Lower extremity revascularization using directional atherectomy: 12-month prospective results of the DEFINITIVE LE study

Delayed Tibioperoneal Trunk Aneurysm after Atherectomy and Balloon Angioplasty

True infrapopliteal aneurysms occur very rarely; the majority of reported cases are secondary to trauma or infection. We report the development of a tibioperoneal trunk aneurysm 6 months after atherectomy and angioplasty and describe subsequent open surgical repair via a great saphenous vein bypass graft.

Calcified Nodules Projecting into the Popliteal Artery Successfully Treated Through the Use of Myocardial Biopsy Forceps

A 69-year-old man on maintenance dialysis underwent endovascular therapy for a refractory wound due to critical limb ischemia in the popliteal and below-knee arteries. Because of bulky calcified nodules projecting into the popliteal artery, conventional balloon angioplasty alone did not seem to provide a sufficient lumen area, and we ablated the calcified nodules by using myocardial biopsy forceps for lesion preparation. Under roadmap guidance, we repeated ablation 39 times to carefully tear off the bulky calcified nodules, and subsequently performed balloon angioplasty in the popliteal artery. Neither flow-limiting dissection nor perforation occurred, and a sufficient lumen area was obtained. After treatment of the popliteal artery, conventional endovascular therapy was performed in the below-knee arteries. One month later, the wound was fully epithelialized. We report a case of critical limb ischemia with calcified nodules projecting into the popliteal artery, in which the use of myocardial biopsy forceps led to good results.

Directional Atherectomy Followed by a Paclitaxel-Coated Balloon to Inhibit Restenosis and Maintain Vessel Patency: Twelve-Month Results of the DEFINITIVE AR Study

Background—

Studies assessing drug-coated balloons (DCB) for the treatment of femoropopliteal artery disease are encouraging. However, challenging lesions, such as severely calcified, remain difficult to treat with DCB alone. Vessel preparation with directional atherectomy (DA) potentially improves outcomes of DCB.

Methods and Results—

DEFINITIVE AR study (Directional Atherectomy Followed by a Paclitaxel-Coated Balloon to Inhibit Restenosis and Maintain Vessel Patency—A Pilot Study of Anti-Restenosis Treatment) was a multicenter randomized trial designed to estimate the effect of DA before DCB to facilitate the development of future end point-driven randomized studies. One hundred two patients with claudication or rest pain were randomly assigned 1:1 to DA+DCB (n=48) or DCB alone (n=54), and 19 additional patients with severely calcified lesions were treated with DA+DCB. Mean lesion length was 11.2±4.0 cm for DA+DCB and 9.7±4.1 cm for DCB (P=0.05). Predilation rate was 16.7% for DA+DCB versus 74.1% for DCB; postdilation rate was 6.3% for DA+DCB versus 33.3% for DCB. Technical success was superior for DA+DCB (89.6% versus 64.2%; P=0.004). Overall bail-out stenting rate was 3.7%, and rate of flow-limiting dissections was 19% for DCB and 2% for DA+DCB (P=0.01). One-year primary outcome of angiographic percent diameter stenosis was 33.6±17.7% for DA+DCB versus 36.4±17.6% for DCB (P=0.48), and clinically driven target lesion revascularization was 7.3% for DA+DCB and 8.0% for DCB (P=0.90). Duplex ultrasound patency was 84.6% for DA+DCB, 81.3% for DCB (P=0.78), and 68.8% for calcified lesions. Freedom from major adverse events at 1 year was 89.3% for DA+DCB and 90.0% for DCB (P=0.86).

Conclusions—

DA+DCB treatment was effective and safe, but the study was not powered to show significant differences between the 2 methods of revascularization in 1-year follow-up. An adequately powered randomized trial is warranted.

Clinical Trial Registration—

http://www.clinicaltrials.gov. Unique Identifier: NCT01366482.

Failure mode and bimodal restenosis of drug-coated balloon in femoropopliteal intervention

BACKGROUND

Pattern of DCB restenosis and associated outcomes in facing complex femoropopliteal lesions remain uncertain.

METHODS

Data were retrospectively collected from dual centers in Taiwan on patients who underwent treatment with DCBs for femoropopliteal lesions between 2013 and 2016. The restenosis pattern was categorized by the index-treated length. Clinical outcomes and time to DCB restenosis were retrospectively analyzed. Cox proportional hazards model identified restenosis predictors.

RESULTS

We recruited a total of 164 patients (91 men; median age 73 years) into the final analysis. The mean lesion length was 204.0 ± 109.2 mm. Of them, 45% total occlusions, 28% severe calcification and 15% in-stent restenosis were treated. Fifty-five patients have DCB restenosis (28 focal and 27 diffuse-occlusive patterns) over a 55-month follow-up. The median restenosis time emerged as a bimodal pattern with a significant difference between the diffuse-occlusive and focal restenosis group (225 vs. 484 days, P = 0.01). The 1-year patency rate after reintervention for DCB restenosis also was different between both restenosis group (29% vs. 65%, P = 0.017). The anticipated timing of escape for diffuse-occlusive or focal restenosis was 687 and 1068 days, respectively. Independent factors were lesion length (P = 0.049) for diffuse-occlusive restenosis and lumen gain of the popliteal artery for focal restenosis (P = 0.034).

CONCLUSIONS

This study demonstrated time to DCB failure emerged as a bimodal pattern of distribution and associations of restenosis pattern to subsequent outcomes after the repeated intervention. Exemption from late catchup restenosis required 3-year observation instead of the 1-year mark for conventional treatment.

Current Status of Distal Embolization in Femoropopliteal Endovascular Interventions

The application of advanced endovascular techniques in very complex femoropopliteal atherosclerotic lesions has shown to expose patients to a higher risk of distal embolization (DE). This complication can affect both the short- and long-term outcomes, leading to worsening ischemia, early minor/major amputation, and longer hospital stay. Recently, there has been an increasing body of evidence on pathophysiology and clinical–radiological management of DE that however has not been systematically addressed by guidelines. The aim of this review was to analyze the current evidence outlining definition and classification, risk assessment, prevention, and management strategies of DE in femoropopliteal endovascular interventions.

