Assessment of 3-Year Patency after Endoluminal versus Surgical Bypass Therapy for Complex Femoropopliteal Artery Disease

PURPOSE

To compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass for complex femoropopliteal (FP) arterial lesions.

MATERIALS AND METHODS

In this retrospective multicenter study, 530 patients with symptomatic peripheral artery disease (Rutherford classification 1-3, 66.0%; 4-6, 34.0%) who underwent either endoluminal bypass with Viabahn stent grafts (n = 276) or surgical bypass (n = 254) (with saphenous vein grafts, 74.4%; prosthetic grafts, 25.6%) for FP arterial lesions between 2010 and 2018 were analyzed. The propensity score-matched analysis was performed to compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass. The primary end point was primary patency (freedom from restenosis). The secondary end points were secondary patency, freedom from target lesion revascularization (TLR), limb salvage, and overall survival. The interaction effect of baseline characteristics on the association of the revascularization strategy with the risk of restenosis was analyzed using the Poisson mixed-effect model.

RESULTS

The propensity score-matched analysis extracted 107 pairs. After propensity score matching, the primary patency rate at 1, 2, and 3 years was 84.5%, 75.1%, and 70.9%, respectively, for the endoluminal bypass group versus 78.6%, 73.3%, and 72.0%, respectively, for the surgical bypass group (P = .65). There was no significant difference in secondary patency, freedom from TLR, limb salvage, and overall survival (all P > .05). The subsequent interaction analysis revealed that the involvement of popliteal lesions, small distal reference vessel diameters, and long lesions favored surgical bypass over endoluminal bypass because of improved primary patency (all P for interaction < .05).

CONCLUSIONS

The 3-year clinical outcomes after endoluminal bypass or surgical bypass for FP arterial lesions were similar.

Social isolation in patients with chronic limb-threatening ischemia: a cross-sectional study

Assistance by family members or friends plays important roles in the course of treating patients with chronic limb-threatening ischemia (CLTI), both during hospitalization and after discharge. The aim of this study was to reveal the prevalence of social isolation and to explore relevant clinical backgrounds in patients with CLTI presenting with tissue loss and requiring revascularization. We analyzed 413 patients registered in a multicenter study in whom revascularization were scheduled for CLTI with tissue loss. Social isolation was analyzed by assessing the residence status of the patients and the involvement of a trusted family member or friend in their daily lives and during hospitalization. Patients living alone accounted for 24.5% (95% confidence interval [CI] 20.1-28.8%) of the study population. Patients receiving welfare were more likely to live alone (P < 0.001). For patients living alone, 21.8% (95% CI 12.8-30.8%) met a trusted family member or friend in their daily lives less than once per year. Younger age and receiving welfare were independently associated with lower frequency of meeting the trusted person in their daily lives (both P < 0.05). The adjusted odds ratio of age and receiving welfare was 0.44 (95% CI 0.29-0.67) per 10-year increase and 3.47 (95% CI 1.43-8.44), respectively. During hospitalization, 9.9% (95% CI 6.8-13.0%) of the patients had no hospital visits by a trusted family member or friend on three key occasions: the patient's first hospital visit, the preoperative explanation regarding the planned operation, and the day of the operation. Younger age and receiving welfare were independently associated with lower frequency of hospital visits by a family member or friend (both P < 0.05). The adjusted odds ratio of age and receiving welfare for no visit versus ≥ 1 visit was 0.51 (0.36-0.74) per 10-year increase and 5.29 (2.46-11.4), respectively. In conclusion, social isolation is common among patients with CLTI, especially younger patients and those on welfare. Practical countermeasures against social isolation are warranted in the management of CLTI.

Early Clinical Outcomes of the Active Seal Technology of the AFX Endovascular Aortic Aneurysm System With the VELA Cuff for Patients With a Conical Proximal Neck

PURPOSE

To evaluate the efficacy of the Active Seal technology employed in the AFX endovascular aortic aneurysm system (AFX), during endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysms (AAAs) having a conical proximal neck.

MATERIALS AND METHODS

A retrospective analysis of the EVAR for AAA with a conical proximal neck using the AFX was performed at 17 Japanese hospitals between January 2016 and August 2020. The conical proximal neck was defined as a cone-shaped proximal neck, with more than 10% diameter increase within a 15 mm length at the proximal landing zone. All anatomical analyses were performed in the core laboratory, and cases with parallel walls within the proximal neck adequate for the landing zone were excluded from the study.

