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AbuRahma AF. When Are Endovascular and Open Bypass Treatments Preferred for Femoropopliteal Occlusive Disease? Ann Vasc Dis 2018; 11:25-40. [PMID: 29682105 PMCID: PMC5882358 DOI: 10.3400/avd.ra.18-00001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Several meta-analyses and multicenter trials have shown that chronic limb ischemia did not occur for up to 5 years in 50%–70% of patients who underwent saphenous vein grafts, with limb salvage and perioperative mortality rates of >80% and 3%, respectively. However, open surgical bypass can have limitations, including postoperative morbidity/wound complications of 10%–20% and prolonged length of hospital stay and outpatient care. Several studies have analyzed clinical outcomes for patients with critical limb ischemia treated with endovascular therapies, but they have been mainly retrospective with significant heterogeneity or were single center. Only few randomized trials have compared surgical vs. endovascular therapy. These included the Bypass vs. Angioplasty in Severe Ischemia of the Leg (BASIL) trial, with no differences found in amputation-free or overall survival rates at 1 year; however, late outcomes favored the surgical group. The Bypass or Angioplasty in Severe Intermittent Claudication (BASIC) trial concluded that the 1-year patency rates were 82% and 43% for bypass and angioplasty, respectively. The BEST Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial is currently enrolling patients. This review analyzed studies comparing open vs. endovascular therapy in patients with femoropopliteal disease. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, West Virginia, USA
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2
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Westin GG, Armstrong EJ, Javed U, Balwanz CR, Saeed H, Pevec WC, Laird JR, Dawson DL. Endovascular therapy is effective treatment for focal stenoses in failing infrapopliteal vein grafts. Ann Vasc Surg 2014; 28:1823-31. [PMID: 25106106 DOI: 10.1016/j.avsg.2014.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts. METHODS We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3- to 6-month intervals for graft surveillance. RESULTS Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% of the patients were free from graft restenosis at 12 months and 31% were at 24 months. Receiver-operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P = 0.03), patency without reintervention (P = 0.01), and assisted patency with secondary intervention (P = 0.02) rates were superior for short lesions compared with long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions. CONCLUSIONS In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow-up with vascular laboratory surveillance is essential.
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Affiliation(s)
- Gregory G Westin
- Division of Vascular and Endovascular Surgery, New York University Medical Center, New York, NY.
| | - Ehrin J Armstrong
- Division of Cardiology, University of Colorado Denver and VA Eastern Colorado Healthcare System, Denver, CO
| | - Usman Javed
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - Christopher R Balwanz
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, MO
| | - Haseeb Saeed
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - William C Pevec
- Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - John R Laird
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - David L Dawson
- Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
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Park KM, Park YJ, Yang SS, Kim DI, Kim YW. Treatment of failing vein grafts in patients who underwent lower extremity arterial bypass. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:307-15. [PMID: 23166890 PMCID: PMC3491233 DOI: 10.4174/jkss.2012.83.5.307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE We attempted to determine risk factors for the development of failing vein graft and optimal treatment in patients with infrainguinal vein grafts. METHODS We retrospectively reviewed a database of patients who underwent infrainguinal bypass using autogenous vein grafts due to chronic atherosclerotic arterial occlusive disease of lower extremity (LE) at a single institute between September 2003 and December 2011. After reviewing demographic, clinical, and angiographic features of the patients with failing grafts, we analyzed those variables to determine risk factors for the development of failing grafts. To determine an optimal treatment for the failing vein grafts, we compared results of open surgical repair (OSR), endovascular treatment (EVT) and conservative treatment. RESULTS Two hundred and fifty-eight LE arterial bypasses using autogenous vein grafts in 242 patients were included in this study. During the follow-up period of 39 ± 25 months (range, 1 to 89 months), we found 166 (64%) patent grafts with no restenosis, 41 (15.9%) failing grafts, 39 (15.1%) graft occlusions, and 12 (4.7%) grafts lost in follow-up. In risk factor analysis for the development of a failing graft, no independent risk factors were identified. After 50 treatments of the 41 failing grafts (24 OSR, 18 EVT, 8 conservative management), graft occlusion was significantly more common in conservative treatment group and severe (>75%) restenosis was significantly more common following EVT than OSR (P = 0.001). Reintervention-free graft patency was also superior in the OSR group to that of the EVT group (87% vs. 42%, P = 0.015). CONCLUSION OSR of failing grafts has better outcomes than EVT or conservative management in treating failing grafts.