Review of the Latest Percutaneous Devices in Critical Limb Ischemia

Critical limb ischemia (CLI) is a terminal stage of peripheral arterial disease that, in the absence of intervention, may lead to lower extremity amputation or death. Endovascular interventions have become a first-line approach to the management of CLI and have advanced considerably within the past decade. This review summarizes the types of percutaneous devices and the techniques that are available for the management of CLI and the data supporting their use. These include devices that establish and maintain vessel patency, including percutaneous transluminal angioplasty, drug-coated balloons, bare metal stents, drug-eluting stents, bioresorbable vascular scaffolds, and atherectomy; devices that provide protection from embolization; and, cell-based therapies. Additionally, ongoing trials with important implications for the field are discussed.

Simple classification and clinical outcomes of angiographic dissection after balloon angioplasty for femoropopliteal disease

OBJECTIVE

Angiographic dissection is considered to be associated with restenosis. However, little is known about the impact of the severity of angiographic dissection on future restenosis.

METHODS

A total of 319 consecutive de novo femoropopliteal lesions were treated by balloon angioplasty alone. All of these lesions were divided into three groups: group A, no angiographic dissection; group B, mild dissection, the width of the dissection was less than one-third of the lumen; and group C, severe dissection, the width of the dissection was more than one-third of the lumen. Kaplan-Meier analysis estimated the primary patency rate at 3 years between the groups.

RESULTS

The primary patency rates at 3 years were 66.0% in group A, 63.8% in group B, and 32.5% in group C (log-rank, P < .001). Cox proportional hazards analysis revealed that a lesion length >100 mm (hazard ratio, 1.734; 95% confidence interval, 1.099-2.735; P = .018) and severe angiographic dissection (hazard ratio, 1.956; 95% confidence interval, 1.276-2.997; P = .002) were predictors of primary patency loss at 3 years. When the lesions were divided into two groups according to the lesion length >100 mm or not, angiographic dissection had a larger impact on restenosis in a long lesion >100 mm (≤100 mm: 65.5% in group A, 75.6% in group B, and 48.0% in group C [log-rank, P = .015]; >100 mm: 68.8% in group A, 42.5% in group B, and 24.2% in group C [log-rank, P = .017]).

CONCLUSIONS

Severe angiographic dissection was associated with future restenosis after balloon angioplasty for femoropopliteal lesions, but mild angiographic dissection was not. Angiographic dissection had more impact on future restenosis particularly in treated long lesions. Stents might not be necessary in short lesions with mild dissection.

One-Year Outcomes Following Directional Atherectomy of Popliteal Artery Lesions: Subgroup Analysis of the Prospective, Multicenter DEFINITIVE LE Trial

Purpose: To report the effectiveness of directional atherectomy for the treatment of popliteal artery occlusive disease. Methods: This subset of the prospective, multicenter, single-arm DEFINITIVE LE trial included 158 patients (mean age 72.0±10.9 years; 82 men) who underwent directional atherectomy in 162 popliteal artery lesions between 2009 and 2011. Forty-eight (30.4%) patients were suffering from critical limb ischemia (CLI). The mean lesion length was 5.8±3.9 cm; 38 (23.5%) arteries were occluded. The primary outcome measure for patients with intermittent claudication (IC) was duplex ultrasound–defined primary patency at 1 year; the outcome for subjects with CLI was freedom from major amputation of the target limb at 1 year. Outcomes and adverse events were independently assessed. Results: Procedure success (≤30% residual stenosis) was achieved in 84.4% of treated lesions; adjunctive stenting was required in 6 (3.7%) of the 162 lesions. The 1-year primary patency rate was 75.0% (IC patients 78.2% and CLI patients 67.5%, p=0.118). The freedom from major amputation in both cohorts was 100%. In both IC and CLI patients, significant improvements were demonstrated at 1 year in the Rutherford category, walking distance, and quality of life in comparison to baseline. Conclusion: This study indicates that directional atherectomy in popliteal arteries leads to favorable technical and clinical results at 1 year for claudicant as well as CLI patients.

Outcome After Crossing Femoropopliteal Chronic Total Occlusions Based on Optical Coherence Tomography Guidance

AIMS

The crossing of chronic total occlusions (CTOs) is the key step for an endovascular treatment. The Ocelot system is a novel device that combines a steerable drilling tip with optical coherence tomography (OCT) technology. It provides intraluminal imaging to help the crossing of CTOs in the femoropopliteal segment. Aim of the study was to determine early and midterm results after recanalization with this device.

METHODS AND RESULTS

During a period of 16 months, 84 CTOs were treated using the Ocelot system and prospectively registered. The primary end points were technical success and the primary and secondary patency of the lesion. Risk factors associated with early and midterm results were also analyzed. In all, 58 (69.0%) lesions were treated for intermittent claudication, 26 (31.0%) for critical limb ischemia, 34 (40.5%) were classified as Trans-Atlantic Inter-Society Consensus II D lesions, and 22 (26.2%) showed severe calcifications. The technical success rate was 72.6%. During 36 months of follow-up (mean 25.9), there were 10 reinterventions. The primary and secondary patency at 36 months were 54.2% and 68.1%, respectively.

CONCLUSIONS

In our experience, the Ocelot system would appear to be a safe and effective tool for increasing the applicability of endovascular techniques. However, the midterm results did not show drastic improvement.

Safety and effectiveness of the Phoenix Atherectomy System in lower extremity arteries: Early and midterm outcomes from the prospective multicenter EASE study

Objectives

To evaluate the novel Phoenix Atherectomy System as percutaneous treatment of de novo and restenotic infrainguinal arterial lesions.

