Late hemodynamic failure following percutaneous transluminal angioplasty for long and multifocal femoropopliteal stenoses

Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia

Background

Femoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass.

Results

A total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5–7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years.

Conclusions

The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.

Long-term results of open and endovascular revascularization of superficial femoral artery occlusive disease

BACKGROUND

First-line treatment for patients with superficial femoral arterial (SFA) occlusive disease has yet to be determined. This study compared long-term outcomes between primary SFA stent placement and primary femoral-popliteal bypass. Periprocedural patient factors were examined to determine their effect on these results.

METHODS

All femoral-popliteal bypasses and SFA interventions performed in consecutive patients with symptoms Rutherford 3 to 6 between 2001 and 2008 were reviewed. Time-dependent outcomes were analyzed using the Kaplan-Meier method and log-rank test. Cox proportional hazards were performed to determine predictors of graft patency. Multivariate analysis was completed to identify patient covariates most often associated with the primary therapy.

RESULTS

A total of 152 limbs in 141 patients (66% male; mean age, 66 ± 22 years) underwent femoral-popliteal bypass, and 233 limbs in 204 patients (49% male; mean age, 70 ± 11 years) underwent SFA interventions. Four-year primary, primary-assisted, and secondary patency rates were 69%, 78%, and 83%, respectively, for bypass patients and 66%, 91%, and 95%, respectively, for SFA interventions. Six-year limb salvage was 80% for bypass vs 92% for stenting (P = .04). Critical limb ischemia (CLI) and renal insufficiency were predictors of bypass failure. Claudication was a predictor of success for SFA stenting. Three-year limb salvage rates for CLI patients undergoing surgery and SFA stenting were 83%. Amputation-free survival at 3 years for CLI patients was 55% for bypass and 59% for SFA interventions. Multivariate predictors (odds ratios and 95% confidence intervals) of covariates most frequently associated with first-line SFA stenting were TransAtlantic Inter-Society Consensus II A and B lesions (5.9 [3.4-9.1], P < .001), age >70 years (2.1 [1.4-3.1], P < .001), and claudication (1.7 [1.1-2.7], P = .01). Regarding bypass as first-line therapy, claudicant patients were more likely to have nondiabetic status (5.6 [3.3-9.4], P < .001), creatinine <1.8 mg/dL (4.6 [1.5-14.9], P = .01), age <70 years (2.7 [CI, 1.6-8.3], P < .001), and presence of an above-knee popliteal artery target vessel (1.9 [CI, 1.1-3.4] P = .02).

CONCLUSION

Indication, patient-specific covariates, and anatomic lesion classification have significant association when determining surgeon selection of SFA stenting or femoral-popliteal bypass as first-line therapy. Patients with SFA disease can have comparable long-term results when treatment options are well matched to patient-specific and anatomic characteristics.

Failure of prolonged dilation to improve long-term patency of femoropopliteal artery angioplasty: results of a prospective trial

PURPOSE

To determine long-term patency of femoropopliteal artery percutaneous transluminal angioplasty (PTA) in a prospective trial during which prolonged balloon inflation was used for optimization of initial results.

MATERIALS AND METHODS

Femoropopliteal PTA was performed in 112 limbs of 97 patients. The mean total length of the treated segments was 7.2 cm (95% CI: 5.99-8.46; median: 5.5 cm). In cases of unsatisfactory primary results after standard dilation for 1-3 minutes, the procedure was continued with prolonged dilation (93 limbs; mean balloon inflation time: 31 min; 95% CI: 24.2-37.7; median: 15 min) with use of the same balloon catheter (77 limbs) or a perfusion balloon catheter (35 limbs). Thirty-four proximal infrapopliteal artery stenoses were treated to improve peripheral runoff and 12 short stents were placed because of flow-limiting dissections.

RESULTS

Primary hemodynamic success established by Doppler ultrasound (US) criteria was achieved in 92.9% (104 of 112) of the limbs. Three major complications were encountered; none were related to prolonged balloon inflation. The primary patency rate according to Kaplan-Meier analysis was 42% (+/-5% SE) at 1 year and 39% (+/-5%) at 2 and 3 years. The corresponding secondary patency rates were 51% (+/-5%) and 47% (+/-5%). Large numbers of diseased vessels in the treated limb (four to 10 instead of one to three), eccentric lesions (as opposed to concentric morphology), and additional treated segments (instead of only femoropopliteal lesions) were associated with poorer long-term patency. The duration of balloon dilation was not a determinant of long-term patency.

CONCLUSION

Although prolonged dilation is safe and feasible in femoropopliteal artery PTA, its routine use is not warranted because it does not result in superior long-term patency rates.

Peter B. Samuels Award. Restenosis after percutaneous transluminal angioplasty

BACKGROUND

Determine the feasibility of studying the natural history of the atherosclerotic plaque following percutaneous transluminal angioplasty (PTA), using duplex scanning.

METHODS

Twenty-three patients with 40 stenoses (>70% and <5 cm in length) in the iliac and femoro-popliteal segments were studied by duplex scanning before PTA, on day 1, weekly for 8 weeks, and at 3 months, 6 months, and 1 year. The following measurements were made: thickness of the plaque, minimal lumen diameter (MLD), and peak systolic velocity ratio (PSVR). A PSVR >2.0 was used to indicate >50% lumen diameter reduction.

