Segmental arterial mediolysis: a commonly overlooked aetiology of acute abdominal pain.

Segmental arterial mediolysis (SAM) is an uncommon condition and commonly missed diagnostic aetiology of acute abdominal pain, initially described in 1976. SAM is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries with notable asymmetric involvement of the walls of the mesenteric arteries and their branches. Clinical presentation ranges from postprandial abdominal discomfort suggestive of mesenteric ischaemia to intra-abdominal bleeding. Pathophysiological explanation and prognosis of these cases are not well understood and therefore no clear guidelines for management exist. In this case report, we emphasise the imaging modalities used to reach the diagnosis and the management options available.

Descriptive title: The body with chronic limb-threatening ischaemia: A phenomenologically derived understanding.

AIMS AND OBJECTIVES: To explore person and family lifeworld narratives of chronic limb-threatening ischaemia (CLTI) after major amputation has been offered as a treatment option. BACKGROUND: Chronic limb-threatening ischaemia manifests as ischaemic pain, ulceration and/or gangrene and is receiving heightened attention due to the increasing health system burden from associated complex wounds and hospitalisations for repeat procedures. The patient and family impact of these manifestations is not well-reported: current studies largely seek to measure treatment outcomes. Patient-reported outcome measurements need to be developed but should be underpinned by rigorous qualitative research. DESIGN: Prospective, longitudinal, qualitative design using interpretive phenomenology. METHODS: The journeys of 19 people with CLTI were explored via 42 semi-structured interviews with 14 patient and 13 family participants. The initial interview was conducted soon after the advice of the need for major amputation, and where amputation followed, participants were invited for a second interview 6 months postprocedure. Hermeneutic phenomenological analysis was guided by Merleau-Ponty's philosophy of embodiment. RESULTS: People with embodied CTLI faced an existential crisis due to the catastrophic impact of creeping decay of their flesh and vascular system, relentless pain and a sense of spreading poison from gangrene, infection and drugs, which disrupted the interleaving of the physical and existential body. Consequent to the creeping decay and surgery, participants also experienced shifting body boundaries and an unreliable body. CONCLUSIONS: The lifeworld of the patient and family living with CTLI is irrevocably altered through the disruption of a spontaneous and reliable body. This shapes subsequent therapeutic relationships and discourse. RELEVANCE TO CLINICAL PRACTICE: People facing CLTI require early patient- and family-centred discussions about the possibility for major amputation and its potential to arrest the further decline of the body and to support the body's existential expression.

The Relationship Between Vein Diameters, Clinical Severity, and Quality of Life: A Systematic Review.

OBJECTIVE/BACKGROUND: The aim was to summarise the evidence for the relationship between vein diameters and clinical severity, and elucidate the relationship between diameters and health related quality of life (HRQoL) METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The MEDLINE and Embase databases were searched from 1946 to 31 August 2018. Reference lists of included studies were searched for further relevant papers. Full text studies in English reporting the relationship between great and small saphenous vein diameters and clinical severity and/or HRQoL scores measured using validated instruments were included. All study designs were included. Studies that did not include relationships between these parameters, non-English studies, and studies focusing on non-truncal veins were excluded. Two reviewers independently performed the study selection, data extraction, and risk of bias assessment. RESULTS: Eleven eligible studies were identified, reporting on 2,732 limbs (range 22-681). Four studies correlated truncal vein diameter with both clinical severity and HRQoL, while seven reported only on clinical severity measures. Multiple instruments were used to quantify HRQoL and clinical severity. Seven studies assessed the relationship with CEAP class, with the majority observing a positive correlation between vein diameter and disease severity. Four studies found weak correlations with VCSS, with one showing correlations with VCSS components. No significant relationship between diameters and HRQoL scores was reported. One study also revealed no correlation with Aberdeen Varicose Vein Questionnaire improvements post-treatment. The majority of studies failed to include C0 and C1 participants. CONCLUSIONS: While further studies are required to improve the level of evidence, the existing literature suggests that truncal vein diameters correlate with clinical severity. Diameters are a poor predictor of HRQoL, with no relationship to patients' perceived impact of chronic venous disease. As such, vein diameter should not be used as a measure to decide who needs venous intervention.

