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Vascular ageing (vascular ageing) is the deterioration of arterial structure and function which occurs naturally with age, and which can be accelerated with disease. Measurements of vascular ageing are emerging as markers of cardiovascular risk, with potential applications in disease diagnosis and prognosis, and for guiding treatments. However, vascular ageing is not yet routinely assessed in clinical practice. A key step towards this is the development of technologies to assess vascular ageing. In this Roadmap, experts discuss several aspects of this process, including: measurement technologies; the development pipeline; clinical applications; and future research directions. The Roadmap summarises the state of the art, outlines the major challenges to overcome, and identifies potential future research directions to address these challenges., (Creative Commons Attribution license.)

Patients attending vascular or diabetic foot clinics commonly have atherosclerotic disease, are at increased risk of cardiovascular disease (CVD), merit high-intensity lipid-modifying therapy to maintain secondary prevention targets and are often sub optimally treated in primary care. We set out to assess the impact of a pharmacist led lipid optimisation clinic in these patients in an area with high levels of social deprivation., Methods: We performed a clinical cohort study to assess the effectiveness of a pharmacist led clinic to optimise lipid lowering therapy by optimising of statin therapy and commencing additional lipid lowering therapy if applicable with monitoring of blood lipid profiles., Results: Of the 216 patients (166 [77%] on statins) triaged by the pharmacist, 175 (81%) had non-high-density lipoprotein (non-HDL) cholesterol levels above the target value of 97 mg/dL (2.5 mmol/L) with a mean non-HDL cholesterol level of 135.73 mg/dL (3.51 mmol/L). Pre optimisation by the prescribing clinical pharmacist 41/216 (19%) patients were at target with a mean non-HDL cholesterol of 135.5 mg/dL improving to 92/137 (67%) patients achieving the target non-HDL cholesterol level with a mean post optimisation non-HDL cholesterol of 94.35 mg/dL (2.44 mmol/L), odds ratio (OR) for being at target 8.67 (95% CI 5.30-14.20). The calculated low-density lipoprotein cholesterol levels (Friedewald) demonstrated a mean reduction of 35.19 (95% CI 29.23-41.38) mg/dL (0.91 [95% CI 0.76-1.07] mmol/L). Proportion on high intensity statin increased from 65 out of 166 (39%) to 129 of 170 (76%) at follow up (OR 4.89 [3.06-7.82]), equivalent to an number needed to treat = 3., Conclusions: A pharmacist led service in undertreated and clinically challenging vascular and diabetic foot patients in an area of high social deprivation produced significant improvements in utilization of high intensity statin and other lipid lowering therapies and attainment of lipid goals., Competing Interests: Declarations of competing interest None, (Copyright © 2024. Published by Elsevier Inc.)

Photoplethysmography is a key sensing technology which is used in wearable devices such as smartwatches and fitness trackers. Currently, photoplethysmography sensors are used to monitor physiological parameters including heart rate and heart rhythm, and to track activities like sleep and exercise. Yet, wearable photoplethysmography has potential to provide much more information on health and wellbeing, which could inform clinical decision making. This Roadmap outlines directions for research and development to realise the full potential of wearable photoplethysmography. Experts discuss key topics within the areas of sensor design, signal processing, clinical applications, and research directions. Their perspectives provide valuable guidance to researchers developing wearable photoplethysmography technology., (Creative Commons Attribution license.)

Methods: This was an open, multicentre, randomized controlled trial. Patients with intermittent claudication attending vascular surgery outpatient clinics were randomized (1:1) to receive either neuromuscular electrical stimulation (NMES) or not in addition to local standard care available at study centres (best medical therapy alone or plus supervised exercise therapy (SET)). The objective of this trial was to investigate the clinical efficacy of an NMES device in addition to local standard care in improving walking distances in patients with claudication. The primary outcome was change in absolute walking distance, measured by a standardized treadmill test at 3 months. Secondary outcomes included intermittent claudication (IC) distance, adherence, quality of life, and haemodynamic changes., Results: Of 200 participants randomized, 160 were included in the primary analysis (intention to treat, Tobit regression model). The square root of absolute walking distance was analysed (due to a right-skewed distribution) and, although adjunctive NMES improved it at 3 months, no statistically significant effect was observed. SET as local standard care seemed to improve distance compared to best medical therapy at 3 months (3.29 units; 95 per cent c.i., 1.77 to 4.82; P < 0.001). Adjunctive NMES improved distance in mild claudication (2.88 units; 95 per cent c.i., 0.51 to 5.25; P = 0.02) compared to local standard care at 3 months. No serious adverse events relating to the device were reported., Conclusion: Supervised exercise therapy is effective and NMES may provide further benefit in mild IC.This trial was supported by a grant from the Efficacy and Mechanism Evaluation Program, a Medical Research Council and National Institute for Health and Care Research partnership. Trial registration: ISRCTN18242823., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Introduction: Shared decision making (SDM) refers to patients and health care professionals working together to reach a decision about treatment/care. In abdominal aortic aneurysm (AAA) treatment options are influenced by patients' clinical characteristics, their preferences, and potential trade-offs between alternative interventions. This is a prime example of where SDM is essential to ensure the right decision is made for the right patient, yet we have little understanding of what happens in practice. This study explored patient experiences to understand SDM practice in AAA surgery., Methods: We used a qualitative approach to describe, and identify improvements to, current treatment decision making in abdominal aortic aneurysm (AAA) surgery. Two groups of patients were interviewed: those at the point of discussing treatment options (with corresponding digitally recorded consultation data) and following surgical intervention from one hospital. Framework analysis was used., Results: Fifteen patients were interviewed, seven at the point of discussing treatment options and eight following surgical intervention. Timing, format and sources of information, verbal framing of interventions and level of patient engagement were key themes. Four areas for improvement were identified: earlier provision and more detailed written information along with signposting to quality on-line information; both intervention options, risks, benefits, and consequences, were not always discussed; some clinicians were somewhat directive in the decision-making process; and patients' treatment values/preferences were not explored-the only example was in one of the eight recorded consultations. Patients could feel overwhelmed by the information and decision and fearful of the impending surgery., Conclusions: More emphasis should be placed on the provision of full information and the exploration of patient values and preferences for treatment. Clinician training and support for patients, including decision aids, could facilitate the decision-making process. Providing written information earlier and guidance on reliable on-line resources would benefits patients and their families., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lecouturier et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Peripheral arterial disease (PAD) is associated with cerebral and coronary artery disease. Symptomatic PAD affects about 5% of people over 55 years; many more have asymptomatic PAD. Early detection enables modification of arterial disease risk factors. Diagnostically, assessment of symptoms or signs can be unreliable; ankle brachial pressure index (ABPI) testing is time-consuming and few healthcare professionals are properly trained. This study assessed the diagnostic accuracy of multi-site photoplethysmography (MPPG), an alternative non-invasive test for PAD, in primary care. PAD patients identified from general practice registers were age- and sex-matched with controls. Participants were assessed using MPPG, ABPI and duplex ultrasound (DUS). Outcome measures were sensitivity and specificity of MPPG and ABPI (relative to DUS) and concordance. MPPG test results were available in 249 of 298 eligible participants from 16 practices between May 2015 and November 2016. DUS detected PAD in 101/249 (40.6%). MPPG sensitivity was 79.8% (95% confidence interval [CI] 69.9-87.6%), with specificity 71.9% (95% CI 63.7-79.2%). ABPI sensitivity was 80.2% (95% CI 70.8-87.6%), with specificity 88.6% (95% CI 82-93.5%). With comparable sensitivity to ABPI, MPPG is quick, automated and simpler to do than ABPI; it offers the potential for rapid and accessible PAD assessments in primary care.

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base., Methods: Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached., Results: The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis., Conclusion: To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit., Competing Interests: Conflicts of interest None of the authors hold any conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Duplex ultrasound (DUS), a non-invasive means of arterial mapping, allows for the reliable diagnosis of peripheral arterial disease (PAD). One of the authors (C.P.O.), developed a standardised DUS based scoring system, devised for rapid detection and reporting of PAD. The purpose of this study was to validate this system, and to determine the diagnostic performance both overall and per disease severity., Methods: In total, 250 participants were recruited, based on diagnosis of (n = 125) or absence of PAD (n = 125) from general practice registers. Right and left legs per subject were handled as independent readings, determining actual PAD status via ankle brachial pressure index (ABPI) < 0.9, and then further grading disease severity using suggested ABPI ranges. Data were excluded if no corresponding ABPI value was obtained per DUS determination or if the ABPI reading was > 1.4, owing to the risk of false negatives due to incompressible vessels. Diagnostic sensitivity and specificity were obtained overall, and per severity classification. Furthermore, inter-rater agreement between ABPI and DUS determined PAD severity was determined by linear weighted Cohen's kappa., Results: The sensitivity and specificity in the detection of disease overall was 81.0% (95% confidence interval [CI] 73.4 - 87.2) and 86.3% (95% CI 82.3 - 89.8), respectively. From mild to severe PAD, sensitivity increased from 71.1% (95% CI 55.7 - 83.6) to 89.3% (95% CI 71.8 - 97.7). Furthermore, a Cohen's kappa value of 0.63 (95% CI 0.57 - 0.69) was obtained, indicating moderate agreement between the two diagnostic methods., Conclusion: The findings of this study validate the diagnostic performance of the standardised