RESULTS

This study included 53 patients, but only 39 patients (mean age, 76.6 ± 6.7 years; 87.0% males; mean aneurysm diameter, 52.0 ± 8.0 mm) were analyzed after being characterized as having a pure conical neck by the core laboratory. The mean proximal neck diameters at the lower renal artery and proximal edge of the aneurysm were 20.0 ± 2.9 mm and 27.5 ± 4.9 mm, respectively. The mean proximal neck length was 21.5 ± 6.0 mm. Instructions for use violations other than the conical neck were observed in 15 patients (38.5%). The VELA cuff was used in all cases; however, additional proximal cuff was required in 9 more cases (23.1%). The Active Seal technology was able to significantly extend the proximal sealing zone from 21.5 ± 6.0 to 26.0 ± 12.2 mm (p = .047). Thirty-six patients completed the 12-month follow-up (one patient was lost to follow-up, and 2 patients died from causes unrelated to the aneurysm), and there were no type-1a and 3 endoleaks with only one reintervention (2.6%) related to type 1b endoleak in the 12-month period. Furthermore, there was no significant enlargement of the proximal neck diameter at 12 months (at 1 month: 20.6 ± 3.4 mm and at 12 months: 21.3 ± 3.8 mm; p = .420).

CONCLUSION

The Active Seal technology of the AFX significantly extended the proximal seal zone and no type-1a endoleak and proximal neck dilation was observed in patients with conical proximal neck at 12 months.

Prediction Models for Two Year Overall Survival and Amputation Free Survival After Revascularisation for Chronic Limb Threatening Ischaemia

OBJECTIVE

The aim of this study was to create prediction models for two year overall survival (OS) and amputation free survival (AFS) after revascularisation in patients with chronic limb threatening ischaemia (CLTI).

METHODS

This was a retrospective analysis of prospectively collected multicentre registry data (JAPAN Critical Limb Ischaemia Database; JCLIMB). Data from 3 505 unique patients with CLTI who had undergone revascularisation from 2013 to 2017 were extracted from the JCLIMB for the analysis. The cohort was randomly divided into development (2 861 patients) and validation cohorts (644 patients). In the development cohort, multivariable risk models were constructed to predict two year OS and AFS using Cox proportional hazard regression analysis. These models were applied to the validation cohort and their performances were evaluated using Harrell's C index and calibration plots.

RESULTS

Kaplan-Meier estimates of two year OS and AFS post-revascularisation in the whole cohort were 69% and 62%, respectively. Strong predictors for OS consisted of age, activity, malignant neoplasm, chronic kidney disease (CKD), congestive heart failure (CHF), geriatric nutritional risk index (GNRI), and sex. Strong predictors for AFS included age, activity, malignant neoplasm, CKD, CHF, GNRI, body temperature, white blood cells, urgent revascularisation procedure, and sex. Prediction models for two year OS and AFS showed good discrimination with Harrell's C indexes of 0.73 (95% confidence interval [CI] 0.69 - 0.77) and 0.72 (95% CI 0.68 - 0.76), respectively CONCLUSION: Prediction models for two year OS and AFS post-revascularisation in patients with CLTI were created. They can assist in determining treatment strategies and serve as risk adjustment modalities for quality benchmarking for revascularisation in patients with CLTI at each facility.

Clinical Impact of Intravascular Ultrasound-Guided Fluoropolymer-Based Drug-Eluting Stent Implantation for Femoropopliteal Lesions

BACKGROUND

Treatment with a fluoropolymer-based drug-eluting stent (FP-DES has been widely applied to the contemporary femoropopliteal practice with durable outcomes. Nevertheless, the impact of intravascular ultrasound (IVUS) utilization on clinical outcomes after FP-DES implantation has not been determined.

OBJECTIVES

This study aimed to investigate the impact of IVUS on 1-year clinical outcomes after FP-DES) implantation for femoropopliteal lesions in patients with symptomatic peripheral artery disease.

