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PubMed2006

Endovascular treatment of peripheral vascular disease.

An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.

Aneurysm↗
PubMed2000

A comparison of bolus chasing and static digital subtraction arteriography in peripheral vascular disease.

The purpose of this study was to compare the techniques of bolus chasing angiography (BCA) and digital subtraction angiography (DSA). 75 patients with symptomatic atherosclerotic peripheral vascular disease were randomly assigned to have their lower limbs examined by BCA or DSA. Dose-area product (DAP), time of examination and dose of contrast medium were measured. Staff doses were measured with personal electronic dosemeters. Image quality was assessed from the laser printed images. DSA produced better images of vessels below the inguinal ligament, particularly the crural vessels (1/76 vs 17/74 non-diagnostic examinations, p < 0.00001) but at a higher DAP (median 53.8 Gy cm2 vs 18.9 Gy cm2, p < 0.01). Contrast medium dose was higher with BCA (29.8 gI2 vs 25.3 gI2, p < 0.01). Staff doses per unit patient dose were 2.3-3.3 times higher with BCA than DSA. Because of the poor long-term prognosis of patients with peripheral vascular disease, the improved image quality obtained by DSA justifies the increased radiation dose.

Aged↗
PubMed1989

Therapeutic, hemodynamic, and metabolic effects of hyperbaric oxygenation in peripheral vascular disease.

Hyperbaric oxygen therapy (HBT) consists of inhaling 100% oxygen under pressure exceeding atmospheric pressure. Patients with various degrees of peripheral vascular disease (stages II, III, and IV according to Fontaine's classification) were treated with HBT. Clinical symptoms improved in 70%. Ankle/brachial index increased by more than 0.10 in 47%. Photoplethysmographic pulse appearance has been detected in roughly one third of patients. Transcutaneous oxygen tension did not, however, improve significantly. Plasma malondialdehyde (MDA) was evaluated as a marker of lipid peroxidation, possibly influenced by hyperbaric oxygen. Surprisingly, the authors found that MDA levels decreased after HBT, probably as a result of the activation of antioxidant systems. These results show that HBT represents a useful approach in the treatment of peripheral vascular disease, since it improves clinical and hemodynamic parameters, with no potentially harmful side effects, such as enhanced lipid peroxidation, at least in the short term.

Aged↗
PubMed1996

Intraarterial pressure measurements during angiographic evaluation of peripheral vascular disease: techniques, interpretation, applications, and limitations.

Many operative and percutaneous procedures are available for the treatment of occlusive disease involving the lower-extremity arterial system. Peripheral vascular disease involving the aorta and lower-extremity vessels usually is attributable to atherosclerosis. The lower-extremity arterial supply is divided segmentally into the inflow (aortoiliac) and outflow (femoropopliteal and tibioperoneal) vessels. Given the length of the lower-extremity vascular system, the propensity for multifocal disease, and the possibility of a nonvascular cause for a patient's symptoms, both localization of disease in arterial segments and determination of the hemodynamic impact of diseased sites are important for judicious treatment planning. This review focuses on the use of intraarterial pressure measurement as an adjunct to angiography and intravascular intervention in evaluating the significance of arterial occlusive disease in lower-extremity arteries.

Angiography↗
PubMed2004

The effect of pancreas transplantation on peripheral vascular disease complications.

BACKGROUND: We sought to determine whether pancreas transplantation reduced the incidence of peripheral vascular complications in diabetics with renal insufficiency. METHODS: A retrospective single-center review was done of 36 kidney-pancreas (KP) and 88 kidney-alone (KA) recipients with a diagnosis of diabetes and end-stage renal disease (ESRD) transplanted between May 1997 and July 2002. Risk factors studied included type of transplant, age, gender, history of smoking, coronary artery disease, hypertension, and peripheral vascular disease (PVD). The endpoint was first peripheral vascular event occurring after transplantation, defined as either an amputation or revascularization procedure. RESULTS: The mean age of the cohort was 51 +/- 9 years, 64% of patients were of male gender, 20% with a history of smoking, 98% with hypertension, 15% with coronary artery disease (CAD), and 12% with a history of PVD. With a median follow-up of 45 months (12 to 79 months), 3/36 (8%) of KP recipients suffered a PVD complication, compared to 10/88 (11%) of KA recipients (P = NS). Similarly, age, gender, a past history of smoking, CAD, and hypertension were not predictive of PVD complications. Five of 15 patients (33%) with a pretransplant history of PVD suffered a postoperative PVD event compared to only 8 of 109 patients (7%) with no prior history of PVD (P =.008). CONCLUSIONS: Restoration of normoglycemia by pancreas transplantation did not reduce the risk of PVD complications in diabetics with renal failure. A pretransplant history of PVD was the only risk factor associated with posttransplant PVD events.

