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PubMed2002

Peripheral vascular disease risk factors among patients undergoing hemodialysis.

Peripheral vascular disease (PVD) is common among patients undergoing hemodialysis, but little is known regarding the risk factors for PVD in this population. Data from waves 1, 3, and 4 of the United States Renal Data System Dialysis Morbidity and Mortality Study were used to examine cross-sectional associations of a range of conventional cardiovascular risk factors and uremia- or dialysis-related variables with PVD. Univariate and multivariate logistic regression models were developed using wave 3 and 4 data. Odds ratios for the multivariate model derived using wave 3 and 4 data were then compared with those obtained with the wave 1 data set. For both data sets, PVD was positively associated with the duration of dialysis (vintage) and malnourished status and was negatively associated with serum albumin and parathyroid hormone levels and predialysis diastolic BP. Kt/V was negatively associated with PVD in waves 3 and 4 but not in wave 1. PVD was associated with increasing age, white (versus non-white) race, male gender, diabetes mellitus, coronary artery disease, cerebrovascular disease, smoking, and left ventricular hypertrophy, as for the general population, but not with hypertension or hyperlipidemia. In conclusion, PVD among hemodialysis patients is associated with both dialysis-specific variables and most conventional cardiovascular risk factors other than hypertension and hyperlipidemia. Future studies should prospectively examine the association of these variables identified in cross-sectional analyses with the de novo development of PVD in this population.

Aged↗
PubMed1975

Vasodilator drugs in peripheral vascular disease.

The use of vasodilator drugs in peripheral vascular disease is reviewed. Discussed are actions and efficacy of direct-acting drugs such as isoxsuprine, papaverinek niacin and cyclandelate; the beta-receptor stimulating drug, nylidrin; and drugs which affect the sympathetic nervous system, such as tolazoline, reserpine, guanethidine, methyldopa, ergot alkaloids and alcohol. Both animal and clinical studies reveal little evidence of the effectiveness of vasodilator drugs in the treatment of obstructive arterial disease. In some patients with vasospastic diseases, vasodilators which act upon the sympathetic nervous system (reserpine and guanethidine) may have an ameliorating effect by increasing cutaneous capillary blood flow.

Arterial Occlusive Diseases↗
PubMed1975

Smoking and other factors affecting the conservative management of peripheral vascular disease.

Three hundred and ninety patients with peripheral vascular disease, who were neither eligible for, nor fit to undergo, surgery, have been studied in a prospective trial to assess the effectiveness of adequate active conservative therapy. These patients were followed up from 4 to 72 months, the duration of the average follow-up being 24 months. There was a 72% over-all improvement rate. The most striking feature of the trial was the correlation between smoking and failure to improve.

Adult↗
PubMed1993

Low-dose aspirin fails to inhibit increased platelet reactivity in patients with peripheral vascular disease.

A study was performed to evaluate the effect of low-dose aspirin (75 mg/day) on platelet reactivity in patients with peripheral vascular disease. Platelet function was measured in 31 patients with advanced peripheral vascular disease requiring surgery. Shear-induced haemostasis and collagen-induced thrombus formation were used as indicators of platelet reactivity. They were measured in non-anticoagulated fresh whole blood samples ex vivo using a haemostatometer. Results were compared with those from 30 age- and sex-matched controls. Shear-induced haemostasis and collagen-induced thrombus formation were also measured in 18 of the 31 patients before the start of aspirin administration (before operation) and 1 week after surgery. Patients with advanced peripheral vascular disease were found to have increased platelet reactivity with a mean(s.e.m.) shear-induced haemostasis index of 1977(180) mmHg s compared with a control value of 3161(234) mmHg s (P < 0.001) and a mean(s.e.m.) collagen-induced thrombus formation index of 3980(460) mmHg s compared with a control value of 5350(420) mmHg s (P = 0.02). Perioperative low-dose aspirin failed to inhibit platelet function in patients with peripheral vascular disease.

Aged↗
PubMed1996

Effect of acute alterations in afterload on left ventricular function in patients with combined coronary artery and peripheral vascular disease.

