INTRODUCTION:Central arterial stiffness and pressure pulsatility are key measures of arterial health and cardiovascular disease (CVD). Acute physical activity (PA) improves vascular function; however, its relationship with arterial health across varying habitual PA levels remains understudied. METHODS:We analyzed Framingham Heart Study (FHS) data (Generation 2: Exam 8, 2005-2008, n = 2999 and Generation 3: Exam 1, 2002-2005, n = 4064). Habitual PA was assessed using a standardized questionnaire. Carotid-femoral pulse wave velocity (niCFPWV, inverse-transformed CFPWV), central pulse pressure (CPP), and forward wave pressure (FWP) were measured using applanation tonometry. We examined associations between PA scores (as quintiles) and arterial health using linear regression and effect modification by age and sex, as well as mediation by arterial health measures on heart failure, CVD mortality, and all-cause mortality. RESULTS:In 6451 FHS participants (mean age 50 ± 15 years, 55% women), the highest quintile of PA was associated with lower aortic stiffness (niCFPWV, β = -0.06 ± 0.02, p = 0.01). Continuous PA was associated with higher CPP (std β = 0.02 ± 0.01, p = 0.03) but not FWP. We observed an age-interaction: PA was associated with lower niCFPWV in individuals ⩾ 48 years (std β = -0.21 ± 0.07, p = 0.005) and higher CPP in those < 48 years (std β = 0.01 ± 0.004, p = 0.01). No significant effect modification by sex was noted. In stratified analyses, PA was associated with higher CPP among individuals without hypertension (β = 0.02 ± 0.01, p = 0.02), but not among those with hypertension. In mediation analyses, vascular measures did not contribute significantly to cardiovascular outcomes. CONCLUSION:Higher PA score was associated with lower arterial stiffness, particularly in older adults, and with higher pressure pulsatility in younger adults.
Hemodialysis is the primary renal replacement therapy in the US for patients with end-stage kidney disease (ESKD). Functioning vascular access, in the form of an arteriovenous fistula (AVF) or graft (AVG), is fundamental to the outcomes for these patients. Over the last decade, changes have occurred in the field of vascular access. Evolving guidelines have placed unprecedented emphasis on individualized access, and rapid innovation-particularly in endovascular technologies-has expanded the toolkit for access creation and maintenance. This narrative review offers vascular medicine providers an in-depth evaluation of contemporary practice relating to hemodialysis access, including a comprehensive review of emerging technologies expected to shape the future of hemodialysis care.
BACKGROUND:The American Heart Association (AHA) Life's Essential 8 (LE8) provides a means of scoring cardiovascular health but has yet to be correlated with vascular function in an African American cohort. METHODS:In a sample of Jackson Heart Study participants (N = 2186, mean age 57 years, 65% women), LE8 scores were calculated per AHA guidelines at baseline visits (2000-2004). Noninvasive vascular assessments were performed within an ancillary study (2012-2017). Tests included carotid-femoral pulse wave velocity, carotid-brachial pulse wave velocity, carotid-radial pulse wave velocity, central pulse pressure, forward pressure wave, and characteristic impedance, as well as brachial artery baseline and hyperemic flow velocities. Linear regression models, adjusted for age, age squared, sex, and heart rate, assessed the associations of LE8 composite and component scores with vascular function. RESULTS:A higher LE8 score was associated with lower carotid-femoral pulse wave velocity (β = -0.32; 95% CI: -0.42, -0.21; p < 0.0001), characteristic impedance (β = -0.57; 95% CI: -0.93, -0.20; p = 0.0024), forward pressure wave amplitude (β = -0.21; 95% CI: -0.26, -0.16; p < 0.0001), central pulse pressure (β = -0.25; 95% CI: -0.32, -0.19; p < 0.0001), and brachial baseline flow velocity (β = -0.013; 95% CI: -0.023, -0.002; p = 0.021). Higher LE8 scores were associated with higher brachial hyperemic flow velocity (β = 0.095; 95% CI: 0.035, 0.15; p = 0.0018). Blood glucose and blood pressure were the components most significantly associated with vascular function. CONCLUSION:Our findings support the concept that a healthy lifestyle is predictive of better vascular function. Future longitudinal studies are warranted to investigate whether improving LE8 scores leads to improved vascular function.
