[The use of Alprostan for patients with intermittent claudication]

Total 50 patients with lower limb intermittent claudication (Fontain-Pokrovsky limb stage of chronic ischemia) due to femoropopliteal or ileofemoral atherosclerotic occlusion were treated with Alprostan (Prostaglandin El) in A.V. Vishnevsky Institute of Surgery, Moscow, from November 2003 to March 2005. The paper presents the analysis of drug's therapeutic effectiveness dependent on the level and severity of arterial lesion.

[Simultaneous reconstruction of visceral aortic branches and renal arteries]

The paper presents a case report of simultaneous reconstruction of visceral aortic branches and renal arteries. The case is interesting because of special operative particularities, that occurred in 54-year-old patient who received previously radiotherapy for abdominal lymphogranulomatosis. Follow-up investigation 4 years after vascular intervention has shown that the patient remained in a satisfactory condition. The paper includes brief literature review concerning the strategy of reconstructive volume choice for this disease.

Cystic adventitial disease: a case report and literature review

Cystic adventitial disease (CAD) is a rare non-atherosclerotic cause of peripheral vascular disease (PVD). We describe a 54-year-old man who presented with calf claudication and catheter angiography showed the typical scallop appearances of CAD. Surgery involved resection of the diseased segment with a femoral popliteal venous bypass graft. A literature review revealed the different theories for pathogenesis, the investigation of choice being catheter angiography and the treatment excision with bypass grafting.

Persistent sciatic artery in a patient with extracranial internal carotid artery aneurysm and infrarenal abdominal aortic aneurysm. A case report

A rare case of a persistent sciatic artery (PSA) in a patient with aneurysms of the internal carotid artery and abdominal aorta is presented. A 70-year-old man was referred with intermittent claudication of the right lower extremity. Angiography and computed tomography demonstrated that this symptom was due to occlusion of the PSA. On preoperative examinations, aneurysms of the extracranial internal carotid artery and abdominal aorta were incidentally discovered, and then surgically treated prior to the management of PSA. Systemic examinations must be performed in patients with PSA in order to scrutinize associated anomalies or vascular disease.

Measuring the rate of change of haemodynamic response at the onset of exercise in normal limbs and those with intermittent claudication

Patients with claudication have an inadequate haemodynamic response to exercise. Blood flow response will not only have a magnitude, but also a rate of change. There is scope for investigating these parameters, as manipulation of the factors which control them may benefit work to improve the treatment for claudication. This work compares the responses for patients with one normal limb and one with intermittent claudication. A custom-built ergometer allows unilateral, infragenicular plantar flexion exercise, whilst common femoral artery blood flow can be measured continuously by Duplex ultrasound. This apparatus was used to measure blood flow before, at the onset of and during a 5 W square-wave exercise stimulus in 15 patients. The claudicant group had a mean steady-state gain that was approximately half that of the normal group at around 170 ml min(-1) (p < 0.001) and a response time that was much shorter (p = 0.006). A mean response time of 21.0 +/- 1.4 s was achieved in claudicant limbs compared to 31.8 +/- 2.9 s in normals. However, the average rate of change of blood flow during this response time was estimated to still be greater for the normal group, at 431.7 +/- 47.1 ml min(-2), than for the claudicant group. The differences in magnitude and rate of change of limb blood flow response to exercise in claudicants were significant and may have implications for the treatment of claudication.

Contrast ultrasound perfusion imaging of lower extremities in peripheral arterial disease: a novel diagnostic method

AIMS

The purpose of this study was to establish contrast-enhanced ultrasound perfusion imaging (CUPI) of the lower extremities as a novel non-invasive diagnostic tool for patients with peripheral arterial disease (PAD).

