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

Advances in Vascular Brachytherapy over the Last 10 Years: Focus on Femoropopliteal Applications

Restenosis and the need for repeated interventions after percutaneous transluminal angioplasty (PTA) remain major drawbacks limiting a widespread application of this minimally invasive technique in the femoropopliteal segment. During the last decade, vascular brachytherapy (BT) emerged as a promising, novel technology with the potential to reduce the rates of restenosis. Meanwhile, several randomized controlled trials have suggested beneficial short and midterm effects of BT in the femoropopliteal arteries. However, despite substantial advances, many questions remain regarding the utility of vascular BT and its dissemination as a practical tool to prevent restenosis. The risk of complications, such as late stent thrombosis, edge effect, catch-up late restenosis, and potential aneurysm formation, as well as the logistical issues associated with the use of this technology in the catheterization laboratory, are delaying the acceptance of BT for routine use. This article reviews the developments of BT for restenosis prevention during the past decade, focusing on implications for peripheral endovascular treatment.

Lower-extremity arterial revascularization: Is there any evidence for diabetic foot ulcer-healing?

The presence of peripheral arterial disease (PAD) is an important consideration in the management of diabetic foot ulcers. Indeed, arteriopathy is a major factor in delayed healing and the increased risk of amputation. Revascularization is commonly performed in patients with critical limb ischaemia (CLI) and diabetic foot ulcer (DFU), but also in patients with less severe arteriopathy. The ulcer-healing rate obtained after revascularization ranges from 46% to 91% at 1 year and appears to be improved compared to patients without revascularization. However, in those studies, healing was often a secondary criterion, and there was no description of the initial wound or its management. Furthermore, specific alterations associated with diabetes, such as microcirculation disorders, abnormal angiogenesis and glycation of proteins, can alter healing and the benefits of revascularization. In this review, critical assessment of data from the literature was performed on the relationship between PAD, revascularization and healing of DFUs. Also, the impact of diabetes on the effectiveness of revascularization was analyzed and potential new therapeutic targets described.

Proximal direct endarterectomy combined with simultaneous distal endovascular therapy for chronic full-length occlusion of the superficial femoral artery in elderly patients

BACKGROUND AND PURPOSE

The most proximal ostial site of the chronic occlusive superficial femoral artery is not suitable for ballooning or stenting because the deep femoral artery may be occluded by these procedures. Thus, the feasibility of performing an open endarterectomy for the occluded ostium of the superficial femoral arteries combined with an endovascular therapy for the remaining distal site was evaluated.

METHODS

Eleven critically ischemic limbs in 10 elderly patients with poor general health were enrolled. They had full-length occlusion of the superficial femoral artery involving its ostium. The ostial site was managed with an open endarterectomy followed by endovascular therapy for the remaining distal site.

RESULTS

All procedures were successfully performed. All patients experienced pain relief, and the wounds healed. During the follow-up observation period (average: 23.9 ± 14.7 months), nine patients died. None of the patients, including those who had lost patency of the superficial femoral artery, received major amputation.

CONCLUSION

Elderly patients, including those who were in terminal stage, were able to withstand the operation, and their postoperative quality of life was not compromised. Although the patency following the surgery was limited, sparing the deep femoral artery could either prevent or delay the recurrence of critical limb ischemia.

Advances in vascular brachytherapy over the last 10 years: focus on femoropopliteal applications

Restenosis and the need for repeated interventions after percutaneous transluminal angioplasty (PTA) remain major drawbacks limiting a widespread application of this minimally invasive technique in the femoropopliteal segment. During the last decade, vascular brachytherapy (BT) emerged as a promising, novel technology with the potential to reduce the rates of restenosis. Meanwhile, several randomized controlled trials have suggested beneficial short and midterm effects of BT in the femoropopliteal arteries. However, despite substantial advances, many questions remain regarding the utility of vascular BT and its dissemination as a practical tool to prevent restenosis. The risk of complications, such as late stent thrombosis, edge effect, catch-up late restenosis, and potential aneurysm formation, as well as the logistical issues associated with the use of this technology in the catheterization laboratory, are delaying the acceptance of BT for routine use. This article reviews the developments of BT for restenosis prevention during the past decade, focusing on implications for peripheral endovascular treatment.

Endovascular brachytherapy prevents restenosis after femoropopliteal angioplasty: results of the Vienna-3 randomised multicenter study

BACKGROUND AND PURPOSE

The aim of the trial was to investigate the effect of Iridium-192 gamma endovascular brachytherapy on reduction of restenosis after femoropopliteal angioplasty.

