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Aims Evidence regarding the health burden of chronic venous insufficiency (CVI), its clinical determinants, and impact on outcome is scarce. Methods and results Systematic phenotyping of CVI according to established CEAP (Clinical-Etiologic-Anatomic-Pathophysiologic) classification was performed in 12 423 participants (age range: 40–80 years) of the Gutenberg Health Study from April 2012 to April 2017. Prevalence was calculated age- and sex-specifically. Multivariable Poisson regression models were calculated to evaluate the relation of CVI with cardiovascular comorbidities. Survival analyses were carried out to assess the CVI-associated risk of death. Replication of findings was done in an independent cohort study (MyoVasc, NCT04064450). The prevalence of telangiectasia/reticular, varicose veins, and CVI was 36.5% [95% confidence interval (CI), 35.6–37.4%], 13.3% [12.6–13.9%], and 40.8% [39.9–41.7%], respectively. Age, female sex, arterial hypertension, obesity, smoking, and clinically overt cardiovascular disease were identified as clinical determinants of CVI. Higher CEAP classes were associated with a higher predicted 10-year risk for incident cardiovascular disease in individuals free of cardiovascular disease (n = 9923). During a mean follow-up of 6.4 ± 1.6 years, CVI was a strong predictor of all-cause death independent of the concomitant clinical profile and medication [hazard ratio (HR) 1.46 (95% CI 1.19–1.79), P = 0. 0003]. The association of CVI with an increased risk of all-cause death was externally validated in the MyoVasc cohort [HR 1.51 (95% CI 1.11–2.05), P = 0.009]. Conclusion Chronic venous insufficiency is highly prevalent in the population and is associated with the presence of cardiovascular risk factors and disease. Individuals with CVI experience an elevated risk of death, which is independent of age and sex, and present cardiovascular risk factors and comorbidities.

The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient’s ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.

Mehr als 200 Mio. Menschen weltweit leiden an einer peripheren arteriellen Verschlusskrankheit (pAVK). Da die pAVK ein signifikanter Risikofaktor fur das Auftreten von akuten vaskularen Ereignissen ist und demzufolge auch die Lebenserwartung der Betroffenen erheblich reduziert ist, gelten sie als Hochrisikopatienten. Die antithrombotische Therapie zahlt zu den wichtigsten medikamentosen Eckpfeilern in der Prophylaxe dieser Ereignisse, aber der Effekt einer ASS(Acetylsalicylsaure)-basierten antithrombozytaren Monotherapie ist begrenzt. Nun gibt es erstmals Hinweise, dass eine Kombination von ASS-basierter Monotherapie mit niedrig dosierter Antikoagulation (Rivaroxaban 2‑mal 2,5 mg) einen signifikanten zusatzlichen Nutzen fur interventions- und nichtinterventionspflichtige Patienten mit symptomatischer pAVK erreichen kann. Diese neuen Erkenntnisse wurden aktuell in Leitlinien thematisiert und in neuen Empfehlungen zusammengefasst und haben erheblichen Einfluss auf die peri- und postinterventionelle antithrombotische Therapie von pAVK-Patienten.

Was ist neu? Gerinnungshemmende Therapie nach peripherer Intervention In Analogie zur Koronarintervention wird nach Katheterinterventionen peripherer Gefäße meist passager eine duale Thrombozytenaggregationshemmung (TZAH) mit ASS 100 mg und Clopidogrel 75 mg durchgeführt. Größere Studien zu diesem Vorgehen fehlten bisher und die Empfehlungen der aktuellen Leitlinien haben den Charakter eines Expertenkonsens. Gerinnungshemmende Therapie nach peripherer Bypassoperation Nach peripherer Bypassanlage empfehlen die aktuellen Leitlinien in der Regel die Monotherapie mit einem TZAH (ASS 100 mg oder Clopidogrel 75 mg). In Einzelfällen wird bei venösen Bypässen eine orale Antikoagulation oder bei Kunststoffbypässen eine duale TZAH eingesetzt. Diese Empfehlungen beruhen jedoch auf wenigen, teils kleinen Studien. Duale gerinnungshemmende Therapie mit niedrigdosiertem Rivaroxaban und ASS Die VOYAGER-PAD-Studie ist mit 6564 Patienten die größte randomisierte Studie zur gerinnungshemmenden Therapie nach Revaskularisation. Es wurde das Konzept einer niedrigdosierten Rivaroxaban-Gabe (2-mal 2,5 mg) plus ASS 100 mg nach erfolgreicher peripherer Revaskularisation untersucht. Die Studie zeigte unter der Kombinationstherapie im Vergleich zur Therapie mit ASS 100 mg allein eine signifikant niedrigere Inzidenz des kombinierten Endpunkts aus akuter Extremitätenischämie, Amputation, Myokardinfarkt, ischämischem Schlaganfall oder Tod aus kardiovaskulärer Ursache. Getriggert wurde dieses Ergebnis primär durch die Reduktion von akuten Gefäßverschlüssen. Es kam zwar insgesamt zu mehr klinisch relevanten Blutungen unter der Kombinationstherapie, eine Erhöhung von intrazerebralen oder vital bedrohlichen Blutungen zeigte sich jedoch nicht. Wenn man Risiko und Nutzen in Bezug setzt, dann verhindert in einer Population von 10 000 Patienten die zusätzliche Gabe von Rivaroxaban 2-mal 2,5 mg pro Jahr 181 primäre Endpunkte auf Kosten von 29 relevante Blutungen.

Oscillometry is an alternative to continuous-wave Doppler (cw-Doppler) to determine peripheral artery disease (PAD) severity using the ankle-brachial index (ABI). cw-Doppler ABI differentiates systolic pressure of ATP and ADP where either one of both values in most patients is higher (high) and the other value is lower (low). In contrast, oscillometric ABI measures the strongest signal and hence misses the lower value. Both do not take pedal perfusion into consideration. Simultaneous determination of tissue microperfusion cares for pedal PAD. ABI was determined by cw-Doppler and oscillometry. Tissue optical perfusion pressure (TOPP) was taken from the first toe using photoplethysmography. 323 patients were evaluated retrospectively in 3 independent groups.

Summary: More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.

