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Peripheral Artery Disease: Epidemiology and Global Perspectives
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Peripheral Artery Disease: Epidemiology and Global Perspectives

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Vascular Medicine".

Deadline for manuscript submissions: 25 June 2024 | Viewed by 38115

Special Issue Editors

Dr. Christian-Alexander Behrendt

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Guest Editor
1. Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
2. German Institute for Vascular Research, Berlin, Germany
Interests: vascular surgery; peripheral artery disease; bypass surgery; peripheral interventions; real-world evidence; registries; outcomes research
Dr. Frederik Peters

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Guest Editor
Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
Interests: vascular medicine; cardiovascular prevention; real-world evidence; statistical analysis; epidemiology
Dr. Ulrich Rother

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Guest Editor
Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
Interests: peripheral artery disease; microcirculation; kidney transplantation; vascular imaging methods

Special Issue Information

Dear Colleagues,

Peripheral artery disease (PAD), more precisely described as peripheral arterial occlusive disease (PAOD), is one of the most important manifestations of systemic atherosclerosis. More than 200 million patients are known to be affected, and more than 500 million patients are affected by diabetes, frequently leading to vascular complications including chronic limb-threatening ischemia. Patients with PAOD exhibit worse disease-specific quality of life when compared to healthy people, and are at risk of major adverse cardiovascular and limb events. There is growing evidence for an East/West divide in disease prevalence and outcome. Moreover, striking differences between countries, reimbursement systems, and between sexes have been described previously. However, interestingly, most valid societal guidelines remain limited to consensus recommendations. For the current Topical Collection, we reach out for reports from observational and randomized studies, as well as for systematic reviews concerning the inhomogeneous diagnostics and care of patients with PAOD.

Dr. Christian-Alexander Behrendt
Dr. Frederik Peters
Dr. Ulrich Rother
Guest Editors

Manuscript Submission Information

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Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • peripheral artery disease
  • epidemiology
  • health services research
  • outcomes
  • registries
  • bypass surgery
  • peripheral endovascular intervention
  • intermittent claudication
  • chronic limb-threatening ischemia

Published Papers (15 papers)

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Editorial

Jump to: Research, Review

4 pages, 200 KiB  
Editorial
Now Is the Time to Bring a Common but Unpopular Noncommunicable Disease into Focus: Peripheral Arterial Disease Takes Limbs and Lives, but It Must Also Touch Our Hearts!
by Christian-Alexander Behrendt, Frederik Peters and Ulrich Rother
J. Clin. Med. 2022, 11(19), 5737; https://doi.org/10.3390/jcm11195737 - 28 Sep 2022
Viewed by 1400
Abstract
We have all learned a great deal from the ongoing pandemic that has already taken more than five million lives in less than three years [...] Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)

