Highlights From the 2023 Vascular Scientific Sessions
- Patients with peripheral artery disease (PAD) that were identified by community screening had greater walking impairment and a higher proportion of people identified as Black, compared to patients with established disease.
- Endovascular intervention was associated with fewer in-hospital complications, readmissions, and costs compared to open repair in patients with symptomatic PAD, according to two large observational trials.
- DNA catalytic enzyme (DNase) may be a promising adjuvant therapy to tissue plasminogen activator (tPA) for stroke thrombolysis, as it targets the deoxyribonucleic acid (DNA) component of thrombus and may improve lysis efficacy.
The 2023 Vascular Scientific Sessions, presented by the Society of Vascular Medicine, were held this year in Washington, D.C. This annual international meeting showcased the latest advances and breakthroughs in clinical, basic science and translational research, as well as lively discussions, debates, and hands-on workshops. Here are a few highlights:
1. Health Equity in Peripheral Artery Disease (PAD)
Sociodemographic factors are associated with worse outcomes in patients with PAD.1,2 Disparity in the prevention, diagnosis, and treatment of PAD was given the stage with emphasis on addressing socioeconomic and cultural barriers through multidisciplinary teams to advance PAD prevention, diagnosis, and treatment. One of the studies presented is described below.
Characteristics of People with PAD Identified with Ankle Brachial Index Testing in Three U.S. Cities.3
Presented by Cetlin et al.
Cetlin et al. compared the demographic characteristics of patients with PAD, defined as an ankle brachial index (ABI) <0.90 during community screening for randomized trials, with the characteristics of patients with established PAD diagnosis, in three U.S. metropolitan cities. There were 2,431 patients (age >50 years old) identified with walking difficulties in the community who used mailed postcards and subsequent ABI testing. Of those, 499 (20.5%) had an ABI <0.90. Compared to 184 PAD patients that were identified from a medical center in the same cities, those with PAD identified from the community had significantly greater walking impairment and included a higher proportion of people who identified as Black.
2. Endovascular Intervention Versus Open Surgical Approach in PAD
The optimal revascularization strategy for symptomatic lower extremity PAD remains an ongoing area of investigation, and recent guidelines do not strongly favor one approach over another.4 While recent randomized clinical trials continued to be analyzed and their implications on clinical practice discussed,5-7 the results of two observational population-based studies were presented.
Symptomatic Below-Knee Peripheral Artery Disease: Does Mode of Intervention Matter? 8
Presented by Asmar et al.
Asmar et al. queried the Nationwide Readmissions Database (2018) for patients that presented with below knee PAD, stratified to endovascular or open surgical approach. Complications, length of stay, 30-day readmission, and hospital charges were compared between the groups. Among 17,096 eligible patients, 1,992 underwent open repair and were matched with 1,992 patients that underwent endovascular repair. Patients undergoing endovascular repair had fewer in-patient acute kidney injury and compartment syndrome complications, and lower hospital charges. Patients with open repair were more likely to be discharged to other rehabilitation facilities (32.5 vs. 19.8%, p< 0.001). There was no difference between the groups with respect to in-hospital mortality (p=0.069) and 1-month rehospitalization (p=0.427).
Open Surgical versus Endovascular Repair of Symptomatic Above-Knee Peripheral Artery Disease: Is Old Still Gold?9
Presented by Asmar et al.
The same group presented results from the Nationwide Readmissions Database (2018), comparing outcomes of 18,652 patients who presented with above-knee PAD and underwent open surgical intervention with a matched group of 18,652 patients that underwent endovascular intervention. Patients undergoing endovascular repair had fewer in-patient complications including deep vein thrombosis, seroma/hematoma, sepsis, and compartment syndrome. Hospital charges were lower with endovascular approach, as was inpatient mortality (2.4 vs. 1.8%, p=0.002) and patients with open repair were more likely to be discharged to other rehabilitation facilities and more likely to be readmitted within 1 month. The 6-month readmission rate with new arterial thrombosis was lower with endovascular repair (23.8% vs. 26.7%, p< 0.001).
Using population-based data, the authors demonstrated lower rates of in-hospital complications, readmissions, and costs with endovascular approach in PAD patients that require intervention, and urged for further evaluation of its indications, risks, and benefits.
3. Basic and Translational Research in Acute Stroke Treatment
Differences in Proteomic Composition of Retrieved Stroke Emboli Associated with Susceptibility to In Vitro Thrombolysis.10
Presented by Akkipeddi et al.
Fibrin, von Willebrand factor, and extracellular DNA from neutrophil extracellular traps (NETs) all contribute to acute ischemic stroke (AIS) thrombus integrity.11 This study demonstrated a synergistic effect of DNA catalytic enzyme (DNase) and tissue plasminogen activator (tPA) in the in-vitro lysis of stroke emboli clot extracts in 26 patients with AIS. Proteomic analysis suggested that the DNA composition of clots is associated with decreased residual clot when subjected to DNase in addition to tPA. These results imply that the addition of DNase to tPA may be a more effective way to lyse stroke emboli, and that DNase may be a potential pharmacologic target in the treatment of AIS.
- Martinez OP, Storo K, Provenzano Z, Murphy E, Tomita TM, Cox S. A systematic review and meta-analysis on the influence of sociodemographic factors on amputation in patients with peripheral arterial disease. J Vasc Surg 2023;Sep 16:[ePub ahead of print].
- GBD 2019 Peripheral Artery Disease Collaborators. Global burden of peripheral artery disease and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Glob Health 2023;11:e1553-e1565.
- Cetlin M, Kim ESH, Xu S, Zhao L, Tian L, McDermott MM. Characteristics of people with PAD identified with ankle brachial index testing in three U.S. cities. Presented at the 2023 Vascular Scientific Sessions, Washington, D.C. September 9, 2023.
- Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;69:1465-1508.
- Farber A, Menard MT, Conte MS, et al; BEST-CLI Investigators. Surgery or endovascular therapy for chronic limb-threatening ischemia. N Engl J Med 2022;387:2305-16.
- Bradbury AW, Moakes CA, Popplewell M, et al.; BASIL-2 Investigators. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet 2023;401:1798-1809.
- Conte MS, O'Banion LA. Apples and oranges? A comparison of BEST-CLI to BASIL-2. J Vasc Surg 2023;78:265-68.
- Asmar S, Sakr F, Aridi H,et al. Symptomatic below-knee peripheral artery disease: does mode of intervention matter? Presented at the 2023 Vascular Scientific Sessions, Washington, D.C. September 8, 2023.
- Asmar S, Aridi H, Sakr F, et al. Open surgical versus endovascular repair of symptomatic above-knee peripheral artery disease: is old still gold? Presented at the 2023 Vascular Scientific Sessions, Washington, D.C. September 8, 2023.
- Akkipeddi SK, Rahmani R, Ellens NR, et al. Differences in proteomic composition of retrieved stroke emboli associated with susceptibility to in vitro thrombolysis. Presented at the 2023 Vascular Scientific Sessions, Washington, D.C. September 8, 2023.
- Murray V, Norrving B, Sandercock PAG, Terent A, Wardlaw JM, Wester P. The molecular basis of thrombolysis and its clinical application in stroke. J Intern Med 2010;267:191-208.
Keywords: Health Equity, Peripheral Arterial Disease, Endovascular Procedures, Stroke
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