Methods

This prospective, multicenter, nonrandomized investigational device exemption trial was conducted across 16 US and German centers between August 2010 and April 2013. Intention-to-treat enrollment was 128 patients (mean age: 71.8 years, 59% male) with 149 lesions (mean length: 34 mm, mean diameter stenosis: 89.5%), and the primary analysis per-protocol population consisted of 105 patients with 123 lesions. The primary efficacy endpoint, technical success, was the achievement of acute debulking with a post-atherectomy residual diameter stenosis ≤50% (before adjunctive therapy). The primary safety endpoint was the major adverse event (MAE) rate through 30 days.

Results

For the primary analysis per-protocol population, the rate of lesion technical success was 95.1% (117/123), with the lower limit of the 95% CI 90.6%, meeting the prospectively established target performance goal of ≥86%. After post-atherectomy adjunctive therapy, residual stenosis was ≤30% for 99.2% (122/123) of lesions (mean final diameter stenosis 10.5%). Improvement of ≥1 Rutherford class occurred for 74.5% of patients through 30 days and for 80% through six months. MAEs were experienced by 5.7% (6/105) of patients through 30 days (with the upper limit of the 95% CI 11.0%, meeting the target performance goal of <20%), and 16.8% through six months. Six-month freedom from TLR and TVR was 88.0% and 86.1%, respectively.

Conclusions

Based on the high rate of technical success and the low rates of MAEs through six months, the Phoenix Atherectomy System is safe and effective for the debulking of lower-extremity arterial lesions.

ClinicalTrials.gov identifier NCT01541774

An Algorithm for the Use of Embolic Protection During Atherectomy for Femoral Popliteal Lesions

OBJECTIVES

This study sought to identify an algorithm for the use of distal embolic protection on the basis of angiographic lesion morphology and vascular anatomy for patients undergoing atherectomy for femoropopliteal lesions.

BACKGROUND

Atherectomy has been shown to create more embolic debris than angioplasty alone. Distal embolic protection has been shown to be efficacious in capturing macroemboli; however, no consensus exists for the appropriate lesions to use distal embolic protection during atherectomy.

METHODS

Patients with symptomatic lower extremity peripheral artery disease treated with atherectomy and distal embolic protection were evaluated to identify potential predictors of DE. Plaque collected from the SilverHawk nose cone subset was sent to pathology for analysis to evaluate the accuracy of angiography in assessing plaque morphology.

RESULTS

Significant differences were found in lesion length (142.1 ± 62.98 vs. 56.91 ± 41.04; p = 0.0001), low-density lipoprotein (82.3 ± 40.3 vs. 70.9 ± 23.2; p = 0.0006), vessel runoff (1.18 ± 0.9 vs. 1.8 ± 0.9; p = 0.0001), chronic total occlusion (131 vs. 10; p = 0.001), in-stent restenosis (33 vs. 6; p = 0.0081), and calcified lesions (136 vs. 65; p < 0.001). In simple logistic regression analysis lesion length, reference vessel diameter, chronic total occlusion, runoff vessels, and in-stent restenosis were found to be strongly associated with macroemboli. Angiographic assessment of plaque morphology was accurate. Positive predictive value of 92.31, negative predictive value of 95.35, sensitivity of 92.31, and specificity of 95.35 for calcium; positive predictive value of 95.56, negative predictive value of 100, sensitivity of 100, and specificity of 92.31 for atherosclerotic plaque. Thrombus/in-stent restenosis was correctly predicted.

CONCLUSIONS

Chronic total occlusion, in-stent restenosis, thrombotic, calcific lesions >40 mm, and atherosclerotic lesions >140 mm identified by peripheral angiography necessitate concomitant filter use during atherectomy to prevent embolic complications.

Endovascular Devices and Revascularization Techniques for Limb-Threatening Ischemia in Individuals With Diabetes

Diabetes mellitus (DM) is a rapidly worsening global epidemic over the last thirty-five years. The increased prevalence of DM has changed the phenotypic expression of atherosclerotic limb threatening ischemia (LTI), resulting in an increase in lesions in the tibial vessels. These patients are also afflicted with peripheral neuropathy, foot deformities, and medial calcification of the vasculature. In response to the evolving phenotype of atherosclerosis, newer minimally invasive tools and techniques have been developed to improve the blood supply in LTI. Arterial access, traditionally obtained from the contralateral common femoral artery (CFA) in a retrograde fashion, is now also frequently being obtained in the ipsilateral limb in an antegrade fashion. Retrograde access of the tibial, pedal, tarsal, or calf collateral vessels is also being utilized to provide a route through which wires, catheters, balloons and stents may be placed. Wires have evolved to have a variety of diameters, materials and coatings providing interventionalists with a wide variety of choices when attempting to traverse blockages in the arteries. When catheters and wires fail to traverse the lesion, newer chronic total occlusion (CTO) devices have been developed to aid in the placement of a wire across the offending lesions. Due to medial calcification associated with DM, atherectomy devices have been developed to debulk the atherosclerotic plaque within the vessel. High pressure balloon angioplasty with or without stents remain the mainstay of intervention, with drug-coated balloons (DCBs) and drug-eluting stents (DESs) now being frequently used to prevent reocclusions of atherosclerotic lesions.

Angiographic classification of patterns of restenosis following femoropopliteal artery intervention: A proposed scoring system

OBJECTIVES

To propose a classification system for characterizing angiographic femoropopliteal artery restenosis patterns associated with common endovascular modalities.

BACKGROUND

Peripheral artery disease is a worldwide issue affecting millions of people. Despite a myriad of endovascular technologies available to treat peripheral artery disease of the femoropopliteal arteries, restenosis remains a common failure mode. Characterizing common patterns of restenosis is important to discern the potential impact of baseline patient, lesion, and procedural characteristics, as well as treatment modalities on either the primary success or the failure patterns associated with restenosis.

