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Acute limb ischemia (ALI) is the sudden onset of decreased blood supply to the extremities and carries a poor prognosis for the affected limb and survival. A rare but well-recognized embolic etiology is a paradoxical embolism, the translocation of a thrombus from venous to arterial circulation through an intracardiac communication, most commonly a patent foramen ovale. The presentation of ALI secondary to a PFO-mediated paradoxical embolism is most often accompanied by combinations of deep vein thrombosis (DVT), pulmonary embolism (PE), and an acute cerebral or visceral ischemia. We present the first documented case of a Rutherford class I ALI secondary to a PFO-mediated paradoxical embolism, ipsilateral DVT, and PE in a 29-year-old female who was surgically managed for her disabling claudication rather than limb salvage. The overlapping presentation of a viable ALI and ipsilateral DVT created a challenging clinical diagnosis. Our review of the literature on PFO-mediated paradoxical emboli involved 43 reports including 51 patients with various arterial thromboses; 19 of these cases involved lower extremity ALI. This case report is the first case to date that demonstrates a paradoxical embolism causing acute lower extremity ischemia with ipsilateral DVT and no additional limb/visceral ischemia to suggest the diagnosis of ALI. We also highlight the role that quality of life plays in vascular surgical decision-making, extending ALI management goals to not only reducing mortality and major amputations, but also improving quality of life., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate the responsiveness of the original low back pain specific Oswestry Disability Index (ODI) and the spinal stenosis specific Zürich Claudication Questionnaire (ZCQ), and to investigate cut-off values for clinical "success" for ODI and ZCQ in surgically treated patients with lumbar spinal stenosis (LSS)., Methods: We included 601 LSS patients (218 with, 383 without degenerative spondylolisthesis) from the NORDSTEN trials. Outcome measures included ODI and ZCQ (symptom severity and physical function scales) with three alternative response parameters: scores at follow-up, absolute and relative changes from baseline to two-year follow-up. Effect size and standardised response mean evaluated internal responsiveness. External responsiveness was assessed by the Spearman rank correlation between patient-reported global perceived effect scale (GPE) and ODI and ZCQ, and receiver operating characteristics (ROC). We evaluated which cut-off values could maximise the percentage of correctly classified patients according to the GPE-anchor "completely recovered" / "much improved" for each parameter., Results: Internal and external responsiveness were high for all three indices with effect sizes, standardized response means, ROC and corresponding area under the curve > 0.8. Correlations with GPE responses were moderate (> 0.50) for absolute change and strong (> 0.67) for relative change and follow-up scores. The 30% ODI relative change cut-off correctly classified 81% of patients to "success", within a range of accurate cut-offs according to the GPE-anchor., Conclusion: ODI and ZCQ demonstrate comparable responsiveness in evaluating outcomes for surgically treated LSS patients. The 30% ODI threshold was consistent with treatment "success" in NORDSTEN trials., Trial Registration: ClinicalTrials.gov; NCT02007083 10/12/2013, NCT02051374 31/01/2014 and NCT03562936 20/06/2018., (© 2024. The Author(s).)

Introduction: Significant health inequalities in major adverse limb events exist. Ethnically minoritized groups are more prone to have a major adverse event following peripheral vascular interventions. This systematic review and meta-analysis aimed to describe the postoperative implications of racial and ethnic status on clinical outcomes following vascular interventions for claudication and chronic limb-threatening ischemia., Methods: Searches were conducted across seven databases from inception to June 2021 and were updated in October 2022 to identify studies reporting claudication or chronic limb-threatening ischemia in patients who underwent open, endovascular, or hybrid procedures. Studies with documented racial and ethnic status and associated clinical outcomes were selected. Extracted data included demographic and clinical characteristics, vascular interventions, and measured outcomes associated with race or ethnicity. Meta-analyses were performed using random-effect models to report pooled odds ratios (ORs) with 95% confidence intervals (CIs)., Results: Seventeen studies evaluating the impact of Black versus White patients undergoing amputation as a primary intervention were combined in a meta-analysis, revealing that Black patients had a higher incidence of amputations as a primary intervention than White patients (OR: 1.91, 95% CI: 1.61-2.27). Another meta-analysis demonstrated that Black patients had significantly higher rates of amputation after revascularization (OR: 1.56, 95% CI: 1.28-1.89). Furthermore, multiple trends were demonstrated in the secondary outcomes evaluated., Conclusions: Our findings suggest that Black patients undergo primary major amputation at a significantly higher rate than White patients, with similar trends seen among Hispanic and First Nations patients. Black patients are also significantly more likely to be subjected to amputation following attempts at revascularization when compared to White patients., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Design: Secondary analysis of a randomized controlled trial., Objective: We investigated the ability to distinguish patients with lumbar spinal stenosis (LSS) who improved from those who did not after receiving nonsurgical treatment. We used the disorder-specific Zurich Claudication Questionnaire (ZCQ) satisfaction subscale as an external anchor and estimated the minimal clinically important differences (MCIDs) for the ZCQ symptom severity and physical function subscales., Summary of Background Data: The ZCQ satisfaction subscale effectively distinguishes surgical patients who improved from those who did not for LSS. However, its responsiveness in nonsurgical treatment has not been evaluated yet., Methods: Eighty-four patients with LSS who received supervised physical therapy or a home exercise program were included. Patients were classified as responders or nonresponders according to the cutoff of 2.5 for the ZCQ satisfaction subscales at six weeks and one year. The external responsiveness of the ZCQ satisfaction subscale was assessed using correlational and receiver-operating characteristic (ROC) curve analyses. MCIDs for the ZCQ symptom severity and physical function subscales were estimated using anchor and distribution approaches., Results: Pearson correlation coefficients between the changes in outcomes and the ZCQ satisfaction subscale at six weeks and one year were 0.37 to 0.58 (symptom severity) and 0.40 to 0.45 (physical function subscales) (>0.30 is considered a good anchor). The area under the ROC curve values were 0.66 to 0.72 and 0.63 to 0.71 for the symptom severity and physical function subscales, respectively (>0.7 is considered acceptable). The MCIDs at six weeks and one year estimated from anchor-based approaches were -0.64 to -0.13 (symptom severity) and -0.39 to 0.10 (physical function), and those from the distribution-based approaches were -0.31 to -0.30 and -0.29 to -0.27, respectively., Conclusions: The findings of this study suggest that the ZCQ satisfaction subscale has less ability to distinguish patients with LSS who improved in the ZCQ symptom severity and physical function subscales from those who did not after nonsurgical treatment, compared to those after surgical treatment., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intermittent Claudication (IC) is exercise pain seen in lower extremity arterial diseases. If it is left untreated, it may be the initial sign of a process leading to amputation. In the present study, the purpose was to compare the postoperative early and mid-term results of the patients who were treated with endovascular methods and those who underwent bypass graft surgery in the treatment due to IC complaints because of isolated Femoropopliteal Arterial Disease., Method: Postoperative first-month, sixth-month, and 12th-month follow-up results, procedure requirements, and demographic characteristics of the 153 patients who underwent femoropopliteal bypass because of isolated Femoropopliteal Arterial Disease and 294 patients who underwent endovascular intervention in our hospital between January 2015 and May 2020 were compared in the study., Results: It was found in demographic characteristics that endovascular intervention was performed more frequently in smokers and graft bypass surgery was performed more frequently in hyperlipidemic patients, and the results were found to be statistically significant. High amputation rates were detected at statistically significant levels in diabetic and hypertriglycemic patients and 1-year primary patency rates were found to be higher in patients who underwent graft bypass surgery. No differences were detected between the two methods in terms of mortality., Conclusion: Interventional treatment modalities must be considered for patients with isolated Femoropopliteal Arterial Disease whose symptoms persist despite exercise and the best medical treatment. We think that Bypass Graft Surgery has more positive results than endovascular interventions when short and medium-term amputation, repetitive intervention needs, and changes in quality of life are compared in patients who receive the same medical treatment., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Metastases to the bone of aortic sarcoma include osteolytic and nonosteolytic lesions. This study aims to review the clinical symptoms, the sites, and diagnostic methods of bone metastases and to compare the osteolytic and nonosteolytic metastases of patients with aortic sarcoma., Methods: A systematic search was conducted in PubMed and scientific journals published from 1972 to 2022. Database included reports of aortic sarcomas with bone metastasis published in English and in French. Characteristics of patients were analyzed with chi-square test or Fisher's exact test between lytic and sclerotic bone metastases., Results: In 29 patients with bone destruction, the symptoms of low back pain and claudication were observed in 10 (34.5%) and 9 cases (31%), respectively. Acute ischemia of the legs and arms accounted for 7 cases (24.1%). There were 4 cases with hypertension (13.8%) and 5 cases with chest pain or abdominal pain or epigastric pain (17.2%). Metastases to the vertebrae, pelvis, and femur were observed in 14 (48.3%), 12 (41.4%), and 11 cases (37.9%), respectively. Osteolytic lesions were detected at the time of diagnosis in 16/29 (55.2%) cases. In 27 aortic sarcoma patients with sclerotic bone metastases, symptoms of hypertension were observed in 10 (37.0%), of back pain in 7 (25.9%), of chest pain or abdominal pain in 5 cases (18.5%). Acute ischemia of the leg occurred in 6 cases (22.2%). Metastases to the vertebrae, bone, pelvis, and femur were observed in 10 (37.0%), 9 (33.3%), 7 (25.9%), and 6 cases (22.2%), respectively. The sign of claudication and methods for detected bone destruction by X-rays were the difference between osteolytic and nonosteolytic metastases of aortic sarcoma (P = 0.019; P = 0.001), respectively., Conclusions: Back pain is a common symptom of aortic sarcoma with bone metastasis. The sign of intermittent claudication is the difference between osteolytic and nonosteolytic metastases of aortic sarcoma. Bone destruction occurred in all bones, but mainly in vertebrae, pelvis, and femur. Methods for detection of bone destruction are mainly by X-rays or computed tomography (CT). Bone destruction was an important sign to detect aortic sarcoma. Sclerotic bone metastases occurred mainly in vertebrae, pelvis, bone, and femur. The detection of sclerotic bone metastases is based on magnetic resonance imaging, positron emission tomography/CT, and autopsy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Arteriovenous fistulas (AVFs) of the lower extremity are uncommon. The main causes are traumatic or iatrogenic, with 15% of traumatic AVFs occurring in the popliteal vessels. Herein, we present a 60-year-old female with a traumatic AVF caused after a car accident 40 years ago. The patient presented with right leg venous claudication and symptoms of congestive heart failure. Duplex ultrasound of lower limb vessels revealed an AVF at the distal part of the tibiofibular trunk. The patient was successfully managed with an endovascular approach using a coil-assisted covered endovascular repair technique of the tibiofibular bifurcation (CERTIFIB) with excellent results and distal vessels patency. At 3 months follow-up, patient presented with an impressive regression of 3 cm of the lower extremity oedema and improvement of both claudication and heart failure., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Cystic adventitial disease (CAD) is an uncommon condition that affects arteries and veins. It can cause a rare type of non-atherosclerotic peripheral vessel disease. The most common vessel affected is the popliteal artery. The number of case reports on CAD of the femoral artery is growing. We present a case of a 62-year-old female presented with claudication of the left leg diagnosed with CAD of the left common femoral artery. The patient was treated surgically with cyst excision and vessel reconstruction with saphenous vein autograft patch plasty. After 8-months the cyste relapsed and she had new claudication complains. We decided to perform new surgery. Surgical treatment consisted of cyst resection by excision of the femoral bifurcation and saphenous vein autograft interposition reconstruction of the bifurcation. We also provide an update on the latest literature of surgical treatment of CAD of the ilio-femoral artery region., Methods: Medline and EMBASE were used to collect articles on CAD of ilio-femoral artery. We included English written or translated case reports or series between 1987 and 2023., Results: Twenty-nine patients out of 28 case reports were included. Most patients were male (59%). Claudication is the most common symptom (76%). Treatment consisted of cyst resection, cyst decompression, Endarterectomy, patch angioplasty and interposition graft using PTFE, Dacron, Great saphenous vein (GSV) or femoral vein autograft. Recurrence appeared in 4 cases (14%)., Conclusion: In accordance to the literature and our experience we recommend complete vessel excision and saphenous vein (or PTFE) interposition bypass as treatment.