METHODS AND RESULTS

Ultrasound contrast agent (SonoVue) was injected into a peripheral vein of 16 control subjects and 16 PAD patients and its appearance in the calf muscle was detected by low-energy harmonic ultrasound. Analysis of the wash-in curves revealed that PAD patients had a significantly longer time to peak intensity (TTP), i.e. duration of maximum contrast perfusion [37 s (19-79 s) in control subjects vs. 56 s (32-104 s) in PAD patients at rest, age-adjusted P=0.002]. Exercise stress test of the calf muscle resulted in a decrease of the TTP, maintaining the significant difference in TTP between the groups [19 s (8-37 s) in control subjects vs. 32 s (18-48 s) in PAD patients after exercise, age-adjusted P=0.004]. Neither ankle-brachial index and TTP nor age and TTP showed a significant correlation.

CONCLUSION

CUPI reflects the regional blood circulation of the calf muscle. In this pilot study, PAD patients show a significantly longer TTP than control subjects. The clinical relevance of CUPI is topic of ongoing studies.

Duration and amplitude decay of acute arterial leg inflow enhancement with intermittent pneumatic leg compression: An insight into the implicated physiologic mechanisms

PURPOSE

By acutely enhancing the arterial leg inflow, intermittent pneumatic leg compression (IPC) improves the walking ability, arterial hemodynamics, and quality of life of claudicants. We quantified the duration of acute leg inflow enhancement with IPC of the foot (IPC(foot)), calf (IPC(calf)), or both (IPC(foot+calf)) and its amplitude decay in claudicants and controls in relation to the pulsatility index, an estimate of peripheral resistance. These findings are cross-correlated with the features of the three implicated physiologic mechanisms: (1) an increase in the arteriovenous pressure gradient, (2) suspension of peripheral sympathetic autoregulation, and (3) enhanced release of nitric oxide with flow and shear-stress increase.

METHODS

Twenty-six limbs of 24 claudicants with superficial femoral artery occlusion or stenoses (>75%) and 24 limbs of 20 healthy controls matched for age and sex, meeting stringent selection criteria, had their popliteal volume flow and pulsating index (peak-to-peak velocity/mean velocity) measured with duplex scanning at rest and upon delivery of IPC. Spectral waveforms were analyzed for 50 seconds after IPC delivery per 5-second segments. The three IPC modes were applied in a true crossover design. Data analysis was performed with the Page, Friedman, Wilcoxon, Mann-Whitney and chi2 tests.

RESULTS

The median duration of flow enhancement in claudicants exceeded 50 seconds with IPC(foot), IPC(calf), and IPC(foot+calf) but was shorter (P < .001) in the controls (32.5 to 40 seconds). Among the three IPC modes, the duration of flow enhancement differed (P < .05) only between IPC(foot) and IPC(foot+calf). After reaching its peak within 5 seconds of IPC, flow enhancement decayed at rates decreasing over time (trend, P < .05, Page test), which in both groups were highest at 5 to 20 seconds, moderate at 20 to 35 seconds, and lowest at 35 to 50 seconds (P < .05, Friedman test). Baseline and peak flow with all IPC modes was similar between the two groups. Pulsatility index attenuation in claudicating limbs lasted a median 32.5 seconds with IPC(foot), 37.5 seconds with IPC(calf), and 40 seconds with IPC(foot+calf); duration of pulsatility index attenuation was shorter in the control limbs with IPC(foot) (30 seconds), IPC(calf) (32.5 seconds), or IPC(foot+calf) (35 seconds), yet differences, as well as those among the 3 IPC modes, were not significant.

CONCLUSION

Leg inflow enhancement with IPC exceeds 50 seconds in claudicants and lasts 32.5 to 40 seconds in the controls. Peak flow occurs concurrently with maximal pulsatility index attenuation, within 5 seconds of IPC. Irrespective of group or IPC mode, the decay rate (%) of flow enhancement is highest within 5 to 20 seconds of IPC, moderate at 20 to 35 seconds, and lowest at 35 to 50 seconds. Since attenuation in peripheral resistance terminates with the mid time period (20 to 35 seconds) of flow decay, and nitric oxide has a half-life of <7 to 10 seconds, the study's data indicate that all implicated physiologic mechanisms (1, 2, and 3) are likely active immediately after IPC delivery (0 to 20 sec) and all but nitric oxide are effective in the mid time period (20 to 35 seconds). As the pulsatility index has returned to baseline, the late phase of flow enhancement (35 to 50 seconds) could be attributable to the declining arteriovenous pressure gradient alone.