METHODS

Studies included in the analysis were from previous core laboratory-adjudicated femoropopliteal artery disease trials and registries reflecting a wide array of treatment modalities.

RESULTS

From the subjects enrolled and analyzed, there were 403 total angiograms for analysis and adjudication. Target lesion revascularization images of the 32 validation cases were evaluated for index treated length, diameter stenosis, and lesion morphology characteristics. The following lesion types are proposed: Type 1 "Focal" pattern, which may be "Edge Proximal" or "Edge Distal" depending on location; a Type 2 "Multifocal" pattern which may also exhibit edge restenosis, but may also be "Edge Bilateral"; a Type 3 "Moderate" pattern and a Type 4 "Diffuse" pattern; and finally, a Type 5 "Occlusion".

CONCLUSIONS

A classification system that enables healthcare professionals to anticipate and describe failures following the index procedure, thereby impacting the choice of options for retreatment, may facilitate consistency and standardization within the heterogeneous field of endovascular device treatments for the femoropopliteal artery.

Debulking Atherectomy in the Peripheral Arteries: Is There a Role and What is the Evidence?

Traditional percutaneous balloon angioplasty and stent placement is based on mechanical plaque disruption and displacement within the arterial wall. On the contrary, transcatheter atherectomy achieves atherosclerotic plaque clearance by means of directional plaque excision or rotational plaque removal or laser plaque ablation. Debulking atherectomy may allow for a more uniform angioplasty result at lower pressures with consequently less vessel barotrauma and improved luminal gain, thereby decreasing the risk of plaque recoil and dissection that may require permanent metal stenting. It has been also argued that atherectomy may disrupt the calcium barrier and optimize drug transfer and delivery in case of drug-coated balloon applications. The authors discuss the various types of atherectomy devices available in clinical practice to date and critically appraise their mode of action as well as relevant published data in each case. Overall, amassed randomized and observational evidence indicates that percutaneous atherectomy of the femoropopliteal and infrapopliteal arteries may achieve high technical success rates and seems to lessen the frequency of bailout stenting, however, at the expense of increased risk of peri-procedural distal embolization. Long-term clinical outcomes reported to date do not support the superiority of percutaneous atherectomy over traditional balloon angioplasty and stent placement in terms of vessel patency or limb salvage. The combination of debulking atherectomy and drug-coated balloons has shown promise in early studies, especially in the treatment of more complex lesions. Unanswered questions and future perspectives of this continuously evolving endovascular technology as part of a broader treatment algorithm are discussed.

Percutaneous Therapies for Peripheral Artery Disease

Percutaneous therapies for peripheral artery disease continue to evolve with new techniques and devices. Although guidelines-recommended therapies have impacted cardiovascular morbidity and mortality, endovascular interventions have been shown to reduce limb pain, improve quality of life, and prolong walking distance for those with claudication and to reduce amputation rates among those with critical limb ischemia. Novel devices such as drug-eluting stents and drug-coated balloons have improved patency for moderate-length lesions, whereas others allow treatment of heavily calcified and tortuous segments. New adjunctive devices to cross lesions and reduce or modify associated plaque have also been developed, although level 1 data regarding their efficacy are sparse. There has also been a better mechanistic understanding of lower extremity endovascular treatment using tools such as intravascular ultrasound. This information has highlighted the need for better stent size selection for the femoropopliteal arterial segments and larger balloon diameters for the tibial arteries. Moreover, a wound perfusion approach with direct in-line flow, the so-called angiosome approach, and reconstruction of the pedal loop have been advocated for improved wound healing. Technical advances such as the tibiopedal access and reentry methods have allowed crossing of lesions that were considered no option for the endovascular approach in the past. Collectively, there has been increased awareness, interest, and commitment by various specialty societies and organizations to advance the treatment of peripheral artery disease and critical limb ischemia. This is also evident by the recent coalition of 7 professional societies and organizations that represented >150 000 allied health professionals and millions of patients with peripheral artery disease at the 2015 Centers for Medicaid and Medicare Services Medicare Evidence Development and Coverage Analysis Committee meeting. The percutaneous therapies for peripheral artery disease continue to evolve with longer follow-up with randomized data and larger prospective registries. In the future, it is hopeful that we will treat the lower extremity arteries according to segments, taking into account plaque morphology, luminal versus subintimal crossing, location, and stenotic versus occlusive disease. Until then, we must identify the most cost-effective, efficacious, and safe treatment for each patient. The goal of this article is to aid the practicing vascular specialist consider the optimal choices for the management of patients with vascular disease.

Lower Extremity Revascularization Using Optical Coherence Tomography-Guided Directional Atherectomy: Final Results of the EValuatIon of the PantheriS OptIcal COherence Tomography ImagiNg Atherectomy System for Use in the Peripheral Vasculature (VISION) Study

PURPOSE

To evaluate the safety and efficacy of a novel optical coherence tomography (OCT)-guided atherectomy catheter in treating patients with symptomatic femoropopliteal disease.

METHODS

The VISION trial ( ClinicalTrials.gov identifier NCT01937351) was a single-arm, multicenter, global investigational device exemption study enrolling 158 subjects (mean age 67.2±10.5 years; 87 men) across 20 participating sites. In this cohort, 198 lesions were treated with an average length of 53±40 mm using the Pantheris catheter alone or Pantheris + adjunctive therapy. The primary safety endpoint was the composite of major adverse events (MAEs) through 6 months (objective performance goal 43.2%). Technical success (primary efficacy outcome) was defined as the percent of target lesions with a residual diameter stenosis ≤50% after treatment with the Pantheris device alone (objective performance goal 87.0%). Procedural success was defined as reduction in stenosis to ≤30% after Pantheris ± adjunctive therapy. Tissue specimens retrieved from each treated lesion were histologically analyzed to evaluate the accuracy and precision of OCT image guidance.

