Study finds correlation between neighbourhood social disadvantage and PAD outcomes

A RECENT STUDY HAS FOUND that, among patients who underwent infrainguinal revascularisation or amputation in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI), those with higher neighbourhood adversity had more advanced peripheral arterial disease (PAD) at presentation and lower rates of revascularisation.

“Studies examining the relationship between socioeconomic disparities and PAD often focus on individual social health determinants and fail to account for the complex interplay between factors that ultimately impact disease severity and outcomes,” authors Lucas Mota (Beth Israel Deaconess Medical Center, Boston, USA) and colleagues write in the Journal of Vascular Surgery (JVS). They claim that area deprivation index (ADI), which they describe as a “validated measure of neighbourhood adversity,” provides a “more comprehensive assessment” of social disadvantage. For this reason, the investigators set out to examine the impact of ADI on PAD severity and its management.

First, the researchers identified all patients who underwent infrainguinal revascularisation—either open or endovascular—or amputation for symptomatic PAD in the VQI registry between 2003 and 2020. They assigned an ADI score of 1–100 to each patient based on their residential ZIP code, with higher ADI scores corresponding with increasing diversity, and categorised patients by ADI quintiles (Q1–Q5).

Mota et al note that the outcomes of interest included indication for procedure (claudication, rest pain or tissue loss) and rates of revascularisation (versus primary amputation). They used multimodal logistic regression to evaluate an independent association between ADI quintile and these outcomes.

The researchers identified 79,973 patients who met their criteria within the VQI database. Specifically, they communicate in JVS that 9,604 (12%) of these patients were in the lowest ADI quintile (Q1), 14,961 (18.7%) in Q2, 19,800 (24.8%) in Q3, 21,735 (27.2%) in Q4, and 13,873 (17.4%) in Q5. There were “significant trends” toward lower rates of claudication (Q1: 39% vs. Q5: 34%, p<0.001), higher rates of rest pain (Q1: 12.4% vs. Q5: 17.8%, p<0.001) as the indication for intervention, Mota and colleagues report in their JVS paper. They add that they found lower rates of revascularisation (Q1: 80% vs. Q5: 69%, p<0.001) with increasing ADI quintiles.

In adjusted analyses, the investigators relay, there was a “progressively higher likelihood” of presenting with rest pain versus claudication, with patients in Q5 having the highest probability when

Rouleaux Club announces Hurting Leg Competition winners

Vaux Robertson (Leicester Vascular Institute, Leicester, UK) and Natalie Yonan (Newcastle Hospitals, Newcastle, UK) were announced as the winners of the Rouleaux Club’s Hurting Leg Competition designed to create patientfacing infographics and infomercials on ‘the hurting leg’ at the 2023 Charing Cross (CX) International Symposium (25–27 April, London, UK).

YONAN WON THE INFOGRAPHIC category with an entry entitled “RING”, which plays on the theme of rest pain, impaired walking, non-healing ulcers and gangrene. Robertson claimed the prize in the infomercial section with a video called “Arterial disease can affect anyone”. The competition was organised by the UK’s vascular surgery trainee association compared with those in Q1 (relative risk: 2; 95% confidence interval [CI]: 1.8–2.2; p<0.001). The authors add that patients in Q5, when compared with those in Q1, also had a higher likelihood of presenting with tissue loss versus claudication (relative risk: 1.4; 95% CI: 1.3–1.6; p<0.001). They also reveal that patients in Q2–Q5 had a lower likelihood of undergoing any revascularisation procedure compared with patients in Q1.

“Further work is needed to better understand neighbourhood factors that are contributing to these disparities in order to identify community-level targets for improvement,” the authors write in their concluding remarks.

Healthcare disparities in the spotlight

Senior author Marc Schermerhorn (Beth Israel Deaconess Medical Center) and colleagues have conducted extensive research on the topic of health disparities in vascular care. At the CX Aortic Vienna 2022 Digital Edition (24–26 October), for example, Schermerhorn spoke on the impact of sex and racial and ethnic factors on abdominal aortic aneurysm (AAA) management and outcome. He concluded that disparities by sex, race and ethnicity “exist at all steps along AAA care,” including AAA detection, clinical trial enrolment and outcomes, among others. Disparities early in the care trajectory likely influence disparities observed later on, he added. in conjunction with CX and was open to medical students and trainees from across the world.

