Percutaneous Superficial Femoral Artery Interventions for Claudication—Does Runoff Matter?

Influence of crural vessel run-off on short- and mid-term outcomes following femoro-popliteal bypass grafting

OBJECTIVES

To determine the influence that the number of patent crural run-off vessels has on short- and mid-term outcomes following femoro-popliteal bypass.

METHODS

All patients undergoing index femoro-popliteal bypass grafting between 2013 and 19 at our unit were included. Preoperative imaging was used to stratify patients into cohorts with either one or ≥2 patent run-off vessels. Primary outcomes measures included bypass patency and limb salvage rates at one and 3 years post-operatively. Survival analysis was performed using Kaplan-Meier curves and Logrank test.

RESULTS

147 bypasses performed on 143 patients were included. 24 patients had one-vessel run-off and 123 had ≥2 vessels patent. Patients with one-vessel run-off had a higher proportion of emergency admissions (54% vs 41%) and diabetes (42% vs 31%). 31% of patients underwent diagnostic angiogram imaging in addition to having duplex ultrasound and/or computed tomography angiography. There were no significant differences in primary, primary-assisted or secondary patency rates between the cohorts at 12 or 36 months. Limb salvage rates were significantly higher amongst those with ≥2 vessel run-off at 12 (86% vs 71%, p = 0.03) and 36 (85% vs 71%, p = 0.04) months. For those with occluded grafts, a higher proportion of patients with ≥2 vessel run-off subsequently had an attempt at redo bypass grafting.

CONCLUSIONS

Femoro-popliteal bypass is a reasonable treatment option for patients with one-vessel run-off. However, whilst patency rates are comparable, clinicians should be aware of the lower successful limb salvage rates for patients with one patent vessel (especially those presenting with tissue loss).

Prognostic Factors for Restenosis of Superficial Femoral Artery after Endovascular Treatment

High incidence of superficial femoral artery (SFA) restenosis after percutaneous transluminal angioplasty (PTA) poses a persistent challenge in peripheral arterial disease (PAD) treatment. We studied how the patients' and lesions' characteristics, thrombin generation, overall haemostatic potential (OHP), and single nucleotide polymorphisms (SNPs) of the NR4A2 and PECAM1 genes affected the likelihood of restenosis. In total, 206 consecutive PAD patients with limiting intermittent claudication due to SFA stenosis who were treated with balloon angioplasty with bailout stenting when necessary were included. Patients' clinical status and patency of the treated arterial segment on ultrasound examination were assessed 1, 6, and 12 months after the procedure. Restenosis occurred in 45% of patients, with less than 20% of all patients experiencing symptoms. In the multivariate analysis, predictors of restenosis proved to be poor infrapopliteal runoff, higher lesion complexity, absence of treated arterial hypertension, delayed lag phase in thrombin generation, and higher contribution of plasma extracellular vesicles to thrombin concentration. Poor infrapopliteal runoff increased the risk of restenosis in the first 6 months, but not later. The negative effect of poor infrapopliteal runoff on SFA patency opens questions about the potential benefits of simultaneous revascularisation of below-knee arteries along with SFA revascularisation.

High-Risk Characteristics for Clinical Failure after Isolated Femoropopliteal Peripheral Vascular Interventions

BACKGROUND

Recent studies suggesting increased late mortality with paclitaxel-coated devices (PCDs) in femoropopliteal peripheral vascular interventions (PVIs) prompted the US Food and Drug Administration to recommend limiting the use of PCDs to "patients at particularly high risk for restenosis". This study's aim is to characterize patients at high risk for restenosis and develop a risk score to guide clinicians in selecting patients for treatment with PCDs.

METHODS

Patients who underwent isolated femoropopliteal PVI for claudication or rest pain from 2016-2019 in the Vascular Quality Initiative were included. Patients who received intervention with a PCD, hybrid procedures, died within 1 year, or had missing follow-up data were excluded. The primary end point was clinical failure at 1 year defined as > 50% restenosis, loss of patency, reintervention, or major amputation. Data were split randomly into 2/3 for development and 1/3 for validation. A parsimonious multivariable hierarchical logistic regression for clinical failure was developed and a risk score was created using beta-coefficients. The risk score was applied to the validation dataset and tested for goodness-of-fit and discrimination.