OBJECTIVE: To assess the effect of acute alterations in afterload by aortoiliac clamping, during peripheral vascular surgery, on left ventricular function. DESIGN: Prospective examination of the left ventricular long axis and transmitral Doppler flow preoperatively and intraoperatively; before aortic clamping, during clamping and 5 min, 15 min, and 5 days after unclamping. SETTING: A tertiary referral centre for cardiac and vascular disease equipped with invasive and non-invasive facilities. PATIENTS: 20 patients (11 men; mean (SD) age 61 (8) years) with significant aortoiliac disease and documented coronary artery disease and 21 normal controls of similar age. RESULTS: Preoperatively: long axis function was abnormal compared with that in normal controls. In systole total long axis excursion and peak shortening rate were reduced, onset of shortening delayed, and there was pre-ejection lengthening (P < 0.001). In diastole there was abnormal shortening during isovolumic relaxation, delaying the onset of long axis lengthening (P < 0.001). Peak lengthening rate was also reduced and A wave excursion increased (P < 0.001). Transmitral Doppler showed increased A wave velocity and reduced peak E/A diastolic flow velocities ratio (P < 0.001). Intraoperatively: preclamping results did not differ from those before operation. With clamping the extent of systolic and diastolic abnormalities promptly increased as to a lesser extent did those of transmitral flow velocity, although heart rate and blood pressure did not change significantly. Total long axis excursion and A wave amplitude were more reduced by aortic than iliac clamping, whereas the onset of lengthening was more delayed and the lengthening velocity more reduced with iliac clamping. Some 5 min after unclamping systolic long axis function had already returned towards normal; total excursion increased, as did the peak shortening rate, and the onset of shortening became less delayed (P < 0.001). In diastole the delayed onset of lengthening regressed, its lengthening velocity increased, and A wave excursion fell (P < 0.001). Early diastolic transmitral flow velocity also increased. This improvement in systolic and diastolic long axis function had progressed 15 min after unclamping but showed no further change at 5 days. At 5 days after operation, however, systolic and diastolic measurements had improved compared with those preoperatively. CONCLUSION: Resting left ventricular long axis function is abnormal in patients with combined coronary artery disease and peripheral vascular disease. It is unaffected by anaesthesia but deteriorates with aortic or iliac clamping, although blood pressure remains unchanged. It promptly improves with unclamping after successful peripheral arterial reconstruction. Thus, even in apparently stable coronary artery disease, resting subendocardial function is labile, showing pronounced alterations with changing after-load, even when arterial pressure itself does not change.

Blood Pressure↗
PubMed2006

Combined peripheral and coronary artery percutaneous intervention in patients with significant coronary and peripheral vascular disease. Case reports and review.

Combined percutaneous coronary and peripheral intervention in patients with coronary and peripheral vascular disease can be time and cost saving. Despite the potential benefit, such hybrid procedures have been rarely reported. We report two cases of hybrid peripheral and coronary intervention that were performed at our institution with excellent outcomes. This is followed by a review of the literature.

Catheterization↗
PubMed1991

Muscle carnitine deficiency in patients with severe peripheral vascular disease.

BACKGROUND: This study was designed to evaluate the effect of severe peripheral arterial insufficiency on carnitine concentrations and carnitine acetyltransferase and palmitoyltransferase activities in the ischemic skeletal muscles of patients with severe peripheral vascular disease. METHODS AND RESULTS: Nine biopsy specimens of ischemic muscles were obtained from five patients undergoing reconstructive vascular surgery. Biopsies from 35 normal subjects served as controls. Ischemic muscles showed a significant reduction in total carnitine from the control value of 20.9 +/- 5.2 to 11.6 +/- 6.2 nmol/mg noncollagen protein (p less than 0.01). A significantly lower free carnitine and acylcarnitine content contributed to this reduction. Similarly, carnitine acetyltransferase activity was reduced in the ischemic muscles from the control value of 102.1 +/- 41.2 to 52.9 +/- 22.1 nmol/min/mg noncollagen protein (p less than 0.01). On the contrary, carnitine palmitoyltransferase activity did not show any change (0.29 +/- 0.05 nmol/min/mg noncollagen protein in the ischemic muscles and 0.28 +/- 0.07 nmol/min/mg noncollagen protein in controls). Carnitine, acylcarnitines, and enzyme activities were also measured in the ischemic muscles in four additional patients 2 days after intravenous administration of L-propionylcarnitine (1.5 g as a single bolus followed by an infusion of 1 mg/kg/min for 30 minutes). Treatment restored normal levels of carnitine and its esters in the ischemic muscles but did not affect enzyme activities. CONCLUSIONS: Demonstration of carnitine deficiency in severe peripheral vascular disease substantiates previous findings showing the efficacy of carnitine supplementation to ischemic muscles. Furthermore, the feasibility of restoring carnitine homeostasis with L-propionylcarnitine provides the basis for clinical trials aimed at assessing the efficacy of this carnitine ester in the treatment of peripheral vascular disease.

