Reporting standards for lower extremity arterial endovascular procedures

Duplex ultrasound for surveillance of lower limb revascularisation

BACKGROUND

Lower extremity atherosclerotic disease (LEAD) - also known as peripheral arterial disease - refers to the obstruction or narrowing of the large arteries of the lower limbs, most commonly caused by atheromatous plaque. Although in many cases of less severe disease patients can be asymptomatic, the major clinical manifestations of LEAD are intermittent claudication (IC) and critical limb ischaemia, also known as chronic limb-threatening ischaemia (CLTI). Revascularisation procedures including angioplasty, stenting, and bypass grafting may be required for those in whom the disease is severe or does not improve with non-surgical interventions. Maintaining vessel patency after revascularisation remains a challenge for vascular surgeons, since approximately 30% of vein grafts may present with restenosis in the first year due to myointimal hyperplasia. Restenosis can also occur after angioplasty and stenting. Restenosis and occlusions that occur more than two years after the procedure are generally related to progression of the atherosclerosis. Surveillance programmes with duplex ultrasound (DUS) scanning as part of postoperative care may facilitate early diagnosis of restenosis and help avoid amputation in people who have undergone revascularisation.

OBJECTIVES

To assess the effects of DUS versus pulse palpation, arterial pressure index, angiography, or any combination of these, for surveillance of lower limb revascularisation in people with LEAD.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared DUS surveillance after lower limb revascularisation versus clinical surveillance characterised by medical examination with pulse palpation, with or without any other objective test, such as arterial pressure index measures (e.g. ankle-brachial index (ABI) or toe brachial index (TBI)). Our primary outcomes were limb salvage rate, vessel or graft secondary patency, and adverse events resulting from DUS surveillance. Secondary outcomes were all-cause mortality, functional walking ability assessed by walking distance, clinical severity scales, quality of life (QoL), re-intervention rates, and functional walking ability assessed by any validated walking impairment questionnaire. We presented the outcomes at two time points: two years or less after the original revascularisation (short term) and more than two years after the original revascularisation (long term).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis when appropriate.

MAIN RESULTS

We included three studies (1092 participants) that compared DUS plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation and arterial pressure index (ABI or TBI) for surveillance of lower limb revascularisation with bypass. One study each was conducted in Sweden and Finland, and the third study was conducted in the UK and Europe. The studies did not report adverse events resulting from DUS surveillance, functional walking ability, or clinical severity scales. No study assessed surveillance with DUS scanning after angioplasty or stenting, or both. We downgraded the certainty of evidence for risk of bias and imprecision. Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (short-term time point) In the short term, DUS surveillance may lead to little or no difference in limb salvage rate (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.49 to 1.45; I² = 93%; 2 studies, 936 participants; low-certainty evidence) and vein graft secondary patency (RR 0.92, 95% CI 0.67 to 1.26; I² = 57%; 3 studies, 1092 participants; low-certainty evidence). DUS may lead to little or no difference in all-cause mortality (RR 1.11, 95% CI 0.70 to 1.74; 1 study, 594 participants; low-certainty evidence). There was no clear difference in QoL as assessed by the 36-item Short Form Health Survey (SF-36) physical score (mean difference (MD) 2 higher, 95% CI 2.59 lower to 6.59 higher; 1 study, 594 participants; low-certainty evidence); the SF-36 mental score (MD 3 higher, 95% CI 0.38 lower to 6.38 higher; 1 study, 594 participants; low-certainty evidence); or the EQ-5D utility score (MD 0.02 higher, 95% CI 0.03 lower to 0.07 higher; 1 study, 594 participants; low-certainty evidence). DUS may increase re-intervention rates when considered any therapeutic intervention (RR 1.38, 95% CI 1.05 to 1.81; 3 studies, 1092 participants; low-certainty evidence) or angiogram procedures (RR 1.53, 95% CI 1.12 to 2.08; 3 studies, 1092 participants; low-certainty evidence). Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (long-term time point) One study reported data after two years, but provided only vessel or graft secondary patency data. DUS may lead to little or no difference in vessel or graft secondary patency (RR 0.83, 95% CI 0.19 to 3.51; 1 study, 156 participants; low-certainty evidence). Other outcomes of interest were not reported at the long-term time point.

AUTHORS' CONCLUSIONS

Based on low certainty evidence, we found no clear difference between DUS and standard surveillance in preventing limb amputation, morbidity, and mortality after lower limb revascularisation. We found no studies on DUS surveillance after angioplasty or stenting (or both), only studies on bypass grafting. High-quality RCTs should be performed to better inform the best medical surveillance of lower limb revascularisation that may reduce the burden of peripheral arterial disease.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action

OBJECTIVES

To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement.

STUDY DESIGN AND SETTING

A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021.

RESULTS

We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description.

CONCLUSION

Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia

OBJECTIVE

In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway (TAP) following intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events following infrainguinal revascularization for CLTI.

METHODS

Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aorto-iliac disease, prior infrainguinal stents or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System (GLASS) scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of re-intervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. Major adverse limb events (MALE) included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation.

RESULTS

184 unique limbs in 163 patients were analyzed. This cohort was composed of 66.9% male patients with a mean age of 72. Baseline characteristics included diabetes (66%), tissue loss (91%) and advanced WIfI stages (30% stage 3, 51% stage 4). GLASS stage 3 anatomic patterns were common (n=119; 65%). 60 limbs were treated with open bypass (65% involving tibial targets) while 124 underwent endovascular intervention (70% including infrapopliteal targets). 12-month freedom from MALE and loss of LBP were 74.0%±3.7% and 48.6%±4.2%, respectively. Diabetes (HR=2.56 [1.13-5.83]; p=.025) and loss of LBP (4.12 [1.96-8.64]; p<.001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR=4.97 [1.89-13.09]; p=.001). Loss of LBP impacted both intermediate-risk limbs (HR=2.85 [1.02-7.97]; p=.047 in WIfI stages 1-3) and high-risk limbs (HR=3.99 [1.32-12.11]; p=.014 in WIfI stage 4). However, loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs. 8% major limb amputation at 12-months in limbs without vs. with maintained LBP).

CONCLUSIONS

Anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).

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.

A systematic review of the ipsilateral retrograde approach to the treatment of femoropopliteal arterial lesions

OBJECTIVE

The endovascular treatment of femoropopliteal lesions is an integral part of managing peripheral arterial disease. The antegrade approach is the most widely used technique with good evidence for its safety and efficacy. However, crossing a lesion, particularly chronic total occlusions (CTO), can be technically challenging and so the retrograde approach is increasingly used to maximize the chances of procedural success. The objective of this systematic review was, therefore, to assess the safety and effectiveness of the ipsilateral retrograde approach to femoropopliteal lesions.

METHODS

A systematic review conforming to the PRISMA standards was undertaken. MEDLINE, EMBASE, and The Cochrane Register were searched between January 1, 1988, and January 1, 2020. Full-text, English-language, peer-reviewed articles pertaining to peripheral arterial disease, endovascular intervention and access site were included.

