Challenges and opportunities in the management of type 2 diabetes in patients with lower extremity peripheral artery disease: a tailored diagnosis and treatment review.

Lower extremity peripheral artery disease (PAD) often results from atherosclerosis, and is highly prevalent in patients with type 2 diabetes mellitus (T2DM). Individuals with T2DM exhibit a more severe manifestation and a more distal distribution of PAD compared to those without diabetes, adding complexity to the therapeutic management of PAD in this particular patient population. Indeed, the management of PAD in patients with T2DM requires a multidisciplinary and individualized approach that addresses both the systemic effects of diabetes and the specific vascular complications of PAD. Hence, cardiovascular prevention is of the utmost importance in patients with T2DM and PAD, and encompasses smoking cessation, a healthy diet, structured exercise, careful foot monitoring, and adherence to routine preventive treatments such as statins, antiplatelet agents, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. It is also recommended to incorporate glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) in the medical management of patients with T2DM and PAD, due to their demonstrated cardiovascular benefits. However, the specific impact of these novel glucose-lowering agents for individuals with PAD remains obscured within the background of cardiovascular outcome trials (CVOTs). In this review article, we distil evidence, through a comprehensive literature search of CVOTs and clinical guidelines, to offer key directions for the optimal medical management of individuals with T2DM and lower extremity PAD in the era of GLP-1RA and SGLT2i.

Accuracy of maximal acceleration time of pedal arteries to diagnose critical limb-threatening ischemia.

INTRODUCTION: Maximal acceleration time of distal arteries of the foot (ATmax) is correlated to ankle-brachial index (ABI) and toe-brachial index (TBI), and seems very promising in diagnosing severe peripheral artery disease (PAD) and especially critical limb-threatening ischemia (CLTI). Our goal was to confirm the cut-off value of 215 ms to predict a toe pressure (TP) ⩽ 30 mmHg. METHODS: A 4-month retrospective study was conducted on patients addressed for suspicion of PAD. Demographic data, ABI, TBI, and Doppler ultrasound scanning parameters of the dorsal pedis and lateral plantar arteries (DPA and LPA) were recorded. RESULTS: A total of 137 patients with 258 lower limbs were included. ATmax was highly correlated to TBI (r = -0.89, p < 0.001). With the cut-off value of 215 ms, ATmax was effective to diagnose TP ⩽ 30 mmHg with a sensitivity of 93% [95% CI 77-99], a specificity of 96% [95% CI 92-98], a positive predictive value of 73% [95% CI 56-86], a negative predictive value of 99% [95% CI 97-100], and an area under the receiver operating characteristics curve of 0.99 [95% CI 0.98-1.00]. ATmax also showed promising results to rule out PAD in healthy patients. CONCLUSION: ATmax is a reliable diagnostic tool to diagnose low TP and could be a new easily performed hemodynamic criterion for diagnosis of CLTI.

Selective elevation in external carotid artery flow during acute gravitational transition to microgravity during parabolic flight.

This study sought to determine to what extent acute exposure to microgravity (0 G) and related increases in central blood volume (CBV) during parabolic flight influence the regional redistribution of intra and extra cranial cerebral blood flow (CBF). Eleven healthy participants performed during two parabolic flights campaigns aboard the Airbus A310-ZERO G aircraft. The response of select variables for each of the 15 parabolas involving exposure to both 0 G and hypergravity (1.8 G) were assessed in the seated position. Mean arterial blood pressure (MAP) and heart rate (HR) were continuously monitored and used to calculate stroke volume (SV), cardiac output ([Formula: see text]), and systemic vascular resistance (SVR). Changes in CBV were measured using an impedance monitor. Extracranial flow through the internal carotid, external carotid, and vertebral artery ([Formula: see text]ICA, [Formula: see text]ECA, and [Formula: see text]VA), and intracranial blood velocity was measured by duplex ultrasound. When compared with 1-G baseline condition, 0 G increased CBV (+375 ± 98 mL, P = 0.004) and [Formula: see text] (+16 ± 14%, P = 0.024) and decreased SVR (-7.3 ± 5 mmHg·min·L-1, P = 0.002) and MAP (-13 ± 4 mmHg, P = 0.001). [Formula: see text]ECA increased by 43 ± 46% in 0 G (P = 0.030), whereas no change was observed for CBF, [Formula: see text]ICA, or [Formula: see text]VA (P = 0.102, P = 0.637, and P = 0.095, respectively).NEW & NOTEWORTHY Our findings demonstrate that in microgravity there is a selective increase in external carotid artery blood flow whereas global and regional cerebral blood flow remained preserved. To what extent this reflects an adaptive, neuroprotective response to counter overperfusion remains to be established.

Performance of the Wells score in predicting deep vein thrombosis in medical and surgical hospitalized patients with or without thromboprophylaxis: The R-WITT study.