Adult↗
PubMed1990

Efficacy of home health care in patients with peripheral vascular disease.

This investigation was designed to study the effects of home health care (HHC) on patients who have been hospitalized with peripheral vascular disease. For a patient to have HHC, the patient had to have a defined wound, educational needs, or both. Sixty patients, 30 with HHC and 30 without, were contacted approximately 30 days after their last hospital discharge. The 30 patients with HHC were deemed to be at increased risk because of multisystem disease with multiple medications, infirmity, early senility, and often complex wounds. In a prospective fashion, each patient was interviewed by either a registered nurse or medical student using a standardized data collection form. The following issues were assessed: incidence of postoperative complications, knowledge of the patient of his or her disease, compliance with medication (knowledge of, regular use), incidence of readmission, and unscheduled clinic or emergency department visits. Upon statistical analysis using the two-sample t-test and Pearson chi-square test, no significant differences were found between the two groups in terms of complications, compliance, or patient education. HHC, therefore, was found to be helpful to patients with peripheral vascular disease. In our study, the use of HHC made the risk of complications in a group of patients with defined teaching needs and wound care needs equal to that in a group with no such defined needs on discharge from the hospital.

Chi-Square Distribution↗
PubMed1994

Exercise-induced changes in oxygen saturation in the calf muscles of elderly subjects with peripheral vascular disease.

This study noninvasively measured hemoglobin oxygen saturation in young (n = 6, 28 +/- 6 yrs), old healthy (n = 20, 68 +/- 7 yrs), and old subjects with mild peripheral vascular disease (PVD) (n = 8, 72 +/- 4 yrs). Hemoglobin oxygen saturation was measured as the difference in absorption at 760 and 850 nm light using near-infrared spectroscopy (NIRS). The lateral soleus muscle was studied after mild plantar flexion exercise. The time constant of recovery of oxygen saturation (HBO2Tc) was 21.5 +/- 8.6 s in young, 26.9 +/- 13.5 s in old healthy subjects. PVD subjects had HbO2Tc values of 104.4 +/- 41.1 s in their "bad" leg and 57.6 +/- 42.2 s in their "good" leg. The correlation between HbO2Tc and ankle-arm pressures was significant (r2 = .63, p < .001). Six younger normal, five older normal, and seven PVD subjects also performed a progressive walking test. Normal subjects completed the test without difficulty, and older normal subjects showed progressive deoxygenation. PVD subjects complained of calf pain (4 out of 5 were able to finish) and showed near-maximal deoxygenation throughout the test. In summary, NIRS measurements show promise as a method of evaluating the kinetics of oxygen saturation, particularly in patients with mild peripheral vascular disease.

Adult↗
PubMed1984

Whole blood and red cell ATP content in patients with peripheral vascular disease: the effect of cigarette smoking and oxpentifylline.

