The Success of Endovascular Therapy for All TransAtlantic Society Consensus Graded Femoropopliteal Lesions

Long-Term Adverse Limb Events After Femoral Artery Endovascular Revascularization: The Boston FAROUT Study

Background

: Patient, lesion, and procedural characteristics may impact the long-term risks of adverse limb outcomes differently after successful endovascular revascularization for lower extremity peripheral artery disease. The study objective was to assess the relationships of patient, lesion, and procedural characteristics to the subsequent risk of major and minor adverse limb events over the decade after successful endovascular revascularization of the superficial femoral artery for chronic limb-threatening ischemia (CLTI) or lifestyle-limiting claudication.

Methods

A retrospective cohort of patients who underwent endovascular revascularization between 2003-2011 were followed for a median of 9.3 (IQR, 6.8-11.1) years. Hazard ratios (HR) and 95% CI from Cox proportional hazards models assessed the risk of major adverse limb events (MALE) (major amputation, bypass, or thrombolysis) or minor revascularization, MALE alone, and minor revascularization alone.

Results

There were 232 index limb revascularizations in 185 patients. Longer lesion length was associated with a higher risk of MALE or minor revascularization (HR, 2.09; 95% CI, 1.22-3.60) and minor revascularization alone (HR, 2.53; 95% CI, 1.39-4.61). Current smoking was linked with minor revascularization (HR, 3.83; 95% CI, 1.54-9.56). CLTI was associated with MALE or minor revascularization (HR, 1.89; 95% CI, 1.09-3.29), and MALE alone (HR, 7.43; 95% CI, 3.11-17.79). Black race/ethnicity (HR, 4.74; 95% CI, 1.51-14.9) and low-density lipoprotein >100 mg/dL (HR, 2.76; 95% CI, 1.20-6.35) were linked to MALE alone.

Conclusions

Factors related to MALE differed from those related to minor revascularization. Lesion length and smoking were linked to minor revascularization, whereas CLTI, Black race/ethnicity, and elevated low-density lipoprotein were linked to MALE.

Endovascular Intervention for the Treatment of Trans-Atlantic Inter-Society Consensus (TASC) D Femoropopliteal Lesions: A Systematic Review and Meta-Analysis

PURPOSE

Advancements in the endovascular treatment of femoropopliteal atherosclerotic lesions have led to treatment of more complex lesions, particularly long lesions. The aim of this study was to determine the meta-analytic primary patency and need for re-intervention among patients treated for very long lesions (>200 mm) at the femoropopliteal segment and to identify potential risk factors for loss of patency.

METHODS

This study was performed according to the PRISMA guidelines. A random effects model meta-analysis was conducted, and the I-square was used to assess heterogeneity.

RESULTS

Fifty-one studies comprised of 3029 patients were included. The mean lesion length was 269 mm. The primary patency rate at 30 days, 6 m, 1-, 2- and 5-years of follow-up was 98%, 76%, 62%, 55%, and 39% respectively. The incidence of TLR was 16% at one year and 32% at two years. The secondary patency rate at 1, 2, 3 and 5 years was 85%, 71%, 64%, and 64% respectively. Heparin bonded ePTFE covered stents (69%) and paclitaxel eluting stents (73%) demonstrated higher 1-year primary patency rates than self-expanding nitinol stents (55%) or uncoated percutaneous transluminal angioplasty (PTA) with provisional stenting (54%). Lesions treated with a heparin bonded ePTFE covered stent had statistically significant higher odds of remaining patent at 1-year of follow-up (OR: 2.74; 95%CI: 1.63-4.61; p < 0.001) than lesions treated with BMS or PTA. Patients with long femoropopliteal lesions causing critical limb ischemia (CLI) developed restenosis or occlusion more often than patients treated for claudication (HR: 1.63; 95%CI: 1.06-2.49; p = 0.026) during an average follow-up of 26 months.

CONCLUSION

Primary stenting of femoropopliteal TASC D lesions using drug eluting stents or covered stents results in sustained patency over time. PTA or uncoated nitinol stents demonstrated lower patency rates. However, additional comparative studies are needed to determine the efficacy of newer technologies for the treatment of complex femoropopliteal lesions and provide evidence for the most optimal treatment approach.