“Over-the-Wire” Inversion Saphenectomy:A Simple, Minimally Invasive Vein Harvesting Technique for Arterial Bypass

PURPOSE

To examine the feasibility and clinical outcome of a novel, minimally invasive technique for harvesting the great saphenous vein (GSV) for use in peripheral arterial bypass surgery.

METHODS

Between May 2001 through March 2003, 27 patients (15 men; mean age 71+/-10 years) underwent extremity bypass procedures for limb salvage (88%) or disabling claudication (12%) using the inversion technique to harvest the GSV. The veins were turned "inside out" using a unique catheter and guidewire system. With the endothelial surface exposed, valve leaflets were excised, and adherent thrombus was washed away. Veins were inverted again to turn the endothelial surface back inside the lumen for use as a bypass conduit.

RESULTS

Inversion vein harvesting and arterial bypass were completed in 24 (89%) of 27 patients; 2 patients were treated with synthetic grafts because of small GSVs. Another patient was found after vein harvesting to have inadequate arterial outflow despite a good quality conduit. The average vein length was 45+/-10 cm; a mean 4+/-1 incisions were made, including those for arterial exposure. Incisions made to divide vein tributaries averaged 2 cm in length. Duration of vein harvesting was 25 minutes (range 5-80). Wound complications were minor (2 hematomas, 2 cases of erythema, 2 seromas). Of 6 grafts that occluded after 30 days, 5 involved small-diameter vein grafts (< 3.5 mm). At a mean 12 months, primary and assisted primary graft patency rates were 88% (14/16) and 94% (15/ 16), respectively, for grafts with minimum diameters > or = 4 mm versus 38% (3/8) primary patency for veins < 4 mm (n = 8, p < 0.001). The limb salvage rate was 92% (22/24).

CONCLUSIONS

Over-the-wire inversion saphenectomy is a simple and reliable minimally invasive technique for arterial bypass. Incisions are small and cosmetically superior to those of the traditional long incision method. One-year follow-up suggests that grafts harvested by inversion technique have excellent durability when the minimum vein diameter is > or = 4 mm, as determined by preoperative vein mapping.

Comparison of Results in Endovascular Interventions for Infrainguinal Lesions: Claudication versus Critical Limb Ischemia

This study analyzed clinical success, patency, and limb salvage after endovascular repair in patients treated for chronic limb ischemia presenting with claudication versus critical limb ischemia. Between October 2001 and August 2004, 115 patients (mean age 71) underwent endovascular treatment for infrainguinal arterial disease. Techniques included subintimal angioplasty and transluminal angioplasty with or without stents. Lesions were classified according to Transatlantic InterSociety Consensus. Follow-up (mean 11 months) included physical exam, ankle-brachial index, and duplex ultrasound. Patency rates were determined using Kaplan-Meier and compared by log-rank analysis. One hundred ninety-nine lesions were treated in 121 limbs using percutaneous techniques. Comorbidities were similar except higher rates of diabetes mellitus (67% vs 41%, P < 0.001) and chronic renal insufficiency (22% vs 7%, P < 0.05) were found in critical limb ischemia patients. Primary patency for claudicants was 100 per cent, 98 per cent, and 85 per cent at 3, 6, and 12 months and 89 per cent, 80 per cent, and 72 per cent for critical limb ischemia, respectively ( P = 0.06). Limb salvage was 91 per cent at 12 months for critical limb ischemia patients. Morbidity was similar between groups, and there was no perioperative mortality. Percutaneous intervention for both claudication and critical limb ischemia provides acceptable 12-month patency with limited morbidity.

Peripheral Angioplasty as the First-choice Revascularization Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study of 993 Consecutive Patients Hospitalized and Followed Between 1999 and 2003

OBJECTIVE

To evaluate the effectiveness of peripheral angioplasty (PTA) as the first-choice revascularisation procedure in diabetic patients with critical limb ischemia (CLI).

