Invest Clin 63(4): 363 - 375, 2022 https://doi.org/10.54817/IC.v63n4a04

Corresponding Author: Ahmet Rıfkı Çora. Isparta City Hospital ,Cardiovascular Surgery Department. Ataturk Bou-

levard No:51, 32200 Isparta, Turkey. Telephone: +905053370228. E-mail: drahmetcora@gmail.com

Relationship between peripheral arterial

disease severity determined by the Glass

classification and triglyceride-glucose index;

novel association and novel classification

system.

Ahmet Rıfkı Çora and Ersin Çelik

Cardiovascular Surgery Department, Isparta City Hospital, Isparta; Turkey.

Keywords: peripheral arterial disease; GLASS classification; triglyceride-glucose index;

insulin resistance.

Abstract. Peripheral arterial disease is a serious clinical manifestation

caused by atherosclerosis. It is one common cause of morbidity and mortality

worldwide. It is commonly seen in males, and its (prevelance) increases with age.

It is most prevalent with smoking, hypertension, diabetes mellitus and hyperlip-

idemia. Novel studies investigate the relationship between triglyceride-glucose

index (TyG) and cardiovascular diseases. Studies investigating the association

of this index and peripheral arterial disease and disease severity are generally

done by using The Trans-Atlantic Inter-Society Consensus (TASC) classification.

We aimed to study this association by using the new Global Limb Anatomic

Staging System (GLASS) classification. Two hundred patients between 25 to

90 years old diagnosed with peripheral arterial disease and admitted to the

hospital for peripheral arterial angiography between July 2021 and December

2021, were evaluated retrospectively with blood parameters and angiographic

images. Patients were divided into two groups: moderate (group 1; n=58) and

severe (group 2; n=142) according to the GLASS classification. No statistical

differences were observed for comorbidities and repeated interventional pro-

cedure rates (p=0.164). Triglyceride values were found to be statistically dif-

ferent between groups (p=0.040). TyG was found higher in group 2 (p= 0.04).

According to the binary logistic regression model, only TyG was found to have

a significant effect as a diagnostic factor (p=0.011). TyG was also significantly

correlated with the Rutherford (p=0.012) and GLASS classification severity

(p<0.001). Peripheral arterial disease and disease severity could be easily moni-

tored with simple calculable TyG. In this way, precautions could be taken, and

morbidities could be prevented.

364 Çora and Çelik

Investigación Clínica 63(4): 2022

Relación entre la gravedad de la enfermedad arterial periférica

determinada por la clasificación GLASS y el índice de

triglicéridos-glucosa; nueva asociación y nuevo sistema

de clasificación.

Invest Clin 2022; 63 (4): 363 – 375

Palabras clave: enfermedad arterial periférica; clasificación de GLASS; indice de

triglicéridos-glucosa; resistencia a la insulina.

Resumen. La enfermedad arterial periférica es una manifestación clínica

importante causada por la aterosclerosis. Es una causa común de morbilidad

y mortalidad en todo el mundo. Se ve comúnmente en hombres y la prevalen-

cia aumenta con la edad. Es más común con el tabaquismo, la hipertensión,

la diabetes mellitus y la hiperlipidemia. Nuevos estudios investigan la relación

entre el índice de triglicéridos-glucosa (TyG) y las enfermedades cardiovascu-

lares. Los estudios que investigan la asociación de este índice y la enfermedad

arterial periférica generalmente se realizan utilizando la clasificación de TASC.

Nuestro objetivo fue estudiar esta asociación utilizando la nueva clasificación

de GLASS (sistema global de estadificación anatómica de extremidades). Dos-

cientos pacientes entre 25 a 90 años con diagnóstico de enfermedad arterial

periférica e ingresados al hospital para angiografía arterial periférica entre julio

de 2021 y diciembre de 2021, fueron evaluados retrospectivamente con pará-

metros sanguíneos e imágenes angiográficas. Los pacientes se dividieron en dos

grupos: leves (grupo 1; n=58) y graves (grupo 2; n=142) según la clasificación

de GLASS. No se observaron diferencias estadísticas para las comorbilidades y

las tasas de procedimientos intervencionistas repetidos (p = 0,164). Los valores

de triglicéridos se encontraron significativamente diferentes entre los grupos

(p= 0,04). El índice de triglicéridos-glucosa se encontró más alto en el grupo

2 (p= 0,04). Según el modelo de regresión logística binaria, solo el índice de

triglicéridos-glucosa resultó tener un efecto significativo como factor diagnós-

tico (p=0,011). El índice de triglicéridos-glucosa también se correlacionó sig-

nificativamente con la gravedad de la clasificación de Rutherford (p=0,012)