The association of race with quality of health in peripheral artery disease following peripheral vascular intervention: The Q-PAD Study.

Black patients have a higher prevalence of peripheral artery disease (PAD) than white patients, and also tend to have a greater extent and severity of disease, and poorer outcomes. The association of race with quality of health (QOH) after peripheral vascular intervention (PVI), however, is less well-known. In our study, we hypothesized that after PVI, black patients experience worse QOH than white patients. We retrospectively assessed racial differences in health status using responses to the Peripheral Arterial Questionnaire (PAQ) at baseline (pre-PVI) and up to 6 months following PVI among 387 patients. We used the PAQ summary score (which includes physical limitation, symptoms, social function and quality of life) as a measure of QOH. We compared QOH scores at baseline and at follow-up after PVI between black ( n=132, 34.1%) and white ( n=255, 65.9%) patients. We then computed the change in score from baseline to follow-up for each patient (the delta) and compared the median delta between the two groups. Multivariable regression was used to model the delta QOH after controlling for factors associated with race or with the delta QOH. There was no significant difference in mean QOH by race either at baseline ( p=0.09) or at follow-up ( p=0.45). There was no significant difference in the unadjusted median delta by race (white 25.3 vs black 21.5, p=0.28) and QOH scores improved significantly at follow-up in both groups, albeit the improvement was marginally lower in black compared with white patients after adjustment for baseline confounders ( b = -6.6, p=0.05, 95% CI -13.2, -0.11).

An integrative review of health-related quality of life in patients with critical limb ischaemia.

AIMS AND OBJECTIVES: To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life. BACKGROUND: Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation. DESIGN: The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al. RESULTS: The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia. CONCLUSIONS: Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required. RELEVANCE TO CLINICAL PRACTICE: A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.

The development and validation of a novel outcome measure to quantify mobility in the dysvascular lower extremity amputee: the amputee single item mobility measure.

OBJECTIVE: This study describes the development and psychometric evaluation of a novel patient-reported single-item mobility measure. DESIGN: Prospective cohort study. SETTING: Four Veteran's Administration Medical Centers. SUBJECTS: Individuals undergoing their first major unilateral lower extremity amputation; 198 met inclusion criteria; of these, 113 (57%) enrolled. INTERVENTIONS: None. MAIN MEASURES: The Amputee Single Item Mobility Measure, a single item measure with scores ranging from 0 to 6, was developed by an expert panel, and concurrently administered with the Locomotor Capabilities Index-5 (LCI-5) and other outcome measures at six weeks, four months, and 12 months post-amputation. Criterion and construct validity, responsiveness, and floor/ceiling effects were evaluated. Responsiveness was assessed using the standardized response mean. RESULTS: The overall mean 12-month Amputee Single Item Mobility Measure score was 3.39 ±1.4. Scores for transmetatarsal, transtibial, and transfemoral amputees were 4.2 (±1.3), 3.2 (±1.5), and 2.9 (±1.1), respectively. Amputee Single Item Mobility Measure scores demonstrated "large" and statistically significant correlations with the LCI-5 scores at six weeks (r = 0.72), four months (r = 0.81), and 12 months (r = 0.86). At four months and 12 months, the correlation between Amputee Single Item Mobility Measure scores and hours of prosthetic use were r = 0.69 and r = 0.66, respectively, and between Amputee Single Item Mobility Measure scores and Trinity Amputation and Prosthesis Experience Scales functional restriction scores were r = 0.45 and r = 0.67, respectively. Amputee Single Item Mobility Measure scores increased significantly from six weeks to 12 months post-amputation. Minimal floor/ceiling effects were demonstrated. CONCLUSIONS: In the unilateral dysvascular amputee, the Amputee Single Item Mobility Measure has strong criterion and construct validity, excellent responsiveness, and does not exhibit floor/ceiling effects.