DESIGN

Prospective study.

METHODS

PTA was employed as first choice revascularisation in a consecutive series of diabetic patients hospitalized for CLI between January 1999 and December 2003.

RESULTS

PTA was successful performed in 993 patients. Seventeen (1.7%) major amputations were carried out. One death and 33 non-fatal complications were observed. Mean follow-up was 26+/-15 months. Clinical restenosis was observed in 87 patients. The 5 years primary patency was 88%, 95% CI 86-91%. During follow-up 119 (12.0%) patients died at a rate of 6.7% per year.

CONCLUSIONS

PTA as the first choice revascularisation procedure is feasible, safe and effective for limb salvage in a high percentage of diabetic patients. Clinical restenosis was an infrequent event and PTA could successfully be repeated in most cases.

Two cases of subintimal angioplasty with proximal stent implantation for long superficial femoral artery occlusions

Subintimal angioplasty is a simple and safe alternative to conventional intraluminal angioplasty for the recanalization of diffuse long femoropopliteal occlusions. However, long-term patency rates are unsatisfactory despite the high initial technical success rates. Two cases of occluded left superficial femoral arteries are presented in which subintimal angioplasty with proximal stent implantation was successfully performed. Self-expanding nitinol stents were placed at the proximal part of subintimal plane to maintain good inflow. In both cases, follow-up angiogram at 6 months demonstrated patent stents with good antegrade flow.

Crimping and repositioning of a maldeployed balloon-expandable arterial stent using a gooseneck snare

PURPOSE

To describe a technique for repositioning a fully deployed iliac stent from the infrarenal aorta into the common iliac artery (CIA).

CASE REPORT

A 58-year-old man was undergoing treatment for a significant right CIA stenosis when a 7x24-mm Palmaz Genesis medium stent was mistakenly deployed in the infrarenal aorta. With the stent still over the guidewire, an 8x60-mm balloon catheter was placed coaxially in the stent. Via a left groin access, a 6-F vascular sheath was introduced retrograde, and a 2.5-cm Amplatz gooseneck snare was advanced into the infrarenal abdominal aorta and pulled back over the stent. The snare was tightly closed to crimp the stent onto the collapsed balloon; this maneuver was repeated several times until the stent was contracted along its entire length. The balloon/stent assembly was carefully pulled back into the right CIA, and the stent was deployed across the target lesion, although there was overlap of the left CIA. Color duplex sonography at 1 year showed no signs of significant iliac arterial stenoses on either side. The patient reported no claudication.

CONCLUSIONS

Using a gooseneck snare, fully deployed balloon-expandable iliac stents can be recrimped on a balloon.

Detection of peripheral vascular stenosis by assessing skeletal muscle flow reserve

OBJECTIVES

We sought to determine whether the severity of peripheral arterial disease (PAD) can be assessed by measuring blood flow reserve in limb skeletal muscle with contrast-enhanced ultrasound (CEU).

BACKGROUND

Noninvasive imaging of distal limb perfusion could improve management of patients with PAD by evaluating the impact of large and small vessel disease, and collateral flow.

METHODS

In 12 dogs, blood flow in the quadriceps femoris was measured by CEU at rest and during either electrostimulated contractile exercise or adenosine infusion. Femoral artery blood flow was measured by Doppler ultrasound. Studies were performed in the absence and presence of either moderate or severe stenosis (pressure gradient of 10 to 20 mm Hg and >20 mm Hg, respectively).

RESULTS

Resting femoral artery blood flow progressively decreased with stenosis severity, while resting skeletal muscle flow was reduced only with severe stenosis (52 +/- 21% of baseline, p < 0.05), indicating the presence of collateral flow. Skeletal muscle flow reserve during contractile exercise or adenosine decreased incrementally with increasing stenosis severity (p < 0.01). The stenotic pressure gradient correlated with skeletal muscle flow reserve for exercise and adenosine (r = 0.70 for both, p < 0.01).

