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RETRACTED ARTICLE: Association of severity of coronary artery disease by SYNTAX score (SS) and lower extremity arterial disease by duplex ultrasound (DUS) study—an Indian perspective

This article was retracted on 29 December 2020

This article has been updated

Abstract

Background

Coronary artery disease (CAD) and lower extremity artery disease (LEAD) often coexist. Ankle brachial index (ABI) has been shown to be an independent predictor of CAD. Studies have reported correlation of CAD and LEAD on the basis of ABI and also invasive angiography. But rigorous searching did not reveal any similar research where severity of LEAD was assessed by duplex ultrasound (DUS).

In this study, we assessed the association of severity and localisation of LEAD by DUS with SYNTAX score (SS).

Results

A total of 637 subjects above 45 years of age with coronary angiographic confirmation of CAD were studied in this single centre cross-sectional, descriptive and analytical research. High SS was significantly more common in subjects with LEAD (p = 0.04). In the femoro-popliteal segment, total occlusion of arteries was found in significantly more proportion of subjects with high SS. A progressive increase in mean SS was noted across the grades of arterial disease in the femoro-popliteal segment (p = 0.007). 85.2% of the LEAD was in the femoro-popliteal segment, while below-knee arterial disease was present in 98.5% of subjects with LEAD. Hypertension, smoking, history of CVE and presentation with ACS independently increased the risk of LEAD.

Conclusion

High prevalence of asymptomatic LEAD and association of high SS with LEAD as a whole as well as femoro-popliteal involvement suggests the need for a point of care DUS study (POCUS) since treatment varies with location and extent of disease which cannot be fathomed by ABI alone. Being the largest study on association of CAD and LEAD from Indian subcontinent till date and also the first study to use non-invasive tool as DUS for LEAD assessment while studying its association with CAD makes this a landmark experience.

Background

Approximately 40% patients have coexisting coronary artery disease (CAD) and lower extremity artery disease (LEAD) and both share the similar risk factors. When one vascular region is diseased, there has been a trend in clinical practice, to look for lesions in various vascular areas [1, 2]. Moreover, coexistence of peripheral arterial disease (PAD) in a patient of CAD increases the risk of mortality [3,4,5,6]. LEAD increases with age with a prevalence of 10–25% in the general population aged > 55 years [7]. Ankle brachial index (ABI) has been shown to be an independent predictor of CAD in several studies [8]. The guidelines recommend duplex ultrasound (DUS) as the first-line imaging for LEAD lesions in combination with ABI measurement due to its high sensitivity, specificity and higher effectiveness at a lower cost per quality-adjusted life-year (QALY) compared to other imaging techniques [9, 10]. SYNTAX score (SS) for coronary angiography has become popular as it can guide the appropriate treatment protocol for revascularization and provides prognostic information [11]. Multiple studies have reported association or correlation of CAD and PAD on the basis of ABI and also invasive peripheral angiography [12,13,14,15]. But rigorous searching did not reveal any research studying the association of CAD and LEAD where severity of PAD was assessed by DUS.

In this study, our objectives were to assess the association of severity of CAD and LEAD by SS and DUS respectively and to find any relation of localisation of LEAD by DUS and severity of CAD by SS.

Methods

Subjects

This research was conducted as a single centre cross-sectional, descriptive and analytical study. Subjects who were admitted to the cardiology department of a tertiary care centre of Eastern India were recruited consecutively over a period of 15 months from 1 May 2018 to 31 July 2019. Purposive sample size was calculated to be ≥ 385 to have confidence level of 95% that the real values are within ± 5% of measured or surveyed value [https://www.calculator.net/sample-size-calculator.html]. Patients above 45 years of age with coronary angiographic confirmation of CAD were included. Exclusion criteria were creatinine clearance ≤ 30 mL/min, previous surgery or intervention for LEAD, history of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), past trauma, surgery in last 3 months, any malignancy, any other inflammatory condition and any anti-inflammatory drug intake apart from aspirin. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. Informed consent was obtained from all patients for being included in the study.

Clinical indices

Detailed history including age, smoking history, diabetes, hypertension, chronic kidney disease (CKD), cerebrovascular events (CVE), and claudication was taken. Claudication was defined as a pain, cramp or sense of fatigue in a muscle group of the lower limbs related to sustained exercise and relieved with a few minutes of rest while standing evenly on both feet [16]. It was assessed by the Edinburgh claudication questionnaire [17]. Medicine history was documented. Detailed physical examination including height, weight, body mass index (BMI) and cardiovascular system examination was carried out. These were recorded in a proforma sheet. Smokers included both current and past smokers. Hypertension was defined as systolic blood pressure > 140 mm Hg and/or diastolic blood pressure > 90 mm Hg or if the patient was on antihypertensive medications.