The coarctation of the aorta (CoA) combined with heart defects or cerebral artery aneurysms is more prevalent in clinical practice. However, cases of concurrent bilateral iliac artery dissection (IAD) are extremely rare and have not been reported. Here, we described a case with CoA combined with bilateral IAD. The patient, a 62-year-old male, presented with acute intermittent claudication accompanied by pain and aching in both lower limbs after walking. Following a thorough medical history inquiry and examination, the patient was diagnosed with acute bilateral IAD combined with CoA. The patient underwent endovascular treatment. Postoperatively, the aortic diameter recovered, and the bilateral IAD disappeared, yielding satisfactory therapeutic results. Conclusively, endovascular treatment of aortic coarctation combined with IAD is an effective therapeutic approach, enhancing patient survival and improving their quality of life., (© 2024 The Author(s). The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Competing Interests: Disclosures None.

Background Context: One of the primary goals of treatments received by individuals with lumbar spinal stenosis with neurogenic claudication is to improve walking ability. Thus, a thorough and valid assessment of walking ability in patients with lumbar spinal stenosis is needed. Duration of continuous walking and steps per day could be relevant when evaluating walking ability in daily living., Purpose: To describe and evaluate a method for estimating continuous walking periods in daily living and to evaluate the known-group validity of steps per day in individuals with lumbar spinal stenosis., Study Design: This is a cross-sectional observational study., Patient Sample: The study contains three study groups: individuals with lumbar spinal stenosis, individuals with low back pain, and a background population from the Lolland-Falster Health Study (LOFUS)., Outcome Measures: Participants in all three study groups wore an accelerometer on the thigh for seven days., Methods: Accelerometer data were processed to summarize the continuous walking periods according to their length: the number of short (4-9 seconds), moderate (10-89 seconds), and extended (≥90 seconds) continuous walking periods per day, and the number of steps per day. Results from the three groups were compared using negative binomial regression with lumbar spinal stenosis as the reference level., Results: Continuous walking periods of moderate length were observed 1.48 (95% CI 1.27, 1.72) times more often in individuals from the background population than in individuals with LSS. Continuous walking periods of extended length were observed 1.53 (95% CI 1.13, 2.06) times more often by individuals with low back pain and 1.60 (95% CI 1.29, 1.99) times more often by individuals from the background population. The number of steps per day was 1.22 (95% CI 1.03, 1.46) times larger in individuals with LBP and 1.35 (95% CI 1.20, 1.53) times larger in individuals from background population., Conclusions: The impact of neurogenic claudication on walking ability in daily living seems possible to describe by continuous walking periods along with steps per day. The results support known-group validity of steps per day. This is the next step toward a clinically relevant and comprehensive assessment of walking in daily living in individuals with lumbar spinal stenosis., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication in the young. Aberrant embryological development results in entrapment of the popliteal artery by myofascial structures of the popliteal fossa. Type 4 PAES is due to aberrant development of the popliteus muscle superficial to the popliteal artery. We present a case of bilateral type 4 PAES, along with intraoperative photography highlighting the anatomical cause for this pathology. Both limbs in this patient were treated successfully with surgical release of the entrapping popliteus muscle via a posterior surgical approach to the popliteal fossa. This report emphasises the importance of determining popliteal artery integrity and entrapment subtype to guide the management of this condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Primary aortic angiosarcomas (PAA) are rare angiosarcomas, frequently diagnosed in advanced stages due to initial misdiagnosis. This case describes a 66-year-old woman, initially presenting with a distal thoracic aorta thrombus and symptomatic bilateral popliteal emboli. Despite initial management and therapeutic anticoagulation, she experienced progressive lower limb claudication and 12 months following initial presentation she re-presented with an obstructing distal thoracic aorta mass and metastatic disease. Histopathology confirmed metastatic epithelioid angiosarcoma. Despite urgent palliative radiotherapy, she died 6 weeks after diagnosis from complications of tumour thromboembolism. Suspicion for PAA should be raised in the case of thrombus in atypical segments (e.g. thoracic aorta) or progressive course despite anticoagulation. Multimodal imaging including MRI and FDG-PET is useful to distinguish from benign aetiologies., (© 2024 Royal Australian and New Zealand College of Radiologists.)