Background Isolated PE is associated with a higher burden of atherosclerotic disease than other manifestations of VTE. Research Question We hypothesized that the presence of isolated PE may signal a chronically elevated risk of arterial thrombotic disease. Study Design and Methods Data from the VTEval Study, a prospective cohort study enrolling individuals with clinical suspicion and imaging-based diagnosis or exclusion of VTE, were analyzed. Patients with PE received whole-leg ultrasonography to assess presence of DVT. Regularized logistic regression identified features that discriminate between isolated PE and other VTE phenotypes at clinical presentation. Survival analyses were performed to evaluate the crude and adjusted 3-year risks of arterial thrombotic disease, recurrent VTE, and death. Results The sample comprised 510 patients. Isolated PE patients (n = 63) had a distinct clinical profile from patients with other VTE phenotypes (n = 447). COPD, peripheral artery disease, atrial fibrillation, and coronary artery disease were significantly more prevalent among patients with isolated PE. Isolated PE patients had significantly higher risk (incidence rate ratio vs DVT-associated PE, 3.7 (95% CI, 1.3-10.8, P = .009); vs isolated DVT, 4.8 (1.7-14.3, P = .001) of arterial thrombotic events (ie, myocardial infarction, stroke/transient ischemic attack). After adjustment for clinical profile and medication intake, the risk of arterial thrombotic events for patients with isolated PE remained quadruple that of other VTE phenotypes (hazard ratio [HR], 3.8 [1.3-10.9], P = .01). Interpretation Patients with isolated PE are at higher risk for arterial thrombosis and may require screening for arterial disease and development of novel therapeutic strategies. Clinical Trial Registration NCT02156401

As a result of the successful completion of their respective phase III studies compared with vitamin K antagonists (VKAs), four direct oral anticoagulants (DOACs) have been approved for the treatment and secondary prevention of venous thromboembolism (VTE). These DOACs—apixaban, dabigatran, edoxaban, and rivaroxaban—have subsequently seen a steady uptake among clinicians since their approval. Despite the suitability of DOACs for a broad range of patients, they are not appropriate in certain situations, whereas in others they require additional considerations such as dose reductions. Subanalyses of phase III trials and studies on specific VTE patient populations have been conducted to evaluate the safety and efficacy of the DOACs in a broad range of settings, such as patients with renal impairment, patients with cancer, patients of childbearing potential, patients with multiple comorbidities and pediatric patients. Furthermore, many recent guidance documents from important hematological societies and other specialists have incorporated several of these developments. These documents also identify the patients for whom DOACs are not suitable and where traditional anticoagulation options such as heparins or VKAs should be considered instead. This review provides an overview of key VTE patient subgroups, the clinical evidence supporting the use of anticoagulation in these patients, and a discussion of the most appropriate approaches to their management, including considerations such as dosing, acute and extended treatment durations, and DOAC selection.

Objective The objective of this study was to analyze the outcome of a contemporary series of femoropopliteal bypass operations with the glutaraldehyde denatured polyester mesh-reinforced ovine collagen prosthesis (OCP; Omniflow II [LeMaitre Vascular, Inc, Burlington, Mass]). The experience of two tertiary centers regarding long-term graft function, secondary reinterventions, and biodegeneration of the OCP prosthesis is presented. Methods Between January 2006 and January 2014, a series of 205 consecutive operations with the OCP in the femoropopliteal position (54 above knee and 151 below knee) were performed in 194 patients in 202 limbs for disabling claudication (72), chronic critical ischemia (105), acute ischemia (18), popliteal artery aneurysm (4), degeneration of a venous or prosthetic graft (5), and infection of a synthetic bypass graft (1). Grafts were observed with duplex ultrasound scan supplemented by additional angiography in case of recurrent ischemia with prospective documentation of follow-up data in a computerized vascular database. Retrospective analysis of graft patency, limb salvage, and diagnosis of aneurysmal graft degeneration was performed. Results The 30-day mortality was 3.9%. Early thrombotic bypass occlusion occurred in 8.2% of cases. Four early graft infections could be successfully managed by local treatment with graft preservation. After a mean (median) follow-up of 56 (55) months (range, 1-135 months), primary patency, primary assisted patency, secondary patency, and limb salvage were 71%, 78%, 78%, and 91% for above-knee bypass and 40%, 50%, 63%, and 87% for below-knee bypass at 5 years. Biodegeneration in the form of graft aneurysm or graft stenosis was detected in 26 grafts (12.6%), resulting in secondary open or endovascular procedures in 16 cases. Conclusions The OCP provides satisfactory medium- and long-term patency and limb salvage in the femoropopliteal position. Aneurysmal degeneration or graft stenosis may develop over time, demanding lifelong duplex ultrasound surveillance and secondary intervention if needed. Its possible infection-resistant behavior in a contaminated field combined with an acceptable graft patency and limb salvage justifies the use of this graft in the absence of autologous vein.

Die periphere arterielle Verschlusskrankheit (pAVK) ist eine haufige Manifestation der Atherosklerose mit hohem Risiko fur kardiovaskulare Ereignisse. Als Screening nach einer pAVK dient die Messung des ABI („ankle-brachial index“). Man unterscheidet das stabile Stadium der Claudicatio intermittens vom Stadium der kritischen Extremitatenischamie (CLI „critical limb ischemia“). In der Therapie sind eine Nikotinkarenz sowie die lipidsenkende Therapie mit Statinen und einem Ziel-LDL(„low-density lipoprotein“)-Cholesterin von weniger als 55 mg/dl zentrale Elemente. Bei Patienten mit symptomatischer pAVK ist eine Thrombozytenaggregationshemmung indiziert. Neben Clopidogrel 75 mg oder Acetylsalicylsaure (ASS) 100 mg kann bei hohem Risiko auch eine Kombinationstherapie von ASS 100 mg und 2‑mal 2,5 mg Rivaroxaban zum Einsatz kommen. Bei kritischer Extremitatenischamie ist immer eine Revaskularisation (perkutane Intervention, Operation) zum Extremitatenerhalt indiziert. Bei Claudicatio intermittens ist das zentrale Element der Therapie ein Gehtraining, eine Revaskularisation kommt bei hohem Leidensdruck zum Einsatz.

