meta-analysis was conducted using the inverse variance or Mantel-Haenszel method. Outcomes included all cause mortality (ACM), cardiovascular mortality (CVM), major adverse cardiac events (MACE), and amputation. Subgroup analysis was performed on studies comparing patients taking high dose vs. combined low and moderate doses of statins. The GRADE criteria assessed the quality of evidence for outcomes. RESULTS: Statin therapy (vs. no statins) was significantly protective for ACM: OR 0.68 (95% CI 0.60 - 0.76) (number needed to treat [NNT] = 48), HR 0.74 (95% CI 0.70 - 0.78) (NNT = 10 - 91); MACE: OR 0.84 (95% CI 0.78 - 0.92) (NNT = 53), HR 0.78 (95% CI 0.65 - 0.93) (NNT = 167); and amputations: OR 0.59 (95% CI 0.33 - 1.07) (NNT = 333), HR 0.74 (95% CI 0.62 - 0.89) (NNT = 50). High doses of statins (vs. combined low and moderate doses) were significantly better protective against ACM OR 0.69 (95% CI 0.43 - 1.09) (NNT = 17), HR 0.74 (95% CI 0.62 - 0.89) (NNT = 16 - 200) but work less significantly for MACE OR 0.77 (95% CI 0.49 - 1.21) (NNT = 25). Amputations were less frequent in patients on high doses HR 0.78 (95% CI 0.69 - 0.90) (NNT = 53 - 1 000). CONCLUSION: Higher dosing of statins confers a significant improvement in patient outcomes, especially ACM and amputations, although the quality of the evidence was variable. Such findings require confirmation in larger, PAD specific trials.

Near-Infrared Autofluorescence in Atherosclerosis Associates With Ceroid and Is Generated by Oxidized Lipid-Induced Oxidative Stress.

[Figure: see text].

Clinical practice patterns and ascertainment bias for cardiovascular events in a randomized trial: A survey of investigators in the BEST-CLI trial.

Ascertainment bias is a well-recognized source of bias in research, but few studies have systematically analyzed sources of ascertainment bias in randomized trials in which blinding is not possible and endpoint assessment is not protocolized. In the current study, we sought to evaluate differences in the clinical practice patterns of trial investigators with respect to bias in the ascertainment of pre-revascularization patient risk and the incidence of secondary endpoints post-revascularization. We conducted a cross-sectional survey of active investigators (n = 936) from the Best Endovascular Versus Best Surgical Therapy for Patients with Critical Limb Ischemia (BEST-CLI) trial. The total survey response rate was 19.6% (183/936). Vascular surgeons were more likely than nonsurgical interventionalists to order tests for cardiac complications after both surgical bypass (p < 0.001) and endovascular revascularization (p = 0.038). Post-procedure, investigators were more likely to order additional testing for cardiac complications in open surgery versus endovascular cases (7% vs 16% never, 41% vs 65% rarely, 43% vs 17% sometimes, 9% vs 2% always, respectively; p < 0.0001). Significant variation in practice patterns exist in the pre- and post-procedure assessment of cardiac risk and events for patients with CLI undergoing revascularization. Variation in the ascertainment of risk and outcomes according to the type of revascularization procedure and physician specialty should be considered when interpreting the results of clinical studies, such as the BEST-CLI trial. ClinicalTrials.gov Identifier: NCT02060630.

An Assessment of Available Information on the World Wide Web for Patients with Lower Limb Arterial Disease.

OBJECTIVE: The quality of patient information relating to intermittent claudication (IC) and peripheral arterial disease (PAD) on the World Wide Web was assessed. METHODS: The quality of websites and YouTube videos was assessed using the search terms "intermittent claudication" and "peripheral arterial disease". The first 50 hits screened for each search term from the three largest search engines by market share, and the first 20 videos from YouTube were screened. Website quality was scored using the University of Michigan Consumer Health Website tool (maximum score 80). Readability was calculated using the Flesch Reading Ease (FRE) score (maximum score 100). Videos were classified by content and upload source. Video reliability was assessed using the JAMA benchmark criteria. Video educational content was assessed using the Global Quality Score (GQS). Subjective content assessment was undertaken. RESULTS: Seventy-six websites were analysed. The majority of websites for both IC (51.7%) and PAD (72.3%) were rated as weak. The median Michigan score for IC (27; interquartile range [IQR] 15, 32.5) was lower that the score for PAD (31; IQR 25.5, 38.8; p = .030). The majority of websites for both IC (69%) and PAD (68.1%) were rated as requiring an above average reading level. The overall median FRE score was 55.9 (IQR 46.6, 60.6) for IC and 55.3 (IQR 44.6, 59.3) for PAD. Twenty-two videos were analysed. Of the 14 videos evaluated as part of the PAD search, the median JAMA score was 2 (2 - 3), the median GQS score was 3 (3 - 3) and the evaluation of content score was 8.5 (7.25 - 11.5). The equivalent scores for the IC search were 2 (2 - 2), 3 (3 - 4), and 5.5 (5 - 8). CONCLUSION: The educational quality and reliability of information both in written and video form on the internet is low. Attention needs to focus on improving the quality of all forms of information delivery to allow proper advocacy for patients.