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Affiliation(s)
- Keun-Myoung Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Collins MJ, Li X, Lv W, Yang C, Protack CD, Muto A, Jadlowiec CC, Shu C, Dardik A. Therapeutic strategies to combat neointimal hyperplasia in vascular grafts. Expert Rev Cardiovasc Ther 2012; 10:635-47. [PMID: 22651839 PMCID: PMC3401520 DOI: 10.1586/erc.12.33] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neointimal hyperplasia (NIH) in bypass conduits such as veins and prosthetic grafts is an important clinical entity that limits the long-term success of vascular interventions. Although the development of NIH in the conduits shares many of the same features of NIH that develops in native arteries after injury, vascular grafts are exposed to unique circumstances that predispose them to NIH, including surgical trauma related to vein handling, hemodynamic changes creating areas of low flow, and differences in biocompatibility between the conduit and the host environment. Multiple different approaches, including novel surgical techniques and targeted gene therapies, have been developed to target and prevent the causes of NIH. Recently, the PREVENT trials, the first molecular biology trials in vascular surgery aimed at preventing NIH, have failed to produce improved clinical outcomes, highlighting the incomplete knowledge of the pathways leading to NIH in vascular grafts. In this review, we aim to summarize the pathophysiologic pathways that underlie the formation of NIH in both vein and synthetic grafts and discuss current and potential mechanical and molecular approaches under investigation that may limit NIH in vascular grafts.
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Affiliation(s)
- Michael J Collins
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
| | - Xin Li
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Xiangya Second Hospital of Central South University, Changsha, Hunan, China
| | - Wei Lv
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University School of Medicine, Jinan, Shandong, China
| | - Chenzi Yang
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Xiangya Second Hospital of Central South University, Changsha, Hunan, China
| | - Clinton D Protack
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
| | - Akihito Muto
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Caroline C Jadlowiec
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
| | - Chang Shu
- Department of Vascular Surgery, Xiangya Second Hospital of Central South University, Changsha, Hunan, China
| | - Alan Dardik
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
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Recent Advances in Percutaneous Management of Iliofemoral and Superficial Femoral Artery Disease. Cardiol Clin 2011; 29:381-94. [DOI: 10.1016/j.ccl.2011.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Slim H, Huang D, Rashid H. A noval approach using angioplasty for recanalization of a chronically occluded bypass vein graft for limb salvage. Vasc Endovascular Surg 2010; 44:377-80. [PMID: 20628069 DOI: 10.1177/1538574410370374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reporting a noval approach for recanalization of a chronically occluded bypass using balloon angioplasty. METHODS A chronically occluded distal bypass graft was managed successfully with balloon angioplasty in a diabetic patient with critically ischemic leg. RESULTS Successful recanalization of the chronically occluded distal bypass graft. Surveillance duplex scans up to 10 months revealed the graft to be patent with pulsatile flow. Patient fully healed. CONCLUSION Balloon angioplasty of a chronically occluded distal bypass is feasible.
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Affiliation(s)
- Hani Slim
- King's College Hospital, Department of Vascular Surgery, London,UK
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The Role of “Cutting” Balloon Angioplasty for the Treatment of Short Femoral Bifurcation Steno-Obstructive Disease. Cardiovasc Intervent Radiol 2010; 33:921-8. [DOI: 10.1007/s00270-010-9802-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 01/04/2010] [Indexed: 11/27/2022]
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Shammas NW. Restenosis after lower extremity interventions: current status and future directions. J Endovasc Ther 2009; 16 Suppl 1:I170-82. [PMID: 19317571 DOI: 10.1583/08-2564.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The incidence of restenosis after percutaneous peripheral interventions (PPI) varies considerably depending upon the vascular bed but appears to be highest in the femoropopliteal and tibioperoneal arteries. The restenosis process in the periphery does not appear to stop at the 6-month mark, as seen with bare metal stents in the coronary arteries, but continues for a longer time, possibly years, after the intervention. This review evaluates the incidence of restenosis following lower extremity arterial interventions and potential drugs or devices that could alter this process, including nonpharmacological (stents, cryoplasty, Cutting Balloon angioplasty, atherectomy, brachytherapy, and photodynamic therapy) and pharmacological (systemic and direct drug delivery) approaches. A global strategy to achieve optimal outcome with PPI is offered: (1) obtain excellent acute angiographic results with less dissection and recoil, (2) protect the distal tibial vascular bed, and (3) reduce smooth muscle cell proliferation with pharmacological intervention.
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Affiliation(s)
- Nicolas W Shammas
- Midwest Cardiovascular Research Foundation, Cardiovascular Medicine, Davenport, Iowa 52803, USA.