Background. Venous thromboembolism is a frequent complication and an important cause of death in patients with paralysis. We aimed to investigate predictors of pulmonary embolism (PE) and the impact of PE on the survival of patients with paralysis in comparison to those with deep venous thrombosis or thrombophlebitis (DVT). Methods: Patients were selected by screening the German nationwide inpatient sample (2005–2017) for paralysis, and were stratified for venous thromboembolism (VTE) and the VTE-sub-entity PE (ICD-code I26). Impact of PE on mortality and predictors for PE were analyzed. Results: Overall, 7,873,769 hospitalizations of patients with paralysis were recorded in Germany 2005–2017, of whom 1.6% had VTE and 7.0% died. While annual hospitalizations increased (2005: 520,357 to 2017: 663,998) (β 12,421 (95% CI 10,807 to 14,034), p &lt, 0.001), in-hospital mortality decreased from 7.5% to 6.7% (β −0.08% (95% CI −0.10% to −0.06%), p &lt, 0.001). When focusing on 82,558 patients with paralysis hospitalized due to VTE (51.8% females, 58.3% aged ≥ 70 years) in 2005–2017, in-hospital mortality was significantly higher in patients with paralysis and PE than in those with DVT only (23.8% vs. 6.3%, p &lt, 0.001). Cancer (OR 2.18 (95% CI 2.09–2.27), p &lt, 0.001), heart failure (OR 1.83 (95% CI 1.76–1.91), p &lt, 0.001), COPD (OR 1.63 (95% CI 1.53–1.72), p &lt, 0.001) and obesity (OR 1.42 (95% CI 1.35–1.50), p &lt, 0.001) were associated with PE. PE (OR 4.28 (95% CI 4.07–4.50), p &lt, 0.001) was a strong predictor of in-hospital mortality. Conclusions: In Germany, annual hospitalizations of patients with paralysis increased in 2005–2017, in whom VTE and especially PE substantially affected in-hospital mortality. Cancer, heart failure, COPD, obesity and acute paraplegia were risk factors of PE.

Background Venous thromboembolism (VTE) is common and associated with high morbidity and mortality. Although chronic inflammation was not categorized as a traditional risk factor for VTE, chronic inflammation might increase the risk to develop VTE events. While studies confirmed an increased cardiovascular morbidity and mortality in psoriatic patients, data regarding the influence of psoriasis on patients' cardiovascular profile and on prognosis of patients with pulmonary embolism (PE) are sparse. Purpose We aimed to investigate the impact of psoriasis on prognosis of PE patients. Methods Hospitalized PE patients were stratified for psoriasis and the impact of psoriasis on outcome was investigated in the German nationwide inpatient sample of the years 2005–2017 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2017, own calculations). Results Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0–80.0] years) were recorded in Germany 2005–2017. Among these, 3,145 patients were additionally coded with psoriasis (0.3%). Psoriatic PE patients were younger (68.0 [57.0–76.0] vs. 72.0 [60.0–80.0] years, P Psoriatic PE patients showed a lower in-hospital case-fatality rate (11.1% vs. 16.0%, P Conclusions Overall, only a minority (0.3%) of all PE cases were coded additionally with psoriasis. PE patients with psoriasis were hospitalized in median four years earlier than those without. Although psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile in PE patients, our data demonstrate a lower in-hospital mortality rate in psoriatic PE, which might be mainly driven by younger age. Our findings may improve the clinical management of these patients and contribute evidence for relevant systemic manifestation of psoriasis. Funding Acknowledgement Type of funding sources: None.

Background: In patients with peripheral artery disease (PAD), the impact of diabetes mellitus (DM) on patient-profile and adverse in-hospital events is not well investigated. Methods: The German nationwide inpatient sample 2005–2019 was used for this analysis. Hospitalized PAD patients were stratified for DM and the influence of DM on patient-profile and adverse in-hospital events was investigated. Results: Our study comprised 2,654,871 hospitalizations (54.3% aged ≥70 years, 36.7% females) of patients with PAD in Germany 2005–2019. Among these, 864,691 (32.6%) patients had DM and 76,716 (2.9%) died during hospitalization. Diabetic PAD patients revealed an aggravated cardiovascular profile (Charlson Comorbidity Index: 6.0 (5.0–8.0) vs. 4.0 (3.0–5.0), p &lt, 0.001). PAD patients with DM showed a higher rate of in-hospital mortality (3.5% vs. 2.6%, p &lt, 0.001), as well as major adverse cardiovascular and cerebrovascular events (MACCE, 4.7% vs. 3.3%, p &lt, 0.001) and had more often operated with amputation surgery (16.4% vs. 9.1%, p &lt, 0.001). DM was an independent predictor of in-hospital mortality (OR 1.077 (95%CI 1.060–1.093), p &lt, 0.001) and MACCE (OR 1.118 (95%CI 1.103–1.133), p &lt, 0.001). In addition, amputations were also associated with DM (OR 1.804 (95%CI 1.790–1.818)), p &lt, 0.001). Conclusions: DM is associated with an unfavorable clinical patient-profile and higher risk for adverse events in PAD patients, including substantially increased in-hospital mortality as well as MACCE rate, and were more often associated with amputation surgeries.

International audience; Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.

In contrast to overanticoagulation, evidence on risk factors and outcome of subtherapeutic oral anticoagulation (OAC) with vitamin K-antagonists (VKAs) under optimum care is limited. We investigated the clinical phenotype, anticoagulation control, and clinical outcome of 760 VKA patients who received OAC therapy by a specialized coagulation service in the thrombEVAL study (NCT01809015). During 281,934 treatment days, 278 patients experience ≥ 1 episode of subtherapeutic anticoagulation control and had lower quality of OAC therapy compared to 482 patients without subtherapeutic international normalized ratio: 67.6%, interquartile range (IQR) 54.9%/76.8% versus 81.0%, IQR 68.5%/90.4%; p

ZusammenfassungDie periphere arterielle Verschlusskrankheit ist eine häufige, chronische Störung der arteriellen Durchblutung v. a. der unteren Extremitäten, wobei fibröse Plaques der Gefäßwand zu Stenosen und Thrombenbildung führen. Bei betroffenen Patienten besteht ein hohes Risiko für kardiovaskuläre Komplikationen im gesamten arteriellen Gefäßsystem, auch nach dortigen Eingriffen. Daher besteht Optimierungsbedarf bei der antithrombotischen Therapie. Zur Mehrfach-Thrombozytenaggregationshemmung durch neue Arzneimittelklassen werden in den nächsten Jahren Studiendaten erwartet. Aktuelle Studien zeigten bei Hemmung der Gerinnungskaskade durch direkte orale Antikoagulanzien klinische Vorteile bei vertretbarem Sicherheitsprofil. Grundlage medikamentöser Therapie bleibt das Management von Risikofaktoren wie Übergewicht und Nikotin sowie die Korrektur metabolischer Störungen. Diese Aspekte sollten den behandelnden Ärzten bekannt sein, um eine optimale Versorgung und Motivation der Patienten zu erreichen.