Laboratory parameters

Lipid parameters and blood glucose were tested apart from routine pre angiographic investigations which included transthoracic echocardiography and creatinine clearance. Dyslipidaemia was diagnosed as per Lipid Association of India Expert Consensus Statement on Management of Dyslipidaemia in Indians or when the subject was on lipid-lowering medicines [18]. Subjects having fasting blood glucose (FBG) > 126 mg/dL or patients on anti-diabetic medicines were diagnosed as diabetes mellitus. Transthoracic echocardiography was done by Vivid S5 machine with a M3S matrix array probe with a frequency range from 1.7 to 3.2 MHz (GE Vingmed, Horten, Norway), and basic 2-dimensional and M-mode measurements were done with evaluation of left ventricular ejection fraction (LVEF). Each echocardiography study was associated with machine integrated ECG recording.

DUS

DUS was performed before doing coronary angiography and after the subject had rested for at least 5 min in supine position. It was carried out by three experienced radiologists who were blinded to clinical data and consensus was required between at least two of them. PHILIPS iu22 xMATRIX Ultrasound system using 1–3 MHz Broadband linear array transducer and 5–7 MHz curved array transducer with colour Doppler and power Doppler assessment was used. The wall, lumen and flow of the common femoral artery (CFA), superficial femoral artery (SFA), popliteal artery (PA), anterior tibial artery (ATA) and posterior tibial artery (PTA) were evaluated. Velocity criteria were based on the peak systolic velocity (PSV) and velocity ratio (VR). LEAD was classified into mild (1–49% stenosis), significant (50–99% stenosis) and total occlusion (100% stenosis) [19].

CAD and SS

Three experienced interventional cardiologists, who were blinded to clinical data, analysed the coronary angiogram performed using conventional techniques by radial artery access. Consensus was required between at least two of them. The lesions were described on the basis of location, number, extent of involvement, thrombus burden, extent of calcification, tortuosity of involved segments, bifurcation or trifurcation involvement and total occlusion. Scoring was done for each lesion. The SYNTAX Score Calculator software version 2.11 (SYNTAX Score Working Group, www.syntaxscore.com) was used to deduce the SS [11]. The SS was graded into low (0–22), intermediate (23–32) and high (> 32) risk.

Statistical analysis

SPSS version 25.0 (IBM Co, Armonk, NY, USA) was used for data analysis. The continuous variables were presented as the mean ± standard deviation (SD) or median with range, and the categorical variables were presented as percentages. Mann-Whitney test or independent t test was used to compare continuous variables among groups and the chi-square test for comparison of proportional data. Chi-square test was used to evaluate categorical parameters and estimation of risk. Analysis of correlations between categorical variables and risk factors was done by binary logistic regression analysis, and continuous variables were analysed by multivariate linear regression analysis. All statistical tests were two-tailed, and p < 0.05 was considered significant.

Results

Patient’s baseline characteristics

A total of 637 subjects above 45 years of age with coronary angiographic confirmation of CAD were studied. Patients’ baseline characteristics and comparison of characteristics among subjects with and without LEAD is shown in Table 1. Two hundred three subjects (31.9%) had LEAD while it was absent in 68.1%. 85.7% of the subjects with LEAD were male (p = 0.008). Hypertension (77.3%) and smoking (61.1%) were significantly more prevalent among subjects with LEAD. CVE occurred in significantly more number of subjects having LEAD (p = 0.003). 76.4% of patients with LEAD complained of claudication while the rest were asymptomatic. 56.4% of the study population had acute coronary syndrome (ACS) while the rest had stable ischemic heart disease (SIHD). ACS patients comprised 64.5% of subjects with LEAD (p = 0.005). Overall mean age, mean BMI and LVEF were 61.8 ± 8.4 years, 25.2 ± 2.5 kg/m2 and 44.9 ± 7.3% respectively with no significant difference between the two groups. 45.1% of all subjects were diabetic, with no significant difference of presence of diabetes between the groups. Nearly 97% of the subjects were having hypercholesterolemia with no significant difference between subjects with and without LEAD.