RESULTS

A total of 8599 articles were screened, of which 38, involving 1940 patients undergoing 2184 retrograde procedures, were included. The mean number of patients per study was 51.1, with three studies including fewer than 10 and four more than 100 patients. The reported follow-up ranged from 30 days to 3 years, and six articles did not report any long-term outcome data. A retrograde approach was used as the primary access route in 45.% of procedures (648/1438) with relevant data. Primary technical success was achieved in 88% (1920/2184; 64%-100%) with a reported complication rate of 11% (235/2117; 0%-27%). Overall, the quality of evidence was poor, with just seven articles deemed to be of high quality with a low risk of bias. A meta-analysis was not deemed appropriate owing to heterogeneity of data.

CONCLUSIONS

An ipsilateral retrograde approach to femoropopliteal lesions has good primary technical success and a low rate of complications. It has a promising role as a bailout, or even a primary access technique, in complex lesions. Patient positioning, puncture site and technique, lesion anatomy, and the size of catheters and devices used are important considerations to achieve the best outcomes. There remains a paucity of robust evidence for its superiority over traditional antegrade approaches, and further work is required to identify the optimal technique and those patients who would benefit most from the approach.

Influence of Infrapopliteal Runoff Vessels on Primary Patency after Superficial Femoral Artery Angioplasty with Stenting in Patients with Claudication

Purpose

The number of infrapopliteal runoff vessels seems to be one of the factors influencing arterial patency in patients who had undergone superficial femoral artery (SFA) angioplasty with stenting. However, the effectiveness of infrapopliteal runoff vessels in predicting patency during SFA angioplasty remains unclear. This study aimed to determine whether the number and quality of infrapopliteal runoff vessels affect the primary patency after SFA angioplasty with stenting in patients with claudication.

Methods

Materials and This study reviewed a retrospective database of patients with claudication who underwent SFA angioplasty with stenting between March 2011 and December 2016. The preoperative computed tomography findings of all patients were reviewed to assess infrapopliteal runoff vessels. The Trans-Atlantic Inter-Society (TASC) II classification and modified Society for Vascular Surgery (SVS) runoff score were used for subsequent analysis. Kaplan–Meier survival curves were constructed, and Fisher’s exact and chi-square tests were used for data analysis.

Results

A total of 153 limbs of 122 patients (88.2% male, mean age: 69.1 years) underwent SFA angioplasty with stenting. The overall primary patency rates of TASC II A/B and C/D cases were 77.1% and 31.2%, respectively, at 36 months (P<0.001). The primary patency rates at 36 months using the modified SVS runoff scoring system were 64.6% and 49.8% for the good-to-compromised (≤9 points) and poor (≥10 points) runoff groups, respectively (P=0.011).

Conclusion

The modified SVS runoff scoring system is effective in predicting primary patency after SFA angioplasty with stenting in patients treated for claudication.

Thromboangiitis obliterans: Aggressive angioplasty provides a potential solution (randomized pilot study)

Background

Thromboangiitis obliterans is an inflammatory disease affecting both medium- and small-sized vessels. Vasodilators, antiplatelets were proposed for treatment but the effect was minimal.

Objective

This study was conducted to investigate the effect of balloon angioplasty on patients with Buerger's disease compared to medical treatment.

Methods

Between January 2006 and December 2016, 82 patients with Buerger's disease were enrolled in the study, of whom 52 were randomized to the aggressive endovascular intervention and 30 were randomized medically by cilostazol and aspirin as a control group. In all, 23% of the patients presented with severe claudication, 50% with ischemic rest pain and 27% with ischemic ulcers. Randomization was done using the opaque envelope method. Allocation concealment was maintained to ensure no selection bias. Patient groups were compared for the duration of ulcer healing, ankle-brachial index, peak systolic velocity changes and transcutaneous oximetry (TcPO2) level for 30 months.

Results

No major procedural complications occurred in the endovascular group. Angiographic success was achieved in 100% of supragenicular lesions but in 90% of infrapopliteal lesions. The endovascular group showed a statistically significant improvement in the ulcer healing size and duration at 6 months after the procedure with a mean time of 3 ± 0.9 months compared to 5.8 ± 1.69 months for the medical treatment group (p < 0.001), the mean TcPO2 from 27.23 ± 16.75 mm Hg (range: 0-56 mm Hg) before the procedure to 71.32 ± 12.94 mm Hg (range: 52-92 mm Hg) following revascularization (p < 0.01). The mean ankle-brachial index significantly improved from 0.54 ± 0.14 preoperatively to 0.82 ± 0.08 at final follow-up (p < 0.01).

Conclusion

The endovascular therapy should be considered as an effective, safe, minimally invasive method in the light of the promising results after a modification of the standard technique.

Angioplasty and stenting for below the knee ulcers in diabetic patients: protocol for a systematic review

BACKGROUND

The worldwide incidence and prevalence of diabetes mellitus (DM) are increasing. DM has a high social and economic burden due to its complications and associated disorders. Peripheral arterial disease (PAD) is closely related to DM. More than 85% of patients with DM will develop PAD in their lifetime, and between 10 and 25% of patients with DM will have a foot ulcer. In such cases, it is important to determine for each patient whether it is necessary and feasible to revascularise the affected limb as well as the optimal technique. Percutaneous transluminal angioplasty (PTA) is designed to restore blood flow through the vessel lumen by various devices including balloons, drug-coated balloons, bare stents, drug-eluting stents and endovascular atherectomes. This systematic review aims to evaluate the effects of PTA in the treatment of lower limb arterial ulcers in diabetic patients.

METHODS

We will search randomised controlled trials (RCTs) and quasi-RCTs in the following databases (e.g., MEDLINE via PubMed, EMBASE, Lilacs, Cochrane Central Register of Controlled Trials, Ibecs, CINAHL, AMED, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov , and OpenGrey). Our search strategy will use the following free-text terms and controlled vocabulary (e.g., Emtree, MeSH) for 'foot ulcer', 'leg ulcer', 'diabetic foot', 'Peripheral Arterial Disease', 'Diabetes Complications', 'Peripheral Vascular Diseases', 'critical limb ischemia', 'below the knee ulcer', 'angioplasty', 'stents', 'stenting', and 'endovascular procedures'. There will be no limits on date or language of publication. Two authors will, independently, select studies and assess the data from them. Risks of bias (RoB) of included studies will be evaluated using the Cochrane's RoB tool. If possible, we will perform and report structured summaries of the included studies and meta-analyses. Results are not available as this is a protocol for a systematic review, and we are currently in the phase of building a sensitive search strategy.

DISCUSSION

While there are several available endovascular techniques for revascularisation, it is unclear which technique has better outcomes for ulcers below the knee in diabetic patients. A systematic review is required to validate and demonstrate these techniques and their outcomes to allow an evidence-based clinical decision.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017065171.