Research

Jump to: Editorial, Review

13 pages, 2873 KiB  
Article
Lower Extremity Amputation and Peripheral Revascularisation Rates in Romania and Their Relationship with Comorbidities and Vascular Care
by Stefan Ionac, Steven K. Rogers, Cosmina I. Bondor, Frank L. Bowling, Iulia Iovanca Dragoi and Mihai Ionac
J. Clin. Med. 2024, 13(1), 52; https://doi.org/10.3390/jcm13010052 - 21 Dec 2023
Cited by 1 | Viewed by 707
Abstract
(1) Background: This retrospective Romanian study aimed to calculate the rate of, and comparison between, amputation and revascularisation for patients with either cardiovascular or diabetic comorbidities. (2) Materials: In our hospital-based database, we analysed patient-level data from a series of 61 hospitals for [...] Read more.
(1) Background: This retrospective Romanian study aimed to calculate the rate of, and comparison between, amputation and revascularisation for patients with either cardiovascular or diabetic comorbidities. (2) Materials: In our hospital-based database, we analysed patient-level data from a series of 61 hospitals for 2019, which covers 44.9% of the amputation patients for that year. The national database is compiled by the national houses of insurance and was used to follow amputations and revascularisations between 2016 and 2021. (3) Results: During the six-year period, the mean number of amputations and revascularisations was 72.4 per 100,000 inhabitants per year for both groups. In this period, a decline in open-surgical revascularisation was observed from 58.3% to 47.5% in all interventions but was not statistically significant (r = −0.20, p = 0.70). The mean age of patients with amputation (hospital-based database) was 67 years. Of these patients, only 5.1% underwent revascularisation in the same hospital prior to amputation. The most common comorbidities in those undergoing amputations were peripheral arterial disease (76.8%), diabetes (60.8%), and arterial hypertension (53.5%). Most amputations were undertaken by general surgeons (73.0%) and only a small number of patients were treated by vascular surgeons (17.4%). (4) Conclusions: The signal from our data indicates that Romanian patients probably have a high risk of amputation > 5 years earlier than Western European countries, such as Denmark, Finland, and Germany. The prevalence of revascularisations in Romania is 64% lower than in the Western European countries. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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9 pages, 924 KiB  
Article
The Frequency of Primary Healthcare Contacts Preceding the Diagnosis of Lower-Extremity Arterial Disease: Do Women Consult General Practice Differently?
by Cindy P. Porras, Martin Teraa, Michiel L. Bots, Annemarijn R. de Boer, Sanne A. E. Peters, Sander van Doorn and Robin W. M. Vernooij
J. Clin. Med. 2022, 11(13), 3666; https://doi.org/10.3390/jcm11133666 - 24 Jun 2022
Cited by 2 | Viewed by 1826
Abstract
Background. Women with lower-extremity arterial disease (LEAD) are often underdiagnosed, present themselves with more advanced disease at diagnosis, and fare worse than men. Objective. To investigate to what extent potential gender differences exist in the frequency and reasons for general practitioner [...] Read more.
Background. Women with lower-extremity arterial disease (LEAD) are often underdiagnosed, present themselves with more advanced disease at diagnosis, and fare worse than men. Objective. To investigate to what extent potential gender differences exist in the frequency and reasons for general practitioner (GP) consultation six months prior to the diagnosis of LEAD, as potential indicators of diagnostic delay. Methods. Individuals older than 18 years diagnosed with LEAD, sampled from the Julius General Practitioner’s Network (JGPN), were included and compared with a reference population, matched (1:2.6 ratio) in terms of age, sex, and general practice. We applied a zero-inflated negative binomial (ZINB) regression model. Results. The study population comprised 4044 patients with LEAD (43.5% women) and 10,486 subjects in the reference population (46.3% women). In the LEAD cohort, the number of GP contacts was 2.70 (95% CI: 2.42, 3.02) in women and 2.54 (2.29, 2.82) in men. In the reference cohort, 1.77 (95% CI: 1.62, 1.94) in women and 1.63 (95% CI: 1.50, 1.78) in men. In the LEAD cohort, 21.9% of GP contacts occurred one month prior to diagnosis. In both cohorts and both sexes, the most common cause of consultation during the last month before the index date was cardiovascular problems. Conclusions. Six months preceding the initial diagnosis of LEAD, patients visit the GP more often than a similar population without LEAD, regardless of gender. Reported gender differences in the severity of LEAD at diagnosis do not seem to be explained by a delay in presentation to the GP. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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13 pages, 1812 KiB  
