13:15 Uhr
PO1:
Patients with traumatic spinal cord injury-a special cardiovascular risk group
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Autor:innen:
U. Wahl (Halle, DE)
T. Hirsch (Halle/Saale, DE)
Introduction:
Major modifiable direct risk factors for atherosclerosis include diabetes mellitus, arterial hypertension, dyslipidemia and nicotine consumption. A traumatic spinal cord injury (SCI) is a dramatic, life-limiting neurological event. Incidence is estimated to be 40 - 80 new cases per million population. There are two peak ages for traumatic SCI in males: between 20 - 29 years of age and over 70. Data from the World Health Organization shows a 2- to 5-fold increased risk of premature death in patients with SCI. The main causes of death were infection (46%), followed by cardiovascular (23%) and malignant diseases (16%). The authors set out to determine the factors which cause the higher cardiovascular risk in patients with SCI.
Methods:
We performed a PubMed and Cochrane database search. After applying specific search criteria, 42 articles were included in our analysis out of a total of 10,784 matches. The articles were selected with the aim of establishing cardiovascular risk factors in patients with traumatic spinal cord injury.
Results:
Patients with SCI are at an increased risk for peripheral artery disease (4.02-fold under the age of 50) even in the absence of cardiovascular risk factors. Major vascular changes to the arteries of patients with SCI include: a reduction in lumen size (-30-50%), increased shear stress (+50-100%), higher vascular stiffness, an impaired reactive hyperemic response (vascular alteration), and a lack of reduced vascular resistance. The findings for carotid atherosclerosis were inconclusive. Furthermore patients with SCI has a higher disposition for diabetes mellitus (2,45-fold), lipid metabolism disorders and coronary artery disease (1,24-fold). A study revealed a significantly lower prevalence of hypertension in patients with SCI than in the comparison group. Paraplegics are more likely to suffer from dyslipidemia, obesity and PAD, while tetraplegics are more likely to have diabetes mellitus.
Conclusion:
SCI patients are at a higher risk for atherosclerosis and peripheral arterial disease, which requires special monitoring of the cardiovascular risk factors. Regarding to the international recommendations the authors propose structured monitoring of the cardiovascular risk factors in patients with SCI. Vascular medicine has a new cardiovascular risk group that requires special attention.
13:20 Uhr
PO2:
Cardiovascular risk factors and secondary prevention medication in symptomatic LEAD patients in Germany – insights from the RECCORD registry
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Autor:innen:
J. Stella (Muenster, DE)
J. Stausberg (Essen, DE)
W. Ito (Kempten, DE)
U. Hoffmann (Munich, DE)
N. Malyar (Muenster, DE)
R. For the (-, DE)
Background: Current guidelines recommend a comprehensive secondary prevention program consisting of optimally controlled cardiovascular risk profile, life-style modification, nicotine abstinence, a structured exercise training and evidence-based pharmacotherapy in all patients with symptomatic lower extremity artery disease (LEAD). We analyzed data from the RECcording COurses of vasculaR Diseases (RECCORD) registry to assess the current real-world setting on classic risk factors and secondary prophylaxis in relation to anatomic vascular segments in symptomatic LEAD patients in Germany.
Patients and methods: RECCORD is a national, prospective, multicenter registry designed to collect demographic and periprocedural data of patients undergoing endovascular revascularization EVR for symptomatic LEAD. We assessed and evaluated these data in relation to four different anatomic vascular segments (aorto-iliac, femoropopliteal, infrapopliteal combined, only infrapopliteal segments), where the EVR was performed.
Results: During a period of 14 months, 1,661 patients were enrolled at 24 vascular centers in Germany. The study population exhibited a high burden of classic cardiovascular risk factors and comorbidities. While the prevalence of diabetes increased from the aorto-iliac (28.3%) to only infrapopliteal segments (60.0%), the prevalence of active smoking conversely decreased from 64.3% at the aorto-iliac to 16.8% at only infrapopliteal segments. Coronary artery disease, chronic heart failure, renal failure and polyneuropathy showed a rising trend from the aorto-iliac downstream to the infrapopliteal segments. About three quarters of all EVR-patients were on lipid lowering agents at baseline. The rate increased significantly after EVR in all subgroups (P < 0.01). More than 80% received platelet inhibitors before index-EVR. All intervention groups showed an increase in platelet inhibitors post-EVR to > 95%.