Table 1 Patients’ baseline characteristics and comparison of characteristics among subjects with and without LEAD

Baseline antiplatelet, statin and antidiabetic medication intake was significantly less among subjects with LEAD. There was no difference between the groups in usage of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), beta-blockers, calcium channel blockers (CCB) and nitrates.

LEAD and SS

High SS was significantly more common in subjects with LEAD (p = 0.04) (Fig. 1a).

Fig. 1
figure1

a Association of grading of SS with LEAD (p = 0.04). b Distribution of obstruction in subjects with LEAD. LEAD, lower extremity arterial disease; SS, SYNTAX score

In the femoro-popliteal segment, total occlusion of arteries were found in significantly more proportion of subjects with high SS (9.3%) than low and intermediate SS separately. Significant occlusion in the femoro-popliteal segment was also more prevalent in the subjects with high SS whereas in the below-knee arterial segment no such association was noted (p = 0.08). Mean SS was 22.2 ± 8.9 with no significant difference between the two groups (Table 1). A progressive increase in mean SS was noted across the grades of arterial disease in the femoro-popliteal segment (p = 0.007). Though mean SS was more in subjects with significant occlusion and total occlusion in the below-knee arterial segment than those with normal arteries, no significant association was noted in this segment between mean SS and grades of LEAD (p = 0.06).

Distribution of LEAD

Figure 1b shows the distribution of obstruction in subjects with LEAD. Figure 2a shows the overall distribution of LEAD. Above 80% of the LEAD were in below-knee arteries (ATA and PTA) whereas only 10–20% of the disease were in the CFA. Figure 2b shows the median distribution and range of SS across the severity of femoro-popliteal and below-knee disease.

Fig 2
figure2

a Distribution of LEAD. b Median distribution and range of SS across the severity of femoro-popliteal and below-knee LEAD. LEAD, lower extremity arterial disease; SS, SYNTAX score

Taking segmental distribution into account, 85.2% of the LEAD was in the femoro-popliteal segment, while below-knee arterial disease was present in 98.5% of subjects with LEAD (95% CI 8.2–18.9, p < 0.0001).

Multinomial logistic regression

Table 2 shows multinomial logistic regression for detection of independent contribution of the baseline factors in LEAD. Keeping other baseline parameters fixed, hypertension, smoking, history of CVE and presentation with ACS independently increased the risk of LEAD. Presence of CKD was found to have independent negative association with LEAD.

Table 2 Predictors of LEAD in patients with CAD

Discussion

Atherosclerosis affects various arterial territories simultaneously since it is a systemic pathological process. Thus, a person with atherosclerotic disease in one vascular territory has higher risk of disease in other territories as well [20,21,22].

Prevalence of LEAD in subjects with CAD

LEAD is prevalent in 7–16% of subjects with CAD as per the Western data [9]. An Indian study by Saran et al. reported the prevalence to be 7.7%, but this was based on only ABI measurement [23]. We found the prevalence of LEAD in subjects with CAD to be 31.9% which was much higher than this previous study by Saran et al. but corroborated with the Indian data by Sarangi et al. (33.3%) [12]. We attribute this higher prevalence to the use of better diagnostic modality in form of DUS. Higher sample size in our study (n = 637) than the study by Saran et al. (n = 207) may have also provided a better picture.

Baseline characteristics

A study has documented the association of complexity in peripheral arterial lesions with complex coronary lesions while another study showed the increased risk for adverse cardiovascular events in patients with LEAD [24, 25]. Baseline risk factors like age, gender, hypertension, diabetes and dyslipidaemia should be taken into account while analysing such associations. In the study by Petracco et al., the baseline demographics were similar in both the groups whereas Sarangi et al. reported the predominance of PAD in diabetics and smokers [12, 15]. Falcão et al. found a significantly higher number of female subjects and subjects with ACS in the PAD group while Saran et al. reported significantly higher mean age, prevalence of diabetes and hypertension in subjects with ABI < 0.9 [14, 23]. In our study, male gender, hypertension, smoking, CVE and ACS were significantly more prevalent in the LEAD group. Baseline intake of antiplatelet, statin and antidiabetic medications were significantly less in subjects with LEAD which may have contributed to the progression of atherosclerotic disease process.