Background: Artificial intelligence (AI) tools created to enhance decision-making may have a significant impact on treatment algorithms for peripheral arterial disease (PAD). A Markov-based AI model was developed to predict optimal therapy based on maximization of calculated quality of life (cQoL), a patient-centered system of assessment designed to report outcomes directly linked to health-related quality of life., Study Design: The AI model was prospectively interrogated immediately after individual interventions for PAD over a 12-year period to test predictive performance. Patient cQoL was determined at each patient follow-up visit., Results: A total of 1,143 consecutive patients were evaluated, with a median follow-up of 18 months. Observed mean annualized cQoL was higher than predicted by the model (0.85 ± 0.38 vs 0.79 ± 0.18, p < 0.0001). Of 5 potential clinical outcomes, the AI model correctly predicted final status in 71.3% of patients, with insignificant model performance deterioration over time (-0.15% per month, r = -0.49, p = 0.063). The chance of having the condition predicted by the model was 0.57 ± 0.32, compared with a theoretical maximum of 0.70 ± 0.19 (p < 0.0001, mean ratio 0.79). The AI model performed better in patients with claudication than limb-threatening ischemia (75.5% vs 63.6%, p = 0.014) but equally well for open or endovascular intervention (69.8% vs 70.5%, p = 0.70). Graft or artery patency and amputation-free survival were better for patients with claudication and those treated with endovascular techniques., Conclusions: AI can successfully predict treatment for PAD that maximizes patient quality of life in most cases. Future application of AI incorporating better estimates of patient anatomic and physiological risk factors and refinement of model structure should further enhance performance., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The most common symptom of peripheral artery disease (PAD) is intermittent claudication that involves the calf, thigh, and/or buttock muscles. How the specific location of this leg pain is related to altered gait, however, is unknown., Objectives: We hypothesized that because the location of claudication symptoms uniquely affects different leg muscle groups in people with PAD, this would produce distinctive walking patterns., Methods: A total of 105 participants with PAD and 35 age-matched older volunteers without PAD (CTRL) were recruited. Participants completed walking impairment questionnaires (WIQ), Gardner-Skinner progressive treadmill tests, the six-minute walk test, and we performed an advanced evaluation of the biomechanics of their overground walking. Participants with PAD were categorized into 4 groups according to their stated pain location(s): calf only (C, n = 43); thigh and calf (TC, n = 18); buttock and calf (BC, n = 15); or buttock, thigh, and calf (BTC, n = 29). Outcomes were compared between CTRL, C, TC, BC and BTC groups using a one-way ANOVA with post-hoc comparisons to identify and assess statistically significant differences., Results: There were no significant differences between CTRL, C, TC, BC and BTC groups in distances walked or walking speed when either pain-free or experiencing claudication pain. Each participant with PAD had significantly dysfunctional biomechanical gait parameters, even when pain-free, when compared to CTRL (pain-free) walking data. During pain-free walking, out of the 18 gait parameters evaluated, we only identified significant differences in hip power generation during push-off (in C and TC groups) and in knee power absorption during weight acceptance (in TC and BC groups). There were no between-group differences in gait parameters while people with PAD were walking with claudication pain., Conclusions: Our data demonstrate that PAD affects the ischemic lower extremities in a diffuse manner irrespective of the location of claudication symptoms., Database Registration: ClinicalTrials.gov NCT01970332., (Copyright © 2023 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Systemic thromboembolism associated with atrial fibrillation (AF) is usually caused by thrombi in the left atrial appendage and acute onset. We experienced an unusual case of a woman in her 60s who presented to the outpatient district having bilateral intermittent claudication for more than 1 month, which turned out to be multiple thromboembolism from asymptomatic AF with tachycardia. She was also complicated with non-ischaemic dilated cardiomyopathy with reduced ejection fraction, consistent with arrhythmia-induced cardiomyopathy (AiCM), along with left atrial and left ventricular thrombi and thromboembolism in multiple organs. Rate control with beta-blockers was not effective. With the administration of amiodarone after adequate anticoagulation therapy, she returned to sinus rhythm, and the ejection fraction was restored. This case is instructive in that AiCM with AF can cause thrombosis in the left ventricle, and the patient may present with worsening intermittent claudication as a result of systemic embolism., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The Walking Impairment Questionnaire (WIQ) is a common and easy-to-use assessment of walking incapacity in people with claudication due to peripheral artery disease (PAD). It has four subscales: pain severity, walking distance, walking speed, and ability to climb stairs. It has not been translated into Gujarati, which limits its use in Indian subjects., Aim: This study aims to translate and assess the validity and reliability of a Gujarati version of WIQ., Materials and Methods: This study had three phases: 1. Forward and backward translation and Cultural adaptation of WIQ into the Gujarati language by two independent translators, 2. Face and content validation by six clinical reviewers and 10 participants with PAD and Type II diabetes, 3. Concurrent and construct validity, test-retest reliability, and internal consistency of Gujarati, the WIQ was assessed on 160 participants with PAD and Type II diabetes who had a mean Ankle Brachial Index (standard deviation) <0.40 (0.1). The concurrent and construct validity of the WIQ was analyzed by correlating the WIQ distance and speed score with 6-minute walk distance (6MWD) and speed and WIQ total score with the Medical Outcome Study Questionnaire Short Form 36 (SF-36) score using Pearson's correlation coefficient. Test-retest reliability was analyzed using an intraclass correlation coefficient (ICC) with a seven-day interval between two questionnaire applications. Internal consistency of the total WIQ score was determined using Cronbach's alpha., Results: Following translation, the Gujarati WIQ was considered acceptable and understandable by people with PAD. There was excellent correlation between the WIQ distance score and 6-minute walk test distance (r = 0.95, P < .05)) , the WIQ speed score and 6-minute walk test speed score (r = 0.89, P < .05)) and the Gujarati WIQ total score and total score of physical functioning domain of SF- 36 (r = 0.99, P < .05). There was excellent test-retest reliability over 7 days for total WIQ score (ICC = 0.94). The Cronbach's alpha for internal consistency of 0.97 for total WIQ score were excellent. This demonstrates the sufficient homogeneity of the total questionnaire., Conclusion: The Gujarati version of the WIQ is reliable and valid and can be used to assess self-reported walking impairment in Gujarati-speaking people with PAD and Type II Diabetes., Competing Interests: Declaration of Competing Interest All co-authors have no conflicts of interest to declare., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To evaluate the triglyceride-glucose index (TyG index) for predicting in-stent restenosis in patients with iliac artery stenosis after percutaneous intervention with stents., Patients and Methods: Subjects with iliac artery stenosis, who underwent an iliac stent intervention and were followed up for at least 2 years were included in the study. Subjects were grouped according to TyG index (Group A, TyG index ≤8.848; Group B 8.849 ≤TyG index ≤9.382 and Group C TyG index ≥9.383). The subject's baseline characteristics, blood parameters, claudication distance, Transatlantic Intersociety Consensus classification, target lesion localization, stent direction, number of stents that were applied, and stent type were noted. Pre- and 1st and 2nd-year post-procedure Rutherford statuses, ankle-brachial index, and stenosis degree were recorded. To calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), Group B and Group C were combined and compared with Group A., Results: In total, 255 subjects were evaluated (female, n=77-30.2%, male, n=178-69.8%). The mean age of the subjects was 66.00±10.00 years (range from 39 to 90 years). The pre-procedure Rutherford measurements were significantly different among the groups (p=0.001). The rates of mild claudication and resting pain in Group A were higher than those in Groups B and C. The rate of moderate claudication in Group C was higher than that in Groups A and B. The rate of severe claudication in Group B was higher than that in Groups A and C. One year after the procedure, there were more asymptomatic cases in Group A than in Groups B and C (p=0.001). The rate of mild claudication in Group C was lower than that in Groups A and B. The rate of moderate claudication in Group C was higher than that in Group A. The rate of severe claudication in Group C was higher than that in Groups A and B. Two years after the procedure, the Rutherford measurements and the rates of mild claudication in Groups A and B were higher than those in Group C. The rate of severe claudication in Group C was higher than that in Groups A and B (p=0.001). One year after the procedure, the computed tomography angiography (CTA) measurements and the rate of full patency in Group A were higher than that in Groups B and C. The rate of 0-50% stenosis in Group B was higher than that in Groups A and C. The rate of 50-70% stenosis in Group C was higher than that in Group A. Two years after the procedure, the CTA measurements and the rates of 70-99% stenosis and 100% occlusion in Group C were higher than those in Groups A and B. The TyG index has high specificity and NPV. However, specificity and PPV levels were found to be quite low., Conclusions: The TyG index was found to be an easy-to-use marker for predicting in-stent restenosis in patients with iliac artery stenosis after percutaneous intervention with stents.