PATIENTS AND METHODS

Between Oct, 1998 and Jul, 2001 a total of 134 patients have been randomized after successful angioplasty to brachytherapy or sham irradiation in a prospective, randomized, multicenter, double blind controlled trial. Patients with de novo lesion of at least 5 cm or recurrent lesion of any length after prior angioplasty have been enrolled. Brachytherapy was performed with 7F centering catheter. Mean lesion length was 9.1cm (1.5-25 cm) and mean intervention length 13.6 cm (4-27.5 cm) in brachytherapy cohort.

RESULTS

In placebo cohort mean lesion length was 10.3 cm (2-25 cm) and mean intervention length 14.1 cm (2-29 cm). A dose of 18 Gy was prescribed 2 mm from the surface of centering balloons. Analyzed (based on angiography) on intention to treat basis the binary restenosis rate at 12 months was 41.7% (28/67) in brachytherapy cohort and 67.1% (45/67) in placebo cohort (chi2 test, P<0.05). Corresponding data for as treated analysis (A total of 38 patients was excluded from analysis due to lack of follow-up, early recurrence within 30 days and >30% residual stenosis after angioplasty) have been 23.4% in the brachytherapy and 53.3% in the placebo group (P<0.05), respectively. The cumulative patency rates after 24 months on intention to treat analysis were 54% in the brachytherapy and 27% in the placebo group (P<0.005). Corresponding data for as treated analysis were 77% in the brachytherapy and 39% in the placebo group (P<0.001). Late thrombosis was not seen.

CONCLUSIONS

Significant reduction of restenosis rate was obtained with endovascular gamma brachytherapy after femoropopliteal angioplasty.

Angioplasty and Primary Stenting of High-grade, Long-segment Superficial Femoral Artery Disease: Is It Worthwhile?

The purpose of this study was to determine the long-term results and efficacy of angioplasty and stenting of long-segment, high-grade superficial femoral artery disease. Seventy-three consecutive primary balloon angioplasty procedures with immediate stenting in 70 patients with SVS/ISCVS grade B2 or C superficial femoral artery (SFA) disease exceeding 5 cm in length were evaluated. The mean lesion length was 16 cm and occlusion constituted 62%, with a runoff score of 8. Forty-nine procedures (67%) were performed for critical ischemia. A total of 135 stents were placed. Follow-up was with 3-month duplex ultrasound; stenosis >50% was considered the end point for failure. Mean follow-up time was 26 months. Initial technical success with intent to treat was 90%. Initial success according to anatomic, hemodynamic, and clinical criteria was 90%, 88%, and 88%, respectively, with intent to treat. Limb salvage in the critical ischemia group was 71%. Overall cumulative primary patency rates at 12, 24, and 48 months were 56%, 35%, and 22%, and secondary patency rates were 69%, 47%, and 37%, respectively. A stented segment length >10 cm and procedure in claudicants incurred an inferior patency rate. Treatment of high-grade SFA lesions with angioplasty and primary setting results in lower long-term patency rate than those with surgery, but combined with secondary interventions this treatment option may be an acceptable alternative in selected patients with critical ischemia. Femoropopliteal bypass remains the procedure of choice.

Angioplasty and elective stenting of de novo versus recurrent femoropopliteal lesions: 1-year follow-up

PURPOSE

To investigate patency rates after percutaneous transluminal angioplasty (PTA) and PTA plus elective stenting in de novo versus recurrent femoropopliteal lesions.

METHODS

The data were collected from a prospective registry including 533 consecutive patients (284 men; median age 71 years, interquartile range [IQR] 72-78) with severe claudication (n=387) or critical limb ischemia (n=146) who underwent femoropopliteal percutaneous interventions during a 36-month period. PTA was used to treat 357 de novo and 99 recurrent lesions; PTA plus elective stent implantation was performed in 58 de novo and 19 recurrent lesions. Patients were followed for a median 12 months (IQR 7-14) using color duplex sonography. Rates of restenosis (>/=50%) were compared by multivariate analysis.

RESULTS

Overall primary technical success was achieved in 517 (97%) patients; 31 (6%) periprocedural complications were encountered. Restenosis occurred in 213 (40%) patients after a median 6 months (IQR 4-7). Twelve-month patency after PTA was 61% in de novo and 33% in recurrent lesions (p<0.0001). Patients with recurrent lesions had a 2.3-fold increased adjusted risk for restenosis after PTA (95% confidence interval 1.7 to 3.2). Twelve-month patency after stenting was 58% in de novo and 52% in recurrent lesions (p=0.9). In patients with de novo lesions, patency rates after PTA and stent were similar (p=0.8); however, in patients with recurrent lesions, elective stenting performed better (p=0.05).