Aged↗
PubMed1987

Limb salvage in the patient with severe peripheral vascular disease: the role of microsurgical free-tissue transfer.

Severe peripheral vascular disease has traditionally precluded the use of free-tissue transfer for lower extremity salvage. In the present series, 10 microvascular transfers performed over a 2-year period are critically evaluated. Vascular surgical consultation was obtained if the preoperative assessment revealed reconstructible vascular disease proximal to the offending wound. Flaps were performed for osteomyelitis in two cases and neurotrophic ulcers in eight cases. Seven of the 10 extremities had prior distal revascularization procedures before the tissue-transfer procedure. There were no anastomotic flap failures; however, one lower extremity underwent below-knee amputation due to sepsis and its cardiovascular sequelae. In properly selected peripheral vascular disease patients, limb salvage can be effected with microsurgical free-tissue transfer. The technique appears invaluable in those patients who have undergone prior contralateral amputation.

Aged↗
PubMed1997

Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus.

BACKGROUND: We assessed the value of the medical history and physical examination in the diagnosis of peripheral vascular disease in diabetic subjects. METHODS: We performed a cross-sectional study in 631 diabetic veteran enrollees of a general internal medicine clinic that compared data obtained from a history and clinical evaluation with the presence of severe peripheral vascular disease defined as an ankle-arm index (AAI) < or = 0.5 derived from Doppler blood pressure measurement. RESULTS: We identified 90 limbs with an AAI < or = 0.5. Results presented below apply to the right leg, but do not differ from the left. Diminished or absent foot peripheral pulses (sensitivity 65%, specificity 78%), venous filling time > 20 sec (sensitivity 22%, specificity 93.9%), age > 65 years (sensitivity 83%, specificity 54%), claudication symptoms in < 1 block (sensitivity 50%, specificity 87%), and patient reported history of physician diagnosed peripheral vascular disease (PVD) (sensitivity 80%, specificity 70%) had the largest positive (or smallest negative) likelihood ratios. Capillary refill time > 5 sec or foot characteristics (absent hair, blue/purple color, skin coolness, or atrophy) conveyed little diagnostic information. Individual factors did not change disease probability to a clinically important degree. A stepwise logistic regression model identified four factors significantly (p < 0.05) associated with low AAI: absent or diminished peripheral pulses, patient reported history of PVD, age, and venous filling time. Substitution of < 1 block claudication for PVD history in this model resulted in a small reduction in model accuracy. CONCLUSIONS: Many purportedly useful historical and exam findings need not be elicited in diabetic patients suspected of having severe peripheral vascular disease, since most information related to probability of this disorder may be obtained from patient age, self-reported history of physician diagnosed PVD (or < 1 block claudication), peripheral pulse palpation, and venous filling time.

Aged↗
PubMed1990

Effects and limitations of pentoxifylline therapy in various stages of peripheral vascular disease of the lower extremity.

