Peripheral arterial calcification: prevalence, mechanism, detection, and clinical implications

Interwoven Nitinol Stent Versus Laser-Cut-Type Nitinol Stent for Long Femoropopliteal Occlusive Disease: A Propensity Matched Analysis

PURPOSE

There are still limited data to determine the efficacy of interwoven nitinol stent (INS) compared with laser-cut nitinol stent (CNS) for the endovascular treatment of long femoropopliteal lesions. The aim of this study is to evaluate the short- and mid-term results of the effectiveness of CNS and INS in the revascularization of long femoropopliteal occlusions. We performed analyses of the primary and secondary outcome measures for subgroups of patients with below-the-knee and "above-the-knee" lesions.

MATERIALS AND METHODS

A retrospective propensity matched analysis was conducted on symptomatic patients (Rutherford category 3-6) with long occlusions of the femoropopliteal segment (> 15 cm) who underwent stenting with either INS or CNS from 2012 to 2020. The primary outcome measure was the primary patency in 2 years. Secondary outcome measures were secondary patency, major adverse cardiovascular events, major adverse limb events, sustained clinical improvement, and mortality.

RESULTS

After propensity score matching, 126 and 125 patients remained in the INS and CNS groups, respectively. There were no cases of major cardiovascular events (MACE) or major limb events in both groups during the perioperative period. There were no significant differences in primary and secondary patency during a 2-year follow-up. There were no stent fractures in the INS group, whereas in the CNS group the stent fractures rate reached 37 (29.6%) patients (p < 0.001). In the "above-the-knee" subgroup, INS and CNS showed comparable primary patency rates. However, the secondary patency rates were 82.0% and 96.9% in INS and CNS groups, respectively (p < 0.001). The secondary sustained clinical improvement rates were 79.8% and 93.9% in INS and CNS subgroups, respectively (p < 0.001). In the "below-the-knee subgroup," INS showed higher primary patency rate (INS: 64.9% CNS: 37.1%; p = 0.04). In the CNS group, the fractures rate "below the knee" was statistically significantly higher compared with stents "above the knee" (p = 0.03).

CONCLUSION

After propensity score matching, INS showed comparable results with CNS for the whole cohort. However, INS seems to achieve better outcomes for femoropopliteal lesion extended to the below-the-knee level.

Thirty-day outcomes from the Disrupt PAD BTK II study of the Shockwave Intravascular Lithotripsy System for treatment of calcified below-the-knee peripheral arterial disease

BACKGROUND

Below-the-knee (BTK) lesions may be particularly challenging to treat owing to length, diffuse disease, and extent of calcification. Landmark interventional clinical studies have not reached consensus on the optimal standard of care for BTK lesions, and many published trials excluded patients with moderate or severe lesion calcification. Calcium modification with intravascular lithotripsy (IVL) was shown to be superior to percutaneous transluminal angioplasty in the femoropopliteal artery and successful in treating BTK lesions in pilot studies. The Disrupt BTK II study is a core laboratory-adjudicated, prospective, multicenter, single-arm study of patients with moderate to severely calcified BTK lesions treated with the Shockwave Medical Peripheral IVL System.

METHODS

Disrupt BTK II enrolled 250 subjects with calcified infrapopliteal lesions and Rutherford category 3-5 presentation from 38 sites in the United States and Europe. The primary safety endpoint was major adverse limb events or postoperative death at 30 days, a composite of all-cause death, above-ankle amputation of the index limb, and/or major reintervention of the index limb involving an infrapopliteal artery. The primary effectiveness endpoint was procedural success, defined as ≤50% residual stenosis for all treated target lesions without serious core laboratory-adjudicated serious angiographic complications. The study used independent angiographic and duplex ultrasound core laboratories, and follow-up is planned through 2 years.

RESULTS

A total of 305 lesions in 250 patients were treated with a procedural success of 97.9%. The mean target lesion length was 76 ± 65 mm, diameter stenosis was 78% ± 18%, and 84.8% had moderate or severe calcification as assessed by an independent angiographic core laboratory. After IVL, residual stenosis was reduced to 29%, and after optional postdilatation and/or stent implantation, to 26%. At 30 days, there were no deaths, major adverse limb event rate was 0.8%, and mean improvement in Vascular Quality of Life scores was 4.0 ± 5.0 (P < .0001). Of the patients with baseline wounds, 15.8% healed and 53.4% were improved at 30 days.

CONCLUSIONS

The Disrupt PAD BTK II study demonstrated that treatment with the Shockwave Medical Peripheral IVL System in patients with moderate-severe calcified lesions resulted in high procedural success, significant reduction in residual stenosis, improvements in patient quality of life, and wound healing, with minimal adverse events at 30-day follow-up.

Efficacy of a novel method: VaSodilator injection via the Over-the-wire lumen during drug-coated balloon dilatation to Prevent the slow-flow phenomenon in treatment of femoropopliteal lesions

In drug-coated balloon (DCB) angioplasty for femoropopliteal lesions, there are adverse effects of drug embolization on downstream non-target organs following the slow-flow phenomenon. We devised a novel method, known as VaSodilator injection via the Over-the-wire lumen during DCB dilatation to Prevent the slow-flow phenomenon in treatment of femoropopliteal lesions (V.S.O.P.), and evaluated its efficacy and safety. This single-center, retrospective, observational study analyzed 196 femoropopliteal lesions treated with IN.PACT Admiral between April 2018 and July 2023. The IN.PACT Admiral is a DCB consisting of a 0.035-inch over-the-wire (OTW) lumen balloon coated with high-dose paclitaxel. Regarding the V.S.O.P. method, we injected vasodilators through the OTW lumen during DCB dilation of the lesions. The cohort was classified into two groups according to the use of the V.S.O.P. method (V.S.O.P. group: n = 53; non-V.S.O.P. group: n = 143). The V.S.O.P. group had lower rates of hemodialysis (21% vs. 43%, p = 0.01) and higher rates of critical limb-threatening ischemia (56% vs. 23%, p < 0.01) and severe calcification lesions (Peripheral Arterial Calcium Scoring Systems score 3/4) (53% vs. 34%, p = 0.01) than the non-V.S.O.P. group. The occurrence of the slow-flow phenomenon was significantly lower in the V.S.O.P. group than in the non-V.S.O.P. group. The V.S.O.P. method could be an effective method for preventing the slow-flow phenomenon after DCB angioplasty for femoropopliteal lesions.

Outcomes of contemporary stents with deep femoral artery coverage

INTRODUCTION

We aimed to investigate deep femoral artery (DFA) status during endovascular treatment (EVT) and the patency of the femoropopliteal (FP) artery and DFA using current stent devices for ostial FP lesions.

METHODS

A multicenter, retrospective study analyzed data from 457 patients who underwent EVT with stent deployment for de novo ostial FP lesions between April 2018 and December 2021 at eight centers in Japan. Propensity score-matched analysis was performed to compare the clinical impacts of DFA coverage for ostial FP lesions with stent deployment. The prognostic value was analyzed based on DFA status during EVT, primary patency of the FP artery, clinically driven-target lesion revascularization (CD-TLR) of the FP artery, and incidence of DFA occlusion/major amputation/acute limb ischemia (ALI) at 3 years.

RESULTS

A total of 132 matched pairs of patients was analyzed using propensity score matching. The percentage of DFA occlusion and stenosis was significantly higher in the DFA coverage group. However, there were no significant differences in terms of primary patency of the FP artery, CD-TLR, DFA occlusion, major amputation, or ALI after 3 years.

CONCLUSIONS

Stent deployment in DFA coverage significantly led to the DFA stenotic events of EVT during the procedure, but patency of the FP artery and DFA, major amputation, and ALI up to 3 years did not differ according to stent deployment for ostial FP lesions.

Percutaneous Deep Venous Arterialization by Balloon Angioplasty without Stent Implantation for Patients with Chronic Limb-Threatening Ischemia Undergoing Hemodialysis: A Retrospective Cohort, Single-Center, Single-Arm Study

PURPOSE

This retrospective, single-center study aimed to determine the efficacy of percutaneous deep venous arterialization in patients on hemodialysis with chronic limb-threatening ischemia.

MATERIALS AND METHODS

Twenty-one consecutive limbs on hemodialysis with chronic limb-threatening ischemia were treated with percutaneous deep venous arterialization using balloon angioplasty following a failed pedal arterial reconstruction between May 2021 and June 2022. An arteriovenous fistula near the ankle joint was created to ensure sufficient venous flow reversal to the pedal veins. In case of occlusion of the tibial artery, a guidewire was advanced (subintimal) to the ankle joint vicinity was technically important. The primary outcome measures were the 6-month complete wound healing and freedom from major amputation rates; the secondary outcome measure was the 6-month amputation-free survival.

RESULTS

Occlusion of all pedal arteries was observed in 17 limbs (81.0%). Arteriovenous fistulas were predominantly created at the distal portions of the posterior tibial artery and vein in 18 limbs (85.7%). No extravasation at the fistulas was observed. Re-intervention was required in 16 limbs (76.2%) due to tibial artery or deep vein occlusion. The 6-month complete wound healing rate was 42.9% (nine limbs), with a median healing time of 85 days (interquartile range: 58-151 days). The 6-month freedom from major amputation and amputation-free survival rates were 90.5% (19 limbs) and 61.9% (13 limbs), respectively.

CONCLUSION

Balloon angioplasty without stent implantation for percutaneous deep venous arterialization is promising for improving the complete wound healing and amputation-free survival rates after pedal artery reconstruction failure.

LEVEL OF EVIDENCE

Level 3b, retrospective cohort study.

Association of Iliofemoral Calcium Score and Major Vascular Complications within the First Year after Lower Limb Endovascular Revascularization

BACKGROUND

The accumulation of calcium load in peripheral lower extremity arteries has been associated with increased severity of peripheral artery disease (PAD) and mortality. While calcium scores are commonly calculated from non-contrast computed tomography (CT) scans, patients with PAD often undergo contrast-enhanced CT scans. This study aims to explore the association between a length-adjusted calcium score (LACS) of the iliofemoral arteries, determined through pre-intervention contrast-enhanced CT, and major adverse events in patients with chronic limb-threatening ischemia (CLTI).