Venous thromboembolism (VTE) is a life-threatening disease with risk of recurrence. Oral anticoagulation (OAC) with vitamin K antagonists (VKA) is effective to prevent thromboembolic recurrence. We aimed to investigate the quality of OAC of VTE patients in regular medical care (RMC) compared to a telemedicine-based coagulation service (CS). The thrombEVAL study (NCT01809015) is a prospective, multi-center study to investigate OAC treatment (recruitment: January 2011&ndash, March 2013). Patients were evaluated using clinical visits, computer-assisted personal interviews, self-reported data and laboratory measurements according to standard operating procedures. Overall, 360 patients with VTE from RMC and 254 from CS were included. Time in therapeutic range (TTR) was higher in CS compared to RMC (76.9% (interquartile range [IQR] 63.2&ndash, 87.1%) vs. 69.5% (52.3&ndash, 85.6%), p &lt, 0.001). Crude rate of thromboembolic events (rate ratio [RR] 11.33 (95% confidence interval [CI] 1.85&ndash, 465.26), p = 0.0015), clinically relevant bleeding (RR 6.80 (2.52&ndash, 25.76), p &lt, 0.001), hospitalizations (RR 2.54 (1.94&ndash, 3.39), p &lt, 0.001) and mortality under OAC (RR 5.89 (2.40&ndash, 18.75), p &lt, 0.001) were consistently higher in RMC compared with CS. Patients in RMC had higher risk for primary outcome (clinically relevant bleedings, thromboembolic events and mortality, hazard ratio [HR] 5.39 (95%CI 2.81&ndash, 10.33), p &lt, 0.0001), mortality (HR 5.54 (2.22&ndash, 13.84), p = 0.00025), thromboembolic events (HR 6.41 (1.51&ndash, 27.24), p = 0.012), clinically relevant bleeding (HR 5.31 (1.89&ndash, 14.89), p = 0.0015) and hospitalization (HR 1.84 (1.34&ndash, 2.55), p = 0.0002). Benefits of CS care were still observed after adjusting for comorbidities and TTR. In conclusion, anticoagulation quality and outcome of VTE patients undergoing VKA treatment was significantly better in CS than in RMC. Patients treated in CS had lower rates of adverse events, hospitalizations and lower mortality. CS was prognostically relevant, beyond providing advantages of improved international ratio (INR) monitoring.

IntroductionEarly discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.MethodsThe multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.ResultsThe primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sdPEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of −9.1% (pConclusionsOur results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.

Background and aims Polyvascular disease (PVD) affects approximately 20% of patients with atherosclerosis and is a strong independent risk factor for ischemic outcomes. However, guidelines do not address screening or treatment for PVD, and there have been no PVD-specific trials. We reviewed subgroup analyses of large randomized controlled trials of more intense antithrombotic therapy to determine whether increased intensity of therapy improved ischemic outcomes in patients with PVD. Methods MEDLINE, MEDLINE in-Process, EMBASE, and the Cochrane Library were queried for randomized controlled trials larger than 5000 patients evaluating secondary prevention therapies in patients with coronary artery disease or lower extremity peripheral artery disease. Results Thirteen trials were included ranging in size from 7243 to 27,395 patients. In 9 trials (CHARISMA, TRA 2°P–TIMI 50, PEGASUS—TIMI 54, VOYAGER PAD, TRACER, EUCLID, TRILOGY ACS, PLATO, and COMPASS), patients in the PVD subgroup treated with increased-intensity antithrombotic therapy had similar or greater relative risk reductions for ischemic events in comparison with the general trial cohorts. In four trials (DAPT, THEMIS, APPRAISE-2, and ATLAS ACS 2 TIMI 51), the PVD subgroup had an increased hazard of ischemic events with increased-intensity therapy compared with the general trial cohorts. Conclusions More intense antithrombotic therapy in patients with PVD was associated with a similar relative risk reduction for ischemic events compared with patients without PVD. Therefore, patients with PVD benefit from a larger absolute risk reduction because of their higher baseline risk. Future trials in patients with atherosclerotic cardiovascular disease should intentionally include PVD patients to adequately assess treatment options for this under-studied, under-treated population.

Die Atherosklerose ist eine Erkrankung des gesamten Gefasbaums. Insbesondere bei Vorliegen einer peripheren arteriellen Verschlusserkrankung (pAVK) muss man mit einer hohen Koinzidenz atherosklerotischer Manifestationen in anderen Gefasregionen rechnen. Dies hat direkt Auswirkungen auf die kardiovaskulare Prognose. Die Atherosklerose ist eine inflammatorische Erkrankung. Eine hohe Inflammationslast ist sowohl mit einer polyvaskularen Atherosklerose als auch mit dem Auftreten kardiovaskularer Ereignisse assoziiert. In der Therapie der polyvaskularen Atherosklerose kommt der Einstellung der kardiovaskularen Risikofaktoren eine zentrale Rolle zu. Auserdem ist die gerinnungshemmende Therapie bei Patienten mit atherosklerotischen Erkrankungen sehr wichtig. Daruber hinaus ist gerade bei Patienten mit einer pAVK Gehtraining eine wichtige Therapieoption, die neben der Gehstrecke viele weitere positive Effekte hat. Ob in der Zukunft auch gezielte antiinflammatorische Therapien zum Einsatz kommen, mussen weitere klinische Untersuchungen zeigen.

Background Heart failure (HF) is a poly-aetiological syndrome with large heterogeneity regarding clinical presentation, pathophysiology, clinical outcome and response to therapy. The MyoVasc study (NCT04064450) is an epidemiological cohort study investigating the development and progression of HF. Methods The primary objective of the study is (a) to improve the understanding of the pathomechanisms of HF across the full spectrum of clinical presentation, (b) to investigate the current clinical classifications of HF, and (c) to identify and characterize homogeneous subgroups regarding disease development using a systems-oriented approach. Worsening of HF, that is, the composite of transition from asymptomatic to symptomatic HF, hospitalization due to HF, or cardiac death, was defined as the primary endpoint of the study. During a six-year follow-up period, all study participants receive a highly standardized, biannual five-hour examination in a dedicated study centre, including detailed cardiovascular phenotyping and biobanking of various biomaterials. Annual follow-up examinations are conducted by computer-assisted telephone interviews recording comprehensively the participants´ health status, including subsequent validation and adjudication of adverse events. Results In total, 3289 study participants (age range: 35 to 84 years; female sex: 36.8%) including the full range of HF stages were enrolled from 2013 to 2018. Approximately half of the subjects (n=1741) presented at baseline with symptomatic HF (i.e. HF stage C/D). Among these, HF with preserved ejection fraction was the most frequent phenotype. Conclusions By providing a large-scale, multi-dimensional biodatabase with sequential, comprehensive medical-technical (sub)clinical phenotyping and multi-omics characterization (i.e. genome, transcriptome, proteome, lipidome, metabolome and exposome), the MyoVasc study will help to advance our knowledge about the heterogeneous HF syndrome by a systems-oriented biomedicine approach. Trial registration ClinicalTrials.gov; NCT04064450.