One hundred one patients with peripheral vascular disease of the lower extremity were entered into a study of the efficacy of oral pentoxifylline to determine if the response to therapy varied with the severity of disease. Ninety-three patients were evaluated before and after 8 weeks of therapy with pentoxifylline, while 8 did not complete the entire course due to adverse drug reactions. Resting and post-stress ankle/arm Doppler indices (AAIs) were measured and, in those patients who could walk on a treadmill, treadmill walking distances were measured. Patients were classified according to pretreatment clinical and treadmill measurements and according to pretreatment resting AAIs. Resting and post-stress AAIs, as well as treadmill walking distances, increased in patients with moderately severe claudication. Patients in this group responded better to therapy than did patients with rest pain or ischemic ulcers, severe claudication, or mild claudication. Patients with a pretreatment resting AAI greater than or equal to 0.5 responded better than those with an AAI less than 0.5. Only 5% of patients reported satisfaction with the results of treatment. These results support the findings that pentoxifylline may be useful only in selected patients with moderately severe peripheral vascular disease of the lower extremity and may not be useful in those with severe or mild disease.

Diabetes Complications↗
PubMed1992

Risk factors for peripheral vascular disease in hypertensive subjects with type 2 diabetes mellitus.

Possible factors predisposing to peripheral vascular disease (PVD) in hypertensive subjects with Type 2 diabetes mellitus were studied. Details of age, sex, duration of diabetes, blood pressure, and smoking habit were recorded in 180 subjects of either White, West Indian Black or Asian ethnic origin. Glycosylated haemoglobin, fasting serum total cholesterol, total high density lipoprotein (HDL), HDL2, low density lipoprotein (LDL-cholesterol), and triglycerides were measured in all subjects. Peripheral vascular disease was defined as an ankle/brachial systolic pressure < 1.0 as measured by the Doppler technique. Multivariate analysis was performed and the following factors were identified as being strongly associated with the presence of PVD with a statistical significance of p < 0.001; LDL-cholesterol, total HDL-cholesterol, age, male sex, diet or oral hypoglycaemic therapy, diastolic blood pressure, and of p < 0.003; systolic blood pressure. When blood pressure was excluded from the analysis the other factors retained their predictive value. We conclude that hypertension and dyslipidaemia are important risk factors for peripheral vascular disease in Type 2 diabetes mellitus.

Blood Pressure↗
PubMed1989

Plasma histamine concentrations are elevated in patients with diabetes mellitus and peripheral vascular disease.

Previous work has shown that plasma and tissue concentrations of histamine are elevated in rats with experimental diabetes mellitus and that leucocytes and platelets from patients with peripheral vascular disease have a higher histamine content than those from controls. In the present study, we have measured: (a) plasma histamine concentrations; (b) leucocyte and platelet histidine decarboxylase (the enzyme responsible for the biosynthesis of histamine) in patients with diabetes mellitus (Types I and II) and peripheral vascular disease; and (c) platelet and leucocyte histamine content. Plasma histamine concentration was significantly higher in patients with diabetes and peripheral vascular disease respectively than that in age-matched controls. Leucocyte histidine decarboxylase activity in diabetic and peripheral vascular disease patients was similar to that in controls, while platelets had no histidine decarboxylase activity. The leucocyte and platelet content of histamine were greater in patients with peripheral vascular disease than those in controls, but they were not altered in diabetic patients. There was no correlation between plasma histamine concentration, leucocyte and platelet histamine content, and histidine decarboxylase activity. We conclude that plasma histamine is elevated in diabetics and in patients with peripheral vascular disease and that platelet and leucocyte histamine content is increased in the latter. This increase in platelet and leucocyte histamine content is not due to an increase in histidine decarboxylase activity of these cells. The increase in plasma and cellular histamine content may contribute to the pathogenesis of increased endothelial permeability in diabetes and to the pathogenesis of intimal damage in atherosclerosis.

Adult↗
PubMed2003

Peripheral vascular disease and one-year mortality following percutaneous coronary revascularization.

The association between peripheral vascular disease and outcomes after percutaneous coronary intervention was examined in the Do Tirofiban and Reopro Give Similar Efficacy Outcome Trial (TARGET). After adjustments in a multivariate model, a history of peripheral vascular disease was found to be associated with a two- to threefold increase in mortality at 1 year after coronary stent placement.

Aged↗
PubMed1988

Doppler sonographic examination of reactive hyperemia in the diagnosis of peripheral vascular disease.