Background: Iloprost has been proposed as a pharmacological option for patients with chronic limb-threatening ischemia (CLTI) in whom revascularization is either not feasible or has been unsuccessful. This pilot study aimed to evaluate the safety and effectiveness of intravenous iloprost at low infusion rates via an elastomeric pump at home (EP-iloprost) versus higher infusion rates via a peristaltic pump in the hospital (PP-iloprost) for 1 year. Methods: This was a cohort study conducted in ‘no-option’ patients for revascularization with CLTI. The follow-up was 3 years. The primary endpoint was the incidence of drug-related adverse events (AEs); the secondary outcome was the composite of all-cause death and major amputations. Results: We enrolled 56 patients who received EP-iloprost as a pilot study. Their outcomes were compared with a cohort of 48 patients who had received PP-iloprost. AEs were reported in 15 (31.3%) patients who received PP-iloprost and in eight (14.3%) who received EP-iloprost ( p = 0.038), with the exposure-adjusted incidence rate being 22.7/100 patient-years in the PP-iloprost group and 8.3/100 patient-years in the EP-iloprost group. Although the two cohorts were not well-suited for comparison due to age differences, there were seven (12.5%) deaths and four (7.1%) major amputations in the EP cohort compared with 11 (22.9%) deaths and 13 (27.1%) major amputations in the PP cohort. Conclusions: These hypothesis-generating data suggest that low-rate infusion of EP-iloprost at home is better tolerated and potentially more effective than high-rate infusion with PP in a hospital setting.
Introduction: Supervised exercise training (SET) is recommended as first-line therapy for symptomatic peripheral artery disease (PAD), but pain and limited tolerance often restrict the effective training dose. Eccentric exercise, such as downhill walking, elicits lower metabolic and cardiovascular responses and may represent a viable alternative to traditional walking. This case report describes the feasibility and physiological and functional effects of a 12-week downhill-walking SET program in a patient with symptomatic PAD.Methods: A 61-year-old man with symptomatic PAD completed a 12-week downhill-walking SET program performed at a preferred walking speed with progressively increasing negative slopes (-4% to -14%). Pre- and post-SET assessments included a graded treadmill test with near-infrared spectroscopy of calf muscle oxygenation, a 6-minute walk test, and lower-limb functional performance tests.Results: Following SET, pain-free (+6%) and maximal (+29%) walking distances improved. These changes were accompanied by reduced calf muscle oxygen desaturation during exercise, an enhanced calf muscle oxygenation overshoot at exercise onset, and faster postexercise reoxygenation. Lower-limb functional performance improved (20-25%), and the time to pain relief after walking tests was reduced (-46%), yet the 6-minute walking distance remained unchanged.Conclusion: This case report describes the implementation of a downhill-walking SET protocol in a patient with symptomatic PAD. The intervention was feasible and was accompanied by changes in walking performance, muscle oxygenation, and functional measures. These observations highlight the potential of an eccentric-based walking approach and support further investigation of this protocol in larger studies involving patients with PAD.
Background: A prior retrospective single-center study involving patients with chronic limb-threatening ischemia (CLTI) demonstrated that sciatic nerve atrophy (SNA) is associated with impaired wound healing (IWH) and reduced amputation-free survival (AFS). We conducted a prospective single-center pilot study to validate the prognostic implications of SNA in predicting wound healing and AFS.Methods: Patients diagnosed with CLTI and associated tissue loss were recruited for participation in this prospective, noninterventional study. The cross-sectional area (CSA) of the sciatic nerve at the mid-to-lower femoral quarter was quantified utilizing computed tomography imaging. SNA was identified based on the predefined CSA threshold. Patient outcomes were evaluated through outpatient clinic visits and telephone follow-ups. Outcomes assessed included wound healing rate, adverse wound outcomes (AWO), and AFS.Results: In the cohort of 52 limbs with CLTI from 52 patients, 19 individuals were categorized into the SNA group. The 6-month wound healing rate was significantly lower in the SNA group (15.8%) compared to the normal group (87.9%) (p < 0.001). The sensitivity and specificity of SNA for predicting AWO at 6 months were 80.0% and 90.6%, respectively. Patients in the SNA group had significantly lower AFS at 1 year (68.4% vs 93.9%, p = 0.011). Multivariable analysis further established that SNA was an independent prognostic factor for both AWO (hazard ratio [HR]: 0.113; 95% CI: 0.034-0.381; p < 0.001) and AFS (HR: 6.135; 95% CI: 1.236-30.303; p = 0.026) following endovascular therapy (EVT).Conclusions: SNA was identified as a predictor for AWO and AFS in patients with CLTI after EVT. Future research should involve rigorous basic and large-scale clinical studies to elucidate the association between SNA and prognosis in patients with peripheral artery disease (PAD)/CLTI and explore the underlying pathophysiological mechanisms.