United States Preventive Services Task Force (USPSTF) states that the benefit of screening for PAD and CAD risk in asymptomatic adults with ABI is not clear cut with current evidence [26]. In our study, 23.6% subjects with DUS diagnosed LEAD were asymptomatic which is quite a sizeable proportion and thus further research regarding benefit of screening and the screening tool to be used is warranted.

LEAD and SS

The study by Korkmaz et al. on 150 patients with ACS reported higher SS in subjects with ABI ≤ 0.9 (p < 0.001) [27]. Benyakorn et al. included a large proportion of subjects with valvular heart disease and they also demonstrated significant negative correlation between ABI and SS [28]. Falcão et al. found that correlation between ABI and SS was lost when analysis was done among patients of obstructive CAD (p = 0.148) [14]. Petracco et al. reported negative correlation between ABI and SS but it was statistically insignificant [15]. In our study, high SS (>32) was more frequently noted in subjects with LEAD (p = 0.04) but mean SS did not vary significantly between the two groups.

Distribution of LEAD

Femoro-popliteal disease was more common than other distributions according to studies by Diehm et al. (51.2%), Hatmayer et al. (77%), Vogt et al. (47.3%) and Chen et al. (common femoral 57.6%) [29]. Contrary to the above data, our study revealed significantly more below-knee arterial disease than femoro-popliteal disease (p < 0.0001). This discrepancy may be attributed to the difference of baseline characteristics of the subjects.

Vuruskan et al. found that angiographic critical stenosis in femoro-popliteal segment was most reliable for the determination of subjects with high SS [30]. In the present study, significant and total occlusion of the femoro-popliteal segment arteries by DUS were found in significantly more proportion of subjects with high SS (p = 0.02). No such association was noted in the below-knee arterial segment (p = 0.08).

Predictors of peripheral artery disease in patients with CAD

Saleh et al. found independent association of age, hypertension, diabetes mellitus and smoking with PAD [31]. Another study found PAD was independent risk factor for CAD and CVE [13]. In the present study, hypertension, smoking, history of CVE and presentation with ACS independently increased the risk of LEAD. Strikingly, the presence of CKD was found to have independent negative association with LEAD which can be due to platelet and clotting factor dysfunction in CKD but needs further insight.

Limitations

The sample size was sizeable but larger population would give a better picture. This study does not provide outcome data due to lack of follow-up. Hospitalised patients with coronary angiographic confirmation of CAD were included thus automatically selecting a population with higher possibility of LEAD. Thus, these results should be treated with caution in general population. We studied only anatomical presentation of coronary and LEAD by angiographic calculation of SS and DUS respectively. Functional assessment of the lesions might find a more robust relationship between the diseases in two territories. Lower limb angiography was not performed hence extent and burden of underlying atherosclerosis may have not been accurately reflected. Exclusion of assessment of renal and aorto-iliac segments also remains a limitation. Randomised studies specifically designed for this purpose are needed to affirm the findings.

Conclusion

High prevalence of asymptomatic LEAD and association of high SS with LEAD as a whole as well as femoro-popliteal involvement suggests the need for a point of care DUS study (POCUS) which is being already used in multiple fields, since treatment varies with location and extent of disease which cannot be appreciated by ABI alone.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Change history

  • 29 December 2020

    This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s43044-020-00091-z.

Abbreviations

ABI:

Ankle brachial index

ACS:

Acute coronary syndrome

ATA:

Anterior tibial artery

BMI:

Body mass index

CABG:

Coronary artery bypass grafting

CAD:

Coronary artery disease

CFA:

Common femoral artery

CKD:

Chronic kidney disease

CVE:

Cerebrovascular events

DUS:

Duplex ultrasound

FBG:

Fasting blood glucose

LEAD:

Lower extremity artery disease

PA:

Popliteal artery

PAD:

Peripheral arterial disease

PCI:

Percutaneous intervention

PSV:

Peak systolic velocity

PTA:

Posterior tibial artery

SD:

Standard deviation

SFA:

Superficial femoral artery

SIHD:

Stable ischemic heart disease

SS:

SYNTAX score

USPSTF:

United States Preventive Services Task Force

VR:

Velocity ratio

References

  1. 1.

    Pellegrino T, Storto G, Filardi PP et al (2005) Relationship betweenbrachial artery flow-mediated dilation and coronary flow reserve in patients with peripheral artery disease. J Nucl Med 46(12):1997–2002

    PubMed  Google Scholar 

  2. 2.