Conclusions: The RECCORD registry data demonstrate an improvement in guidelines-recommended secondary preventive pharmacotherapy compared to previous findings. The increased implementation of best medical treatment for LEAD could be due to the treatment in highly specialized vascular centeres. Despite the favourable trend, every fourth and every fifth LEAD patient does not receive any lipid lowering and antiplatelet medication, respectively, demonstrating the persistent lack of guidelines-adherence in LEAD patients.
13:25 Uhr
PO3:
Haemorrhagic cystic adventitial degeneration mimicking thrombus of the popliteal artery
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Autor:innen:
V. Schmitt (Mainz, DE)
M. Schwaderlapp (Mainz, DE)
I. Kalaja (Mainz, DE)
K. Keller (Mainz, DE)
A. Schuch (Mainz, DE)
M. Gins (Mainz, DE)
J. Lerma Monteverde (Mainz, DE)
J. Nawasrah (Mainz, DE)
A. Hoppen (Mainz, DE)
G. Weißer (Mainz, DE)
T. Münzel (Mainz, DE)
A. Neufang (Mainz, DE)
C. Espinola-Klein (Mainz, DE)
Case report: A 45 years old male patient was admitted to the Department of Angiology from an angiologic practice due to an arterial thrombus in the popliteal artery of the right leg. The patient complained about pain since two weeks in the right calf after a walking distance of about 500 m. Until then, no cardiovascular disease was diagnosed and the patient had no medication intake.
Vascular ultrasound presented the picture of an intraarterial thrombus in the popliteal artery and a hyperechogenic structure in the popliteal vessel wall, which was misinterpreted as homogenous atherosclerotic plaque. Due to the sonographic finding of an arterial thrombus anticoagulation therapy with unfractionated heparin was initiated and mechanical thrombectomy was performed by rotation thrombectomy. After successful thrombectomy, no typical stenosis could be identified. Therefore, further diagnostic assessment was performed.
Due to the unknown origin of the thrombus, transesophageal echocardiography was implemented, in which a thrombus in the left atrial appendage was excluded but a persistent foramen ovale was supposed. Furthermore, provocation test regarding popliteal entrapment was positive. Additional imaging using magnetic resonance angiography was conducted. Surprisingly, a cystic lesion was detected between media and adventitia in the sense of a cystic adventitial degeneration of the popliteal artery wall. In context with the duplex sonographic finding, bleeding into the cyst must be suspected and a typical hypoechogenic structure was missing by the initial duplex scan.
The patient was interdisciplinary discussed in the internal vascular team board and transferred to vascular surgery. There, the lesion was successfully removed. In the following duplex sonographic control-examinations a good postoperative result was observed with a normal caliber of the popliteal artery and triphasic flow pattern. The patient was free from symptoms after surgical therapy.
Summary and Conclusion: The present case represents a rare finding of a haemorrhagic cystic adventitial degeneration and development of an intraluminal thrombus due to luminal compression. The blood-filled cyst delayed the correct diagnosis since the typical picture of cystic adventitial degeneration expected in the ultrasound examination was not present.
The reported case highlights the need for critical reconsideration of own diagnoses especially if the aimed therapeutic achievements remain absent. Additional diagnostics with MR angiography led to the correct diagnosis of this seldom disorder. Rapid interdisciplinary discussion and introduction of the patient to a specialized center for vascular surgery led to adequate therapy and freedom from symptoms.