Was ist neu? Antithrombotische Therapie bei stabiler PAVK Die aktuellen deutschen und europäischen Leitlinien empfehlen bei Patienten mit einer peripheren arteriellen Verschlusskrankheit (PAVK) die Monotherapie mit einem Thrombozytenaggregationshemmer (ASS 100 mg oder Clopidogrel 75 mg).In der COMPASS (Cardiovascular OutcoMes for People using Anticoagulation StrategieS) -Studie wurde Patienten mit PAVK 2 × 2,5 mg Rivaroxaban zusätzlich zu ASS 100 mg gegeben. Dies führte zur signifikanten Reduktion kardiovaskulärer Ereignisse (MACE = Major Adverse Cardiovascular Events) wie kardiovaskulärer Tod, Myokardinfarkt und Schlaganfall. Ebenfalls signifikant reduziert wurden periphere Ereignisse (MALE = Major Adverse Limb Events) wie ischämiebedingte Major-Amputation und eine akute schwere Ischämie.Liegt bei Patienten mit einer PAVK die Indikation zur oralen Antikoagulation vor (z. B. bei Vorhofflimmern), empfehlen die aktuellen deutschen und europäischen Leitlinien die Monotherapie mit oralen Antikoagulantien ohne zusätzliche Thrombozytenaggregationshemmung. Antithrombotische Therapie nach peripherer Revaskularisation Nach peripherer Intervention wird in Analogie zur Koronarintervention meist passager eine duale Plättchenhemmung durchgeführt. Nach peripherer Bypass-Anlage wird in der Regel die Monotherapie mit einem Thrombozytenaggregationshemmer empfohlen. In Einzelfällen kann bei komplexem Venenbypass eine orale Antikoagulation und bei Kunststoffbypass eine duale Plättchenhemmung eingesetzt werden.

Die 2017 veroffentlichte „European Society of Cardiology“(ESC)-Leitlinie „Periphere Arterielle Erkrankungen“ (PAE, „peripheral arterial diseases“) umfasst Empfehlungen zur Diagnostik und Therapie von atherosklerotischen Manifestationen in peripheren Gefasen. Es werden zu allen arteriellen Versorgungsgebieten mit Ausnahme der Aorta und Koronararterien Empfehlungen formuliert. Der folgende Kommentar bezieht sich auf die Ubersetzung der Pocket-Leitlinie und ist fokussiert auf die Empfehlungen zur Sekundarpravention, zur peripheren arteriellen Verschlusskrankheit (pAVK) und zur Karotisstenose. In den Empfehlungen zur Sekundarpravention wird die Atherosklerose als Erkrankung des gesamten Gefassystems betrachtet. Generell wird eine konsequente Einstellung der kardiovaskularen Risikofaktoren mit absoluter Rauchkarenz, dem Einsatz von Statinen sowie einer Blutdruck- und Blutzuckerkontrolle empfohlen. Patienten mit Claudicatio intermittens sollten moglichst ein supervidiertes Gehtraining betreiben. Ein Thrombozytenaggregationshemmer sollte gegeben werden, wenn eine symptomatische pAVK vorliegt oder bei weiteren Manifestationen der Atherosklerose wie beispielsweise einer koronaren Herzerkrankung (KHK). Liegt eine starke Einschrankung im Alltag vor, wird eine Revaskularisation empfohlen. Bei Vorliegen einer Indikation zur Revaskularisation sollte bei kurzen Gefasverschlussen (z. B.

ZusammenfassungDie Leitlinie der Europäischen Gesellschaft für Kardiologie empfiehlt bei Patienten mit manifester peripherer arterieller Verschlusskrankheit (PAVK) ebenso wie bei KHK oder zerebrovaskulärer Erkrankung einen LDL-C-Zielwert

Objective Use of autologous veins as peripheral bypass graft may become critical in the presence of significant varicose degeneration of the harvested vein. External support of such dilated veins with standard polytetrafluoroethylene (PTFE) prostheses was recommended as an option to use these veins for peripheral bypass. A single-center experience with this technique regarding long-term graft function, secondary reinterventions, and potential graft degeneration is presented. Methods Between January 1995 and January 2006, there were 54 patients with varicose veins who underwent 57 consecutive infrainguinal vein bypass operations with PTFE reinforcement in 57 limbs. Indications for surgery consisted of disabling claudication (5), chronic critical ischemia (40), popliteal aneurysm (11), and acute ischemia (1). Grafts were observed with duplex ultrasound scan supplemented by additional angiography in case of recurrent ischemia, with prospective documentation of follow-up data in a computerized vascular database. Graft patency, limb salvage, and possible degeneration of the vein grafts were retrospectively analyzed. Results Mean follow-up was 79 months (range, 1-219 months). The 30-day mortality was 2%. Secondary procedures to maintain or to restore bypass patency were necessary in 12 grafts (21%). Primary, primary assisted, and secondary patency rates were 54%, 73%, and 73% after 5 years for all bypasses, with a limb salvage rate for limbs operated on for chronic critical or acute ischemia of 83%. Significant stenosis of a reinforced vein segment was detected in one case after 56 months, with subsequent replacement of the vein graft with a biologic vascular prosthesis. Conclusions Good late graft patency and limb salvage combined with a low rate of late vein graft degeneration justify the use of external PTFE reinforcement of varicose vein segments in infrainguinal bypass surgery.

[2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)]

The current European Society of Cardiology (ESC) guidelines on peripheral arterial diseases include recommendations on diagnostics and treatment of atherosclerotic manifestations in peripheral arteries. Because of the high coincidence of atherosclerosis in different arterial territories, screening for other atherosclerotic lesions is necessary in patients with clinical symptoms in one vascular bed. Consistent treatment of cardiovascular risk factors is important in all patients with peripheral atherosclerosis. This includes smoking cessation, statin therapy and control of blood pressure and blood glucose. All patients with carotid artery stenosis should be treated with antiplatelet drugs. In patients with symptomatic carotid artery stenosis and low periprocedural risk, early revascularization is recommended when the degree of stenosis is more than 50%. In asymptomatic carotid artery stenosis revascularization should only be considered if the risk for cerebral embolization is high and the periprocedural risk is low. Patients with peripheral arterial occlusive disease should only be treated with an antiplatelet drug if they are symptomatic. In cases of intermittent claudication supervised exercise training is strongly recommended. When activities of daily life are compromised despite training, revascularization by endovascular therapy first should be considered. In chronic limb-threatening ischemia early revascularization should be considered, preferably by venous bypass surgery. In patients with arterial hypertension and specific risk factors screening for renal artery stenosis is recommended. Particularly in patients with atherosclerotic renal artery stenosis, the indications for revascularization should be assessed very carefully.