    Ross AJ, Gao Z, Luck JC et al (2017) Coronary exercise hyperemia is impaired in patients with peripheral arterial disease. Ann Vasc Surg 38:260–267

    Article  Google Scholar 

  3. 3.

    Eagle KA, Rihal CS, Foster ED, Mickel MC, Gersh BJ (1994) Long-termsurvival in patients with coronary artery disease: importance of peripheral vascular disease. The coronary artery surgery study (CASS)investigators. J Am CollCardiol 23:1091–1095

    CAS  Article  Google Scholar 

  4. 4.

    Krumholz HM, Chen J, Chen YT, Wang Y, Radford MJ (2001) Predicting one-year mortality among elderly survivors of hospitalization for anacute myocardial infarction: results from the cooperative cardiovascular project. J Am CollCardiol 38:453–459

    CAS  Article  Google Scholar 

  5. 5.

    Chiu JH, Topol EJ, Whitlow PL, Hsu AP, Tuzcu EM, Franco I, Moliterno DJ (2003) Peripheral vascular disease and one-year mortality following percutaneous coronary revascularization. Am J Cardiol 92:582–583

    Article  Google Scholar 

  6. 6.

    Narins CR, Zareba W, Moss AJ, Marder VJ, Ridker PM, Krone RJ, Lichstein E (2004) Relationship between intermittent claudication, inflammation, thrombosis, and recurrent cardiac events among survivors ofmyocardial infarction. Arch Intern Med 164:440–446

    Article  Google Scholar 

  7. 7.

    Cimminiello C (2002) Peripheral arterial disease – epidemiology and pathophysiology. Thromb Res 106:295–301

    Article  Google Scholar 

  8. 8.

    Leng GC, Fowkes FGR, Lee AJ (1996) Use of the ankle brachial pressure index to predict cardiovascular events and death – a cohort study. BMJ 313:1440–1444

    CAS  Article  Google Scholar 

  9. 9.

    Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I, ESC Scientific Document Group (2018) 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries endorsed by: the European stroke organization (ESO) the Task Force for the diagnosis and treatment of peripheral arterial diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 39(9):763–816

    Article  Google Scholar 

  10. 10.

    Collins R, Cranny G, Burch J, Aguiar-Ibanez R, Craig D, Wright K, Berry E, Gough M, Kleijnen J, Westwood M (2007) A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease. Health Technol Assess 11:1–184

    Google Scholar 

  11. 11.

    Serruys PW, Morice M-C, Kappetein AP et al (2009) Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. New Engl J Med 360(10):961–972

    CAS  Article  Google Scholar 

  12. 12.

    Sarangi S, Srikant B, Rao DV, Joshi L, Usha G (2012) Correlation between peripheral arterial disease and coronary artery disease using ankle brachial index-a study in Indian population. Indian Heart J 64(1):2–6

    Article  Google Scholar 

  13. 13.

    Pang XH, Han J, Ye WL, Sun X, Ding Y, Huang WJ, Zhao YM, Lou HY, Shan LZ, Kang YX, Song XX, Zhang SZ, Gu W, Shan PF (2017) Lower extremity peripheral arterial disease is an independent predictor of coronary heart disease and stroke risks in patients with type 2 diabetes mellitus in China. Int J Endocrinol 2017:9620513

    Article  Google Scholar 

  14. 14.

    Falcão FJ, Rodrigues Alves CM, Caixeta A, de FreitasGuimarães L, de Sousa Filho JT, Soares JA, Helber I, Carvalho AC (2013) Relation between the ankle-brachial index and the complexity of coronary artery disease in older patients. ClinInterv Aging 8:1611–1616

    Google Scholar 

  15. 15.

    Petracco AM, Carlos BL, Farias PG, Santos TG, de Oliveira PD, Claudio DL et al (2018) Assessment of the relationship of ankle-brachial index with coronary artery disease severity. Int J Cardiovasc Sci 31(1):47–55

    Google Scholar 

  16. 16.

    Smith RB III (1990) Claudication. In: Walker HK, Hall WD, Hurst JW, (ed) Clinical methods: the history, physical, and laboratory examinations, 3rd edn. Boston: Butterworths; Chapter 13. Available from: https://www.ncbi.nlm.nih.gov/books/NBK235/

  17. 17.

    Edinburgh claudication questionnaire. (2002). Occasional paper (Royal College of General Practitioners), (82), 44.

  18. 18.