Article
The Incidence of Chronic Limb-Threatening Ischemia in the Midland Region of New Zealand over a 12-Year Period
by Odette Hart, Nicole Xue, Brittany Davis-Havill, Mark Pottier, Minesh Prakash, Sascha-Akito Reimann, Jasmin King, William Xu and Manar Khashram
J. Clin. Med. 2022, 11(12), 3303; https://doi.org/10.3390/jcm11123303 - 09 Jun 2022
Cited by 6 | Viewed by 2185
Abstract
The epidemiology of severe PAD, as characterized by short-distance intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI), remains undefined in New Zealand (NZ). This was a retrospective observational cohort study of the Midland region in NZ, including all lower limb PAD-related surgical and [...] Read more.
The epidemiology of severe PAD, as characterized by short-distance intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI), remains undefined in New Zealand (NZ). This was a retrospective observational cohort study of the Midland region in NZ, including all lower limb PAD-related surgical and percutaneous interventions between the 1st of January 2010 and the 31st of December 2021. Overall, 2541 patients were included. The mean annual incidence of short-distance IC was 15.8 per 100,000, and of CLTI was 36.2 per 100,000 population. The annual incidence of both conditions was greater in men. Women presented 3 years older with PAD (p < 0.001). Patients with short-distance IC had lower ipsilateral major limb amputation at 30 days compared to CLTI (IC 2, 0.3% vs. CLTI 298, 16.7%, p < 0.001). The 30-day mortality was greater in elderly patients (<65 years 2.7% vs. ≥65 years 4.4%, p = 0.049), but did not differ depending on sex (females 36, 3.7% vs. males 64, 4.1%, p = 0.787). Elderly age was associated with a worse survival for both short-distance IC and CLTI. There was a worse survival for females with CLTI. In conclusion, PAD imposes a significant burden in NZ, and further research is required in order to reduce this disparity. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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14 pages, 2215 KiB  
Article
Utilization and Regional Differences of In-Patient Services for Peripheral Arterial Disease and Acute Limb Ischemia in Germany: Secondary Analysis of Nationwide DRG Data
by Matthias Trenner, Christoph Knappich, Bianca Bohmann, Simon Heuberger, Hans-Henning Eckstein and Andreas Kuehnl
J. Clin. Med. 2022, 11(8), 2116; https://doi.org/10.3390/jcm11082116 - 11 Apr 2022
Cited by 7 | Viewed by 1946
Abstract
Background: Peripheral arterial disease (PAD) and acute limb ischemia (ALI) pose an increasing strain on health care systems. The objective of this study was to describe the German health care landscape and to assess hospital utilization with respect to PAD and ALI. Methods: [...] Read more.
Background: Peripheral arterial disease (PAD) and acute limb ischemia (ALI) pose an increasing strain on health care systems. The objective of this study was to describe the German health care landscape and to assess hospital utilization with respect to PAD and ALI. Methods: Secondary data analysis of diagnosis-related group statistics data (2009–2018) provided by the German Federal Statistical Office. Inclusion of cases encoded by the International Classification of Diseases (ICD-10) codes for PAD and arterial embolism or thrombosis. Construction of line diagrams and choropleth maps to assess temporal trends and regional distributions. Results: A total of 2,589,511 cases (median age 72 years, 63% male) were included, of which 2,110,925 underwent surgical or interventional therapy. Overall amputation rate was 17%, with the highest rates of minor (28%) and major amputations (15%) in patients with tissue loss. In-hospital mortality (overall 4.1%) increased in accordance to Fontaine stages and was the highest in patients suffering arterial embolism or thrombosis (10%). Between 2009 and 2018, the annual number of PAD cases with tissue loss (Fontaine stage IV) increased from 97,092 to 111,268, whereby associated hospital utilization decreased from 2.2 million to 2.0 million hospital days. Hospital incidence and hospital utilization showed a clustering with the highest numbers in eastern Germany, while major amputation rate and mortality were highest in northern parts of Germany. Conclusions: Increased use of endovascular techniques was observed, while hospital utilization to treat PAD with tissue loss has decreased. This is despite an increased hospital incidence. Addressing socioeconomic inequalities and a more homogeneous distribution of dedicated vascular units might be advantageous in reducing the burden of disease associated with PAD and ALI. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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9 pages, 663 KiB  
Article
Long-Term Outcomes of Extra-Anatomic Femoro-Tibial Bypass Reconstructions in Chronic Limb-Threating Ischemia