13:30 Uhr
PO4:
Frequency of vascular occlusion in patients with Pseudoxanthoma elasticum and the interventional approach
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Autor:innen:
M. Stumpf (Bonn, DE)
M. Mickan (Bonn, DE)
A. Lenzen (Bonn, DE)
T. Mahn (Bonn, DE)
D. Skowasch (Bonn, DE)
G. Nickenig (Bonn, DE)
C. Schaefer (Bonn, DE)
N. Schahab (Bonn, DE)
Introduction
Pseudoxanthoma elasticum (PXE, OMIM 264800) is a rare, hereditary disease with an estimated prevalence between 1 in 25,000 and 56,000 of the general population. Its main features are progressive loss of vision, characteristic alterations of the skin varying from yellowish coalescing papules to lax and redundant skin, and severe, early-onset atherosclerosis.
Although vascular occlusion, severe intermittent claudication, and reduced quality of life are main hallmarks of the disease, reports on interventional therapy of vascular alterations are scarce. In total, only four reports encompassing seven patients of interventional and surgical revascularization have been published since 1976. Percutaneous transluminal angioplasty was performed on five patients of which the majority suffered from re-occlusion.
This ongoing study retrospectively surveys all patients with PXE examined in our department since 2015 regarding the severity of lower limb atherosclerosis, frequency of vascular occlusion, and performed interventional therapies.
Patients and Methods
98 patients with PXE and 30 in hospital control patients with high risk cardiovascular profile are integrated in this study. All patients underwent extensive angiological examination including measurement of ancle brachial index (ABI) and colour-coded duplex sonography (CCDS). Percutaneous transluminal angioplasty (PTA) in patients with PXE were monitored up to three follow-up examinations, if possible.
Results
Patients with PXE were significantly younger (51.2 ± 13.6 vs. 63.7 ± 12.3 years; p < .001), presented with lower body mass index (26.6 ± 5.0 vs. 32.5 ± 6.9 kg/m²; p < .001), and lower number of packyears (4.9 ± 10.7 vs. 15.6 ± 22.1; p < .05). Arterial hypertonia and type II diabetes also were significantly more frequent in the control group (p < .001). Although patients with PXE and control patients were equally affected from PAD in general (84,7% vs. 73,3%), PXE patients presented with significantly higher classes according to Fontaine (p < .01). Vascular occlusion of lower extremity arteries was significantly more frequent in patients with PXE (n = 29, 29,6%) compared to control (n = 0, p < .01). The femoral arteries were most frequently affected.
A total number of 20 different vessels were intervened via PTA due to either (sub)total occlusion (n = 10) or high-grade stenosis (n =10). After a mean period of 8.8 months, restenosis occurred in 33.3 % of the cases.
Discussion
Peripheral artery disease in patients with PXE is common. Patients with PXE are more severely affected compared to patients with high cardiovascular risk profile and present with more severe clinical symptoms assessed via Fontaine classification. PTA is a safe approach in progressing vascular occlusion in PXE with high risk of re-stenosis. Therefore, intervened patients should be monitored closely. Walking exercise after intervention is crucial to maintain benefits of interventional therapy.
13:35 Uhr
PO5:
Anticoagulation in patients with morbid obesity
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Autor:innen:
T. Tran (Darmstadt, DE)
G. Werner (Darmstadt, DE)
J. Herold (Darmstadt, DE)
History: A 45-year-old female patient presented to our vascular clinic with soft tissue phlegmon of the left groin after groin thrombendarterectomy, as well as fever and diarrhea for 5 days.
Examination: The clinical examination of the 182 kg patient (body mass index of 60 kg/m2) revealed soft tissue phlegmon and wound dehiscence of the left groin. While hospitalization, the patient reported dyspnea, especially at night, and additional angina pectoris symptoms.
Diagnosis: Wound healing disorder with phlegmon of the left groin. The resting electrocardiogram showed a ST-elevation myocardial infarction with complete right bundle branch block. In addition, the unvaccinated patient had Covid-19 disease and the computer tomography showed bilateral pulmonary embolism with infarct pneumonia, as well as unclear anemia.
Therapy: The phlegmon and wound dehiscence were treated with antibiotics and surgery. Myocardial infarction was followed by coronary angiography, which revealed spontaneous long-stretch dissection of the left anterior descending artery and ramus diagonalis 1. Due to difficult access in morbid obesity via the inguinal vessels and poor compliance of the patient during cardiac catheterization via the right radial artery, stent implantation was not performed in the presence of TIMI grade 3 and thus no prognostic relevance. This was followed by therapy with dual antiplatelet agents. Due to bilateral pulmonary embolism, anticoagulation was also necessary.