Reactive oxygen and nitrogen species (ROS and RNS, e.g. H2O2, nitric oxide) confer redox regulation of essential cellular signaling pathways such as cell differentiation, proliferation, migration and apoptosis. At higher concentrations, ROS and RNS lead to oxidative stress and oxidative damage of biomolecules (e.g. via formation of peroxynitrite, fenton chemistry). Peripheral artery disease (PAD) is characterized by severe ischemic conditions in the periphery leading to intermittent claudication and critical limb ischemia (end stage). It is well known that redox biology and oxidative stress play an important role in this setting. We here discuss the major pathways of oxidative stress and redox signaling underlying the disease progression with special emphasis on the contribution of inflammatory processes. We also highlight therapeutic strategies comprising pharmacological (e.g. statins, angiotensin-converting enzyme inhibitors, phosphodiesterase inhibition) and non-pharmacological (e.g. exercise) interventions. Both of these strategies induce potent indirect antioxidant and anti-inflammatory mechanisms that may contribute to an improvement of PAD associated complications and disease progression by removing excess formation of ROS and RNS (e.g. by ameliorating primary complications such as hyperlipidemia and hypertension) as well as the normalization of the inflammatory phenotype suppressing the progression of atherosclerosis. Keywords: Oxidative stress, Redox signaling, Peripheral artery (occlusive) disease, Claudication and critical limb ischemia, Walking distance, Antioxidant therapy

Die periphere arterielle Verschlusskrankheit (PAVK) ist die haufigste Ursache fur Durchblutungsstorungen der peripheren Arterien. Patienten mit PAVK haben oft weitere Manifestationen der Atherosklerose im Gefasbaum. Zu den typischen Symptomen zahlt die Claudicatio intermittens, im fortgeschrittenen Stadium kommt es zu Ruheschmerz oder akralen Lasionen. Da die Mehrzahl der Patienten klinisch asymptomatisch ist, sollte man bei Patienten mit kardiovaskularen Risikofaktoren gezielt nach einer PAVK suchen. Die Messung des Knochel-Arm-Index (Ankle Brachial Index [ABI]) eignet sich zur einfachen und kostengunstigen Basisdiagnostik. Bestatigt sich der Verdacht auf eine PAVK, sollte sich eine funktionelle angiologische Diagnostik anschliesen, bei der die Duplexsonographie eine zentrale Rolle spielt. Bei unklarem Befund und manchmal auch zur genaueren Therapieplanung ist eine zusatzliche radiologische Bildgebung sinnvoll, wenn moglich mithilfe der Magnetresonanzangiographie.

Abstract. The prevalence of peripheral artery disease (PAD) is increasing worldwide and is strongly age-related, affecting about 20 % of Germans over 70 years of age. Recent advances in endovascular and surgical techniques as well as clinical study results on comparative treatment methods strengthened the need for a comprehensive review of the published evidence for diagnosis, management, and prevention of PAD. The interdisciplinary guideline exclusively covers distal aorta and atherosclerotic lower extremity artery disease. A systematic literature review and formal consensus finding process, including delegated members of 22 medical societies and two patient self-support organisations were conducted and supervised by the Association of Scientific Medical Societies in Germany, AWMF. Three levels of recommendation were defined, A = „is recommended/indicated”, B = „should be considered”, C = “may be considered”, means agreement of expert opinions due to lack of evidence. Altogether 294 articles, including 34 systematic reviews and 98 RCTs have been analysed. The key diagnostic tools and treatment basics have been defined. In patients with intermittent claudication endovascular and/or surgical techniques are treatment options depending on appropriate individual morphology and patient preference. In critical limb ischaemia, revascularisation without delay by means of the most appropriate technique is key. If possible and reasonable, endovascular procedures should be applied first. The TASC classification is no longer recommended as the base of therapeutic decision process due to advances in endovascular techniques and new crural therapeutic options. Limited new data on rehabilitation and follow-up therapies have been integrated. The article summarises major new aspects of PAD treatment from the updated German Guidelines for Diagnosis and Treatment of PAD. Limited scientific evidence still calls for randomised clinical trials to close the present gap of evidence.

International audience; Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.

Renal impairment, a source of chronic hypercoagulability[1][1] and inflammation,[2][2] is known to reduce the specificity of the D-dimer test in the diagnosis of venous thromboembolism (VTE).[3][3] This leads to many false positives in such patients and consequently to additional costs, as well as

Standard-dose intravenous recombinant interleukin-2 (rIL-2) is indicated for the treatment of some subtypes of cancer; however, severe adverse events, including venous thromboembolism (VTE), may complicate its administration. Low-dose subcutaneous rIL-2 is being studied for the management of immune-mediated diseases, since it can modulate the immunological response by specifically targeting T regulatory (Treg) cells; importantly, it is supposed to cause fewer or no complications. In this systematic review and meta-analysis of phase II-III randomized controlled trials (RCTs), we investigated the safety of low-dose (

Stroke is the second leading cause of death worldwide. Ischemic strokes, which are caused by atrial fibrillation/flutter (AF), may be more devastating than those that occur without AF.The purpose of this study was to investigate the impact of AF on adverse events in hospitalized ischemic stroke patients and to estimate the elevated impact of AF on the occurrence of these adverse events.The nationwide German inpatient sample of the years 2005-2015 was used for this analysis. Ischemic stroke patients were identified by ICD code I63 and stratified by AF. Logistic regression models were used to investigate the impact of AF on adverse in-hospital events and adjusted for age, sex, and comorbidities to prove the independence of the associations.Overall, 2,958,697 hospitalized ischemic stroke patients (50.5% female, 65.4% age70 years) were included in the analysis. Of these patients, 849,466 (28.7%) were diagnosed with AF. Overall, 9.0% of the stroke patients died in-hospital. The case fatality rate increased with age and was higher in stroke patients with AF than in those without AF (13.0% vs 7.3%; P.001). AF was an important predictor of in-hospital death (odds ratio 1.30; 95% confidence interval 1.28-1.31; P.001) and adverse events during hospitalization, independent of age, sex, and comorbidities. Deterioration of patient prognosis due to AF was especially pronounced in younger patients.AF in ischemic stroke patients is associated with higher in-hospital mortality and higher rate of adverse events during hospitalization, independent of age, sex, and comorbidities.

Aims To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban. Methods and results We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for ≥3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of α = 0.004 ( Conclusion Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE.

