The Role of “Cutting” Balloon Angioplasty for the Treatment of Short Femoral Bifurcation Steno-Obstructive Disease

Surgical, Endovascular, and Multimodal Approaches to the Management of Atherosclerotic Common Femoral Artery Disease

Common femoral artery disease is at the heart of nearly all treatment algorithms and decisions for patients with symptomatic peripheral arterial disease. Surgical endarterectomy has been the mainstay of common femoral treatment with a wealth of data supporting its safety, efficacy, and durability. Advances in endovascular technology and techniques for the management of iliac and superficial femoral artery disease has resulted in a paradigm shift in management. The common femoral artery has been aptly named a "no stent zone" due to anatomic and disease-specific challenges that have limited the role for endovascular techniques. New technology and techniques in the endovascular management of common femoral disease seek to change our treatment strategies. A multimodal approach utilizing a combination of angioplasty, atherectomy, and stenting has been shown most beneficial, although limited long-term data leave durability an unanswered question. While surgical treatment remains the gold standard, advances in the endovascular approach will certainly continue to improve outcomes. As truly isolated common femoral disease is a rarity, a collaborative approach combining all benefits of open and endovascular techniques in the treatment of peripheral arterial disease is essential.

Open Surgical Thrombendarterectomy Versus Endovascular Treatment in Occlusive Processes of the Femoral Artery Bifurcation

BACKGROUND

The standard treatment of occlusive processes of the femoral artery bifurcation is thrombendarterectomy (TEA). Endovascular techniques (ENDO) have recently been put forward as a potential alternative. It is unclear so far which modality yields better outcomes with respect to long-term revascularization and periprocedural complications. Method: Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD. Results: 42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO. Conclusion: In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation.

METHODS

Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD.

RESULTS

42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO.

CONCLUSION

In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation.

Systematic review and meta-analysis of endovascular versus open repair for common femoral artery atherosclerosis treatment

BACKGROUND

Encouraging recent reports on endovascular treatment of common femoral artery (CFA) atherosclerotic disease has rendered the question regarding the place of this technique evermore pertinent and legitimizes the performance of randomized trials. The present comprehensive review focused on the early and midterm outcomes to help assess the benefit/risk balance of endovascular vs open repair for CFA treatment.

METHODS

Embase and Medline searches were conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) standards to identify studies from 2000 to 2018 reporting on endovascular repair (ER), open surgery (OS), and comparisons of both techniques for CFA atherosclerosis treatment. The outcomes measured were 30-day mortality, morbidity, reintervention rates, midterm patency, late reintervention, and restenosis rates.

RESULTS

Twenty-eight studies were eligible: 14 OS (1920 patients), 12 ER (1900 patients), and 2 comparative randomized trials (197 patients). The meta-analysis of the comparative studies revealed no differences in 30-day mortality or reintervention rates but improved 30-day morbidity after ER. At 1 year, the primary patency rates did not differ between ER and OS, nor did the late reintervention rate. In the noncomparative studies, with a mean follow-up period of 23.8 months for ER and 66 months for OS, the restenosis rate was 14.4% and 4.7%, respectively. The reported stent fracture rate was 3.6%. In the ER cohort, the overall primary patency at 1, 2, and 3 years was 81.9%, 77.8%, and 75.1%, respectively. For the OS cohort, the overall primary patency rate at 1, 2, and 3 years was 93.4%, 91.4%, and 90.5%, respectively.

CONCLUSIONS

Despite expectations, our analysis of the reported data suggests that the perioperative mortality is not in favor of ER; however, the perioperative morbidity showed an advantage for ER compared with OS. Also, although comparable in the first year, the long-term primary patency rate was much greater after OS. At present, the place of ER for CFA treatment still requires further definition. Additional clarification of the indications and more research are both required to determine the optimal endovascular technology and femoral bifurcation reconstruction with stenting.

Efficacy of Cutting Balloon Angioplasty for Chronic Total Occlusion of Femoropopliteal Arteries

BACKGROUND

Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion subset where maintaining long-term patency after endovascular treatment is challenging. We evaluated the efficacy of cutting balloon angioplasty (CBA) for de novo FP-CTOs in patients with symptomatic lower limb ischemia.