The relationship between erythrocyte ATP content and the presence of atherosclerotic peripheral occlusive vascular disease was investigated. In 20 elderly patients with severe peripheral vascular insufficiency (10 male, 10 female; age 68.8 +/- 12.5 years; Mean +/- SD) the mean erythrocyte ATP content was 1.57 +/- 0.16 mmol/litre. In a sex and age matched group (69.1 +/- 9.6 years) with no signs or symptoms of peripheral or myocardial ischaemia, erythrocyte ATP content did not differ significantly (1.49 +/- 0.29 mmol/litre). In young healthy volunteers, there was no difference in erythrocyte ATP content between males and females or between cigarette smokers and non-smokers, nor were the values for the young group different from those obtained from the elderly patients. The effect of oxpentifylline administration on erythrocyte ATP levels in patients with peripheral vascular disease was also studied. Administration of oxpentifylline (1.6 g per day in divided doses) over 7 days had no effect on erythrocyte ATP content in 10 patients (5 male, 5 female) with ischaemic lower limbs. These results suggest that measurement of erythrocyte ATP content is unlikely to be a useful index in the assessment of peripheral vascular disease.

Adenosine Triphosphate↗
PubMed1995

The prevalence of peripheral vascular disease in familial hypercholesterolaemia.

OBJECTIVES: In patients with familial hypercholesterolaemia (FH), the prevalence of haemodynamically significant peripheral vascular disease (PVD) was measured in relation to lipoproteins, general risk factors and the presence of coronary artery disease (CAD). DESIGN: A case control study. SETTING: The outpatient lipid clinic of a university hospital (tertiary referral centre). SUBJECTS: Patients with heterozygous FH [n = 68; age 45.8 +/- 11.6 years; untreated LDL-cholesterol 9.2 +/- 2.0 mmol L-1] were compared with control subjects matched for gender, age, weight, smoking and presence of hypertension [n = 27; age 44.0 years; LDL-cholesterol 3.8 +/- 1.3 mmol L-1]. MAIN OUTCOME MEASURES: PVD was assessed during cholesterol-lowering treatment using ankle/arm blood pressure ratios and analyses of Doppler-derived blood flow velocities in the femoral artery at rest and during reactive hyperaemia. The diagnosis of CAD was assessed clinically. RESULTS: Haemodynamically significant PVD was found in 21 (31%) FH patients and in one (3.7%) control subject, predominantly localized in the femoro-popliteal vessels. CAD was present in 30 (44.1%) FH patients and in one (3.7%) control subject. PVD could be demonstrated in 50% of FH patients with CAD [relative risk 3.2 (95% CI 1.4-7.2)] and in 19% as the first manifestation of vascular disease. Males and females were equally affected. Mean arterial blood pressure of FH patients with PVD was higher compared to FH patients without PVD. CONCLUSIONS: Haemodynamically significant PVD appears to be more prevalent in FH patients than is generally assumed, especially in those with CAD. A relation with lipoprotein levels could not be demonstrated.

Adult↗
PubMed1993

Symptomatic peripheral vascular disease: selection of imaging parameters and clinical evaluation with MR angiography.

In the first phase of this study, seven healthy subjects underwent examination with two-dimensional time-of-flight (TOF) magnetic resonance (MR) angiography to develop a protocol for evaluation of peripheral arterial vasculature from the infrarenal aorta to the foot. In the second phase, 73 patients with symptomatic peripheral vascular disease underwent examination with both conventional contrast material-enhanced arteriography and two-dimensional TOF MR angiography to evaluate the clinical usefulness of MR angiography. Postinterventional and intraoperative angiography or direct surgical exploration was the standard of reference. In 32 patients, discrepancies occurred between findings on arteriograms and those on MR angiograms; most of these discrepancies were caused by improved depiction of runoff vessels on MR angiograms. The demonstration with MR angiography of blood vessels not seen on conventional arteriograms, unidentified stenoses, or misidentified blood vessels altered surgical management in 12 patients (16%). Metal-clip artifacts obscured clinically important disease on MR angiograms in two patients. It is concluded that two-dimensional TOF MR angiography is very useful in preoperative assessment of patients with severe peripheral vascular disease.

Adult↗
PubMed2004

Pharmacological revascularisation in coronary and peripheral vascular disease.