Patient and Institutional Costs of Failure of Angioplasty of the Superficial Femoral Artery.

BACKGROUND: Debate surrounds the optimal management of superficial femoral artery (SFA) disease. Randomized trial data rarely reflect real world findings, specifically the consequences to the patient of angioplasty failure. We observed the effect of a failed SFA angioplasty on the need for repeated clinic visits, hospital readmissions, imaging requirements, and reinterventions. METHODS: We reviewed a consecutive series of 148 patients (94 men, median age 72 years) undergoing solely SFA angioplasty over a 2-year period. Patient preangioplasty demographics and 2-year post-PTA follow-up data were collated, including hospital attendances (inpatient/outpatient), further imaging (including radiation exposure) and revascularization attempts. We defined "failed angioplasty" as presence of clinical symptoms with radiological evidence of significant restenosis after an initial successful primary SFA angioplasty. RESULTS: Fifty-four patients represented with a failed angioplasty (median time of 4 months after index PTA). In this group, failure of index angioplasty resulted in a further 185 restenosis-related clinic visits and a total of 537 bed days of inpatient stay. This group underwent a further 149 imaging events and required a further 34 endovascular revascularization procedures and 12 infrainguinal bypass procedures. These interventions and investigations corresponded to overall effective radiation dose across all patients of 190.69 mSv. Of the cohort of 99 patients who did not have a "failed angioplasty," they required 100 clinic visits, 21 further scans (total radiation dose 6.42 mSv), and 36 bed days of inpatient admission. CONCLUSIONS: Failed angioplasty results in significant additional consequences for patients and health-care systems. Further work should focus on refining decision-making, providing the right procedure to the right patient at the right time.

The Effect of Frailty on Long Term Outcomes in Vascular Surgical Patients.

OBJECTIVE: Frailty is a multidimensional vulnerability due to age associated decline. The impact of frailty on long term outcomes was assessed in a cohort of vascular surgical patients. METHODS: Patients aged over 65 years with a length of stay greater than two days admitted to a tertiary vascular unit over a single calendar year were included. Demographics, mode of admission, and diagnosis were recorded alongside a variety of frailty specific characteristics. Using the previously developed Addenbrookes Vascular Frailty Score (AVFS - 6 point score: anaemia on admission, lack of independent mobility, polypharmacy, Waterlow score > 13, depression, and emergency admission) the effect of frailty on five year mortality and re-admission rates was assessed using multivariable regression techniques. The AVFS was further refined to assess longer term outcomes. RESULTS: In total, 410 patients (median age 77 years) were included and followed up until death or five years from the index admission. One hundred and thirty-four were treated for aortic aneurysm, 75 and 96 for acute and chronic limb ischaemia respectively, 52 for carotid disease, and 53 for other pathologies. The in hospital mortality rate was 3.6%. The one, three, and five year survival rates were 83%, 70% and 59%; and the one, three, and five year re-admission free survival rates were 47%, 29%, and 22% respectively. Independent predictors of five year mortality were age, lack of independent mobility, high Charlson score, polypharmacy, evidence of malnutrition, and emergency admission (p < .010 for all). Patients with AVFS 0 or 1 had restricted mean survival times which were one year longer than those with AVFS 2 or 3 (p < .001), who in turn had restricted mean survival times over one year longer than those with AVFS of 4 or more (p < .001). CONCLUSION: Frailty factors are strong predictors of long term outcomes in vascular surgery. Further prospective studies are warranted to investigate its utility in clinical decision making.

18F-Fluoride Positron Emission Tomographic Imaging of Penile Arteries and Erectile Dysfunction.