Determining the Minimally Important Difference for the VascuQol Sumscore and Its Domains in Patients with Intermittent Claudication.

OBJECTIVES: The VascuQol is a questionnaire for health related quality of life (HRQL) in patients with intermittent claudication (IC), and is frequently used to evaluate treatment effects. Yet, the interpretation of change in score on a questionnaire is not always obvious. The minimally important difference (MID) represents the smallest change in score on a questionnaire that is considered relevant by patients. This study aims to determine the MID for the VascuQol sumscore and its different domains for patients with IC. METHODS: A total of 118 participants were recruited from the SUPER study, a multicenter randomized controlled trial comparing angioplasty with supervised exercise therapy for alleviation of IC due to an iliac artery stenosis or occlusion. All patients completed the VascuQol and the Short Form 36 (SF-36) questionnaires at baseline and after 12 months of follow up. Two anchor based methods for MID calculation were applied. Two anchors were used: six global rating of change questions aimed at the VascuQol sumscore and subscales and the health transition item of the SF-36, both recorded at 12 months of follow up. RESULTS: The MID for the VascuQol sumscore ranged between 1.19 and 1.66 for improvement and 0.08 and 0.41 for deterioration. For the pain domain, MID values ranged from 1.48 to 1.91 for improvement and 0.19 to 0.34 for deterioration. Finally, for the activities domain MID values ranging from 1.55 to 2.2 and from 0.12 to 0.26 for improvement and deterioration were found, respectively. Since the correlations between the anchors and the symptom, social and emotional subscales were below the threshold of 0.3, the MID was not calculated for these subscales. CONCLUSIONS: The range of MID values found in this study is an indication of the smallest change score on the VascuQol questionnaire score that is considered relevant by patients with IC. They may help to better interpret trial results and set treatment goals.

Robust estimation of the proportion of treatment effect explained by surrogate marker information.

In randomized treatment studies where the primary outcome requires long follow-up of patients and/or expensive or invasive obtainment procedures, the availability of a surrogate marker that could be used to estimate the treatment effect and could potentially be observed earlier than the primary outcome would allow researchers to make conclusions regarding the treatment effect with less required follow-up time and resources. The Prentice criterion for a valid surrogate marker requires that a test for treatment effect on the surrogate marker also be a valid test for treatment effect on the primary outcome of interest. Based on this criterion, methods have been developed to define and estimate the proportion of treatment effect on the primary outcome that is explained by the treatment effect on the surrogate marker. These methods aim to identify useful statistical surrogates that capture a large proportion of the treatment effect. However, current methods to estimate this proportion usually require restrictive model assumptions that may not hold in practice and thus may lead to biased estimates of this quantity. In this paper, we propose a nonparametric procedure to estimate the proportion of treatment effect on the primary outcome that is explained by the treatment effect on a potential surrogate marker and extend this procedure to a setting with multiple surrogate markers. We compare our approach with previously proposed model-based approaches and propose a variance estimation procedure based on a perturbation-resampling method. Simulation studies demonstrate that the procedure performs well in finite samples and outperforms model-based procedures when the specified models are not correct. We illustrate our proposed procedure using a data set from a randomized study investigating a group-mediated cognitive behavioral intervention for peripheral artery disease participants.

Association between frailty and subclinical peripheral vascular disease in a community-dwelling geriatric population: Taichung Community Health Study for Elders.

