Clinical outcome and restenosis following percutaneous transluminal angioplasty for ischaemic rest pain or ulceration

Magnetic Resonance Angiography in the Follow-up of Distal Lower-Extremity Bypass Surgery: Comparison with Duplex Ultrasound and Digital Subtraction Angiography

PURPOSE

The danger of limb loss as a consequence of acute occlusion of infrapopliteal bypasses underscores the requirement for careful patient follow-up. The objective of this study was to determine the agreement and accuracy of contrast material-enhanced moving-table magnetic resonance (MR) angiography and duplex ultrasonography (US) in the assessment of failing bypass grafts. In cases of discrepancy, digital subtraction angiography (DSA) served as the reference standard.

MATERIALS AND METHODS

MR angiography was performed in 24 consecutive patients with 26 femorotibial or femoropedal bypass grafts. Each revascularized limb was divided into five segments--(i) native arteries proximal to the graft; (ii) proximal anastomosis; (iii) graft course; (iv) distal anastomosis; and (v) native arteries distal to the graft-resulting in 130 vascular segments. Three readers evaluated all MR angiograms for image quality and the presence of failing grafts. The degree of stenosis was compared to the findings of duplex US, and in case of discrepancy, to DSA findings. Two separate analyses were performed with use of DSA only and a combined diagnostic endpoint as the reference standard.

RESULTS

Image quality was rated excellent or intermediate in 119 of 130 vascular segments (92%). Venous overlay was encountered in 26 of 130 segments (20%). In only two segments was evaluation of the outflow region not feasible. One hundred seventeen of 130 vascular segments were available for quantitative analysis. In 109 of 117 segments (93%), MR angiography and duplex US showed concordant findings. In the eight discordant segments in seven patients, duplex US overlooked four high-grade stenoses that were correctly identified by MR angiography and confirmed by DSA. Percutaneous transluminal angioplasty was performed in these cases. In no case did MR angiography miss an area of stenosis of sufficient severity to require treatment. Total accuracy for duplex US ranged from 0.90 to 0.97 depending on the reference standard used, whereas MR angiography was completely accurate (1.00) regardless of the standard definition.

CONCLUSION

Our data strongly suggest that the accuracy of MR angiography for identifying failing grafts in the infrapopliteal circulation is equal to that of duplex US and superior to that of duplex US in cases of complex revascularization. MR angiography should be included in routine follow-up of patients undergoing infrapopliteal bypass surgery.

Balloon angioplasty in chronic critical limb ischemia: factors affecting clinical and angiographic outcome

PURPOSE

To assess factors that affect clinical and angiographic outcome in chronic critical limb ischemia (CLI) 12 months after primary, technically successful balloon angioplasty (BA) in infrainguinal arteries.

METHODS

Sixty consecutive patients (37 women; mean age 75 +/- 10 years, range 53-99) with technically successful BA in 66 limbs were followed for 12 months or until death, for major amputation, or repeat target lesion revascularization (TLR). Assessment at baseline and 1 day and 12 months after BA or at an endpoint event, if feasible, was performed with angiography or duplex ultrasound (above-knee revascularization only). Mortality, limb prognosis, and restenosis rate were correlated with cardiovascular risk factors, hemodynamic measures, and angiographic features.

RESULTS

Mortality was 25% at 1 year; compared to survivors, nonsurvivors more often had coronary artery disease (93% versus 44% for survivors, p<0.001), bilateral CLI (60% versus 29%, p=0.033), and higher fibrinogen levels (5.1 g/L versus 4.3 g/L, p=0.049). CLI resolved in more than half (35, 53%) of the limbs without repeat TLR. The major amputation rate was 6%. Limb prognosis correlated with ankle pressures after BA. Restenosis rates were 65% at the femoropopliteal and 56% at the infrapopliteal level (NS); these correlated with the length of the treated arterial segment (8.7 cm with restenosis versus 4.0 cm without, p<0.001).

CONCLUSIONS

High mortality in CLI was associated with an extensive, clinically manifest arteriosclerotic process and high fibrinogen levels. Limb prognosis and restenosis after BA were primarily influenced by local hemodynamic and technical factors. Despite considerable restenosis, more than 90% of survivors avoided major amputations.

Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene

PURPOSE

The purpose of this study was to evaluate the results of combining intraoperative balloon angioplasty (IBA) of the superficial femoral artery (SFA) with distal bypass graft originating from the popliteal artery as a method of lower extremity revascularization in diabetic patients with gangrene.