y la clasificación de GLASS (p<0,001). La enfermedad arterial periférica y la

gravedad de la enfermedad podrían controlarse fácilmente con TyG calculable

simple. De esta manera, se podrían tomar precauciones y prevenir morbilidades.

Received: 14-03-2022 Accepted: 20-07-2022

INTRODUCTİON

Peripheral arterial disease (PAD) is an

important disease that arises from systemic

atherosclerosis and has effected about 200

million people worldwide 1,2. Although PAD is

most commonly seen among males, its inci-

dence in women has increased especially at

ages over 50 years 3. Its prevelance incereas-

es with age, and the reported rate is about

20% or above in individuals who are over 80

years 4. It is a pathology that could result in

The association between the peripheral arterial disease and triglyceride-glucose index 365

Vol. 63(4): 363 - 375, 2022

morbidities ranging from lower extremity

ulcers to limb losses. Despite the high mor-

bidity rates, PAD tends to be asymptomatic

until it reaches the advanced stage 5. Its pre-

sentation can vary from asymptomatic phase

to critical limb ischemia (CLI) and most

of the patients that are admitted to hospi-

tals suffer from intermittent claudication.

The most common diagnostic test for PAD

is ankle-brachial index (ABI) measurement

and values ≤ 0.90 is considered as arterial

stenosis and its sensitivity in diagnosing PAD

is 95% 6,7. Doppler ultrasonography generally

is the first imaging method choosed for diag-

nosing PAD.

Despite this type of clinical course and

well-known adverse outcomes, the patho-

physiology of PAD has not yet been fully un-

derstood. The well-known main underlying

pathology of PAD is atherosclerosis 8. Since

atherosclerosis is a common underlying pa-

thology, the risk factors for PAD are; hyper-

tension (HT), smoking, diabetes mellitus

(DM) and hyperlipidemia 9.

Insulin resistance (IR), is usually one of

the main events underlying DM, a pathology

characterized by decreased insulin sensitiv-

ity of peripheral tissues 10 and the resulting

chronic hyperinsulinemia is significantly as-

sociated with atherosclerotic cardiovascular

disease (CVD) 11-13. It has been detected that

insulin-resistant patients endure higher car-

diovascular risk than insulin-sensitive sub-

jects 14. According to these reports, an as-

sociation with IR and vascular disease is very

likely but exact pathogenesis of this relation

remain controversial. The effect on the vas-

cular area is one of the pathological mecha-

nism evaluated in the association between

DM and PAD 15. IR related vascular damage

includes functional and structural vascular

injury such as; vascular wall elasticity loss

(arterial stiffness), increased intima-media

thickness, impaired vasodilation and vascu-

lar calcification 16.

Also the relationship between the tri-

glycerides (TGs), CVD and atherosclerosis is

still controversial. Recent studies have pro-

vided evidence that TGs and TG-rich lipopro-

teins are among the causes of CVD 17.

The triglyceride-glucose index (TyG),

a calculated index by using fasting blood

glucose and triglyceride values, has been

defined as a novel marker of IR 18-20 and stud-

ies have shown a relationship between the

TyG and CVD, stroke, carotid atherosclero-

sis and coronary artery disease (CAD) 21-23.

Although many studies have evaluated the

association of this index with CAD, CVD and

carotid atherosclerosis, there are currently

very few data about its association with PAD

and disease severity. We aimed to investigate

the association between TyG and PAD sever-

ity, by using a new anatomical classification

for PAD named Global Limb Anatomic Stag-

ing System (GLASS).

MATERİAL AND PATİENTS

Our study is a retrospective observa-

tional comparative study that compares re-

sults of individuals allocated into two groups

according to the severity of their lesions.