DUS scoring system, as well as its capacity to grade severity of disease, offering a potential tool for the identification of PAD in community/research settings following initial screening methods. Confirmatory work could include a comparison of DUS determined disease with gold standard methods of non-invasive angiography, and novel tools such as toe flex near infrared spectroscopy and multisite photoplethysmography., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: It is generally assumed by practitioners and guideline authors that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (VTE), defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), or both. This is the second update of the review first published in 2008., Objectives: The aim of this review was to assess the efficacy of combined intermittent pneumatic leg compression (IPC) and pharmacological prophylaxis compared to single modalities in preventing VTE., Search Methods: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 18 January 2021. We searched the reference lists of relevant articles for additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) or controlled clinical trials (CCTs) of combined IPC and pharmacological interventions used to prevent VTE compared to either intervention individually., Data Collection and Analysis: We independently selected studies, applied Cochrane's risk of bias tool, and extracted data. We resolved disagreements by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity. We assessed the certainty of the evidence using GRADE. The outcomes of interest were PE, DVT, bleeding and major bleeding., Main Results: We included a total of 34 studies involving 14,931 participants, mainly undergoing surgery or admitted with trauma. Twenty-five studies were RCTs (12,672 participants) and nine were CCTs (2259 participants). Overall, the risk of bias was mostly unclear or high. We used GRADE to assess the certainty of the evidence and this was downgraded due to the risk of bias, imprecision or indirectness. The addition of pharmacological prophylaxis to IPC compared with IPC alone reduced the incidence of symptomatic PE from 1.34% (34/2530) in the IPC group to 0.65% (19/2932) in the combined group (OR 0.51, 95% CI 0.29 to 0.91; 19 studies, 5462 participants, low-certainty evidence). The incidence of DVT was 3.81% in the IPC group and 2.03% in the combined group showing a reduced incidence of DVT in favour of the combined group (OR 0.51, 95% CI 0.36 to 0.72; 18 studies, 5394 participants, low-certainty evidence). The addition of pharmacological prophylaxis to IPC, however, increased the risk of any bleeding compared to IPC alone: 0.95% (22/2304) in the IPC group and 5.88% (137/2330) in the combined group (OR 6.02, 95% CI 3.88 to 9.35; 13 studies, 4634 participants, very low-certainty evidence). Major bleeding followed a similar pattern: 0.34% (7/2054) in the IPC group compared to 2.21% (46/2079) in the combined group (OR 5.77, 95% CI 2.81 to 11.83; 12 studies, 4133 participants, very low-certainty evidence). Tests for subgroup differences between orthopaedic and non-orthopaedic surgery participants were not possible for PE incidence as no PE events were reported in the orthopaedic subgroup. No difference was detected between orthopaedic and non-orthopaedic surgery participants for DVT incidence (test for subgroup difference P = 0.19).  The use of combined IPC and pharmacological prophylaxis modalities compared with pharmacological prophylaxis alone reduced the incidence of PE from 1.84% (61/3318) in the pharmacological prophylaxis group to 0.91% (31/3419) in the combined group (OR 0.46, 95% CI 0.30 to 0.71; 15 studies, 6737 participants, low-certainty evidence). The incidence of DVT was 9.28% (288/3105) in the pharmacological prophylaxis group and 5.48% (167/3046) in the combined group (OR 0.38, 95% CI 0.21 to 0.70; 17 studies; 6151 participants, high-certainty evidence). Increased bleeding side effects were not observed for IPC when it was added to anticoagulation (any bleeding: OR 0.87, 95% CI 0.56 to 1.35, 6 studies, 1314 participants, very low-certainty evidence; major bleeding: OR 1.21, 95% CI 0.35 to 4.18, 5 studies, 908 participants, very low-certainty evidence). No difference was detected between the orthopaedic and non-orthopaedic surgery participants for PE incidence (test for subgroup difference P = 0.82) or for DVT incidence (test for subgroup difference P = 0.69)., Authors' Conclusions: Evidence suggests that combining IPC with pharmacological prophylaxis, compared to IPC alone reduces the incidence of both PE and DVT (low-certainty evidence). Combining IPC with pharmacological prophylaxis, compared to pharmacological prophylaxis alone, reduces the incidence of both PE (low-certainty evidence) and DVT (high-certainty evidence). We downgraded due to risk of bias in study methodology and imprecision. Very low-certainty evidence suggests that the addition of pharmacological prophylaxis to IPC increased the risk of bleeding compared to IPC alone, a side effect not observed when IPC is added to pharmacological prophylaxis (very low-certainty evidence), as expected for a physical method of thromboprophylaxis. The certainty of the evidence for bleeding was downgraded to very low due to risk of bias in study methodology, imprecision and indirectness. The results of this update agree with current guideline recommendations, which support the use of combined modalities in hospitalised people (limited to those with trauma or undergoing surgery) at risk of developing VTE. More studies on the role of combined modalities in VTE prevention are needed to provide evidence for specific patient groups and to increase our certainty in the evidence., (Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)