RESULTS

Among 4,856 treated patients, 718 (14.8%) experienced clinical failure within 1 year. Clinical failure was associated with age ≤ 50 years, female sex (48.1% vs. 39.5%), insulin-dependent diabetes (29.9% vs. 23.1%), creatinine > 2.0 mg/dL (9.9% vs. 5.7%), prior ipsilateral lower extremity revascularization (48.5% vs. 38.5%), prior ipsilateral minor amputation (5.3% vs. 1.7%), rest pain versus claudication (30.8% vs. 18.7%), occlusion length ≥ 20 cm (18.8% vs. 15.0%), and Trans-Atlantic Inter-Society Consensus II Classification C or D (40.4% vs. 28.0%), all P ≤ 0.01. Risk score development was performed using a multivariable regression. The model demonstrated good fit and discrimination (C-statistic 0.71 in development and 0.72 in validation dataset). Predicted clinical failure was 8.9% for standard-risk (45.9% of interventions), 15.5% for high-risk (44.2% of interventions), and 33.8% for very high-risk patients (9.8% of interventions).

CONCLUSIONS

A novel risk score was created with good discrimination for identifying patients at high risk for clinical failure at 1 year after femoropopliteal PVI for claudication and rest pain. Patients at high risk and very high risk for clinical failure may benefit from alternative strategies including PCDs.

Mid-Term Outcomes of Endovascular Therapy for TASC II D Femoropopliteal Lesions with Critical Limb Ischaemia: A Retrospective Analysis

OBJECTIVE

This study evaluated the mid-term results of endovascular therapy (EVT) for Trans-Atlantic Inter-Society (TASC) II D femoropopliteal lesions in patients with critical limb ischaemia (CLI).

METHODS

Fifty-seven limbs of 54 patients with CLI due to TASC II D femoropopliteal lesions who underwent EVT at the First Hospital of Hebei Medical University were retrospectively analysed in single-centre, observational study. The patient characteristics, endovascular procedural details, freedom from target lesion revascularisation (TLR), patency rates, ulcer healing rate, and limb salvage rate were accessed.

RESULTS

The patients' mean age was 68.2 ± 8.2 years. All patients were treated by EVT. The final technical success rate was 98.2% (56/57). There were 23 cases of pain at rest, 18 cases of ulcer, and 15 cases of gangrene. The median length of the treated segment was 286 ± 42 mm (56/56) and the mean number of stents placed per patient was 2.0 ± 0.8 (49/56). The postoperative ankle-brachial index (ABI) was significantly higher than that of the preoperative ABI (P < 0.05). The perioperative complication rate was 10.7% (6/56). The re-stenosis or occlusion rate was 44.6% (25/56). The estimated rates of freedom from TLR at 1 year, 2 years, and 3 years were 86.8%, 67.0%, and 62.5%, respectively. Univariate analysis showed that predictors of freedom from TLR were the number of runoff vessels, length of the lesion, and complexity of the lesion, while predictors for re-stenosis or occlusion were the length and the complexity of the lesion. The ulcer healing rate was 93.8%. The limb salvage rates were 76.4%, 74.4%, and 70.9% at 1, 2, and 3 years after treatment, respectively.

CONCLUSIONS

The mid-term outcomes of EVT for TASC II D femoropopliteal lesions in patients with CLI indicated that this treatment approach is safe and effective, and is clinically applicable.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia

OBJECTIVE

The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI).

METHODS

This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan-Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement.

RESULTS

Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford's category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different (p = .006). Group 1 had significantly lower amputation rate at 36 months (p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40-36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02-0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07-16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02-0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015-29.95, p = .002) were the significant independent predictors of LCI.

CONCLUSION

The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

Wound outcomes and factors associated with wound healing after first-time femoropopliteal artery intervention in patients with ischemic tissue loss

BACKGROUND/OBJECTIVE

This study's goal is to describe wound outcomes at 2 years following intervention for atherosclerotic femoropopliteal lesions in patients with ischemic tissue loss.