METHODS

A cohort of CLTI patients subjected to endovascular revascularization between 2005 and 2017 at a tertiary referral center were categorized into 2 groups. The complication group experienced one of the composite outcomes (reintervention, above-the-ankle amputation, and/or all-cause mortality within 1 year of the primary endovascular procedure), while control patients did not encounter this composite endpoint. Patients from the complication group were matched one-to-one with controls based on sex and Fontaine classification. LACS was calculated (Ca volume[mm3]/length[cm]) at 3 arterial segments; 1. the common iliac artery (CIA), 2. the external iliac artery and common femoral artery (EIA + CFA), and 3. the superficial femoral artery plus the popliteal artery (SFA + PA). Binary logistic regression analysis was conducted to investigate the association between LACS in the different arterial segments and the occurrence of the composite binary outcome (complication and control) and LACS of the different segments, adjusting influences of age, sex, BMI >25, Fontaine classification, diabetes mellitus type 1 & 2, chronic kidney disease stage, and hemodialysis treatment.

RESULTS

Sixty-four CLTI patients were included in this study (complication group [n = 32], and control group [n = 32]). A significant difference (higher LACS was found for the complication group in the CIA, the SFA + PA, as well as the total trajectory. CLTI patients with high LACS in the SFA + PA or the total trajectory were more likely to suffer adverse events (SFA + PA: OR: 1.010, 95% CI: 1.000-1.020, P = 0.04; Total LACS: OR: 1.008, 95% CI: 1.000-1.017, P = 0.05).

CONCLUSIONS

Patients with a high calcium load in the ilio-femoral arteries are at increased risk of major adverse events during 1 year after endovascular revascularization. The calcium score, derived from contrast-enhanced CT scans, holds potential utility in decision making for CLTI patients.

Coronary drug-coated balloons: A comprehensive review of clinical applications and controversies

Drug-coated balloons have emerged as a promising therapeutic option in the treatment of cardiovascular disease. This review article provides an overview of the concept of drug-coated balloons and their clinical applications in both de novo and treated coronary artery disease. A summary of key clinical trials and registry studies evaluating drug-coated balloons is presented for reference. Overall, this article aims to provide clinicians and researchers with a comprehensive understanding of the current state of drug-coated balloon technology and its implications in clinical practice.

Impact of Below-the-Knee Runoff in Patients With Lower Extremity Artery Disease Who Underwent Endovascular Therapy Using Drug-Coated Balloons in Femoropopliteal Lesions

BACKGROUND

The impact of below-the-knee (BK) runoff after drug-coated balloon (DCB) treatment in femoropopliteal (FP) lesions has not been well investigated.

METHODS

This retrospective multicenter observational study enrolled 291 consecutive patients with lower extremity artery disease who underwent endovascular therapy with DCBs for FP lesions between January 2018 and December 2021. Patients were classified into four groups based on the BK runoff. Outcome measures included primary patency, freedom from clinically driven target lesion revascularization (CD-TLR) and amputation, and overall survival rates at 24 months. The predictors of restenosis at 24 months were also investigated.

RESULTS

In total, 43, 98, 117, and 33 patients were classified into three, two, one, and no BK runoff groups, respectively. In three, two, one, and no BK runoff groups, the primary patency rates were 72.1%, 67.3%, 61.4%, and 44.1% (p = 0.028); freedom from CD-TLR rates were 87.1%, 78.8%, 71.7%, and 47.1% (p < 0.001); freedom from amputation rates were 95.2%, 97.9%, 92.8%, and 91.5% (p = 0.499); and overall survival rates were 89.4%, 83.2%, 76.6%, and 61.2% (p = 0.007), respectively, at 24 months. Multivariate analysis showed that chronic limb-threatening ischemia, no BK runoff, Lutonix use, and residual stenosis > 30% were independent predictors of primary patency loss at 24 months. The risk score, calculated as the number of predictors, reflected the risk of restenosis.

CONCLUSION

No BK runoff was associated with worse midterm primary patency, freedom from CD-TLR, and overall survival rates than at least one BK runoff.

Lower Extremity Arterial Calcification Predicts Referral to a Closed Unit After Primary Total Hip Arthroplasty

BACKGROUND

We aimed to determine the association between lower extremity arterial calcification (LEAC) and referral to a closed unit (CU), length of stay, 90-day readmissions, and 1-year mortality in primary total hip arthroplasty (THA) patients.

METHODS

We retrospectively analyzed 705 patients who underwent primary THA, identifying 64 patients (9.13%) who had LEAC and 641 who did not have LEAC. Patients who had LEAC were older (77 ± 10.0 versus 67 ± 11.5 years; P < 0.001) and had more comorbidities, except for a history of thromboembolic and oncologic diseases (P > 0.05). A preoperative antero-posterior pelvic radiograph was used to assess the presence of LEAC. Admission to CU, length of stay, 90-day readmissions, and 1-year mortality were recorded. A logistic regression model was used to identify risk factors for referral to CU.

RESULTS

Patients who had LEAC had a higher incidence of admission to the intensive care unit (8 of 64 [12.5%] versus 8 of 641 [1.09%]; P < 0.001), a longer hospital stay (4.7 ± 1.8 versus 4.2 ± 1.3 days; P = 0.006), more readmissions (16 of 64 [25%] versus 33 of 641 [5.15%]; P < 0.001), and a higher 1-year mortality rate (6 of 64 [9.3%] versus 0 of 641 [0%]; P < 0.001) than patients who did not have LEAC. Of the patients who had LEAC admitted to CU, only 3 of 8 had a previous indication to do so in the preoperative assessment performed by the Department of Anesthesiology, while all non-LEAC ones referred to CU did so. Logistic regression analysis showed that LEAC was a risk factor for admission to CU (odds ratio = 4.77; 95% confidence interval: 1.12 to 20.25; P = 0.034).

CONCLUSIONS

The presence of LEAC was a risk factor for transfer to CU, longer in-hospital stays, more readmissions, and a higher 1-year mortality rate. Identifying patients who have LEAC can aid in the preoperative assessment and risk stratification of patients planned for primary THA.

Moscatilin inhibits vascular calcification by activating IL13RA2-dependent inhibition of STAT3 and attenuating the WNT3/β-catenin signalling pathway

INTRODUCTION

Vascular calcification, a devastating vascular complication accompanying atherosclerotic cardiovascular disease and chronic kidney disease, increases the incidence of adverse cardiovascular events and compromises the efficacy of vascular interventions. However, effective therapeutic drugs and treatments to delay or prevent vascular calcification are lacking.

OBJECTIVES

This study was designed to test the therapeutic effects and mechanism of Moscatilin (also known as dendrophenol) from Dendrobium huoshanense (an eminent traditional Chinese medicine) in suppressing vascular calcification in vitro, ex vivo and in vivo.

METHODS

Male C57BL/6J mice (25-week-old) were subjected to nicotine and vitamin D3 (VD3) treatment to induce vascular calcification. In vitro, we established the cellular model of osteogenesis of human aortic smooth muscle cells (HASMCs) under phosphate conditions.

RESULTS

By utilizing an in-house drug screening strategy, we identified Moscatilin as a new naturally-occurring chemical entity to reduce HASMC calcium accumulation. The protective effects of Moscatilin against vascular calcification were verified in cultured HASMCs. Unbiased transcriptional profiling analysis and cellular thermal shift assay suggested that Moscatilin suppresses vascular calcification via binding to interleukin 13 receptor subunit A2 (IL13RA2) and augmenting its expression. Furthermore, IL13RA2 was reduced during HASMC osteogenesis, thus promoting the secretion of inflammatory factors via STAT3. We further validated the participation of Moscatilin-inhibited vascular calcification by the classical WNT/β-catenin pathway, among which WNT3 played a key role in this process. Moscatilin mitigated the crosstalk between WNT3/β-catenin and IL13RA2/STAT3 to reduce osteogenic differentiation of HASMCs.

CONCLUSION

This study supports the potential of Moscatilin as a new naturally-occurring candidate drug for treating vascular calcification via regulating the IL13RA2/STAT3 and WNT3/β-catenin signalling pathways.

Two-Year Outcomes of Excimer Laser Ablation Combined with Drug-Coated Balloon for Treating De Novo Lesions and In-Stent Restenosis in Femoropopliteal Artery of Chronic Limb-Threatening Ischemia Patients

BACKGROUND

To evaluate the safety and efficacy of excimer laser ablation (ELA) combined with drug-coated balloon (DCB) in the treatment of chronic limb-threatening ischemia (CLTI) patients with de novo and in-stent restenosis (ISR) lesions in the femoropopliteal artery (FPA).

METHODS

A retrospective, single-center analysis was performed on data collected between January 2017 and December 2021. The study included CLTI patients who underwent treatment with ELA combined with DCB for de novo and ISR lesions in the FPA. The primary endpoint was the 24-month primary patency rate. Secondary endpoints included technical success rate and the incidence of major adverse events (MAEs), defined as death, major limb amputation, or target vessel revascularization.

RESULTS

A total of 44 patients were included in the study, comprising 24 cases in the de novo lesion group and 20 cases in the ISR group. The mean patient age was 73.4 ± 7.7 years, with approximately one-third presenting with concomitant chronic coronary artery disease (CAD) or cerebrovascular disease (CVD). Around one-third of the patients exhibited foot ulcers or gangrene, with a mean lesion length of 239.09 ± 120.09 mm. In the de novo lesion group, 79.2% of lesions were classified as chronic total occlusions (CTOs), whereas 75% of lesions in the ISR group were categorized as Tosaka III. For such complex lesions, the technical success rate was 100% in both groups. The primary patency rates for the de novo group were 86.9% at 12 months and 64.3% at 24 months, compared to 77.0% and 56.5% in the ISR group. Freedom from target lesion revascularization (TLR) rates in the de novo group were 95.8% and 85.4% at 12 and 24 months, respectively, while the ISR group achieved rates of 88.9% and 76.6%. Despite lower primary patency and freedom from TLR rates in the ISR group, the differences were not statistically significant (P = 0.74).MAE were observed in 12.5% of patients in the de novo group and 35% in the ISR group, with no statistically significant difference (P = 0.27).

CONCLUSION

For CLTI patients with complex lesions, including extensive occlusions and severe calcification, the combination of ELA and DCB demonstrates high technical success and favorable safety profiles for both de novo and ISR lesions. Mid-term outcomes indicate a potential trend toward better efficacy in treating de novo lesions compared to ISR lesions.

Adjunctive intravascular lithotripsy for heavily calcified carotid stenosis: a dual-center experience and technical case series

BACKGROUND

Heavily calcified carotid stenosis (HCCS) is considered an exclusion for carotid angioplasty and/or stenting (CAS), amenable only to carotid endarterectomy. This study presents preliminary retrospective dual-center experience utilizing the Shockwave S4 intravascular lithotripsy (IVL) system (Shockwave Medical) as an adjunct to CAS for HCCS.