The Wells score had shown weak performance to determine pre-test probability of deep vein thrombosis (DVT) for inpatients. So, we evaluated the impact of thromboprophylaxis on the utility of the Wells score for risk stratification of inpatients with suspected DVT. This bicentric cross-sectional study from February 1, 2018 to January 31, 2019 included consecutive medical and surgical inpatients who underwent lower limb ultrasound study for suspected DVT. Wells score clinical predictors were assessed by both ordering and vascular physicians within 24 h after clinical suspicion of DVT. Primary outcome was the Wells score's accuracy for pre-test risk stratification of suspected DVT, accounting for anticoagulation (AC) treatment (thromboprophylaxis for ⩾ 72 hours or long-term anticoagulation). We compared prevalence of proximal DVT among the low, moderate and high pre-test probability groups. The discrimination accuracy was defined as area under the receiver operating characteristics (ROC) curve. Of the 415 included patients, 30 (7.2%) had proximal DVT. Prevalence of proximal DVT was lower than expected in all pre-test probability groups. The prevalence in low, moderate and high pre-test probability groups was 0.0%, 3.1% and 8.2% (p = 0.22) and 1.7%, 4.2% and 25.8% (p < 0.001) for inpatients with or without AC, respectively. Area under ROC curves for discriminatory accuracy of the Wells score, for risk of proximal DVT with or without AC, was 0.72 and 0.88, respectively. The Wells score performed poorly for discrimination of risk for proximal DVT in hospitalized patients with AC but performed reasonably well among patients without AC; and showed low inter-rater reliability between physicians. ClinicalTrials.gov Identifier: NCT03784937.

Proficiency of Medical Students at Obtaining Pressure Measurement Readings Using Automated Ankle and Toe Measuring Devices for Diagnosis of Lower Extremity Peripheral Artery Disease.

BACKGROUND: Pressure measurement is a key component in the diagnosis of lower extremity peripheral artery disease (PAD) but is technically challenging and time-consuming for nonvascular specialists, thus hindering its wider implementation. The aim of this study was to assess the proficiency of students at obtaining satisfactory ankle or toe pressure readings for PAD diagnosis using 2 automated devices. METHODS: Medical students followed a training session after which they performed ankle and toe pressure measurements to calculate the ankle-brachial index (ABI) using the MESI ABPI MD® device, and the toe-brachial index (TBI) using the SYSTOE® device. Blinded vascular specialists took the same measurements. Use of the automated devices was considered satisfactory when a valid reading was measured in as few attempts as possible. A comparison was made of each student's proficiency at performing valid ankle and toe pressure measurements. The secondary objective was to compare the readings taken by the vascular specialists with those of the students. RESULTS: Forty-three medical students were included. Mean number of attempts was 1.23 ± 0.48 with the MESI ABPI MD device and 1.44 ± 0.55 with the SYSTOE device (P = 0.04). There was no statistically significant difference between ABI readings taken by the students and those taken by the vascular specialists, 1.17 (0.90; 1.39) vs. 1.18 (0.86; 1.39) (P = 0.33), contrary to TBI readings 0.70 (0.22; 1.74) vs. 0.72 (0.23; 1.16) (P = 0.03). Measurement duration for the students and vascular specialists was 3.75 min ± 1.12 min and 2.26 min ± 0.82 min (P < 0.01) with the MESI ABPI MD device and 4.30 min ± 1.23 min and 3.33 min ± 1.49 min (P = 0.03) with the SYSTOE device. Correlation coefficients between the students and the vascular specialists were 0.56 and 0.34 with the MESI ABPI MD and SYSTOE devices (P < 0.05). CONCLUSIONS: After a brief theoretical training session, the medical students were better at taking ankle pressure measurements than toe pressure measurements with an automated device for the purposes of PAD diagnosis. It would be of value to assess the advantages of these automated devices in primary care practice in future research.

Normative and pathological values of hemodynamic and Doppler ultrasound arterial findings in children.

Doppler ultrasound is an effective, useful and remarkably powerful tool in pediatric imaging. If possible, its use is always favored to avoid exposure to radiation or sedatives. By waveform spectrum analysis, Doppler ultrasound reveals information on blood flow and details on normal physiology and pathological processes undiscernible from gray-scale imaging alone. However, Doppler ultrasound remains underused, largely due to the difficult interpretation of changes in Doppler waveforms during childhood. This article provides a narrative review of the literature regarding the normative values and the physiological arterial changes through childhood according to age, weight or height, as well as frequent pathological arterial findings in children, classified by arterial territory.

French vascular physicians' practices in indicating antiplatelet and anticoagulation therapy in venous thromboembolism.

