Adverse reactions after intravascular iodinated contrast media administration and their management.

Endovascular interventions and diagnostic examinations using iodinated contrast media (ICM) are standard of care in current vascular medicine. Although ICM use is generally considered safe, it may be associated with adverse reactions, vary from minor disturbances to rare, but severe life-threatening complications. This position paper of European Society of Vascular Medicine integrates current knowledge and summarizes the key information related to the use of intravascular ICM, serving as recommendation on prevention and management of acute, late, and very late adverse reactions. It should help the health professionals in all fields of vascular medicine to make decisions in daily practice for safe use of contrast media.

Ankle-Brachial Index: Diagnostic Tool of Peripheral Arterial Disease and Predictor of Cardiovascular Risk-An Update of Current Knowledge.

The ankle-brachial index (ABI) was introduced as a screening method for the diagnosis of lower extremity peripheral arterial disease (PAD). Later findings recognized ABI as a prognostic marker of adverse cardiovascular events due to its relation to atherosclerosis in other vascular territories. This narrative review aims to appraise the validity, reliability, and utility of ABI in the detection of PAD and the determination of global atherosclerotic cardiovascular risk. While the ABI value can be influenced by different physiological characteristics including age, sex, body position, and techniques used for ABI determination, it has high specificity and reproducibility in the assessment of vascular patients. In conclusion, when used correctly, the ABI remains a reliable and invaluable indicator of lower-limb perfusion and a useful tool for predicting the risk of future cardiovascular events. However, its underutilization in clinical settings is noteworthy.

Prognostic Factors for Restenosis of Superficial Femoral Artery after Endovascular Treatment.

High incidence of superficial femoral artery (SFA) restenosis after percutaneous transluminal angioplasty (PTA) poses a persistent challenge in peripheral arterial disease (PAD) treatment. We studied how the patients' and lesions' characteristics, thrombin generation, overall haemostatic potential (OHP), and single nucleotide polymorphisms (SNPs) of the NR4A2 and PECAM1 genes affected the likelihood of restenosis. In total, 206 consecutive PAD patients with limiting intermittent claudication due to SFA stenosis who were treated with balloon angioplasty with bailout stenting when necessary were included. Patients' clinical status and patency of the treated arterial segment on ultrasound examination were assessed 1, 6, and 12 months after the procedure. Restenosis occurred in 45% of patients, with less than 20% of all patients experiencing symptoms. In the multivariate analysis, predictors of restenosis proved to be poor infrapopliteal runoff, higher lesion complexity, absence of treated arterial hypertension, delayed lag phase in thrombin generation, and higher contribution of plasma extracellular vesicles to thrombin concentration. Poor infrapopliteal runoff increased the risk of restenosis in the first 6 months, but not later. The negative effect of poor infrapopliteal runoff on SFA patency opens questions about the potential benefits of simultaneous revascularisation of below-knee arteries along with SFA revascularisation.

Smoking and Diabetes Attenuate Number of CD34+ Haematopoietic Stem Cells in Peripheral Blood of Patients with Advanced Peripheral Artery Disease.

Peripheral artery disease (PAD) is a globally prevalent problem with limited treatment options, leaving up to a fifth of patients remediless. The emergence of new studies on cell therapy in recent years offers a new promising option for their treatment. Our aim was to explore how the number of CD34+ hematopoietic cells in the peripheral blood of PAD patients is associated with patients' functional as well as atherogenic factors. We selected 30 patients with advanced PAD, recorded their performance in a walking test in standard conditions and sampled their blood for further analysis with an emphasis on CD34+ cell selection and counting. No correlation of the CD34+ cell number was confirmed with any of the observed laboratory parameters. There was an association between the claudication distance and the number of CD34+ cells (r = -0.403, p = 0.046). The number of CD34+ cells differed between patients with and without type II diabetes (p = 0.071) and between active smokers, past smokers, and non-smokers (p = 0.035; p = 0.068, p = 0.051, respectively), with both smoking and presence of diabetes type II having a negative effect on the number of CD34+ cells. Our study demonstrated a dependence of the CD34+ cell number on the patient's characteristics.

Revascularization of Peripheral Arteries in Patients with Intermittent Claudication Decreases Inflammatory Biomarkers.