METHODS

A retrospective review of 135 first-time endovascular procedures for chronic femoropopliteal atherosclerotic lesions related to ischemic tissue loss was performed. The final wound outcomes were categorized according to the initial wound healing, recurrence and the need of major/minor amputation.

RESULTS

At 2-years of follow up, 76 limbs (56.3%) showed complete wound healing without recurrence, however, wound development occurred at other sites on the same foot following complete primary healing in 11 limbs (8.1%). Tolerable wounds persisted or wounds recurred at the same site in 30 limbs (22.2%), and 18 limbs (13.3%) needed major amputations. Independent factors that prevented wound healing without recurrence at 2 years were renal insufficiency (HR = 0.225, 95% C.I. = 0.091-0.556, p = 0.001), ankle pressure < 50 mmHg or flat forefoot PVR (HR = 0.328, 95% C.I. = 0.124-0.867, p = 0.025) and functional performance < 4 metabolic equivalents (MET) (HR = 0.150, 95% C.I. = 0.063-0.360, p < 0.001).

CONCLUSION

Wound outcome classifications showed detailed information regarding clinical outcomes in patients with ischemic tissue loss. Renal insufficiency, ischemia grade 3 and poor functional performance were independent risk factors that prevented wound healing.

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.

Effectiveness of combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass: A paradigm shift in surgical open bypass for chronic limb-threatening ischemia

OBJECTIVES

The purpose of this study was to evaluate the results of combining superficial femoral artery endovascular therapy with distal bypass originating from the popliteal artery as a method of lower extremity revascularization in patients with chronic limb-threatening ischemia.

METHODS

The records of patients undergoing combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass for chronic limb-threatening ischemia from January 2014 to April 2020 at a single institution were retrospectively reviewed. The patients' background, operative details, and long-term outcomes were analyzed.

RESULTS

Fifty-two popliteal-to-distal bypasses with superficial femoral artery endovascular therapy were performed in 49 patients (33 men; mean age, 76 ± 9 years; diabetes mellitus, 80%; end-stage renal disease with hemodialysis, 47%). The Trans-Atlantic Inter-Society Consensus II classification of superficial femoral artery-popliteal lesion was "A" in 8 (15%) patients, "B" in 14 (27%) patients, "C" in 24 (46%) patients, and "D" in 6 (12%) patients. The intervention for superficial femoral artery lesions was plain old balloon angioplasty in 4 patients, self-expandable nitinol stent in 15 patients, drug-coated balloon in 18 patients, drug-eluting stent in 4 patients, stent graft in 10 patients, and interwoven nitinol stent in 1 patient. Distal bypass originated from the above-knee popliteal artery in 9 (17%) limbs and the below-knee popliteal artery in 43 (83%) limbs. The most common outflow artery was the posterior tibial artery (44%). The mean follow-up period was 17 ± 17 months. The primary and secondary patency of the graft was 44% and 72%, respectively, at 1 year and 39% and 72%, respectively, at 3 years. Primary patency and freedom from clinical-driven target lesion revascularization of superficial femoral artery endovascular therapy lesions were 85% and 90%, respectively, at 1 year and 63% and 75%, respectively, at 3 years. Limb salvage was 97% at 1 year and 92% at 3 years. Wound healing was 67% at 6 months and 83% at 12 months.

CONCLUSIONS

Combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass may be a promising approach for patients with chronic limb-threatening ischemia because of durable patency, acceptable wound healing, and good limb salvage.