Clinical outcomes of extended endovascular recanalization of 16 consecutive Buerger’s disease patients

Objective

Buerger’s disease is one of the worst diseases causing peripheral artery occlusions (especially lower extremity) with increased morbidity and mortality. Endovascular treatment of the diseased arteries gains preference over bypass surgery nowadays. Here, we aimed to present the clinical outcomes of 16 consecutive Buerger’s disease patients underwent extended endovascular recanalization which is a new technique to restore direct blood flow to at least one foot artery, with the performance of angioplasty for each tibial and foot artery obstructions.

Methods

A total of 16 consecutive patients with confirmed diagnosis of Buerger’s disease that percutaneously treated in our center between February 2014 and March 2018 were included in the study. The mean age of the patients was 44.25 ± 4.28 ranging from 36 to 50 years. After physical examination and complementary diagnostic tests, performance of extended angioplasty for occluded arteries was intended to restore direct blood flow to at least one of the blow-the-knee arteries.

Results

A successful extended endovascular treatment was performed in 20 of 22 limbs, achieving a technical success of 91%. All patients were successfully discharged without any complication. Mean follow-up duration was 21.43 ± 7.08 months. Reintervention was performed in one patient and minor amputation was needed in one of the failed limbs. Limb salvage rate was 100%. A significant difference was observed based on Rutherford classification, ankle brachial index, direct blood flow to foot, presence of ulcer and rest pain when compared before and after the intervention.

Conclusion

We showed successful extended endovascular recanalization of Buerger’s disease patients with a high technical success rate and sustained clinical improvement. Extended endovascular recanalization could be a therapeutic option in Buerger’s disease patients, since they are not good candidates for surgery.

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia

OBJECTIVES

This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options.

BACKGROUND

Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported.

METHODS

We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016.

RESULTS

All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months.

CONCLUSION

Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.

Outcome of Surgical and Endoluminal Intervention for Infrainguinal Bypass Anastomotic Strictures

The objective of this study was to compare the outcomes of percutaneous transluminal angioplasty (PTA) versus open surgical repair of anastomotic strictures affecting infrainguinal bypasses. Anastomotic strictures affecting 39 bypasses in 36 patients were identified among 593 consecutive infrainguinal arterial reconstructions performed between 1994 and 2004. The mean age of affected patients was 65 ±2 years (range: 61 to 101 years). The original bypasses, with vein grafts outnumbering prosthetic grafts 2 to 1, were performed for acute (5%) and chronic (54%) limb-threatening ischemia, disabling claudication (28%), or popliteal aneurysms (13%). Anastomotic strictures were first recognized an average of 16 ±3 months (range 2 to 92 months) postoperatively. Strictures affected the distal anastomosis in 62% of cases and the proximal anastomosis in 38%. Primary patency, assisted primary patency, secondary patency, and limb salvage were assessed following PTA or open surgical repair of the strictures. Anastomotic strictures were detected following acute (41%) and chronic (18%) limbthreatening ischemia, claudication (13%), or during routine graft surveillance (28%) in asymptomatic patients. Graft thrombosis, occurring in 51% of patients at the time of presentation, was not affected by the site of anastomotic stricture, although prosthetic grafts were affected more than vein grafts (92% vs 31%). Interventions included PTA (67%) and conventional open procedures (33%). The latter included vein patch angioplasty, short interposition grafts, and redo bypasses. The stricture site and bypass material used in the original revascularization did not affect reintervention patency rates. Sixteen (62%) of the endovascular procedures were performed on a graft presenting with thrombosis, while only 4 (31%) were initially treated with operative therapy. Treatment of thrombosed grafts resulted in an 18-month patency of 32% compared to an 80% patency in treating grafts that were not occluded at the time of presentation (p <0.05). No anastomotic stricture repaired operatively required reintervention, whereas 42% of those treated by PTA required a mean of 1.3 additional reinterventions (p <0.03). Anastomotic strictures affecting infrainguinal bypass grafts contribute to low patency rates. Outcomes can be significantly improved if these strictures are identified before graft thrombosis. Open surgical repair, compared to PTA, provides improved graft function as evident by fewer subsequent interventions required to maintain graft patency.

Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology

Accompanying the rapid growth of interest in percutaneous vascular interventions, there has been increasing interest among cardiologists in performing noninvasive vascular testing using ultrasound. In an attempt to provide recommendations on the best practices in vascular laboratory testing, this report has been prepared by a writing group from the American Society of Echocardiography (ASE) and the Society for Vascular Medicine and Biology. The document summarizes principles integral to vascular duplex ultrasound--including color Doppler, spectral Doppler waveform analysis, power Doppler, and the use of contrast. Appropriate indications and interpretation of carotid artery, renal artery, abdominal aorta, and peripheral artery ultrasound imaging are described. A dedicated section summarizes noninvasive techniques for physiologic vascular testing of the lower extremity arteries--including measurement of segmental pressures and pulse volume plethysmography. The use of exercise testing in the evaluation of peripheral artery disease, ultrasound evaluation of the lower extremities after percutaneous revascularization, and the diagnosis and management of iatrogenic pseudoaneurysm (PSA) is also discussed. A section on the important topic of vascular laboratory accreditation is included. Finally, additional details regarding proper technique for performance of the various vascular tests and procedures are included in the Appendix.

Infrainguinal Atherectomy Using the Transluminal Endarterectomy Catheter: Patency Rates and Clinical Success for 144 Procedures

Purpose:

To determine if atherectomy using the transluminal endarterectomy catheter (TEC) is an effective endoluminal therapy for infrainguinal occlusive disease.

Methods:

Three surgeons used the TEC for 144 infrainguinal atherectomy procedures in 133 patients. The indications were severe claudication in 83, critical ischemia in 56, and graft stenosis in 5 limbs. The pathology was stenosis in 36 and occlusion in 105 limbs. Balloon dilation was also performed in 109 and stenting in 17 limbs.

Results:

There was initial technical and anatomic success in 124 (86%) procedures. There were 67 technically successful procedures at mean follow-up of 19 months, although 3 of these limbs with gangrene and extensive distal disease required major amputation. There were 26 failures due to stenosis leading to further intervention and 51 due to occlusion. Twenty of these cases were managed conservatively, 21 were treated with repeat endovascular intervention, 31 with bypass grafting, and 5 with amputation. Repeat intervention in 52 limbs resulted in 36 with patent arteries, 10that are occluded, and 6that required amputation. Thirteen of the 14 amputations were for limbs with critical ischemia, but 1 was in a patient with claudication. Life-table analysis showed that the primary patency rate was 51%, the assisted primary patency rate was 61%, and the secondary patency rate was 75% at 15 months. The clinical success rate was 49%, and the salvage rate for limbs with critical ischemia was 78% at 12 months. Univariate log-rank testing showed no significant differences according to the clinical presentation or pathology, but results were worse for lesions > 5 cm long due to more frequent immediate failures. However, multivariate Cox regression analysis showed that results were significantly worse for critical ischemia than for claudication, stenosis compared to occlusions, for limbs with poor runoff, for operations performed by percutaneous rather than an open approach, and for those performed more recently.