Background Arteriogenesis is promoted by flow- and pressure-related forces such as tangential wall stress and laminar shear stress. Exercise training (ET) is known to promote arteriogenesis in peripheral arterial disease (PAD) patients. It remains unclear whether supervised ET (SET) promotes arteriogenesis more efficiently than non-SET (nSET). Methods and results Forty PAD patients participated in a SET or nSET training programme ( n = 20 each) and were compared to 20 healthy individuals without any history of cardiovascular events. Femoral artery diameter, flow and velocity were measured by ultrasound. Tangential wall stress and laminar shear stress were calculated for femoral arteries. Follow-up was performed after a mean of 7.65 ± 1.62 months. At follow-up, only the SET group showed a significant increase in lumen diameter of the profunda femoral artery ( p = 0.03), accompanied by an increase of tangential wall stress ( p = 0.002). Laminar shear stress decreased, but remained higher for the SET group compared to controls ( p

For the surgical treatment of critical limb ischemia one of the decisive influencing factors for short-term and long-term limb salvage is the use of autologous veins as bypass material. There is currently a lack of studies on the long-term assessment of alternative bypass materials, which can be used for critical limb ischemia due to a lack of autologous vein material. A prospective database was established that included all patients with critical limb ischemia who received a bypass with the Omniflow-II™ prosthesis. From 2006 until 2014 bypass surgery with the Omniflow-II™ prosthesis was carried out in 123 patients. The mortality was 5 % while the morbidity was 14 % and the 5‑year survival rate was 37 %. In patients with a popliteal bypass (n = 62), the primary and secondary patency rates were 34 % and 69 %, respectively after 5 years. The corresponding results for the crural position (n = 61) over the same time period were 32 % and 34 %, respectively. After 5 years, the group receiving popliteal bypass surgery showed a limb salvage rate of 98 % whereas the crural group had a rate of 70 %. In this study we could demonstrate very promising results using the Omniflow-II™ prosthesis for the surgical treatment of critical limb ischemia.

The formation of monocyte-platelet aggregates and neutrophil-platelet aggregates (MPA and NPA, respectively) is influenced by inflammation, but also might contribute to an exacerbation of inflammatory responses in atherosclerotic plaque. The purpose of this study was to analyze MPA and NPA proportions in regard to different stages of peripheral arterial disease (PAD). Forty-five patients with intermittent claudication (IC) (3 groups: Rutherford (R)-1, R-2, and R-3; each n = 15), 20 patients with critical limb ischemia (CLI) (Rutherford 5 (40%) and 6 (60%)), and 20 healthy controls were studied. Analyses of monocyte (Mon) subpopulations (CD14++CD16- (classical) Mon1, CD14++CD16+ (intermediate) Mon2, CD14+CD16++ (non-classical) Mon3), MPA, and NPA was performed from whole blood by flow cytometry. Controls showed an increased proportion of the Mon1 subpopulation (p < 0.001), whereas CLI patients showed a significant increase of the Mon2 subpopulation compared to controls, R-1, or R-2 patients (p < 0.0001). For the Mon3 subpopulation, CLI and R-3 patients showed an increased proportion (p < 0.05). MPA formation with the proinflammatory Mon2 and Mon3 subpopulations was increased in CLI patients (both p < 0.01). Similarly, NPA was significantly increased in CLI patients (p < 0.05). Serological markers of inflammation and procoagulation (fibrinogen [r = 0.459, p < 0.001], soluble triggering receptor expressed on myeloid cells (sTREM-1) [r = 0.237, p < 0.05] and P-Selectin [r = 0.225, p < 0.05]) correlated directly with MPA formation on the Mon2 subpopulation. We found an association of inflammatory and procoagulatory markers with increased formation of MPA on the Mon2 subpopulation. Since R-3 patients also had significantly increased MPA, one can speculate that the inflammatory burden might promote an aggravation of the disease.

Zusammenfassung Hintergrund: Bei der kritischen Extremitätenischämie (CLI) liefert der pedale Bypass zur A. dorsalis pedis oder zur distalen A. tibialis posterior gute Langzeitergebnisse in Hinsicht auf Funktion und Fußerhalt. Im Einzelfall ist aber aufgrund des angiografischen Befunds ein Bypassanschluss auf pedale Seitenäste erforderlich. Methode: In einer prospektiven Datenbank untersuchten wir alle Patienten, die bei schwerer Extremitätenischämie eine Bypassanlage zu einem pedalen Seitenast erhielten. Die Patienten wurden in regelmäßigen Abständen klinisch und mittels Duplexsonografie nachuntersucht. Wesentlicher Zielparameter war die Beinerhaltungsrate. Ergebnisse: Von Januar 1998 bis Juni 2014 führten wir von insgesamt 534 pedalen Bypassanlagen 72 Bypässe zu pedalen Seitenästen bei 72 Patienten (59 Männer und 13 Frauen) durch. Die proximale Bypassanastomose lag in 30 Fällen supragenual und bei 42 Patienten infragenual. In 6 Fällen diente die A. tarsalis lateralis als Anschlussgefäß, in 15 Fällen die laterale und in 24 Fällen die mediale Plantararterie. Bei 27 Patienten erfolgte der distale Anschluss auf die Plantarbifurkation. Alle Rekonstruktionen wurden komplett autolog durchgeführt. Die Beinerhaltungsrate nach 5 und 10 Jahren lag jeweils bei 82 %. Schlussfolgerung: Der Bypass zu pedalen Seitenästen ist eine sinnvolle Methode zum Extremitätenerhalt bei kritischer Ischämie, falls kaliberstärkere Arterien nicht mehr zur Verfügung stehen.

Purpose and methods A meta-analysis using data from seven German population-based cohorts was performed by the German Epidemiological consortium of Peripheral Arterial Disease (GEPArD) to investigate whether one question about claudication is more efficient for PAD screening than established questionnaires. Claudication was defined on the basis of the answer to one question asking for pain in the leg during normal walking. This simple question was compared with established questionnaires, including the Edinburgh questionnaire. The associations of claudication with continuous ABI values and decreased ABI were analyzed by linear and logistic regression analysis, respectively. The results of the studies were pooled in a random effect meta-analysis, which included data from 27,945 individuals (14,052 women, age range 20–84 years). Results Meta-analysis revealed a significant negative association between claudication and ABI, which was stronger in men (β = -0.07; 95%CI -0.10, -0.04) than in women (β = -0.02; 95%CI -0.02, -0.01). Likewise, the presence of claudication symptoms was related to an increased odds of a decreased ABI in both men (Odds ratio = 5.40; 95%CI 4.20, 6.96) and women (Odds ratio = 1.99; 95%CI 1.58, 2.51). Conclusions Asking only one question about claudication was able to identify many individuals with a high likelihood of a reduced ABI with markedly higher sensitivity and only slightly reduced specificity compared to more complex questionnaires. At least in men, this question should be established as first screening step. CA extern