METHODS

As a subanalysis of the CAPSICUM (contemporary outcomes after paclitaxel-eluting peripheral stent implantation for symptomatic lower limb ischemia with superficial femoral or proximal popliteal lesion) study, the present investigation analyzed 1,091 patients with symptomatic peripheral artery disease who underwent endovascular therapy with FP-DES for femoropopliteal lesions. One-year clinical outcomes were compared between patients treated with IVUS and those treated without IVUS after propensity score matching. The primary outcome measure was 1-year restenosis. The incidence of aneurysmal degeneration was also assessed.

RESULTS

A total of 843 (77.2%) patients underwent IVUS-guided FP-DES implantation. After propensity score matching, the 1-year restenosis was not significantly different between the groups (11.5% [95% CI: 9.1%-14.0%] vs 15.5% [95% CI: 10.9%-20.1%]; P = 0.22). The frequency of aneurysmal degeneration at 1 year was significantly higher in the IVUS group than in the non-IVUS group (19.8% [95% CI: 16.3%-23.4%] vs 7.1% [95% CI: 3.3%-11.0%]; P < 0.001). IVUS use was associated with a lower restenosis risk in patients with chronic total occlusion but not in those without (P for interaction = 0.044).

CONCLUSIONS

The present study revealed that 1-year restenosis risk was not significantly different between the 2 groups, whereas the incidence of aneurysmal degeneration was significantly higher in the IVUS group.

1-Year Outcomes of Thromboendarterectomy vs Endovascular Therapy for Common Femoral Artery Lesions: CAULIFLOWER Study Results

BACKGROUND

Thromboendarterectomy (TEA) is the gold-standard treatment for common femoral artery (CFA). However, because of its low invasiveness and short hospitalization duration, CFA endovascular therapy (EVT) is performed in real-world practice. However, the clinical benefits and appropriate target population for CFA EVT remain unclear.

OBJECTIVES

The aims of this study were to compare the clinical outcomes of TEA with those of EVT in patients with symptomatic CFA diseases and to identify the adequate target population for CFA EVT.

METHODS

A total of 1,193 consecutive patients who underwent EVT (n = 761) or TEA (n = 432) for CFA were identified and retrospectively reviewed from a registry of 66 institutions. The primary outcome was 1-year primary patency compared between EVT and TEA using propensity score matching. An interaction analysis was performed to explore the appropriate target population for CFA EVT.

RESULTS

After propensity score matching, the 1-year primary patency rate was significantly higher in the TEA group (82.3% vs 96.6%; P < 0.001), whereas perioperative complications were more frequently observed in the TEA group (P = 0.047). Nonambulatory status attenuated the HR of EVT vs TEA for restenosis risk (P = 0.021), whereas the presence of nodular calcification significantly increased the HR (P = 0.040). In the EVT subgroup analysis for restenosis risk, stent use showed the lowest HR compared with plain balloon angioplasty and drug-coated balloon angioplasty (P < 0.001).

CONCLUSIONS

TEA showed superior 1-year patency compared with EVT in a nationwide multicenter study. Nonambulatory status attenuated the superiority, whereas the presence of nodular calcification enhanced it.

Clinical features and prognosis of patients with and without diabetes mellitus undergoing endovascular aortic aneurysm repair

BACKGROUND

This study aimed to compare the clinical features and prognoses of patients with and without diabetes mellitus (DM) who underwent endovascular repair for aortic aneurysm (AA).

METHODS

We analyzed the clinical database of a prospective multicenter study, registering 929 patients who underwent their first endovascular AA repair in Japan between January 2016 and June 2018. The baseline characteristics and prognoses (including all-cause mortality and cardiovascular events) after repair were compared between the DM and non-DM groups. Prognoses were also compared between the groups after propensity score matching.