METHODS

Patients with symptomatic or asymptomatic HCCS (de novo stenosis or in-stent restenosis (ISR)) undergoing IVL+CAS were included. Charts were reviewed for demographic, imaging, procedural, and outcome data. The primary endpoint was composite major adverse event (MAE) rate: death, ipsilateral stroke, or myocardial infarction (MI) within 30 days of IVL+CAS. Secondary endpoints included technical and procedural success, residual stenosis, and ISR postprocedure.

RESULTS

Fifteen patients underwent 17 IVL+CAS procedures: de novo HCCS=13, heavily calcified ISR=4; symptomatic disease was addressed in seven cases. Procedures were performed transfemorally under conscious sedation with dual protection; flow reversal through a balloon guide catheter, and distal embolic protection system (EPS) use. Median pre-IVL+CAS stenosis was 73% (IQR 60-80%). Technical success (IVL+CAS+ EPS use) was achieved in all cases. Median post-IVL+CAS residual stenosis was 27% (IQR 12-33%), achieving <50% residual stenosis and procedural success in all. Five patients required dopamine infusion for postprocedural hypotension. No periprocedural ipsilateral strokes occurred. MAE rate was 6.7% (95% CI 0.2% to 32%), including one MI resulting in death. Additionally, one ISR (6.3%; 95% CI 0.2% to 30.2%) identified 160 days after IVL+CAS was retreated with angioplasty.

CONCLUSIONS

IVL+CAS was safe and effective for treating symptomatic and asymptomatic HCCS, achieving high rates of freedom from MAE. IVL has potential to expand the role of CAS in difficult to treat HCCS.

Intravascular Ultrasound-Guided vs Angiography-Guided Drug-Coated Balloon Angioplasty in Patients With Complex Femoropopliteal Artery Disease

BACKGROUND

Intravascular ultrasound (IVUS) guidance has been shown to yield favorable outcomes for endovascular treatment of femoropopliteal artery (FPA) disease with drug-coated balloon (DCB) angioplasty. However, the specific benefits of IVUS for treatment of complex FPA lesions remain uncertain.

OBJECTIVES

In this study, the authors compared the clinical impact of IVUS-guided vs angiography-guided DCB angioplasty in patients with complex or noncomplex FPA lesions.

METHODS

This study was a prespecified, primary subgroup analysis of the randomized IVUS-DCB trial. Patients with FPA undergoing DCB angioplasty were randomized to receive the procedure under IVUS or angiography guidance. The primary endpoint was 12-month primary patency; secondary endpoints included clinically driven target lesion revascularization (CD-TLR), sustained clinical improvement, and hemodynamic improvement.

RESULTS

Among the 237 patients enrolled, 158 had complex FPA (Trans-Atlantic Inter-Society Consensus II [TASC II] type C/D), and 79 had noncomplex FPA (TASC II type A/B). In complex FPA, IVUS guidance was associated with significantly higher rates of primary patency (82.1% vs 60.3%; HR for loss of primary patency: 0.34; 95% CI: 0.16-0.70; P = 0.002), freedom from CD-TLR (90.0% vs 76.9%; HR: 0.31; 95% CI: 0.13-0.75; P = 0.01), and sustained clinical and hemodynamic improvement relative to angiography guidance. There was no significant difference in primary patency (87.5% vs 88.2%; HR: 1.84; 95% CI: 0.39-8.60; P = 0.44) or occurrence secondary endpoints between the IVUS-guidance and angiography-guidance groups for patients with noncomplex FPA.

CONCLUSIONS

In endovascular treatment of FPA using DCB, IVUS guidance was significantly associated with improved 12-month clinical outcomes, particularly in patients with complex FPA lesions.(Intravascular Ultrasound-Guided Drug-Coated Balloon Angioplasty for Femoropopliteal Artery Disease [IVUS-DCB] trial; NCT03517904).

Association of Postprocedure Ankle-Brachial Index With Outcomes Following Drug-Coated Balloon Angioplasty in Femoropopliteal Artery Disease

Endovascular treatment of femoropopliteal artery (FPA) disease with drug-coated balloons (DCBs) may face complications such as arterial recoil, dissection, and residual stenosis. Angiography has limited accuracy for evaluating blood flow through revascularized target lesions. Thus, there is a need for postprocedure hemodynamic assessment in treated limbs. This study aims to explore how postprocedure ankle-brachial index (ABI) influences outcomes following DCB treatment for FPA disease. This study included patients in a multicenter registry (K-VIS ELLA) treated with DCB for FPA disease between January 2006 and August 2021. Optimal postprocedure ABI cutoff for predicting clinically driven target lesion revascularization (TLR) was determined using receiver operating characteristic curve analysis. Independent predictors of TLR were identified using multivariable Cox regression analysis. A total of 654 limbs (514 patients) treated with DCB for FPA were evaluated by ABI at 1-day (median, interquartile range, 1 to 2 days) postprocedure and followed up for a median of 370 days. The optimal immediate postprocedure ABI cutoff value for predicting TLR was 0.72 (area under the curve, 0.68). Significantly improved TLR-free and major adverse limb event-free survival rates were observed with a postprocedure ABI ≥ 0.72 (hazard ratio [HR] = 0.24, 95% confidence intervals [CI] = 0.16 to 0.37, p < 0.001; HR = 0.25, 95% CI = 0.16 to 0.38, p < 0.001, respectively). Independent predictors of TLR were postprocedure ABI < 0.72 (HR 3.76; 95% CI, 2.33 to 6.07; p < 0.001) and presence of anemia (HR 2.01; 95% CI, 1.03 to 3.92; p = 0.041). An immediate postprocedure ABI is a significant predictor of TLR risk following DCB treatment for FPA disease, underscoring the value of hemodynamic assessment in optimizing angioplasty outcomes.

Clinical validity of the Japanese below-the-knee chronic total occlusion scoring system for the prediction of successful guidewire crossing

OBJECTIVE

To validate the Japanese below-the-knee (J-BTK) chronic total occlusion (CTO) score for the prediction of successful guidewire crossing (S-GC) in angiographic evaluation.

METHODS

A prospective, multicenter, nonrandomized study examined 751 consecutive BTK CTOs in 497 patients treated with endovascular therapy in 16 Japanese medical centers from April 2021 to March 2022. The cohort was classified into 2 groups: an S-GC group and a failed guidewire crossing group.

RESULTS

The J-BTK CTO score, which assigned one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel," was used to categorize BTK CTOs into 4 grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.5%, 89.1%, 62.5%, and 27.3%, respectively. The area under the receiver-operating characteristic curve for S-GC was 0.8304. Although the previous J-BTK CTO study enrolled only de novo lesions, both de novo and restenotic lesions were evaluated in this study. De novo lesions have a lower chance of S-GC (odds ratio: 0.24, 95% confidence interval: 0.09-0.67) in the multivariate analysis, and the area under the receiver-operating characteristic curve of the modified J-BTK CTO score, which additionally assigned two points to "De novo lesion," was 0.846. The modified J-BTK CTO score showed an appropriate calibration (Hosmer-Lemeshow P = .957).

CONCLUSIONS

The J-BTK CTO score and the modified J-BTK CTO score predict the probability of an S-GC of BTK CTOs and stratify the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.

Dichotomous grouping of peripheral arterial calcification grades: A practical predictor of outcome after endovascular therapy in peripheral arterial disease

BACKGROUND

There is a general agreement that arterial calcification affects the results of endovascular therapy for peripheral arterial disease (PAD). In addition to lacking evidence for their impact, existing calcification scores are complex, and not practical in everyday decision making. The global limb anatomic staging system (GLASS) adopted dichotomous grouping of calcification grades.

OBJECTIVE

In this study we aim to investigate the impact of peripheral arterial calcification scoring after dichotomous grouping on midterm outcomes following endovascular therapy for PAD.

METHODS

This prospective study included all consecutive patients with PAD indicated for endovascular therapy procedure who presented to our tertiary referral center in the period between October 2020 and October 2021. Patients were grouped into Group A (n = 40): with no-to mild calcification (PACSS grade 0,1 and 2), and Group B (n = 53): with severe calcification (PACSS grades 3 and 4). Primary endpoints included technical success rate, primary patency rates, and major adverse limb events rate (MALE) during 2 years of follow-up.

RESULTS

The mean age of the studied cases (n = 93) was 59.31 ± 6.46 years (range 50-75). 70 patients (75.3%) were males, and 23 (24.7%) were females. There was no statistically significant difference between the two groups regarding technical success rate (97.5% in group A versus 94.33% in Group B, p = .457). The Primary patency rate after 1 year was lower in group B (74%) compared to group A (89.7%), but this difference was not statistically significant (p = .059). However, the 2-year primary patency rate was significantly lower in group B compared to group A (64% versus 84.6% respectively, p = .034). MALE rate after 2 years was significantly higher in group B (28%) as compared to group A (10.4%), P = .048. Studying suspected risk factors revealed that severe calcification was more common in patients with ischemic heart disease (34%) and chronic kidney disease (11%), P= .003 and .002 respectively. Logistic regression analysis showed that patients suffered from IHD and those with length of lesion ≥ 5 cm are about five times more likely to have severe calcification compared to their counterparts (OR = 4.875, 95%CI = 1.293-18.383, p = .019, and OR = 4.513, 95% CI = 11.138-17.893, p = .032), respectively.

CONCLUSION

The presence of severe calcification is associated with significantly lower midterm primary patency rates and higher rate of major adverse limb events after endovascular intervention for lower limb denovo arterial lesions.

Intravascular Lithotripsy and Drug-Coated Balloon Angioplasty for Severely Calcified Common Femoral Artery Atherosclerotic Disease

OBJECTIVES

Intravascular lithotripsy (IVL) followed by drug-coated balloon (DCB) angioplasty might be a valuable alternative to surgery for calcified common femoral artery (CFA) atherosclerotic disease. Nonetheless, the 12 months performance of this treatment strategy remains unknown. This study reports on the 12 months outcomes of IVL with adjunctive DCB angioplasty for calcified CFA lesions.

METHODS

This is a retrospective single-center, single-arm study. Consecutive patients treated by IVL and DCB for calcified CFA disease between February 2017 and September 2020 were evaluated. The primary measure outcome of this analysis was primary patency. Procedural technical success (<30% stenosis), freedom from target lesion revascularization (TLR), secondary patency, and overall mortality were additionally analyzed.

