Endovascular stents for intermittent claudication

Endovascular stents for intermittent claudication

BACKGROUND

Endovascular stents have been suggested as a means to improve the patency of arteries after angioplasty in patients with intermittent claudication. This is an update of a Cochrane review published in 2002.

OBJECTIVES

The null hypothesis to be tested by this review is that for individuals with claudication the use of an endovascular stent, in addition to percutaneous transluminal angioplasty, does not improve symptoms of life-style limiting claudication when compared to percutaneous angioplasty alone.

SEARCH STRATEGY

For this update the Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched August 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 3).

SELECTION CRITERIA

Randomised trials comparing angioplasty alone versus angioplasty with endovascular stents in patients with intermittent claudication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted the data. Only published trial data were used but unpublished data were sought for the update. Effectiveness was measured by the pre-defined primary outcome measures restenosis or reocclusion rates and maximum walking distance.

MAIN RESULTS

Two studies were included involving a total of 104 participants. Both studies included only individuals with femoro-popliteal disease. They compared angioplasty and stenting with the Palmaz stent against angioplasty alone. Although one study showed a slight statistical advantage in arterial patency after angioplasty alone, this was not found when the two studies were combined. No differences in the secondary outcomes were detected in either study.

AUTHORS' CONCLUSIONS

The small number of relevant studies identified together with the small sample sizes and methodological weaknesses severely limit the usefulness of this review in guiding practice. The results from larger multicentre trials are needed.

Evaluation of peripheral atherosclerosis: a comparative analysis of angiography and intravascular ultrasound imaging

OBJECTIVE

Angiography remains a critical component for diagnostic imaging and therapeutic intervention in peripheral arterial disease (PAD). The goal of this study was to compare angiography with corresponding intravascular ultrasound (IVUS) imaging of the same vessels in patients with PAD.

METHODS

From 2004 to 2008, 93 patients undergoing angiography for PAD were recruited in a prospective observational analysis. At the time of angiography, diseased lower extremities were interrogated using a 10-cm IVUS pullback with registration points. IVUS data were analyzed with radiofrequency techniques for vessel and lumen diameter, plaque volume, plaque composition, and cross-sectional area. Similarly, three vascular surgeons blinded to the IVUS data graded corresponding angiographic images according to vessel diameter, degree of stenosis, degree of calcification, and extent of eccentricity. Statistical analyses of matched IVUS images and angiograms were performed.

RESULTS

The distribution of demographic and risk variables were typical for PAD: 54% male, 96% hypertension, 78% hyperlipidemia, 44% diabetic, 87% tobacco history, 65% coronary artery disease, and 10% end-stage renal disease. Symptoms precipitating the angiographic evaluation included claudication (53%), rest pain (18%), and tissue loss (29%). Angiographic and IVUS interpretation were similar for luminal diameters, but external vessel diameter was greater by IVUS imaging (7.0 +/- 0.7 vs 5.2 +/- 0.8 mm, P < .05). The two-dimensional diameter method resulted in a significant correlation for stenosis determination (r = 0.84); however, IVUS determination of vessel area stenosis was greater by 10% (95% confidence interval, 0.3%-21%, P < .05). IVUS imaging indicated that a higher proportion of plaques were concentric. Grading of calcification was moderate to severe in 40% by angiography but in only 7% by IVUS (P < .05).

CONCLUSIONS

In the evaluation of PAD, angiography and IVUS imaging provide similar luminal diameters and diameter-reducing stenosis measurements. Determination of overall vessel diameter and interpretation of plaque morphology by angiography are discordant from IVUS-derived data.

Stent-Assisted Angioplasty at the Level of the Common Femoral Artery Bifurcation:Midterm Outcomes

PURPOSE

To report the midterm outcome after stent-assisted angioplasty of occlusive disease at the common femoral artery bifurcation.

METHODS

Between 1995 and 2002, 27 consecutive patients (18 men; mean age 70 years, range 47-90) underwent angioplasty with stent implantation in 33 limbs; target sites included 19 common femoral arteries, the origins of 2 superficial or 4 profunda femoris arteries, and 8 bypass anastomoses.

RESULTS

Technical success was 100%. Patients were followed for a mean 30 months (95% CI 21 to 39), at which time the cumulative primary patency was 86% (95% CI 85% to 88%). At 3 years, 83% of the arteries were patent. Five restenoses were due to neointimal hyperplasia in 4 cases (3 bypass grafts) and strut failure of the only balloon-expandable stent used in this series. Restenoses due to neointimal hyperplasia at bypass anastomoses (3/ 8) were more common than in native arteries (2/25) (p=0.078); cumulative primary patency for the bypass subgroup was 71% (95% CI 59% to 82%) at a mean 23-month follow-up; 75% and 60% of the anastomoses were patent after 1 and 2 years, respectively.

CONCLUSIONS

Angioplasty of obstructions in the common femoral artery and its bifurcation with implantation of self-expanding stents shows good midterm primary patency. Native artery lesions have a better outcome than stenoses at bypass anastomoses. The procedure does not preclude further endovascular interventions at the puncture site.

Recent developments in vascular surgery

The authors of this review discuss the changing role of vascular surgery and the impact of developments such as endovascular interventions and new techniques for treating varicose veins