Peripheral artery disease (PAD) is a condition related to atherosclerosis affecting >200 million people worldwide, and it increases cardiovascular morbidity (mainly from myocardial infarction and stroke) and mortality. Indeed, PAD patients are classified as patients at very high cardiovascular risk. The most common manifestation of PAD is intermittent claudication, which is associated with reduced mobility and leg pain. Nevertheless, asymptomatic PAD is the most frequent form of PAD worldwide; therefore, it remains underdiagnosed and undertreated. The major risk factors for PAD are smoking, diabetes mellitus, hyperlipidemia, hypertension, overweight/obesity, age, male sex, and black race. Hence, the first and most relevant approach in PAD treatment is lifestyle management, with measures such as smoking cessation, healthy diet, weight loss, and regular physical exercise. This should also be supported by an optimal pharmacological approach including lipid-lowering drugs, antihypertensive drugs, antidiabetic agents, and antithrombotics., (Copyright © 2023 Elsevier España, S.L.U. All rights reserved.)

This is a case report of a woman in her 60s with Rutherford class 3 bilateral calf claudication and a resting right Ankle Brachial Index (ABI) 0.49 and left ABI 0.57. The arteriogram of lower extremities demonstrates bilateral persistent sciatic arteries (PSAs). The patient had severe stenosis of left common iliac artery, and thus underwent successful stenting resulting in normalisation of flow and filling of PSA with symptom resolution., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In peripheral arterial disease (PAD) patients with intermittent claudication (IC), the combination of aerobic and resistance exercises could counteract muscle loss and attenuate disease progression. This study analyzed the effects of six months of a combined exercise program on walking ability, lower limb body composition, cardiovascular risk factors, and Ankle-Brachial Index (ABI)., Methods: Twenty-three patients (age 63.2±1.5 years and ABI 0.58±0.07) with PAD and IC were allocated to a control group (CG) or a supervised exercise group (SUP). Ten patients underwent six months of treadmill walking combined with resistance exercises, three times a week. The CG (N.=13) received a recommendation for walking. All patients were measured at baseline (M0), after three months (M3), and six months (M6)., Results: During constant treadmill protocol, the claudication onset time/distance (COT/COD), absolute claudication time/distance (ACT/ACD), and number of pauses of overall patients significantly improved at M3 and M6. Between groups were found significant differences in COT and COD at M6 (P=0.005 and P=0.007, respectively); and in ACT and ACD at M3 (P=0.003 for both) and at M6 (P=0.005 and P=0.005, respectively), with major improvements in the SUP. Over the six months, a significant group effect was found in fat-free mass (P=0.041) and predicted muscle mass (P=0.039) of the lower ABI leg, with greater improvements in the SUP., Conclusions: A supervised exercise program that combines aerobic and resistance training improves PAD symptoms and has additional benefits for patients. Patients in the program showed improvements in walking ability, lower-limb body composition, perceived exertion, and heart rate during treadmill walking.

Background: In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization., Methods: A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models., Results: We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis., Conclusions: Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Peripheral artery disease (PAD) is a common condition representing a spectrum of clinical disease. Intermittent claudication, which is defined as PAD with lower extremity pain on exertion that resolves with rest, represents mild-to-moderate PAD. Intermittent claudication is associated with a low risk of limb loss long-term but is a significant marker of systemic cardiovascular risk. Here, we describe the workup, diagnosis, and management of intermittent claudication., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Purpose: To determine the equity in access to trials of exercise interventions for adults with intermittent claudication due to peripheral arterial disease., Methods: Systematic electronic database searches of MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Clinical Trials, PEDRO, Opengrey, ISRCTN and ClinincalTrials.gov for randomised controlled trials of exercise interventions for adults with intermittent claudication were conducted. Data extraction was informed by Cochrane's PROGRESS-Plus framework., Results: Searches identified 6412 records. Following the screening of 262 full texts, 49 trials including 3695 participants were included. All trials excluded potential participants on at least one equity factor. This comprised place of residence, language, sex, personal characteristics (e.g., age and disability), features of relationships (e.g., familial risk factors) and time-dependent factors, (e.g., time since revascularisation). Overall, 1839 of 7567 potential participants (24.3%) were excluded based on equity factors. Disability was the most frequently reported factor for exclusions., Conclusion: Trialists endeavour to enrol a representative sample in exercise trials whilst preserving the safety profile of the intervention. This review highlights that these efforts can inadvertently lead to inequities in access as all trials excluded potential participants on at least one equity factor. Future exercise trials should optimise participation to maximise generalisability of findings. PROSPERO registration no. CRD42020189965.Implications for rehabilitationEquity factors influence health opportunities and outcomes.All trials of exercise for people with intermittent claudication excluded adults on at least one equity factor.Disability was the predominant factor for exclusions from trials.Trials should optimise participation to maximise generalisability of results as these findings are used to inform treatment and service design.