RESULTS

Thirty-three (n=33) patients were included in this study. The majority presented with lifestyle limiting claudication (n=20, 61%), 52% (n=17) of the patients had chronic kidney disease (CKD) and 33% (n=11) had diabetes. The procedural technical success was 97% (n=32). A flow-limiting dissection post IVL was observed in 2 patients (6%) and a peripheral embolization in a single patient (3%), while the bail-out stenting rate amounted to 12% (n=4). No perforation was observed. The median length of hospital stay was 2 days (interquartile range 2-3). At 12 months, the primary patency was 72%. The freedom from TLR and the secondary patency rates were 94% and 88%, respectively. The 12-month survival amounted to 100% and 75% (n=25) of the patients were asymptomatic or presented with mild claudication. The presence of chronic limb-threatening ischemia (CLTI) (hazard ratio [HR], 0.92; confidence interval (CI); 0.18-4.8, p=0.7) or CKD (HR, 1.30; 95% CI, 0.29-5.8; p=0.72), as well as the use of a 7 mm IVL catheter (HR, 0.59; 95% CI, 0.13-2.63; p=0.49) or of high-dose DCB (HR, 0.68; 95% CI, 0.13-3.53; p=0.65) did not influence the primary patency.

CONCLUSIONS

In this study, the combination of IVL and DCB angioplasty for calcified CFA disease was associated with low risk for periprocedural complications, acceptable 12 months clinical outcomes, and low rates of reinterventions.

CLINICAL IMPACT

Intravascular lithotripsy in combination with DCB angioplasty can be an alternative to surgery in highly selected patients with CFA atherosclerotic disease. In this Cohort the combination therapy lead to acceptable clinical results and low reintervention rates at 12 months.

Clinical Outcomes Following Low-Dose Second-Generation "Ranger" Drug-Coated Balloon Angioplasty for Femoropopliteal Artery Disease

PURPOSE

To reveal the rate of 1-year freedom from restenosis and to determine the factors associated with the restenosis risk in femoropopliteal (FP) lesions treated with a Ranger drug-coated balloon (DCB) in real-world clinical settings.

METHODS

This multicenter, prospective observational study enrolled 1131 patients and 1453 de novo or restenotic FP lesions (mean age=75±9 years; female=35.3%, mean lesion length=19.2±16.0 cm; chronic total occlusion [CTO]=33.7%; severe calcification=33.7%) that underwent successful Ranger DCB angioplatsy between March 2021 and December 2022.

RESULTS

The primary endpoint was 1-year freedom from restenosis and its associated factors. Bail-out stenting was performed in 5.3%. During the follow-up, restenosis was detected in 249 cases. Freedom from restenosis by the Kaplan-Meier analysis was estimated to be 85.2% and 81.0% at 12 and 14 months, whereas freedom from target lesion revascularization (TLR) was 91.7% and 90.0% at 12 and 14 months. The patterns of restenosis were focal (39.2%), tandem (12.3%), diffuse (17.2%), and occlusive (31.3%). Independent risk factors of restenosis were female sex, diabetes mellitus, no runoff, history of revascularization, lesion length ≥25 cm, and CTO.

CONCLUSIONS

Our study demonstrated that 1-year freedom from restenosis after Ranger DCB for FP lesions in a real-world clinical setting was acceptable. Independent predictors of restenosis were female gender, diabetes mellitus, no runoff, history of revascularization, lesion length ≥25 cm, and CTO.

CLINICAL IMPACT

Our study demonstrated the true performance of Ranger DCB in real-world practice, with a very low rate of bail-out stenting and no use of atherectomy devices. In addition, it also elucidated morphologies associated with restenosis and the risk factors for restenosis after DCB. Freedom from re-stenosis and TLR at 1-year after Range DCB angioplasty was 84.5% and 91.5%. Two thirds of restenosis had a non-occlusive pattern, and independent predictors of restenosis were female gender, diabetes mellitus, no runoff, history of revascularization, lesion length ≥25 cm, and CTO.

Inter- and Intra-observer Agreement of the Peripheral Arterial Calcium Scoring System in Patients Undergoing (Infra)Popliteal Endovascular Interventions

PURPOSE

Peripheral arterial calcification is an important predictor of outcomes after both conservative and endovascular treatment. Digital subtraction angiography (DSA)-based calcification scores are limited by low sensitivity and inter-observer agreement. The Peripheral Arterial Calcium Scoring System (PACSS) assesses the severity of target lesion calcification. The newly introduced modified PACSS (mPACSS) also evaluates target vessel calcification. This study aimed to assess the inter- and intra-observer reliability of PACSS and mPACSS on computed tomography angiography (CTA) in (infra)popliteal endovascular interventions.

METHODS

A random sample of 50 limbs from the prospective multicenter Dutch Chronic Lower Limb-Threatening Ischemia Registry (THRILLER) were included. Three experienced independent raters scored PACSS on CTA. Three months later, one blinded rater assessed the same 50 CTA scans, keeping track of assessment time. The reliability of the original 5-step PACSS, a simplified binary PACSS (0-2 vs 3-4) and the 7-step mPACSS were tested using Cohen's and Fleiss' kappa statistics.

RESULTS

In total, 50 limbs (mean age 70.1 ± 11.0, 29 men) with 41 popliteal and 40 infrapopliteal lesions were scored. Inter-observer agreement of PACSS and binary PACSS were moderate (κ = 0.60) and substantial (κ = 0.72), respectively, while intra-observer agreement was almost perfect in both scores (κ = 0.86). Inter- and intra-observer agreement of mPACSS were moderate (κ = 0.48) and substantial (κ = 0.77), respectively. Mean assessment time for an experienced rater was 3.43 ± 0.93 min per CTA scan.

CONCLUSION

Both the semi-quantitative PACSS and mPACSS scores for (infra)popliteal arteries can be performed reliably on pre-operative CTA.

Technical aspects of the new BYCROSSTM atherectomy device - preliminary results after 28 patients

Purpose: Technical aspects are crucial for the planning and performing of the atherectomy to treat peripheral arterial disease. This report illustrates the use of a novel atherectomy device and investigates the feasibility, efficacy, and safety procedures involved in performing the atherectomy on 28 patients.

MATERIALS AND METHODS

We performed a prospective analysis of patients who underwent an atherectomy with the BYCROSSTM Atherectomy device between August 2022 and September 2023 at a tertiary referral centre. Patients with a lesion below the aortic bifurcation (vessel diameter ≥ 3mm) having a de novo or restenotic (stent-included) present were recruited. Major adverse events (MAE) are defined as amputation, death, myocardial infarction, or angiographic distal embolization that require a separate intervention.

RESULTS

Of the 28 patients treated with the BYCROSS device, 23 were men with a mean age of 65.6 ± 9,6 years and a mean BMI of 24,6 ± 3.9 kg/m2. Most patients had a typical atherogenic risk profile as well as multiple preexisting comorbidities. In all patients, a symptomatic peripheral arterial disease (PAD) was the main reason for an intervention. The most common Rutherford category was 5 (12/28). The most common lesion region was the femoropopliteal segment (25/28) with 23 de novo stenosis. Mean lesion length was 218,0 ± 93,7 mm. The mean PACCS Score was 3,0 ± 1,0. Stenosis grade was by mean 99,3 ± 3,7%. Ankle Brachial Index (ABI) increased significantly after BYCROSS atherectomy (pre- 0,44 ± 0,43 vs. post-procedure 0,84 ± 0,30 P<0,001. Target lesion/vessel revascularization (TLR/TVR) within the first 30 days was 3,6% (1/28). 30-day MAE rate was 14,3% (vessel perforation in 3/28 patients, embolism in 1/28). There were no deaths, index limb amputations, or myocardial infarctions.

CONCLUSION

The BYCROSSTM atherectomy system is a new device with numerous advantages in treating high-grade, calcifying stenosis and occlusion processes in PAD. Based on the above findings, the BYCROSSTM Atherectomy device represents a feasible, safe, and effective method for endovascular treatment of peripheral arterial disease.

Mean Pressure Gradient and Fractional Flow Reserve at A Superficial Femoral Artery Dissection after Drug-Coated Balloon Angioplasty

OBJECTIVES

Residual dissection is a concern in endovascular treatment with a DCB, and there is limited knowledge of hemodynamics at a dissection lesion. Therefore, the objective of this study is to evaluate the mean pressure gradient (MPG) and fractional flow reserve (FFR) at a residual dissection after DCB angioplasty for the superficial femoral artery (SFA).

METHODS

A total of 59 cases with residual SFA dissection treated with DCB angioplasty at a single center were analyzed retrospectively. The dissection was classified into 6 types (A-F). The primary endpoints were MPG and FFR at a residual dissection lesion after DCB angioplasty, using evaluation with a pressure wire.

RESULTS

The median lesion length was 70 (40-130) mm with 24% popliteal involvement, and 11 cases (18%) had chronic total occlusion. A completion angiogram revealed dissection of types A (n = 33, 56%), B (n = 18, 31%), C (n = 7, 12%), and D (n = 1, 2%). The median MPGs in type A, B, and C cases were 0 (0-2), 0 (0-4), and 3 (0-6) mmHg, with a significant lower in type C cases than in type A cases (A vs C, P = .021). The median FFRs in type A, B, and C cases of 1.0 (.98-1.00), 1.0 (.96-1.00), and .98 (.95-1.00) did not differ significantly among dissection types (A vs B, P = .86; A vs C, P = .055; B vs C, P = .15).

CONCLUSIONS

This is the first report of hemodynamics at a SFA dissection. The results suggest that low-grade dissection (types A or B) does not affect MPG and FFR at a SFA lesion. This indicates that a bailout stent may be unnecessary for patients with dissection of types A or B. A further investigation is needed to determine whether a scaffold is required for a SFA lesion with type C dissection.

Predictors of recurrent restenosis after repeat drug-coated balloon therapy for drug-coated balloon restenosis in femoropopliteal lesions: Results of the RECURRENCE study

BACKGROUND

Despite the widespread use of drug-coated balloons (DCBs) for femoropopliteal (FP) lesions, there is still no consensus on treatment strategies for DCB restenosis. This study aimed to determine the risk factors for recurrent restenosis after repeat DCB therapy for DCB restenosis in FP lesions.

METHODS

This multicenter retrospective study assessed 1176 consecutive limbs in 860 patients who successfully received initial DCB therapy for FP lesions at four cardiovascular centers between May 2018 and December 2022. Among these patients, 118 consecutive limbs of 104 patients treated via repeat DCB for primary DCB restenosis were enrolled.