METHODS

Seventy-three limbs of 67 symptomatic patients with de novo FP-CTOs successfully recanalized using CBA alone were enrolled in this study. Primary patency was defined as the absence of recurrent symptoms and no deterioration of the ankle-brachial index (ABI) >0.10 from the immediate postinterventional value.

RESULTS

The mean age was 73.5 ± 7.3 years, and 59.7% of patients had diabetes mellitus. Most lesions were classified as Trans-Atlantic Inter-Society Consensus II type C (n = 18; 24.7%) or type D (n = 44; 60.3%), with mean lesion and occluded lengths of 24.8 ± 11.4 and 17.8 ± 11.2 cm, respectively. No procedure-related adverse events occurred, except one distal embolization. The ABI significantly increased after intervention from 0.52 ± 0.12 to 0.80 ± 0.15 (P < 0.0001), with marked improvement in clinical symptoms (Rutherford stage: 2.7 ± 1.0 to 1.1 ± 1.2, P < 0.0001). The mean follow-up period was 31.2 ± 18.0 months, and the primary patency rates at 12 and 24 months were 75.3% and 60.6%, respectively. The independent predictive factors of failed patency were baseline hemoglobin A1c (P = 0.031, hazard radio [HR] 1.51 per 1%), occluded length ≥15 cm (P = 0.036, HR 2.90), and severe dissection (P = 0.033, HR 2.85). Vessel calcification and diameter did not affect primary patency.

CONCLUSIONS

CBA is a feasible option for endovascular treatment of FP-CTOs. Diabetic status, occlusion length, and severe dissection after CBA are independent negative predictors of long-term patency.

Endovascular Treatment of Common Femoral Artery Atherosclerotic Disease

Common femoral artery atherosclerosis is a common cause of claudication and critical limb ischaemia. Surgical endarterectomy with or without patch angioplasty has been considered the gold standard for the treatment of common femoral peripheral artery disease. Endovascular intervention to the common femoral artery has gained popularity in recent years as devices and technical skills have advanced. A systematic review of the literature from 1987 to 2018 for endovascular treatment of common femoral artery disease was conducted. This article summarises the data on acute and long-term outcomes for endovascular treatment of common femoral artery disease.

Crossover stenting across the deep femoral artery entry: a multicenter retrospective study

Crossover stenting of femoral bifurcation raises the concern of jeopardizing the deep femoral artery (DFA) entry, thereby increasing future risk of limb-threatening ischemia and amputation. This retrospective multicenter study compared clinical outcomes of crossover stenting and non-crossover stenting for ostial superficial femoral artery (SFA) lesions. We reviewed 125 limbs in 103 patients with successful stent implantation for ostial SFA lesions and allocated them to two groups, based on whether the stent crossed over the DFA orifice (CO, n = 54) or not (NC, n = 71). The decision of applying whether CO or NC was at the operators' discretion. Primary endpoints were incidences of major amputation and acute limb ischemia (ALI) at 24 months, and secondary endpoints were incidences of death, target lesion revascularization (TLR), composite of amputation or death, and major adverse limb events which was a composite of major amputation, ALI, TLR, or death at 24 months. Baseline characteristics were similar between the groups. Major amputation occurred only in the NC group, while ALI occurred only in the CO group. Kaplan-Meier estimation showed no significant differences in incidences of major amputation (NC: 3.0% vs. CO: 0.0%, p = 0.21), ALI, or any of the secondary endpoints. However, there was a trend towards higher incidence of ALI in the CO group (NC 0.0% vs. CO 3.9%, p = 0.11). Crossover stenting did not result in a significant difference in major amputation compared to non-crossover stenting within 24 months. However, it showed a trend towards higher incidence of ALI.

A pooled analysis of common femoral and profunda femoris endovascular interventions

Background

Atherosclerotic disease of common femoral and profunda femoris arteries has been historically treated with surgical endarterectomy. Endovascular treatment of common femoral artery and profunda femoris artery disease is increasingly reported in the recent literature. This review summarizes short- and mid-term outcomes of endovascular interventions to the common femoral artery and common femoral artery.

