Endovascular Treatment of Iliofemoral Disease for the Improvement of Heart Failure with Preserved Ejection Fraction

Peripheral artery disease (PAD) is a significant risk factor in the development of difficult-to-treat conditions, such as heart failure with preserved ejection fraction (HFpEF). Arterial stiffness phenomena, such as the aortic augmentation index (AIx), are key predictors of age-dependent isolated systolic hypertension (ISH). These phenomena cause an increase in both pulsatile load and aortic blood pressure (AoBP).

Approximately 90% of PAD patients have some form of isolated systolic hypertension, which can cause a local increase in pulse wave reflection, thereby increasing the left ventricular (LV) afterload and promoting the development of HFpEF. Previous studies have shown that endovascular treatment of flow-limiting stenoses can reduce both blood pressure and the AIx.

Purpose of Study Endovascular Treatment in Iliofemoral Disease: Impact on Heart Failure with Preserved Ejection Fraction

This study focused on analyzing peripheral hemodynamics through the measurement of total peripheral resistance (TPR), aortic function via physical-mechanical flow and pulsatile load parameters, and aortic inflow through the assessment of LV systolic function. Baasen et al.’s hypothesis suggested that endovascular treatment would improve LV diastolic function, leading to clinical improvements in PAD patients.

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Patients with symptomatic PAD (Rutherford II or III), LV ejection fraction ≥50%, and an HFpEF score ≥5 were included in the Duesseldorf PTA registry. Treatment for iliac artery lesions involved angioplasty with Passeo 35 balloons and Dynamic balloon-expandable stents, while femoropopliteal segments were treated with Passeo-Lux 18 drug-eluting balloons. Innova stents were placed when necessary.

Hemodynamic and Functional Benefits of Endovascular Treatment in Symptomatic PAD Patients

A total of 30 patients with symptomatic PAD and HFpEF were included. Antihypertensive treatment was similar in both groups, including a control group with conservative management after the diagnostic study (n=5). There were no cardiac or cerebrovascular events, nor complications related to the affected limb. The ankle-brachial index (ABI) significantly increased during follow-up from 0.67 ± 0.14 to 0.84 ± 0.17 and 0.88 ± 0.14 at 1 and 30 days, respectively. TPR decreased significantly (p=0.041) following successful treatment, with a sustained effect over time.

Regarding aortic systolic blood pressure, there was a decrease of −8 mmHg he next day (P=0.056) and one of −9 mmHg during follow-up (P=0.036). The mean pulse pressure was also reduced by −8 mmHg, and arterial compliance significantly increased. Aortic inflow parameters (ejection fraction, stroke volume, or cardiac output) did not show significant changes after the procedure.

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Echocardiographic parameters related to diastolic dysfunction improved significantly, with improved septal and lateral velocities, as well as a decrease in the E/e’ ratio, tricuspid regurgitant flow, and atrial volume index. Additionally, walking distance significantly improved, from 79 ± 44 m at baseline to 213 ± 135 m and 242 ± 136 m during follow-up. Functional class also improved significantly (P=0.033).

Conclusions

This is the first study to demonstrate that endovascular treatment of flow-limiting lesions in patients with PAD and HFpEF can significantly reduce aortic pulsatile load and TPR. Furthermore, there was an acute and sustained improvement in LV diastolic dysfunction.

Original Title: Endovascular Treatment of Flow-Limiting Iliofemoral Stenosis Improves Left Ventricular Diastolic Function in Patients With HFpEF by Reducing Aortic Pulsatile Load.

Reference: Baasen S, Stern M, Wischmann P, Schremmer J, Sansone R, Spieker M, Wolff G, Bönner F, Quast C, Heiss C, Kelm M, Busch L. Endovascular Treatment of Flow-Limiting Iliofemoral Stenosis Improves Left Ventricular Diastolic Function in Patients With HFpEF by Reducing Aortic Pulsatile Load. Circ Heart Fail. 2024 Sep;17(9):e011258. doi: 10.1161/CIRCHEARTFAILURE.123.011258. Epub 2024 Sep 9. PMID: 39247971; PMCID: PMC11398288.