Conclusions:

TEC atherectomy may have a place in selected patients, but the optimal circumstances for its use and long-term efficacy require further study.

Clinical Experience with a New Nitinol Self-Expanding Stent in Peripheral Arteries

Purpose:

To evaluate a new self-expanding nitinol coil stent in stenotic or occluded peripheral arteries.

Methods:

Seventy-three symptomatic patients (58 men; mean age 67 years) were treated with nitinol stents for lesions in the iliac artery (9 stenoses); superficial femoral artery (SFA) (39 stenoses, 6 occlusions); popliteal artery and tibioperoneal trunk (9 stenoses, 7 occlusions); and 3 bypass grafts. Mean diameter stenosis was 84.4% ± 9.9% (range 75% to 100%), and mean lesion length was 45 ± 23 mm (range 20 to 120 mm).

Results:

Eighty-eight 40-mm-long stents with diameters between 5 and 8 mm were implanted percutaneously for suboptimal dilation (n = 45); dissection (n = 21); and restenosis (n = 7). All stents but one were implanted successfully; the malpositioned stent was removed, and another stent was successfully deployed. There were 3 (4.1%) failures due to thrombosis at 24 hours. During the mean 16-month follow-up (range to 44 months), 4 restenoses (3 femoral, 1 popliteal) have occurred; 2 were treated with repeat dilation and 2 underwent bypass. Primary and secondary patency rates at 18 months were 87% and 90%, respectively, for all lesions (iliac: 100% for both; femoral: 85% and 88%; popliteal: 87% and 100%).

Conclusions:

This new nitinol stent seems to be safe and effective with favorable long-term results, even in distal SFA lesions and popliteal arteries. Its flexibility and resistance to external compression allow its placement in tortuous arteries and near joints.

Strecker Stents in the Femoropopliteal Arteries: Value of Duplex Ultrasonography in Restenosis Assessment

Purpose:

Experience with Strecker stent implantation in the femoropopliteal arteries has been described; however, few of the reports were prospective studies, and none routinely used site-specific assessment methods for follow-up evaluation of stent patency. The purpose of this study was to evaluate 1-year Strecker stent patency using duplex ultrasound imaging to obtain a more precise delineation of stent restenosis than is possible with other noninvasive assessment modalities.

Methods:

A prospective study involved 52 patients with 57 sites treated by angioplasty and Strecker stent deployment in the femoropopliteal arteries. Assessment included clinical evaluation; ankle-brachial index (ABI) measurements at rest and after exercise; and duplex ultrasound imaging preprocedurally and at 3 and 12 months after the intervention.

Results:

All 74 stents were deployed successfully in the 35 occluded arteries and 22 stenotic lesions. Acute reocclusion occurred in 6 (10%). At 3 months, primary patency was 81% and secondary patency 84%. Mean (± SD) ABIs increased from 0.64 ± 0.15 at rest and 0.32 ± 0.17 after exercise to 0.89 ± 0.14 and 0.68 ± 0.23, respectively (p < 0.0001). At 12 months, primary patency was 79%, and secondary patency was 82%. Mean ABIs were 0.82 ± 0.15 at rest and 0.52 ± 0.22 after exercise at 12 months (p < 0.0001 compared with preprocedural ABIs). Analysis of the length of lesion treated showed better results with shorter diseased segments, but this was not statistically significant (p > 0.05). Better outcomes were also obtained when one stent was used rather than two stents at 12 months (p = 0.15), but there was no difference at 3 months (p = 0.3). Thirty-four percent of the stented segments progressed from < 20% stenosis at 3 months to > 50% stenosis at 12 months. Overall, 19 (43%) of 44 segments progressed from < 50% stenosis at 3 months to a > 50% stenosis at 12 months. Restenosis seen at 3 months generally was in the native artery just proximal or distal to the stent, but at 12 months, restenosis was mainly inside the stent.

Conclusions:

Strecker stents at 1-year demonstrated satisfactory patency in the femoropopliteal arteries when deployed for angioplasty salvage or recurrent disease. The 3- and 12-month evaluations obtained with duplex ultrasound provided site-specific hemodynamic data for stent assessment. Resting ankle pressures were a poor index of restenosis.

Endoluminal Grafting for Aneurysmal and Occlusive Disease in the Superficial Femoral Artery: Early Experience

Purpose:

To examine whether endoluminal grafts (ELGs) of radially expandable polytetrafluoroethylene (PTFE) can successfully form durable internal conduits to revascularize lengthy occlusive disease and exclude aneurysms in the femoropopliteal (FP) arteries.

Methods:

Under protocol, implantation of an unpredilated PTFE tube ELG anchored with Palmaz stents using a low-profile percutaneous delivery system was attempted in 50 symptomatic patients for a variety of pathologies: (1) restenosis; (2) complex lesions unlikely to be treated successfully with other endoluminal therapies; (3) acute angioplasty failure; and (4) aneurysms. There were 37 occlusions, 14 stenoses, and 2 long, combined stenoticaneurysmal lesions in 47 native arteries, 5 FP grafts, and 1 femorotibial (FT) vein graft. Thirty-two percent of the patients had ≤ 1 vessel runoff. The average lesion length was 20.4 ± 11.4 cm (range 1.5 to 40), and the mean preoperative ankle-brachial index (ABI) at rest was 0.53 ± 0.14.

Results:

In a 20-month period through April 1995, 50 patients (34 males, 16 females; mean age 69.5 years, range 45 to 87) underwent 54 procedures in 53 limbs; 55 ELGs were successfully deployed in 51 limbs; 2 patients were converted to FP bypass owing to technical problems (96% procedural success). There were 18 inhospital complications: 1 distal wire dissection repaired with an additional ELG; 2 hematomas requiring surgical repair; 1 graft collapse; 1 pseudoaneurysm at the site of a mid-ELG leak; 7 minor access sequelae; and 6 acute ELG thromboses, 4 treated with lytic therapy and balloon dilation, 1 with open thrombectomy, and 1 with bypass grafting. The mean postoperative ABI was 1.01 ± 0.10. During the 30-day postprocedure period, 2 ELGs rethrombosed and 2 other limbs (3 ELGs) occluded; 1 thrombosis and 1 rethrombosis were lysed successfully, but the other 2 patients had an FP bypass. Over the mean 8.3 ± 5.5 month follow-up, 6 additional ELGs occluded and 1 reoccluded; 4 were successfully treated by endovascular techniques for a primary patency of 72% and secondary patency of 84% by life-table analysis.