Patients with intermittent claudication have significantly higher levels of inflammatory biomarkers, particularly interleukins, which is also a consequence of exercise limitation. Physical activity, which is one of the preventive measures against atherosclerosis, is associated with a decrease in inflammatory biomarkers. Therefore, in our study, we investigated the effects of revascularization of peripheral arteries in patients with intermittent claudication on functional capacity and levels of inflammatory markers. The study included 26 patients with intermittent claudication who underwent percutaneous transluminal angioplasty (PTA). Before the procedure and 2-4 months after successful revascularization, the ankle-brachial index (ABI), functional capacity using the treadmill test, and the walking impairment questionnaire (WIQ) were determined. Inflammatory biomarkers were also measured before and after procedures. Successful revascularization was associated with an increase in intermittent claudication: 120 (20-315) versus 300 (100-1000 m), P < 0.001. Treadmill testing showed a significant increase in initial and maximal walking distance. After revascularization, ABI increased significantly (0.55 vs 0.82, P < 0.003). Improvement in functional performance was also demonstrated by WIQ. Two to three months after revascularization, some inflammatory biomarkers decreased significantly: fibrinogen, interleukin-6 (IL-6), and interleukin-8 (IL-8). The high-sensitivity C-reactive protein (hsCRP) and tumor necrosis factor-alpha (TNFα) also did not decrease significantly. The levels of some inflammatory markers: IL-6, TNFα, and fibrinogen were significantly related to the improvement in patients' functional capacity. The results of our study show that successful revascularization of the lower limb arteries not only improves the functional capacity of patients with intermittent claudication, but also reduces the systemic inflammatory response and may have a preventive effect on local and concomitant other atherosclerotic diseases.

Clinical Outcomes after Endovascular Revascularisation of the Femoropopliteal Arterial Segment in Patients with Anticoagulant versus Antiplatelet Therapy: A Single-Centre Retrospective Cohort Study.

To prevent atherothrombotic events, patients with peripheral arterial disease are typically prescribed antiplatelet therapy (APT). However, some of them receive anticoagulant therapy (ACT) due to comorbidities. Our aim was to determine possible differences in the effectiveness and safety of both treatments in patients after endovascular femoropopliteal revascularisation. We retrospectively analysed 1247 patients after successful femoropopliteal revascularisation performed in a single tertiary medical centre and classified them into the ACT or APT group, based on their prescribed treatment. The groups were characterised by descriptive statistics, and their characteristics were adjusted for confounders by propensity score matching. Effectiveness and safety outcomes were assessed within one year after revascularisation. The odds ratio for the composite outcome of all-cause death, PAD exacerbation, and major amputation due to vascular causes with ACT versus APT was 1.21 (95% CI 0.53-2.21; p = 0.484). The odds ratio for major bleeding as defined by the International Society on Thrombosis and Haemostasis with ACT versus APT was 0.77 (95% CI 0.13-3.84; p = 0.251). We found no statistically significant difference in the effectiveness and safety of ACT, when compared to APT in patients with similar cardiovascular risk factors and other baseline characteristics. Further prospective research is warranted.

Walking Impairment Questionnaire and Walking Tests are Reliable Indicators of Success of Treatment of Peripheral Artery Disease.

The functional capacity of patients with peripheral arterial disease (PAD) represents an important indicator of patient health and quality of life. The aim of this prospective study was to investigate the validity of a walking impairment questionnaire (WIQ) compared with walking tests for the estimation of the therapeutic effect of lower limb revascularization. The study included 36 patients with PAD in whom successful percutaneous revascularization of a lower limb was performed due to disabling intermittent claudication. Before the revascularization procedure and 4-6 weeks after successful revascularization, clinical examination, ankle brachial index (ABI) measurement, 6-min walk test, treadmill test, and WIQ were performed. After revascularization, significant improvement in walking capacity was shown by both 6-min walk test and treadmill exercise test as well as with WIQ. However, the increase in ABI was borderline. Significant correlations between improvement of 6-min walk test and treadmill exercise test results and the sum of WIQ points were found. The ABI was significantly correlated with treadmill maximal walking distance only. According to our results, the WIQ correlates well with walking tests and is a reliable indicator of effective revascularization of lower limb arterial occlusions, even in patients with a nonsignificant improvement of the ABI.

Bailout stenting in femoropopliteal arterial segment.

