Association between Physical Activity and Mortality in Patients with Claudication.

PURPOSE: This study aimed to determine the association between light-intensity physical activity and the incidence of all-cause and cardiovascular mortality in patients with peripheral artery disease (PAD) limited by claudication followed for up to 18.7 yr. METHODS: A total of 528 patients with PAD and claudication were screened in Baltimore between 1994 and 2002, and 386 were deemed eligible for the study. At baseline, patients were classified into three physical activity groups: 1) physically sedentary, 2) light intensity, and 3) moderate to vigorous intensity based on a questionnaire. All-cause and cardiovascular mortality of patients through December 2014 was determined using the National Death Index and the U.S. Department of Veterans Affairs and the U.S. Department of Defense Suicide Data Repository. RESULTS: Median survival time was 9.9 yr (interquartile range, 4.9-15.7 yr; range, 0.38-18.7 yr). During follow-up, 257 patients (66.6%) died, consisting of 40/48 (83.3%) from the sedentary group, 135/210 (64.3%) from the light-intensity group, and 82/128 (64.0%) from the moderate- to vigorous-intensity group. For all-cause mortality, light-intensity activity status (hazard ratio [HR] = 0.523, P = 0.0007) and moderate- to vigorous-intensity status (HR = 0.425, P < 0.0001) were significant predictors. During follow-up, 125 patients died because of cardiovascular causes (32.4%), in which light-intensity activity status (HR = 0.511, P = 0.0113) and moderate- to vigorous-intensity activity status (HR = 0.341, P = 0.0003) were significant predictors. CONCLUSIONS: Light-intensity physical activity is associated with nearly 50% lower risk of all-cause and cardiovascular mortality in high-risk patients with PAD and claudication. Furthermore, moderate- to vigorous-intensity physical activity performed regularly is associated with 58% and 66% lower risk of all-cause and cardiovascular mortality, respectively. The survival benefits associated with light-intensity physical activity make it a compelling behavioral intervention that extends beyond improving ambulation.

Lower Limb Revascularization for Peripheral Arterial Disease in 10,951 Procedures over 11 years in a Public Health System: A Descriptive Analysis of the Largest Brazilian City.

BACKGROUND: Worldwide, peripheral arterial disease (PAD) is a disease with high morbidity, affecting more than 200 million people. Our objective was to analyze the surgical treatment for PAD performed in the Unified Health System of the city of São Paulo during the last 11 years based on publicly available data. METHODS: The study was conducted with data analysis available on the TabNet platform, belonging to the DATASUS. Public data (government health system) from procedures performed in São Paulo between 2008 and 2018 were extracted. Sex, age, municipality of residence, operative technique, number of surgeries (total and per hospital), mortality during hospitalization, mean length of stay in the intensive care unit and amount paid by the government system were analyzed. RESULTS: A total of 10,951 procedures were analyzed (either for claudicants or critical ischemia-proportion unknown); 55.4% of the procedures were performed on males, and in 50.60%, the patient was older than 65 years. Approximately two-thirds of the patients undergoing these procedures had residential addresses in São Paulo. There were 363 in-hospital deaths (mortality of 3.31%). The hospital with the highest number of surgeries (n = 2,777) had lower in-hospital mortality (1.51%) than the other hospitals. A total of $20,655,272.70 was paid for all revascularizations. CONCLUSIONS: Revascularization for PAD treatment has cost the government system more than $20 million over 11 years. Endovascular surgeries were performed more often than open surgeries and resulted in shorter hospital stays and lower perioperative mortality rates.

High-Intensity Statin Therapy Is Associated With Improved Survival in Patients With Peripheral Artery Disease.

BACKGROUND: The relative benefit of higher statin dosing in patients with peripheral artery disease has not been reported previously. We compared the effectiveness of low- or moderate-intensity (LMI) versus high-intensity (HI) statin dose on clinical outcomes in patients with peripheral artery disease. METHODS AND RESULTS: We reviewed patients with symptomatic peripheral artery disease who underwent peripheral angiography and/or endovascular intervention from 2006 to 2013 who were not taking other lipid-lowering medications. HI statin use was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg. Baseline demographics, procedural data, and outcomes were retrospectively analyzed. Among 909 patients, 629 (69%) were prescribed statins, and 124 (13.6%) were treated with HI statin therapy. Mean low-density lipoprotein level was similar in patients on LMI versus HI (80±30 versus 87±44 mg/dL, P=0.14). Demographics including age (68±12 versus 67±10 years, P=0.25), smoking history (76% versus 80%, P=0.42), diabetes mellitus (54% versus 48%, P=0.17), and hypertension (88% versus 89%, P=0.78) were similar between groups (LMI versus HI). There was a higher prevalence of coronary artery disease (56% versus 75%, P=0.0001) among patients on HI statin (versus LMI). After propensity weighting, HI statin therapy was associated with improved survival (hazard ratio for mortality: 0.52; 95% confidence interval, 0.33-0.81; P=0.004) and decreased major adverse cardiovascular events (hazard ratio: 0.58; 95% confidence interval 0.37-0.92, P=0.02). CONCLUSIONS: In patients with peripheral artery disease who were referred for peripheral angiography or endovascular intervention, HI statin therapy was associated with improved survival and fewer major adverse cardiovascular events compared with LMI statin therapy.