RESULTS

In total, 226 patients (24.3%) had DM. Compared with non-DM patients, DM patients had higher pack-years of smoking (P = 0.011), higher body mass index (P = 0.009), lower high-density lipoprotein cholesterol levels (P = 0.038), higher triglyceride levels (P = 0.025), and lower left ventricular ejection fraction (P = 0.005). Meanwhile, the low-density lipoprotein cholesterol and blood pressure levels showed no significant intergroup difference (all P > 0.05). DM patients had a higher prevalence of myocardial infarction (P = 0.016), history of coronary revascularization (P = 0.015), and lower extremity artery disease (P = 0.019). Lesion characteristics and procedures were similar between the groups (all P > 0.05). DM patients had a higher risk of all-cause mortality and cardiovascular events than non-DM patients (both P < 0.001). Subsequent propensity score matching also demonstrated that DM patients had a significantly lower rate of overall survival (P = 0.001) and freedom from cardiovascular events (P = 0.010). The Kaplan-Meier estimates at 1 year for the overall survival were 85.6% (95% confidence interval [CI], 80.9% to 90.5%) and 94.3% (95% CI, 91.7% to 97.0%) for patients with and without DM, respectively. The corresponding estimates for freedom from cardiovascular events were 79.8% (95% CI, 74.5% to 85.5%) and 87.7% (95% CI, 84.2% to 91.3%), respectively.

CONCLUSIONS

Among patients undergoing endovascular AA repair, those with DM had more cardiovascular risk factors. DM patients had a higher incidence rate of all-cause mortality and cardiovascular events. Matching analysis indicated that DM per se would be a risk factor for poor prognoses after AA repair.

1-Year Outcomes of Fluoropolymer-Based Drug-Eluting Stent in Femoropopliteal Practice: Predictors of Restenosis and Aneurysmal Degeneration

OBJECTIVES

This study aimed to investigate the 1-year risk of restenosis and aneurysmal degeneration and explore the associated factors after femoropopliteal implantation of fluoropolymer-based drug-eluting stents (FP-DESs) for symptomatic atherosclerotic peripheral artery disease in real-world practice.

BACKGROUND

Although clinical trials have demonstrated that FP-DES implantation has favorable 1-year outcomes, its performance in real-world practice has not been well elucidated.

METHODS

This multicenter, prospective, observational study evaluated 1,204 limbs (chronic limb-threatening ischemia: 34.8%, mean lesion length: 18.6 ± 9.9 cm, chronic total occlusion: 53.2%, bilateral wall calcification: 41.9%) of 1,097 patients with peripheral artery disease (age: 75 ± 9 years, men: 69.4%, diabetes mellitus: 60.8%, chronic kidney disease: 66.2%) undergoing Eluvia (Boston Scientific) drug-eluting stent implantation for femoropopliteal lesions. The primary outcome measure was 1-year restenosis, whereas the secondary outcome measures were 1-year occlusive restenosis, stent thrombosis, target lesion revascularization, and aneurysmal degeneration.

RESULTS

The 1-year occurrence rates of restenosis (12.9%), occlusive restenosis (9.2%), stent thrombosis (3.3%), target lesion revascularization (6.2%), and aneurysmal degeneration (16.8%) were found. Multivariate analysis demonstrated that dialysis, chronic limb-threatening ischemia, history of revascularization, a smaller reference vessel diameter, chronic total occlusion, and spot stenting were significantly associated with an increased risk of 1-year restenosis, whereas intravascular ultrasound use and subintimal wire passage were significantly associated with an increased risk of 1-year aneurysmal degeneration.

CONCLUSIONS

This study documented the 1-year clinical outcomes after femoropopliteal endovascular therapy with FP-DES implantation in real-world practice. The 1-year restenosis rate would be clinically acceptable, whereas the occurrence of occlusive restenosis and aneurysmal degeneration should be noted.

10-Year clinical outcomes of hemodialysis patients with peripheral arterial disease due to infrainguinal disease undergoing endovascular therapy

