Society for Vascular Surgery appropriate use criteria for management of intermittent claudication.

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term "inappropriate" was replaced with the phrase "risk outweighs benefit." The term "appropriate" was also replaced with "benefit outweighs risk." The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

The correlation between the psoas muscle/vertebral body ratio and the severity of peripheral artery disease.

BACKGROUND: The measurement of psoas muscle area is a new and potentially useful tool for assessing the frailty of patients in the context of various disease states ranging from cancer to abdominal aortic aneurysms (AAAs). Considering the similarity of risk factors for frailty and atherosclerosis, we sought to investigate whether patients with peripheral artery disease (PAD) have smaller psoas muscle areas in general. Furthermore, we investigated whether PAD symptom severity correlates with psoas muscle size. METHODS: A chart review was conducted on 146 patients with PAD. Of these patients, 85 (58%) had a computed tomography scan within the last 5 years and were included in the study. Fifty-five patients with AAA and no occlusive disease were included as controls. Cross-sectional areas of the psoas muscles and L4 vertebral body were collected at the mid-L4 level for all patients. Total psoas muscle area was calculated and divided by L4 area to correct for body habitus. Ankle-brachial indices and Rutherford classification were collected as measures of PAD severity. Logistic and multiple regressions were run to assess the difference in psoas muscle/vertebral body ratio between patients with PAD and AAA and within PAD patients, respectively. RESULTS: PAD patients have a lower psoas muscle/vertebral body ratio controlled for sex and age than patients with AAA (P < 0.05). However, among patients with PAD, psoas muscle/vertebral body ratio does not correlate with severity of symptoms. CONCLUSIONS: Using psoas muscle area as a measure of frailty, patients with PAD may be frail as a group. However, the severity of each patient's symptoms does not appear to correlate with the patient's degree of frailty. Prospective studies with larger populations are needed to clarify whether the psoas muscle area has any prognostic value in PAD.

Single center experience with modified eversion carotid endarterectomy.

BACKGROUND: Transaortic endarterectomy is a well-described technique for surgical revascularization of orificial atherosclerotic renovascular disease. Adopting this technique to carotid endarterectomy (CEA), modified eversion carotid endarterectomy (MECE), uses a traditional longitudinal arteriotomy that is confined to the bulb. This obviates the need for patch closure, simplifies the procedure, and permits easy conversion to traditional patch closure carotid endarterectomy (PCEA) for technical defects. We compared the safety and efficacy of this technique with PCEA. METHODS: Three vascular surgeons performed 223 CEAs between July 2004 and December 2008 at a tertiary teaching hospital. Outcomes measured included perioperative stroke rate, morbidity rate, mortality rate, and late restenosis. The incidence of moderate (60-79%) and severe (≥80%) restenosis was examined at <6 weeks, 1 year, and ≥2 years after operation. All patients included in this study underwent follow-up for >12 months. Data were analyzed with Student's t-test (p < 0.05 = significant). RESULTS: CEA was performed for symptomatic disease in 40.4% (90/223) of patients. One surgeon performed MECE in 73.3% (99/135) of his patients during this period; the remaining patients (n = 124) underwent traditional PCEA. Intraoperative completion duplex ultrasound was performed for all patients. In 5.1% (5/99) of the patients, MECE was converted to PCEA for residual flaps. Intraoperative carotid cross-clamping time was significantly shorter in the MECE group (29.2 minutes vs. 52.2 minutes, p < 0.05). For patients in the PCEA group, the overall mortality rate was 1.8% (4/223), and perioperative stroke rate was 1.4% (3/223). Overall morbidity was 7.2%, which was similar between the two groups. Late restenosis rate on duplex scan was 7.1% (1.0% severe stenosis), early occlusion occurred in one patient with PCEA, and the reintervention rate was 1.0% (2/196). The incidence of late restenosis was similar between the MECE and PCEA group (8.4% vs. 6.2%, p = 0.55). Mean follow-up was 26.3 months for the MECE group and 29.4 months for the PCEA group. CONCLUSIONS: MECE is a safer alternative to conventional endarterectomy with a restenosis rate comparable with PCEA, offers the potential advantage of shorter clamping time, and obviates the need for patch closure.

Transcranial Doppler ultrasonography of the basilar artery in patients with retrograde vertebral artery flow.