Two hundred patients that were between 25 and

90 years old, admitted to our outpatient clinic,

diagnosed with PAD and hospitalized for periph-

eral arterial angiography between July 2021-De-

cember 2021 were investigated retrospective-

ley. Patient data were obtained from Isparta

City Hospital’s hospital registration system

and angiography laboratory archive. The study

was approved by Suleyman Demirel Univer-

sity Medical Faculty Ethical Committee (Num-

ber:72867572-050.01.04-196235).

Patients that were admitted to outpa-

tient clinic with intermittant claudication

or extremity ulcers, diagnosed with PAD as

a result of clinical examination (absence

of palpable peripheral pulses) and low ABI

measurement (ABI≤ 0.9). The Rutherford

Classification was used for clinical staging

of existing disease. According to Ruther-

ford Classification, asymptomatic patients

staged as “Cathegory 0”, mild claudication

as “Cathegory 1”, moderate claudication as

“Cathegory 2”, severe claudication staged

366 Çora and Çelik

Investigación Clínica 63(4): 2022

as “Cathegory 3”, ischemic rest pain as

“Cathegory 4”, minor tissue loss “Cathego-

ry 5” and major tissue loss expressed as

“Cathegory 6” 24.

Patients diagnosed with PAD as a result

of clinical examination were taken to color

Doppler ultrasonography (Toshiba Applio

500; Japan) and if a pathology was detected,

Computed Tomographic Angiography (CTA)

(Hitachi Supria; Japan) was applied for de-

tailed evaluation. After performing CTA, pa-

tients that had peripheral arterial stenosis

more than 50% were hospitalized for periph-

eral arterial angiography for further evalu-

ation and treatment. Angiographies per-

formed in Isparta City Hospital angiography

laboratory (Toshiba Infinix; Japan) by the

same physician with local anesthesia from

right or left femoral artery approaches with

6F sheath by using Seldinger technique. An-

tegrad or retrograd approaches selected ac-

cording to the lesions of the patients evalu-

ated by CTA images.

Patients who underwent peripheral an-

giography were evaluated by novel GLASS

anatomic classification in terms of PAD se-

verity. (Table 1) GLASS classification is a

new anatomic classification system using

angiographic findings for severity of PAD.

It was published in 2019 by joining of three

Table 1

Global Limb Anatomic Staging System (GLASS).

Aorta-Iliac Grading

1Stenosis of the common and external iliac artery, chronic total occlusion of either common or

external iliac artery (not both), stenosis of the infrarenal aorta; any combination of these.

Chronic total occlusion of the aorta; chronic total occlusion of common and external iliac arte-

ries; severe diffuse disease and/or small-caliber (<6 mm) common and external iliac arteries;

concomitant aneurysm disease; severe diffuse in-stent restenosis in the aorta-iliac system.

Femoro-Popliteal (FP) Grading

0 Mild or no significant (<50%) disease

1Total length SFA disease <1/3 (<10 cm); may include single focal CTO (<5 cm) as long as not

flush occlusion; popliteal artery with mild or no significant disease.

2Total length SFA disease 1/3–2/3 (10–20 cm); may include CTO totaling <1/3 (10 cm) but not

flush occlusion; focal popliteal artery stenosis <2 cm, not involving trifurcation.

3Total length SFA disease >2/3 (>20 cm) length; may include any flush occlusion <20 cm or

non-flush CTO 10–20 cm long; short popliteal stenosis 2–5 cm, not involving trifurcation.

4Total length SFA occlusion >20 cm; popliteal disease >5 cm or extending into trifurcation; any

popliteal CTO.

Infra-Popliteal (IP) Grading

0 Mild or no significant (<50%) disease.

1 Focal stenosis <3 cm not including TP trunk.

2Total length of target artery disease <1/3 (<10 cm); single focal CTO (<3 cm not including TP

trunk or target artery origin).

3Total length of target artery disease 1/3–2/3 (10–20 cm); CTO 3–10 cm (may include target

artery origin, but not TP trunk).

4Total length of target artery disease >2/3 length; CTO >1/3 (>10 cm) of length (may include

target artery origin); any CTO of TP trunk.

The association between the peripheral arterial disease and triglyceride-glucose index 367

Vol. 63(4): 363 - 375, 2022

vascular societies 25. With this new anatomic

staging system, better assessment of limb

ischemia and better characterization of the

anatomic specifications of vascular disease

could be achieved 26.