CONCLUSIONS

Contrast-enhanced ultrasound of limb skeletal muscle can be used to assess the severity of PAD by measuring muscle flow reserve during either contractile exercise or pharmacologic vasodilation. Unlike currently used methods, this technique may provide a measure of the physiologic effects of large- and small-vessel PAD, and the influence of collateral perfusion.

Early Surgical Outcome After Failed Primary Stenting for Lower Limb Occlusive Disease

PURPOSE

To evaluate the early results of revascularization after failed primary stent placement for lower limb occlusive disease.

METHODS

A retrospective review was conducted of 25 consecutive patients (16 men; mean age 65 years, range 32-89) treated between January 2001 to October 2003 for infrainguinal stent failure at a median 6.6 months (range 3-60) after primary stent implantation (27 femoropopliteal and 20 popliteal-crural) at referring hospitals. All surgical procedures for stent failure were performed at tertiary centers. The results of bypass grafting for failed stenting were compared to a contemporaneous cohort of patients undergoing primary bypass surgery performed by the same surgeons.

RESULTS

At the time of admission, 22 stents were thrombosed, and 3 patent stents presented with >50% in-stent stenosis. Twenty patients had 7 femoropopliteal or 9 femorodistal vein bypasses and 4 reconstructions of the common femoral or profunda femoris artery. Four patients had 3 primary amputations and 1 lumbar sympathectomy. One patient with claudication was treated conservatively. Procedure-related complications were observed in 40%; 30-day mortality was 4% (1/25). Early (30-day) graft thrombosis occurred in 6 (30%) of 20 arterial reconstructions, necessitating 8 secondary amputations (44% [11/ 25] overall amputation rate). A total of 47 surgical procedures were performed in the 24 surviving patients (median 2 operations per patient, range 1-9) over an 11-month period (range 1-57). Primary patency rates at 30 days and at 6 and 12 months were 67%, 44%, and 33%, respectively, in the poststent bypass cohort versus 98%, 96%, and 88%, respectively, in a contemporaneous group of patients treated with primary bypass grafting.

CONCLUSIONS

Failed stents in lower limb arteries often require distal reconstructive bypass surgery, which is associated with high complication rates and poor outcome, including major amputations. There is no scientific evidence to support stenting below the inguinal ligament.

[Sudden incapacity of walking]

Two cases of pain and sudden incapacity of walking are presented. In one case aortic dissection, and in the other a massive cholesterol embolism due to aortography were the causing events. The diagnostic evaluation of the patients and the organisation of the emergency services were insufficient in both cases. There was also a lack of adequate communication with patients and relatives, leading to a loss of trust in the hospitals. Although the diagnoses were incorrect, this had no influence on the clinical courses. Nevertheless, the demonstrated deficiencies should stimulate the reevaluation of one's own emergency concept.

Natural history of stenosis in the iliac arteries in patients with intermittent claudication undergoing clinical treatment

PURPOSE

Inspite of the long experience with the treatment of intermittent claudication, little is known about the natural history of stenotic lesions in the iliac segment. With the advent of endovascular treatment, this knowledge has become important.

METHODS

Fifty-two stenosis, diagnosed using arteriography, in 38 claudicant patients were analyzed. After a minimum time interval of 6 months, a magnetic resonance angiography was performed to determine whether there was arterial occlusion. The primary factors that could influence the progression of a stenosis were analyzed, such as risk factors (smoking, hypertension, diabetes, sex, and age), compliance with clinical treatment, initial degree of stenosis, site of the stenosis, and length of follow-up.

RESULTS

The average length of follow-up was 39 months. From the 52 lesions analyzed, 13 (25%) evolved to occlusion. When occlusion occurred, there was clinical deterioration in 63.2% of cases. This association was statistically significant (P = .002). There was no statistically significant association of the progression of the lesion with the degree or site of stenosis, compliance with treatment, or length of follow-up. Patients who evolved to occlusion were younger (P = .02). The logistic regression model showed that the determinant factors for clinical deterioration were arterial occlusion and noncompliance with clinical treatment.