by Alexander Meyer, Evgenia Boxberger, Christian-Alexander Behrendt, Shatlyk Yagshyyev, Irina Welk, Werner Lang and Ulrich Rother
J. Clin. Med. 2022, 11(5), 1237; https://doi.org/10.3390/jcm11051237 - 24 Feb 2022
Cited by 3 | Viewed by 1896
Abstract
(1) Background: While tibial bypass surgery still plays a role in the treatment of patients with chronic limb-threatening ischemia and diabetic foot syndrome; only a few centers have recorded considerable numbers of these conditions. The current study aimed to determine contemporary practice with [...] Read more.
(1) Background: While tibial bypass surgery still plays a role in the treatment of patients with chronic limb-threatening ischemia and diabetic foot syndrome; only a few centers have recorded considerable numbers of these conditions. The current study aimed to determine contemporary practice with special focus on the performance of extra-anatomic grafting to the infrapopliteal arteries. (2) Methods: A retrospective, single-center study included patients with tibial bypass grafts from 1 January 2008 to 31 December 2019. Primary endpoints were complication rate, graft patency, amputation, overall survival, and major adverse cardiac (MACE) or limb event (MALE). The cohort was stratified by extra-anatomic vs. anatomic position. (3) Results: A total of 455 patients (31% female) with Rutherford stage 4 (12.5%) and 5/6 (69.5%) were included (thereof, 19.5% had high amputation risk according to the Wound Ischemia Foot Infection score). Autologous reconstruction was performed in 316 cases, and prosthetic reconstruction in 131 cases, with a total of 51 (11.2%) extra-anatomic grafts. Early occlusion rate was 9.0% with an in-hospital overall mortality of 2.8%. The in-hospital rate of MACE was 2.4% and of MALE, 1.5%. After one, three and five years, the primary patency of venous bypasses was 74.5%, 68.6% and 61.7%, respectively. For prosthetic grafts, this was 55.1%, 46.0%, and 38.3%, respectively (p < 0.001). The patency of extra-anatomic prosthetic grafts performed significantly better compared with anatomically positioned prosthetic grafts (log-rank p = 0.008). In multivariate analyses, diabetes (hazard ratio, HR 1.314, CI 1.023–1.688, p = 0.032), coronary artery disease (HR 1.343, CI 1.041–1.732, p = 0.023), and dialysis dependency (HR 2.678, CI 1.687–4.250, p < 0.001) were associated with lower odds of survival (4) Conclusion: In this large, single-center cohort, tibial bypass surgery demonstrated satisfactory results with overall low perioperative complication rates and long-term patency rates of 60% and 38%, respectively. Extra-anatomic bypasses represent a feasible alternative to venous grafts in terms of patency. A tailored, patient-centered approach considering predictors such as diabetes, dialysis dependency, and coronary artery disease along with prediction models may further improve the long-term results in the future. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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9 pages, 241 KiB  
Article
Distribution of Mobile Health Applications amongst Patients with Symptomatic Peripheral Arterial Disease in Germany: A Cross-Sectional Survey Study
by Kastriot Alushi, Irene Hinterseher, Frederik Peters, Ulrich Rother, Moritz S. Bischoff, Spyridon Mylonas, Eberhard Grambow, Alexander Gombert, Albert Busch, Daphne Gray, Nikolaos Konstantinou, Konstantinos Stavroulakis, Marco Horn, Hartmut Görtz, Christian Uhl, Hannes Federrath, Hans-Heinrich Trute, Thea Kreutzburg and Christian-Alexander Behrendt
J. Clin. Med. 2022, 11(3), 498; https://doi.org/10.3390/jcm11030498 - 19 Jan 2022
Cited by 18 | Viewed by 2544
Abstract
Background: Broadly available digital and mobile health applications (also known as mHealth) have recently gained increasing attention by the vascular community, but very little is known about the dissemination and acceptance of such technologies in certain target populations. The current study aimed to [...] Read more.
Background: Broadly available digital and mobile health applications (also known as mHealth) have recently gained increasing attention by the vascular community, but very little is known about the dissemination and acceptance of such technologies in certain target populations. The current study aimed to determine the user behaviour and acceptance of such digital technologies amongst patients with peripheral arterial disease (PAD). Methods: A cross-sectional survey of consecutively treated inpatients at 12 university institutions, as well as one non-university institution, was conducted. All admitted patients with symptomatic PAD were surveyed for 30 consecutive days within a flexible timeframe between 1 July and 30 September 2021. The factors associated with smartphone use were estimated via backward selection within a logistic regression model with clustered standard errors. Results: A total of 326 patients participated (response rate 96.3%), thereof 102 (34.0%) were treated for intermittent claudication (IC, 29.2% women, 70 years in median) and 198 were treated for chronic limb-threatening ischaemia (CLTI, 29.5% women, 70 years in median). Amongst all of the patients, 46.6% stated that they had not changed their lifestyle and health behaviour since the index diagnosis (four years in median), and 33.1% responded that they were not aware of the reasons for all of their medication orders. Amongst all those surveyed, 66.8% owned a smartphone (IC: 70.6%, CLTI: 64.1%), thereof 27.9% needed regular user support. While 42.5% used smartphone apps, only 15.0% used mobile health applications, and 19.0% owned wearables. One out of five patients agreed that such technologies could help to improve their healthy lifestyle. Only higher age was inversely associated with smartphone possession. Conclusions: The current survey showed that smartphones are prevalent amongst patients with peripheral arterial disease, but only a small proportion used mobile health applications and a considerable number of patients needed regular user support. Almost half of the patients did not change their lifestyle and one third were not aware of the reasons for their medication orders, emphasising room for improvement. These findings can further help to guide future projects using such applications to identify those target populations that are reachable with digital interventions. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
13 pages, 480 KiB  
Article
Diabetes Mellitus and Its Impact on Patient-Profile and In-Hospital Outcomes in Peripheral Artery Disease
by Karsten Keller, Volker H. Schmitt, Markus Vosseler, Christoph Brochhausen, Thomas Münzel, Lukas Hobohm and Christine Espinola-Klein
J. Clin. Med. 2021, 10(21), 5033; https://doi.org/10.3390/jcm10215033 - 28 Oct 2021
Cited by 13 | Viewed by 1891
Abstract
Background: In patients with peripheral artery disease (PAD), the impact of diabetes mellitus (DM) on patient-profile and adverse in-hospital events is not well investigated. Methods: The German nationwide inpatient sample 2005–2019 was used for this analysis. Hospitalized PAD patients were stratified for DM [...] Read more.
Background: In patients with peripheral artery disease (PAD), the impact of diabetes mellitus (DM) on patient-profile and adverse in-hospital events is not well investigated. Methods: The German nationwide inpatient sample 2005–2019 was used for this analysis. Hospitalized PAD patients were stratified for DM and the influence of DM on patient-profile and adverse in-hospital events was investigated. Results: Our study comprised 2,654,871 hospitalizations (54.3% aged ≥70 years, 36.7% females) of patients with PAD in Germany 2005–2019. Among these, 864,691 (32.6%) patients had DM and 76,716 (2.9%) died during hospitalization. Diabetic PAD patients revealed an aggravated cardiovascular profile (Charlson Comorbidity Index: 6.0 (5.0–8.0) vs. 4.0 (3.0–5.0), p < 0.001). PAD patients with DM showed a higher rate of in-hospital mortality (3.5% vs. 2.6%, p < 0.001), as well as major adverse cardiovascular and cerebrovascular events (MACCE, 4.7% vs. 3.3%, p < 0.001) and had more often operated with amputation surgery (16.4% vs. 9.1%, p < 0.001). DM was an independent predictor of in-hospital mortality (OR 1.077 (95%CI 1.060–1.093), p < 0.001) and MACCE (OR 1.118 (95%CI 1.103–1.133), p < 0.001). In addition, amputations were also associated with DM (OR 1.804 (95%CI 1.790–1.818)), p < 0.001). Conclusions: DM is associated with an unfavorable clinical patient-profile and higher risk for adverse events in PAD patients, including substantially increased in-hospital mortality as well as MACCE rate, and were more often associated with amputation surgeries. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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11 pages, 581 KiB  
Article
Prevalence of Peripheral Arterial Disease and Associated Vascular Risk Factors in 65-Years-Old People of Northern Barcelona
by Gabriela Gonçalves-Martins, Daniel Gil-Sala, Cristina Tello-Díaz, Xavier Tenezaca-Sari, Carlos Marrero, Teresa Puig, Raquel Gayarre, Joan Fité and Sergi Bellmunt-Montoya
J. Clin. Med. 2021, 10(19), 4467; https://doi.org/10.3390/jcm10194467 - 28 Sep 2021
Cited by 5 | Viewed by 2098
Abstract
Objective: To determine the prevalence and risk factors associated with peripheral arterial disease (PAD) in Northern Barcelona at 65 years of age. Methods: A single-center, cross-sectional study, including males and females 65 years of age, health care cardholders of Barcelona Nord. PAD was [...] Read more.
