Carlos Mena-Hurtado

Background: Despite efforts to promote limb salvage in chronic limb‐threatening ischemia (CLTI), the factors associated with meaningful health status improvement after revascularization remain poorly understood. We examined predictors of meaningful 1‐year health status improvement following revascularization for CLTI. Methods: We pooled endovascular and surgical arms from the BEST‐CLI (Best Endovascular Versus Best Surgical Therapy in Patients With CLTI) randomized controlled trial, including patients with CLTI (150 international sites, 2014–2019). Health status was assessed at baseline and 1 year using the peripheral artery disease‐specific Vascular Quality of Life questionnaire, the generic European Quality‐of‐Life 5 Dimensions, and the Short Form‐12 Physical and Mental Component Summary. Distribution‐based minimal clinically important difference thresholds were defined as 0.5 SD of baseline health status scores. Multivariable logistic regression identified predictors of no meaningful 1‐year improvement (same/worsened versus improved). Results: Among 1017 patients (72.0% men, mean age 66.8±9.7 years), clinically meaningful improvements were reported by 76.5% for Vascular Quality of Life, 52.8% European Quality‐of‐Life 5 Dimensions, 56.7% for Short Form‐12 Physical Component Summary, and 42.1% for Short Form‐12 Mental Component Summary, regardless of revascularization type (surgical versus endovascular). Cardiometabolic risk factors and higher preprocedural health status increased the odds of no meaningful improvement. Revascularization type was not associated with Vascular Quality of Life improvement (odds ratio, 1.059 [95% CI, 0.91–1.23]; P =0.445; C statistic=0.77). Conclusions: One‐year postrevascularization, over three‐fourths of individuals with CLTI perceived meaningful improvements in peripheral artery disease‐specific health, and over half improved overall physical health, regardless of procedure type. Cardiometabolic risk factors and higher preprocedural health status predicted 1‐year health status response. REGISTRATION: URL: https://clinicaltrials.gov ; Unique identifier: NCT02060630

Peripheral artery disease (PAD) affects millions worldwide and is associated with high mortality, major amputations, and detrimental effects on functional and health status. PAD management is multifactorial and encompasses addressing cardiovascular and metabolic risk factors, improving symptoms and vessel patency through exercise therapy or revascularization, and medications. PAD frequently develops under complex biopsychosocial circumstances, and those same mechanisms impact treatment and outcomes. In these contexts, depression and anxiety play a significant role and are known to be associated with a higher risk of developing PAD and worse disease and treatment outcomes. Incorporating depression and anxiety assessment and treatment can complement the traditional approach to cardiovascular disease management to improve outcomes, given that we know they influence the development and progression of PAD and its treatment. In this review, we evaluate various biological and behavioral mechanisms linking depression, anxiety, and PAD, as well as the role of depression and anxiety in treatment planning. We stress the importance of considering these disorders when managing PAD with both medical and surgical approaches and discuss future avenues for a holistic, team-based, and multidisciplinary approach to improve long-term outcomes in individuals with PAD.

BACKGROUND: Cerebral hemodynamic impairment in patients with asymptomatic high-grade (>70%) internal carotid artery (ICA) stenosis is associated with risk of stroke and cognitive decline, but correlations between the degree of stenosis and hemodynamic impairment are derived from small case series. Using baseline data from 242 participants in the CREST-H study (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis–Hemodynamics), we hypothesized that the degree of stenosis in the ICA would correlate with time-to-peak (TTP) delay in ipsilateral cerebral blood flow using MR/CT perfusion scans, adjusting for demographic and cardiovascular risk variables. METHODS: From all participants, ICAs were insonated using a 7 to 10 MHz probe for peak systolic velocity (PSV) and end diastolic velocity. Dynamic contrast perfusion imaging was standardized across 61 CREST-H sites, using standard sequential T2*-weighted perfusion imaging. CT perfusion used standard clinical protocols. TTP delay was calculated in the ipsilateral versus contralateral hemispheres. In cross-sectional analysis, linear regression was used to model TTP delay as the outcome variable and PSV, end diastolic velocity, and PSV ICA/common carotid artery ratio on the index and nonindex side as primary predictor variables in 6 separate models, adjusting for covariates, followed by automated backward elimination model reduction. RESULTS: Among 392 CREST-H participants, the 242 with complete data for all variables were included in the regression analysis (age, 70±7.6; 62% M). End diastolic velocity on the index side correlated with TTP delay (β=0.003, P =0.005). PSV had a similar correlation but did not reach significance (β=0.001, P =0.099), nor did ICA/common carotid artery ratio (β=0.003, P =0.126). Nonindex side PSV, end diastolic velocity, and ICA/common carotid artery ratio showed no correlation with TTP delay ( P =0.268, P =0.495, P =0.380, respectively). Circle of Willis completeness did not correlate with TTP. CONCLUSIONS: In this large cohort of patients with high-grade asymptomatic carotid stenosis, higher end-diastolic flow velocities correlated with greater TTP delays, supporting a definition of hemodynamically significant stenosis. Our findings have implications for the management of asymptomatic carotid stenosis, which will be tested in the CREST-H study. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03121209.