Discussion: Previously, anticoagulation with a direct oral anticoagulant was not recommended in patients with a body mass index > 40 kg/m2 or weight > 120 kg attributable to the risk of underdosing (decreased plasma levels and shorter half-lives). Recent studies now indicate a clear advantage of rivaroxaban and apixaban under normal doses in patients up to 150 kg. Additionally, there is the option of anticoagulation with fondaparinux. In patients with over 100 kg, 10 mg of fondaparinux can be used subcutaneously once daily.
In our case, the patient was initially treated with acetylsalicylic acid and clopidogrel as dual antiplatelet agents, and with fondaparinux 10 mg subcutaneously once a day. During the course, treatment was switched to marcumar. The patient was discharged with an international normalized ratio of 2.41 and monitors her therapy with a CoaguChek. We consider COVID infection and immobilization as the most likely triggers for pulmonary embolism.
We raise the following points for discussion: how long should anticoagulation be given, at what dose, and in what combination with dual antiplatelet agents?
13:40 Uhr
PO6:
Contractility loss of lower limb muscles in symptomatic peripheral artery disease and mediasclerosis detected by ultrasound shear wave elastography - a pilot study
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Autor:innen:
S. Piepenburg (Freiburg, DE)
M. Maslarska (Freiburg, DE)
G. Freund (Freiburg, DE)
K. Kaier (Freiburg, DE)
C. von zur Mühlen (Freiburg, DE)
D. Westermann (Freiburg, DE)
C. Hehrlein (Freiburg, DE)
Background & Aim:
Symptomatic peripheral arterial disease (PAD) is difficult to diagnose non-invasively in the presence of mediasclerotic arteries (severe calcification), which are incompressible by blood pressure cuffs. Standard ankle-brachial index (ABI) measurements in these PAD patients are often not helpful. Shear wave elastography (SWE) is a modern ultrasound technique to detect contractility loss of peripheral muscles by means of a reduced muscle stiffness during exercise. This novel ultrasound method has previously been established in patients with chronic heart failure by documenting cardiac output failure related peripheral muscle weakness. In this pilot study, we examined whether SWE may be a reproducible tool for diagnosing ischemic muscle contractility loss in patients with PAD and concomitant arterial mediasclerosis.
Methods & Results:
N=13 consecutive patients with peripheral artery disease and mediasclerosis were enrolled in this pilot study. Thirteen patients were symptomatic in different stages of PAD due to significant arterial stenosis or occlusions of the lower limb arteries as assessed by oscillography and duplex sonography. ABI was invalid in all 13 patients. Mean SWE measurements of medial gastrocnemius lower limb muscles showed significant muscle weakness at maximum excercise (active dorsal flexion of the foot, 103.4 +/- 25.9 kPa on the asymptomatic vs. 62.5 +/- 21.9 kPa in the symptomatic lower leg (p < 0.001). Oscillography confirmed the SWE results by a decreased signal on the clinically symptomatic side.
Conclusion:
SWE is reproducibly detecting peripheral muscle weakness and contractility loss during exercise in the symptomatic legs of mediasclerotic PAD patients. SWE of lower limb muscles may help to establish non-invasive diagnosis of symptomatic PAD patients with invalid ABI measurements. Larger randomized clinical trials are necessary to confirm our results.
13:45 Uhr
PO7:
Once-weekly Insulin Icodec Demonstrated Better Glycaemic Control vs Once-daily Insulin Degludec in Basal Insulin-Treated Type 2 Diabetes
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Autor:innen:
M. Kellerer (Stuttgart, DE)
A. Philis-Tsimikas (San Diego, US)
M. Asong (Søborg, DK)
E. Franek (Warsaw, PL)
T. Jia (Søborg, DK)
J. Rosenstock (Dallas, US)
K. Stachlewska (Søborg, DK)
H. Watada (Tokyo, JP)
Background and aims
Insulin icodec (icodec) is a once-weekly (OW) basal insulin analogue in development. The 26-week, randomised, treat-to-target, multicentre, open-label, phase 3 ONWARDS 2 trial assessed the efficacy and safety of OW icodec vs once-daily (OD) insulin degludec (IDeg) when switching from daily basal insulin in people with inadequately-controlled type 2 diabetes (T2D; HbA1c 7.0–10.0%) +/- non-insulin anti-diabetic drugs.