Objective: To determine the prevalence and risk factors associated with peripheral arterial disease (PAD) in Northern Barcelona at 65 years of age. Methods: A single-center, cross-sectional study, including males and females 65 years of age, health care cardholders of Barcelona Nord. PAD was defined as an ankle–brachial index (ABI) < 0.9. Attending subjects were evaluated for a history of common cardiovascular risk factors. A REGICOR score was obtained, as well as a physical examination and anthropometric measurements. Results: From November 2017 to December 2018, 1174 subjects were included: 479 (40.8%) female and 695 (59.2%) male. Overall prevalence of PAD was 6.2% (95% CI: 4.8–7.6%), being 7.9% (95% CI: 5.9–9.9%) in males and 3.8% (95% CI: 2.1–5.5%) in females. An independent strong association was seen in male smokers and diabetes, with ORs pf 7.2 (95% CI: 2.8–18.6) and 1.8 (95% CI: 1.0–3.3), respectively, and in female smokers and hypertension, with ORs of 5.2 (95% CI: 1.6–17.3) and 3.3 (95% CI: 1.2–9.0). Male subjects presented with higher REGICOR scores (p < 0.001). Conclusion: Higher-risk groups are seen in male subjects with a history of smoking and diabetes and female smokers and arterial hypertension, becoming important subgroups for our primary healthcare centers and should be considered for ABI screening programs. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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9 pages, 831 KiB  
Article
The Global Limb Anatomic Staging System (GLASS) for CLTI: Improving Inter-Observer Agreement
by Joep G. J. Wijnand, Devin Zarkowsky, Bian Wu, Steven T. W. van Haelst, Evert-Jan P. A. Vonken, Thomas A. Sorrentino, Zachary Pallister, Jayer Chung, Joseph L. Mills, Martin Teraa, Marianne C. Verhaar, Gert J. de Borst and Michael S. Conte
J. Clin. Med. 2021, 10(16), 3454; https://doi.org/10.3390/jcm10163454 - 04 Aug 2021
Cited by 15 | Viewed by 4549
Abstract
Objective: The 2020 Global Vascular Guidelines aim at improving decision making in Chronic Limb-Threatening Ischemia (CLTI) by providing a framework for evidence-based revascularization. Herein, the Global Limb Anatomic Staging System (GLASS) serves to estimate the chance of success and patency of arterial pathway [...] Read more.
Objective: The 2020 Global Vascular Guidelines aim at improving decision making in Chronic Limb-Threatening Ischemia (CLTI) by providing a framework for evidence-based revascularization. Herein, the Global Limb Anatomic Staging System (GLASS) serves to estimate the chance of success and patency of arterial pathway revascularization based on the extent and distribution of the atherosclerotic lesions. We report the preliminary feasibility results and observer variability of the GLASS. GLASS is a part of the new global guideline and posed as a promising additional tool for EBR strategies to predict the success of lower extremity arterial revascularization. This study reports on the consistency of GLASS scoring to maximize inter-observer agreement and facilitate its application. Methods: GLASS separately scores the femoropopliteal (FP) and infrapopliteal (IP) segment based on stenosis severity, lesion length and the extent of calcification within the target artery pathway (TAP). In our stepwise approach, we used two angiographic datasets. Each following step was based on the lessons learned from the previous step. The primary outcome was inter-observer agreement measured as Cohen’s Kappa, scored by two (step 1 + 2) and four (step 3) blinded and experienced observers, respectively. Steps 1 (n = 139) and 2 (n = 50) were executed within a dataset of a Dutch interventional RCT in CLTI. Step 3 (n = 100) was performed in randomly selected all-comer CLTI patients from two vascular centers in the United States. Results: In step 1, kappa values were 0.346 (FP) and 0.180 (IP). In step 2, applied in the same dataset, the use of other experienced observers and a provided TAP, resulted in similar low kappa values 0.406 (FP) and 0.089 (IP). Subsequently, in step 3, the formation of an altered stepwise approach using component scoring, such as separate scoring of calcification and adding a ruler to the images resulted in kappa values increasing to 0.796 (FP) and 0.730 (IP). Conclusion: This retrospective GLASS validation study revealed low inter-observer agreement for unconditioned scoring. A stepwise component scoring provides acceptable agreement and a solid base for further prospective validation studies to investigate how GLASS relates to treatment outcomes. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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13 pages, 1149 KiB  
Article
Sex Disparities in Long-Term Mortality after Paclitaxel Exposure in Patients with Peripheral Artery Disease: A Nationwide Claims-Based Cohort Study
by Christian-Alexander Behrendt, Art Sedrakyan, Konstantinos Katsanos, Joakim Nordanstig, Jenny Kuchenbecker, Thea Kreutzburg, Eric A. Secemsky, Eike Sebastian Debus, Ursula Marschall and Frederik Peters
J. Clin. Med. 2021, 10(13), 2978; https://doi.org/10.3390/jcm10132978 - 02 Jul 2021
Cited by 5 | Viewed by 3547
Abstract