BACKGROUND: Fluorine-18 sodium fluoride (NaF), a bone-seeking radiopharmaceutical used to detect osseous metastases, localizes in regions of microcalcification in atherosclerosis. OBJECTIVES: To determine if atherosclerosis of penile arteries plays a role in erectile dysfunction (ED), this study analyzed NaF images in prostate cancer patients. METHODS: NaF positron emission tomography-computed tomography bone scans were evaluated in 437 prostate cancer patients (age 66.6 ± 8.7 years). Their urologic histories were reviewed for prevalent ED (diagnosed before the scan date) or incident ED (no ED at first scan, but developed during 1-year follow-up); patients with no ED (neither before the scan nor during follow-up) were included as a control group. A semicircular region of interest was set on the dorsal one-half of the penis (to avoid residual excreted activity in the urethra) on 5 contiguous slices at the base of the penis on positron emission tomography-computed tomography coronal reconstructions, and the average standardized uptake value (SUVmax) was described as NaF uptake. RESULTS: Of 437 patients, 336 (76.9%) had prevalent ED, 60 incident ED (13.7%), and 41 had no ED (9.4%). SUVmax in patients with prevalent (median 1.88; interquartile range [IQR]: 1.67 to 2.16) or incident (median 1.86; IQR: 1.72 to 2.08) ED was significantly higher than no ED (median 1.42; IQR: 1.25 to 1.54) patients (p < 0.001). After adjustment for other risk factors, the odds ratio of prevalent or incident ED was 25.2 (95% confidence interval: 9.5 to 67.0) for every 0.5-U increment in SUVmax with receptor operating characteristic area of 0.91 (95% confidence interval: 0.88 to 0.94). CONCLUSIONS: NaF uptake in penile vessels suggests that atherosclerosis is associated with ED in prostate cancer patients. The importance of NaF uptake needs to be tested in noncancer subjects and cause-effect relationship needs to be established.

Site and Burden of Lower Limb Atherosclerosis Predicts Long-term Mortality in a Cohort of Patients With Peripheral Arterial Disease.

OBJECTIVE/BACKGROUND: Lower limb peripheral arterial disease (PAD) is becoming increasingly common. Lower limb perfusion, as determined by the ankle brachial pressure index (ABPI), is a recognised predictor of overall mortality. The increasing role of non-invasive imaging in patient assessment may aid in the ability to predict poor patient outcomes. METHODS: This study included all patients undergoing a lower limb arterial duplex over a period of 20 months. The site and burden of atherosclerosis within the lower limb was determined using the well validated Bollinger score. Patient demographic data were also collated. The primary outcome measure was all cause mortality. RESULTS: A total of 678 patients were included (median age 74 years). The overall median follow up period was 69.9 months. Of these, 307 patients reached the primary end point, which was death. Independent predictors of all cause mortality included total Bollinger score (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.18 [p < .001]; OR per 10 points), femoropopliteal Bollinger score (OR 1.34, 95% CI 1.11-1.08 [p = .05]; OR per 10 points), and crural Bollinger score (OR 1.03, 95% CI 1.01-1.03 [p = .03]). There was also a significant association between mortality and age, a prior history of ischaemic heart disease, a history of congestive cardiac failure and chronic renal failure (chronic kidney disease ≥ 3). Statin and antiplatelet therapy were protective. CONCLUSION: This contemporary study confirms poor long-term outcomes still exist in patients with PAD. The site and severity of lower limb atherosclerosis are independent predictors of long-term mortality.

18F-FDG Uptake on PET/CT in Symptomatic versus Asymptomatic Carotid Disease: a Meta-Analysis.

INTRODUCTION: The role of positron emission tomography (PET)/computed tomography (CT) in the determination of inflammation in arterial disease is not well defined. This can provide information about arterial wall inflammation in atherosclerotic disease, and may give insight into plaque stability. The aim of this review was to perform a meta-analysis of PET/CT with 18F-FDG (fluorodeoxyglucose) uptake in symptomatic and asymptomatic carotid artery disease. METHODS: This was a systematic review, following PRISMA guidelines, which interrogated the MEDLINE database from January 2001 to May 2017. The search combined the terms, "inflammation", "FDG", and "stroke". The search criteria included all types of studies, with a primary outcome of the degree of arterial vascular inflammation determined by 18F-FDG uptake. Analysis involved an inverse weighted variance estimate of pooled data, using a random effects model. RESULTS: A total of 14 articles (539 patients) were included in the meta-analysis. Comparing carotid artery 18F-FDG uptake in symptomatic versus asymptomatic disease yielded a standard mean difference of 0.94 (95% CI 0.58-1.130; p < .0001; I2 = 65%). CONCLUSIONS: PET/CT using 18F-FDG can demonstrate carotid plaque inflammation, and is a marker of symptomatic disease. Further studies are required to understand the clinical implication of PET/CT as a risk prediction tool.

Editor's Choice - Calcification of Thoracic and Abdominal Aneurysms is Associated with Mortality and Morbidity.