CONCLUSIONS

Recurrent stenosis after prior femoropopliteal balloon angioplasty is an independent risk factor for restenosis; these lesions exhibit disappointing patency after repeated PTA. Stent implantation may improve intermediate-term results in these patients.

Late reoperations after surgical and endovascular lower limb revascularisation

OBJECTIVES

to evaluate the rate of late reoperations after primary lower limb revascularisation.

METHODS

a prospectively collected database of 639 consecutive patients, undergoing 763 primary arterial reconstruction for lower limb occlusive disease during the five-year period 1989 through 1993, was analysed with regard to the rates and locations of late (after 30 days) re-operation. The reconstruction was supra-inguinal in 527 (69%) cases, surgical in 391 (Group IA) and endovascular in 136 (Group IB). Infra-inguinal reconstruction had been performed in 236 (31%) cases, surgical in 160 (Group IIA) and endovascular in 76 (Group IIB). The 499 men and 140 women were followed during an average of 32 (range 1-122) months.

RESULTS

the 5-year cumulative reoperation rates were 25% after supra-inguinal surgery and 28% after supra-inguinal angioplasty, respectively (NS). The rates were 47% and 33% after infra-inguinal surgery and angioplasty, respectively ( p=0.04).

CONCLUSION

limbs treated for occlusive arterial disease carry a high risk of late reoperation whether the initial procedure is open surgery or angioplasty. Reoperations were twice as common for infra-inguinal procedures.

Balloon dilation and stent implantation for treatment of femoropopliteal arterial disease: meta-analysis

PURPOSE

To perform a meta-analysis of long-term results of balloon dilation and stent implantation in the treatment of femoropopliteal arterial disease.

MATERIALS AND METHODS

The English-language literature was searched for studies published between 1993 and 2000. Inclusion criteria for articles were presentation of long-term primary patency rates, standard errors (explicitly reported or derivable), and baseline characteristics of the study population. Two reviewers independently extracted data, and discrepancies were resolved by consensus. Primary patency rates were combined by using a technique that allows adjustment for differences across study populations. Analyses were adjusted for lesion type and clinical indication.

RESULTS

Nineteen studies met the inclusion criteria, representing 923 balloon dilations and 473 stent implantations. Combined 3-year patency rates after balloon dilation were 61% (standard error, 2.2%) for stenoses and claudication, 48% (standard error, 3.3%) for occlusions and claudication, 43% (standard error, 4.1%) for stenoses and critical ischemia, and 30% (standard error, 3.7%) for occlusions and critical ischemia. The 3-year patency rates after stent implantation were 63%-66% (standard error, 4.1%) and were independent of clinical indication and lesion type. Funnel plots demonstrated an asymmetric distribution of the data points associated with stent studies.

CONCLUSION

Balloon dilation and stent implantation for claudication and stenosis yield similar long-term patency rates. For more severe femoropopliteal disease, the results of stent implantation seem more favorable. Publication bias could not be ruled out.

Endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal angioplasty : results of a prospective randomized study

BACKGROUND

Inasmuch as endovascular brachytherapy (BT) has gained recent interest because of its inhibitory effect on mechanisms leading to restenosis after percutaneous transluminal angioplasty (PTA), we performed this randomized study to determine its efficacy for prophylaxis of restenosis after femoropopliteal PTA.

METHODS AND RESULTS

One hundred thirteen patients (63 men, 50 women; mean age 71 years) with de novo or recurrent femoropopliteal lesions were included in this randomized trial comparing the restenosis rate after PTA plus BT (57 patients, PTA+BT group) versus PTA (56 patients, PTA group) without stent implantation. The mean treated length was 16.7 cm (PTA+BT group) versus 14.8 cm (PTA group). In patients randomized to PTA plus BT, a dose of 12 Gy was applied by an (192)Ir source 3 mm from the source axis. Follow-up examinations included measurement of the ankle-brachial index, color-flow duplex sonography, and angiography. The primary end point of the study was patency after 6 months. The overall recurrence rate after 6 months was 15 (28.3%) of 53 in the PTA+BT group versus 29 (53.7%) of 54 in the PTA group (chi(2) test, P<0.05). The cumulative patency rates at 12 months of follow-up were 63.6% in the PTA+BT group and 35.3% in the PTA group (log-rank test, P<0.005).

CONCLUSIONS

This is the first randomized study to demonstrate the efficacy of endovascular BT for prophylaxis of restenosis after femoropopliteal PTA. The value of this approach should now be improved by modification of the BT procedure and by combination with stent implantation.

Clinical failure after percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries

OBJECTIVE

Anatomic patency after percutaneous transluminal angioplasty (PTA) of the superficial femoral and popliteal arteries does not guarantee clinical success. The aim of this report is to determine the causes of clinical failure after PTA.