Background: Randomized controlled trials have reported excess mortality in patients treated with paclitaxel-coated devices versus uncoated devices, while observational studies have reported the opposite. This study aims to determine the underlying factors and cohort differences that may explain these opposite results, with specific [...] Read more.
Background: Randomized controlled trials have reported excess mortality in patients treated with paclitaxel-coated devices versus uncoated devices, while observational studies have reported the opposite. This study aims to determine the underlying factors and cohort differences that may explain these opposite results, with specific focus on sex differences in treatment and outcomes. Methods: Multicenter health insurance claims data from a large insurance fund, BARMER, were studied. A homogeneous sample of patients with an index of endovascular revascularization for symptomatic peripheral arterial occlusive disease between 2013 and 2017 was included. Adjusted logistic regression and Cox regression models were used to determine the factors predicting allocation to paclitaxel-coated devices and sex-specific 5-year all-cause mortality, respectively. Results: In total, 13,204 patients (54% females, mean age 74 ± 11 years) were followed for a median of 3.5 years. Females were older (77 vs. 71 years), and had less frequent coronary artery disease (23% vs. 33%), dyslipidemia (44% vs. 50%), and diabetes (29% vs. 41%), as well as being less likely to have a history of smoking (10% vs. 15%) compared with males. Mortality differences were mostly attributable to the female subgroup who were revascularized above the knee (hazard ratio, HR 0.78, 95% CI: 0.64–0.95), while no statistically significant differences were observed in males. Conclusions: This study found that females treated above the knee benefited from paclitaxel-coated devices, while no differences were found in males. Ongoing and future registries and trials should take sex disparities into account. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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8 pages, 233 KiB  
Article
The Association of Periodontitis and Peripheral Arterial Occlusive Disease in a Prospective Population-Based Cross-Sectional Cohort Study
by Nicole Jacobi, Carolin Walther, Katrin Borof, Guido Heydecke, Udo Seedorf, Ragna Lamprecht, Thomas Beikler, Sebastian E. Debus, Christoph Waldeyer, Stefan Blankenberg, Renate B. Schnabel, Ghazal Aarabi and Christian-Alexander Behrendt
J. Clin. Med. 2021, 10(10), 2048; https://doi.org/10.3390/jcm10102048 - 11 May 2021
Cited by 4 | Viewed by 2477
Abstract
Objectives: Peripheral arterial occlusive disease (PAOD) and periodontitis are common chronic diseases, which together affect almost 1 billion people worldwide. There is growing evidence suggesting a relationship between chronic inflammatory conditions such as periodontitis and PAOD. This study aims to determine an association [...] Read more.
Objectives: Peripheral arterial occlusive disease (PAOD) and periodontitis are common chronic diseases, which together affect almost 1 billion people worldwide. There is growing evidence suggesting a relationship between chronic inflammatory conditions such as periodontitis and PAOD. This study aims to determine an association between both entities using high quality research data and multiple phenotypes derived from an epidemiological cohort study. Design: This population-based cross-sectional cohort study included data from 3271 participants aged between 45 and 74 years enrolled in the Hamburg City Health Study (NCT03934957). Material & Methods: An ankle-brachial-index below 0.9, color-coded ultrasound of the lower extremity arteries, and survey data was used to identify participants with either asymptomatic or symptomatic PAOD. Periodontitis data was collected at six sites per tooth and included the probing depth, gingival recession, clinical attachment loss, and bleeding on probing index. Multivariate analyses using logistic regression models were adjusted for variables including age, sex, smoking, education, diabetes, and hypertension. Results: The baseline characteristics differed widely between participants neither affected by periodontitis nor PAOD vs. the group where both PAOD and severe periodontitis were identified. A higher rate of males, higher age, lower education level, smoking, diabetes, and cardiovascular disease was observed in the group affected by both diseases. After adjusting, presence of severe periodontitis (odds ratio 1.265; 97.5% CI 1.006–1.591; p = 0.045) was independently associated with PAOD. Conclusion: In this cross-sectional analysis of a prospective cohort study, an independent association between periodontitis and PAOD was revealed. The results of the current study emphasize a potential for preventive medicine in an extremely sensitive target population. Future studies should determine the underlying factors modifying the relationship between both diseases. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)