The aim of this review is to provide clinicians with an update on the evolution and current status of the carotid duplex criteria, as well as clinical applications for the diagnosis and follow-up of carotid disease. The ‘duplex concept’ combined real-time B-mode imaging and pulsed Doppler flow detection in a single instrument, which enabled direct visualization of blood vessels and analysis of flow patterns. The first application of the prototype duplex scanner built in the 1970s was the evaluation of extracranial carotid artery disease, and the validation studies performed at the University of Washington established the first carotid duplex criteria, including the 125 cm/s peak systolic velocity (PSV) threshold for ⩾ 50% internal carotid stenosis. Over time, those criteria have been widely adopted and modified, resulting in significant variability among vascular laboratories. In the 1990s, the randomized clinical trials of medical versus surgical management of carotid disease prompted further refinement of the carotid criteria to include a PSV threshold of 230 cm/s for the clinically important internal carotid stenosis category of ⩾ 70%. The Society of Radiologists in Ultrasound (SRU) proposed a set of criteria in 2003 that included both of these PSV thresholds. However, concern regarding a lack of standardization prompted the Intersocietal Accreditation Commission (IAC) to conduct an independent validation study of the SRU criteria. The main recommendation from the IAC study, published in 2021, was to increase the PSV threshold for ⩾ 50% internal carotid stenosis to 180 cm/s. Although the carotid duplex criteria have been validated primarily for atherosclerotic lesions, they have also been applied to nonatherosclerotic carotid conditions such as dissection, aneurysms, and fibromuscular dysplasia. Duplex scanning plays a major role in follow-up after carotid interventions, although modified velocity criteria must be used to avoid overestimating the severity of restenosis. There is growing evidence that certain histologic plaque features are associated with ischemic cerebrovascular events, independent of the degree of stenosis, and some of these, such as intraplaque hemorrhage, may be identified on B-mode imaging. Although velocity parameters have been the primary components of the carotid duplex criteria, it is likely that assessment of plaque morphology will increase the overall clinical value of carotid duplex scanning in the future.
Introduction: Cilostazol is a phosphodiesterase 3 (PDE3) inhibitor and is one of the only approved medications shown to improve walking performance in patients with peripheral artery disease (PAD). However, its effects on skeletal muscle pathophysiology are poorly understood. Because skeletal muscle dysfunction contributes to mobility impairment in PAD, this study aimed to evaluate whether patients taking cilostazol exhibit differences in skeletal muscle pathophysiology compared to those not taking cilostazol.Methods: We conducted a cross-sectional analysis of 50 patients with PAD, including 15 patients taking cilostazol and 35 not taking cilostazol. Calf muscle strength was assessed via isometric dynamometry. Gastrocnemius muscle biopsies were analyzed for myofiber morphology, mitochondrial function using high-resolution respirometry, and gene expression via RNA sequencing.Results: No significant differences were observed in calf muscle strength (p = 0.49), myofiber cross-sectional area (Type I: p = 0.53; Type IIa: p = 0.59), or capillary density (p = 0.74) between groups. However, mitochondrial oxygen consumption under physiological energy demand was significantly higher in cilostazol-treated patients (p = 0.0137), although oxidative phosphorylation conductance (p = 0.38) and mitochondrial hydrogen peroxide emission were not different. RNA sequencing revealed transcriptomic overlap between groups, but gene set enrichment analysis identified upregulation of pathways related to mitochondrial gene expression and downregulation of inflammatory signaling in patients taking cilostazol.Conclusion: Cilostazol use in patients with PAD is associated with increased skeletal muscle mitochondrial oxygen consumption and modest transcriptomic changes, but it does not appear to alter muscle strength, fiber size, or capillarization. These findings suggest a limited impact of cilostazol on skeletal muscle structure, although potential metabolic effects warrant further investigation.
The importance of management strategies for subclavian artery aneurysms (SAAs) is underscored by the risks of aneurysm rupture and distal ischemia. However, there is no consensus on the optimal timing or strategies for treatment due to their low incidence. The existing literature primarily comprises case reports and small retrospective studies, providing limited high-quality evidence. The preservation of the vertebral artery (VA) is critical to the prognosis of SAA repair, particularly when a dominant ipsilateral VA exists and the circle of Willis is incomplete. In this review, we integrate published literature together with our center’s experience to classify SAAs into four types based on the anatomical relationship between the VA and the aneurysm, and we outline the treatment strategies for each type. Furthermore, given the substantial influence of diverse etiologies on disease progression, we address the clinical features and management approaches for SAAs based on distinct etiologies.