RESULTS

The Kaplan-Meier estimate of freedom from recurrent restenosis was 74.6% at 1 year. Cox proportional hazard multivariate analysis revealed that recurrent restenosis was independently associated with the time from initial DCB to primary restenosis (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.79-0.92; p < 0.001), history of ≥2 endovascular therapies (EVTs) (HR, 3.11; 95%CI, 1.36-7.12; p = 0.007), and PACSS grade 3 or 4 (HR, 2.76; 95%CI, 1.15-6.63; p = 0.023). Furthermore, receiver operating characteristic curve analysis showed that the cutoff value of the time from initial DCB to primary restenosis to prevent recurrent restenosis was 12.6 months, with an area under the curve of 0.841 (p < 0.001).

CONCLUSION

Repeat DCB therapy for DCB restenosis might be an acceptable strategy, particularly for restenosis that occurred more than 12.6 months after initial DCB, given the rate of freedom from recurrent restenosis.

The effect of uric acid and albumin ratio in undergoing lower extremity endovascular interventions for peripheral arterial disease related contrast induced nephropathy

BACKGROUND

Among patients undergoing percutaneous vascular intervention, contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality. Serum uric acid/albumin ratio (UAR) has emerged as a new marker associated with poor cardiovascular outcomes. We aimed to evaluate the relationship between UAR and CIN occurrence in patients treated for peripheral artery disease.

METHODS

Patients underwent percutaneous intervention due to peripheral artery disease were enrolled. The primary endpoint was development of contrast related nephropathy. Patients were divided into 2 groups according to the CIN occurrence.

RESULTS

A total of 663 patients were enrolled and mean age was 62 ± 10 years. After the intervention, 45 patients had CIN and 618 patients did not have CIN. Logistic regression analysis was performed to define the parameters of CIN. Male gender, diabetes, UAR, contrast volume, presence of coronary artery disease, and C-reactive protein levels were found significant in univariate analysis. However, only UAR was found significant in multivariate analysis (odds ratio 95% confidence interval: 3.426 (1.059-11.079), (P = 0.040)).Therefore, it is the only independent predictor for occurrence of CIN.

CONCLUSIONS

UAR is a reliable scoring system, which predicts CIN in such patient group. This score is not only cost-effective also simple, which can be easily applied into the clinical practice.

Clinical outcomes and risk factors associated with drug-coated balloon treatment for femoropopliteal artery disease in patients on maintenance hemodialysis

The effect of drug-coated balloons (DCB) on hemodialysis (HD) in patients with femoropopliteal (FP) disease remains uncertain. This study aimed to investigate the outcomes of DCB therapy in patients with FP artery disease on HD. A total of 185 patients with FP lesions (140 HD patients) who underwent DCB treatment were included in the study. The incidence of restenosis and target lesion revascularization (TLR) at 12 months were measured. Risk factors for TLR were also investigated. The mean age was 71.7 years, and diabetes was observed in 82.3% of patients. The mean duration of receiving dialysis was 8.8 years. The mean lesion length was 11.0 cm, and approximately half of the lesions were severely calcified. Severe dissection after DCB therapy was observed in 19.5% of patients. During the follow-up period, 74 restenosis, 68 TLRs, 8 major amputations, and 28 deaths were observed. The freedom rates from restenosis and TLR at 12 months were 63.8% and 71.3%, respectively. The freedom rates after low- and high-dose DCB at 12 months were 61.9% and 70.6% for restenosis (P = 0.49) and 66.4% and 79.4% for TLR (P = 0.095), respectively. Independent risk factors for TLR at 12 months of age were diabetes, chronic limb-threatening ischemia, and severe calcification. When patients were divided into four groups according to the number of these three risk factors, the rates of freedom from TLR at 12 months were 100%, 94.8%, 76.7%, and 30.3% in the groups with no risk factors, any one risk factor, any two risk factors, and all risk factors, respectively (P < 0.0001). Clinical outcomes after endovascular therapy in HD patients with FP disease remain unsatisfactory, even if they are treated with DCB. In particular, patients on HD with diabetes, chronic limb-threatening ischemia, and severe calcification have poor outcomes.

Efficacy and safety of the needle rendezvous technique for infrainguinal arterial calcified lesions

BACKGROUND

Lower extremity artery disease is increasingly prevalent, and complex lesions such as calcified chronic total occlusions pose significant challenges during endovascular therapy. The needle rendezvous technique, which involves puncturing a needle toward the guidewire within the lesion or lumen and advancing the guidewire into the needle lumen to achieve guidewire externalization, offers a potential solution. If device passage remains challenging, the Rendezvous-PIERCE technique can be subsequently employed by advancing the needle over the externalized guidewire to modify the lesion directly. This study aimed to evaluate the procedural outcomes of needle rendezvous in infrainguinal arterial occlusive lesions.

METHODS

This single-center, retrospective, single-arm study included patients treated with needle rendezvous between August 2020 and March 2024. The primary outcome was technical success rate, defined as the device passage following guidewire externalization using needle rendezvous. Secondary outcomes included the rates of procedural success, complications, and 30-day clinical-driven target lesion revascularization (CDTLR).

RESULTS

Twenty-five patients (25 limbs) with 52% on hemodialysis and 80% having chronic limb-threatening ischemia in 52% and 80% were enrolled. All cases involved bilateral calcified occlusions, and 72% targeted the infrapopliteal artery segment. The average needle rendezvous time was 3.7 ± 2.0 min. Rendezvous-PIERCE was performed in 28% of cases. All cases achieved 100% technical and procedural success, with no procedure-related complications. The 30-day CDTLR rate was 8%, limited to below-the-knee lesions.

CONCLUSIONS

Needle rendezvous is a safe and effective technique for treating complex infrainguinal arterial occlusions, providing a viable alternative when conventional methods fail.

Atherectomy Followed by Drug-Coated Balloon Angioplasty Versus Surgery for Symptomatic Deep Femoral Artery Arteriosclerotic Disease

PURPOSE

Limited data are available regarding endovascular therapy of arteriosclerotic lesions of the deep femoral artery (DFA). In this study, we compare the outcomes of atherectomy combined with drug-coated balloon (DCB) angioplasty and open repair of DFA lesions.

METHODS

This is a multicenter retrospective registry of patients with peripheral artery occlusive disease Rutherford categories 2 to 5 treated by surgical profundaplasty (SP) or atherectomy followed by DCB for DFA lesions (symptomatic DFA). The primary endpoint was clinically driven target lesion revascularization (CD-TLR). Overall mortality, target limb reinterventions, major amputation, and major adverse limb events (MALEs) were additionally analyzed.

RESULTS

A total of 373 patients treated for an arteriosclerotic lesion of the DFA between February 2015 and August 2021 were included, 301 treated by SP and 72 with atherectomy and DCB. The rates of chronic limb threatening ischemia (CLTI) were 42.2% and 22.2% (p<0.002) for the surgical and endovascular groups, respectively. A previous DFA intervention was more frequent in the endovascular group (30.6% vs 15.3%; p<0.003). Patients who had an open repair were more likely to have an occlusion of the profunda (34.9% vs 19.7%, p=0.014), severe calcified lesions (26.5% vs 5.6%, p=0.001), and lesions longer than 20 mm (95.7% vs 88.7%, p=0.024). After propensity score matching, no significant differences were found with regard to technical and hemodynamic success. At 24 months, no difference was found in terms of freedom from CD-TLR (95.7% vs 96.8%), freedom from all-cause mortality (94.2% vs 98.5%), freedom from MALE (90.4% vs 93.9%), and amputation-free survival (93.8% vs 97%). Following endovascular therapy, length of stay was significantly lower (p<0.001) and any reintervention on the index limb was more frequent (p=0.039).

CONCLUSION

Patients with CLTI, occlusion of profunda, severe calcified lesions, and longer lesions are more frequently treated by open surgery, while reinterventions are more commonly treated by atherectomy and DCB. In patients with comparable clinical and lesion characteristics after matching, endovascular and surgical reconstruction of DFA lesions showed similar mid-term clinical outcomes. However, the risk of reintervention at the index limb is higher after endovascular treatment. Randomized studies are now warranted to compare both techniques in terms of medical and financial aspects.

CLINICAL IMPACT

Atherectomy followed by DCB of symptomatic DFA is safe and effective. In patients with comparable clinical and lesion characteristics, outcomes are comparable with surgery. However, the risk of reintervention at the index limb is higher after endovascular treatment. Therefore, whenever possible an additional outflow vessel revascularization should be performed by the time of the primary intervention. Randomized studies are warranted to compare endovascular techniques and open surgery also under economic aspects.

The Association between Fatty Liver Index and Lower Limb Arterial Calcification in Patients with Type 2 Diabetes Mellitus

Background

Peripheral arterial calcification is a prevalent condition in patients with type 2 diabetes mellitus (T2DM), resulting in lower-limb amputation and reduced life quality. Non-alcoholic fatty liver disease (NAFLD), which can be simply evaluated using the fatty liver index (FLI), is closely associated with T2DM development. In this study, we aimed to explore the relationship between FLI and lower limb arterial calcification (LLAC) in T2DM patients and to reveal the value of T2DM patients with NAFLD in predicting the occurrence of LLAC.

Methods

A total of 77 T2DM patients with LLAC who underwent comprehensive physical and health examinations, serological examinations, as well as lower limb computed tomography imaging at Sun Yat-sen Memorial Hospital of Sun Yat-sen University between January 2018 and January 2019 were enrolled in this study. The FLI was calculated using body mass index, waist circumference, triglycerides, and γ-glutamyl transferase. Additionally, LLAC was evaluated using computed tomography with the Agatston scoring algorithm. The patients were divided into three groups based on their FLI values: Non-liver disease group (FLI <30, n = 29), borderline-liver disease group (30 ≤ FLI < 60, n = 32), and NAFLD group (FLI ≥60, n = 16). Univariate and multivariate binary logistic regression analyses were employed to investigate the association between FLI and LLAC in T2DM patients. Furthermore, differences in LLAC among groups were analyzed using post-hoc multiple comparisons and ordinal logistic regression model analysis.

Results

Univariate and multivariate analyses showed that age and FLI influenced LLAC severity in T2DM patients. Moreover, T2DM patients in the NAFLD group had significantly lower LLAC scores than those in the Non-liver disease group. The correlation analysis showed that FLI was negatively associated with LLAC scores (R = -0.31, p = 0.006), while age was positively associated (R = 0.361, p = 0.001).

Conclusions

Our study revealed an inverse relationship between FLI and the degree of LLAC. This indicates that, based on evidence in the current research, NAFLD may not be reliable as a predictor of LLAC in T2DM patients.