Objective: Endurance athletes such as cyclists may develop intermittent claudication owing to iliac artery endofibrosis after long-lasting extreme hemodynamic challenges. This study investigated short-term (<1.5 years) and long-term (>5 years) satisfaction and safety after a surgical endarterectomy and autologous patching., Methods: Data of endurance athletes who underwent an endarterectomy for flow limitation of the iliac artery owing to endofibrosis between 1997 and 2015 in one center were studied. Maximal cycling exercise tests, ankle-brachial index with flexed hips, echo-Doppler examination (peak systolic velocity), and contrast-enhanced magnetic resonance angiography were performed before and 6 to 18 months after surgery. Short-term and long-term satisfaction were evaluated using questionnaires. Potential patch dilatation was assessed using echo-Doppler., Results: Analysis of 68 patients (79 legs; 55.7% males, median age at the time of surgery, 34 years; interquartile range, 26-41 years) demonstrated that cycling workload at symptom onset improved from 226 ± 97 to 333 ± 101 (P < .001) Watts. Peak workload increased from 326 ± 111 to 352 ± 93 Watts (P < .001). Ankle-brachial index with flexed hips increased from 0.34 (interquartile range [IQR], 0.00-0.47) to 0.59 (IQR, 0.51-0.69; P < .001). Peak systolic velocity with extended and flexed hip decreased from 2.04 m·sec -1 (IQR, 1.52-2.56 m·3sec -1 ) to 1.25 m·sec -1 (IQR, 0.92-1.62 m·sec -1 ; P < .001) and 2.40 m·sec -1 (IQR, 1.81-2.81 m·sec -1 ) to 1.15 m·sec -1 (IQR, 0.97-1.60 m·sec -1 ; P < .001), respectively. Thirty-day major complication rate was 5.1% (hematoma requiring evacuation n Legs  = 2, septic bleeding from deep infection n Legs  = 1, and iliac occlusion requiring thrombectomy n Legs  = 1). In the short term, 91.2% of patients reported symptom reduction with a 93.7% overall satisfaction rate. After a median of 11.1 years (IQR, 7.8-17.6 years), the overall satisfaction was 91.7%; 94.5% of patients reported persistent symptom reduction. Patch dilatation of >20 mm was observed in two patients. Linear mixed model analysis revealed no alarming patch dilatation in the long term., Conclusions: Endarterectomy with an autologous patch for intermittent claudication owing to iliac artery endofibrosis in endurance athletes shows high rates of patient satisfaction and symptom reduction in both the short and long term. The risk of surgical complications or patch dilatation is mild. A surgical intervention for flow limitation of the iliac artery owing to endofibrosis is safe and successful., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The aim was to analyze the risk of progression to chronic limb-threatening ischemia (CLTI), amputation and subsequent interventions after revascularization versus noninvasive therapy in patients with intermittent claudication (IC)., Background: Conflicting evidence exists regarding adverse limb outcomes after each treatment strategy., Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. MEDLINE, Web of Science, and Google Scholar were searched aided by a health sciences librarian through August 16, 2022. Randomized control trials (RCTs) comparing invasive (endovascular or surgical revascularization) and noninvasive treatment (exercise and/or medical treatment) were included. PROSPERO registration was completed (CRD42022352831)., Results: A total of 9 RCTs comprising 1477 patients (invasive, 765 patients; noninvasive, 712 patients) were eligible. During a mean of 3.6-year follow-up, progression to CLTI after invasive [5 (2-8) per 1000 person-years] and noninvasive treatment [6 (3-10) per 1000 person-years] were not statistically different [rate ratio (RR): 0.77; 95% CI, 0.35-1.69; P =0.51, I2 =0%]. Incidence of amputation (RR: 1.69; 95% CI, 0.54-5.26; P =0.36, I2 =0%) and all-cause mortality (hazard ratio: 1.26; 95% CI, 0.91-1.74; P =0.16, I2 =0%) also did not differ between the groups. However, the invasive treatment group underwent significantly more revascularizations (RR: 4.15; 95% CI, 2.80-6.16; P <0.00001, I2 =83%). The results were not changed by fixed effect or random-effects models, nor by sensitivity analysis., Conclusions: Although there is equivalent risk of progression to CLTI, major amputation and all-cause mortality compared with noninvasive treatment, invasive treatment for patients with IC led to significantly more revascularization procedures and should be used selectively in patients with major lifestyle limitation. Guideline recommendation of noninvasive treatment for first-line IC therapy is supported., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lower extremity atherosclerotic disease (LEAD) - also known as peripheral arterial disease - refers to the obstruction or narrowing of the large arteries of the lower limbs, most commonly caused by atheromatous plaque. Although in many cases of less severe disease patients can be asymptomatic, the major clinical manifestations of LEAD are intermittent claudication (IC) and critical limb ischaemia, also known as chronic limb-threatening ischaemia (CLTI). Revascularisation procedures including angioplasty, stenting, and bypass grafting may be required for those in whom the disease is severe or does not improve with non-surgical interventions. Maintaining vessel patency after revascularisation remains a challenge for vascular surgeons, since approximately 30% of vein grafts may present with restenosis in the first year due to myointimal hyperplasia. Restenosis can also occur after angioplasty and stenting. Restenosis and occlusions that occur more than two years after the procedure are generally related to progression of the atherosclerosis. Surveillance programmes with duplex ultrasound (DUS) scanning as part of postoperative care may facilitate early diagnosis of restenosis and help avoid amputation in people who have undergone revascularisation., Objectives: To assess the effects of DUS versus pulse palpation, arterial pressure index, angiography, or any combination of these, for surveillance of lower limb revascularisation in people with LEAD., Search Methods: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 February 2022., Selection Criteria: We included randomised controlled trials (RCTs) and quasi-RCTs that compared DUS surveillance after lower limb revascularisation versus clinical surveillance characterised by medical examination with pulse palpation, with or without any other objective test, such as arterial pressure index measures (e.g. ankle-brachial index (ABI) or toe brachial index (TBI)). Our primary outcomes were limb salvage rate, vessel or graft secondary patency, and adverse events resulting from DUS surveillance. Secondary outcomes were all-cause mortality, functional walking ability assessed by walking distance, clinical severity scales, quality of life (QoL), re-intervention rates, and functional walking ability assessed by any validated walking impairment questionnaire. We presented the outcomes at two time points: two years or less after the original revascularisation (short term) and more than two years after the original revascularisation (long term)., Data Collection and Analysis: We used standard Cochrane methodological procedures. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis when appropriate., Main Results: We included three studies (1092 participants) that compared DUS plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation and arterial pressure index (ABI or TBI) for surveillance of lower limb revascularisation with bypass. One study each was conducted in Sweden and Finland, and the third study was conducted in the UK and Europe. The studies did not report adverse events resulting from DUS surveillance, functional walking ability, or clinical severity scales. No study assessed surveillance with DUS scanning after angioplasty or stenting, or both. We downgraded the certainty of evidence for risk of bias and imprecision. Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (short-term time point) In the short term, DUS surveillance may lead to little or no difference in limb salvage rate (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.49 to 1.45; I² = 93%; 2 studies, 936 participants; low-certainty evidence) and vein graft secondary patency (RR 0.92, 95% CI 0.67 to 1.26; I² = 57%; 3 studies, 1092 participants; low-certainty evidence). DUS may lead to little or no difference in all-cause mortality (RR 1.11, 95% CI 0.70 to 1.74; 1 study, 594 participants; low-certainty evidence). There was no clear difference in QoL as assessed by the 36-item Short Form Health Survey (SF-36) physical score (mean difference (MD) 2 higher, 95% CI 2.59 lower to 6.59 higher; 1 study, 594 participants; low-certainty evidence); the SF-36 mental score (MD 3 higher, 95% CI 0.38 lower to 6.38 higher; 1 study, 594 participants; low-certainty evidence); or the EQ-5D utility score (MD 0.02 higher, 95% CI 0.03 lower to 0.07 higher; 1 study, 594 participants; low-certainty evidence). DUS may increase re-intervention rates when considered any therapeutic intervention (RR 1.38, 95% CI 1.05 to 1.81; 3 studies, 1092 participants; low-certainty evidence) or angiogram procedures (RR 1.53, 95% CI 1.12 to 2.08; 3 studies, 1092 participants; low-certainty evidence). Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (long-term time point) One study reported data after two years, but provided only vessel or graft secondary patency data. DUS may lead to little or no difference in vessel or graft secondary patency (RR 0.83, 95% CI 0.19 to 3.51; 1 study, 156 participants; low-certainty evidence). Other outcomes of interest were not reported at the long-term time point., Authors' Conclusions: Based on low certainty evidence, we found no clear difference between DUS and standard surveillance in preventing limb amputation, morbidity, and mortality after lower limb revascularisation. We found no studies on DUS surveillance after angioplasty or stenting (or both), only studies on bypass grafting. High-quality RCTs should be performed to better inform the best medical surveillance of lower limb revascularisation that may reduce the burden of peripheral arterial disease., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Introduction: Peripheral artery disease (PAD) patients with claudication symptoms exhibit impaired functional capacity, which has been associated with disease severity, worse quality of life and higher risk of cardiovascular events. Different tests have been used to assess functional capacity in PAD patients. Therefore, understanding the characteristics, strengths and limitations of these tests are important to support the choice of tests to be used in clinical practice., Areas Covered: This review summarizes the main methods to assess functional capacity in PAD patients, discussing their psychometric properties, applications, and limitations., Expert Opinion: Robust evidence supports the use of treadmill and six-minute walk tests in PAD patients, as their results are associated with clinically meaningful outcomes, adequate psychometric properties and are sensitive to effects of interventions. On the other hand, other functional tests (Shuttle-walk test, outdoor walking capacity test, timed-up and go, four-meter walk test, heel-rise test, short physical performance battery and modified physical performance battery) are related to activities of daily living and do not require sophisticated equipment and can be easily used in clinical practice. However, these other tests still need evidence regarding their clinical relevance, reliability, and ability to detect long-term intervention changes, providing further investigation directions.