Syncope in pulmonary embolism (PE) could be the first sign of haemodynamic compromise. We aimed to investigate pathomechanisms of syncope and its impact on mortality. For this study, patients (aged ≥ 18years) were selected by screening the German nationwide inpatient sample for PE and stratified included patients by syncope (2011–2014). We analysed predictors of syncope in haemodynamically stable PE. Impact of syncope on in-hospital mortality in haemodynamically stable and unstable PE and benefit of systemic thrombolysis in haemodynamically stable PE with syncope (PE + Syncope) were analyzed. The German nationwide inpatient sample comprised 293,640 (84.9%) haemodynamically stable and 52,249 (15.1%) unstable PE patients; among them 2.3% had syncope. Right ventricular dysfunction (RVD) was a key predictor for syncope. In-hospital mortality-rate was lower in haemodynamically stable (6.4% vs. 7.6%, P

To investigate the impact of obesity and underweight on adverse in-hospital outcomes in pulmonary embolism (PE).Patients diagnosed as having PE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification code I26 in the German nationwide inpatient database were stratified for obesity, underweight, and normal weight/overweight (reference group) and compared regarding adverse in-hospital outcomes.From January 1, 2011, through December 31, 2014, 345,831 inpatients (53.3% females) 18 years and older were included in this analysis; 8.6% were obese and 0.5% were underweight. Obese patients were younger (67.0 vs 73.0 years), were more frequently female (60.2% vs 52.7%), had a lower cancer rate (13.6% vs 20.5%), and were more often treated with systemic thrombolysis (6.4% vs 4.3%) and surgical embolectomy (0.3% vs 0.1%) vs the reference group (P.001 for all). Overall, 51,226 patients (14.8%) died during in-hospital stay. Obese patients had lower mortality (10.9% vs 15.2%; P.001) vs the reference group and a reduced odds ratio (OR) for in-hospital mortality (OR, 0.74; 95% CI, 0.71-0.77; P.001) independent of age, sex, comorbidities, and reperfusion therapies. This survival benefit of obese patients was more pronounced in obesity classes I (OR, 0.56; 95% CI, 0.52-0.60; P.001) and II (OR, 0.63; 95% CI 0.58-0.69; P.001). Underweight patients had higher prevalence of cancer and higher mortality rates (OR, 1.15; 95% CI, 1.00-1.31; P=.04).Obesity is associated with decreased in-hospital mortality rates in patients with PE. Although obese patients were more often treated with reperfusion therapies, the survival benefit of obese patients occurred independently of age, sex, comorbidities, and reperfusion treatment.

Peripheral artery disease (PAD) and chronic obstructive pulmonary disease (COPD) are both related with high in-hospital mortality. We aimed to investigate the impact of COPD on the in-hospital outcomes in PAD.PAD patients were selected based on ICD-code I70.2 of the German nationwide database, stratified for COPD and compared regarding adverse in-hospital outcomes.Between 01/2005-12/2015, 5,611,827 inpatients (64.8% males) were diagnosed with PAD; of those, 13.6% were coded additionally with COPD. Overall, 277,894 PAD patients (5.0%) died during in-hospital course. Prevalence of cardiovascular diseases as well as cancer (12.1% vs. 7.0%, P 0.001) was higher in PAD patients with COPD compared to PAD patients without COPD. PAD patients with COPD showed more often lower PAD stages according to Fontaine classification (PAD stage I: 27.1% vs. 19.3%, P 0.001; PAD stage IIa: 34.9% vs. 35.5%, P 0.001; PAD stage IIb: 14.5% vs. 13.6%, P 0.001; PAD stage III: 11.8% vs. 14.8%, P 0.001; PAD stage IV: 13.8% vs. 19.6%, P 0.001). The all-cause in-hospital mortality was significantly higher in PAD patients with COPD compared to those without COPD (6.5% vs. 4.7%, P 0.001). Cardiovascular events comprising pulmonary embolism and myocardial infarction occurred more often in coprevalence with PAD and COPD. COPD was an independent predictor of in-hospital death (OR 1.16 (95%CI 1.15-1.17) P 0.001) and an independent predictor for pulmonary embolism (PE, OR 1.44 (1.40-1.49), P 0.001) in PAD patients.COPD was associated with a high in-hospital mortality in PAD patients probably driven by higher frequencies of PE and cancer.

AIMS: Carotid intima media thickness (CIMT) predicts cardiovascular (CVD) events, but the predictive value of CIMT change is debated. We assessed the relation between CIMT change and events in individuals at high cardiovascular risk. METHODS AND RESULTS: From 31 cohorts with two CIMT scans (total n = 89070) on average 3.6 years apart and clinical follow-up, subcohorts were drawn: (A) individuals with at least 3 cardiovascular risk factors without previous CVD events, (B) individuals with carotid plaques without previous CVD events, and (C) individuals with previous CVD events. Cox regression models were fit to estimate the hazard ratio (HR) of the combined endpoint (myocardial infarction, stroke or vascular death) per standard deviation (SD) of CIMT change, adjusted for CVD risk factors. These HRs were pooled across studies. In groups A, B and C we observed 3483, 2845 and 1165 endpoint events, respectively. Average common CIMT was 0.79mm (SD 0.16mm), and annual common CIMT change was 0.01mm (SD 0.07mm), both in group A. The pooled HR per SD of annual common CIMT change (0.02 to 0.43mm) was 0.99 (95% confidence interval: 0.95-1.02) in group A, 0.98 (0.93-1.04) in group B, and 0.95 (0.89-1.04) in group C. The HR per SD of common CIMT (average of the first and the second CIMT scan, 0.09 to 0.75mm) was 1.15 (1.07-1.23) in group A, 1.13 (1.05-1.22) in group B, and 1.12 (1.05-1.20) in group C. CONCLUSIONS: We confirm that common CIMT is associated with future CVD events in individuals at high risk. CIMT change does not relate to future event risk in high-risk individuals. The PROG-IMT project, which includes this publication, has been funded by the German Research Foundation (Deutsche Forschungsgemeinschaft, www.dfg.de) under the grants DFG Lo 1569/2-1 and DFG Lo 1569/2-3, received by MWL. The DFG had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Simon Thompson is supported by the British heart Foundation (CH/12/2/29428). Some of the contributing studies were funded by different parties, as listed in the acknowledgement section. Here, too, the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Sí