Although symptomatic peripheral arterial disease (PAD) is common in patients with hemodialysis (HD), few studies have evaluated the long-term clinical outcomes of revascularization in this population. The aim of the current study was to investigate the 10-year clinical outcomes of HD patients with PAD undergoing endovascular therapy (EVT). We retrospectively analyzed 750 limbs from 578 HD patients with symptomatic PAD due to infrainguinal lesions, treated with EVT, between May 2004 and November 2011. The primary outcome was 10-year mortality and the secondary outcome was 10-year freedom from major adverse limb events (MALEs). Predictors for each outcome were evaluated by Cox proportional-hazards model. The 10-year rate of survival and freedom from MALEs was 23.6 ± 3.1% and 76.4 ± 2.9%, respectively. In the multivariate analysis, patients with over 80 years [hazard ratio (HR) 2.10; 95% confidence interval (CI) 1.58-2.80; p < 0.001], non-ambulatory status (HR 1.55; 95% CI 1.19-2.03; p = 0.001), absence of hypertension (HR 1.59; 95% CI 1.19-2.08; p = 0.001), heart failure (HR 1.36; 95% CI 1.02-1.80; p = 0.03), and tissue loss (HR 1.65; 95% CI 1.28-2.12; p < 0.001) were at an increased risk of 10-year mortality. Cerebrovascular diseases (HR 1.60; 95% CI 1.03-2.49; p = 0.038), no cilostazol use (HR 1.69; 95% CI 1.09-2.70; p = 0.021), tissue loss (HR 3.87; 95% CI 2.37-6.34; p < 0.001), and poor below-the-knee (BTK) run-off (HR 1.68; 95% CI 1.04-2.71; p = 0.035) were significantly associated with MALEs. After risk stratification analysis based on risk score assignment according to number of predictors, 10-year survival and freedom from MALE were lower in the higher score groups (10-year survival rates according to number of risk factors: 0, 35.1%; 1, 20.3%; 2-5, 10.8%; respectively, p < 0.001, 10-year freedom from MALE rates in patients with greater number of risk factors: 0-1, 90.2%; 2-3, 65.5%; 4-5, 61.6%; respectively, p < 0.001). The 10-year clinical outcomes after EVT for HD patients with PAD due to infrainguinal disease were clinically suboptimal. Risk stratification based on these predictors before EVT would be useful in estimating future adverse outcome.

Twelve-Month Outcomes From the Japanese Post-Market Surveillance Study of the Viabahn Endoprosthesis as Treatment for Symptomatic Peripheral Arterial Disease in the Superficial Femoral Arteries

PURPOSE

To assess the midterm safety and effectiveness of the Gore® Viabahn® Endoprosthesis as treatment for symptomatic peripheral arterial disease (PAD) in the superficial femoral arteries (SFA).

MATERIALS AND METHODS

A prospective, multicenter, post-market surveillance study was conducted in Japan. Patients with symptomatic SFA lesions ≥ 10 cm and reference vessel diameters ranging from 4.0 to 7.5 mm were eligible for enrollment; patients with traumatic or iatrogenic vessel injury in the thoracic, abdominal, or pelvic arteries were excluded. Outcomes evaluated at 12 months were primary patency (PP), primary-assisted patency (PAP), secondary patency (SP), freedom from target lesion revascularization (fTLR), occurrence of device- or procedure-related serious adverse events (SAEs), and stent fractures.

RESULTS

From August 2016 to May 2017, 321 patients were enrolled at 64 Japanese sites (mean age, 73.9±8.7 years; 77.3% male). Hypertension, diabetes, and end stage renal disease were present in 84.4%, 54.8%, and 23.1% of patients, respectively. Mean lesion length was 23.6 cm±6.6 cm, with lesions ≥ 15 cm in 271 patients (84.4%). TASC C/D lesions accounted for 86.6% (39.1% TASC C, 47.5% TASC D); 26.5% had critical limb ischemia. Baseline ABI was 0.60±0.16. A total of 562 devices were implanted in 324 limbs, with a majority of patients (68.8%) receiving 2 stents. Through 12 months, 92.1% of patients were evaluable. Kaplan-Meier-estimated PP, PAP, and SP at 12 months was 85.6%, 91.7%, and 94.8%, respectively. Twelve-month fTLR was 92.3%. Mean change in ABI at 12 months was 0.343±0.21; mean improvement in Rutherford class was 2.5. Device- or procedure-related SAEs occurred in 3.1% through 30 days, with a majority of early SAEs consisting of access complications. Through 12 months, a cumulative 10.6% had device- or procedure-related SAEs, with the most common being device occlusions in 4.0%. Lower limb amputation occurred in 0.9% and was related to pre-existing ulceration or gangrene in all 3 cases. No stent fractures were observed at 12-month x-ray evaluation.

CONCLUSION

In a real-world Japanese patient population characterized by long SFA lesions and complex PAD, the Viabahn endoprosthesis was associated with excellent patency rates through 12 months and an acceptable safety profile.

Ten-Year Clinical Follow-Up Following Bare-Nitinol Stent Implantation for Femoropopliteal Artery Disease

Aim: More than 5-year clinical outcomes after femoropopliteal (FP) stenting with bare-nitinol stent (BNS) have not yet been unclear. We investigate the long-term patency and mortality following FP stenting with BNS.