After 12 hours of overnight fasting, ve-

nous blood samples for biochemical and he-

matological parameter measurements were

taken from the blood drawn from the ante-

cubital vein at the first day after hospital

admission for blood analysis. Biochemical

analysis included the serum lipid profile and

fasting glucose levels (Variant 2-Turbo, Bio-

Rad; Japan).

TyG is calculated as Ln (fasting triglyc-

erides (mg/dL) × fasting glucose (mg/dL)

/ 2). ABI was calculated as the ratio of high-

est systolic ankle pressure to highest systolic

brachial pressure measured manually.

Patients diagnosed with Buerger dis-

ease, vasculitis, acute limb ischemia, system-

ic inflammatory diseases, chronic liver and

hematological diseases; patients operated or

had vascular interventions before outpatient

clinic admission; patients who have known

malignancy and whose index could not be

calculated due to the abscence of laboratory

parameters were excluded from the study.

Statistical Analysis

Statistical analyses of the study were

performed with SPSS 25.0 (IBM Incorp, IL,

USA) program. Descriptive measures were

presented as mean±SD or median (Q1-Q3)

for numerical measurements according to

their normality, and frequency (percentage

ratio) for categorical measurements. The

normality of numerical measurements was

analyzed with the Kolmogorov-Smirnov test.

Independent group comparisons were per-

formed by using the Student’s t-test and the

Mann-Whitney U test. Chi-square test was

used to determine the relationships between

the categorical variables, distribution-appro-

priate correlation analyzes were used to de-

termine the relationships between numeri-

cal measurements. To determine the factors

that affect the severity of PAD, univariate

and multivariate logistic regression models

were established. The goodness-of-fit values

and significance of the model were calcu-

lated. The model was created by using the

forward likelihood ratio logistic regression

method for avoiding the multicollinearity

problem. In order to determine the diagnos-

tic features of the TyG index, ROC analysis

was performed and diagnostic rates were

calculated. A p<0.05 value was considered

statistically significant by taking the type-I

error rate as 5% throughout the study.

The power analysis of the study was per-

formed with the GPower 9.1.2 (Universitaet

Kiel, Germany) program. By calculating the

triglyceride and glucose values and TgG in-

dex of the patients that were selected for the

pilot study, the effect size was calculated for

mild to moderate and severe patient groups

(d=0.742). The sample size for each group

was calculated as n=54 for the power value

of 95% and margin of error of 5%. However,

the moderate:severe ratio was taken as 1:2,

since the number of patients with severity

was observed to be higher among the pa-

tients admitted to the hospital.

CTO: Chronic Total Occlusion; SFA: Superficial Femoral Artery; TP:Tibio-peroneal.

Table 1

CONTINUATION

Inframalleolar/Pedal Grading

0 Target artery crosses ankle into foot, with intact pedal arch

1 Target artery crosses ankle into foot; absent or severely diseased pedal arch

2 No target artery crossing ankle into foot

368 Çora and Çelik

Investigación Clínica 63(4): 2022

RESULTS

Two hundred patients diagnosed with

PAD that underwent peripheral arterial angi-

ography were included in the study. Patients

were divided into two groups for the sever-

ity of their lesions according to GLASS clas-

sification as Group 1 (moderate- G1) and

Group 2 (severe- G2), (Table 2).

There was no difference for mean age,

gender and comorbidities between the study

groups. While chronic kidney disease (CKD)

was found to be higher in the G2, CAD was

found to be slightly higher in G1. Lower ex-

tremity amputation rates were found signifi-

cantly higher in G2 (Table 3).

Patients were also evaluated according

to the Rutherford classificiation and stastis-

tically significant association with GLASS

classification was observed (p˂0.001). Sta-

tistically significant relationship was also

found between the PAD severity determined

by GLASS classification and ABI (p˂0.001).

TyG values showed statistically signifi-

cant difference between the groups. TyG was

higher in severe group (G2) compared to

the moderate group (G1) (p=0.04). When

TyG comparison was studied for Rutherford

classification among study groups (Table 2),

TyG was observed significant higher in se-

vere group compared to the moderate group

(p=0.012).