Background: Disabling peripheral arterial disease (PAD) of femoropopliteal segment is usually treated with percutaneous balloon dilatation, and when this is not successful, stent is placed. Long-term patency of stent is often compromised due to in-stent restenosis (ISR). We aimed to identify factors associated with bailout stenting, and to recognise risk factors for ISR in procedures without paclitaxel application. Patients and methods: We analysed 592 consecutive successful femoropopliteal interventions performed in patients with either disabling intermittent claudication or chronic critical limb ischemia (CLI). In patients with stent implantation, clinical and ultrasound (US) examination were performed one year after the intervention to establish the presence of ISR, defined as >50% stenosis on US imaging. Results: Bailout stenting was required in 133 (22.5%) procedures. Patients with stent placement were younger (70±10 vs 72±11 years, p=0.007) and less often presented with CLI (29.3% vs 40.5%, p=0.019). They more often reported smoking (63.2% vs 49.2%, p=0.005), less often had diabetes mellitus (35.3% vs 47.5%, p=0.013) and arterial hypertension (82.0% vs 90.8%; p=0.004). Stenting was also dependent on lesion complexity (TASC II C>B>A; p<0.001). Subgroup analysis of 110 procedures with bare metal stent (BMS) placement performed in 107 patients revealed ISR in 46.4% of stents, in half of cases it was symptomatic. Neither clinical nor lesion characteristics proved to differ between the group of procedures with ISR and group of procedures without ISR. Conclusions: Factors associated with bailout stenting were age, diabetes mellitus, arterial hypertension, smoking, clinical picture of PAD and complexity of treated lesions. We did not find any risk factors influencing development of ISR in BMS.

Distal embolization during percutaneous revascularization of the lower extremity arteries.

Background: Percutaneous endovascular therapy is nowadays the leading treatment option for patients with symptomatic peripheral arterial disease, but it can be complicated with distal embolization (DE). Patients and methods: We retrospectively analyzed 2054 endovascular revascularization interventions performed in patients with disabling claudication or chronic critical limb ischemia in the Catheterisation Laboratory of the Department of Vascular Diseases, University Medical Centre Ljubljana between January 2014 and December 2018. Lesions were treated by balloon angioplasty and/or stent implantation, without atherectomy. Results: The overall incidence of DE was 0.9%. DE was more frequent in females than males (1.6% vs 0.5%, p = 0.011), in the absence of antiplatelet treatment prior to intervention compared to previous antiplatelet treatment (2.1% vs 0.6%, p = 0.005) and in femoropopliteal stenting compared to angioplasty without stenting (2.2% vs 0.8%, p = 0.037). DE was successfully managed with percutaneous aspiration, in combination with angioplasty when necessary, in 84% of cases. In remaining 16% of patients, DE was managed with surgical thromboembolectomy. Conclusions: The incidence of DE during endovascular revascularization of chronic atherosclerotic lesions in lower limb arteries without use of atherectomy was low. DE was more frequent in women, in patients without prior antiplatelet treatment and in femoropopliteal stenting. The majority of DE was successfully managed percutaneously.

Diabetes and smoking are more important for prognosis of patients with peripheral arterial disease than some genetic polymorphisms.

Background: The role of genetic polymorphisms in peripheral arterial disease (PAD) is incompletely understood. We tested whether selected single nucleotide polymorphisms (SNPs) were associated with PAD and with adverse events in an observational study cohort. Also, the role of diabetes and smoking was studied. Patients and methods: 742 patients with PAD and 713 age- and gender-matched control subjects were subjected to yearly physical and laboratory investigations and were managed for 5 years according to the European guidelines on cardiovascular disease prevention. The occurrence of all-cause death, cardiovascular death, non-fatal myocardial infarction, ischemic stroke or critical limb ischemia (major events) and revascularization procedures (minor events) was recorded. In 655 patients with PAD and 612 control subjects the following SNPs were determined: rs1466408, rs13428968 and rs12803 of NR4A2 gene, rs10499563 of IL6 gene, rs668 and rs12953 of PECAM1 gene, and rs10861032 of Chr12 locus. Results: The distribution of selected SNPs did not differ between patients with PAD and control subjects, and neither between subjects with or without major adverse events. In contrast, diabetes and smoking affected survival and event-free survival. Among patients with PAD, diabetes doubled the hazard ratio (HR) for cardiovascular death and smoking doubled the HR for death or major event. The 5-year survival of diabetics with PAD was 0.80 (CI 0.75-0.85) and of non-diabetics with PAD 0.87 (CI 0.84-0.90), p = 0.045. The 5-year survival of active smokers with PA D was 0.80 (CI 0.75-0.62), of former smokers 0.83 (CI 0.79-0.88), and of never-smokers 0.89 (CI 0.86-0.93), p = 0.024. Conclusions: SNPs of NR4A2, IL6, PECAM1 and Chr12 were not associated with PAD or with major adverse events. However, diabetes and smoking were associated with worse survival and event-free survival in patients with PAD.