METHODS

The records of all patients who have undergone PTA of the femoropopliteal arterial segment by our vascular group were retrospectively reviewed. Only patients with complete records and at least one postprocedure clinical and anatomic assessment within the same 30-day time interval were included. Success was defined according to the Society for Vascular Surgery/International Society for Cardiovascular Surgery Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures. Anatomic cumulative patency and clinical success were calculated according to life table analysis on an intent-to-treat basis.

RESULTS

We identified 85 patients who met inclusion criteria. We treated 112 lesions with an average stenosis of 80% +/- 16% and lesion length of 2.3 +/- 1.8 cm. Technical failure occurred in six (5.4%) of 112 lesions. Cumulative clinical success was 69% at 1 year, 54% at 2 years, 49% at 3 years, and 40% at 4 years. Anatomic patency was 74% at 1 year, 62% at 2 years, 57% at 3 years, and 52% at 4 years. There were 45 clinical failures; of these, twenty-seven (60%) occurred in conjunction with anatomic failure. Anatomic failure was due to restenosis in 12 patients (44%), occlusion in eight patients (30%), and restenosis with progression of disease in six patients (22%). Anatomic failure at the time of the procedure occurred in one patient (4%). Clinical failure occurred despite anatomic patency in the remaining 18 patients (40%). Etiology for clinical failure in this latter group included progression of disease within the treated vessel in 12 patients (67%), iliac disease in three patients (17%), tibial disease in two patients (11%), and bypass graft failure in one patient (5%). Fifty percent of all 45 clinical failures were successfully treated with supplemental percutaneous procedures.

CONCLUSION

A PTA is an acceptable therapeutic option for the treatment of focal occlusive disease of the femoropopliteal arterial segment. Most clinical failures were due to anatomic failure, but a significant number occurred despite patency at the PTA site. Although primary clinical success rates were inferior to surgical bypass graft, supplemental PTA was possible in 50% of patients. Repeat percutaneous treatment may extend the interval of clinical success and may obviate the need for surgical bypass graft.

Percutaneous transluminal angioplasty of infrainguinal vessels

In the last decade, percutaneous angioplasty (PTA) has been used with increasing frequency to treat infrainguinal atherosclerotic lesions. In hopes of better delineating the role of PTA, we undertook a retrospective analysis of infrainguinal PTA in one hospital over a 7-year period. The charts of all patients receiving infrainguinal PTA from 1989 to 1996 were reviewed. Demographics, site and type of lesion, and results of treatment were recorded. Survival curves were plotted using the Kaplan-Meier method following current Society of Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) guidelines. Differences in times to first failure were tested using the log rank method. Failures were documented by duplex ultrasound. All patients requiring repeat intervention underwent contrast angiography. In selected patients with stenotic lesions <3 cm, infrainguinal PTA may be an appropriate initial treatment modality. However, 5-year patency rates are significantly lower than those achieved by saphenous vein grafting. The efficacy of the procedure is markedly decreased when used to treat arterial stenoses >3 cm in length as well as occlusions, and surgical revascularization may be a more appropriate initial therapeutic procedure.

Ultrasonic-pathologic comparison of postangioplasty myointimal hyperplasia and primary atheroma of the superficial femoral artery

The purpose of this study was to characterize postangioplasty myointimal hyperplasia as compared to primary atheroma of superficial femoral arteries using color-coded duplex sonography (CCD), and to correlate sonographic findings with the histopathology of samples obtained from these lesions by catheter atherectomy (Redha-cut device). Preinterventionally, homogeneity, echogeneity, and the surface of plaques were described using CCD in nine cases with secondary stenoses after percutaneous transluminal angioplasty and in seven cases with primary atheroma. Myointimal hyperplasia of femoral restenoses showed a homogeneous (7 of 9 vs. 1 of 7) and hypoechogenic (7 of 9 vs. 0 of 7) wall thickening compared to primary atheromas (p < 0.05). Primary atherosclerotic plaques showed a rather heterogeneous, hypo- and hyperechogenic ultrasonic appearance with or without echo shadowing in six of seven cases. The surface of restenoses was more often regular than that of primary atherosclerotic lesions, but this finding did not reach statistical significance (6 of 9 vs. 2 of 7, p = 0.14). Thrombotic material appeared homogeneous and hypoechogenic in three of five cases and could not be discriminated from intimal hyperplasia. In summary, postangioplasty intimal hyperplasia is characterised by a hypoechogenic, homogeneous, rather regularly confined vessel wall thickening and can be differentiated from primary atheroma at CCD.