Abdominal aortic aneurysm (AAA) affects over 35 million individuals and poses a potentially fatal risk. Risk stratification and surveillance strategies are well established, but their impact on patient-reported outcomes (PROs) remains diffuse and may vary by clinical and biopsychosocial profiles. It is also unclear whether individuals with this often ‘silent’ condition experience thriving or growth concepts referred to as ‘flourishing.’ To address these gaps, we systematically reviewed PRO studies in AAA to answer three questions: (1) Are there instruments tailored to AAA phenotypes (rupture, elective repair, surveillance, screening), and what patient-centered dimensions are measured? (2) What mental health assessments are commonly used? (3) Do existing PROs capture elements of flourishing? We included 16 studies. Generic PRO tools were frequently used but limited in scope. Five AAA-specific instruments were identified, focusing on physical symptoms, treatment satisfaction, and disease burden. Most were developed using Classical Test Theory, with item burden ranging from 11 to 70 items, and primarily targeted surveillance or elective surgery populations. Mental health assessment was minimal – typically single items embedded in health status instruments addressing anxiety and depression. Flourishing was indirectly assessed through measures of social connection and emotional well-being. Current PRO approaches fail to capture the heterogeneous, patient-centered experience of living with AAA. We propose a growth-based framework for PRO evaluation using adaptive testing to accommodate clinical complexity while minimizing response burden, supporting integrative, value-based, patient-centered care.

Improvements in medical therapy, carotid-artery stenting, and carotid endarterectomy call into question the preferred management of asymptomatic carotid stenosis. Whether adding revascularization to intensive medical management would provide greater benefit than intensive medical management alone is unclear. We conducted two parallel, observer-blinded clinical trials that enrolled patients with high-grade (≥70%) asymptomatic carotid stenosis across 155 centers in five countries. The stenting trial compared intensive medical management alone (medical-therapy group) with carotid-artery stenting plus intensive medical management (stenting group); the endarterectomy trial compared intensive medical management alone (medical-therapy group) with carotid endarterectomy plus intensive medical management (endarterectomy group). The primary outcome was a composite of any stroke or death, assessed from randomization to 44 days, or ipsilateral ischemic stroke, assessed during the remaining follow-up period up to 4 years. A total of 1245 patients underwent randomization in the stenting trial and 1240 in the endarterectomy trial. In the stenting trial, the 4-year incidence of primary-outcome events was 6.0% (95% confidence interval [CI], 3.8 to 8.3) in the medical-therapy group and 2.8% (95% CI, 1.5 to 4.3) in the stenting group (P = 0.02 for the absolute difference). In the endarterectomy trial, the 4-year incidence of primary-outcome events was 5.3% (95% CI, 3.3 to 7.4) in the medical-therapy group and 3.7% (95% CI, 2.1 to 5.5) in the endarterectomy group (P = 0.24 for the absolute difference). From day 0 to 44, in the stenting trial, no strokes or deaths occurred in the medical-therapy group and seven strokes and one death occurred in the stenting group; in the endarterectomy trial, three strokes occurred in the medical-therapy group and nine strokes occurred in the endarterectomy group. Among patients with high-grade stenosis without recent symptoms, the addition of stenting led to a lower risk of a composite of perioperative stroke or death or ipsilateral stroke within 4 years than intensive medical management alone. Carotid endarterectomy did not lead to a significant benefit. (Funded by the National Institute of Neurological Disorders and Stroke and others; CREST-2 ClinicalTrials.gov number, NCT02089217.).