Methods

All published series in the English language were identified through a systematic PubMed search. Standard descriptive statistics, reported as mean ± SD, were applied to perform the pooled analysis and calculate the overall outcome measures. Combined overall effect sizes were calculated using fixed-effect meta-analysis.

Results

The analysis included 20 studies with a total of 836 patients (897 limbs, mean age of 70.5 ± 4.3 years, critical limb ischemia 39.6%). Technical success was 95%. Angioplasty alone was undertaken in 68.8% of cases and stenting in 22.3%. Access complications occurred in 2.4% of cases. Post-operative major adverse limb events occurred in 2% and major adverse cardiovascular events in 1% of cases. Primary patency at 6, 12 and 24 months was 87%, 77% and 73%, respectively. Subgroup analysis revealed a significantly higher mean primary patency at 12 months for routine stenting compared to a selective stenting strategy (91.4% versus 75%; p < 0.05).

Conclusions

Endovascular interventions to the common femoral artery and common femoral artery can be performed safely with high technical success. Endovascular therapy may be a favored approach over endarterectomy for highly selected patients of poor surgical risk, with limited life expectancy and those with wound-healing considerations such as re-operative fields or prone to infection.

The Design of an Improved Force Focused Angioplasty Catheter

Atherosclerosis is a disease that causes obstructions to develop within the arterial system; these obstructions can result in an acute vascular event such as a heart attack or stroke, and potentially death. In the majority of cases a standard angioplasty balloon is sufficient to dilate the site of an obstruction; however difficult obstructions, such as heavily calcified lesions require specialist dilation solutions. One such example of a device is Boston Scientific's cutting balloon. An analysis of the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database demonstrates that the original cutting balloon has a number of distinct adverse events associated with it. In this study we describe the design, manufacturing, and testing of a new force focused angioplasty balloon that has the potential to reduce or eliminate the adverse events associated with the Boston Scientific cutting balloon. This design incorporates two elastomeric materials to aid recoiling of the device namely: nitinol and a silicone elastomer. New methods of manufacturing are described in this study, that ensure that precision molding and assembly can occur. To determine the effectiveness of our device, we simulated concentric calcified lesions with a surrogate chalk model. These results demonstrate that our device has a significantly lower lesion burst pressure in comparison to a standard angioplasty balloon, 174 atm versus 12.48 atm. To determine if our device reduced potential snagging, and thus reduced the risk of withdrawal resistance being encountered, we performed a withdrawal resistance test. A noticeably lower withdrawal force is associated with our device, the high peaks on the Boston Scientific device indicate that there may be wings forming on the balloon and these are catching on the tip of the introducer sheath. Finally, we demonstrated in vivo efficacy of our device in a porcine model. By the use of elastomeric recoiling features in a new cutting balloon design we have been able to overcome the three main reported adverse events associated with the Boston Scientific cutting balloon. Subsequently we experimentally demonstrated this improved efficacy for one particular peripheral balloon size (e.g., 5 mm diameter).

Endovascular Treatment of the Common Femoral Artery for Limb Ischemia

Objective:

To determine the short- and mid-term outcomes of percutaneous endovascular common femoral artery (CFA) revascularization (eCFR) of the CFA.

Methods:

A review of patients who underwent eCFR for limb ischemia between 2006 and 2012 was performed. Limb salvage, patient survival, survival free from reintervention, and survival free from amputation rates were determined. Median (range) follow-up was 28 (1-71) months.

Results:

In all, 115 patients underwent 121 eCFR for CFA occlusion (n = 13) or stenosis (n = 108); 109 (90%) were technically successful and 7 (6%) had significant perioperative complications; access site hematoma (n = 2) and thromboembolism (n = 5). Thirty-day mortality and amputation rates were 2.5% and 0.8%, respectively. The 1- and 3-year limb salvage rates were 97% and 97%, respectively. The 1- and 3-year survival free from reintervention rates were 77% and 57%, respectively. The 1- and 3-year survival free from amputation rates were 84% and 70%, respectively.

Conclusion:

These novel data demonstrate that eCFR is a durable treatment for patients with limb ischemia associated with CFA disease.

Endovascular treatment of critical ischemia in the diabetic foot: new thresholds, new anatomies

This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.