CONCLUSIONS

The progression of a stenosis to occlusion, which occurred in 25% of the cases, caused clinical deterioration. Clinical treatment was important, but it did not forestall the arterial occlusion. Prevention of occlusion could be achieved by early endovascular intervention or with the development of drugs that might stabilize the atherosclerotic plaque.

Multidetector row CT angiography of the lower limb arteries: a prospective comparison of volume-rendered techniques and intra-arterial digital subtraction angiography

AIM

To assess whether multi-detector CT angiograms (MDCTA) of the lower limb arteries, compared with conventional digital subtraction angiograms (DSA), could replace invasive arteriography in patients with symptomatic peripheral arterial disease.

MATERIALS AND METHODS

In a prospective comparative analysis of MDCTA and DSA in 44 patients, MDCTA was analyzed using volume-rendered images acquired at a workstation and viewed in tandem with the original axial data. Designated arterial segments were graded according to their degree of stenosis.

RESULTS

We found agreement for the degree of stenosis in 88.8% and 85.4% of 1024 segments analysed for two observers. The sensitivity for treatable lesions (>50% stenosis) was 79.1% and 72% with a specificity of 93.3% and 92.6%. DSA failed to visualize 7.3% of segments that were visible with MDCTA. These segments were exclusively downstream to long segment occlusions.

CONCLUSION

MDCTA using 4-slice machines is insensitive to detecting significant arterial stenoses in the lower limb arteries. MDCTA is superior to DSA in its visualization of arterial territories downstream to significant occlusive disease.

Subintimal Angioplasty in the Treatment of Patients with Intermittent Claudication: Long Term Results

OBJECTIVES

Reporting the long-term results of subintimal angioplasty (SA) in patients with intermittent claudication (IC).

DESIGN

A prospective study.

PATIENTS

One hundred and sixteen SA procedures were performed in 104 patients, from February 1997 to January 2000.

METHODS

This is a prospective study of patients treated for IC with infrainguinal SA. Primary assisted patency rates were calculated, also on intention to treat basis. Univariate and multivariate Cox regression tests were used to assess whether patency was correlated with co-morbidities, run-off or occlusion length.

RESULTS

There was no early mortality. Technical success was achieved in 101 cases (87%). Primary assisted patency rates on intention to treat basis (116 cases) at 6, 12, 36 and 60 months were 69, 62, 57 and 54%, respectively. For successfully recanalized patients (101 cases) these respective numbers are 79, 70, 66 and 64%. Length of occlusion, age and male gender were independent risk factors for reocclusion.

CONCLUSIONS

The satisfactory results obtained in the present study are probably due to two main factors. First, the three participating radiologist are highly skilled and experienced. Secondly, a conscientious surveillance was adhered to, so that restenoses could be diagnosed and treated early. SA is a relevant alternative to bypass surgery in patients with disabling IC due to long femoro-popliteal occlusions. It is far less traumatic than conventional vascular reconstructions, complications are few and not serious. Very importantly, SA never interfered with later successful vascular surgery. Therefore, we have adopted SA as the primary treatment for patients with IC when medical treatment alone has not been satisfactory.

Training guided by pain threshold speed. Effects of a home-based program on claudication

AIM

To verify the effectiveness of a 120 day home-based program guided by the pain threshold speed (PTS).

METHODS

Twenty-nine patients with stable claudication were measured for ankle pressure (AP), ankle-brachial index (ABI), PTS, maximal speed (Smax) on treadmill. Daily walking sessions at a speed 20-30% below PTS were prescribed. Determination of the training speed was supervised and facilitated at home. The program included a daily record of exercise data and symptoms, an intermediate PTS re-evaluation to adjust the training speed, and the reassessment of all the parameters after 120 days.

