title: Impact of routine coronary catheterization in low extremity artery disease undergoing percutaneous transluminal angioplasty: study protocol for a multi-center randomized controlled trial.
abstract: BACKGROUND
  The prevalence of significant obstructive coronary artery disease with complex lesions is high in patients who have low extremity artery disease (LEAD). However, intermediate- or long-term cardiovascular prognosis of LEAD patients undergoing percutaneous transluminal angioplasty (PTA) remains poor. Accordingly, prophylactic coronary revascularization may modify short- and long-term cardiovascular outcomes of LEAD patients receiving PTA. Because myocardial ischemic symptoms are often masked in LEAD and the accuracy of non-invasive stress tests is usually limited, a high-quality randomized controlled trial aimed at the investigation of the prognostic role of coronary evaluation strategies before PTA is warranted.
  
  
  METHODS
  The proposed study is designed as a prospective, multi-center, open-label, superiority, randomized controlled trial. The study is conducted in high-volume centers for PTA and coronary revascularization in Taiwan. To meet the inclusion criteria, the patients must be at least 20 years old, have known LEAD, and have been admitted for elective PTA. We plan to enroll 450 participants who are randomly allocated to a routine group (routine coronary angiography without a previous non-invasive stress test before PTA) and a selective group (selective coronary angiography based on the results of non-invasive stress tests before PTA) with 1:1 ratio. Besides, we expect to enroll about 250 additional participants, who are not willing to be randomly assigned, in the registration group. The choice of revascularization procedure depends on the operator's or cardiovascular team's suggestion and the patient's decision. Clinical follow-up will be performed 30 days after PTA and every 6 months until the end of the 1-year follow-up for the last randomly assigned participant. The primary endpoint is the composite major adverse cardiac event on long-term follow-up. Pre-specified secondary and other endpoints are also evaluated. Those assessing biomarkers and clinical endpoints are all blinded after assignment to interventions.
  
  
  CONCLUSIONS
  The results of the trial will, for the first time, support better decision-making for coronary evaluation before PTA in LEAD. If favorable, routine coronary angiography followed by revascularization will improve cardiovascular outcomes in LEAD patients undergoing PTA.
  
  
  BACKGROUND
  ClinicalTrials.gov identifier: NCT02169258 (registered on 21 June 2014); registry name: Routine Coronary Catheterization in Low Extremity Artery Disease Undergoing Percutaneous Transluminal Angioplasty (PIROUETTE-PTA).
authors.affiliation: Department of Internal Medicine, Tainan Municipal Hospital, Tainan, Taiwan. ichih1230@yahoo.com.tw.
authors.forename: I-Chih
authors.initials: IC
authors.lastname: Chen
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. appollolee@yahoo.com.tw.
authors.forename: Cheng-Han
authors.initials: CH
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. chaotinghsing@gmail.com.|Division of Cardiology, Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, No. 138, Sheng-Li Road, North District, Tainan, 704, Taiwan. chaotinghsing@gmail.com.
authors.forename: Ting-Hsing
authors.initials: TH
authors.lastname: Chao
authors.affiliation: Division of Cardiology, Department of Internal Medicine, E-Da University College of Medicine and Hospital, Kaohsiung, Taiwan. arthurtseng@me.com.
authors.forename: Wei-Kung
authors.initials: WK
authors.lastname: Tseng
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University and Hospital, Kaohsiung, Taiwan. lth@kmu.edu.tw.
authors.forename: Tsung-Hsien
authors.initials: TH
authors.lastname: Lin
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Chang-Gung Memorial Hospital Kaohsiung, Kaohsiung, Taiwan. wenjung.chung@gmail.com.
authors.forename: Wen-Jung
authors.initials: WJ
authors.lastname: Chung
authors.affiliation: Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. b85401104@gmail.com.
authors.forename: Jen-Kwan
authors.initials: JK
authors.lastname: Li
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan. huang304@gmail.com.
authors.forename: Hsuan-Li
authors.initials: HL
authors.lastname: Huang
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. larry@mail.ncku.edu.tw.
authors.forename: Ping-Yen
authors.initials: PY
authors.lastname: Liu
authors.affiliation: Department of Otolaryngology, Far Eastern Memorial Hospital, New Taipei City, Taiwan. tingkuan@ualberta.ca.|Division of Public Health and Preventive Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. tingkuan@ualberta.ca.
authors.forename: Ting-Kuang
authors.initials: TK
authors.lastname: Chao
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University and Hospital, Kaohsiung, Taiwan. ksmale@seed.net.tw.
authors.forename: Chuin-Yuan
authors.initials: CY
authors.lastname: Chu
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. chaoth@mail.ncku.edu.tw.
authors.forename: Chih-Chan
authors.initials: CC
authors.lastname: Lin
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University and Hospital, Kaohsiung, Taiwan. pochao.hsu@gmail.com.
authors.forename: Po-Chao
authors.initials: PC
authors.lastname: Hsu
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. wenhuanglee@gmail.com.
authors.forename: Wen-Huang
authors.initials: WH
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. ptlee31@gmail.com.
authors.forename: Po-Tseng
authors.initials: PT
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. heng@mail.ncku.edu.tw.
authors.forename: Yi-Heng
authors.initials: YH
authors.lastname: Li
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. hero-4811@yahoo.com.tw.
authors.forename: Shih-Ya
authors.initials: SY
authors.lastname: Tseng
authors.affiliation: Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan. tsailm@mail.ncku.edu.tw.
authors.forename: Liang-Miin
authors.initials: LM
authors.lastname: Tsai
authors.affiliation: Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. jueyhwang@ntu.edu.tw.
authors.forename: Juey-Jen
authors.initials: JJ
authors.lastname: Hwang
mesh_terms: D000800:Angioplasty, Balloon / Q000009:adverse effects; D006328:Cardiac Catheterization / Q000009:adverse effects; D002985:Clinical Protocols; D017023:Coronary Angiography / Q000009:adverse effects; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy; D005080:Exercise Test; D006801:Humans; D035002:Lower Extremity / Q000098:blood supply*; D062645:Percutaneous Coronary Intervention; D058729:Peripheral Arterial Disease / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012107:Research Design; D012307:Risk Factors; D013624:Taiwan; D013997:Time Factors; D016896:Treatment Outcome