Intravascular lithotripsy in infra-popliteal peripheral artery disease

Chronic limb-threatening ischemia (CLTI) carries a significant risk of limb loss and thus demands urgent attention. Calcified atherosclerotic disease affecting the infra-popliteal (IP) arteries poses a formidable challenge for effective revascularization due to the narrow vessel diameter and the common presence of extensively calcified, long occlusive lesions. Intravascular lithotripsy (IVL) is an endovascular treatment that induces microfractures in the medial calcifications of blood vessels, thereby facilitating the clearance of calcified obstructive arterial lesions. This review assesses the growing body of evidence from multiple prospective studies that have investigated the role of IVL in the treatment of peripheral arterial disease (PAD) involving the IP segment. The clinical efficacy of IVL has been extensively studied and validated in various trials and real-world experiences. These studies consistently demonstrate IVL's ability to achieve vessel preparation, with excellent procedural success rates and low rates of major adverse events. Moreover, IVL has shown remarkable versatility, proving effective across a wide spectrum of PAD, including iliac artery disease, femoropopliteal disease and IP calcified disease. The available results from existing literature are encouraging and demonstrates safety and efficacy of the technology in treating calcified PAD. Additional studies on a larger scale are needed to better understand its long-term effects.

Vascular Calcification: Where is the Cure?

With the progress of aging, the incidence of vascular calcification (VC) gradually increases, which is correlated with cardiovascular events and all-cause death, aggravating global clinical burden. Over the past several decades, accumulating approaches targeting the underlying pathogenesis of VC have provided some possibilities for the treatment of VC. Unfortunately, none of the current interventions have achieved clinical effectiveness on reversing or curing VC. The purpose of this review is to make a summary of novel perspectives on the interventions of VC and provide reference for clinical decision-making.

Effectiveness of Atherectomy and Drug-Coated Balloon Angioplasty in Femoropopliteal Disease: A Comprehensive Outcome Study

Purpose

Atherectomy has been reintroduced for debulking calcified atheroma to enhance the efficacy of drug-coated balloons (DCBs); however, its efficacy in severe calcification and related outcomes have not been fully evaluated. This study aimed to evaluate the outcomes of atherectomy and DCB angioplasty for treating femoropopliteal occlusive disease (FPOD).

Materials and Methods

From 2014 to July 2022, 85 limbs in 76 patients with FPOD underwent atherectomy with DCB angioplasty. We evaluated the efficacy of this procedure using primary patency (PP) and clinically driven target lesion revascularization (CD-TLR)-free survival. PP was defined as the duration of uninterrupted patency without occlusion or a peak systolic velocity ratio more than 2.5 at the target lesion. Lesion calcification was evaluated according to Peripheral Arterial Calcium Scoring System, and Grade 4 was classified as severe.

Results

Seventy-one (84%) cases were male, and 56 limbs (66%) were treated for claudication. Rotational and directional atherectomies were performed in 62 (73%) and 23 limbs, respectively. The improvement in the median ankle-brachial index was 0.36 (interquartile range, 0.25-0.48). Median follow-up duration was 19.4 months. The overall PP and CD-TLR-free survival rates were 77% and 93% at 1 year and 64% and 83% at 2 years, respectively. On multivariable analysis, female sex (adjusted hazard ratio [aHR], 3.77; 95% confidence interval (CI), 1.30-10.87, P=0.014), dialysis (aHR, 4.35; 95% CI, 1.33-13.22, P=0.015), and severe calcification (aHR, 2.42; 95% CI, 1.07-5.46, P=0.033) were independent risk factors for poor PP. Dialysis (aHR, 11.07; 95% CI, 3.72-32.92, P<0.001) and severe calcification (aHR, 3.19; 95% CI, 1.15-8.84, P=0.026) were identified as independent risk factors for CD-TLR.

Conclusion

Atherectomy with DCB angioplasty for FPOD did not work well in female patients, patients with lesions with severe calcification, and patients undergoing dialysis. Therefore, careful monitoring of these patients is crucial for patency loss and the requirement for revascularization. Additionally, for these patients requiring revascularization, surgical bypass may be appropriate for suitable candidates; whereas more proactive conservative management may be justified for claudicants.

The Untold Story: Early and Mid-Term Results of Subintimal Angioplasty in Superficial Femoral Artery Versus Popliteal Artery Chronic Total Occlusion

OBJECTIVES

This study aims to compare the immediate and mid-term outcomes of subintimal angioplasty (SIA) of chronic total occlusions (CTOs) of superficial femoral artery (SFA) versus popliteal artery (PA) and to identify possible predictors of loss of limb-based patency (LBP).

METHODS

This is a retrospective analysis of chronic lower-limb ischemia (CLI) patients (Rutherford classes 3-6) presenting with CTO of SFA or PA treated by SIA and selective stenting in the period 2018 to 2021. Immediate outcomes were compared between the SFA and PA groups, including technical success, perioperative complications, and 30-day major amputation and mortality rates. Mid-term outcomes for technically successful procedures included limb-based patency (LBP), wound healing rate, amputation-free survival (AFS), and major adverse limb events (MALEs).

RESULTS

A total of 450 CLI patients underwent SIA of CTO at the SFA (n=260, 57.8%) and the PA (n=190, 42.2%). The indication for revascularization was chronic limb-threatening ischemia in 80.8% of SFA group and 84.2% of PA group. Technical success rate was higher in the PA group compared to the SFA group (96.3% vs 91.2%; p=0.03). The 30-day amputation rates were comparable between the SFA and PA groups (7.7% vs 6.8%, p=0.7, respectively). No perioperative mortality or systemic major complications occurred in the present study. Kaplan-Meier estimate of the 1-year rates were significantly better for SFA group regarding LBP (82% for SFA group vs 43% for PA group, p=0.006), AFS (88% vs 64%, p=0.02), and wound healing (79% vs 58%, p=0.027), respectively. The number of runoff vessels was the only factor associated with loss of LBP (hazard ratio [HR], 0.055; 95% confidence interval [CI]: 0.001-3.020, p=0.039).

CONCLUSIONS

Subintimal angioplasty is an effective and safe endovascular treatment option of CTO at SFA and PA with satisfactory immediate outcomes. The mid-term outcomes, however, are better for SFA lesions in terms of improved LBP, AFS, and wound healing rates.

CLINICAL IMPACT

Subintimal angioplasty is a valuable tool in the armamentarium of endovascular surgeons, as re-entry devices aren't always widely accessible. This study aims to assess the technical outcomes of peripheral vascular interventions for infrainguinal chronic total occlusions and identify possible predictors for successful subintimal angioplasty .Subintimal angioplasty is an effective treatment option for infrainguinal CTO with difference in result of immediate outcomes in popliteal lesions and SFA lesions.

Clinical outcomes of acute limb ischaemia caused by femoropopliteal stent thrombosis

BACKGROUND

Although femoropopliteal-specific stents have durable patency, stent thrombosis (ST) may occur, which can lead to acute limb ischaemia (ALI).

AIMS

We aimed to investigate the clinical features and outcomes of ALI caused by femoropopliteal ST in patients with lower extremity artery disease.

METHODS

This multicentre retrospective study included 499 patients with ALI - of whom 108 patients had ALI caused by femoropopliteal ST (ST-ALI) and 391 patients had ALI caused by other aetiologies (de novo ALI) - who underwent treatment between September 2011 and March 2023. Clinical features and outcomes were compared between the two groups. The primary outcome measure was 12-month amputation-free survival; factors associated with amputation or death were investigated using multivariate Cox proportional hazards regression analysis.

RESULTS

Patients with ST-ALI were significantly more likely to exhibit conventional atherosclerotic risk factors, including diabetes mellitus (63% vs 26%) and haemodialysis (51% vs 10%) compared to patients with de novo ALI, whereas patients with de novo ALI were older (80 years vs 74 years) and more likely to have atrial fibrillation (49% vs 18%) than patients with ST-ALI. The 12-month amputation-free survival rate was significantly lower in the ST-ALI group than that in the de novo ALI group (51% vs 76%; p<0.001). Multivariate analysis revealed that ST-ALI, older age, haemodialysis, atrial fibrillation, the presence of a wound, peak C-reactive protein level, and non-ambulatory status all have an independent, positive association with death or major amputation.

CONCLUSIONS

The current study revealed that patients with ST-ALI had worse clinical outcomes than those with de novo ALI, highlighting the need to maximise ST prevention.

Treatment extent of femoropopliteal disease and clinical outcomes following endovascular therapy

BACKGROUND

Endovascular therapy (EVT) has become the preferred treatment modality for femoropopliteal disease. However, there is limited evidence regarding its procedural and clinical outcomes according to the affected area.

AIMS

The aim of this study is to investigate clinical outcomes and device effectiveness according to treatment extent in the superficial femoral artery (SFA), popliteal artery (PA), or both.

METHODS

In this study, we analysed EVT for SFA (2,404 limbs), PA (155 limbs), SFA/PA (383 limbs) using the population in the K-VIS ELLA (Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Diseases) registry. The primary endpoint was target lesion revascularisation (TLR) at 2 years.

RESULTS

The SFA/PA group exhibited a higher prevalence of anatomical complexity, characterised by long lesions, moderate to severe calcification, and total occlusion. The procedures were successful in 97.2% of SFA, 92.9% of PA, and 95.6% of SFA/PA EVTs. The 2-year TLR rates were 21.1%, 18.6%, and 32.7% in the SFA, PA, and SFA/PA groups, respectively. SFA/PA EVT was associated with a significantly increased risk for TLR compared to the SFA group (adjusted hazard ratio [HR] 1.48 [1.09-2.00]; p=0.008) and a trend towards an increased risk compared to the PA group (adjusted HR 1.80 [1.00-3.27]; p=0.052). After overlap weighting, the use of a drug-coated balloon (DCB) was shown to be beneficial, with the lowest TLR rate after SFA and SFA/PA EVT.

CONCLUSIONS

In this large real-world registry, SFA/PA EVT was associated with an increased risk for TLR at 2 years compared to the SFA or PA EVT groups, with favourable outcomes when using a DCB or drug-eluting stent in the SFA/PA EVT group.

Perioperative Vascular Access Mapping in Patients with Hemodialysis: A Comparative Study of Access Navigation and Selection in Jordan

Purpose

This study aimed to elucidate the impact of three different mapping methods on the outcomes of arteriovenous fistula (AVF), including the traditional physical examination (PE) method, color duplex ultrasonography (CDU) mapping conducted by a radiologist (CDU-R), and CDU mapping performed by the operating surgeon (CDU-S).