Background: As antiplatelet therapy becomes widespread, physicians face the issue patients being treated with antiplatelet agents (APA) and anticoagulants for venous thromboembolism (VTE). Bleeding risk of this combination is increased 1.5-2.5-fold. The aim of this survey is to assess French vascular physician's management of this combination at the beginning of the treatment and at 6 months of treatment for VTE. Patients and methods: French vascular physicians were surveyed between September and December 2017, using 4 fictional scenarios regarding a VTE event diagnosed in a patient under antiplatelet therapy plus isolated questions in an online questionnaire, sent by the French Society of Vascular Medicine to its members. Out of 1812 physicians, 179 returned valid questionnaires: the response rate was 9.9%. Results: Firstly 97.2% of respondents acknowledged extra risk with this combination; and 63% ceased antiplatelet therapy when initiating anticoagulants; while 36% did not. Secondly, four strategies emerged: 31.4% ceased APA and prescribed full-dose anticoagulants at initiation and at 6 months; 32% associated reduced-dose anticoagulation with APA at 6 months, regardless of what they decided at initiation; 16.5% prescribed isolated full-dose anticoagulants at initiation and reduced-dose at 6 months; lastly 11.2% associated full-dose anticoagulant with antiplatelet therapy at initiation and at 6 months. Conclusions: French vascular physicians adopted different strategies according to estimated risk/benefit ratio. Prospective randomized controlled trials should compare these strategies in order to make recommendations.

True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis: Five Cases and Literature Review.

BACKGROUND: The donor artery after a long-standing arteriovenous fistula (AVF) for hemodialysis usually evolves exceptionally toward a true aneurysmal degeneration (AD). The purpose of this article was to describe true brachial artery AD in end-stage renal disease patients after AVF creation, as well as its influencing factors and treatment strategies. METHODS: We present a retrospective, observational, single-center study realized in Caen University Hospital's Vascular Surgery Department from May 1996 to November 2015. The inclusion criteria were true AD of the brachial artery after a vascular access for hemodialysis. A literature research, using the same criteria, was performed on the articles published between 1994 and 2015. The used databases included MEDLINE (via PubMed), EMBASE via OVID, Cochrane Library Database, and ResearchGate. RESULTS: Our series includes 5 patients. Twenty-one articles were found in the literature: 17 case reports, 3 series, and 1 review. The same triggering factors for AD (high flow and immunosuppressive treatment) were found. The mean age at the time of AVF creation, first renal transplantation, and AD's diagnosis were respectively 26 (range 15-49), 29.2, and 48.6 years (range 37-76) in our series versus 34 (range 27-39), 40.4 (range 28-55), and 55.5 years (range 35-75) in cases found in the literature. The time spread after AVF creation and aneurysmal diagnosis was about 20.6 years (range 18-25) in our study versus 20.5 years (range 9-29) in the case reports. Our surgical attitude corresponds principally to that described in the literature. Nevertheless, we describe for the first time one case of arterial transposition to exclude the brachial aneurysm using superficial femoral artery. CONCLUSIONS: Arterial aneurysm is a rare, but significant complication after a long-term creation of hemodialysis access. High flow and immunosuppression may accelerate this process. Young age of the patients may act as a benefic factor and delay the AD. Arterial transposition could be an option in the absence of any venous conduit, if anatomy does not permit the use of prosthetic grafts.

Can the scoring of the walking estimated limitation calculated by history (WELCH) questionnaire be simultaneously simplified and improved?

BACKGROUND: The WELCH questionnaire includes 4 items (A, B, C and D) and estimates the maximal walking time (MWT) on treadmill in patients with claudication. Its scoring was empirically defined. We aimed to test various methods for scoring to estimate whether the scoring of the WELCH could be improved or simplified. PATIENTS AND METHODS: In 423 patients, we tested 8 methods (from H1 to H8) of weighing D or calculating α, ß and γ in the equation MWT = (αA + ßB + γC) * D. RESULTS: While the WELCH Pearson r was 0.639 and area under ROC curve for the ability to walk 5 minutes on treadmill was 0.795 for the reference empirical method, tested hypotheses resulted in values ranging 0.566 to 0.661 for the Pearson r values and 0.750 to 0.809 for the areas under ROC curve respectively. CONCLUSIONS: None of the tested methods simultaneously improved the correlation to MWT, remained simple enough to be scored by mental calculation and ranged between intuitive minimal and maximal values. The original empirical scoring seems a good compromise between accuracy and simplicity.

A prospective longitudinal study of risk factors for abdominal aortic aneurysm.

The aim of this study was to identify risk factors for abdominal aortic aneurysm (AAA) from the largest Welsh screening cohort to date. Patients were recruited from 1993 (to 2015) as part of the South East Wales AAA screening programme through general practitioners. Demographic data and risk factors were collected by means of a self-report questionnaire. Statistical tests were performed to determine whether associations could be observed between AAA and potential risk factors. Odds ratios (OR) were also calculated for each of the risk factors identified. A total of 6879 patients were included in the study. Two hundred and seventy-five patients (4.0%) presented with AAA, of which 16% were female and 84% were male. Patients with AAA were older than the (no AAA) control group (p < 0.0001). The following risk factors were identified for AAA: family history of AAA (p < 0.0001); history of vascular surgery (p < 0.0001), cerebrovascular accident (p < 0.0001), coronary heart disease (p < 0.0001), diabetes (p < 0.0001), medication (p = 0.0018), claudication (p < 0.0001), smoking history (p = 0.0001) and chronic obstructive pulmonary disorder (p = 0.0007). AAA is associated with classical vascular risk factors, in addition to other less-well-documented risk factors including previous vascular surgery. These findings have practical implications with the potential to improve future clinical screening of patients in order to reduce AAA mortality.