OBJECTIVE: Reversal of flow in the extracranial vertebral artery secondary to a proximal subclavian/innominate artery stenosis or occlusion is a frequent finding during carotid duplex ultrasonography. The characteristics of basilar artery flow are not well defined in these patients. The objective of this study is to evaluate basilar artery flow in patients with retrograde vertebral artery flow. METHODS: From a transforaminal vice transforamen approach with the patient seated, pulsed Doppler scan spectral waveforms were obtained from the distal segment of each vertebral artery (depths of 66 mm and 70 mm) and throughout the basilar artery (depths of 80 mm up to 116 mm). The direction of flow and the peak flow velocity were recorded at each location. In the subset of patients with antegrade flow, we initiated a 5-minute period of arm ischemia (produced by brachial blood pressure cuff inflated to a suprasystolic pressure) and compared flow direction to baseline. RESULTS: Twenty-five patients with retrograde vertebral artery flow on carotid duplex ultrasonography underwent transcranial Doppler (TCD) ultrasonography scan of the distal vertebral arteries and the basilar artery. There were 10 males (58-85-years-old; mean 70.7 years) and 15 females (47-85-years-old; mean 66.0 years). An additional 11 patients who had normal vertebral flow underwent TCD and served as a control group. Nineteen patients (76%) demonstrated antegrade basilar artery flow at rest. Six patients (24%) demonstrated abnormal basilar artery flow at rest. Five had complete reversal of flow; one had intermittent flow reversal which became retrograde throughout the cardiac cycle following a period of arm ischemia ipsilateral to the patient's retrograde vertebral artery flow. No patient with retrograde vertebral artery flow and antegrade basilar artery flow at rest demonstrated a change in basilar artery peak velocity or direction of flow following arm ischemia. CONCLUSION: Less than 25% of patients with retrograde vertebral artery flow on carotid duplex ultrasonography scan demonstrated a corresponding reversal of flow in the basilar artery. The vast majority of patients do not develop flow reversal in the basilar artery. Provocative maneuvers to increase collateral flow to the arm ipsilateral to retrograde vertebral artery flow did not appear to alter basilar artery flow velocity or direction of flow. Transcranial Doppler ultrasonography is indicated in patients with retrograde vertebral artery flow to document basilar artery flow, especially prior to intervention in patients with symptoms suggestive of posterior cerebral circulation insufficiency.

Superior hemodynamic performance of a thigh-length versus knee-length intermittent pneumatic compression device.

OBJECTIVE: There is a lack of consensus regarding which length of intermittent pneumatic compression (IPC) device provides optimal thromboprophylaxis. This trial was conducted to compare hemodynamic performance of a thigh-length and knee-length IPC device. The hypothesis is that thigh-length IPC will be more efficient in preventing stasis. METHODS: This single-center trial tested the thigh-length sleeve (TLS) and knee-length sleeve (KLS) in 47 healthy volunteers. Peak systolic velocity and total volume flow were measured at rest and during the 11-second compression cycle. Measurements were obtained at the popliteal vein for the KLS and at the common femoral vein for the TLS. RESULTS: The study was completed by 47 volunteers (32 women, 15 men), who were a mean age of 39.7 years (range, 18-68 years). There was a statistically significant difference in augmented total volume flow and peak systolic velocity between the KLS and TLS favoring the TLS: median total volume flow was 357.54 mL/min for the KLS vs 668.21 mL/min for the TLS (P < .0001), and median peak systolic velocity was 47.70 cm/s for the KLS vs 58.47 cm/s for the TLS (P = .0019). CONCLUSIONS: This trial suggests that the improved hemodynamic effects of a thigh-length IPC system may provide superior thromboprophylaxis to a knee-length IPC.

A comparison of treadmill and arm-leg ergometry exercise testing for assessing exercise capacity in patients with peripheral arterial disease.

PURPOSE: To compare the results of treadmill exercise testing (TM) to arm-leg ergometry testing (AL) in patients with peripheral arterial disease (PAD). METHODS: Twelve men and 8 women with PAD (mean age, 62 +/- 10 years) completed a treadmill test and an arm-leg ergometer exercise test. Oxygen uptake, heart rate, rate-pressure product (x10(-3)), ratings of claudication and perceived exertion, and power were measured. RESULTS: Peak oxygen uptake, heart rate, and rate-pressure product were similar between TM and AL. Exercise duration was longer and the peak power higher on the AL than on the TM. Claudication pain > or =3/4 was the reason for test termination in all subjects during TM test and in 13 subjects during AL. Nine patients discontinued due to severe claudication on both tests, but the pain occurred later in AL than TM. CONCLUSIONS: Although peak oxygen uptake was similar between the 2 exercise tests, patients with PAD exercised longer and to a higher peak power during the AL. These data suggest that the AL test may be used to evaluate peak exercise capacity in patients with PAD. The AL may also provide an alternate method for detecting PAD and coronary heart disease.

Radial artery as conduit for distal renal artery reconstruction.