Therapeutic angiogenesis is a novel approach to the treatment of ischaemic or occlusive coronary and peripheral vascular disease. The therapeutic concept is based on the restoration of distal blood flow by the enlargement of existing vessels and tissue perfusion by the induction of new capillaries. Initial studies have focused on the direct application of endothelial growth factors, vascular endothelial growth factor and fibroblast growth factor, or the delivery of genes using either a plasmid or adenoviral vector. Recently, new angiogenic agents such as hypoxia inducible factor-1alpha, fibroblast growth factor-4, Del-1 and hepatocyte growth factor have entered clinical testing. Moreover, stem-cell therapy or factors mobilising bone marrow progenitor cells have provided evidence for a new avenue for therapeutic angiogenesis. Numerous preclinical studies and several initial clinical trials have provided encouraging data in support of the feasibility of promoting biological revascularisation by the administration of angiogenic factors or cells.

Angiogenesis Inducing Agents↗
PubMed1993

Neuropsychological function in peripheral vascular disease amputee patients.

Approximately 75% of major lower-extremity amputations are the result of peripheral vascular disease (PVD). Factors that predispose a patient to PVD (smoking, hyperlipidemia, diabetes mellitus) are also risk factors for the development of cerebrovascular disease, which could adversely affect rehabilitation. The purpose of this study was to test the hypothesis that cognitive deficits are present in amputee patients with PVD. Fourteen patients with lower-extremity amputations secondary to PVD (4 women, 10 men; mean age = 67.4 years) were recruited from a tertiary-care center for physical rehabilitation. Fourteen community-dwelling healthy volunteers (9 women, 5 men; mean age = 69.9 years) served as age-matched and education-matched controls. To assess a broad range of cognitive function, we administered standard neuropsychological tests of memory and learning, language, praxis, visuospatial skills, and abstract reasoning. PVD patients performed significantly more poorly on certain measures of psychomotor speed (Wechsler Adult Intelligence Scale-Revised Digit Symbol subtest) and problem solving/abstract reasoning (Modified Card Sorting Test) relative to controls (using the Bonferroni correction for multiple comparisons, p < .002). There were trends toward poorer patient performance on certain measures of oral fluency, concentration, reasoning, and visuoperceptual organization and constructional skills (p < .01). We propose that these cognitive deficits may be the result of unrecognized concomitant cerebrovascular disease in PVD patients and are part of a generalized pattern of vascular disease. Future research should control affective factors such as stress or depression surrounding amputation and attempt to identify the etiologic or demographic factors that are associated with neuropsychological deficits in patients with PVD.

Age Factors↗
PubMed1981

The value of electrocardiogram monitoring during treadmill testing for peripheral vascular disease.

In evaluating the arterial hemodynamics of the lower extremities in patients with peripheral vascular disease, the treadmill exercise test offers useful information concerning the peripheral circulation. The addition of electrocardiographic (EKG) monitoring during the treadmill examination provides a method of estimating the effectiveness of coronary circulation. In three groups of patients studied, the results demonstrated that EKG monitoring during the treadmill exercise test will reveal previously unsuspected arrhythmias and ischemia. Thus the safety of the patient is enhanced. In patients followed through the operative period, there was a high correlation between exercise-induced EKG changes and perioperative cardiac problems. The value of EKG monitoring during treadmill testing is clear and offers predictive information to the surgeon contemplating a revascularization procedure.

Arrhythmias, Cardiac↗
PubMed1987

A multicenter double blind controlled study of lipo-PGE1, PGE1 incorporated in lipid microspheres, in peripheral vascular disease secondary to connective tissue disorders.

Lipo-PGE1 is a drug preparation of PGE1 (prostaglandin E1) incorporated in lipid microspheres similar in properties to liposomes. A multicenter, placebo controlled, double blind test of lipo-PGE1 was carried out in patients with severe peripheral vascular disease secondary to diffuse connective tissue disorders. A total of 135 patients received a 90 min intravenous infusion of either 10 micrograms lipo-PGE1 or placebo every day for 4 weeks. A significant improvement was noted in the lipo-PGE1 group compared with the placebo group in the final overall improvement of peripheral vascular disease (p less than 0.001) and in the healing of ulcers (p less than 0.01), whereas, there was no difference in Raynaud's syndrome between the 2 groups. Side effects in the lipo-PGE1 group were few and were no different from controls. These results indicate that lipo-PGE1 at a low dose is beneficial in the treatment of peripheral vascular disease, and that lipid microspheres are useful as a drug delivery system for such purposes.

