A Novel Angiographic Risk Score for Femoropopliteal Interventions

Purpose To present a novel angiographic scoring system that stratifies the risk of restenosis after endovascular therapy (EVT) to inform the decision to use paclitaxel-eluting devices in the femoropopliteal segment. Materials and Methods A prospective, multicenter registry including 1799 limbs of 1578 patients (mean age 74±9 years; 1090 men) with symptomatic peripheral artery disease undergoing intravascular ultrasound–supported femoropopliteal EVT was used as the basis for developing the angiographic score. Multivariable analysis identified baseline patient and limb characteristics associated with restenosis at 12 months. These risk factors for 12-month restenosis were explored using a generalized linear mixed model with a logit-link function in which the inter-institutional and inter-subject variability were treated as random effects. The multiple imputation method was adopted to address missing data. Results of the regression analysis are presented as the odds ratio (OR) with 95% confidence interval (CI). Results Twelve-month primary patency was estimated to be 65.1% (95% CI 62.7% to 67.5%). After multivariable analysis, distal reference vessel diameter per 1 mm (OR 0.71, 95% CI 0.62 to 0.81, p<0.001), lesion length per 10 cm (OR 1.39, 95% CI 1.19 to 1.62, p<0.001), and chronic total occlusion (OR 1.56, 95% CI 1.15 to 2.10, p=0.004) were independently associated with the 12-month restenosis risk, whereas baseline patient risk factors were not. Compared to bare nitinol stent implantation, plain angioplasty (OR 2.31, 95% CI 1.67 to 3.18, p<0.001) was independently associated with a higher risk of 12-month restenosis, while drug-eluting stents (OR 0.65, 95% CI 0.43 to 0.99, p=0.045) and stent-grafts (OR 0.24, 95% CI 0.12 to 0.50, p<0.001) were independently associated with a lower risk of 12-month restenosis. The angiographic score, which was developed by using the 3 angiographic factors but not the TransAtlantic Society Consensus II (TASC) class, was significantly and independently associated with 12-month restenosis. Conclusion The current study demonstrated a novel angiographic score for 12-month restenosis after femoropopliteal EVT in a real-world clinical practice. The developed score was significantly and independently associated with the 12-month restenosis risk, but the TASC class was not.

The Cost of Materials for Intra-Arterial Thrombectomy

This paper reports the cost of endovascular materials used for the treatment of large-vessel ischemic stroke in the anterior circulation according to the angiographic score and clinical results at three months. From November 2009 to July 2011, 57 ischemic patients (mean age, 64.6 ±13.8 years) with anterior large vessel occlusion were included. Mean National Institutes of Health Stroke Scale (NIHSS) on admission was 18.4 ± 4.9. Mean duration of symptoms until the arterial puncture was 207±67 minutes. Recanalization was assessed using the Thrombolysis In Myocardial Infarction (TIMI) score. Patient selection was performed on a non-enhanced CT scanner. According to the TIMI final angiographic score and the modified Rankin score (mRS) at three months, we determined the cost of the material used. Complete (n=12, TIMI grade 3) or partial perfusion (n=35, TIMI grade 2) was achieved in 47 (82.5%) lesions. At three months, 33.3% (n=19) had a mRS score ≤ 2. The mean cost of the material used in the operative room was 5018±2402 euro. Intra-arterial thrombolysis presents a substantial initial cost and the long-term economic impact has to be evaluated. Our health system has to take the price of these new technologies into account for future medical choices and urgently evaluate them in randomized controlled trials.

Abstract 3666: Major Role of Ly6chi/7/4hi/ccr2+ Monocytes in Post-ischemic Neovascularization

Circulating mouse monocytes consist of two main subsets, Ly6CHi7/ 4HiCCR2+CX3CR1loCCR5+ and Ly6Clo7/4loCCR2-CX3CR1HiCCR5+ monocytes.We sought to investigate their respective role in postischemic neovascularization and unravel the mechanisms involved in their recruitment to ischemic tissues. Postischemic neovascularization was impaired in MCP-1−/− or CCR2−/− but not in CCR5−/− or CX3CR1−/− mice with operatively-induced hindlimb ischemia (n=10 per groups). Overexpression of MCP-1 in the ischemic muscle by plasmid electrotransfer improved foot perfusion, angiographic score and capillary density by 1.4-, 1.8- and 1.4-fold, respectively (p<0 .01 versus control). In contrast, overexpression of Fractalkine or Rantes, the ligands of CX3CR1 and CCR5 respectively, had no significant effects (n=10 per groups) suggesting that recruitment of 7/4HiCCR2+ monocytes play a significant role in this setting. In this line, flow cytometry analysis revealed that monocytes infiltration in ischemic muscle peaked at day 3 and dropped to levels comparable to those in non ischemic muscle on day 7. 7/4Hi monocytes predominated from day 1 to day 3 (52% of infiltrated Cd11b+ cells) whereas 7/4lo prevailed from day 7 onward. MCP-1 or CCR2 deficiency fully abrogated infiltration of both monocytes subsets, while overexpression of MCP-1 in the ischemic muscle selectively increased 7/4Hi monocytes infiltration (287% of wild-type, p<0.05). In contrast, monocytes subsets infiltration was slightly reduced in CX3CR1−/− mice (p<0.05 versus MCP-1−/−) and unchanged in CCR5−/− mice. Interestingly, MCP-1 deficiency or upregulation also led to changes in monocyte subtypes levels in both bone marrow and blood. MCP-1/CCR2 signaling plays a major role in monocytes mobilization from the bone marrow and recruitment to the ischemic tissue. We also suggest that inflammatory 7/4Hi/CCR2 monocytes represent a major component of the inflammatory response in post-ischemic neovascularization.

Prothrombotic activity is associated with the anatomical as well as the functional severity of peripheral arterial occlusive disease

SummaryThe importance of prothrombotic activity in cardiovascular disease has been well established. However, limited data exist on the relationship between prothrombotic activity and the severity of peripheral arterial occlusive disease (PAD).The objective of the present study was to investigate the relationship between markers of haemostasis and the diagnostic measures of PAD: ankle-brachial-index (ABI), maximum treadmill walking distance and angiographic score. In a cross-sectional study of 127 patients (mean age 66 years; 64% males) with angiographically verified PAD, fasting blood samples were drawn, and citrated plasma was obtained for determination of selected haemostatic variables: von Willebrand factor (vWF), thrombomodulin (sTM), thrombin-antithrombin complex (TAT), soluble tissue factor (sTF), tPA antigen (tPAag) and D-dimer were all significantly correlated with the angiographic score (p<0.05 for all). D-dimer, tPAag and fibrinogen were inversely correlated with the maximum treadmill walking distance, (p<0.0001, p<0.04 and p<0.05, respectively), whereas fibrinogen was the only variable correlating to ABI (r = –0.223, p<0.05). After adjustment for relevant covariates, D-dimer and TAT remained statistically significantly associated with the angiographic score (p<0.001), and fibrinogen was, independent of other risk factors, inversely related with both the maximum treadmill walking distance and the ABI (p<0.01 for both).This rather large study in patients with PAD showed that plasma levels of D-dimer, TAT and fibrinogen significantly predicted the extent of atherosclerosis, evaluated by angiographic score, maximum treadmill walking distance and ABI, respectively. These findings demonstrate a prothrombotic state in PAD patients, which might be of importance in future diagnosis and treatment of the disease.