Conclusions:

Endovascular grafting is a conceptually attractive technique that has the potential to expand the current boundaries of interventional treatment. This preliminary experience attests to the feasibility and safety of ELG deployment in the superficial femoral arteries. Whether such a device can match the durability of classical revascularization techniques remains to be determined in clinical trials when device configurations and deployment techniques have been standardized.

Iliac and Femoropopliteal Lesions: Evaluation of Balloon Angioplasty and Classical Surgery

Purpose:

The purpose of this study was to compare the characteristics of patients treated for atherosclerotic disease of the lower extremities with balloon angioplasty (BA) or classical surgery (CS) and to assess the outcome of both techniques.

Methods:

The records of 1364 patients who were treated with BA or CS for chronic lower limb ischemia between 1986 and 1993 were analyzed. Demographic features of patients, immediate and long-term survival, patency, and amputation rates were compared in both groups according to the level of the revascularization (iliac or femoropopliteal).

Results:

Patients undergoing BA were slightly younger (62.3 years versus 65.9 years for CS group; p = NS) and demonstrated symptoms consistent with less severe atherosclerotic disease (81% claudication in the BA group versus 48% in the CS patients; p < 0.001). At 30 days post-treatment in the BA and CS groups, respectively, there were 0.7% and 4% deaths (p < 0.01); 13% and 6% primary failures (p = 0.013); 13% and 6% secondary failures (p = 0.01); 0.3% and 12% general complications (p = 0.001); and 3% and 8% nonvascular complications (p = 0.007). At the iliac level, in the angioplasty (n = 134 limbs) and surgery (n = 721 limbs) groups, respectively, the mean age was 57.6 and 63.7 years (p < 0.01), and claudication was present in 91% and 72. Perioperative mortality was 0% and 1.9. The 4-year survival rates were 95% and 88%; patency was 70% and 79%; and the amputation rates were 0% and 5. At the femoropopliteal level, in the angioplasty (n = 138 limbs) and surgery (n = 656 limbs) groups, respectively, the mean age was 67.8 and 66.8 years (NS), and claudication was present in 69% and 28. Perioperative mortality was 0.9% and 5.5. The 4-year survival rates were 95% and 78%; and patency was 44% and 65. At 2 years, the amputation rates were 6% and 12.

Conclusions:

Patients treated by BA were younger, especially in the iliac group, and had less symptomatic lesions than patients treated with surgery. Surgery achieved a better long-term patency at the cost of a higher immediate complication rate and mortality. Whenever technically feasible, BA may be the better choice for initial therapy in appropriate patients suffering from chronic lower limb ischemia.

Immediate Stenting of Iliofemoral Occlusive Lesions: A Surgeon's Early Experiences

Purpose:

To report the early and midterm results of balloon angioplasty and immediate stenting of atherosclerotic iliofemoral lesions in an operating room setting.

Methods:

Sixty-one patients (41 men, mean age 70 ± 8 years, range 49 to 86) underwent balloon dilation and systematic stenting for 80 stenotic and occlusive lesions in the iliac (n = 47) and superficial femoral (n = 33) arteries in 72 limbs. One hundred two stents (63 VascuCoil, 33 Wallstent, and 6 miscellaneous) were placed. Patients were followed with serial duplex scans at 3-month intervals.

Results:

Initial technical success by intention-to-treat was 96.2% (77/80) (iliac: 100%, femoral: 90.9% [30/33]). There were 9 (11.3%) procedure-related complications and no deaths. Initial success by anatomic, hemodynamic, and clinical limb criteria were 100%, 95%, and 94.4%, respectively. Thirty procedures were performed for limb salvage with a success rate of 86.7%. Six patients (7 limbs) died during follow-up of unrelated causes. Fifty-nine (81.9%) limbs were available for duplex follow-up over a mean 17.7 months (range 3 to 37). Cumulative patency rates were 87.3% at 2 years for iliac stents and 66.6% at 18 months for femoral stents with an overall 2-year patency rate of 76.3%. The only independent risk factors affecting late patency were the site of angioplasty, stent diameter, lesion grade, and the preoperative ankle-brachial index. Stents placed with a diameter ≤ 5 mm and > 5 mm had 1-year patency rates of 51.0% and 97.6%, respectively (p = 0.004)

Conclusions:

Iliac and femoral angioplasty and immediate stenting have acceptable midterm patency rates. The patency of femoral stenting is inferior and is adversely affected by stents ≤ 5 mm in diameter.

Long-term Results with the Palmaz Stent in the Superficial Femoral Artery

Purpose:

Femoral stenting has demonstrated inconsistent and often disappointing long-term results. To compare our experience, we retrospectively analyzed a series of patients who had Palmaz balloon-expandable stents placed exclusively for superficial femoral artery (SFA) lesions.

Methods:

From January 1990 to November 1993, 39 patients were evaluated for claudication (79%) or critical ischemia in 42 limbs. The culprit lesions were confined to the SFA: 24 (57%) occlusions and 18 (43%) stenoses, including 3 restenotic lesions. Stenting was elective in 12 (29%) cases: the 3 restenoses and 9 chronic, calcified occlusions. The remaining stents were applied for postangioplasty residual stenosis or angioscopic findings of thrombogenic luminal irregularities. A total of 55 prostheses were successfully implanted. All patients were maintained on ticlopidine and followed by routine duplex scanning. Follow-up angiography was performed in 28 (72%) patients between 4 and 45 months.

Results:

In the postprocedural period, two acute thromboses (4.8%) occurred within 48 hours in patients who had long occlusions and poor runoff; no other major complications were encountered, for a clinical success rate of 95%. Follow-up evaluation ranged from 4 months to 4 years with a mean of 25 months. The restenosis rate was 19% (34% in occlusions; 10% in stenotic lesions, p = NS). At 24 months, cumulative primary patency was 77% and secondary patency 89%.

Conclusions:

Palmaz stents performed well in the SFA, demonstrating a low acute thrombosis rate and good long-term patency. The incidence of restenosis is likely to be greater in occlusions than in stenoses.

Does Conversion of Intended Remote Iliac Artery Endarterectomy Alter the Early and Long-Term Outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures.

From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39–83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures.

Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 ± 15% to a primary assisted patency of 88 ± 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 ± 7.4%. The primary and secondary patency rates in group 2 were 86 ± 19% and 100%, respectively.

RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.

Impact of runoff grade after endovascular therapy for femoropopliteal lesions

BACKGROUND

We conceived a new method, runoff grade, to evaluate runoff after endovascular therapy (EVT). We evaluated the validity of using runoff score based on angiographic findings.

METHODS

The subjects were 859 consecutive patients (males, 69%; mean age, 73.0 ± 9.0 years) who underwent EVT for de novo femoropopliteal lesions at Kokura Memorial Hospital. We evaluated the postprocedural tibial runoff, named it runoff grade, classified it into 0 through 2, and retrospectively assessed the relationship with the outcome of EVT. Primary, secondary, and assisted primary patency rates and freedom from major adverse limb events (MALE) were compared between runoff grades.