RESULTS

The primary efficacy outcome was achieved in 192 (97.0%) of the 198 lesions treated with the Pantheris catheter. Across all lesions, mean diameter stenosis was reduced from 78.7%±15.1% at baseline to 30.3%±11.8% after Pantheris alone (p<0.001) and to 22.4%±9.9% after Pantheris ± adjunctive therapy (p<0.001). Of the 198 target lesions, 104 (52.5%) were treated with the Pantheris alone, 84 (42.4%) were treated with Pantheris + adjunctive angioplasty, and 10 (5.1%) with Pantheris + angioplasty + stenting. The composite MAE outcome through 6 months occurred in 25 (16.6%) of 151 subjects. There were no clinically significant perforations, 1 (0.5%) catheter-related dissection, 4 (2%) embolic events, and a 6.4% clinically driven target lesion revascularization rate at 6 months. The 40-lesion chronic total occlusion (CTO) subset (mean lesion length 82±38 mm) achieved a similar significant reduction in stenosis to 35.5%±13.6% after Pantheris alone (p<0.001). Histological analysis of atherectomy specimens confirmed <1% adventitia in 82.1% of the samples, highlighting the precision of OCT guidance. Characterization of the OCT-guided lesions revealed evidence of an underestimation of disease burden when using fluoroscopy.

CONCLUSION

OCT-guided atherectomy for femoropopliteal disease is safe and effective. Additionally, the precision afforded by OCT guidance leads to greater removal of plaque during atherectomy while sparing the adventitia.

Angiographic Dissection Patterns and Patency Outcomes After Balloon Angioplasty for Superficial Femoral Artery Disease

PURPOSE

To investigate the angiographic dissection patterns after balloon angioplasty for superficial femoral artery (SFA) lesions, the clinical outcome associated with each dissection pattern, and the predictive factors for severe dissection.

METHODS

A retrospective, multicenter analysis examined 621 patients (mean age 72.8±9.5 years; 414 men) with 748 symptomatic de novo SFA lesions treated with endovascular therapy. Vessel dissection after the initial balloon angioplasty procedure was graded into 7 types according to a modified version of the coronary artery classification types A to F. Severe vessel dissection patterns were defined as type C or higher. Nitinol stent implantation was performed in 555 (74.2%) lesions for residual stenosis >30% or flow-limiting dissection; 193 lesions (25.8%) were treated with balloon angioplasty only. To determine the clinical outcomes associated with each dissection pattern and identify predictive factors for severe dissection, 2-year follow-up data for the 193 lesions treated with balloon angioplasty only were analyzed for primary patency and clinically driven target lesion revascularization (TLR).

RESULTS

No dissection was found in 16% (120/748) of lesions, and types A and B dissections were seen in 19% (142/748) and 23% (172/748), respectively. Dissection grades above type C were observed in 42% of cases, most frequently type D (180/748, 24%) and less often type C (37/748, 5%), type E (67/748, 9%), and type F (30/748, 4%). The bailout stent implantation rate increased according to dissection severity. At up to 2 years, the severe dissection group (types C-F) showed a significantly lower patency rate (p<0.001) and higher clinically driven TLR (p<0.001) compared to the nonsevere group (no dissection and types A and B dissections). Severe dissection was a significant risk factor for restenosis, which rose progressively from types C to F. Multivariate analysis identified a small reference vessel diameter <5 mm (p=0.001), lesion length >15 cm (p=0.001), and chronic total occlusion (p<0.001) as independent predictors of severe dissection. In subgroup analysis, vessels with a small reference diameter and TASC II C and D lesions had a higher prevalence of severe dissection.

CONCLUSION

Severe dissection was found in 42% of cases after PTA. A small vessel diameter and/or TASC II C/D lesions were related to a high incidence of dissection. Severe dissection during procedures employing balloon angioplasty only could affect long-term patency.

Contemporary Outcomes of Endovascular Intervention for Critical Limb Ischemia

Critical limb ischemia (CLI) remains a significant cause of morbidity and mortality in patients with peripheral arterial disease. Optimal treatment strategies for CLI remain controversial. The only randomized trial comparing surgical with endovascular revascularization suggests no significant difference in limb salvage between open surgical bypass and angioplasty. Although novel endovascular strategies are now available, their efficacies remain largely untested in a randomized fashion. This review provides an overview of the data surrounding contemporary outcomes of endovascular therapy with an emphasis on current knowledge gaps.

Usefulness of intraopertive ultrasonography during directional atherectomy using SilverHawk/TurboHawk system

PURPOSE

Directional atherectomy (DA) was introduced for the management of infrainguinal arterial stenosis or occlusive lesions. The procedure success rate in the DEFINITIVE LE study was determined using radiologic imaging. The aim of our study was to determine the usefulness of intraoperative ultrasonography (USG) during DA for evaluating the early results of this procedure.

METHODS

Patients who underwent DA from January to December 2014 were reviewed retrospectively. Twenty lesions from 14 patients with femoral artery stenosis (>70% stenosis) with short segment occlusive lesions (<2 cm in length) were treated. Among 20 lesions, 3 were treated with the TurboHawk system with a protective device due to lesion calcification. The percentage of stenosis during and after DA was determined with USG.

RESULTS

Median follow-up was 5.1 months, and the procedural success rate (<30% stenosis at the end of the procedure) was 100% on angiography, but only 30% on intraoperative USG. On USG, median residual stenosis was 40% (range, 28%-42%) at the end of DA, 40% (range, 30%-55%) at 1 month, 55% (range, 35%-85%) at 6 months, and 64% (range, 60%-100%) at 1 year. There was one dissection, but no cases of perforation, pseudoaneurysm, or thrombosis. Primary patency, which was defined as a peak systolic velocity ratio ≤3.5 with no reintervention at 6 months, was found in 18 lesions (90%), and 11 of 14 patients (78.6%) were free of ischemic symptoms such as claudication at 6 months.