Methods: This study was a multicenter retrospective study of a prospectively maintained database. From April 2004 to December 2011, 1824 consecutive patients (2211 limbs) who underwent FP stenting with BNS for de novo lesions were selected and analyzed. Primary endpoint was primary patency which was defined as treated vessel without restenosis and reintervention and its associated factors.

Results: The prevalence of diabetes mellitus and dialysis was 60.5% and 23.8%, respectively. Chronic limb-threatening ischemia (CLTI) accounted for 30.8%. Chronic total occlusion (CTO) was found in 52.7%, and lesion length was more than 20 cm in 22.6%. During the median follow-up of 3.8 years (interquartile range, 1.4 to 7.4 years), 1049 cases lost patency, whereas 355 cases were dead without experiencing loss of patency. The primary patency (95% CI) was estimated to be 74.8%, 47.3% and 29.1% at 1-, 5- and 10-year. On multivariate analysis, female sex, age ≥ 80 years, diabetes, dialysis, CLTI, CTO, arterial calcification, long lesion (＞20 cm), and small vessel (≤ 4 mm) were the independent predictors of primary patency after FP stenting. In addition, the prognostic impact of age ≥ 80 years, CLTI, and arterial calcification was significantly attenuated afterwards (P＜0.05).

Conclusions: Ten-year patency after BNS implantation for FP disease has been continuously reducing up to 10 years and the prognostic impact of risk factors was changed over time.

Clinical outcomes of endovascular procedure using VIABAHN® VBX covered stent in complex aortoiliac artery disease: Result from AVOCADO study

OBJECTIVE

To investigate the safety and efficacy of a balloon-expandable covered stent in the treatment of complex aortoiliac artery disease.

BACKGROUND

Peripheral intervention in complex aortoiliac disease still remains a challenge.

METHODS

We retrospectively analyzed symptomatic patients with aortoiliac disease who were treated with GORE® VIABAHN® VBX covered stent (W.L. Gore & Associates, Flagstaff, AZ). The primary study outcome was a 1-year primary patency without the necessity of any subsequent clinically-driven target revascularization (CD-TLR) based intervention. The proportion of technical success, defined in terms of the absence of residual stenosis, stent edge dissection, and procedure-related severe complications, was also reported.

RESULTS

VBX covered stent was used in 231 patients. Key patient characteristics include mean age of 73.4 ± 9 years, 77% male, 45% diabetes, and 18% suffering from end-stage renal dysfunction on dialysis. TASC II CD lesions were observed in 51% patients, which included 81% calcified lesions. Combined therapy with standard self-expandable stent was performed in 40% patients. The technical success rate was 92.6%. During median follow-up after 13.1 months, the primary patency rate was estimated to be 93.4% (95% confidence interval, 90.0%-96.8%) at 12 months, whereas the rate of freedom from TLR was 95.3% (92.5%-98.2%). As per the univariate analysis, the TASC II classification, number of diseased regions, and chronic total occlusion were significantly associated with risk of restenosis.

CONCLUSIONS

The results of the year-long AVOCADO study demonstrated that usage of the novel VBX covered stent has a patency-based advantage with reduced chances for subsequent revascularization procedures.

Isolated giant true intercostal artery aneurysm with arteriovenous fistula: A case report

OBJECTIVES

Intercostal artery aneurysm (IAA) is a very rare condition. Interestingly, only one study reported a case of intercostal aneurysm caused by an arteriovenous fistula (AVF). Here, we report the case of a patient with non-ruptured isolated giant true IAA caused by an AVF (size, 28 × 41 mm).

METHODS

Treatment options for IAA include open surgery and endovascular treatment (EVT). We chose EVT, as it is minimally invasive. The right 11th intercostal artery and aneurysm diverged from the aorta. Two outflow arteries, one inflow artery, and an AVF from the aneurysm were confirmed, and coil embolization was performed. The artery of Adamkiewicz did not communicate with the right 11th intercostal artery. We performed angiography and confirmed occlusion of IAA with endoleak.

RESULTS

There were no clinical findings indicative of spinal cord infarction after treatment. The patient did not develop complications and was discharged the day after treatment. Endoleak was not observed on computed tomography angiography findings at 1 month after treatment.