Materials and methods
Eligible participants were randomised (1:1) to OW icodec (n=263) or OD IDeg (n=263). After initiation, insulin doses were titrated weekly to achieve a pre-breakfast self-measured blood glucose target of 80–130 mg/dL (4.4–7.2 mmol/L). Primary endpoint was change in HbA1c from baseline to week 26.
Results
At week 26, from a mean baseline of 8.17% (icodec) and 8.10% (IDeg), HbA1c was reduced to a greater extent with icodec (-0.93%) vs IDeg (-0.71%) confirming non-inferiority (P < 0.0001) and superiority (P = 0.0028; estimated treatment difference, ETD: –0.22% [95% confidence interval, CI: –0.37;–0.08]). Overall, an estimated 40% of icodec and 26% of IDeg participants achieved HbA1c < 7.0%; the odds of achieving this target significantly favoured icodec vs IDeg (estimated odds ratio [95% CI]: 1.88 [1.26;2.79]; P = 0.019). Overall rates of combined level 2 or 3 hypoglycaemia were < 1 event per person-year of exposure (PYE) for both arms with no statistically significant difference between treatments (0.73 [icodec] vs 0.27 PYE [IDeg]; estimated rate ratio: 1.93 [95% CI: 0.93;4.02]; P = 0.0782). The estimated mean weekly insulin dose from week 24–26 was 268 U/week (~38 U/day) for icodec and 244 U/week (~35 U/day) for IDeg (estimated treatment ratio: 1.10 [95% CI: 1.10;1.20]; P = 0.0348). The estimated mean body weight change from baseline to week 26 was 1.40 kg (icodec) and -0.30 kg (IDeg) (ETD: 1.70 kg [95% CI: 0.76; 2.63]; P = 0.0004). No new safety concerns were identified for icodec. Change from baseline to week 26 in Diabetes Treatment Satisfaction Questionnaire total treatment satisfaction score significantly favoured icodec vs IDeg (ETD: 1.25 [95% CI: 0.41; 2.10]; P = 0.0036).
Conclusion
OW icodec treatment demonstrated superiority in HbA1c reduction and significantly greater treatment satisfaction vs OD IDeg in people with T2D previously treated with basal insulin. There was no statistically significant difference in overall level 2 and 3 hypoglycaemia. Reducing insulin from 365 to 52 injections/year could aid insulin therapy adherence and further improve glycaemic control in T2D.