    Iyengar SS, Puri R, Narasingan SN (2016) Lipid Association of India Expert Consensus Statement on Management of Dyslipidemia in Indians 2016: part 1 - executive summary. J Clin Prev Cardiol 5:51–61

    Article  Google Scholar 

  19. 19.

    Eiberg JP, Grønvall Rasmussen JB, Hansen MA, Schroeder TV (2010) Duplex ultrasound scanning of peripheral arterial disease of the lower limb. Eur J Vasc Endovasc Surg 40:507–512

    CAS  Article  Google Scholar 

  20. 20.

    Heras M, Chamorro A (2000) Atherosclerosis: a systemic condition that requires a global approach. Eur Heart J 21(11):872–873

    CAS  Article  Google Scholar 

  21. 21.

    Viles-Gonzalez JF, Fuster V, Badimon JJ (2004) Atherothrombosis: a widespread disease with unpredictable and life-threatening consequences. Eur Heart J 25(14):1197–1207

    CAS  Article  Google Scholar 

  22. 22.

    Saçar M, Önem G, Sarıoğlu Büke A et al (2013) The effect of distance based learning on the fifth stage medical students’ perception in peripheral vascular diseases course: a questionnaire survey. Anadolu Kardiyol Derg 13(3):275–277

    PubMed  Google Scholar 

  23. 23.

    Saran R, Bhagat R, Narain V et al (2012) Prevalence of peripheral arterial diseases in patient with coronary artery diseases of Indian origin. Heart 98:E266

    Article  Google Scholar 

  24. 24.

    Aykan AÇ, Hatem E, Karabay CY et al (2015) Complexity of lower extremity peripheral artery disease reflects the complexity of coronary artery disease. Vascular. 23(4):366–373

    Article  Google Scholar 

  25. 25.

    Subherwal S, Bhatt DL, Li S et al (2012) Polyvascular disease and long-term cardiovascular outcomes in older patients with nonST-segment-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 5(4):541–549

    Article  Google Scholar 

  26. 26.

    Preventive Services Task Force US, Curry SJ, Krist AH et al (2018) Screening for peripheral artery disease and cardiovascular disease risk assessment with the ankle-brachial index: US Preventive Services Task Force recommendation statement. JAMA. 320(2):177–183

    Article  Google Scholar 

  27. 27.

    Korkmaz L, Adar A, Erkan H et al (2012) Ankle-brachial index and coronary artery lesion complexity in patients with acute coronary syndromes. Angiology. 63(7):495–499

    Article  Google Scholar 

  28. 28.

    Benyakorn T, Kuanprasert S, Rerkasem K (2012) A correlation study between ankle brachial pressure index and the severity of coronary artery disease. Int J Low Extrem Wounds 11(2):120–123

    Article  Google Scholar 

  29. 29.

    Chen Q, Shi Y, Wang Y, Li X (2015) Patterns of disease distribution of lower extremity peripheral arterial disease. Angiology. 66(3):211–218

    Article  Google Scholar 

  30. 30.

    Vuruskan E, Saracoglu E, Polat M, Duzen IV (2017) Prediction of coronary artery disease severity in lower extremity artery disease patients: a correlation study of TASC II classification, Syntax and Syntax II scores. Cardiol J 24(5):495–501

    Article  Google Scholar 

  31. 31.

    Saleh A, Makhamreh H, Qoussoos T et al (2018) Prevalence of previously unrecognized peripheral arterial disease in patients undergoing coronary angiography. Medicine (Baltimore) 97(29):e11519

    Article  Google Scholar 

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AM and DK made substantial contributions to the conception and design of the work; SN, AM and KB to the acquisition, analysis and interpretation of data; AM and DK have drafted the work and substantively revised it, SN, AM, DK and KB have approved the submitted version and have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Correspondence to Anindya Mukherjee.

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Ethical approval and consent was taken.

Institutional ethics committee of NRS Medical College, Kolkata, India, approved the study. Reference no. – No/NMC/959.

Informed written consent for participation was obtained from individual patients.

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N/A as anonymity was not compromised.

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The authors declare that they have no competing interests.

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Nandi, S., Mukherjee, A., Khanra, D. et al. RETRACTED ARTICLE: Association of severity of coronary artery disease by SYNTAX score (SS) and lower extremity arterial disease by duplex ultrasound (DUS) study—an Indian perspective. Egypt Heart J 72, 56 (2020). https://doi.org/10.1186/s43044-020-00091-z

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