There was no difference observed for

serum total cholesterol, high density lipo-

protein (HDL), and low density lipoprotein

(LDL) values among the moderate and se-

vere groups. The results of biochemical pa-

rameters were summarised in Table 4.

Since the TyG and PAD severity as-

sociation was found significant in study

groups, ROC analysis was applied to deter-

mine the index diagnostic value for PAD

severity. A significant but low-level ROC

curve was obtained. Diagnostic ratios were

calculated as 65.5% sensitivity and 58.9%

specificity (Fig. 1).

In order to determine the diagnostic

factors effecting G2, a binary logistic regres-

sion model was created by taking G1 as the

reference group. Demographic variables (age

and gender), TyG, HDL, LDL and total cho-

lesterol values were included in the model.

Variables that could cause multicollinearity

problem were excluded. The model was cre-

ated by using the forward stepwise logistic

regression method. The model was found sig-

nificant (Omnibus X2=6.971; p=0.008 and

Hosmer-Lemeshow X2=10.03; p=0.262).

Goodness of fit was found at medium-level

(Nagelkerke R2=0.05). Only TyG was found

to have a significant effect on the model as

a diagnostic factor (OR=2.075), (Table 5).

DİSCUSSİON

In our study, we aimed to investigate

the relationship between the severity of PAD,

which is determined by using the GLASS

classification, and the TyG. According to

the best of our knowledge, our study is the

first to examine the association of TyG with

the severity of PAD determined by using this

novel classification system; and similar to

other few studies reported in the literature,

we have found a significant relationship be-

tween TyG and PAD severity. Since we aimed

Table 2

Study groups divided according to GLASS and Rutherford classification.

Group 1 (Moderate) Group 2 (Severe)

Femoropopliteal 0-2/Aorta-iliac 1 Femoropopliteal 3-4/Aorta-iliac 2

Infrapopliteal 0-2 Infrapopliteal 3-4

Pedal 0 Pedal 1-2

Rutherford Class 0-2 Rutherford Class 3-6

The association between the peripheral arterial disease and triglyceride-glucose index 369

Vol. 63(4): 363 - 375, 2022

to determine this association by using novel

GLASS classification, we also evaluated the

GLASS classification system to understand

its relationship with the PAD severity. For

this purpose, we compared this system with

the Rutherford classification and ABI mea-

surements and found significant agreement

between the GLASS and PAD severity.

There has been some studies that inves-

tigated multiple pathological consequences

of atherosclerosis; however, PAD has been

paid less attention than the other patholo-

gies like CAD or stroke 27. Based on the lat-

est reports, it is estimated that 5.56% ratio

of people worldwide aged 25 years and older

had PAD 28. But only 10% of PAD patients

Table 3

Demographic spesifications and comorbidities.

Group1

N=58 (28.3)

Group2

N=142 (71.1)

Total

N=200

Specifications Cathegories N (%) N (%) N (%) p

Gender Female 4 (6.9) 23 (16.2) 27 (13.6) 0.095

Male 54 (93.1) 119 (83.8) 171 (86.4)

Diabetes Mellitus none 26 (44.8) 65 (45.8) 90 (45.5) 0.885

Ye s 32 (55.2) 77 (54.2) 108 (54.5)

Hypertension None 16 (27.6) 44 (31) 59 (29.8) 0.561

Ye s 42 (72.4) 98 (69) 139 (70.2)

Smoker None 37 (63.8) 98 (69) 133 (67.2) 0.379

Ye s 21 (36.2) 44 (31) 65 (32.8)

Coronary Artery Disease None 31 (53.4) 89 (63.1) 119 (60.1) 0.216

Ye s 27 (46.6) 52 (36.9) 78 (39.4)

Chronic Renal Failure None 54 (93.1) 127 (89.4) 179 (90.4) 0.462

Ye s 4 (6.9) 15 (10.6) 19 (9.6)

Repeated Intervention None 48 (82.8) 127 (89.4) 173 (87.4) 0.164

Ye s 10 (17.2) 15 (10.6) 25 (12.6)

Amputation None 52 (89.7) 107 (75.4) 159 (79.5) 0.023*

Ye s 6 (10.3) 35 (24.6) 41 (20.5)

Rutherford Classification 0+ 5 (8.8) 0 5 (2.5)

