Abstract
To the Editor,
We are grateful to İşcan et al. for their interest and valuable comments on our paper. 1 With regard to the first question, we have clearly mentioned that routine peripheral angiography cannot be used as a screening method for lower extremity artery disease (LEAD) during coronary angiography in routine clinical practice, but speculated to perform peripheral angiography in the same session as an alternative method for the detection of LEAD in a selected subgroup (with a history of smoking, coronary artery disease (CAD), and age > 65 years). This is a unique subgroup which was not recruited in clinical trials before. The clinical spectrum of LEAD is wide including asymptomatic patients. Thus, we may identify asymptomatic LEAD patients during coronary angiography easily and correctly. Some non-invasive tools such as ankle brachial index (ABI) are mostly used for the identification of LEAD in studies, but there remain some concerns about ABI. First, the diagnostic performance of ABI depends on arterial stiffening-calcification, body position, pain during cuff inflation, pre-measurement rest time, and location (distal-proximal) of the disease. Second, several barriers for the implementation of a systematic LEAD screening program including time constraints, lack of space, reimbursement, staff availability, and staff training were identified. Some reports suggested screening for LEAD with a regular ABI at the time of hospital admission, but it is not a routine practice at the moment due to these hindering factors. 2 Besides, despite the diagnosis of LEAD through ABI, it may be already overlooked, especially in asymptomatic patients and may miss patients who are only symptomatic with exercise. Moreover, there are conditions in which angiography may be preferred. First, angiography seems to be in the foreground in case of below the knee lesions. Second, the presence of LEAD is a risk factor for a major vascular access complication. Once we make the diagnosis of LEAD in a patient, this may affect the access site choice to overcome major vascular access complications in the future interventions. Peripheral angiography may be the fastest and the most accurate diagnostic tool in these cases. Third, identification of asymptomatic LEAD on the top of CAD may affect the management of patients who are candidates for surgery, and great saphenous vein harvesting is planned. Thus, when surgery is of choice as revascularization, peripheral angiography during coronary angiography may be faster and more versatile with regard to accuracy, location, severity, burden, variation of the anatomy, and existence of the collaterals of the disease. As regards the second question, asymptomatic individuals with LEAD, even identified by a low ABI, have not been followed up in many studies. In accordance with this, our aim was not to investigate the effects of screening program in terms of its effect on outcomes during follow-up. However, we know that there is a potential of progression in asymptomatic LEAD to symptomatic disease due to cardiovascular risk factors. Additionally, guideline emphasizes the increased risks of cardiovascular mortality and morbidity (myocardial infarction, stroke) even after adjustment for conventional risk factors in individuals with asymptomatic/symptomatic LEAD. This subgroup of patients deserve more attention and strict risk factor modification during follow-up. Moreover, we do not really know how many of the asymptomatic patients were masked by the angina or other reasons which was not the outcome in our study. Keeping these in mind, we commence at least a closer monitoring and general cardiovascular prevention actions such as quitting smoking, healthy life style changes, statins and exercise training especially in masked LEAD. This approach is in agreement with the former reports. In essence, we know that the pursuit of undiagnosed LEAD is not a systematic clinical approach in patients suffering from coronary events. Given the importance of active screening by ancillary modalities (mostly ABI) for LEAD in patients undergoing coronary angiography, it still remains underestimated or neglected by clinicians. Thus, we emphasize that peripheral angiography during coronary angiography may facilitate screening process and may have a role in some subgroups of patients. Convenience of this systematic strategy may be questionable or under debate, but it is far from your thought and subject of randomized controlled trials. Eventually, further randomized studies with more subjects will enlighten us on the costs, safety, and efficacy of our conclusions and your questions.