Patency and limb salvage after femoral endarterectomy and iliac stenting are not affected by severity of iliac disease.

OBJECTIVE: The hybrid procedure of femoral endarterectomy and iliac artery stenting (FEIS) has been used as an alternative to traditional open surgical repair of iliofemoral arterial occlusive disease, but whether the severity of the iliac disease component affects long-term results is not well understood. METHODS: This was a retrospective cohort study of patients undergoing FEIS at Geisinger Health System from January 1, 2004, through December 31, 2013, for the treatment of symptomatic iliofemoral atherosclerotic occlusive disease. The cohort was stratified according to the severity of the iliac occlusive disease component into patients with mild iliac disease (group 1) and patients with severe iliac disease (group 2). RESULTS: Between January 1, 2004, and December 31, 2013, 99 patients underwent 111 total FEIS procedures. The mean age of the cohort was 67.4 years. Men composed 61% of patients. Indications for surgery were claudication (41%), ischemic rest pain (36%), and tissue loss (23%). At 5 years of follow-up, there was no difference in primary patency (73% in group 1 vs 68% in group 2 [P = .67]) and limb salvage (90% in group 1 vs 92% in group 2 [P = .51]). There was a trend toward higher overall mortality in group 2 patients vs group 1 patients (53% vs 81%; P = .08), but this did not reach statistical significance. Univariate analysis did not identify any device-related or anatomic factors predictive of patency. CONCLUSIONS: When combined iliofemoral arterial occlusive disease is treated with FEIS, the severity of the iliac disease component does not affect long-term patency or limb salvage.

Association between gender and outcomes of lower extremity peripheral vascular interventions.

OBJECTIVE: The purpose of this study was to evaluate the association of gender with outcomes of peripheral vascular intervention (PVI) for intermittent claudication and critical limb ischemia (CLI). METHODS: We reviewed 3338 patients (1316 [39%] women) undergoing PVI for claudication (1892; 57%) or CLI (1446; 43%) in the Vascular Study Group of New England from January 2010 to June 2012. Kaplan-Meier analysis, stratified by indication, was used to assess relationships between gender and the main outcome measures of major amputation, reintervention, and survival during the first year. RESULTS: Indications for PVI included claudication (n = 719 [38%] vs n = 1173 [62%]) and CLI (n = 597 [41%] vs n = 849 [59%]) in women and men, respectively (P = .0028). Women were older (69 vs 66 mean years; P < .00001), with less diabetes (43% vs 49%; P = .01), renal insufficiency (4.6% vs 7.3%; P = .0029), coronary artery disease (28% vs 35%; P < .00001), smoking (76% vs 86%; P = .01), and statin use (60% vs 64%; P = .0058). Technical success (95% vs 94%; P = .11), vascular injury (1.3% vs 1.0%; P = .82), and distal embolization (1.6% vs 1.3%; P = .46) were similar. Higher rates of hematoma (7.1% vs 3.4%; P ≤ .0001) and access site occlusion (0.91% vs 0.24%; P = .0085) were observed in women compared with men. There were no differences in major amputation (0.6% vs 0.6%; P = .81) or mortality (2.1% vs 1.5%; P = .20) rates at 30 days between women and men. Reinterventions (surgical and percutaneous) were similar between genders for claudicants (log-rank test, P = .75) and CLI patients (log-rank test, P = .93). Major amputation rates during the first year were not different for women and men and with claudication (log-rank test, P < .55) or CLI (log-rank test, P < .23). One-year survival was not different between women and men with claudication (95% vs 96%; P = .19) or CLI (77% vs 79%; P = .35). CONCLUSIONS: Whereas we observed higher rates of access site complications including hematoma and occlusion in women, we found no other evidence for gender disparity in reinterventions, major amputation, or survival rates after PVI for patients with claudication or CLI.

Prospective comparison of arm veins and greater saphenous veins as infrageniculate bypass grafts.

OBJECTIVES: to compare arm and saphenous veins for infrageniculate bypass grafting. DESIGN: prospective non-randomised study. MATERIALS: two hundred patients, of which 197 had ischaemic tissue loss or rest pain. METHODS: two hundred and eleven infrageniculate vein bypass procedures using 176 greater saphenous veins and 35 arm veins. RESULTS: the cumulative primary graft patency rate at 1-month and 2 years was 80% and 61% for saphenous vein and 89% and 42% for arm vein. The corresponding rates for secondary patency were 84.5% and 68%, and 91% and 57%, respectively. These results corresponded to a relative risk of secondary failure of 1.53 (95% CI 0.71, 3.31) for arm vein grafts. In subgroup analyses, this estimate was 0.93 and 2.1 for primary vs secondary bypasses and 0.38 and 2.06 for single-vein vs spliced-vein bypasses. Among arm veins, cephalic vein grafts performed better than basilic vein grafts. Early mortality was 14% for arm vein and 10% for saphenous vein. CONCLUSION: in the setting of infrageniculate bypass grafting, arm vein grafts are not equivalent to greater saphenous vein grafts, but contribute importantly to a policy of using autologous veins. The possibility of equivalence remains for the arm vein graft that uses a cephalic vein or is a primary procedure.