AIM: Frailty is a common syndrome in the elderly and is linked to poor outcomes. Walking performance is one of the indicators of frailty and can be associated with peripheral vascular disease (PVD). The association between frailty and PVD is unclear. The present study investigates the association between frailty and PVD in the elderly. METHODS: This cross-sectional study was carried out in a geriatric population of ≥65-year-old residents of Taichung, Taiwan, in June 2009. The association between frailty and subclinical PVD was analyzed using logistic regression with adjustments for PVD risk factors. RESULTS: The community-based study consisted of 1036 individuals (539 male and 497 female subjects) with a mean age of 74.2 ± 6.6 years. Frailty was found in 143 (13.8%), and subclinical PVD was identified in 74 (7.1%) individuals using the Ankle Brachial Index < 0.9 as a cut-off. Frail individuals were associated with an increased risk for subclinical PVD with an odd ratios (OR) of 3.168 (95% CI 1.803-5.566, P < 0.001). Individuals' diastolic blood pressure (OR 0.975, 95% CI 0.951-0.999, P = 0.038) and high-density cholesterol (OR 0.976, 95% CI: 0.956-0.996, P = 0.019) were independently associated with subclinical PVD. CONCLUSIONS: Frailty syndrome in the elderly is associated with subclinical peripheral arterial disease indicated using the Ankle Brachial Index. The association between frailty and PVD is independent of subject's age, blood pressure and serum lipoprotein level.

Psychological distress and risk of peripheral vascular disease, abdominal aortic aneurysm, and heart failure: pooling of sixteen cohort studies.

OBJECTIVES: Examine the little-tested relation of psychological distress with peripheral vascular disease, abdominal aortic aneurysm, and heart failure. METHODS: Pooling of raw data from 166,631 male and female participants in 16 UK-based cohort studies. Psychological distress was measured using the 12-item General Health Questionnaire. Peripheral vascular disease, abdominal aortic aneurysm, and heart failure events were based on death register linkage. RESULTS: During a mean follow-up 9.5 years there were 17,368 deaths of which 8625 were cardiovascular disease-related. Relative to the asymptomatic group (0 score), the highly distressed group (score 7-12) experienced an elevated risk of peripheral vascular disease (adjusted hazard ratio; 95% confidence interval: 3.39; 1.97, 5.82) and heart failure (1.76; 1.37, 2.26). Psychological distress was weakly related to the risk of death from abdominal aortic aneurysm. As anticipated, distress was associated with cardiovascular disease, coronary heart disease, and all strokes combined. CONCLUSIONS: In the present study, we provide new evidence of mental health-related cardiovascular disease presentations.

Association of depression with complications of type 2 diabetes--the Chennai Urban Rural Epidemiology Study (CURES- 102).

OBJECTIVE: The aim of the study was to assess the relationship between depression and diabetic complications among urban south Indian type 2 diabetic subjects [T2DM]. METHODS: T2DM subjects [n = 847] were recruited from the Chennai Urban Rural Epidemiology Study [CURES], a population based study in Chennai (formerly Madras) in South India. A previously validated depression questionnaire [PHQ-12 item] was administered. Four field stereo retinal colour photography was done and diabetic retinopathy [DR] was classified according to the Early Treatment Diabetic Retinopathy Study grading system. Neuropathy was diagnosed if the vibratory perception threshold of the right great toe, measured by biothesiometry, was > or = 20. Nephropathy was diagnosed if urinary albumin excretion was > or = 300 microg/mg creatinine. Peripheral vascular disease [PVD] was diagnosed if an ankle-brachial index was < 0.9. Coronary artery disease [CAD] was diagnosed based on a past history of documented myocardial infarction and/or electrocardiographic evidence of Q wave and/or ST segment changes. RESULTS: Of the 847 T2DM studied, 198 (23.4%) were found have depression. The prevalence of depression was significantly higher among diabetic subjects with DR (35.0% vs 21.1%, p < 0.001), neuropathy (28.4% vs 15.9%, p = 0.023), nephropathy (35.6% vs 24.5%, p = 0.04) and PVD (48.0% vs 27.4%, p < 0.001) as compared to subjects without these complications. DR, neuropathy, nephropathy, and PVD were associated with depression even after adjusting for age, gender, duration of diabetes and glycated haemoglobin. DR (Odds ratio [OR] = 2.19, Confidence interval [CI]:1.45-3.51, p < 0.001) was associated with depression even after adjusting for neuropathy and nephropathy. There was also a significant association between depression and neuropathy, after adjusting for retinopathy and nephropathy (OR = 2.07, CI: 1.41-3.04, p < 0.001). There was a significant association of depression with nephropathy but this was lost (OR = 1.71, CI: 0.87-3.35, p = 0.119) after adjustment for retinopathy. PVD (OR = 3.52, CI: 1.94-6.40, p < 0.001) remained significantly associated with depression even after adjusting for CAD. However, there was no significant association of depression with CAD (OR = 0.73, CI: 0.42 -1.27, p = 0.264). CONCLUSION: Among Asian Indians, the prevalence of depression is higher in T2DM subjects with retinopathy, neuropathy, nephropathy and PVD compared to those without the respective complications.