CONCLUSIONS

In our patient, an AVF might have caused IAA. Endovascular treatment for non-ruptured isolated giant IAA is a safe and minimally-invasive treatment. We found that performing EVT is beneficial when the size of the IAA exceeds 30 mm.

Ileocolic arterial aneurysm associated with segmental arterial mediolysis: A case report

OBJECTIVES

Segmental arterial mediolysis is a rare disease that most commonly affects the superior mesenteric artery among abdominal arteries. However, aneurysms involving the ileocolic arterial branch of the superior mesenteric artery are extremely rare. Here, we describe the treatment of a patient with an ileocolic arterial aneurysm suspected to have occurred secondary to segmental arterial mediolysis.

METHODS

We confirmed the diagnosis of ileocolic arterial aneurysm, which showed the characteristic "string-of-beads" appearance of the distal main trunk of the superior mesenteric artery on angiography. We performed endovascular coil embolization for the aneurysm, and for both the inflow and outflow vessels. After confirming that the aneurysm was no longer visible, the treatment was completed.

RESULTS

There were no clinical findings suspicious of ischemic enteritis or intestinal necrosis after embolization. We confirmed that the ileocolic arterial aneurysm was not observed on computed tomography angiography one month after treatment.

CONCLUSIONS

While development of an ileocolic arterial aneurysm associated with segmental arterial mediolysis is very rare, it is at a high risk of sudden rupture. Therefore, coil embolization is a useful intervention in such patients and can be implemented based on the size and morphology of the aneurysm.

Incidence, diagnosis and treatment of popliteal artery entrapment syndrome in current vascular practice in Japan

Few data regarding popliteal artery entrapment syndrome (PAES) is available in Japan. In this study, we investigated incidence, diagnosis and treatment of PAES in current vascular practice. A retrospective analysis of all patients with PAES visiting 31 participating institutes between 2003 and 2015 was conducted. Thirty-five limbs (28 patients) were identified during the 13-year study period, and the incidence of PAES was 0.12% of all peripheral artery disease cases revascularized. Mean age was 32.0 ± 16.9 years old, and 60 and more years old was 10.7%. Also, 92.9% were male and 39.3% were athletes. Most frequent initial symptoms were intermittent claudication in 23 limbs (65.7%); 4 limbs (11.4%) had chronic limb-threatening ischemia. CT scan was most frequently (94.3%) used for the diagnostic imaging followed by MRI (45.7%) and duplex ultrasound (45.7%). Stress test such as dorsal flexion during duplex ultrasound was used only in 28.6%. Thirty-two limbs (91.4%) received surgical treatment, including 23 arterial reconstructions (71.9%); there were no major perioperative complications. All patients achieved improvement of their symptoms, and the average ankle brachial index increased from 0.69 ± 0.22 to 1.00 ± 0.14 post-surgery. The average postoperative follow-up period was 26.0 months with only one reintervention during the follow-up. In conclusion, PAES was a rare condition and traditional surgical treatment was solid. However, given a broad spectrum of clinical feature of PAES and less usage of diagnostic duplex ultrasound with stress test, there might be a miss- or delayed diagnosis of PAES even in the current vascular practice.

Extracorporeal high-pressure therapy (EHPT) for malignant melanoma consisting of simultaneous tumor eradication and autologous dermal substitute preparation

Surgical resection of skin tumors leads to large defects in surrounding normal tissues, which should be reconstructed thereafter using the patient's own tissues taken from the other site. Our challenge is to solve this problem in dermal malignant melanoma (MM) by a novel process, named extracorporeal high pressure therapy (EHPT), in which the tissue containing tumor is resected and pressurized, and the treated tissue is re-transplant back to the same position as a tumor-free autologous dermal substitute. The key points are complete tumor death and preservation of native extra cellular matrix (ECM) by the hydrostatic pressure. We found that high hydrostatic pressure at 200 MPa for 10 min at room temperature is completely cytocidal against MM cells in suspension form, in monolayer form, and even in the solid tumor form. MM tumor-bearing nude mice were established by injected human MM cells intradermally and treated by EHTP. The denaturation of the dermal extra cellular matrices was so mild that the pressurized skin was well engrafted as tumor free autologous dermal tissues, resulting in the complete eradication of the MM without any unnecessary skin reconstruction surgery. This very simple and short pressing treatment was proved to make the tumor tissue to the transplantable and tumor-free autologous dermal substitute, which can be applicable to the other temporally resectable tissues.