Long Chronic Total Occlusions: Revascularization Strategies

The treatment of chronic total occlusions (CTO) in patients with peripheral arterial disease (PAD) is a complex topic with multiple treatment techniques and treatment strategies. The interventionalist treating patients with PAD should have both a defined treatment algorithm and multiple techniques available for crossing these challenging lesions. This article will cover techniques for treating CTOs and provide an overview of current available evidence.

Efficacy and safety of endovascular treatment for femoropopliteal lesions of TASC II type C and D compared with TASC II type A and B in Korea

Objective

To compare the long-term safety and clinical efficacy of endovascular treatment for TASC-II type C/D femoropopliteal lesion compared with TASC-II type A/B femoropopliteal lesion in Korea.

Methods

A total of 179 limbs [TASC-II A/B femoropopliteal lesion (group I, n = 105 limbs) and TASC-II C/D (group II, n = 74 limbs)] were retrospectively analyzed from patients who underwent angioplasty with or without primary stent implantation between February 2008 and November 2012 at two medical centers in South Korea. The major adverse limb event was defined as a composite of target lesion revascularization, symptom relapse with abnormal ankle brachial index, and major amputation.

Results

Immediate procedural success rates were not significantly different (96.2% vs. 95.7%, p = 0.450). Although major adverse limb event, mainly driven by symptom relapse with abnormal ankle brachial index, were significantly higher in group II ( p = 0.013), the incidence of major amputation was very low and similar in both groups.

Conclusion

Even though there were higher incidences of overall procedural complication and major adverse limb event, the technical success rate of endovascular treatment for TASC-II C/D femoropopliteal lesion was comparable to endovascular treatment for TASC-II A/B FPL without an increase in major procedural complications or serious clinical events during follow-up.

Strategies to Approaching Lower Limb Occlusions

Endovascular management of chronic total occlusions (CTO) can be challenging both from decision-making and technical perspectives. Successful treatment and management of a CTO requires the operator to have an understanding of the salient imaging findings, a thorough knowledge of the various technical challenges of the procedure, and comprehension of the importance and necessity of long-term clinical management. This article outlines a general approach to endovascular management of lower limb CTOs and discusses indications, techniques, potential complications, and therapeutic options of the procedure.

Contemporary Management of Femoral Popliteal Revascularization

Symptomatic peripheral artery disease of the femoral popliteal segment can be treated by surgical and endovascular revascularization, but controversy exists about the best approach. Conventional approaches to revascularization have focused on lesion anatomy to decide on bypass versus endovascular treatment, but advances in endovascular therapy make an endovascular-first approach increasingly feasible-either as a single approach or as an adjunct to short-segment bypass (ie, hybrid procedure). In this review, we discuss the medical, endovascular, and surgical treatment of femoral popliteal revascularization with a special emphasis on advances in percutaneous therapy.

Management of critical lower limb ischemia in endovascular era: experience from 511 patients

This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.

Predictors of medium-term patency in percutaneous endovascular therapy of femoro-popliteal lesions

BACKGROUND

The objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency.

PATIENTS AND METHODS

Retrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011.

RESULTS

The immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was invloved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length>20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively.

CONCLUSIONS

Angioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.

Clinical efficacy of successful angioplasty in critical ischemia--a cohort study

BACKGROUND

To evaluate the impact of percutaneous angioplasty (PA), objectively assessed with duplex-ultrasound, on 3-year clinical outcome.

METHODS

Thirty-nine patients with atherosclerotic disease successfully treated by PA were included (40 limbs). All patients had critical ischemia with rest pain and ischemic ulcers due to infrainguinal obstructions alone. The patients were submitted to duplex ultrasound examination on the day before and on the first or second day after the procedure. Peak systolic velocities (PSV) were recorded in the anterior tibial, posterior tibial, and fibular arteries at the level of distal third of the leg. All patients were followed for 3 years. Comparison between groups with good and bad results were based on perioperative VPS gradient (GPSV) of the mean of the VPS in the 3 arteries. After 3 years, a good result was defined as a patient having no pain and complete healing of a previous ulcer or minor amputations.