The impact of vascular leg disorders on physical activity in methadone-maintained adults.

Chronic venous disorders (CVD) and peripheral arterial disease (PAD) may affect diverse physical activity domains. How CVD and PAD and other relevant variables affect physical activity was examined in 569 opioid-addicted adults. Both CVD and PAD were significantly inversely related to daily walking, sports, and active living. Effects remained significant in the latent variable regression after controlling covariates. Overall activity was very low; most participants walked less than a half mile daily and rarely engaged in sports. Motivation for physical activity was the strongest predictor (ß = .55) of daily physical activity. Health-care professionals promoting physical activity for injection users should consider the vascular health of their legs and motivational variables in addition to general health.

Smoking cessation has no influence on quality of life in patients with peripheral arterial disease 5 years post-vascular surgery.

OBJECTIVES: Smoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers. DESIGN: Cohort study. METHODS: Data of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ). RESULTS: After adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28-1.43; PAQ: OR = 0.76, 95% CI = 0.35-1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42-1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09-3.17; PAQ: OR = 1.63, 95% CI = 1.00-2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72-1.90). CONCLUSIONS: There was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention.

Younger women with symptomatic peripheral arterial disease are at increased risk of depressive symptoms.

OBJECTIVES: Gender disparities, particularly among young women with cardiovascular disease, are a growing cause for concern. Depression is a prevalent and prognostically important comorbidity in peripheral arterial disease (PAD), but its prevalence has not been described as a function of gender and age. Therefore, we compared depressive symptoms at the time of PAD diagnosis and 6 months later by gender and age in PAD patients. METHODS: The study enrolled 444 newly diagnosed patients with PAD (32% women) from two Dutch vascular outpatient clinics. Patients' depressive symptoms were assessed with the 10-item Center for Epidemiological Studies Depression Scale (CES-D) at baseline and 6 months later (CES-D scores >or=4 indicate significant depressive symptoms). Logistic regression models were constructed to evaluate the relationship among four gender-age groups (women <65 and >or=65 years; men <65 and >or=65 years [reference category]) and baseline and 6-month follow-up depressive symptoms. RESULTS: Initially, 33% of women <65 years had significant depressive symptoms, and 6 months later, significant depressive symptoms had developed in 19% of the other younger women. These rates were much higher than other gender-age groups (range at baseline, 11%-16%; 6-month incidence, 6%-10%; P or=65 years, whereas other gender-age groups were not at risk. Additional adjustment for change in the ankle-brachial index did not explain the increased depression risk in younger women (OR, 3.5; 95% CI, 1.2-10.2). CONCLUSIONS: Significant depressive symptoms are more common in younger women with PAD than in other gender-age groups, both at the time of diagnosis and 6 months later. To eradicate gender-based disparities in PAD, depression screening and monitoring in younger women may be an important direction for future research and intervention.

Mediators and readiness to exercise in patients at risk of symptomatic peripheral arterial disease.