CONCLUSION

Our results demonstrated that DA with intraoperative USG is an effective treatment option for short segment occlusive lesions of the femoral artery.

Directional Atherectomy With Antirestenotic Therapy vs Drug-Coated Balloon Angioplasty Alone for Isolated Popliteal Artery Lesions

Purpose: To report a single-center study comparing drug-coated balloon (DCB) angioplasty vs directional atherectomy with antirestenotic therapy (DAART) for isolated lesions of the popliteal artery. Methods: Seventy-two patients were treated with either DCB angioplasty alone (n=31) or with DAART (n=41) for isolated popliteal artery stenotic disease between October 2009 and December 2015. The majority of patients presented with lifestyle-limiting claudication (74% vs 86%, respectively). Vessel calcification (29% vs 29%, respectively), mean lesion length (47 vs 42 mm, respectively), and number of runoff vessels were comparable between the groups. The primary outcome measure was primary patency; secondary outcomes were technical success (<30% residual stenosis or bailout stenting), secondary patency, and freedom from clinically driven target lesion revascularization (TLR). Results: The technical success rate following DCB was 84% vs 93% (p=0.24) after DAART. The 12-month primary patency rate was significantly higher in the DAART group (65% vs 82%; hazard ratio 2.64, 95% confidence interval 1.09 to 6.37, p=0.021), while freedom from TLR did not differ between the 2 treatment strategies (82% vs 94%, p=0.072). Secondary patency at 12 months was identical for both groups (96% vs 96%). Although not statistically significant, bailout stenting was more common after DCB angioplasty (16% vs 5% for DAART, p=0.13) and aneurysmal degeneration of the popliteal artery was seen more often after DAART (7% vs 0% for DCB alone, p=0.25). Popliteal artery injury was observed in 2 patients treated using DAART (5% vs 0% for DCB alone, p=0.5), whereas distal embolization rates were comparable between the groups (3% for DCB alone vs 5% for DAART, p=0.99). Conclusion: In this study, the use of DAART was associated with a higher primary patency rate compared with DCB angioplasty for isolated popliteal lesions. Nonetheless, both treatment options were associated with excellent 12-month secondary patency. Aneurysmal degeneration of the popliteal artery and increased bailout stenting could compromise the outcomes of DAART and DCB, respectively.

Zilver PTX Post-Market Surveillance Study of Paclitaxel-Eluting Stents for Treating Femoropopliteal Artery Disease in Japan: 12-Month Results

OBJECTIVES

This multicenter, prospective, post-market surveillance study in Japan evaluates the paclitaxel-coated Zilver PTX stent in real-world patients with complex lesions.

BACKGROUND

The Zilver PTX stent is the first drug-eluting stent (DES) approved for the superficial femoral artery. Previously, results from a large randomized study and a complementary, large single-arm study supported the safety and effectiveness of the DES.

METHODS

There were no exclusion criteria, and consecutive patients with symptomatic peripheral artery disease (PAD) treated with the DES were enrolled in the study. Clinically driven target lesion revascularization (TLR) was defined as reintervention performed for ≥50% diameter stenosis after recurrent clinical symptoms of PAD. Clinical benefit was defined as freedom from persistent or worsening symptoms of ischemia. Patency was evaluated by duplex ultrasound where physicians considered this standard of care.

RESULTS

In this study, 907 patients were enrolled at 95 institutions in Japan. There were numerous comorbidities including high incidences of diabetes (58.8%), chronic kidney disease (43.8%), and critical limb ischemia (21.5%). Lesions were also complex, with an average length of 14.7 cm, 41.6% total occlusions, and 18.6% in-stent restenosis. In total, 1,861 DES were placed in 1,075 lesions. Twelve-month follow-up was obtained for >95% of eligible patients. Freedom from TLR was 91.0%, and clinical benefit was 87.7% through 12 months. The 12-month primary patency rate was 86.4%.

CONCLUSIONS

Despite more challenging lesions, results from the current study are similar to outcomes from the previous Zilver PTX studies, confirming the benefit of the Zilver PTX DES in a real-world patient population. (Zilver PTX Post-Market Study in Japan; NCT02254837).

Ubiquitous Nature of Distal Athero/Thromboembolic Events during Lower Extremity Atherectomy Procedures Involving the Superficial Femoral Artery

This study aims to evaluate occurrence, size, composition, and clinical significance of embolized debris during superficial femoral artery atherectomy using all commercially available atherectomy devices. Distal athero/thromboembolic events (DATE) are a universal phenomenon in lower extremity atherectomy procedures (LEAPs) due to the sheer volume of atheroma and the thrombus burden in peripheral arterial disease. Some of these events can be clinically significant. We prospectively gathered clinical and histopathological data on all commercially available atherectomy devices by using embolic protection devices (EPD) in every case. After intervention, the contents of EPD were examined both microscopically and macroscopically. Data from 59 consecutive patients undergoing LEAP were analyzed. DATE occurred 100% of the time. The composition of particulate debris varied with the device used. Grossly visible agglomerated debris was captured by the filter in the majority of patients 54/59 (91.5%). Clinically significant debris, defined by the Preventing Lower Extremity Distal Embolization Using Embolic Filter Protection registry as particle diameter > 0.2 cm, was found in 33/59 (56%) patients. The size of captured debris particles ranged from 0.1 to 2.4 mm. While DATE occurred in all patients, clinically significant DATE occurred in 56% patients undergoing LEAP regardless of the atherectomy device. In spite of a large fraction of the clinically significant debris occurring on our routine dual antiplatelet regimen, no patient suffered an amputation. Although DATE was prevented by the use of EPD in all 59 cases, more data are needed to determine whether the use of EPD translates into a long-term clinical benefit. Use of EPD and optimal thromboprophylaxis should be considered in patients, especially in the setting of compromised distal runoff.