One-Year Outcomes of Heparin-Bonded Stent-Graft Therapy for Real-World Femoropopliteal Lesions and the Association of Patency With the Prothrombotic State Based on the Prospective, Observational, Multicenter Viabahn Stent-Graft Placement for Femoropopliteal Diseases Requiring Endovascular Therapy (VANQUISH) Study

Purpose:

To evaluate the real-world primary patency of heparin-bonded stent-graft therapy for femoropopliteal (FP) occlusive disease and identify any clinical factors, including the prothrombotic state, associated with the loss of patency.

Materials and Methods:

This multicenter study prospectively enrolled 424 limbs of 371 patients (mean age 75±8 years; 247 men) scheduled for Viabahn stent-graft placement in the FP segment. A full-coverage strategy using only a Viabahn stent-graft was preferred, but “spot stenting” with the Viabahn was also allowed. The prothrombotic state was assessed by measuring platelet reactivity. Vascular morphology was evaluated using intravascular ultrasound (IVUS). Primary patency was estimated using the Kaplan-Meier method in the subgroup of patients having full lesion stent-graft coverage (n=343 limbs, 81.1%). The secondary outcomes were major amputation, surgical reconstruction, target lesion revascularization (TLR), and thrombotic occlusion. Regression analyses were used to explore associations of baseline and clinical variables with loss of patency; the results are given as the odds ratio (OR) and 95% confidence interval (CI).

Results:

The 1-year primary patency estimate was 80.3% (95% CI 75.5% to 85.1%) in the full-coverage group. There were 7 surgical reconstructions, 46 TLRs, 21 acute thrombotic occlusions, and 1 major amputation during the 1-year follow-up in the full-coverage group. Only angiography- and IVUS-determined vessel diameters were significantly associated with loss of patency, with crude ORs of 0.64 (95% CI 0.45 to 0.89, p=0.009) and 0.67 (95% CI 0.51 to 0.90, p=0.009), respectively, per 1-mm increase, whereas other variables, including the prothrombotic state (p=0.74), were not. Multivariable analysis demonstrated that only IVUS-determined vessel diameter was independently associated with loss of patency (adjusted OR per 1-mm increase 0.72, 95% CI 0.52 to 1.00, p=0.049).

Conclusion:

FP stent-graft placement achieved acceptable patency at 1 year in a real-world setting. A smaller vessel size was significantly associated with loss of patency, whereas the prothrombotic state was not.

Predictive Model for Mortality Risk Including the Wound, Ischemia, Foot Infection Classification in Patients Undergoing Revascularization for Critical Limb Ischemia

Background:

The aim of this study was to develop a predictive model for mortality risk based on preoperative risk factors, including the Wound, Ischemia, Foot Infection (WIfI) classification, in patients undergoing revascularization for critical limb ischemia.

Methods:

We analyzed a database of the Surgical reconstruction versus Peripheral Intervention in Patients With Critical Limb Ischemia registry, a multicenter, prospective, observational study that included 520 critical limb ischemia patients (192 surgical and 328 endovascular patients).

Results:

Multivariate Cox regression analysis identified old age, impaired mobility, low body mass index, renal failure, heart failure, and high WIfI grade as independent risk factors for all-cause mortality (all P <0.05). The risk score comprising these risk factors discriminated the mortality risk well; the 2-year survival rate was >90% in the first quantile of the risk score and ≈20% in the fifth quantile. The area under the time-dependent receiver operating characteristics curve was 0.829 for thirty-day mortality and 0.811 for 2-year mortality. Adding more detailed preoperative information to the predictive model revealed that cystatin C-based estimated glomerular filtration rate, left ventricular ejection fraction, and cholinesterase levels were additional independent risk factors, but the predictive accuracy of the model was not significantly improved, according to the time-dependent receiver operating characteristics curve and net reclassification improvement.

Conclusions:

The current study developed a risk score for mortality using preoperative risk factors, including the WIfI classification, in critical limb ischemia patients undergoing revascularization.