UNLABELLED: Reconstruction of the renal artery with both saphenous vein and prosthetic material as bypass graft is durable in atherosclerotic disease. Extensive experience with saphenous vein grafts in pediatric patients and patients without atherosclerosis reveals a disturbing incidence of vein graft aneurysm degeneration. Distal renal artery reconstruction involving small branch vessels is generally not amenable to prosthetic reconstruction. We report a new approach to distal renal artery bypass grafting to avert these limitations. CASE: A 43-year-old man with previously normal blood pressure had malignant hypertension, which proved difficult to control despite use of a beta-blocker and an angiotensin II inhibitor. At renal angiography a fusiform aneurysm was revealed in a posterior branch of the right renal artery. The renal artery aneurysm was resected, and the left radial artery was harvested and used as a sequential aortorenal bypass graft to the two branch renal arteries. The postoperative course was uneventful, and the patient now has normal blood pressure with a calcium channel blocker for maintenance of the radial artery graft. Pathologic analysis revealed a pseudoaneurysm with dissection between the media and external lamella, consistent with fibromuscular dysplasia. CONCLUSION: Autologous artery is the preferred conduit for renal reconstruction in the pediatric population. On the basis of cardiac surgery experience, we used the radial artery and found it to be a technically satisfactory conduit for distal renal reconstruction in a patient without atherosclerosis.

Hypothenar hammer syndrome: Distal ulnar artery reconstruction with autologous inferior epigastric artery.

Digital artery embolization and ulnar artery thrombosis are consequences of repetitive trauma and can lead to digit loss and debility from ischemia and cold intolerance. We postulate that an arterial autograft is a theoretically superior conduit to traditional saphenous vein, and report reconstruction with inferior epigastric artery. Three adult male smokers, ages 39 to 49 years, had severe digital ischemia and cold-induced vasospasm. Arteriograms confirmed occlusion of the distal ulnar artery without direct perfusion of the superficial palmar arch, distal digital artery embolization, and normal proximal vasculature. All reconstructions were performed from the distal most patent ulnar artery at the wrist to the superficial palmar arch (1 patient) or sequentially to the involved common digital arteries (2 patients), with inferior epigastric artery. Handling characteristics and size match between the arterial autografts and bypassed arteries was excellent. Patency has been confirmed with duplex scanning at follow-up of 8 to 24 months, with resolution of cold intolerance and successful digital preservation.

Long-term results of peripheral arterial disease rehabilitation.

PURPOSE: Although the Peripheral Arterial Disease Rehabilitation Program (PADRx) improves walking ability and quality of life over brief periods of follow-up, the long-term durability of results has not been established. This study examined functional status, walking ability, and quality of life in patients several months after completion of a 12-week PADRx. METHODS: Patients who completed a PADRx were eligible for participation. A Medical Outcomes Study 36-Item Short Form (SF-36), Walking Impairment Questionnaire (WIQ), and physical activity questionnaire were administered by telephone. A progressive treadmill test was performed on-site. RESULTS: Of 63 eligible patients, 14 were lost to follow-up, 11 refused participation, and four died. Thirty-four patients had completed PADRx 20 to 80 months previously (mean, 48.2 +/- 13.7 months), and completed the phone survey. Fifteen patients reported exercising a minimum of 60 min/wk for 3 months (EX group), and 19 had not exercised in the preceding 3 months (SED group). Self-reported SF-36 values were significantly different between the EX and SED groups for Physical Function (43.3 +/- 8.2 vs 34.2 +/- 7.8), Role-Physical Function (41.2 +/- 7.7 vs 32.8 +/- 9.2), and Bodily Pain (46.9 +/- 8.8 vs 38.9 +/- 7.1), as well as the Physical Composite (43.5 +/- 6.5 vs 34.0 vs 5.8) domains of the SF-36. Similarly the WIQ demonstrated significant differences in Walking Distance (46.8 +/- 36.2 vs 7.8 +/- 9.4), Walking Speed (47.5 +/- 32.6 vs 14.5 +/- 13.9), and Stair Climbing (60.6 +/- 36.6 vs 37.1 +/- 27.6), favoring the EX group. Sixteen patients, equally distributed between the EX and SED groups, completed the progressive treadmill test. Both groups had experienced improvement (P <.05) in claudication pain time and maximal walking time after completing the 12-week supervised program. The EX group maintained increased claudication pain time of 121% and maximum walking time of 109% over baseline, whereas the SED group values had returned to baseline (P <.05). CONCLUSIONS: Patients with claudication realize symptomatic and functional improvement with supervised exercise programs. Those who continue to exercise will potentially maintain these benefits and experience improved health-related quality of life.