METHODS

Among 380 infrainguinal bypass grafts performed over a 6-year period, there were 110 reversed saphenous vein bypass grafts to the tibial or pedal arteries to treat diabetic patients with gangrene. Diffuse infrainguinal disease was treated with femoral-distal bypass graft (long; n = 46). Popliteal-distal bypass graft was performed when the inflow femoral artery was not significantly diseased (short; n = 52). Focal SFA stenosis and severe infrageniculate disease were treated with combined IBA of the SFA and distal bypass graft originating from the popliteal artery (combined; n = 12). Follow-up was performed with duplex scan surveillance of both the bypass graft and IBA sites. Treatment groups were compared with life-table analysis.

RESULTS

There were no perioperative graft failures or amputations. The perioperative mortality rate was 1% (1 of 110). The 2-year primary patency rates were similar in the three groups: 72% in the long bypass graft group, 82% in the short bypass graft group, and 76% in the combined group (P =.8, log-rank test). SFA IBA sites developed recurrent stenosis in two patients, at 7 and 48 months; both were detected with surveillance and treated with percutaneous transluminal balloon angioplasty. The overall 5-year rate of primary patency was 63%, secondary patency was 78%, limb salvage was 81%, and survival was 35%. There were no significant differences among the three treatment groups with respect to these outcomes.

CONCLUSION

Results with the combined procedure were similar to those achieved with either femoral-distal bypass graft or popliteal-distal bypass graft without SFA IBA. These data suggest that IBA of the inflow SFA may be combined with popliteal to distal bypass graft and that this technique is a reasonable alternative to longer, femoral-origin bypass graft in selected diabetic patients with gangrene.

Relationship of femorodistal bypass patency to clinical outcome. Iloprost Bypass International Study Group

OBJECTIVE

To investigate the relationship between bypass patency, limb survival and clinical symptoms after femorodistal bypass procedures.

DESIGN

Multicentre, prospectively planned 12-month postoperative follow-up.

PATIENTS AND METHODS

Five hundred and seventeen patients undergoing femorodistal bypass surgery for severe ischaemia. Clinical symptoms, bypass patency were recorded at regular intervals up to 12 months postoperatively.

RESULTS

Complete follow-up data was obtained on 498 patients (96%). Fifty-six (17%) of the 341 patients with patent bypasses had either rest pain or ulcers or had undergone major amputation at 12 months. Of the 167 patients with an occluded bypass, 22 patients (13%) had improved clinical symptoms and a total of 59 patients (35%) had avoided major amputation at 12 months. The clinical outcome for patients classified preoperatively as Fontaine stage IV was significantly worse than for those in stage III preoperatively despite similar bypass patency rates.

CONCLUSIONS

There is a fair correlation between technical and clinical outcome after femorodistal bypass surgery at 12 months, but there are significant numbers of patients with occluded bypasses who have a good clinical outcome and of patients with patent bypasses who have a poor clinical outcome. The reporting of symptoms in addition to bypass patency would aid the interpretation of surgical results.

The predictive value of laser Doppler fluxmetry and transcutaneous oximetry for clinical outcome in patients undergoing revascularisation for severe leg ischaemia

OBJECTIVES

To investigate the predictive value of laser Doppler fluxmetry and transcutaneous oximetry in 41 patients undergoing technically successful revascularisation for severe leg ischaemia.

DESIGN

Toe and ankle systolic arterial pressures, transcutaneous oxygen tension (tcpO2), and stressed laser Doppler fluxmetry at the foot (time to peak laser Doppler flux following 2 min arterial occlusion, tp LDF, and the response of LDF to raising the leg 40 cm, the elevated:supine LDF ratio) were measured before revascularisation. Six months later these measurements were compared in those patients who were clinically improved, and those who still had symptoms of severe ischaemia or had lost their limb.

SETTING

Vascular Laboratory, St. George's Hospital, London SW17, U.K.

RESULTS

Six months following revascularisation 30 (73%) of the 41 patients had partial or complete symptomatic relief. Six (15%) had undergone major amputation and five (12%) still had symptoms of severe ischaemia. Before intervention toe and ankle systolic pressures were similar in the 30 who were improved and the 11 who had lost, or were still at risk of losing, their leg. Pre-revascularisation tcpO2 was significantly lower (18.3 mm Hg vs 33.5 mm Hg; p < 0.05) and tp LDF significantly longer (140 s vs 92 s; P < 0.05) in the 11 patients who were not clinically improved at 6 months. Whilst pre-revascularisation toe and ankle pressures below 30 mm Hg and 50 mm Hg respectively identified only 55% of those patients who were not improved 6 months later, a tp LDF in excess of 100 s identified 82% (p < 0.05) and was noted in five of the six amputees.

CONCLUSION

Microcirculatory assessments performed in patients with limb-threatening ischaemia are likely to be more deranged in those patients who suffer clinical failure or amputation despite an apparently successful revascularisation procedure.