Retrospective Multicenter Comparison of S.M.A.R.T. CONTROL and MISAGO Stents in Treatment of Femoropopliteal Lesions

PURPOSE

To compare primary patency between MISAGO (Terumo Corporation, Tokyo, Japan) and S.M.A.R.T. CONTROL (Cordis Corporation, Miami Lakes, Florida), second-generation and first-generation nitinol stents, in femoropopliteal lesions.

MATERIALS AND METHODS

This multicenter, retrospective study included 240 cases with MISAGO stent implantation and 1,265 cases with S.M.A.R.T. stent implantation. The S.M.A.R.T. group had more Trans-Atlantic Inter-Society of Consensus (TASC) II class C/D lesions (53% vs 41%, P = .001) and smaller reference vessel diameter (RVD) (5.3 mm ± 0.9 vs 5.5 mm ± 0.9, P < .001).

RESULTS

Kaplan-Meier estimates of 2-year primary patency after S.M.A.R.T. and MISAGO stent implantation were 67% and 55% (P = .007). Interaction analysis revealed that TASC II classification and RVD had a significant influence on the association of MISAGO versus S.M.A.R.T. stents with the outcome. The study population was stratified according to TASC II classification and RVD, and MISAGO and S.M.A.R.T. stents were compared after propensity score matching. There was no significant difference in 2-year patency between the 2 stents in the subgroup with TASC II class A/B and RVD ≥ 5 mm (S.M.A.R.T. 82% ± 4 vs MISAGO 74% ± 5, P = .480). MISAGO stents had lower primary patency than S.M.A.R.T. stents in cases with TASC II class C/D or RVD < 5 mm (S.M.A.R.T. 62% ± 6 vs MISAGO 25% ± 6, P = .015).

CONCLUSIONS

S.M.A.R.T. and MISAGO stents had similar patency in simple lesions, but MISAGO stents had lower patency than S.M.A.R.T. stents in more complex lesions.

Techniques in Vascular and Interventional Radiology Drug Delivery Technologies in the Superficial Femoral Artery

Peripheral arterial disease (PAD) affects over 8 million people in the United States alone. Although great strides have been made in reducing the burden of cardiovascular disease the prevalence of PAD is expected to rise with the age of global population. PAD characterized by narrowing of arterial blood can be asymptomatic or cause limb threatening claudication. It has been classically treated with bypass, but these techniques have been supplanted by endovascular therapy. Plain old balloon angioplasty has been successful in helping revascularize lesions, but its effect has not been durable because of restenosis. This prompted the creation of several technologies aimed at reducing restenosis. These advances slowly improved outcomes and the durability of endovascular management. Among the main tools used in current endovascular practice are drug-delivery devices aimed at inhibiting the inflammatory and proliferative pathways that lead to restenosis. This article examines the current drug-delivery technologies used in the superficial femoral artery.

Strategies to Approaching Lower Limb Occlusions

Endovascular management of chronic total occlusions (CTO) can be challenging both from decision-making and technical perspectives. Successful treatment and management of a CTO requires the operator to have an understanding of the salient imaging findings, a thorough knowledge of the various technical challenges of the procedure, and comprehension of the importance and necessity of long-term clinical management. This article outlines a general approach to endovascular management of lower limb CTOs and discusses indications, techniques, potential complications, and therapeutic options of the procedure.

Outcomes of Endovascular Therapy for Upper Extremity Peripheral Artery Disease With Critical Hand Ischemia

PURPOSE

To investigate the clinical outcomes of endovascular therapy (EVT) for upper extremity peripheral artery disease (PAD) with critical hand ischemia (CHI).

METHODS

A subanalysis was performed of multicenter registry data on 36 consecutive patients (mean age 65.7±10.3 years; 19 men) who underwent EVT from January 2003 to December 2013 for angiographically diagnosed de novo upper limb PAD with CHI in 40 limbs. Fifty percent of patients had diabetes, and two-thirds were on hemodialysis. Technical success of EVT was straight-line flow to the hand and final residual diameter stenosis ≤50% for balloon angioplasty alone and ≤30% without flow-limiting dissection for subclavian artery stenting. The primary outcome was 12-month amputation-free survival [AFS; freedom from a composite of major (above-the-wrist) amputation and death]. The 12-month secondary outcomes were overall survival, limb salvage, freedom from major adverse limb events (MALE; major amputation or any repeat revascularization of the limb), and wound healing (complete epithelialization without death or major amputation).

RESULTS

Initial success was achieved in 87% (35 of 40 limbs); 1 patient experienced puncture site problems, and 3 (8%) of 36 patients (4 treated limbs) died within 30 days. Hand symptoms were alleviated in 37 (92%) limbs. The mean follow-up was 26.8±27.8 months. Seven fingers (5 limbs) underwent phalanx amputations and 2 limbs had an amputation above the wrist. Complete wound healing was achieved in only 5 (19%) of 26 surviving patients at 12 months. At 1 year, the Kaplan-Meier estimates for AFS, overall survival, limb salvage, and freedom from MALE were 56.4%, 59.4%, 93.1%, and 78.5%, respectively. Univariate analysis revealed that the predictors of AFS at 1 year were diabetes (p=0.03), hemodialysis (p<0.001), PAD (p=0.003), and the presence of a wound (p<0.001). During follow-up, 20 (56%) patients died; a cardiovascular cause accounted for 40% of deaths.

CONCLUSION

Endovascular therapy for upper limb PAD with CHI was technically successful and alleviated symptoms in the majority of cases, but the prognosis of patients with CHI was extremely poor in real-world clinical practice.

Successful Use of Orbital Atherectomy as an Adjunct in Treating Extensively Calcified Mesenteric Artery Lesions

BACKGROUND

To describe the use of orbital technique of atherectomy as an adjunct to successful angioplasty and stent placement of the superior mesenteric artery (SMA).