RESULTS

Mean age was 68.5±8.1 years with no difference in demographic characteristics (P>0.05). In 26 cases, the long-term result was good. Healing time ranged from 4 to 130 weeks (median 26.5). Bad long-term results were observed in 12 cases. Two lesions remained unhealed despite patent angioplasty. In 10 cases, a second procedure was carried out (repeat angioplasty in 6 and bypass in 4). TransAtlantic Inter-Society Consensus (TASC) II category A/B registered better clinical success then TASC II category C/D (P<0.05) at 1-year follow-up but not at 3 years (P=0.36). Two-year limb salvage was 92.5%±4.2%. Primary patency was 52.5%±9.5% at 3 years. GVPS was 21.9 cm/sec in the good results group and 24.7 cm/sec in the bad results group (P>0.05). The quality of the initial result, as measured by GPSV, was not associated with long-term success (P>0.05).

CONCLUSIONS

An initially successful procedure indicated by the degree of increased flow is not related to long-term durability and ulcer healing.

Revascularization by angioplasty of type D femoropopliteal and long infrapopliteal lesion in diabetic patients with critical limb ischemia: are TASC II recommendations suitable? A population-based cohort study

Feasibility of revascularization of type D femoropopliteal and long infrapopliteal lesions by angioplasty (peripheral translumenal angioplasty [PTA]) in diabetic patients with critical limb ischemia (CLI) according to the TransAtlantic Inter-Society Consensus (TASC) II recommendations was studied. A total of 292 diabetic patients were admitted for CLI; 308 limbs underwent a PTA. Out of 211 femoropopliteal lesions treated with PTA, 44 were TASC II type A, 45 type B, 48 type C, and 76 type D lesions. In 44 of the 76 patients with type D lesions revascularized by PTA, no artery was patent down to the foot before the PTA. In 172 limbs with all infrapopliteal arteries occluded, revascularization was carried out down to the foot in 167 limbs. Follow-up was 3.1 ± 0.3 years. A first episode of restenosis occurred in 66/308 limbs with an incidence/year of 7.9. PTA procedures were successfully repeated in 57/66 restenosis episodes: secondary patency was 97.1%. The incidence/year of type D femoropopliteal lesions was 5.4, the incidence/year in others was 5.0, without statistically significant differences: P = .417. The only variable found significantly associated with restenosis occurrence on logistic analysis was the presence of lesions in both femoropopliteal and infrapopliteal axes. A total of 26/308 above-the-ankle amputations were performed, with an incidence/year of 2.5. Multivariate analysis showed the independent role of only crural artery occlusion after PTA. These data show that the choice to refer to angioplasty diabetic patients with type D and/or long infrapopliteal lesions without good run-off at the foot and/or high surgical risk allowed high revascularization feasibility, with an optimal amputation outcome.

Long-term outcomes of endovascular repair versus open repair of abdominal aortic aneurysm

OBJECTIVES

To compare the long-term outcomes of endovascular repair (EVAR) versus open repair for abdominal aortic aneurysm (AAA).

DESIGN

We retrospectively reviewed consecutive AAA patients treated with EVAR (n = 89) or open repair (n = 136) from January 1998 to December 2008.

RESULTS

More patients in the open repair group had a longer duration of hospital stay. The operation time was significantly longer in open surgery than in EVAR (p <0.001), and the percentage of patients requiring a transfusion was higher in the open repair group than in EVAR. Patients in the open repair group had a higher incidence of cardiac insufficiency after surgery than did those in the EVAR group. Kaplan-Meier analysis indicated that the proportion of patients without complications in the EVAR group was significantly less than that in the open repair group (68.1% vs. 91.1%; p <0.0001), and the long-term survival rate in EVAR group was similar to open surgery group (87.5% vs. 91.1%; p = 0.555). Thrombosis was found inside of the aneurysm; postoperative complications in the EVAR group included ischemic legs, graft stenosis, and endoleaks that required further endoluminal treatment.

CONCLUSIONS

Endovascular repair of abdominal aortic aneurysm causes less trauma in patients with AAAs in the short term, and patients treated with EVAR have similar survival rate with open repair in the long term, but have postoperative complications requiring further interventional treatment.