RESULTS

Overall patients showed a reduction of systemic blood pressure (151.3+/-14.3 to 147.6+/-18.3 mmHg; 77.1 +/-9.1 to 72.4+/-8, p=0.008) while AP did not. ABI increased from 0.65+/-0.13 to 0.71+/- 0.18 (p=0.01). PTS and Smax rose from 3.2+/-1.1 to 4.2+/-1.5 km/h (p=0.0001) and from 3.9+/-1.3 to 4.6+/-1.3 km/h (p=0.0001), respectively. According to their compliance, patients were divided into 3 groups: 1) trained (T, n=14): exercise at the prescribed speed, 2) free-walkers (FW, n=7): walking speed markedly below PTS and 3) untrained (U, n=8): incomplete program compliance. T group showed symptom reduction up to pain disappearance. The ABI change (0.72+/-0.09 to 0.82+/- 0.16, p<0.02) was correlated to AP increase (r= 0.879). PTS and Smax rose from 3.6+/-1.1 to 5.4+/-0.8 km/h (p<0.02) and from 4.7+/-1.2 to 5.7+/-0.7 (p<0.02), respectively. FW showed improvement of all parameters, and U a better walking efficiency.

CONCLUSIONS

In patients with claudication, a low-cost home-based program driven by PTS allows dramatic improvements of functional parameters.

Primary stent-supported angioplasty for treatment of below-knee critical limb ischemia and severe claudication

OBJECTIVES

The objective of this study was an investigation of the safety and efficacy of primary below-knee stent-supported angioplasty (BKSSA) for restoring straight inline arterial flow in patients with critical limb ischemia (CLI) or lifestyle-limiting claudication (LLC).

BACKGROUND

Surgical tibial bypass for CLI and severe LLC is associated with significant morbidity, mortality, and graft failure, whereas percutaneous angioplasty is suboptimal.

METHODS

Below-knee stent-supported angioplasty was attempted in 82 patients (92 limbs) with either CLI (68%) or severe LLC (32%). Patients received daily aspirin, thienopyridine, and glycoprotein IIb/IIIa agents during the procedure. One-month major adverse events (MAEs) were defined as death, myocardial infarction, major unplanned amputation, need for surgical revascularization, or major bleeding. Clinical success was defined as improved resting ankle brachial index by > or =0.10, relief of resting pain, healing of ulceration or amputation, and improvement of claudication.

RESULTS

Mean age of patients was 74 +/- 17 years. In 86 limbs, straight inline flow was restored to at least one tibial vessel. Technical success was 94% for de novo lesions and there were no MAEs. Ankle brachial indexes increased for all groups (CLI = 0.32 +/- 0.13 to 0.9 +/- 0.14 and LLC = 0.65 +/- 0.09 to 0.95 +/- 0.12; p < or = 0.0001, pre vs. post). Relief of rest pain and healing of ulcerations and amputations were seen in 96% (47 of 49) of patients with CLI who underwent successful intervention.

CONCLUSIONS

Below-knee stent-supported angioplasty for CLI and LLC improves ankle brachial indexes comparable to tibial bypass, heals amputations and ulcerations, relieves rest pain, and improves ambulation. Because BKSSA is associated with minimal MAE, it may hold promise as an alternative therapy for patients with CLI and LLC.

Using the Angio-Seal to Achieve Hemostasis in Prosthetic Endovascular Surgery: Report of Three Cases

At least 10% of patients who undergo bilateral aortofemoral bypass are at risk of needing a reoperation for late prosthetic thrombosis because of reduced outflow as the disease progresses. To prevent occlusion of the prostheses, we performed endovascular surgery with transprosthetic access for distal stenosis. We report our experience of using the Angio-Seal with transprosthetic access after angioplasty in three patients who had undergone bilateral aortofemoral bypass. Hemostasis was achieved in all three patients. There were no complications, such as hemorrhage, hematoma, or prosthetic infection, and all three patients were discharged within 24 h. At the 12-, 15-, and 24-month follow-up, none of the patients had any sign of recurrent claudication. Using the Angio-Seal in bilateral aortofemoral bypass provided the means of treating distal stenosis by endovascular surgery with transprosthetic access. This method is both rapid and safe, and may broaden the indications for the endovascular treatment of distal arteriopathies in patients with vascular prostheses.