CASE REPORT

The technique is demonstrated in a 68-year-old man with critical SMA stenosis. The SMA was cannulated with 0.014-in wire, but the lesion was highly stenotic and densely calcified and prevented the passage of even the smallest 1.5-mm balloon. Orbital atherectomy was thus performed with a 1.25-mm CSI crown. Balloon angioplasty was then possible with a 4 mm × 2 cm balloon followed by placement of a 7 mm × 22 mm balloon-mounted stent.

CONCLUSIONS

The use of atherectomy as an adjunct to angioplasty and stenting in extensive, calcified SMA lesions supports the value of this technique to avoid a much larger and morbid open procedure.

Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice

Introduction The office-based endovascular facility has increased in number recently due in part to expedient patient experience. This study analyzed treatment outcomes of procedures performed in our office-based endovascular suite. Methods Treatment outcomes of 5134 consecutive procedures performed in our office-based endovascular suites from 2006 to 2013 were analyzed. Five sequential groups (group I-V) of 1000 consecutive interventions were compared with regard to technical success and treatment outcomes. Results Our patients included 2856 (56%) females and 2267 (44%) males. Procedures performed included diagnostic arteriogram, arterial interventions, venous interventions, dialysis access interventions, and venous catheter management, which were 1024 (19.9%), 1568 (30.6%), and 3073 (60.0%), 621(12.1%), and 354 (6.9%), respectively. The complication rates for group I, II, III, IV, and V were 3%, 1.5%, 1%, 1.1%, and 0.7%, respectively. The complication rate was higher in group I when compared to each of the remaining four groups ( p < 0.05). Nine patients (0.18%) died within the 30-day period following their procedures, and none were procedure related. Conclusions Endovascular procedure can be performed safely in an office-based facility with excellent outcomes. Lessons learned in establishing office-based endovascular suites with efforts to reduce procedural complications and optimize quality patient care are discussed.

Maximizing Lumen Gain With Directional Atherectomy

PURPOSE

To describe the use of a low-pressure balloon inflation (LPBI) technique to delineate intraluminal plaque and guide directional atherectomy in order to maximize lumen gain and achieve procedure success.

TECHNIQUE

The technique is illustrated in a 77-year-old man with claudication who underwent superficial femoral artery revascularization using a HawkOne directional atherectomy catheter. A standard angioplasty balloon was inflated to 1 to 2 atm during live fluoroscopy to create a 3-dimensional "lumenogram" of the target lesion. Directional atherectomy was performed only where plaque impinged on the balloon at a specific fluoroscopic orientation. The results of the LPBI technique were corroborated with multimodality diagnostic imaging, including digital subtraction angiography, intravascular ultrasound, and intra-arterial pressure measurements.

CONCLUSION

With the LPBI technique, directional atherectomy can routinely achieve <10% residual stenosis, as illustrated in this case, thereby broadly supporting a no-stent approach to lower extremity endovascular revascularization.

In-Hospital Outcomes of Atherectomy During Endovascular Lower Extremity Revascularization

Contemporary data on clinical outcomes after utilization of atherectomy in lower extremity endovascular revascularization are sparse. The study cohort was derived from Healthcare Cost and Utilization Project nationwide inpatient sample database from the year 2012. Peripheral endovascular interventions including atherectomy were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The subjects were divided and compared in 2 groups: atherectomy versus no atherectomy. Two-level hierarchical multivariate mixed models were created. The coprimary outcomes were in-hospital mortality and amputation; secondary outcome was a composite of in-hospital mortality and periprocedural complications. Hospitalization costs were also assessed. Atherectomy utilization (odds ratio, 95% CI, p value) was independently predictive of lower in-hospital mortality (0.46, 0.28 to 0.75, 0.002) and lower amputation rates (0.83, 0.71 to 0.97, 0.020). Atherectomy use was also predictive of significantly lower secondary composite outcome of in-hospital mortality and complications (0.79, 0.69 to 0.90, 0.001). In the propensity-matched cohort, atherectomy utilization was again associated with a lower rate of amputation (11.18% vs 12.92%, p = 0.029), in-hospital mortality (0.71% vs 1.53%, p 0.001), and any complication (13.24% vs 16.09%, p 0.001). However, atherectomy use was also associated with higher costs ($24,790 ± 397 vs $22635 ± 251, p <0.001). Atherectomy use in conjunction with angioplasty (with or without stenting) was associated with improved in-hospital outcomes in terms of lower amputation rates, mortality, and postprocedural complications.

National trends for the treatment of peripheral arterial disease in Korea between 2004 and 2013

Purpose

Peripheral arterial disease (PAD) has been a major public health issue in the elderly. Advances in endovascular surgery have led to a substantial shift in the management of PAD. Although the nationwide trend of PAD treatment in the Western countries was reported, limited data have been available on this in Korea. This study examined the national trend in the treatment of PAD in Korea over the past decade.

Methods

Health Insurance Review and Assessment Service data were used. We sought to analyze trends in the open and endovascular surgery for the treatment of PAD in Medicare beneficiaries between 2004 and 2013. We also analyzed trends in each types of surgery in the lower extremity. A linear-by-linear association was performed to determine the changes of PAD treatment for this period.

Results

The rate of open surgery per 100,000 Medicare beneficiaries decreased significantly from 8 procedures in 2004 to 6 in 2013. At the same time, endovascular surgery increased from 23 procedures in 2004 to 59 in 2013. Endovascular surgery in the lower extremity increased more than twofold, while the open surgery decreased by 39%. The rate of balloon angioplasty among endovascular surgery was increased by almost threefold, while the bypass surgery using artificial graft decreased by half.

Conclusion

Endovascular surgery is now performed more commonly than open surgery for PAD treatment. Balloon angioplasty increased by almost threefold, while the bypass surgery using artificial graft decreased by about 50%.