Patients' radiation doses during percutaneous endovascular procedures in arteries of the lower limbs.

BACKGROUND: Percutaneous endovascular revascularisation interventions are increasingly used in treatment of lower extremity artery disease and may expose patients to substantial radiation. PATIENTS AND METHODS: Dose-area product (DAP) was retrospectively analysed in 1063 consecutive interventions performed in adult patients with lower extremity artery disease in a single tertiary medical centre. Differences between procedure types, stratified according to anatomical region and arterial lesion complexity were evaluated. RESULTS: Median DAP for diagnostic interventions was 35.6 (15.0-52.4) Gy cm2 in aorto-below-knee arteriography and 3.2 (2.0-4.5) Gy cm2 in ipsilateral femoral arteriography (p < 0.001). For angioplasty without stenting, median DAP was 53.4 (28.6-87.4) Gy cm2 for pelvic interventions vs. 5.9 (4.3-8.6) Gy cm2 for antegrade ipsilateral femoropopliteal interventions (p < 0.001). For stenting, median DAP was 54.9 (32.5-91.2) Gy cm2 for pelvic interventions vs. 8.3 (6.0-12.3) Gy cm2 for antegrade ipsilateral femoropopliteal interventions (p < 0.001). Inside the same anatomical region, diagnostic interventions were associated with significantly lower DAP than therapeutic interventions. Stenting vs no stenting increased DAP values only in antegrade ipsilateral femoropopliteal interventions (8.3 (6.0-12.3) vs 5.9 (4.3-8.6) Gy cm2 (p < 0.001). Arterial lesion complexity affected DAP values only in antegrade ipsilateral femoropopliteal therapeutic interventions. CONCLUSIONS: The most important factor influencing patients' radiation doses was the anatomical region. Pelvic interventions were associated with 6-11-times higher DAP values than femoropopliteal interventions with antegrade ipsilateral approach. Stenting and complexity of lesions increased DAP only in antegrade ipsilateral femoropopliteal interventions.

Increased Plasma Cathepsin s at the Time of Percutaneous Transluminal Angioplasty is Associated with 6-months' Restenosis of the Femoropopliteal Artery.

BACKGROUND: We tested the hypothesis that increased levels of cathepsin S and decreased levels of cystatin C in plasma at the time of percutaneous transluminal angioplasty (PTA) are associated with the occurrence of 6-months' restenosis of the femoropopliteal artery (FPA). METHODS: 20 patients with restenosis and 24 matched patients with patent FPA after a 6-months follow-up were in - cluded in this study. They all exhibited disabling claudication or critical limb ischemia and had undergone technically successful PTA. They were all receiving statins and ACE in hi - bitors (or angiotensin II receptor antagonist) before the PTA and the therapy did not change throughout the observational period. Plasma concentrations of C-reactive protein were < 10 mg/L and of creatinine within the reference range at the time of the PTA. Plasma concentration and activity of cathepsin S, together with its potent inhibitor cystatin C, were measured the day before and the day after the PTA. RESULTS: The increased plasma concentration and activity of cathepsin S at the time of PTA was associated with the occurrence of 6-months' restenosis of FPA, independently of established risk factors (lesion complexity, infrapopliteal run-off vessels, type of PTA, age, gender, smoking, diabetes, lipids) and of cystatin C. Plasma cystatin C concentration was not associated with restenosis and did not correlate with cathepsin S activity and concentration in the plasma. CONCLUSION: Increased level of plasma cathepsin S at the time of PTA is associated with 6-months' restenosis of PTA, independently of established risk factors.

May-Thurner syndrome: old acquaintance, new perspective : Case report.

May-Thurner syndrome (MTS) results from a frequent anatomic variant in which compression of the left common iliac vein between the body of the fifth lumbar vertebra and the pulsating right common iliac artery can cause deep venous thrombosis (DVT) of the left lower limb. While anticoagulation remains the mainstay treatment of acute DVT, catheter-directed thrombolysis combined with stenting provides a safe and effective method for relieving acute symptoms and preventing postthrombotic syndrome in patients with MTS. In this article the diagnostic and treatment methods are presented in the case report of a 65-year-old woman with MTS who suffered iliofemoral DVT. Knowledge of anatomy is crucial for understanding and recognizing MTS as well as for treating MTS with endovascular procedures.