Patients and Methods

This retrospective study was conducted at a tertiary center in Jordan. Patients were divided into three groups based on the venous mapping method: PE, CDU-R, and CDU-S. Various outcomes were analyzed, including immediate technical success, clinical adequacy at 3 months, and 1-year patency rates. Additional demographic and clinical factors influencing access patency or contributing to early failure were also examined.

Results

The study included 303 eligible patients: 100 in the PE group, 103 in the CDU-R group, and 100 in the CDU-S group. The overall immediate technical success rate was 72%, which was highest in the CDU-S group (95%, p < 0.001). Additionally, the CDU-S group had the highest clinical access adequacy rate (78%, p < 0.01). Notably, the mapping method also influenced the anatomical location of the AVF, as none of the patients in the radiologist group had a forearm AVF. CDU-R, forearm location, intraoperative arterial calcifications, and operative duration were identified as predictors of AVF failure.

Conclusion

The results suggest that perioperative vascular mapping by the operating surgeon not only results in a higher rate of immediate success but also improves access adequacy and prevents unnecessary delays in providing an effective lifeline for hemodialysis patients. The present study highlights the burden of access failure in these patients and the evolving evidence surrounding preoperative vein mapping.

Endovascular therapy in intermittent claudication: Impact of IVUS guidance on treatment decisions

Conservative therapy is favored over revascularization for patients with peripheral arterial disease (PAD) and intermittent claudication (IC) owing to the better long-term results. The adjunctive use of intravascular ultrasound (IVUS) significantly improves endovascular therapy. However, data on IVUS and IC is scarce. Therefore, the aim of this investigation was to determine the safety and efficacy of IVUS in patients with IC and to evaluate discrepancies compared to angiography and potential consequences for treatment.This was a single-center prospective cohort study. Twenty patients with IC and femoropopliteal disease eligible for endovascular therapy were enrolled. Procedural data and discrepancies between IVUS and angiography were recorded.In total, 30 lesions were treated. IVUS-based measurements yielded substantially higher reference vessel diameters (RVD) and lesion lengths compared to DSA alone (RVD: 5.37 ± 0.71 mm vs. 4.74 ± 0.63 mm, p<.001, lesion length: 62.4 ± 41.4 mm vs. 42.18 ± 30.2 mm, p<.001). In 24 of 30 lesions (80%), a significant discrepancy in RVD (defined as difference >0.5 mm) and lesion length (defined as >20 mm) was determined between IVUS and standard DSA. Subsequently, IVUS assessment led to upsizing in 14 of 30 lesions (47%) and downsizing in 3 of 30 lesions (10%). On average, IVUS led to the selection of considerably larger balloons (5.25 ± 0.62 vs. 4.74 ± 0.63, p<.004) and device length (78.97 ± 44.19 mm vs. 42.18 ± 30.2, p<.001). Serious adverse events did not occur. Technical success was achieved in all cases.IVUS is safe and provides advantages regarding the evaluation of IC by depicting RVD and lesion length more reliably than standard DSA. More precise assessment of lesions resulted in the use of significantly larger devices. · The safety and efficacy of IVUS are confirmed for the distinct cohort of patients with IC.. · IVUS provides advantages for the evaluation of IC by depicting RVD and lesion length more reliably than standard DSA.. · More precise assessment of stenoses resulted in the selection of significantly larger devices, hence suggesting substantial clinical impact.. Hartung V, Augustin AM, Gruschwitz P et al. Endovascular therapy in intermittent claudication: Impact of IVUS guidance on treatment decisions. Fortschr Röntgenstr 2024; DOI 10.1055/a-2379-8857.

Korean Multicenter Registry of ELUVIA Stent for Femoropopliteal Artery Disease: K-ELUVIA Registry

BACKGROUND AND OBJECTIVES

The K-ELUVIA study aimed to investigate the clinical effectiveness and safety of Eluvia™, a polymer-coated, paclitaxel-eluting stent, for femoropopliteal artery disease using data from a prospective Korean multicenter registry.

METHODS

A total of 105 patients with femoropopliteal artery disease who received endovascular treatment (EVT) with Eluvia™ stents at 7 Korean sites were enrolled in a prospective cohort and followed for 2 years. The primary endpoint was the 2-year clinical patency. The secondary endpoint was 2-year freedom from clinically driven target lesion revascularization (TLR).

RESULTS

Mean patient age was 68.2±10.4 years, and most patients (82.7%) were male. Mean lesion length was 168.3±117.6 mm. Chronic total occlusion was found in 57.7% of patients. Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) type C or D lesions were present in 46.1% of patients. Procedural success was achieved in 99.0% of patients. The clinical patency rate was 84.4% at 1 year after EVT and 76.3% at 2 years post-EVT. The freedom from TLR rate was 89.1% at 1 year after EVT and 79.1% at 2 years post-EVT. Chronic total occlusion (hazard ratio [HR], 3.53; 95% confidence interval [CI], 1.08-11.67; p=0.039) and smaller mean stent diameter (HR, 0.40; 95% CI, 0.16-0.98; p=0.044) were identified as independent predictors of loss of clinical patency at 2 years.

CONCLUSIONS

The K-ELUVIA study demonstrated favorable 2-year clinical effectiveness and safety outcomes of Eluvia stent for femoropopliteal artery lesions in real-world practice.

Influence of a Novel Morphology-Driven Classification on Limb Salvage after Isolated Tibial Intervention for Chronic Limb Threatening Ischemia

BACKGROUND

Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI.

METHODS

A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated.

RESULTS

1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003).

CONCLUSIONS

Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.

Pedal Vessel Calcification and Risk of Major Adverse Foot Events in the Diabetic Neuropathic, Nephropathic Foot

BACKGROUND

We aimed to determine the relative risk of pedal vessel calcification (PVC) on major adverse foot events (MAFEs) and chronic kidney disease (CKD) stage in patients with diabetes mellitus (DM) and peripheral neuropathy (PN).

METHODS

We retrospectively reviewed electronic medical records of 152 patients with diagnoses of DM, PN, and CKD stages one to five who had at least one foot radiograph obtained. PVC was scored (from 0-4) based on foot anatomic location and radiology reported MAFEs, which includes foot fracture, Charcot neuroarthropathy, foot ulcer, osteomyelitis, or minor amputation. Risk ratios (RR) with 95% confidence intervals (95% CI) and Poisson regressions were performed assessing the risk of sustaining MAFEs with number of PVCs and stage of CKD.

RESULTS

The risk of any MAFE increased as PVC score increased (RR = 1.23); the risk of any MAFE increased as CKD stage increased (RR = 1.35); and risk of any PVC increased as CKD stage increased (RR = 1.71).

CONCLUSIONS

Pedal vessel calcification on a foot radiograph increases the risk of any MAFE and increases with progressive stage of CKD. Pedal vessel calcification may serve as a gateway to prompt investigation, treatment, or referral for at-risk diabetic neuropathic, nephropathic patients.

Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia

OBJECTIVE

Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions.

METHODS

A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated.

RESULTS

A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS.

CONCLUSIONS

Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.

Successful use of lithoplasty for re-expansion of covered iliac stents with unilateral occlusion

BACKGROUND

Vessel wall calcification is associated with stent under-expansion and in-stent restenosis. The traditional approaches to treat peripheral artery calcification are percutaneous transluminal angioplasty (PTA) and atherectomy. Shockwave intravascular lithotripsy (IVL) uses sonic wave pressure to disrupt calcium of the severely calcified lesions. Published reports of IVL to treat in-stent restenosis are limited to coronary interventions and bare metal platforms.

METHODS

We describe the case of a 55-year-old male with extremely compressed under-expanded covered stents associated with severe wall calcification that resulted in stent occlusion.

RESULTS

The IVL system balloon was deployed uneventfully, in a phased manner. Bilateral bare metal stents were also placed in a kissing fashion to further re-expand the arterial segments. Reintervention with IVL facilitated successful revascularization and the stent remained patent at 24 months.

CONCLUSION

Our case highlights the use of IVL as an effective tool in the management of vessel wall calcification both for primary and secondary interventions.

High-Dose Drug-Coated Balloon Versus Polymer-Based Drug-Eluting Stent for Femoropopliteal Artery Disease Treatment

PURPOSE

Clinical trials have demonstrated that high-dose drug-coated balloon (HD-DCB) and polymer-based drug-eluting stent (PB-DES) treatments for femoropopliteal (FP) artery disease have favorable outcomes. However, which one would be better remained unrevealed.

METHODS

This study used the databases of 2 large-scale multicenter prospective drug-coated balloon (DCB) and drug-eluting stent (DES) registries. The study included 2470 patients with symptomatic FP lesion treated with IN.PACT Admiral DCB or Eluvia DES at 69 centers. A propensity-score-based paired analysis was conducted. Primary endpoint was 1-year restenosis rate. Secondary endpoints were 1-year reocclusion rate, target lesion revascularization (TLR), acute thrombosis, bypass conversion, major amputation, major adverse limb event (MALE), and all-cause death.

RESULTS

A total of 1535 patients were treated with HD-DCB, and 935 patients were treated with PB-DES. The propensity-score matching extracted 678 pairs, with no remarkable intergroup difference in baseline characteristics. The 1-year restenosis rate was significantly lower in the PB-DES group than in the HD-DCB group (16.0% vs 22.0%, p=0.016). The other endpoints (reocclusion rate, TLR, acute thrombosis, bypass conversion, major amputation, MALE, and all-cause death) did not differ between the groups. No baseline characteristics had any significant interaction effect on the association of HD-DCB vs PB-DES with restenosis risk (all p>0.05).

CONCLUSIONS

This study demonstrated that the 1-year TLR, reocclusion rate, and other endpoints did not differ between the PB-DES group and the HD-DCB group despite the lower restenosis in the PB-DES group.

CLINICAL IMPACT

One-year restenosis rate was significantly lower in the polymer-based DES group than in the high-dose DCB group for foemoropopliteal disease. However, there is no difference in the other endpoints between two groups.

Below-the-Ankle Antegrade Teleferic Technique: New Approach for Below-the-Ankle Revascularization in Challenging Cases of Chronic Limb-Threatening Ischemia

PURPOSE

To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible.

TECHNIQUE

When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire.

CONCLUSION

The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it.

CLINICAL IMPACT

The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized.The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

Establishing a Classification System for Predicting Flow-Limiting Dissection After Balloon Angioplasty Using Explainable Machine-Learning Models: A Multicenter Retrospective Cohort Study

Objective:

Percutaneous transluminal angioplasty (PTA) is the primary method for treatment in peripheral arterial disease. However, some patients experience flow-limiting dissection (FLD) after PTA. We utilized machine learning and SHapley Additive exPlanations to identify and optimize a classification system to predict FLD after PTA.