RESULTS

The mean follow-up period was 31 ± 25 months. The lesion length was 91.5 ± 83.0 mm. The rate of stent use was 52.0%. The primary patency rates at 1, 2, and 3 years were 68.1%, 59.1%, and 53.9%; the secondary patency rates were 90.9%, 88.1%, and 85.9%; the assisted primary patency rates were 79.4%, 72.6%, and 68.5%; and freedom from MALE was 72.5%, 64.8%, and 61.0%, respectively. The primary patency rates at 1, 2, and 3 years were significantly lower in the runoff grade 0 group than in the other groups (55.5% vs 66.7% and 75.6%; 35.8% vs 57.6% and 69.2%; 35.8% vs 53.3% and 60.9% for grade 0, 1, 2, respectively; log-rank, P < .0001). Secondary patency rate (78.5% vs 91.8% and 91.8%; 76.3% vs 88.6% and 89.9%; 72.8% vs 86.3% and 88.2%, respectively; P = .015), assisted primary patency rate (67.0% vs 78.5% and 85.1%; 56.9% vs 71.6% and 79.3%; 47.6% vs 68.0% and 74.8%; respectively, P = .0002), and freedom from MALE (60.8% vs 71.2% and 79.4%; 44.3% vs 64.0% and 72.6%; 36.6% vs 60.7% and 68.5%, respectively; P < .0001) were also similar. After adjustment for age, gender, diabetes, hemodialysis, critical limb ischemia, TransAtlantic Inter-Society Consenus II classification, and stent use, runoff grade was an independent predictor of primary patency.

CONCLUSIONS

Vessels with runoff grade 0 had significantly worse cumulative outcomes. Our results suggested that runoff grade seemed to play an important role to keep the primary patency.

Two-year outcome of the self-expandable stent for chronic total occlusion of the iliac artery

To evaluate the 2-year results obtained with self-expandable stent for chronic total occlusion (CTO) of the iliac artery, a retrospective study was performed of patients who underwent endovascular therapy (EVT) for chronic iliac artery CTO who presented from April 2007 to September 2012. 82 patients with 86 occluded iliac arteries underwent successful recanalization and stenting with a self-expandable stent. The primary equivalence end point was a composite of restenosis, mortality, target vessel revascularization, and limb salvage rates. Patients were followed up with the presence of a palpable femoral artery pulse, resolution of symptoms, and noninvasive vascular laboratory testing reviewed at 1, 3, and 6 months after EVT and then were evaluated at 6-month intervals. In patients who gave consent, repeat angiography was done in sixty-one of 86 lesions (70.1 %) for follow-up. The mean follow-up was at 27.6 ± 17.8 months (range 3-60 months). All stents were placed in the true lumen under intravascular ultrasound (IVUS) guidance. There were no cases of peripheral embolization or iliac artery rupture after the procedure. The ankle-brachial index increased significantly from 0.55 ± 0.19 to 0.88 ± 0.17 (P < 0.001). The primary patency rate was 96.5 % at 2 years. The MLD immediately after the procedure was 5.10 ± 0.26 mm and increased significantly to 5.40 ± 0.28 mm at the period of follow-up angiography. The 2-year outcome of endovascular therapy with self-expandable stents for CTO of the iliac artery had an acceptable result.

Mid-term outcomes following endovascular re-intervention for iliac artery in-stent restenosis

OBJECTIVES

We sought to evaluate the procedural characteristics and clinical outcomes of endovascular repair for iliac artery (IA) in-stent restenosis (ISR).

BACKGROUND

An increasing percentage of patients with complex IA occlusive disease are treated with an endovascular approach, but the outcomes of IA-ISR have not been well described.

METHODS

We analyzed all endovascular procedures for treatment of IA-ISR performed at our institution between July 2006-December 2010. The primary outcome was primary patency, defined as <50% stenosis as assessed by clinical examination and duplex ultrasonography (DUS).

RESULTS

Forty-one lesions in 24 patients who underwent repeated endovascular intervention for treatment of IA-ISR. Most lesions were unilateral and involved the common IA (66%). The mean length of ISR was 30.1 ± 14.1 mm with type I (focal) and II (diffuse) ISR occurring with the greatest frequency (34% and 39%, respectively). All patients underwent balloon angioplasty; adjunctive stenting zwas performed in 27 (66%) of the lesions. Type II ISR lesions more frequently required stenting (13/16 lesions, P = 0.02 compared with other patterns of ISR). Procedural success was 100% with a mean gain of 0.13 in the ankle-brachial index (P = 0.001). The 6- and 12-month primary patency rates were 96% and 82%, respectively. The 12-month primary-assisted patency rate was 90% with clinically driven target lesion revascularization (TLR) in three patients.

CONCLUSIONS

Endovascular treatment of IA-ISR using an approach of balloon angioplasty followed by selective stenting is associated with high-patency rates and low rates of TLR at 1 year.

The number of patent tibial vessels does not influence primary patency after nitinol stenting of the femoral and popliteal arteries

OBJECTIVE

Initial TransAtlantic Inter-Society consensus (TASC) II classification has been shown to influence the patency of stented femoral and popliteal arteries. Although several studies have shown the effect of the number of runoff vessels on the durability of infrainguinal angioplasty without stenting, the influence of tibial vessel runoff on the patency of primarily stented femoral and popliteal arteries has not been as well defined. The purpose of this study was to determine whether the number of patent tibial vessels affects primary patency after primary stenting of the femoral and popliteal arteries.

METHODS

The records of all patients undergoing angioplasty and primary nitinol stenting of the femoral and popliteal arteries, by or under the supervision of one vascular surgeon, were reviewed. Results were analyzed by both the number of patent tibial vessels documented on periprocedural angiography and by using a modified Society for Vascular Surgery runoff score. TASC II classification was also recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. Fisher exact and χ(2) tests were used to compare categoric factors.

RESULTS

During a 7-year period, 289 limbs in 236 patients underwent primary stenting of the femoral and popliteal arteries. Overall primary patency was 70.3% at 12 months, 52.4% at 24 months, and 39.1% at 36 months. Limbs classified as TASC A or B had significantly better patency rates than those classified as TASC C or D (P < .001). While the number of runoff vessels decreased with worsening of the TASC classification (P = .024), overall (P = .355), and within individual TASC classes (P ≥ .092 for each), there was no difference in the primary patency of stented segments with good runoff and those with compromised runoff. Limbs with poor runoff (one or no vessels) were no more likely to fail with occlusion than their counterparts with two or three patent tibial vessels (P = .383). The number of patent tibial vessels at the time of initial stenting did not impact ultimate limb salvage (P = .063).

CONCLUSIONS

The number of patent tibial vessels does not influence the primary patency of primarily stented femoral and popliteal arteries. TASC II classification appears to be significantly more predictive of initial failure after angioplasty and stenting of these vessels.