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Bosiers M, Deloose K, Cagiannos C, Verbist J, Peeters P. Use of the Angiosculpt Scoring Balloon for Infrapopliteal Lesions in Patients with Critical Limb Ischemia: 1-Year Outcome. Vascular 2009; 17:29-35. [DOI: 10.2310/6670.2009.00001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The AngioSculpt Scoring Balloon Catheter (AngioScore, Inc., Fremont, CA) is composed of a semicompliant balloon encircled by three nitinol spiral struts providing targeted lesion scoring on balloon inflation. Between April 2005 and April 2006, procedural and follow-up data on 31 patients (mean age 76 years; 54.8% males) endovascularly treated for severe infrapopliteal disease were collected. The AngioSculpt catheter was used to treat 36 complex, tibioperoneal, atherosclerotic lesions. All patients had symptomatic critical limb ischemia (Rutherford 4–5) and single-vessel runoff to the ankle. Complication-free survival at 1 month was the safety end point, whereas primary patency and limb salvage were the efficacy end points evaluated at 1 year. The AngioSculpt balloon was successfully inflated in all 36 target lesions. Eleven patients (35.5%) required additional stenting for minor dissections or suboptimal stenosis reduction. The 1-month complication-free survival was 96.8%. One-year survival, primary patency, and limb salvage rates were 83.9 ± 6.6%, 61.0 ± 9.3%, and 86.3 ± 6.4%, respectively. The 1-year data show the AngioSculpt Scoring Balloon Catheter to be an effective and safe treatment for infrapopliteal, atherosclerotic lesions in patients with critical limb ischemia. However, more patients, a longer follow-up, and randomized studies comparing it with conventional balloon angioplasty and stenting in the infrapopliteal region are required.
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Affiliation(s)
- Marc Bosiers
- *Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium; †Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Koen Deloose
- *Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium; †Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Catherine Cagiannos
- *Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium; †Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Jürgen Verbist
- *Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium; †Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Patrick Peeters
- *Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium; †Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
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Predictors of failure after angioplasty of infrainguinal vein bypass grafts. J Vasc Surg 2008; 49:117-21. [PMID: 19028063 DOI: 10.1016/j.jvs.2008.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 08/07/2008] [Accepted: 08/09/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Percutaneous transluminal angioplasty (PTA) has had an expanding role as primary therapy for vein graft stenosis with variable results. The aim of this study is to identify patient and graft characteristics predictive of failure after PTA of infrainguinal vein grafts. METHODS Retrospective review from Jan 2004 to Mar 2007 of patients undergoing angioplasty for failing grafts. Demographics, comorbidities, procedural data, and follow-up information were recorded. PTA failure was defined as first significant event including restenosis by duplex scan (>3.5 x velocity ratio), occlusion, redo-PTA, surgical revision, or amputation. Descriptive, logistic regression and life-table analyses were performed. RESULTS Eighty-seven grafts in 79 patients underwent PTA. Mean age was 70 years (median 70; range, 39-89 years), 71% were male and 52% were symptomatic (40% with limb-threat). Mean follow-up was 17 months (median 17.4; range, 0.03-39.8 months). Freedom from PTA failure was 58% (standard error [SE] 0.0574) at 12 months. Predictors of PTA failure by multivariate analysis were: time from bypass <3 months (hazard ratio [HR] 5.8; 95% confidence interval [CI] 1.91-18.0; P = .002), stenosis length >2 cm (HR 2.7; 95% CI 1.33-5.83; P = .007) and multiple stenoses (HR 2.5; 95% CI 1.29-5.1; P = .007). PTA patency for grafts with favorable lesions (single, less than 2 cm lesions in grafts older than 3 months) was 71% vs 35% for unfavorable lesions at 12 months. Limb-salvage was 95% and 90% and overall survival was 92% and 81% at 12 and 24 months, respectively. CONCLUSION PTA of failing infrainguinal vein grafts is a reasonable primary therapy for favorable lesions. Early graft stenosis, long, and multiple stenoses are markers for procedural failure and are better served with surgical revision.
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Basile A, Tsetis D, Chlouverakis G, Calcara G, Ardita G, Giulietti G, Di Salvo M, Granata A, Lupattelli T, Patti MT. Treatment of anastomotic stenoses of peripheral bypass grafts with cutting balloon angioplasty. Radiol Med 2008; 113:719-26. [DOI: 10.1007/s11547-008-0275-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Accepted: 11/07/2007] [Indexed: 11/30/2022]
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Schneider PA, Caps MT, Nelken N. Infrainguinal vein graft stenosis: Cutting balloon angioplasty as the first-line treatment of choice. J Vasc Surg 2008; 47:960-6; discussion 966. [DOI: 10.1016/j.jvs.2007.12.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 12/01/2007] [Accepted: 12/13/2007] [Indexed: 11/17/2022]
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