Methods:

This was a multi-center, retrospective, cohort study. The cohort comprised 407 patients who underwent treatment of the femoropopliteal (FP) arteries in 3 institutions between January 2021 and June 2023. Preoperative computed tomography angiography images were evaluated to identify FP artery grading, chronic total occlusion (CTO), and vessel calcification (peripheral artery calcium scoring system [PACSS]). After PTA, FLD was identified by angiography. We trained and validated 6 machine-learning models to estimate FLD occurrence after PTA, and the best model was selected. Then, the sum of the Shapley values for each of CTO, FP, and PACSS was calculated for each patient to produce the CTO-FP-PACSS value. The CTO-FP-PACSS classification system was used to classify the patients into classes 1 to 4. Univariate and multivariate analyses were performed to validate the effectiveness of the CTO-FP-PACSS classification system for predicting FLD.

Results:

Overall, 407 patients were analyzed, comprising 189 patients with FLD and 218 patients without FLD. Differences in sex (71% males vs 54% males, p<0.001), CTO (72% vs 43%, p<0.001), FP (3.26±0.94 vs 2.66±1.06, p<0.001), and PACSS (2.39±1.40 vs 1.74±1.35, p<0.001) were observed between patients with and without FLD, respectively. The random forest model demonstrated the best performance (validation set area under the curve: 0.82). SHapley Additive exPlanations revealed CTO, PACSS, and FP as the 3 most influential FLD predictors, and the univariate and multivariate analyses confirmed CTO-FP-PACSS classification as an independent FLD predictor (multivariate hazard ratio 4.13; p<0.001).

Conclusion:

The CTO-FP-PACSS classification system accurately predicted FLD after PTA. This user-friendly system may guide surgical decision-making, helping choose between PTA and additional devices to reduce FLD in FP artery treatment.

Clinical impact

We utilised machine-learning techniques in conjunction with SHapley Additive exPlanations to develop a clinical classification system that predicts the probability of flow-limiting dissection (FLD) after plain old balloon angioplasty. This classification system categorises lesions into Classes 1–4 based on three factors: chronic total occlusion, femoropopliteal grading, and peripheral artery calcium scoring. Each class demonstrated a different probability of developing FLD. This classification system may be valuable for surgeons in their clinical practice, as well as serving as a source of inspiration for other researchers.

Evaluation of the efficacy of combined device strategies for long femoropopliteal artery disease

One of the major problems associated with bare nitinol stent implantation is stent fracture, particularly in the popliteal artery. The purpose of this study was to determine whether drug coated balloons (DCB), interwoven stents (IWS), or plain old balloon angioplasty (POBA) would be suitable for use in distal femoropopliteal (FP) long lesions when an Eluvia stent was implanted proximal to a lesion. This was a multi-center retrospective study enrolling patients undergoing concomitant use of Eluvia with DCB, IWS or POBA for symptomatic atherosclerotic femoropopliteal disease (lesion length > 15 cm) [Rutherford category 2-6] between January 2018 and September 2021. 79 patients with 89 femoropopliteal lesions were enrolled in this study. The mean lesion length and the percentage of the popliteal artery involvement was 24.3 ± 6.4 cm vs 24.0 ± 9.0 cm vs 26.6 ± 6.2 cm and 65.8% vs 89.4% vs 67.8% for the Eluvia + DCB, Eluvia + IWS, and Eluvia + POBA groups, respectively. The 1-year Kaplan-Meier estimates of primary patency and freedom from major adverse limb events (MALEs) were 53.3% vs 44.1% vs 24.2% and 62.4% vs 51.0% vs 28.1%, respectively. Eluvia + POBA was associated with a lower rate for 1-year primary patency (HR 2.49; 95% confidence interval (CI): 1.28-4.87; p = 0.007 and HR 2.38; 95% CI: 1.13-5.77; p = 0.04). In SFA long lesions with proximal Eluvia implantation, distal implantations of either a DCB or IWS were comparable, as opposed to POBA alone which generated worse results.

Outcomes of Excimer Laser Ablation Combined with Drug-coated Balloon in Atherosclerotic Lesions of the Popliteal Artery

BACKGROUND

The treatment of atherosclerotic lesions in the popliteal artery is challenging. This study aims to investigate the efficacy and safety of excimer laser ablation (ELA) combined with drug-coated balloon (DCB) for these lesions.

METHODS

From June 2019 to December 2021, data of patients who underwent ELA combined with DCB in the popliteal artery were retrospectively reviewed. Demographics, lesion characteristics, periprocedural complications, and follow-up information were analyzed. The primary endpoint was primary patency. Secondary endpoints included major amputation-free survival rate, technical success, bailout stenting, clinically-driven target lesion reintervention, improvement of ankle-brachial index (ABI), and Rutherford class.

RESULTS

A total of 61 patients were enrolled. The mean age was 73.4 ± 11.7 years. 20 (32.8%) patients had stenotic lesions, while 41 (67.2%) patients had chronic total occlusions. The mean length of these lesions was 7.3 ± 2.8 cm. Procedure technical success rate was 95.1%. Bailout stent was performed in 3 (4.9%) patients. Intraprocedural distal embolization occurred in 3 (4.9%) patients, while flow limiting dissections occurred in 3 (4.9%) patients. The mean ABI was significantly improved from 0.45 ± 0.13 at baseline to 0.90 ± 0.12 after ELA, 0.88 ± 0.11 at 6 months and 0.85 ± 0.12 at 12 months during the follow-up period. The median follow-up time was 28.2 ± 6.1 months. Reintervention was performed in 5 (8.2%) patients. The 2-year primary patency was 83.5%.

CONCLUSIONS

ELA combined with DCB is a safe and effective strategy in the treatment of popliteal artery atherosclerotic lesions with low rates of bail-out stenting and high primary patency.

Predicting residual pressure gradients after balloon angioplasty in patients with femoropopliteal artery lesions

In endovascular therapy (EVT) for femoropopliteal artery (FPA) lesions, studies examining the relationship between lesion morphology and hemodynamic status are limited. The purpose of this study was to investigate FPA lesion characteristics, including imaging findings and their cutoff values that can predict hemodynamic significance after balloon angioplasty. This single-center retrospective study enrolled 50 de novo FPA lesions from 43 patients treated under intravascular ultrasound (IVUS) usage between June 2022 and March 2023. As a physiological parameter, the pressure gradient was measured, and the cutoff value of the residual pressure gradient (RPG) was defined as a systolic pressure > 10 mmHg through the lesions after balloon angioplasty. The pressure gradients were measured using a 0.014-inch wire-guided, rapid exchange-type microcatheter, Navvus II (Acist, Eden Prairie, Minnesota, USA). Predictive risk factors for RPG were analyzed using the random forest (RF) method. The relationship between the variables, RPG, and the cutoff points of each predictor was assessed using the partial dependence plot (PDP) method. RPG was observed in 20% of the lesions after balloon angioplasty. The RF model revealed that the percent diameter stenosis (%DS) and minimum lumen area (MLA) on IVUS assessment were strong predictive factors for RPG after balloon angioplasty. The PDP model revealed that a higher %DS (cutoff 30%) and smaller MLA (cutoff 10 mm2) could predict RPG after balloon angioplasty. Conventional lesion parameters such as %DS and MLA can predict hemodynamic significance during EVT for FPA lesions.

Clinical implications of diverse calcification patterns in endovascular therapy for femoral-popliteal arterial occlusive disease

OBJECTIVE

The aim of this study was to investigate whether intimal arterial calcification (IAC) and medial arterial calcification (MAC) are correlated with the various clinical outcomes following endovascular therapy (EVT) for peripheral arterial disease (PAD).

METHODS

This single-center retrospective study comprised 154 consecutively hospitalized individuals with PAD who underwent EVT for de novo femoral-popliteal calcific lesions from January 2016 to July 2021. The predominant calcification patterns of IAC and MAC were assessed using a semi-quantitative computed tomography scoring system. The Kaplan-Meier method and Cox regression were conducted to evaluate the correlations between calcification patterns and medium- to long-term outcomes.

RESULTS

The distribution of calcification patterns was as follows: IAC in 111 patients (72%) and MAC in 43 patients (28%). No remarkable variation was noted between the IAC and MAC groups regarding age (P = .84) and gender (P = .23). The MAC group indicated lower rates of 4-year primary patency, assisted primary patency, secondary patency, and amputation-free survival (AFS) compared with the IAC group (24% ± 7% vs 40% ± 6%; P = .003; 30% ± 8% vs 51% ± 6%; P = .001; 51% ± 8% vs 65% ± 5%; P = .004; and 43% ± 9% vs 76% ± 5%; P < .001, respectively). There was no significant difference in the rate of freedom from clinically driven target lesion revascularization between the MAC and IAC groups (63% ± 10% vs 73% ± 5%; P = .26). Stepwise multivariable Cox regression analysis demonstrated that MAC was associated with poor patency (hazard ratio, 1.81; 95% confidence interval, 1.12-2.93; P = .016) and AFS (hazard ratio, 2.80; 95% confidence interval, 1.52-5.16; P = .001).

CONCLUSIONS

Compared with IAC, MAC is independently associated with lower medium- to long-term patency and AFS after EVT for de novo femoral-popliteal occlusive lesions.

Management of Pseudoaneurysm as a Delayed Complication after Using Rotational Atherectomy in Popliteal Artery Atherosclerosis: A Case Report

Although intravascular atherectomy is widely used for debulking calcified atheromas in peripheral arterial disease, it is associated with complications. Delayed rupture with pseudoaneurysm formation is rare. We report the case of a 73-year-old man who developed a 24 mm×20 mm×27 mm popliteal artery (PA) pseudoaneurysm after rotational atherectomy. Initially, the patient presented with intermittent claudication. Preoperative computed tomographic angiography (CTA) showed a severely calcified atheroma in the PA. Rotational atherectomy was performed using the Jetstream™ device (Boston Scientific). Postoperatively, the ankle-brachial index and symptoms improved. However, 6 days after the atherectomy, the patient complained of calf pain and swelling. Follow-up CTA revealed a pseudoaneurysm and hematoma in the popliteal fossa. Open conversion with removal of the heavily calcified plaque and patch angioplasty were performed via the posterior approach. Delayed PA rupture and pseudoaneurysm formation after rotational atherectomy are rare; however, they require prompt management.