A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease

OBJECTIVE

This trial was conducted to determine if covered stents offer a patency advantage over bare-metal stents in the treatment of aortoiliac arterial occlusive disease.

METHODS

The Covered Versus Balloon Expandable Stent Trial (COBEST), a prospective, multicenter, randomized controlled trial, was performed involving 168 iliac arteries in 125 patients with severe aortoiliac occlusive disease who were randomly assigned to receive a covered balloon-expandable stent or bare-metal stent. Patient demographic data, clinical signs and symptoms, TransAtlantic Inter-Society Consensus (TASC) classification, and preprocedure and postprocedure ankle-brachial index measurements were recorded. The primary end points included freedom from binary restenosis and stent occlusion of the treated area, as determined by ultrasound imaging or quantitative visual angiography, or both. Postprocedural follow-up was at 1, 6, 12, and 18 months.

RESULTS

Aortoiliac lesions treated with a covered stent were significantly more likely to remain free from binary restenosis than those that were treated with a bare-metal stent (hazard ratio [HR], 0.35; 95% confidence interval (CI), 0.15-0.82; P = .02). Freedom from occlusion was also higher in lesions treated with covered stents than in those treated with a bare-metal stent (HR, 0.28; 95% CI, 0.07-1.09); however, this did not reach statistical significance (P = .07). Subgroup analyses demonstrated a significant difference in freedom from binary restenosis for covered stents in TASC C and D lesions compared with a bare stent (HR, 0.136; 95% CI, 0.042-0.442). This difference was not demonstrated for TASC B lesions (HR, 0.748; 95% CI, 0.235-2.386).

CONCLUSIONS

COBEST demonstrates covered and bare-metal stents produce similar and acceptable results for TASC B lesions. However, covered stents perform better for TASC C and D lesions than bare stents in longer-term patency and clinical outcome.

Ambulatory percutaneous angioplasty in patients with claudication

BACKGROUND

The aim of this study was to evaluate the feasibility of outpatient peripheral angioplasty in patients who were treated for lower limb claudication.

METHODS

Between February 1 and December 31, 2007, a monocentric observational study was carried out on 98 consecutive patients who presented with claudication (mean age: 63 years [range: 31-90]; 81 men) and were treated by using a percutaneous femoral approach for either iliac (n = 62) or femoropopliteal lesions (n = 36). Exclusion criteria were requiring a renal angioplasty or an associated surgical procedure, having a creatinine clearance value of <30 mL/min/1.73 m(2), body mass index exceeding 35 kg/m(2), and critical ischemia or vascular surgery history at the site of femoral puncture. Treatment involved manual compression and/or use of a closure system, after which the patients were made to wear a compression bandage. After 4 hours, the patients were carefully examined for the presence of a local complication (puncture site), a general complication (thoracic pain), or a complication related to the surgical procedure (early thrombosis). When no complications were detected, the patients were allowed to get up and walk. At the sixth hour, the patients were again examined for the presence of the aforementioned complications. In the absence of any complications, the patients were deemed as "fit to be discharged" and were allowed to stroll about inside the hospital. The following day, a final evaluation was carried out just before their discharge. The risk factors and comorbidities were evaluated.

RESULTS

At the sixth postoperative hour, 78 patients (80%) were deemed as "fit to be discharged." The remaining 20 (20%) were deemed as "unfit to be discharged" because of either a major hematoma (n = 3, including two redo surgeries and a blood transfusion) or a minor evolutive hematoma. All the complications (n = 17) occurred before the fourth postoperative hour. Bilateral femoral puncture was the only risk factor found to be associated with contraindication to being discharged in the evening (OR = 3.8, p = 0.02).

CONCLUSION

Ambulatory treatment for patients with claudication treated with an endovascular approach was possible because complications that required overnight surveillance always occurred within the first 4 postoperative hours. Bilateral femoral puncture is a potential risk factor for failure of outpatient management.

Four-year randomized prospective comparison of percutaneous ePTFE/nitinol self-expanding stent graft versus prosthetic femoral-popliteal bypass in the treatment of superficial femoral artery occlusive disease

BACKGROUND

This is a randomized prospective study comparing the treatment of superficial femoral artery occlusive disease percutaneously with an expanded polytetrafluoroethylene (ePTFE)/nitinol self-expanding stent graft (stent graft) versus surgical femoral to above-knee popliteal artery bypass with synthetic graft material.

METHODS

One hundred limbs in 86 patients with superficial femoral artery occlusive disease were evaluated from March 2004 to May 2005. Patient symptoms included both claudication and limb threatening ischemia with or without tissue loss. Trans-Atlantic InterSociety Consensus (TASC II) A (n = 18), B (n = 56), C (n = 11), and D (n = 15) lesions were included. Patients were randomized prospectively into one of two treatment groups; a percutaneous treatment group (group A; n = 50) with angioplasty and placement of one or more stent grafts, or a surgical treatment group (group B; n = 50) with a femoral to above-knee popliteal artery bypass using synthetic conduit (Dacron or ePTFE). Patients were followed for 48 months. Follow-up evaluation included clinical assessment, physical examination, ankle-brachial indices, and color flow duplex sonography at 3, 6, 9, 12, 18, 24, 36, and 48 months.

RESULTS

Mean total lesion length of the treated arterial segment in the stent graft group was 25.6 cm (SD = 15 cm). The stent graft group demonstrated a primary patency of 72%, 63%, 63%, and 59% with a secondary patency of 83%, 74%, 74%, and 74% at 12, 24, 36, and 48 months, respectively. The surgical femoral-popliteal group demonstrated a primary patency of 76%, 63%, 63%, and 58% with a secondary patency of 86%, 76%, 76%, and 71% at 12, 24, 36, and 48 months, respectively. No statistical difference was found between the two groups with respect to primary (P = .807) or secondary (P = .891) patency.

CONCLUSION

Management of superficial femoral artery occlusive disease with percutaneous stent grafts exhibits similar primary patency at 4-year (48 month) follow up when compared with conventional femoral-popliteal artery bypass grafting with synthetic conduit. This treatment method may offer an alternative to treatment of the superficial femoral artery segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable.

Outcome analysis of infrapopliteal percutaneous transluminal angioplasty and bypass graft surgery with nonreversed saphenous vein for individuals with critical limb ischemia

OBJECTIVE

To compare the results of percutaneous transluminal angioplasty (PTA) and bypass graft surgery (BGS) for the treatment of infrapopliteal lesions in individuals presenting with critical limb ischemia (CLI).

METHOD

A total of 48 infrapopliteal PTAs and 50 infrapopliteal BGS were compared retrospectively. All grafts used nonreversed saphenous vein in a single length as a substitute.