<0.001*

1+ 25 (43.9) 3 (2.1) 28 (14.1)

2+ 21 (36.8) 4 (2.8) 25 (12.6)

3+ 2 (3.5) 84 (59.2) 86 (43.2)

4+ 1 (1.8) 41 (28.9) 42 (21.1)

3 (5.3)

8 (5.6)

2 (1.4)

11 (5.5)

2 (1.0)

Age (years) 67.09±9.22 68.47±11.42 0.207

ABI 0.67±0.13

0.77; 0.69-0.82

0.31±0.12

0.28; 0.24-0.36 <0.001*

*: Significant at the 0.05 level according to the Chi-Square test; +: the related Rutherford class is significantly

different between the groups. ABI: Ankle-Brachial Index.

370 Çora and Çelik

Investigación Clínica 63(4): 2022

Table 4

Biochemical parameters.

Group1 (N=58) Group2 (N=142)

Avarage±SS

Median; Q1-Q3

Avarage±SS

Median; Q1-Q3 p

Triglyceride

(mg/dL)

135.33±54.29

129; 88.75-161.86

172.28±84.31

153.5; 113-210 0.040*

Fasting Blood Glucose 132.86±45.62

116.5; 95.25-165

137.56±52.64

126.5; 94.75-173.5 0.269

LDL 105.22±35.39

113.5; 75.25-130.75

116.08±37.31

111.14; 88-140 0.875

VLDL 27.43±11.21

26; 18.25-32.24

34.03±16.42

30; 22-41.25 0.061

HDL 42.9±16.02

40; 34-46.75

41.73±13.53

40; 33-48 0.907

Total Cholesterol 170.81±38.16

174.5; 145.5-199.25

188.87±48.97

181.5; 156-220.25 0.541

TyG 8.96±0.54

8.9; 8.69-9.41

9.21±0.61

9.2; 8.78-9.49 0.040*

*: Significant at the 0.05 level according to the Mann-Whitney U test.

TyG: Triglyceride-Glucose Index; LDL: Low density Lipoprotein; HDL:High density Lipoprotein; VLDL: Very Low

Density Lipoprotein,

Fig. 1. Triglyceride-Glucose Index ROC curve for patients with severe lesion.

The association between the peripheral arterial disease and triglyceride-glucose index 371

Vol. 63(4): 363 - 375, 2022

demonstrate typical symptomatology and

the others remain undiagnosed 5. Therefore,

it is important to determine the appropriate

biomarkers for the PAD risk and its severity.

With regular measurement of the levels of

these biomarkers will be important in terms

of determining the risk of PAD or monitor-

ing the course of the diagnosed disease. By

this means, taking early measures could pre-

vent the progression of the disease at early

clinical stages.

Insulin is a hormone that regulates the

cell metabolism, and IR is characterized by

a deficit in insulin uptake by peripheral tis-

sues. This resistance impairs glucose uptake

and glycogen synthesis of tissues and creates

an imbalance in lipid oxidation. As glucose

homeostasis deteriorates, insulin secretion

increases. Secondary to hyperinsulinemia,

oxidative stress and an increase in inflamma-

tory responses occur 29,30. Endothelial cells

get affected by this oxidative stress, endo-

thelial function gets impaired and athero-

sclerosis develops in the chronic period 31.

For these reasons, IR has been seen as an im-

portant risk factor for CVD 32,33. It has been

shown that IR and hyperinsulinemia are as-

sociated with the development of HT, dyslip-

idemia and atherosclerosis 34,35. But data that

have reported association of IR and PAD are

limited 36,37. A cross-sectional study of 3242

adults from data in the National Health and

Nutrition Examination Survey identified a

positive relation between IR and PAD 26,37. A

study with 4208 participants over the age of

65 years in the Cardiovascular Health Study,

found that IR was associated with a higher

risk of clinical PAD 27,38. In some reports, TyG

was defined as a marker with high specifity

and sensitivity for IR 11,38.