Purpose: Intermittent claudication (IC) refers to leg pain that is induced by walking and relieved by rest. Neurogenic IC is usually associated with lumbar canal stenosis (LCS). We present rare findings from an autopsied patient who had neurogenic IC caused by vasculitis in the cauda equina., Methods: We performed antemortem neurological and electrophysiological assessments, sural nerve biopsy, and post-mortem examination of the spinal cord and brain., Results: A 61-year-old man noted sudden-onset leg pain that was not associated with any traumatic trigger. His leg pain consistently appeared when the patient walked and quickly faded on stopping. Spine surgery and cardiovascular departments both made a diagnosis of IC. However, magnetic resonance imaging (MRI) did not show LCS, and all ankle-brachial pressure indices were normal. He subsequently developed diffuse muscle weakness of the legs a month after disease onset. Myeloperoxidase antineutrophil cytoplasmic autoantibody was seropositive (140 IU/mL), and a sural nerve biopsy revealed axonal injury and angiitis. MRI showed multiple cerebral infarctions. He was diagnosed with microscopic polyangiitis (MPA) and underwent corticosteroid therapy. He died from complications two months after the onset. A post-mortem study revealed vasculitis in the subarachnoid space of the cauda equina, spinal cord, and brain parenchyma. The cauda equina showed a combined loss of small and large axonal fibres. The lumbar cord displayed central chromatolysis of the lower motor neurons., Conclusion: MPA is a rare cause of neurogenic IC when the symptom is acute and multimodal. Small-vessel vasculitis affecting the cauda equina may underlie MPA-associated IC., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Cystic adventitial disease (CAD) is an important and rare non-atherosclerotic cause of intermittent claudication and critical limb ischemia. Since the first case of CAD involving the external iliac artery was described by Atkins and Key in 1947, approximately 300 additional cases have been reported., Objectives: The aim of this article is to report a rare vascular disorder, predominantly seen in young healthy men with minimal cardiovascular risk factors., Methods: We report a rare case of cystic adventitial disease of a young policeman. To confirm the diagnosis, an ultrasonography and a conventional angiography were performed. The therapeutic approach was surgical first., Results: The procedure was successful without any complication, and the patient was discharged to home 4 days after procedure., Conclusion: While CAD is rare, the diagnosis should be suspected in a young patient who presents with arterial insufficiency and no risk factors for atherosclerosis. Catheter angiography is the investigation of choice in the absence of multislice CT and good MRA. It seems that the treatment that assures the best long-term results is reconstructive arterial bypass surgery.

Background: The prevalence of peripheral artery disease (PAD) and leg symptoms are higher in Black than White adults. We studied the effects of self-reported lower extremity symptoms and ankle-brachial indices (ABI) groups on outcomes., Methods: Black participants in the Jackson Heart Study with baseline ABI and PAD symptom assessments (exertional leg pain by the San Diego Claudication questionnaire) were included. Abnormal ABI was < 0.90 or > 1.40. Participants were divided into (1) normal ABI, asymptomatic, (2) normal ABI, symptomatic, (3) abnormal ABI, asymptomatic, and (4) abnormal ABI, symptomatic to examine their associations with MACE (stroke, myocardial infarction, fatal coronary heart disease) and all-cause mortality, using Kaplan-Meier survival curves and stepwise Cox proportional hazard models adjusting for Framingham risk factors., Results: Of 4586 participants, mean age was 54.6 ± 12.6 years, with 63% women. Compared with participants with normal ABI who were asymptomatic, participants with abnormal ABI and leg symptoms had highest risk of MACE (adjusted HR 2.28; 95% CI 1.62, 3.22) and mortality (aHR 1.82; 95% CI 1.32, 2.56). Participants with abnormal ABI without leg symptoms had higher risk for MACE (aHR 1.49; 95% CI 1.06, 2.11) and mortality (aHR 1.44; 95% CI 1.12, 1.99). Participants with normal ABI and no leg symptoms did not have higher risks., Conclusion: Among Black adults, the highest risk for adverse outcomes were in symptomatic participants with abnormal ABIs, followed by asymptomatic participants with abnormal ABIs. These findings underscore the need for further studies to screen for PAD and develop preventative approaches in Black adults with asymptomatic disease.

Background: Recent studies have shown that antegrade access for treatment of infrainguinal peripheral vascular disease is associated with decreased radiation exposure and contrast use without a significant increase in access complication, although data are limited on antegrade superficial femoral artery (SFA) access for larger sheath sizes. We aim to describe a single institution's contemporary experience with percutaneous antegrade SFA access., Methods: A retrospective review of percutaneous, infrainguinal endovascular interventions for arterial occlusive disease at a major academic institution was conducted between 2018 and 2020. Antegrade, percutaneous, SFA access cases were included. Information on demographics, indication, sheath size, arteries treated, type of intervention, concurrent pedal access, closure devices, and complications was collected and analyzed., Results: A total of 45 patients with an average body mass index of 25.25 were identified. Indications for intervention included tissue loss (64.4%), rest pain (6.7%), claudication (13.3%), and acute limb ischemia (11.1%). Of which, 80.0% of patients had multilevel interventions. Angioplasty was performed in 68.8% of patients, stenting in 8.3%, atherectomy in 15.6%, and thrombectomy in 7.3%. Nearly a quarter of cases involved concurrent pedal access. Maximum sheath size was 4F for 4.4% of patients, 5F for 28.9%, 6F for 46.7%, 7F for 11.1%, and 8F for 8.9%. The closure device was utilized in 75.6% of cases, with no closure device failures. In the entire cohort, there were no demonstrated access site complications., Conclusions: This study demonstrates percutaneous, antegrade SFA access for complex endovascular interventions for infrainguinal occlusive disease can be effectively utilized, even with larger sheath size. Moreover, routine use of closure devices is safe, improving patient comfort and expediting time to ambulation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aim: To investigate the safety and efficacy of short recovery day-case pathway following lower-limb angioplasty in both intermittent claudication and critical limb ischaemia patients., Materials and Methods: A retrospective analysis was undertaken of the medical records of consecutive outpatients treated with lower-limb angioplasty over a 1-year period within an interventional radiology (IR) day-case unit in a high-volume vascular centre. Standard post-angioplasty care at York Teaching Hospital is discharge 3 h after puncture site haemostasis without the routine use of closure devices. The rates of successful same-day discharge, procedure success, complications, and re-admissions were calculated with 30-day follow-up., Results: The cohort included 301 patients (57% intermittent claudication and 43% critical limb ischaemia) undergoing 605 angioplasties using access sheath size ranging from 4 to 7 F. Closure devices were used in only 7% of patients. Successful same-day discharge achieved in 98% of patients (294/301), with seven admitted overnight because of complications. Eleven patients (3.6%) were re-admitted within 30 days. Technical success rates were 92%, and 96% when including partially successful interventions, with 4% technical failure. Twelve patients (4%) developed minor complications and four major complications (1%). There were no significant differences in complication rates between small and larger sheath sizes (p>0.05). No procedure-related death was recorded within 30 days., Conclusion: Lower-limb angioplasty can be performed safely as day-case procedure with a short recovery protocol within IR departments for both patients with intermittent claudication (IC) and critical limb ischaemia (CLI). This may significantly increase patient throughput and alleviate pressure on stretched hospital inpatient resources by safely discharging patients on the day of procedure., (Copyright © 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Objective: Functional popliteal artery entrapment syndrome (fPAES) is an underdiagnosed and undertreated etiology of atypical claudication. Symptoms of fPAES include deep posterior muscle cramping and pain with exercise and, unlike anatomic PAES, there are seldom vascular complications. Common noninvasive diagnostic modalities include ankle-brachial index, arterial duplex Doppler ultrasound (DUS) examination, and cross-sectional imaging such as magnetic resonance angiography (MRA). Entrapment can be difficult to reproduce during diagnostic testing, requiring provocative maneuvers. Because we believed different provocative maneuvers provide different diagnostic efficacy, we sought to optimize our diagnostic approach to fPAES., Methods: We performed a retrospective review of patients before and after optimizing our noninvasive imaging protocol comparing patients with fPAES versus other atypical claudicants with chronic compartment syndrome., Results: Arterial DUS examination and exercise ankle-brachial index were important components of our protocol with a significant decrease in systolic posterior tibial blood pressure of -14 mm Hg after exercise, whereas nonentrapment release patients had an overall increase of 8 mm Hg (P = .006). Arterial DUS examination of the distal PA with forced plantarflexion demonstrated a trend toward an increase in the measured velocity ratio, especially in the middle and distal PA. MRA with stressed plantar flexion findings were positive in 6 of 11 patients with fPAES, with false negatives likely owing to patients' inability to maintain a provocative position for the duration of the MRA., Conclusions: Diagnosing fPAES is challenging owing to a lack of standardized diagnostic testing and provocative maneuvers. Different maneuvers demonstrated varying diagnostic yields for fPAES. Exercise ABIs were the most reliable vascular laboratory test to detect changes attributable to fPAES and to distinguish it from chronic compartment syndrome. Segmental PA DUS examination seems to be promising as a means of detecting PA impingement. Stress positional MRA effectively demonstrates anatomic PAES, but has a false-negative rate for fPAES., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Peripheral arterial disease (PAD) causes blockage of the arteries, altering the blood flow to the lower limbs. This blockage can cause the individual with PAD to feel severe pain in the lower limbs. The main contribution of this research is the discovery of a solution that allows the automatic detection of the onset of claudication based on data analysis from patients' smartphones. For the data-collection procedure, 40 patients were asked to walk with a smartphone on a thirty-meter path, back and forth, for six minutes. Each patient conducted the test twice on two different days. Several machine learning models were compared to detect the onset of claudication on two different datasets. The results suggest that we can identify the onset of claudication using inertial sensors with a best case accuracy of 92.25% for the Extreme Gradient Boosting model.