Fifty-four patients with angiographically confirmed peripheral vascular disease (PVD) were examined in order to find out whether the occlusive form of this disease can be better diagnosed by measuring the reappearance time and mean velocity of the blood flow during reactive hyperemia than by determining the peripheral systolic blood pressure, using Doppler ultrasound for both measurements. It was shown that the Doppler pressure was only reliable for a screening diagnosis of PVD. However, using the reappearance time of reactive hyperemia, it was possible to distinguish specific localization types of sclerosis; while reactive hyperemia already reached its half maximum in controls in 4.6 s this occurred in the stenosis type of PVD after 6.9 s, in the upper leg occlusion type after 21.6 s, in the lower leg occlusion type after 46.6 s, and in the multilevel disease after 70.1 s. The delay in the half-maximum reappearance time was significantly different, not only in comparison with controls (P less than 0.001) but also in the specific types of occlusive PVD as compared with one another (P less than 0.01). Regarding the intensity of velocity it could also be shown that the mean velocity of blood flow during reactive hyperemia was lower in all patients with PVD than in controls. Again this alteration during reactive hyperemia was significant, not only in comparison with controls (P less than 0.001), but also when the specific stages of severity according to Fontaine were compared with one another (P less than 0.05).2+n the basis of these findings it can be stated that in

Arterial Occlusive Diseases↗
PubMed2006

Occult renal impairment is common in patients with peripheral vascular disease and normal serum creatinine.

OBJECTIVE: The incidence of peripheral vascular disease (PVD) and angiography/angioplasty is rising annually. The UK Small Aneurysm Trial and other trials have shown renal function is a predictor of increased mortality and failed infrainguinal bypass despite patent vessels. Renal function is classically assessed by serum creatinine (SCr). However, SCr can be normal despite significant renal impairment. A more sensitive test is creatinine clearance (CrCl) as determined by 24-hour urine collection in combination with SCr. We studied the incidence of renal impairment, as defined by CrCl, in PVD patients with normal SCr. METHODOLOGY: All patients with PVD sufficient to necessitate angiography and normal SCr (< or =120 micromol/l - men; < or =97 micromol/l - women) had their CrCl assessed prior to angiography: using both 24-hour urine collection and the Cockcroft-Gault formula. Various blood tests, a detailed history and examination were performed. A control group of arthritic patients, age and sex-matched with similar SCr, also had their CrCl determined. RESULTS: 65 of 76 patients (86%) with normal SCr had a subnormal CrCl (<100 ml/min) and 49 (65%) had a CrCl below 60 ml/min. In the control group of arthritic patients, the proportion having impaired CrCl was significantly less - 67% below 100 mls/min (p=0.0471) and only 15% below 60 mls/min (p<0.0001). The median and interquartile range CrCl of 52 [38-81] mls/min for PVD patients was significantly worse than for control patients (80 [68-119] mls/min -p<0.0001). The Cockcroft-Gault formula for calculating CrCl did not correlate well with the urinary CrCl for the control group but did for PVD patients (p<0.0001). Factors associated with a significantly reduced CrCl were age of at least 75 years, SCr of at least 85 micromol/l and a history of coronary heart disease (all p<0.05). This had a sensitivity of 88% and specificity of 82% for identifying subnormal CrCl. Statin use was associated with a significantly improved CrCl (p=0.040). CONCLUSION: Most PVD patients with normal serum creatinine have occult, significantly impaired renal function as defined by creatinine clearance. Vascular surgeons should include creatinine clearance in pre-operative assessment of renal function especially in patients over 75 years old, with a history of coronary heart disease or a serum creatinine over 85 micromol/l. The method of determining creatinine clearance could be the Cockcroft-Gault calculation or ideally 24-hour urinary creatinine clearance measurement. This would allow appropriate early referral to a nephrologist for further investigation and management. It is worth noting that statin use seems to be associated with a protective effect on renal function.

Aged↗
PubMed1995

Prospective evaluation of peripheral vascular disease in heart transplant recipients.