The positive relationship of TyG with

CVD and atherosclerosis has been shown in

many studies 39-41. Li et al. reported in a ret-

rospective study that the TyG could be used

as a high risk predictor for CVD 42. In a study

conducted with 5014 healthy individuals,

high levels of the TyG were shown to be as-

sociated with an increased risk of CVD 41. In

another study involving 4319 patients, a sig-

nificant association of the TyG with the pres-

ence of coronary calcification was reported

39. IR and PAD association was reported in

some studies 27,36,37. Although there are stud-

ies on the association of the TyG with coro-

nary and carotid diseases, studies that show

the relationship of the TyG and PAD severity

is rare. Chiu et al. reported a significant asso-

ciation between the TyG and low ABI in their

study 43. Kim et al., on the other hand, found

that the TyG was associated with arterial

stiffness and coronary artery calcification in

Korean adults 44. Among these studies, the

study conducted by Duran Karaduman et al.

showed a significant relationship between

the TyG elevation and PAD severity 3. In addi-

tion, there are studies that have investigated

the predictability of the TyG for critical limb

ischemia 45.

Table 5

Diagnostic factors effective on patients with severe lesion.

Factors Beta p OR %95 CI

Age 1.528 0.216

Gender 3.002 0.083

TyG 0.730 0.011* 2.075 1.183-6.640

LDL 2.264 0.132

HDL 0.017 0.896

T. cholesterol 3.193 0.074

TyG: Triglyceride-Glucose Index; LDL: Low density Lipoprotein; HDL:High density Lipoprotein; T.Cholesterol: Total

Cholesterol. *: Significant at the 0.05 level according to the Binary logistic regression analysis.

372 Çora and Çelik

Investigación Clínica 63(4): 2022

Despite all these reports, studies that

examine the severity of the PAD and TyG as-

sociation according to the anatomical clas-

sification systems developed for PAD, such

as TASC, are very limited. In the study con-

ducted by Duran Karaduman et al, the re-

lationship between the TyG and PAD com-

plexity and severity was investigated by

using TASC classification 3. In our study we

found a statistically significant correlation

between TyG and the severity and complex-

ity of PAD detected with GLASS classifica-

tion (p=0.04) similar to the findings of the

reports on the association of TyG and PAD

severity determined with other angiographic

classification systems like TASC 3. We also

compared this novel system with Rutherford

system and ABI measurements to determine

the positive association of PAD severity and

this system. We observed a statistically sig-

nificant association (p˂ 0.01), (Table 3).

Serum lipids also play an important

role in developing atherosclerosis. LDL is

the best known parameter for this risk but

the relationship between the TGs, CVD and

atherosclerosis is still controversial. Recent

studies have provided evidence on the fact

that TG and TG-rich lipoproteins are among

the causes of CVD 10. It has been shown that

the simultaneous presence of hypertriglyc-

eridemia (HTG) promotes the formation of

high atherogenic small dense LDL particles

46. As a summary, there is a relation between

TG levels and atherosclerosis 47,48. In our

study, TG levels were also found significantly

higher in G2 (p=0.04).

There were some limitations of our

study. The low number of patients was one

of the most important limiting factor. It was

mostly due to the limited number of inter-

ventional procedures performed in our clin-

ic. In addition, the laboratory parameters

that were used in the calculation of TyG were

absent in the data of some patients; there-

fore, the index could not be calculated and

these patients were compulsorily excluded

from the study. This was another factor that

reduced our case number. We think that the

low diagnostic value of TyG detected by ROC

analysis could increase if the study could be

performed with more patients, and by this

means the study could become more valu-

able.

TyG is an easily calculable index. In our

study we found a significant relationship be-

tween the severity of PAD and TyG, which was

determined by using the novel GLASS clas-

sification, similar to previous studies which

use other anatomic classification systems. In

the light of these findings, we think that this

index would be a useful and simple marker

for detecting the patients’ disease severity

for newly diagnosed or cases has been treat-

ed with medically or other invasive methods.

Possible early detection of worse onset or

worsening of the diagnosed disease can be

predicted by routine use of this parameter,

and morbidities could be prevented by apply-

ing appropriate treatments to these patients

in early periods. But more large scale studies

are needed to support this conclusion.

Funding

Authors declare no funding for this article.

Conflict of Interest

Authors declare no conflicts of interests

ORCID authors

• Ahmet Rıfkı Çora:

0000-0002-4892-9463

• Ersin Çelik: 0000-0002-0015-3280

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