Outcomes of endovascular treatment for infrapopliteal peripheral artery disease based on the updated TASC II classification

We retrospectively analyzed all endovascular procedures of infrapopliteal arterial lesions (n = 383) performed in 270 patients at our institution between December 2008 and January 2018. The overall technical success rate was 97% and yielded 98% for stenoses (n = 214) and 95% for occlusions (n = 169). Trans-Atlantic Inter-Society Consensus (TASC II) classification had no impact on success rates (TASC A + B vs C + D; 96.5% vs 96.9%, p = 0.837). Freedom from clinically driven target lesion revascularization (TLR) after 6 and 12 months was 88.3% and 77.2%. TLR was comparable for TASC A to C lesions and no difference was observed comparing groups of moderately complex TASC A/B lesions and more complex TASC C/D lesions (TASC A + B vs C + D; 78.5% vs 74.2%, p = 0.457). Freedom from TLR was significantly lower in very complex TASC D lesions (TASC A + B + C vs D; 79.7% vs 42.5%, p < 0.001). Multivariate analysis identified TASC D lesions (hazard ratio D/A: 1.5; overall p = 0.002), Fontaine class III and IV (hazard ratio III or IV/IIa or IIb: 2.4; p = 0.041), and occlusive lesions (hazard ratio occlusion/stenosis: 2.4; p = 0.026) as predictors for TLR. In conclusion, endovascular therapy for infrapopliteal artery disease was safe and accompanied with a promising long-term outcome.

Impact of number of run-off vessels on interwoven nitinol mesh stents patency in the femoropopliteal segment

Objective

To evaluate the impact of run-off vessels number on the outcomes of Supera stent (Abbott Vascular, Santa Clara, Calif, USA) for treatment of femoropopliteal occlusive disease.

Methods

We retrospectively evaluated the medical records of 188 consecutive patients (mean age 68.2 ± 9.6 years, 100 males) undergone angiography and woven mesh stent implantation in femoral or popliteal arteries or both arterial segments, in our institution between January 1 2014 and January 1 2018. Target lesion revascularization and major adverse limb events at 12-month were evaluated comparing patients with 1-, 2- or 3-run-off vessels in the foot.

Results

Interventional success was achieved in 100%. Stent implantation involved in the femoral site in 56 patients (30.3%), the femoropopliteal in 92 patients (48.9%) and the popliteal site in 40 patients (21.3%). A significant improvement of ankle-brachial index (0.29 ± 0.6 vs. 0.88 ± 0.3, P < 0.001) and Rutherford class (5.3 ± 0.8 vs. 0.7 ± 1.9, P < 0.01) were observed before discharge. The median follow-up duration was 12.3 months (inter quartile range: 11.0 to 13.9). During the follow-up period, 52 patients (27.6%) had clinical events. Primary patency at 12 months was 72.4%. The primary patency significantly increased when the runoff status. Comparing the number of events among patients with different number of run-off vessels, a significant difference (P < 0.001) was observed for patients having one (24.0%) and two run-off vessels (15.0%).

Conclusions

The outcomes of Supera stent in femoropopliteal occlusive disease depend strictly on the number of run-off vessels.

Midterm Outcomes of Common Femoral Endarterectomy Combined with Inflow and Outflow Endovascular Treatment for Chronic Limb Threatening Ischaemia

OBJECTIVE

To assess mid term outcomes of common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with chronic limb threatening ischaemia (CLTI).

METHODS

This was a prospective study. All patients who, for the first time, underwent planned one stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularisation procedure to achieve limb salvage in patients with CLTI due to multilevel disease were included between January 2015 and May 2017. Demographics, and clinical and lesion characteristics for each patient were reported. The primary outcome was primary patency. Secondary outcomes were technical success, peri-operative morbidity and mortality, assisted primary patency, secondary patency, clinically driven target lesion revascularisation and amputation free survival.

RESULTS

Three groups were created according to the endovascular treatment zone: group 1 (inflow, n = 60); group 2 (outflow, n = 46); and group 3 (combined inflow and outflow, n = 53). CFA endarterectomy was a fixed step in all cases. The overall technical success was 98%. The peri-operative complication rate was 14% and the mortality rate was 2%. Patients in group 3 demonstrated a significantly lower primary patency rate (53.9% ± 7.1%; p < .001) at 24 months but improved secondary patency rate of (94.0% ± 3.4%). Based on the outcomes of the Cox regression multivariable analysis, lesion length (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.06-1.14; p < .001), chronic total occlusion (CTO) (HR 0.50, 95% CI 0.25-0.98; p = .046), peripheral artery calcium scoring system (PACSS) grade 4 (HR 2.44, 95% CI 1.27-4.68; p = .008), incomplete revascularisation (HR 3.32, 95% CI 1.64-6.73; p = .001), and dyslipidaemia (HR 0.50, 95% CI 0.27-0.93; p = .031) were the only significant independent predictors of loss of primary patency.