Cystic adventitial disease (CAD) is a rare cause of claudication in which a mucinous cyst forms within the adventitial layer of a blood vessel, most commonly the popliteal artery, resulting in luminal narrowing. This paper presents a case of a man in his mid-50s with unilateral lower limb popliteal artery CAD, which was not initially identified on either duplex ultrasonography or CT angiography. He was successfully treated with surgical resection of the affected segment of the popliteal artery and autologous vein grafting., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Clinical practice guidelines recommend supervised exercise therapy (SET) as first-line therapy for patients with peripheral artery disease (PAD) and intermittent claudication (IC). The Society for Vascular Surgery Appropriate Use Criteria for IC deems excercise therapy (ET) as appropriate for all patients with IC. However, compliance with recommendations for the use of ET is often poor owing to the lack of availability, patient travel requirements, and cost. Results of home-based ET programs have been mixed with a trend toward improved results with more frequent patient engagement. The feasibility, use, and effectiveness of a 12-week app-based structured ET program using cognitive-behavioral therapy (CBT) techniques for IC was evaluated., Methods: Patients with PAD confirmed by an abnormal ankle-brachial index or toe-brachial index and IC were recruited prospectively to participate in Society for Vascular Surgery SET, a 12-week app-based ET program. Participants performed home 6-minute walk tests, completed quality-of-life surveys, received education options via micro learning courses (eg, What is PAD?, Exercise, and Nutrition), and ongoing health coaching using CBT techniques. They were instructed to record at least three 30-minute ET walks a week using their personal mobile phones. Programming also included daily doses of health education, coaching, and reminders sent via text message., Results: One hundred thirty-nine patients (37% women; mean age, 65 years) were enrolled across 20 institutions (44% offered in-person ET programs). One hundred twenty patients (86%) completed the program. Participants recorded 201,163 minutes of walking 8,013,520 steps with the ET program, completing a total of 5049 SET walks. Nineteen enrolled participants (14%) became inactive because they either paused (14 participants: medical reasons, travel, or other) or withdrew (5 participants: security concerns, lack of motivation). Ninety-two percent of patients met their stated CBT specific, measurable, achievable, relevant, and time-bound goals. Freedom from intervention at 6 months was 92% and 69% at 12 months., Conclusions: Deployment of a 12-week app-based ET program for PAD incorporating CBT was feasible in achieving 86% program completion and effective at meeting guideline recommended activity goals. Ninety-two percent of participants achieved their CBT specific, measurable, achievable, relevant, and time-bound goals. The use of ET was increased by virtue of offering this program at institutions that did not offer ET., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Endovascular treatment (EVT) has replaced open repair as the first option in intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) in several centers. However, evidence of the most optimal post-procedural surveillance strategy is sparse. This study aimed to compare two routine surveillance programs after EVT of IC/CLTI: clinical and hemodynamic assessment (CHA) vs. duplex ultrasound (DUS) and clinical/hemodynamic assessment in combination., Methods: Between February 2012 and December 2015, all patients with EVT of IC/CLTI were allocated to either CHA or DUS-based routine surveillance programs. The allocation-ratio was 1:2 (CHA:DUS), and propensity score matching (PSM) was used to control baseline differences between the groups. Follow-up visits in the CHA group consisted of clinical assessment and ABI at 3, 6, 12 and 24 months. Follow-up visits in DUS group consisted of clinical assessment, ABI, and target vessel DUS at 1, 3, 6, 12, 18 and 24 months., Results: In total, 340 legs in 305 patients suffering from IC/CLTI were included; 111 (33%) in the CHA-group and 229 (67%) in the DUS group. The two groups were identical except for a significantly lower incidence of diabetes mellitus in the CHA group than the DUS group, 55% vs. 72%, respectively (P=006). Based on PSM, the CHA-group vs. the DUS-group was burdened of an increased risk of amputation (12.5% vs. 8.27%, HR=0.41 [95% CI: 0.17-0.96]), and a higher mortality (21.2% vs. 12.8%, HR=0.37 [95% CI: 0.19-0.72]). The reported differences in reintervention rate (7.5% vs. 12.8%, HR=1.12 [95% CI: 0.44-2.84]) were insignificant. The mean follow-up was 317 days (SD=0.214) in the CHA group and 611 days (SD=0.298) in the DUS group., Conclusions: Our results suggest that DUS-based routine surveillance after EVT of IC/CLTI is superior to CHA-based routine surveillance in improved amputation rate and mortality.

Introduction: Outcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era., Methods: A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan-Meier curves and Cox proportional hazards ratios (HR)., Results: A total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011)., Conclusions: Femoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Peripheral arterial disease (PAD) is a phenotype of atherosclerotic disease often associated with cerebrovascular or coronary artery disease. The incidence of cardiovascular events in patients with PAD is 5.4% per year, which is higher than that of cerebrovascular or coronary artery disease. The most useful screening method for PAD is the ankle brachial pressure index (ABI). The ABI should be measured in (1) all patients with lower limb symptoms such as claudication, (2) all patients aged 65 years and over, and (3) those aged 50 to 65 years who have risk factors such as smoking and diabetes mellitus. PAD is diagnosed if the ABI is <0.9. A comprehensive cardiac rehabilitation program includes complete smoking cessation, blood pressure control with antihypertensive medications and salt reduction for hypertension, glycemic control for diabetes mellitus, and appropriate medications such as antiplatelet agents and statins. A multidisciplinary team approach is effective in comprehensive cardiac rehabilitation for patients with PAD, even those with critical limb ischemia (CLI). Exercise therapy is a crucial and essential treatment for PAD, except in CLI. Exercise therapy is contraindicated in patients with acute arterial occlusion and CLI with infection. PAD is often associated with other atherosclerotic diseases; the patient should be monitored for ischemic heart disease during the initial exercise stress test using the Gardner treadmill protocol. Supervised exercise therapy is highly recommended (Class I, Level of Evidence A). Alternatively, a home-based exercise program is feasible (Class IIa, Level of Evidence A). The exercise type (treadmill, track walking, ergometer), frequency (3 to 5 days per week), intensity (speed and incline), and duration (30 minutes) are determined based on the exercise stress test results for each patient. Exercise should be continued at least 3 times a week for at least 12 weeks. Cilostazol is highly recommended (Class I, Level of Evidence A)., (Copyright © 2021. Published by Elsevier Ltd.)