13:50 Uhr
PO8:
Hypoglycemia Frequency and Physiological Response to Double or Triple Doses of Once Weekly Insulin Icodec vs Once-Daily Insulin Glargine in T2D
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Autor:innen:
T. Pieber (Graz, AT)
E. Svehlikova (Graz, AT)
K. Arfelt (Søborg, DK)
R. Cailleteau (Søborg, DK)
S. Deller (Graz, AT)
K. Thomsen (Aalborg, DK)
M. Hart (Graz, AT)
I. Mursic (Graz, AT)
H. Haahr (Søborg, DK)
Insulin icodec is a basal insulin in development for once-weekly (OW) dosing. The aim of this study was to compare the hypoglycemia frequency and response after icodec vs insulin glargine U100 (IGlar) overdosing. In a randomized, open-label, two-period crossover trial, 43 individuals with T2D on basal insulin±metformin (mean±SD age 56±9 yrs, HbA1c 7.2±0.7%) received OW icodec for 6 weeks and once-daily IGlar for 12 days at equimolar total weekly doses based on the individual daily run-in IGlar dose (mean 30±14 U) titrated to a fasting SMPG target of 80 - 130 mg/dL. Once at steady state, double (DD) and triple (TD) doses of icodec and IGlar were followed by hypoglycemia induction 44 h (icodec) or 7 h (IGlar) post-dose (expected time of maximum glucose-lowering effect): First, euglycemia was maintained at 100 mg/dL by variable i.v. glucose. Then, PG was allowed to decrease to a nadir of no less than 45 mg/dL maintained for 15 min. Euglycemia was restored by constant i.v. glucose. Hypoglycemic symptom score (HSS) and counterregulatory hormones were assessed at PG 100 mg/dL and at predefined PG levels until nadir PG. For DD, clinically significant hypoglycemia (PG < 54 mg/dL) occurred in 40 vs 36% of subjects for icodec vs IGlar (odds ratio 1.28; p=0.63). For TD, clinically significant hypoglycemia occurred in 53 vs 70% of subjects (odds ratio 0.48; p=0.14), mean nadir PG was 56 vs 52 mg/dL (treatment ratio 1.07; p < 0.001), change in HSS at nadir PG was comparable for icodec vs IGlar (treatment difference 0.46; p=0.77), responses in adrenaline, noradrenaline and cortisol during hypoglycemia development were greater for icodec vs IGlar, while glucagon and growth hormone levels increased similarly. In conclusion, a DD or TD of once-weekly insulin icodec does not lead to increased risk of hypoglycemia compared to once-daily IGlar. During hypoglycemia, a comparable symptomatic response and a moderately greater endocrine response were seen for icodec vs IGlar.
13:55 Uhr
PO9:
Entfällt - DIASHOE - Digital Education for Diabetic Foot Control
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Autor:in:
T. Hubel (Pirmasens, DE)
The DiaShoe project is not a research project, but aims to educate about the relationship between footwear and diabetic foot syndrome.
The most common complication of diabetes affects the lower limbs. The changes in the body caused by diabetes can lead to various irreversible changes in the lower limbs, causing what is known as diabetic foot syndrome. These changes are primarily due to neuropathy and ischaemic conditions that occur in the thighs, legs and feet. Such complications can even lead to ulcers and, in the most severe cases, gangrene, which can only be cured by amputation.
Expert medical reports indicate that the main cause of lower limb complications is related to wearing inappropriate footwear. Proper footwear helps to maintain locomotor activity and control the effects of diabetic foot syndrome. Therefore, it is crucial to buy appropriate footwear and practice appropriate foot care. With proper care and the use of well-suited shoes, people with diabetes can control DFS and avoid serious complications.
The overall aim of the project is to inform and guide shoe manufacturers, patients, informal caregivers, healthcare workers and shoe shop salespeople on how best to address this problem through prevention and skills development by creating 3 digital education packages for 3 different target groups available in 6 languages (English, Portuguese, Spanish, German, Romanian, Czech, Polish)
Objectives and Impact
Improve knowledge of Diabetic Foot Control through footwear among target groups that are either directly affected by diabetes, or in contact with people with diabetes (relatives, educators, informal caregivers). The project also targets health technicians and shoe-hop clerks, who are in a position to advise people with diabetes on their choice of footwear. DiaSHOE also develops training material for footwear manufacturers interested in the market opportunities of improving/differentiating their products and offering footwear for people with special needs.
Develop new curricula for footwear professionals (designers, technicians, managers) based on the current knowledge of the relationship between footwear and Diabetic Foot Control. These new curricula will lead to updated qualifications in the Sectoral National Qualification Framework of each partner country and contribute to improving the correspondent European Qualification Framework at sectoral level, increase the quality of education/training and the employability of the workforce in these sectors.
Promote research and development in the field of diabetic foot control and diabetic footwear.
Project Partner
Centro Tecnológico do Calçado de Portugal / Portugal
Czech Footwear and Leather Association / Czechia
European Footwear Confederation / Belgium
Globalnet sp. z o.o. / Poland
Instituto Technológico del Calzado y Conexas / Spain
Georghe Asachi Technical University of Iasi / Romania
Prüf- und Forschungsinstitut Pirmasens e.V. /Germany