To inform future walking interventions, we sought to identify exercise mediators that are associated with readiness to exercise in persons with either asymptomatic peripheral arterial disease (PAD) or disease risk factors. We enrolled participants excluded from a larger behavioral intervention trial for persons with diabetes mellitus and PAD. Participants completed surveys assessing exercise mediators and stage of readiness to exercise (precontemplation, contemplation, or action). Data were analyzed using nonparametric tests. Participants in the stage of action substituted physical activity as an alternative, rewarded themselves, and committed themselves more than other participants (P < .01). Action participants perceived more benefits to exercise than precontemplation participants (P < .05). Contemplation and action participants had higher outcome expectations for exercise, and action participants received more enjoyment from physical activity than precontemplation participants (P < .05 and P = .05, respectively). Identifying these mediators is important for future exercise interventions and treatments.

The influence of socio-economic deprivation on rates of major lower limb amputation secondary to peripheral arterial disease.

OBJECTIVES: To investigate a hypothesised link between socio-economic deprivation and rates of major lower limb amputation within the catchment of a district general hospital in the United Kingdom. DESIGN: An analysis of a demographic database collated using patients identified by the OPCS codes for lower limb amputations. MATERIALS: All patients undergoing a lower limb amputation as a result of peripheral vascular disease, as identified by ICD-10 code, between January 2003 and January 2009 were included in the study. METHODS: A case-control study was undertaken, comparing the Index of Multiple Deprivation 2007 (IMD) scores of major lower limb amputees, to those of the catchment population. Multivariate analysis was not undertaken. RESULTS: A total of 327 patients underwent 445 lower limb amputations during the 6-year period. A comparative plot of cumulative frequency of IMD score in the catchment and amputation groups indicates greater numbers of major amputations in more deprived postcodes (P=0.004). The catchment population was further divided into population-matched deprivation quintiles. A significant increase in the number of amputations occurred in the two most deprived quintiles (OR (95%CI)=1.654 (1.121-2.440), P=0.011) CONCLUSIONS: This study indicates a positive association between increasing social deprivation and rates of lower limb amputation. If the most deprived quintiles are combined, this increase in amputation rates is approximately 65%. This inequity should be further investigated, and consideration given to targeted care within areas of greater social deprivation.

Computer and internet use in vascular outpatients--ready for interactive applications?

BACKGROUND: Exploring patients' computer and internet use, their expectations and attitudes is mandatory for successful introduction of interactive online health-care applications in Angiology. PATIENTS AND METHODS: We included 165 outpatients suffering from peripheral arterial disease (PAD; n = 62) and chronic venous and / or lymphatic disease (CVLD; n = 103) in a cross-sectional-study. Patients answered a paper-based questionnaire. RESULTS: Patients were predominantly female (54.5%). 142 (86.1%) reported regular computer use for 9.7 +/- 5.8 years and 134 (81.2 %) used the internet for 6.2 +/- 3.6 years. CVLD-patients and internet-user were younger and higher educated, resulting in a significant difference in computer and internet use between the disease groups (p < 0.01 for both). Time spent online summed up to 4.3 +/- 2.2 days per week and 1.44 +/- 1.2 hours per day for all internet users without significant differences between the groups. The topics retrieved from the internet covered a wide spectrum and searches for health information were mentioned by 41.2 %. Although confidence in the internet (3.3 +/- 1.1 on a 1-6 Likert scale) and reliability in information retrieved from the internet (3.1 +/- 1.1) were relatively low, health-related issues were of high actual and future interest. 42.8% of the patients were even interested in interactive applications like health educational programs, 37.4% in self-reported assessments and outcome questionnaires and 26.9% in chatforums; 50% demanded access to their medical data on an Internetserver. Compared to older participants those < 50 yrs. used the internet more often for shopping, chatting, and e-mailing, but not for health information retrieval and interactive applications. CONCLUSIONS: Computers are commonly used and the internet has been adopted as an important source of information by patients suffering from PAD and CVLD. Besides, the internet offers great potentials and new opportunities for interactive disease (self-)management in angiology. To increase confidence and reliability in the medium a careful introduction and evaluation of these new online applications is mandatory.