Ligamentum flavum hypertrophy (LFH) is a known contributor to lumbar spinal canal stenosis (LSCS). However, the clinical significance and quantitative role of LFH compared to other components, such as disc bulging and facet hypertrophy, have not yet been examined. We investigated the correlation between the quantitative radiological factors, clinical symptoms, and outcomes in patients with LSCS. In total, 163 patients diagnosed with single-level (L4-L5) stenosis were included. The patients were divided into 2 groups according to claudication severity: >100 m for mild (n = 92) and < 100 m for severe (n = 71). The visual analog scale (VAS) was used to quantify back and leg pain, and the Oswestry Disability Index (ODI) and Short form-36 (SF-36) physical component summary (PCS) scores, and Macnab criteria were evaluated as clinical factors 6 months after treatment. We measured the baseline canal cross-sectional area, ligamentum flavum (LF) area, disc herniation area, dural sac area, fat area, and LF thickness using MRI. A comparative analysis was performed to evaluate the association between radiologic and clinical factors. Additionally, further comparative analyses between the types of surgeries were performed. Among various radiologic factors, the baseline LF thickness (odds ratio [OR] 1.73; 95% confidence interval [CI] 1.25-2.41) was the only major contributing factor to the severity of claudication in the multivariate logistic regression analysis. The types of surgery (decompression alone vs fusion) did not significantly differ in terms of their clinical outcomes, including back and leg VAS, ODI, SF-36 PCS, and satisfaction with the MacNab classification. LF thickness is a major factor contributing to claudication severity., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Endovascular atherectomy enables minimally invasive plaque removal in peripheral artery disease (PAD)., Aims: We aimed to evaluate the safety and the long-term effectiveness of the Phoenix atherectomy for the treatment of complex and calcified lesions in PAD patients., Methods: Consecutive all-comer patients with PAD underwent the Phoenix atherectomy. Device safety in terms of perforation and distal embolisation were evaluated. Lesion calcifications were categorised by the Peripheral Arterial Calcium Scoring System (PACSS) and lesion complexity was assessed by the Transatlantic Inter-Society Consensus (TASC). Clinically driven target lesion revascularisation (TLR) was assessed., Results: A total of 558 lesions were treated in 402 consecutive patients. Clinical follow-up was available at 15.7±10.2 months for 365 (91%) patients. Of 402 patients, 135 (33.6%) had claudication, 37 (9.2%) had ischaemic rest pain and 230 (57%) exhibited ischaemic ulcerations. Lesions were mostly identified in the femoropopliteal segments (55%), followed by below-the-knee (BTK) segments (32%). Complex TASC C/D lesions and moderate to severe calcifications (PACSS score ≥2) were present in 331 (82%) and 323 (80%) patients, respectively. The mean lesion length was 20.6±14.3 cm. Five (1%) perforations and 10 (2%) asymptomatic embolisations occurred. Bail-out stenting was performed in 4%, 16% and 3% of patients with common femoral artery, femoropopliteal and BTK lesions, respectively. During follow-up, 5 (3.9%) patients with claudication and 52 (21.9%) patients with critical limb-threatening ischaemia (CLTI) died (hazard ratio [HR] 3.7; p<0.001). Freedom from TLR was 87.5% (112 of 128) in patients with claudication and 82.3% (195 of 237) in patients with CLTI, respectively (HR 1.8; p=0.03)., Conclusions: The Phoenix atherectomy can be safely performed in patients with complex lesions with a relatively low rate of bail-out stenting and clinically acceptable TLR rates., German Clinical Trials Register: DRKS00016708.

Objective: Despite limited evidence supporting atherectomy alone over stenting/angioplasty as the index peripheral vascular intervention (PVI), the use of atherectomy has rapidly increased in recent years. We previously identified a wide distribution of atherectomy practice patterns among US physicians. The aim of this study was to investigate the association of index atherectomy with reintervention., Methods: We used 100% Medicare fee-for-service claims to identify all beneficiaries who underwent elective first-time femoropopliteal PVI for claudication between January 1, 2019, and December 31, 2019. Subsequent PVI reinterventions were examined through June 30, 2021. Kaplan-Meier curves were used to compare rates of PVI reinterventions for patients who received index atherectomy versus nonatherectomy procedures. Reintervention rates were also described for physicians by their overall atherectomy use (by quartile). A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with reinterventions., Results: A total of 15,246 patients underwent an index PVI for claudication in 2019, of which 59.7% were atherectomy. After a median of 603 days (interquartile range, 77-784 days) of follow-up, 41.2% of patients underwent a PVI reintervention, including 48.9% of patients who underwent index atherectomy versus 29.8% of patients who underwent index nonatherectomy (P < .001). Patients treated by high physician users of atherectomy (quartile 4) received more reinterventions than patients treated by standard physician users (quartiles 1-3) (56.8% vs 39.6%; P < .001). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [CI], 1.21-1.46), Black race (vs White; aHR; 1.18; 95% CI, 1.03-1.34), diabetes (aHR, 1.13; 95% CI, 1.07-1.21), and urban residence (aHR, 1.11; 95% CI, 1.01-1.22). Physician factors associated with reintervention included male sex (aHR, 1.52; 95% CI, 1.12-2.04), high-volume PVI practices (aHR, 1.23; 95% CI, 1.10-1.37), and physicians with a high use of index atherectomy (aHR, 1.49; 95% CI, 1.27-1.74). Vascular surgeons had a lower risk of PVI reintervention than cardiologists (vs vascular; aHR, 1.22; 95% CI, 1.09-1.38), radiologists (aHR, 1.55; 95% CI, 1.31-1.83), and other specialties (aHR, 1.59; 95% CI, 1.20-2.11). The location of services delivered was not associated with reintervention (P > .05)., Conclusions: The use of atherectomy as an index PVI for claudication is associated with higher PVI reintervention rates compared with nonatherectomy procedures. Similarly, high physician users of atherectomy perform more PVI reinterventions than their peers. The appropriateness of using atherectomy for initial treatment of claudication needs critical reevaluation., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The importance of the profunda femoris for aortoiliac inflow procedure patency is well-recognized. We aim to quantify the characteristics of the profunda femoris and its relation to patency following aortoiliac inflow procedures., Methods: Patients undergoing aortoiliac inflow procedures between 2009 and 2019 were identified. These were classified into aorto-bifemoral bypass (ABF), extra-anatomic bypass (EAB), femoral endarterectomy (FEA), and iliac stenting. Preoperative imaging characteristics of the profunda femoris were reviewed as well as outcomes., Results: We performed 269 procedures in 202 patients. Of these, 162 were men (59.8%), with a mean age of 61 years (standard deviation, 11.45 years). A total of 123 patients (45.3%) presented with claudication, 69 (25.9%) with critical limb ischemia, and 30 (11.2%) with acute limb ischemia. Fifty patients (18.6%) underwent ABF, 44 (16.4%) underwent EAB, 57 (21.2%) underwent FEA, and 158 (58.7%) underwent iliac stenting. Fourteen patients (5.2%) underwent FEA plus iliac stenting. Fifty-two patients (19.2%) had an occluded superficial femoral artery. Twenty-four patients (8.9%) had additional outflow procedures performed during the index operation, including infrainguinal endovascular intervention in 10 patients (3.7%), infrainguinal bypass in 10 patients (3.7%), and femoropopliteal thrombectomy in 5 patients (1.9%). The mean follow-up was 17.5 months with overall 2-year primary patency (PP) of 79%. Two-year PP was 94.7% for FEA, 85.6% for ABF, 79.8% for iliac stents, and 62.5% for EAB. Unadjusted analysis revealed that loss of primary assisted patency was associated with active smoking (67.6% vs 48.6%; P = .035), lower creatinine (mean, 0.84 vs 1.06 mg/dL; P = .003), critical limb ischemia vs claudication (37.8% vs 21.4%; P = .037), and profunda femoris with fewer than five branches >2 mm in size (88.2% vs 68.5%; P = .011). Multivariate analysis confirmed that a profunda with five or more branches >2 mm in diameter was significantly associated with a lower risk of thrombosis (odds ratio, 0.30; P = .034). Size of the profunda greater than 6 mm approached statistical significance on univariate analysis (35% of the non-thrombosed vs 21% in the thrombosed; P = .073), but did not significantly affect risk of thrombosis on the multivariate analysis (odds ratio, 0.58; P = .25). The 2-year PP when all operations were considered was 76% compared with 72% for profunda with fewer than five branches > 2 mm., Conclusions: Anatomic characteristics of the profunda are associated with patency of inflow procedures. Care should be taken to assess the main profunda and branch diameters on preoperative imaging. A concomitant infrainguinal procedure should be considered in cases of profunda with inadequate large branches, to ensure long-term patency of the inflow operation., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)