CONCLUSION

Common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with CLTI is safe, with acceptable patency rates, despite the need for secondary interventions. Dyslipidaemia, lesion length, CTO, PACSS grade 4, and incomplete revascularisation are independent predictors of primary patency loss. The current study analysis supports the recommendation to stage the procedure based on patient risk and degree of limb threat.

Impact of Tibial Runoff on Outcomes of Endovascular Treatment for Femoropopliteal Atherosclerotic Lesions

Objectives:

The aim of this study is to investigate the impact of tibial runoff on outcomes of femoropopliteal interventions for atherosclerotic lesions.

Methods:

A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed.

Results:

The distribution rates of good tibial runoff (runoff score <7) and poor tibial runoff (runoff score ≥7) were 37.0% and 63.0%, respectively. In the poor tibial runoff group, the patients were older ( P = .019), and the proportion of male was lower ( P = .014). There was a significantly higher proportion of rest pain or tissue loss ( P < .001), and the prevalence of stroke ( P = .031) and renal insufficiency ( P = .005) was significantly higher in the poor runoff group. After femoropopliteal intervention, the amputation-free survival ( P = .03) and freedom from ischemia ( P = .003) were significantly lower in the poor runoff group. The interventions targeting below-the-knee (BTK) lesions performed concomitantly for critical limb ischemia or tissue loss with poor tibial runoff did not show a significant advantage in terms of freedom from ischemia; however, minor trends of longer lasting freedom from ischemia were observed when BTK intervention was combined.

Conclusion:

The patients with poor runoff showed significantly lower amputation-free survival and freedom from ischemia. In poor tibial runoff limbs with critical limb ischemia or tissue loss, BTK intervention did not demonstrate additional significant beneficial outcomes; however, there was a minor trend of longer lasting freedom from ischemia after concomitant BTK intervention.

Abluminal-Coated Drug-Eluting Bifurcation-Dedicated Stent for the Treatment of Tibioperoneal Bifurcation

Endovascular treatment of below-the-knee region disease is often challenging because of the involvement of arterial bifurcations. Several cases have been reported on the use of coronary stents for the treatment of these patients, but limited evidence is available on the use of dedicated coronary bifurcation devices. We here report the endovascular treatment of a symptomatic bifurcation lesion in below-the-knee region, using a self-expanding Biolimus A9-eluting stent in combination with a "conventional" coronary drug-eluting stent.

Outcomes of accelerated catheter-directed thrombolysis in patients with acute arterial thrombosis

Current intra-arterial catheter-directed thrombolysis (CDT) protocols recommend treatment with small doses of a thrombolytic agent, which excludes patients in need of urgent revascularization. We evaluated the effects of accelerated thrombolysis utilizing increased recombinant tissue plasminogen activator (rt-PA) doses. Forty-one patients with acute, thrombotic limb ischemia (ALI) were treated using accelerated CDT. The treatment consisted of an initial dose of 10 mg rt-PA for 30 minutes followed by a 3-hour course of a continuous intra-arterial 10 mg/hour rt-PA infusion. Simultaneously, intravenous unfractionated heparin (500 IU/hour) was administered. No deaths occurred. Satisfactory lysis was achieved in 37 of the 41 patients (90.2%). All significant underlying lesions were corrected (89.2%). Complications developed in nine patients (22%); the most frequent complication (four patients, 9.8%) was puncture site hematoma. The reintervention rate was 2.6% and 15.4% at the 1 and 6-month follow-ups, respectively. The major amputation rate was 10.3% and 12.8% at the 1 and 6-month follow-ups, respectively. Outflow compromise was adversely related to successful outcome at the 6-month follow-up ( p=0.01). In conclusion, this study confirms the effectiveness and safety of the accelerated CDT regimen for treatment of thrombotic ALI at a single center, but requires confirmation in further studies.