RESULTS

Thirty stenoses were available for measurement and analysis. Mean reduction in plaque thickness after angioplasty was greater in echolucent plaques (2.33 +/- 0.9 mm) than echogenic plaques (0.83 +/- 0.6 mm; P < 0.0001). Successful angioplasty (PSVR <2.0) and increase in MLD in echolucent plaques was the result of plaque compression; in echogenic plaques, of wall dilatation. The incidence of restenosis (PSVR >2.0) at 6 months was 12 of 30 (40%) remaining unchanged at 1 year; of the lesions that restenosed, 33% recurred before week 8 and the remainder between weeks 8 and 24, suggesting different mechanisms. During follow-up, all plaques showed "growth"; <2 mm in 17 (57%; group A) and >2 mm in the remaining 13 (43%; group B). The incidence of restenosis (PSVR >2.0) was 4 of 17 (23%) in group A and 8 of 13 (61%) in group B (P <0.05).

CONCLUSION

Duplex scanning provides valuable information on both luminal diameter and plaque thickness; it may be used to study the natural history of plaques following angioplasty and also the effects of therapeutic agents aimed at reducing restenosis.

Evaluation of femoropopliteal arteries with duplex ultrasound after angioplasty. Can we predict results at one year?

OBJECTIVES

To determine if Duplex ultrasound (DUS) 1 day after percutaneous transluminal angioplasty (PTA) is prognostic for haemodynamic and clinical results at 1 year.

DESIGN

Prospective study.

PATIENTS AND METHODS

Thirty-four femoropopliteal artery segments were treated with PTA. The peak systolic velocity ratio (PSV ratio = PSV in stenosis: PSV in normal segment) was determined with DUS before PTA, 1 day after PTA and 1 year after PTA. Clinical results were assessed with the SVS/ISCVS (Society for Vascular Surgery/International Society for CardioVascular Surgery) results classification.

RESULTS

A 1 year, clinical benefit from PTA was seen in 16 of 25 patients (64%) and haemodynamic improvement in 20 of 34 treated segments (59%). With DUS three residual stenoses were found 1 day after PTA; all occluded within 1 year. Segments with good DUS results after PTA showed haemodynamic deterioration in 30%. Clinical improvement was seen in most patients with DUS improvement, whereas no change or deterioration was found in patients with both good and poor DUS results at 1 year.

CONCLUSIONS

Residual stenosis on DUS 1 day after PTA is prognostic for failure within 1 year. However, good DUS results after PTA cannot predict haemodynamic success. Haemodynamic success at 1 year does not imply clinical success.

Should percutaneous transluminal angioplasty be recommended for treatment of infrageniculate popliteal artery or tibioperoneal trunk stenosis?

PURPOSE

The purpose of this study was to determine the effectiveness of percutaneous transluminal angioplasty (PTA) for treatment of patients with localized stenosis of the infrageniculate popliteal artery and tibio-peroneal trunk (IGPA).

METHODS

The records of 25 patients undergoing IGPA PTA from 1983 to 1993 were reviewed. Patients underwent follow-up with clinical examinations, ankle-brachial indexes, Duplex scanning, and arteriography. Demographic variables and cardiovascular risk factors were analyzed and correlated with outcome.

RESULTS

Mean follow-up was 44 months. With life-table analysis, clinical and hemodynamic success was 59%, 32%, and 20% at 1, 2, and 3 years, respectively. Average time to recurrence was 17 months. Sixteen patients required a subsequent procedure; two had only repeat PTA, six had repeat PTA followed by arterial bypass, and eight had bypass alone. The mean additional benefit of repeat PTA was 8 months. Eleven of the 14 patients treated with bypass became symptom-free with patent grafts at a mean follow-up of 52 months. No risk factor was statistically significant in predicting success of IGPA PTA.

CONCLUSIONS

IGPA PTA is an expensive temporizing measure with a high rate of recurrence requiring subsequent intervention. The procedure should be restricted to patients with limited life expectancy or contraindications to operation.

Treatment of recurrent femoral or popliteal artery stenosis after percutaneous transluminal angioplasty

PURPOSE

This study was undertaken to compare repeat percutaneous transluminal angioplasty (rPTA), arterial reconstruction, and noninvasive therapy for treatment of patients with recurrent stenosis after PTA of the superficial femoral or popliteal artery.

METHODS

From 1983 to 1993, 93 patients were treated for recurrent femoropopliteal stenosis. Indication for treatment was claudication in 72 patients, rest pain in 9, and ischemic ulcer in 12. Thirty-six patients (38%) were treated with arterial bypass, 35 (38%) with rPTA, and 22 (24%) with exercise and medication. Patients were monitored with clinical examination, ankle-brachial indexes, and duplex scanning. Follow-up ranged from 6 to 110 months (mean 42 months).

RESULTS

With life-table analysis, the clinical and hemodynamic success of patients treated with rPTA was 41% at 1 year, 20% at 2 years, and 11% at 3 years. For patients treated with arterial bypass, the primary graft patency rate was 84%, 72%, and 72% at 1, 2, and 3 years, respectively. The secondary graft patency rate was 94%, 88%, and 88% at the same intervals. All patients with patent grafts were symptom free. All 22 patients treated with noninvasive therapy continued to have symptoms, but none required amputation during follow-up (range 6 to 108 months). Overall, patients with claudication did better than those treated for rest pain or an ischemic lesion after either rPTA or arterial bypass, but no other variable was statistically significant in predicting outcome.

CONCLUSIONS

This study finds that arterial bypass is safe and more effective than rPTA in treating patients with recurrent stenosis. Preoperative evaluation is unable to select patients likely to benefit from rPTA. Repeat PTA should be reserved for patients with limited life expectancy or contraindications to operation.