Earlier in the year, at the SVS Vascular Annual Meeting (VAM 2022; 15–18 June, Boston, USA), Aderike Anjorin (Duke University Medical Center, Durham, USA) presented the findings of a study of over 7,000 chronic limb-threatening ischaemia patients under the guidance of senior investigator Schermerhorn. She reported that Black and Hispanic patients had higher three-year amputation and reintervention rates. “Interventions to improve early diagnosis, risk factor modification, and postoperative surveillance in these populations may confer long-term limb salvage benefits,” the speaker told VAM attendees in closing her presentation.

Rouleaux Club executive committee member Claire Dawkins (Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK) explained why the society created the contest. “Chronic limbthreatening ischaemia [CLTI] and the hurting leg are a major issue,” she told CX 2023. “It is high prevalence, is increasing in incidence and is often, certainly in the UK and, from what I understand, globally there is often a delayed presentation. This has all been exacerbated by COVID, with many difficulties of the patient pathways and pressures on general practice, or family doctors.”

Key are ways to get patients to present as early as possible, said Dawkins. There is little vascular surgery-specific [information] in the public domain in terms of patient awareness and education, she explained. “When I am talking to patients in the UK, they have very little awareness of peripheral arterial disease or CLTI. So, the aim for this is to really get that message out there.”

Rouleaux Club president Leanna Erete (Royal Free Hospital, London, UK) handed over cheques of £500 each to Robertson and Yonan.

“I think there are great things in all of those [entries],” said audience member Jonathon Boyle (Cambridge University Hospitals NHS Trust, Cambridge, UK). “One of the most successful campaigns has been the FAST campaign for stroke, and that is a very simplistic infographic—you have basically got four pictures and four letters pretty much. Take everything away and bring it all together. Have your prize winners today, but then take the best bits from every infographic and try and get one slightly more simplified than the ones you have shown. For the public, they need to be fairly easy to understand.”

Leanna Erete and Vaux Robertson

Handheld ECG device scoops CX 2023 Innovation

Showcase prize

Judges of the CX 2023 Dragon’s Den-style contest—the finale of the 2023 Charing Cross (CX) International Symposium (25–27 April, London, UK) Innovation Showcase programme— described the field of entrants to this year’s edition of the competition as the strongest line-up in its history.

THE JUDGING PANEL OF physician-innovators selected HeartEye, a Netherlandsbased developer of handheld electrocardiogram (ECG) devices, as the overall winner of the innovation prize, which comes with a £1,000 award. Honourable mention was given to four other entrants.

Peter Doevendans (UMC Utrecht, Utrecht, The Netherlands) gave an overview of the HeartEye technology in a short presentation entitled

‘ECG anytime, anywhere in 60 seconds’, describing it as a “digital transformation” for ECG acquisition. HeartEye is a pocket-sized device that can take clinical-standard ECG readings wirelessly, negating the need for a large, stationary ECG unit. The technology, which has been developed with the support of an Innovative Medical Devices Initiative (IMDI) grant from the Netherlands Organisation for Health Research and Development (ZonMw) is patented,

Detecting, predicting and preventing aortic ruptures with computational modelling

IN PHYSICS OF FLUIDS, BY American Institute of Physics (AIP) Publishing, researchers from the Indian Institute of Technology (BHU) Varanasi and Indian Institute of Technology Kanpur made a computational model of the cardiovascular system in order to predict early abdominal aortic aneurysm (AAA) rupture and monitor patients’ blood vessel conditions. The team investigated the effect of realistic, patient-specific AAA shapes on the haemodynamics of pulsatile Newtonian fluids in an aortofemoral artery under normal and diseased conditions.

Predicting the risk of AAA rupture involves a combination of imaging studies, such as ultrasound, computed tomography (CT) scans, magnetic resonance imaging (MRI), and haemodynamics, as well as clinical factors such as age, sex, smoking history, and family history of AAA.

“If an AAA is detected early, treatment options such as surgical repair or endovascular stent grafting are available to prevent rupture,” said the authors. “These treatments are both effective at reducing the risk of rupture and improving survival rates.” and could be marketed to healthcare providers or direct to consumers within two years, Doevendans noted.

