Percutaneous transluminal angioplasty and enclosed thrombolysis versus percutaneous transluminal angioplasty in the treatment of femoropopliteal occlusions: results of a prospective randomized trial

Rheolytic thrombectomy, angioplasty, and selective stenting for subacute isolated popliteal artery occlusions

OBJECTIVE

We have observed that some patients with isolated popliteal artery occlusions (PAOs) harbor varying degrees of organized clot, as suggested by the rapidity with which these occlusions are traversed with the Glidewire. We hypothesized that debulking such PAOs by using rheolytic thrombectomy without adjunctive thrombolysis before percutaneous transluminal angioplasty and selective stenting (PTA/S) is safe and enables single-session treatment with minimal risk of embolization.

METHODS

Between February 2004 and January 2007, 16 male patients (mean age, 68.9 +/- 11.1 years; range, 54-84 years) presenting with disabling claudication (n = 1), rest pain (n = 5), and tissue loss (n = 10; mean duration, 11 +/- 8 weeks; range, 4-26 weeks) were prospectively followed up after rheolytic thrombectomy and angioplasty and selective stenting of their PAO.

RESULTS

The mean occlusion length was 11.6 +/- 4.5 cm. After rheolytic thrombectomy, the occlusions were converted to long stenoses (mean length of 7.6 +/- 3.6 cm). Self-expanding stents were used in 10 of 16 (mean length of 8.3 +/- 4.4 cm). Additional recanalizations of occlusions of the iliac artery and proximal superficial femoral artery were performed before popliteal artery recanalizations in two patients. Ankle-brachial indexes increased from 0.27 +/- 0.22 to 0.94 +/- 0.13. No case of distal embolization was observed. Adjuvant thrombolysis was used in only one case to improve runoff. Inline flow to the foot was achieved in 15 of 16 cases. Three occlusions occurred at 3, 6, and 20 months after surgery (mean follow-up, 15.7 +/- 10.0 months), and two patients underwent successful thrombolysis. The third patient refused further intervention and remains a claudicant. One-year primary and secondary patency rates were 84% and 92%, respectively. Two limb losses occurred at 7 and 9 months as a result of recurrent foot infection in patients with diabetes, both with patent popliteal arteries (1-year limb salvage rate, 83%).

CONCLUSIONS

We advocate debulking isolated subacute PAOs with rheolytic thrombectomy when they are easily crossed, because this enables recanalization of these lesions in a single setting, thus obviating the additional need for thrombolysis in most cases, with seemingly minimal risk of distal embolization. This simple approach is effective and widely available.

Influence of fibrinogen and hematocrit on the early outcome of angioplasty in patients with PAOD

PURPOSE

To evaluate any correlation of fibrinogen and hematocrit with the early success of balloon angioplasty for peripheral arterial occlusive disease (PAOD) and compare the outcomes of angioplasty in diabetic and nondiabetic patients.

METHODS

From November 1997 through October 2000, 330 patients (246 men; mean age 63.6+/-10.9 years; 221 nondiabetic, 109 diabetic) with known PAOD were treated with percutaneous procedures. The majority of patients (239, 72.4%) were Fontaine stage IIa or IIb; the remaining (91, 27.6%) had critical limb ischemia (Fontaine stages III and IV). Fibrinogen and hematocrit assays were performed on all patients upon admission, and the results were then correlated with early angioplasty success.

RESULTS

With advancing PAOD stage, fibrinogen concentrations increased significantly in both nondiabetic (p<0.006) and diabetic (p<0.02) patients, while angioplasty success rates declined by a factor of 3 in nondiabetics and 2 in diabetics. There was a significantly stronger association between low fibrinogen values and successful interventions relative to unsuccessful interventions (p<0.048). Interestingly, compared with nondiabetics, the angioplasty success rate in diabetics was associated with significantly higher fibrinogen levels (p<0.044) and lower hematocrit (p<0.022).

CONCLUSIONS

Our findings appear to indicate that hemorheological factors, such as fibrinogen and hematocrit, can affect early angioplasty success. Moreover, high fibrinogen concentrations appear to be detrimental to early angioplasty success. Interestingly, low hematocrit levels in diabetics may partially offset the negative effects of hyperfibrinogenemia.