Propensity Score Analysis Comparing Clinical Outcomes of Drug-Eluting vs Bare Nitinol Stents in Femoropopliteal Lesions

Purpose: To present a propensity score matching analysis comparing the 1-year outcomes of de novo femoropopliteal lesions treated with drug-eluting stents (DES) or bare nitinol stents (BNS). Methods: A retrospective review was conducted of 452 limbs in 389 patients (mean age 74±8 years; 284 men) treated with DES implantation and 1808 limbs in 1441 patients (mean age 72±9 years; 1023 men) implanted with BNS for de novo femoropopliteal lesions. One-year follow-up data were available on all patients. The primary endpoint was 12-month restenosis assessed by duplex ultrasonography or follow-up angiography within ±2 months. Secondary endpoint was major adverse limb events (MALE) including major amputation, any reintervention, and restenosis. Results: The BNS group was more likely to have current smoking, chronic total occlusion, and poor below-the-knee runoff. The stratification analysis demonstrated that diabetes mellitus (DM) and reference vessel diameter (RVD) had a significant interaction on the association of DES vs BNS implantation with restenosis (interaction p<0.05). Thus, the population was stratified into 4 subgroups (1: –DM, RVD ≥5 mm, 2: +DM, RVD ≥5 mm, 3: –DM, RVD <5 mm, and 4: +DM, RVD <5 mm); the RVD threshold was empirically determined. There were no significant intergroup differences in baseline variables after matching. There was no significant difference in restenosis risk between DES and BNS in the RVD ≥5 mm subgroup regardless of the presence of DM. The DES group had a significantly higher restenosis risk in the RVD <5 mm subgroup regardless of the presence of DM. No significant difference was observed in the risk of major amputation, reintervention, or MALE in any subgroup. Conclusion: These results suggest that a first-generation DES was not superior to a conventional BNS for femoropopliteal lesions.

An overview of optimal endovascular strategy in treating the femoropopliteal artery: mechanical, biological, and procedural factors

Treatment of the femoropopliteal (FP) artery remains a challenge to the endovascular specialist. Long-term patency is low with a high rate of target lesion revascularization. The true patency rate varies considerably between studies partly because there is a lack of uniform performance criteria and reporting standards in peripheral arterial interventions. Literature review supports three principles that emerge as important components of an optimal strategy in treating the FP artery: (1) improving vessel compliance and subsequently less dissections and bailout stenting, (2) reducing smooth muscle cell proliferation, and (3) protecting outflow vessels from distal embolization. In this overview, we examine current data that support the validity of this strategy.

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.

Stenting below-the-knee bifurcations with dedicated bifurcation stent BiOSS Lim - first in man case report

The best treatment strategy for below the knee bifurcation disease is not known. We present first two cases with successful implantation of dedicated coronary bifurcation sirolimus eluting stent BiOSS Lim (Balton, Poland) in complex bifurcation and trifurcation lesions of tibioperoneal trunk. Both implantations were uncomplicated with sustained short-term result at 30-day control Duplex ultrasound and remarkable clinical improvement. Our report demonstrates feasibility and short-term effectiveness of implantation of dedicated coronary bifurcation stent in below-the-knee bi- and tri-furcations.

Comparison of embolic load in femoropopliteal interventions: percutaneous transluminal angioplasty versus stenting

PURPOSE

To compare the incidence of distal emboli occurring during percutaneous transluminal angioplasty (PTA) and primary stent on the superficial femoral artery (SFA) METHODS: A total of 50 consecutive patients were entered in a prospective, randomized trial. Inclusion criteria were the presence of symptomatic limb ischemia due to stenosis or occlusion of the SFA. An embolic protection device was placed in the popliteal artery. The patients were then randomly assigned to undergo primary stent implantation or PTA. The filters were retrieved and sent for histologic examination.