Adolescent↗
PubMed2003

Peripheral vascular disease in Type 2 diabetic Chinese patients: associations with metabolic indices, concomitant vascular disease and genetic factors.

AIMS: Conventional and genetic risk factors have been reported to play a role in the pathogenesis of vascular disease, but do not explain the lower burden of cardiac and peripheral vascular disease (PVD) in Chinese compared with Caucasians. The role of renin-angiotensin system (RAS) gene polymorphisms and conventional vascular risk factors has not been determined. METHODS: A total of 3097 Chinese diabetic subjects were screened for PVD, which was identified in 194 of the 2967 patients with Type 2 diabetes. Biochemical parameters and the genotype and allele frequencies of three RAS gene polymorphisms, the angiotensin-converting enzyme (ACE) insertion/deletion, angiotensinogen (AGT) M235T and angiotensin II type 1 receptor (AT1R) A1166C polymorphisms were then compared between the PVD patients and 1046 age, gender and diabetes duration-matched patients without PVD. RESULTS: PVD identified in 6.5% was associated with significantly worse glycaemic control, lipid profile and renal function. Smoking was more common, as were the other macro- and microvascular diseases. The prevalence of hypertension was similar between the groups, yet diastolic blood pressure was slightly lower in the PVD group. The ACE D allele was significantly more frequent in patients with PVD compared with the matched diabetic controls (38.1 vs. 29.8%, P = 0.039). No differences in the AT1R or AGT polymorphisms were observed. CONCLUSIONS: PVD was associated with a worse metabolic profile and greater concomitant vascular disease than controls. The ACE I/D polymorphism was associated with PVD in these Type 2 diabetic patients.

Aged↗
PubMed1983

The utility of digital subtraction arteriography in peripheral vascular disease.

Digital subtraction angiography (DSA), whether used in conjunction with intravenous or intraarterial injection techniques, has an established role in evaluation of peripheral vascular disease. Use of DSA can reduce the time, cost, and patient discomfort of the standard arteriographic study. While it is limited by field size and patient cooperation in some instances, the utility of noninvasive imaging using intravenous DSA and the added anatomic detail of intraarterial DSA for roadmapping and delineation of small distal vessels provide the basis for future integration of standard arteriographic and DSA methods in assessment of peripheral vascular disease.

Aged↗
PubMed2002

UKPDS 59: hyperglycemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes.

OBJECTIVE: To determine the role of hyperglycemia in prospective analyses of peripheral vascular disease (PVD) in type 2 diabetes, taking into account other potential risk factors. RESEARCH DESIGN AND METHODS: Potential risk factors for the development of PVD were examined in 3,834 of 5,102 individuals enrolled in the U.K. Prospective Diabetes Study (UKPDS) without PVD at diagnosis of diabetes, followed for 6 years, and for whom relevant data were available. PVD was defined as two of the following: ankle-arm blood pressure index < 0.8, absence of both dorsalis pedis and posterior tibial pulses to palpation in one or both legs, and intermittent claudication. Logistic regression was used to estimate the association between potential risk factors measured 3-4 months after diagnosis of diabetes and incident PVD. The prevalence of PVD at 3-year intervals to 18 years was determined. RESULTS: Hyperglycemia, assessed as HbA(1c), was associated with an increased risk for incident PVD, independent of other risk factors including age, increased systolic blood pressure, reduced HDL cholesterol, smoking, prior cardiovascular disease, peripheral sensory neuropathy, and retinopathy. Each 1% increase in HbA(1c) was associated with a 28% increased risk of PVD (95% CI 12-46), and each 10-mmHg increase in systolic blood pressure with a 25% increase in risk (95% CI 10-43). CONCLUSIONS: Hyperglycemia, as well as smoking, dyslipidemia, and blood pressure are potentially modifiable risk factors for the development of PVD.

Adult↗