INTRODUCTION: Cardiovascular events are common in people with aortic aneurysms. Arterial calcification is a recognised predictor of cardiovascular outcomes in coronary artery disease. Whether calcification within abdominal and thoracic aneurysm walls is correlated with poor cardiovascular outcomes is not known. PATIENTS AND METHODS: Calcium scores were derived from computed tomography (CT) scans of consecutive patients with either infrarenal (AAA) or descending thoracic aneurysms (TAA) using the modified Agatston score. The primary outcome was subsequent all cause mortality during follow-up. Secondary outcomes were cardiovascular mortality and morbidity. RESULTS: A total of 319 patients (123 TAA and 196 AAA; median age 77 [71-84] years, 72% male) were included with a median follow-up of 30 months. The primary outcome occurred in 120 (37.6%) patients. In the abdominal aortic aneurysm group, the calcium score was significantly related to both all cause mortality and cardiac mortality (odds ratios (OR) of 2.246 (95% CI 1.591-9.476; p < 0.001) and 1.321 (1.076-2.762; p = 0.003)) respectively. In the thoracic aneurysm group, calcium score was significantly related to all cause mortality (OR 6.444; 95% CI 2.574-6.137; p < 0.001), cardiac mortality (OR 3.456; 95% CI 1.765-4.654; p = 0.042) and cardiac morbidity (OR 2.128; 95% CI 1.973-4.342; p = 0.002). CONCLUSIONS: Aortic aneurysm calcification, in either the thoracic or the abdominal territory, is significantly associated with both higher overall and cardiovascular mortality. Calcium scoring, rapidly derived from routine CT scans, may help identify high risk patients for treatment to reduce risk.

Morphometric Assessment as a Predictor of Outcome in Older Vascular Surgery Patients.

BACKGROUND: Frailty is a recognized predictor of poor outcome in patients undergoing surgical intervention. Frailty is intricately linked with body morphology, which can be evaluated using morphometric assessment via computerized tomographic (CT) imaging. We aimed to assess the predictive power of such objective assessments in a broad cohort of vascular surgical patients. METHODS: A consecutive series of patients aged over 65 years admitted to a vascular unit, who had undergone CT imaging of the abdomen, were analyzed. Demographic and patient-specific data were collated alongside admission relevant information. Outcomes included mortality, length of stay, health care-related costs, and discharge destination. Images were analyzed for 4 morphometric measurements: (1) psoas muscle area, (2) mean psoas density, (3) subcutaneous fat depth, and (4) intra-abdominal fat depth, all taken at the level of the fourth lumbar vertebra. RESULTS: Two hundred and ten patients were initially analyzed. Forty-four patients had significant retroperitoneal and abdominal abnormalities that limited appropriate CT analysis. Decreased subcutaneous fat depth was significantly associated with mortality, readmission within 12 months, and increased cost of health care (P < 0.01, adjusted for confounders). Psoas muscle area was significantly associated with readmission-free survival. CONCLUSIONS: Morphometric analysis predicts poorer outcome in a broad cohort of vascular surgery patients. Such assessment is likely to enhance patient counseling regarding individual risk as well as enhancing the ability to undertake risk-modified surgical audit.

Mechanochemical Ablation for Treatment of Truncal Venous Insufficiency: A Review of the Current Literature.

Mechanochemical ablation (MOCA) is a nonthermal nontumescent technique used in the treatment of superficial venous disease. This review analyzed the available data on the efficacy and safety of MOCA. A systematic literature search was performed. Of 101 studies identified, 14 were suitable for inclusion. The studies were found to be heterogeneous in design, and the quality of evidence was found to be low or very low. MOCA was demonstrated to be effective in the short-term with minimal complications. Consensus guidelines and definitions of reporting outcome measures must be standardized to allow comparison with other techniques.

Variability in Atherosclerotic Disease Progression within the Infrainguinal Arterial Circulation is Dependent on Both Patient and Anatomical Factors.

BACKGROUND: Studies suggest 25% of patients with symptomatic peripheral arterial disease develop symptom progression over time, yet there is minimal data related to actual atherosclerotic progression. METHODS: Patients who underwent consecutive duplex imaging of the lower limb arteries, at least 6 months apart with no intervening arterial intervention, were identified. Atherosclerotic burden was determined for both femoropopliteal (FP) and crural (CR) arterial segments utilizing the Bollinger score (BoS). Overall change in BoS over time was determined, and patients were divided into group 1: disease progression and group 2: no change/disease regression. Patient demographics, comorbidities, and long-term outcomes were collated. RESULTS: A total of 215 FP segments (155 men; median age 74 years) were assessed with 82 limbs showing atherosclerotic disease progression. FP atherosclerotic progression was associated with increased age, a diagnosis of ischemic heart disease and hypertension, and a lack of prescription of both an antiplatelet therapy and an angiotensin-converting enzyme inhibitor (all P < 0.05). FP atherosclerotic progression was also associated with an increased longer term mortality rate. A total of 272 CR arterial segments (190 men; median age 74 years) were assessed with 86 limbs showing atherosclerotic disease progression. CR atherosclerotic disease progression was associated with a diagnosis of diabetes mellitus at baseline (P = 0.019). CONCLUSIONS: A number of variable factors predict atherosclerotic progression. Differences exist between factors and the arterial segments affected (FP/CR). This suggests that underlying atherosclerotic processes may vary depending on arterial segment, warranting further investigation.