RESULTS

Stenting in the SFA produced more emboli (1.44 mm(3)) than PTA (0.772 mm(3)), P = .031. Reanalyzing the patients according to actual treatment performed, volume of debris in the stent group was 1.271 mm(3) and in the PTA group was 0.191 mm(3), P = .00087.

CONCLUSION

Volume of embolized material during endovascular interventions in the SFA-above-knee popliteal artery is higher when a stent is used.

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.

Clinical outcomes after endovascular treatment of superficial femoral disease in patients with disabling claudication and critical limb ischemia: midterm analysis

We present the midterm clinical outcomes and predictors of balloon angioplasty and stent placement in atherosclerotic femoropopliteal (FP) arterial disease. Between January 2002 and August 2006, 155 patients (men = 56%; 71.4 ± 10.5 years) underwent 171 FP angioplasty or stent for claudication (n = 82, 54%) or critical limb ischemia ([CLI] n = 70, 46%). Follow-up was obtained through September 30, 2009. The average follow-up was 3.25 ± 1.73 years. In claudicants versus CLI, the 12-month patency for TransAtlantic InterSociety Consensus II (TASC II) classification (TASC A/B) was 93% versus 80%, respectively, and TASC C/D 83% versus 80%. At 3 years, TASC A/B was 82% versus 80%, respectively, and TASC C/D was 56% versus 80%, respectively. The predictor of clinical failure in claudicants was chronic renal insufficiency (CRI) and in CLI, the predictor of amputation was hyperlipidemia.

Sirolimus-eluting stents vs. bare-metal stents for treatment of focal lesions in infrapopliteal arteries: a double-blind, multi-centre, randomized clinical trial

AIMS

Preliminary reports indicate that sirolimus-eluting stents reduce the risk of restenosis after percutaneous infrapopliteal artery revascularization. We conducted a prospective, randomized, multi-centre, double-blind trial comparing a polymer-free sirolimus-eluting stent with a placebo-coated bare-metal stent in patients with either intermittent claudication or critical limb ischaemia who had a de-novo lesion in an infrapopliteal artery.

METHODS AND RESULTS

161 patients were included in this trial. The mean target lesion length was 31 ± 9 mm. The main study endpoint was the 1-year primary patency rate, defined as freedom from in-stent-restenosis (luminal narrowing of ≥50%) detected with duplex ultrasound if not appropriate with angiography. Secondary endpoints included the 6-month primary patency rate, secondary patency rate, and changes in Rutherford-Becker classification after 1 year. Twenty-five (15.5%) patients died during the follow-up period. One hundred and twenty-five patients reached the 1-year examinations. The 1-year primary patency rate was significantly higher in the sirolimus-eluting stent group (80.6%) than in the bare-metal stent group (55.6%, P= 0.004), and the 1-year secondary patency rates were 91.9 and 71.4% (P= 0.005), respectively. The median (interquartile range) change in Rutherford-Becker classification after 1 year was -2 (-3 to -1) in the sirolimus-eluting stent group and -1 (-2 to 0) in the bare-metal stent group, respectively (P= 0.004).

CONCLUSION

Mid-term patency rates of focal infrapopliteal lesions are substantially improved with sirolimus-eluting stent compared with bare-metal stent. Corresponding to the technical results, the changes in Rutherford-Becker classification reveal a significant advantage for the sirolimus-eluting stent.

Primary everolimus-eluting stenting versus balloon angioplasty with bailout bare metal stenting of long infrapopliteal lesions for treatment of critical limb ischemia

PURPOSE

To report the long-term outcomes of a single-center prospective study investigating primary placement of everolimus-eluting metal stents for recanalization of long infrapopliteal lesions compared to a matched historical control group treated with plain balloon angioplasty and provisional placement of bare metal stents in a bailout manner.

METHODS

The study included 81 patients (63 men; mean age 71 years, range 45-85) suffering from critical limb ischemia (CLI) and angiographically proven long-segment (at least 1 lesion >4.5 cm) de novo infrapopliteal artery disease who underwent below-the-knee revascularization with either primary placement of everolimus-eluting stents (n = 47, 51 limbs, 102 lesions) or angioplasty and bailout bare metal stenting (n = 34, 36 limbs, 72 lesions). Clinical and angiographic follow-up was collected at regular time intervals. Primary clinical and angiographic endpoints included patient survival, major amputation-free survival, angiographic primary patency, angiographic binary restenosis (>50%), and overall event-free survival. Results were stratified according to endovascular treatment received. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding factors of heterogeneity.