RESULTS

Secondary patency and limb salvage rates in 24 months for the surgical group were 64.7% and 73.2%, respectively. For PTA group, these values were 63.7% and 68.2%, without differences between groups (log rank; P = .45 and .39, respectively). Bypass graft surgery presented better results of secondary patency (72.9% vs 57.1%) and limb salvage (83.5% vs 53.6%) than PTA for patients with Transatlantic Inter-Society Consensus (TASC) D lesions (P = .04 and P = .01, respectively).

CONCLUSIONS

Both BGS and PTA provided similar results of patency and limb salvage for individuals with infrapopliteal atherosclerotic disease presenting with CLI. Bypass graft surgery had better results than PTA when TASC D lesions were present.

Long-term outcomes of diabetic patients undergoing endovascular infrainguinal interventions

OBJECTIVE

Diabetes mellitus (DM) has traditionally predicted poor outcomes after lower extremity revascularization for peripheral vascular disease (PVD). This study assessed the influence of DM on long-term outcomes of percutaneous transluminal angioplasty, with or without stenting (PTA/stent), in patients with PVD.

METHODS

From January 2002 to December 2007, 920 patients underwent 1075 PTA/stent procedures. Patients were stratified into DM and non-DM cohorts. Study end points included primary patency (PP), assisted patency (AP), limb salvage, and survival and were evaluated using Kaplan-Meier and Cox regression analyses.

RESULTS

There were 533 DM and 542 non-DM limbs. Median follow-up was 34 months. Overall, the 5-year actuarial PP was 42% +/- 2.4%, AP was 81% +/- 2.0%, limb salvage was 89% +/- 1.6%, and survival was 60% +/- 2.4%. On univariate analysis, DM vs non-DM was associated with inferior 5-year PP (37% +/- 3.4% vs 46% +/- 3.3%; P = .009), limb salvage (84% +/- 2.6% vs 93% +/- 1.8%, P < .0001), and survival (52% +/- 3.5% vs 68% +/- 3.1%, P = .0001). AP did not differ between DM and non-DM patients (P = .18). In the entire cohort, DM (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.01-1.54; P = .04), single-vessel peroneal runoff (HR, 1.54; 95% CI, 1.16-2.08; P = .003), and dialysis (HR, 1.59; 95% CI, 1.10-2.33; P = .02) were associated with decreased PP on multivariate analysis. The only variables on multivariate analysis to predict limb loss and death were critical limb ischemia (HR, 9.09; 95% CI, 4.17-20.00; P < . 0001; HR, 2.99; 95% CI, 2.01-4.44; P < .0001, respectively) and dialysis (HR, 2.94; 95% CI, 1.39-5.00; P = .003; HR, 4.24; 95% CI 2.80-6.45; P < .0001, respectively).

CONCLUSIONS

DM is an independent predictor of decreased long-term primary patency after PTA/stent. Although acceptable assisted patency rates can be achieved with close surveillance and reintervention, long-term limb salvage remains inferior in diabetic patients compared with non-diabetic patients due to a more severe clinical presentation and poor runoff.

Five-year retrograde transpopliteal angioplasty results compared with antegrade angioplasty

INTRODUCTION

Retrograde transpopliteal angioplasty (PA) is a potentially useful alternative technique for endovascular treatment of infra-inguinal arterial disease when antegrade transfemoral puncture (FA) is technically not possible or appropriate. This study aimed to investigate the outcomes of PA compared with FA during a 5-year period.

PATIENTS AND METHODS

A retrospective study was performed to assess 88 PA and 275 FA performed between January 2003 and January 2008. Assessments of patients, indication for procedure, disease site, stenosis severity, procedure outcomes and time to further intervention were recorded.

RESULTS

FA was used to treat more patients with critical ischaemia (42.2% vs 30.7%; P = 0.014)). PA was used to treat more proximal superficial femoral lesions (P < 0.001) and occlusive lesions (P = 0.001). Overall, 84.1% of PA and 82.5 % of FA were technically successful. There was no difference in local puncture site complication rates. Significantly more FA resulted in distal thrombus/embolism (8.4% vs 3.4%; P = 0.044). Further intervention was required in 27.3% of PA and 36.0% of FA. The time interval to re-intervention was not different between the groups.

CONCLUSIONS

PA is safe with comparable success rates and long-term outcomes to an FA. PA is a useful alternative approach for treating occlusive, proximal disease.

Insulin use is associated with poor limb salvage and survival in diabetic patients with chronic limb ischemia

OBJECTIVE

The goal was to compare the outcomes in patients with disabling claudication (DC) or critical limb ischemia (CLI) to determine if diabetics (DM) have poorer patency, limb salvage (LS), and survival rates than nondiabetic patients and if the diabetic regimen affects these outcomes.

METHODS

All patients who presented with DC or CLI between June 2001 and September 2008 were included. Non-DM patients were compared with those with DM who are currently managed by diet only or oral medications (D-OM), oral medications plus insulin (OM+INS), or insulin alone (INS).

RESULTS

Of the 746 patients (886 limbs), there were 406 patients (464 limbs) in non-DM, 96 patients (135 limbs) in D-OM, 98 patients (118 limbs) in OM+INS, and 146 patients (185 limbs) in INS groups. There were more patients with coronary artery disease, hypertension, and renal insufficiency in the DM group than non-DM, with the INS group having the highest incidence of renal insufficiency/dialysis (46%/20%). Gangrene and foot sepsis were significantly more frequent in patients in OM+INS (45%/3%) and INS (50%/6%) than non-DM (15%/0.2%) and D-OM groups (25%/1%; P < .001). More patients in the INS group (14%) and OM+INS (9%) had primary amputation than non-DM (4%) and D-OM (4%; P < .01). Mean follow-up was 26.3 +/- 20.7 months. Overall survival following revascularization was similar in D-OM and non-DM and OM+INS and INS, the latter being significantly worse (P < .001). The LS rate in D-OM and non-DM was also identical, whereas OM-INS and INS had significantly worse LS, with OM-INS marginally better than INS (P = .094). Primary patency (PP) was worse in endovascular-treated patients on insulin than non-DM and D-OM patients (P < .001), whereas PP was similar between groups in open-treated patients. Multivariate analysis showed that coronary artery disease, renal insufficiency, chronic obstructive pulmonary disease, indication for intervention, insulin use, nonambulatory status, and statin drug non-use were independently associated with decreased survival, whereas insulin use, presence of gangrene, need for infrapopliteal interventions, and nonambulatory status were independently associated with limb loss. TransAtlantic Inter-Society Consensus (TASC) classification of the treated lesions being C or D, infrapopliteal interventions, and indication of intervention (DC vs CLI) were independently associated with primary patency, whereas insulin use was not.

CONCLUSIONS

Diabetic patients who present with limb ischemia can be subdivided into three distinct subgroups based on their diabetic regimen. The survival and LS rates of those controlled with diet or OM are nearly identical to nondiabetics, both of which are significantly better than OM+INS or INS. The PP rate in endovascular-treated patients is worse in patients who are on insulin. Being on insulin is independently associated with decreased survival and limb loss but not PP.