PURPOSE: Retrospective reviews suggest that the progression of peripheral vascular disease (PVD) may be accelerated in heart transplant recipients. This study was undertaken to determine the incidence and to identify those risk factors that may be associated with the development or progression of PVD in these patients. METHODS: Between January 1990 and December 1993 a prospective vascular screening protocol including abdominal ultrasonography, Doppler-derived ankel-brachial pressure indexes (ABI), and carotid artery duplex imaging was added to the routine preoperative and annual postoperative evaluation of 239 heart transplant recipients. RESULTS: Thirty-one significant vascular lesions were detected in 10% (24 of 239) of patients 52 +/- 9 years of age at a mean of 3.2 years after transplant. The distribution of lesions included carotid artery stenosis (11), femoropopliteal occlusive disease (10), aortoiliac occlusive disease (five), aortic aneurysm (four), and renal artery stenosis in one patient. Revascularization procedures were performed in 12 (50%) patients (carotid endarterectomy (four), aortobifemoral bypass grafting (three), abdominal aortic aneurysm repair (two), transluminal angioplasty (two), splenorenal bypass (one), and femorotibial bypass grafting (one)). One patient with diabetes mellitus (DM) was found to have noncompressible vessels during pretransplant evaluation. An additional 26 patients (11%), seven with DM, had noncompressible vessels in the lower extremities during the follow-up period. Logistic regression analysis revealed that the development of posttransplant PVD was associated with smoking (p < 0.05) and ischemic cardiomyopathy as an indication for transplantation (p < 0.05). The development of noncompressible vessels was associated with younger age (p < 0.05) and the presence of diabetes (p < 0.05). CONCLUSION: Posttransplant peripheral vascular disease occurred in 10% of heart transplant recipients and is associated with pretransplant ischemic cardiomyopathy and smoking. A previously unrecognized subgroup of patients who have noncompressible vessels after operation is described. If the long-term survival of the heart transplant recipient is to be improved, routine follow-up to identify and treat those patients at greater risk appears justified.

Adolescent↗
PubMed2002

Impaired carotid and femoral viscoelastic properties and elevated intima-media thickness in peripheral vascular disease.

BACKGROUND: We undertook a study to determine whether peripheral vascular disease of the lower extremity (PVD) per se affects the arterial viscoelastic properties and intima-media thickness (IMT) of the carotid and femoral arteries. METHODS: Thirty-five patients with PVD, 35 age- and gender-matched control subjects were examined with ultrasound scan wall tracking system, with the simultaneous measurement of blood pressure for carotid and femoral IMT and viscoelastic properties. RESULTS: Subjects with PVD have significantly impaired carotid elastic properties including compliance (mean (SD): 6.50 (2.39) vs 9.93 (4.07) %mmHg(-1)x10(-2), P<0.001), Petersen's elastic modulus (1.77 (0.69) vs 1.19 (0.63) mmHg x 10(3), P=0.001) and stiffness index (17.92 (7.21) vs 12.10 (6.17), P=0.001) when compared to non-PVD controls. They also have significantly altered femoral elastic properties including Petersen's elastic modulus (5.94 (4.98) vs 3.64 (3.27) mmHg x 10(3), P=0.025) and stiffness index (58.42 (47.76) vs 36.96 (33.43), P=0.033). The carotid (0.85 (0.35) vs 0.59 (0.23) mm, P<0.001) and femoral (1.05 (0.39) vs 0.69 (0.31) mm, P<0.001) IMTs are also significantly elevated in PVD patients. After adjustment for the presumed cardiovascular load assessed on the basis of a cumulative total vascular risk score, as well as age, systolic and diastolic pressure, the carotid viscoelastic indices and the carotid and femoral IMTs remained highly significant. However, the difference in femoral elastic variables was no longer evident. CONCLUSION: PVD per se affects the femoral and carotid wall mechanics and morphology similarly to other cardiovascular risk factors and events. These parameters may provide further information for cardiovascular risk assessment in addition to the classical risk factors and the Framingham equation. Indeed, some guidelines have suggested that additional factors such as the carotid scan may influence the clinician's decision to intervene with therapy.

Aged↗