Using image-based computational blood dynamics, the researchers mimicked specific health conditions and investigated various hemodynamic parameters. Their patient-specific geometric models of a human aortofemoral artery were constructed from 3D medical imaging data.

To solve the blood flow governing equations under the pulsating conditions caused by the heart’s beating, they used finite elementbased simulations. The team found that aneurysm size alters the blood flow velocity distribution. In addition, flow separation occurs during systolic deceleration, and the vortex begins to travel in the aneurysm sac. Among other complex dynamics, this may influence the blood circulation of lower extremities.

“In the future, such computational work will help in development of digital twins of the cardiovascular system,” said first author Sumit Kumar (BHU, Varanasi, India). Digital twins are virtual patient representations that receive real-time updates on a variety of data variables, an AIP press release explains.

“We have been doing this for a number of years, and this was the toughest by far,” said judging panellist Robert Mitchell (Park City, USA), before the announcement of HeartEye as the winner of the prize.

Euphrates Vascular, the developer a nano-scale endovascular system to address microvascular occlusion and no reflow, was among those singled out by the judges as being of particular interest. Presenter David Deaton (Medstar Georgetown University Hospital, Washington, DC, USA) told the judges that the Pulse NanoMed device extends the reach of current therapies, and has been given approval to begin a US Food and Drug Administration (FDA) investigational device exemption (IDE) trial in patients with acute ischaemic stroke.

Tilo Kölbel (University of Hamburg, Hamburg, Germany) introduced Mokita Medical, which has developed a technology to address air embolisation during procedures such as thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI), a cause of stroke and cognitive decline. The Mokita technology uses a gas-soluble fluid to eliminate air from devices, and is being developed into a disposable device that can be connected to the delivery system for a transcatheter procedure.

The company is planning a first-inman study for 2024, and anticipates commercialisation from 2026 onwards.

Mitchell praised Kölbel’s work in this area as being “really important and impactful”, and said that the entry had been one of the options strongly considered for the prize.

Another technology featured in the session included a non-invasive, wearable monitoring system for arteriovenous fistulas (AVFs), intended to aid early identification of failing AVFs. The innovation, presented by Ali Kordzadeh (Anglia Ruskin University, Braintree, UK) is worn like a wristwatch by patients to monitor venous outflow. Novel device coating materials were also exhibited, with Tony Simula (Mawson Lakes, Australia) detailing Bioinvisible, a drug-free polymer coating that could replace existing drug coatings in devices such as stents, vascular grafts and heart valves.

Amsterdam UMC leads an AI-powered hunt for high-risk vascular patients

A new study will focus on using artificial intelligence (AI) to predict the worsening of vascular disease in people with an aortic aneurysm or peripheral arterial disease (PAD), a press release reports. VASCUL-AID is a large European study led by Amsterdam UMC, and recently launched thanks to a Horizon grant worth €6.4 million.

KAK KHEE YEUNG (Amsterdam UMC, Amsterdam, The Netherlands) comments: “Our vessels are an important part of the cardiovascular system that keeps people alive. Once you have a vascular disorder such as an aneurysm, we see that the aggravation of these diseases also increases the chance that you will eventually die from another cardiovascular disease. This indicates to us that we also need to investigate how we can stop these conditions that seem to occur outside the heart, but that do affect the functioning of the cardiovascular system. At the moment it is not possible to predict the course of aneurysm or of PAD. People live in uncertainty about how their disease will develop and this results in many hospital visits and treatments. We would like to identify and isolate people with a high risk of their condition worsening from the large group in order to develop a more specific treatment plan. VASCULAID should make this possible.” The press release states that VASCUL-AID will unite partners across Europe to develop infrastructure in which data from patients with aneurysms and PAD can be monitored. Six clinics across Europe, including Oxford University, will actively collect data from these patients. Using genetic data and imaging studies, as well as looking at protein profiles in blood and medication use. This will then be combined with existing databases and biobanks. Patients will also gather their own data. An app has been developed that will gather data from telephones and wearable device relating to, for example, daily activity and quality of life as well as their heart rate.