RESULTS

Baseline demographics were well matched. No significant differences were identified between the 2 groups with regard to overall 3-year patient survival (82.2% versus 65.7%; p = 0.90) and amputation-free survival (77.1% versus 86.9%; p = 0.20). Up to 3 years, lesions fully covered with everolimus-eluting stents were associated with significantly higher primary patency [hazard ratio (HR) 7.98, 95% CI 3.69 to 17.25, p < 0.0001], reduced binary restenosis (HR 2.94, 95% CI 1.74 to 4.99, p < 0.0001), and improved overall event-free survival (HR 2.19, 95% CI 1.16 to 4.13, p = 0.015) versus the matched historical control group.

CONCLUSION

Primary infrapopliteal everolimus-eluting stenting for CLI treatment significantly inhibits restenosis and improves long-term angiographic patency and overall patient event-free survival compared to balloon angioplasty and bailout bare metal stenting.

Restenosis after lower extremity interventions: current status and future directions

The incidence of restenosis after percutaneous peripheral interventions (PPI) varies considerably depending upon the vascular bed but appears to be highest in the femoropopliteal and tibioperoneal arteries. The restenosis process in the periphery does not appear to stop at the 6-month mark, as seen with bare metal stents in the coronary arteries, but continues for a longer time, possibly years, after the intervention. This review evaluates the incidence of restenosis following lower extremity arterial interventions and potential drugs or devices that could alter this process, including nonpharmacological (stents, cryoplasty, Cutting Balloon angioplasty, atherectomy, brachytherapy, and photodynamic therapy) and pharmacological (systemic and direct drug delivery) approaches. A global strategy to achieve optimal outcome with PPI is offered: (1) obtain excellent acute angiographic results with less dissection and recoil, (2) protect the distal tibial vascular bed, and (3) reduce smooth muscle cell proliferation with pharmacological intervention.

Primary nitinol stenting for femoropopliteal disease

The 1- to 2-year primary patency rates associated with self-expanding nitinol stents for the treatment of symptomatic femoropopliteal disease are superior to those for percutaneous transluminal angioplasty (PTA) and the first-generation stainless steel balloon-expandable stents. The advantages of nitinol stents include improved radial strength and flexibility, the ability to recover from being crushed, reduced foreshortening, and (importantly) deployability without balloon dilation of the stent edge (which may decrease the incidence of the edge stenosis, or "candy-wrap" effect, often observed with balloon-expandable stents). The technical success rate associated with primary deployment of nitinol stents is very high, and acute to 6-month patency results are predictably excellent. Prior to the introduction of nitinol stents, the original guidelines (2000) of the multidisciplinary TransAtlantic Inter-Society Consensus (TASC I) recommended only an adjunctive role for femoropopliteal stents following suboptimal PTA. The abbreviated 2007 TASC II report essentially extended this recommendation to nitinol stents. Here, current trials of nitinol stenting in the femoropopliteal segment are discussed, with emphasis on the advantages of primary (and often direct) deployment in selected circumstances dependent on factors including lesion length, lesion location, indication for treatment (critical limb ischemia or claudication, in-stent restenosis, stent-graft restenosis), and the relative appropriateness of other modalities (e.g., covered stents). Technical considerations in primary nitinol stenting are briefly reviewed. Open questions regarding the factors involved in nitinol stent fracture and the possible association of fracture and restenosis are examined in the context of current clinical trials. A new generation of femoropopliteal nitinol stents combining superior durability and flexibility is expected soon. Development and implementation of uniform reporting and surveillance standards is important for optimizing current and future research.

Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia

CONTEXT

Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented.

AIMS

To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions.

METHODS

A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time.

RESULTS

Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI - preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention.

CONCLUSION

Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.