Review

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11 pages, 1000 KiB  
Review
Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review
by Gerhard Ruemenapf, Stephan Morbach and Martin Sigl
J. Clin. Med. 2022, 11(8), 2155; https://doi.org/10.3390/jcm11082155 - 12 Apr 2022
Cited by 15 | Viewed by 3084
Abstract
Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is [...] Read more.
Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible (“too late”, “too sick”, “no technical option”). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. Methods: The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. Results: If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. Conclusions: Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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9 pages, 1162 KiB  
Review
Treatment of Peripheral Arterial Occlusive Disease around the Globe: Malta
by Anthony Pio Dimech, Samuel Anthony Galea, Kevin Cassar and Matthew Joe Grima
J. Clin. Med. 2021, 10(24), 5747; https://doi.org/10.3390/jcm10245747 - 08 Dec 2021
Cited by 2 | Viewed by 2559
Abstract
Introduction: Malta is a small island in the middle of the Mediterranean with a population of 514,564 inhabitants and is served by one public tertiary hospital, Mater Dei Hospital. The Vascular unit was set up in 2007. The aim of this review is [...] Read more.
Introduction: Malta is a small island in the middle of the Mediterranean with a population of 514,564 inhabitants and is served by one public tertiary hospital, Mater Dei Hospital. The Vascular unit was set up in 2007. The aim of this review is to analyse the work related to peripheral arterial occlusive disease (PAOD) in Malta with an in-depth focus on amputations and revascularisation procedures since the introduction of the Vascular unit. Method: Various sources of data have been interrogated to address this subject. Population and prevalence data on obesity and type II diabetes mellitus from 2003 to 2019 was obtained from the National Statistics Office, the World Health Organization, and the International Diabetes Federation, respectively. The Maltese Vascular Register (MaltaVasc), and in-hospital reports from 2003 to 2019 was used to obtain data on revascularisation procedures, major amputations and minor amputation rates in Malta. Results: Malta has one of the highest rates of obesity in Europe. In 2015, the prevalence rate was 30.6%. Similarly, data from the International Diabetes Federation Atlas showed that the prevalence rate of T2DM among adults was 14% in 2017. There was a mean of 33 open/hybrid procedures per 100,000 population (28–38, 95% confidence interval) between 2005 and 2009 and a mean of 57 endovascular procedures per 100,000 population (46–68, 95% confidence interval) during the same time-period. From 2009 to 2019, there was a mean of 16 major amputations and 78 minor amputations per 100,000 population. Conclusion: A significant reduction in major amputation rates with an increase in minor amputation rates and revascularisation rates has been noted since the establishment of the vascular unit in Malta. During this period, there has been an increase in prevalence in obesity and T2DM together with an aging population. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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11 pages, 465 KiB  
Review
A Divide between the Western European and the Central and Eastern European Countries in the Peripheral Vascular Field: A Narrative Review of the Literature
by Endre Kolossváry, Martin Björck and Christian-Alexander Behrendt
J. Clin. Med. 2021, 10(16), 3553; https://doi.org/10.3390/jcm10163553 - 12 Aug 2021
Cited by 8 | Viewed by 2213
Abstract
Thirty years after the transition period, starting from 1989, Central and Eastern European countries (CEECs), representing one-fifth of the entire European population, share many historical, societal, political, economic, and cultural characteristics. Although accumulating data on coronary heart diseases and cerebrovascular diseases support these [...] Read more.
Thirty years after the transition period, starting from 1989, Central and Eastern European countries (CEECs), representing one-fifth of the entire European population, share many historical, societal, political, economic, and cultural characteristics. Although accumulating data on coronary heart diseases and cerebrovascular diseases support these observations, in the case of peripheral arterial disease, data are scarce. The present review attempts to summarise the shreds of data that may highlight a divide in this field between CEECs and Western European countries. Disparities in risk factors and peripheral vascular care across Europe seem to be tangible and can be seen as a signal of existing differences. Improvements in research and development and the collection and cross-border share of scientific data are essential to initiate and facilitate convergence in this field. Full article
(This article belongs to the Special Issue Peripheral Artery Disease: Epidemiology and Global Perspectives)
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