Effectiveness of a Smoking Cessation Program for Peripheral Artery Disease Patients: A Randomized Controlled Trial

Abstract

and much work needs to be done to identify the causes of regional variability. Finally, it needs to be emphasized that "fistula first" does not mean "fistula only." Patients with poor likelihood of maturation of a fistula, or a short life expectancy, may be better candidates for a graft.Complex Plaques in the Proximal Descending Aorta: An Underestimated Embolic Source of Stroke Harloff A, Simon J, Brendecke S, et al. Stroke 2010;41:1145-50. Conclusion: Retrograde flow from complex descending aorta plaques is a potential source of emboli to all brain territories.Summary: Complex aortic plaques are defined as Ն4 mm in thickness, or those associated with ulceration or that have mobile thrombi. Such plaques are considered a significant source of stroke. When such plaques are located in the ascending aorta or the aortic arch, embolization can be through antegrade flow from the aorta into a major cerebral vessel. However, the incidence of complex plaques is highest in the proximal descending aorta. Plaques in this location have only previously been considered a source of stroke in the setting of severe aortic valve insufficiency resulting in retrograde flow in the aorta during diastole. However, it now appears that diastolic retrograde flow in the descending thoracic aorta may be common in patients with atherosclerosis and therefore serve as a potentially overlooked mechanism of stroke (Svedlund S, et al, Cerebrovasc Dis 2009;27:22-8).The authors hypothesize that retrograde flow in the proximal descending thoracic aorta has the potential to reach all the supra-aortic arteries and, thus, may be a previously underappreciated source of stroke in the setting of a complex descending aorta plaque. They studied 94 consecutive acute stroke patients who had aortic plaques Ն3 mm in thickness as determined by transesophageal echocardiography. All subjects underwent magnetic resonance imaging (MRI) to localize complex plaques and to measure timeresolved 3-dimensional (3D) blood flow within the aorta. The 3D visualization was then used to determine if diastolic retrograde flow connected plaque location with origins of the left subclavian, left common carotid, or innominate artery. If retrograde flow associated with a complex descending thoracic aortic plaque reached a supra-aortic vessel that supplied the territory of an MRI-determined acute embolic retinal or cerebral infarction, the distal thoracic aortic plaque was considered a possible embolic source for the stroke.Decreasing heart rate was correlated with increasing flow reversal to the aortic arch (P Ͻ .02). Retrograde flow associated with complex proximal descending aortic plaques reached the left subclavian artery in 58.5% of cases, the left common carotid artery in 24.5%, and the brachiocephalic artery in 13.8%. Stroke etiology was determined in 57 of the 94 patients in the study and was not determined in the remaining 37 patients, so-called cryptogenic stroke. Potential embolization from a descending thoracic aortic plaque was identified in 19 of 57 patients (33.3%) wi...

2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline)

“…In patients with PAD specifically, comprehensive smoking cessation programs that included individualized counseling and pharmacological support significantly increased the rate of smoking cessation at 6 months compared with verbal advice to quit smoking (21.3% versus 6.8%, Pϭ0.02). 29 Tobacco cessation interventions are particularly critical in individuals with thromboangiitis obliterans, because it is presumed that components of tobacco may be causative in the pathogenesis of this syndrome, and continued use is associated with a particularly adverse outcome. 42 Table 4 contains recommendations for antiplatelet and antithrombotic drugs.…”

The Role of Supervised Exercise Therapy in Peripheral Arterial Obstructive Disease

“…A physician advice coupled with frequent follow-up achieves 1-year smoking cessation rates of approximately 5% compared with only 0.1% in individuals who try to quit smoking without a physician's intervention (16). In patients with PAOD, comprehensive smoking cessation programs that included individualized counseling and pharmacological support significantly increased the rate of smoking cessation at 6 months compared with verbal advice to quit smoking (21.3% versus 6.8%, p<0.02) (17). Therefore the focused update of the guideline for the management of smoking patients recommended that current smokers or former smokers should be asked about their status of tobacco use at every visit (Level of Evidence: A).…”

Smoking Interventions

“…A meta-analysis of successful smoking cessation intervention studies suggests that factors associated with success included face-to-face counseling, advice from both providers and nonphysician counselors, and the number of sessions, with more being better (12). These aspects are key components of the randomized clinical trial conducted by Hennrikus et al (13) in this issue of the Journal.…”

“…Hennrikus et al (13) reports a randomized trial using a smoking cessation program for patients with PAD. Patients with documented PAD who were identified as current smokers were eligible for the study.…”