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Fereydooni A, Chandra V, Schneider PA, Giasolli R, Lichtenberg M, Stahlhoff S. Serration Angioplasty Is Associated With Less Recoil in Infrapopliteal Arteries Compared With Plain Balloon Angioplasty. J Endovasc Ther 2023:15266028231215284. [PMID: 38059463 DOI: 10.1177/15266028231215284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
PURPOSE Recoil following balloon angioplasty of tibial arteries is a known mechanism of lumen loss and widely considered to be a contributing factor in early failure or later restenosis. The Serranator balloon has been designed to provide a controlled lumen gain while minimizing vessel injury. The objective of this study was to assess the ability to define and measure postangioplasty recoil in infrapopliteal arteries and to compare recoil after serration angioplasty and plain balloon angioplasty (POBA). METHODS This multi-center, sequential comparative study included patients with de novo or restenotic lesions of infrapopliteal arteries up to 22 cm in length. Patients were enrolled sequentially and underwent alternating POBA or serration angioplasty with Serranator. The study captured angiographic imaging at pre, immediately post, and 15-minute after angioplasty. Vessel recoil, final diameter stenosis, and dissection were compared using core laboratory analysis. RESULTS This study enrolled 36 patients who underwent treatment of 39 infrapopliteal lesions. There was no significant difference between Serranator (n=20) and POBA (n=19) with respect to baseline demographics and lesion characteristics. Arterial recoil (>10%) occurred in 25% of Serranator-treated lesions versus 64% in POBA-treated lesions (p=0.02. Clinically relevant recoil (>30%) was present after serration angioplasty in 10% of patients and after POBA in 53% (p=0.01). There was no significant difference in technical success (100% for both), dissection rate between Serranator (5%) and POBA (5.2%). CONCLUSIONS Arterial recoil occurs after infrapopliteal angioplasty. Serration angioplasty produces substantially less arterial recoil compared with POBA. Additional studies are needed to assess whether reduced arterial recoil translates into superior long-term clinical outcomes. CLINICAL IMPACT Prior studies have demonstrated over 90% recoil in patients after balloon angioplasty (POBA) of the infrapopliteal vessels, which significantly impacts the durability and impact of endovascular interventions in this clinical space. This study compared recoil after infrapopliteal angioplasty with serration angioplasty and POBA. Serration angioplasty produces substantially less arterial recoil compared with POBA. Additional studies are needed to assess whether reduced arterial recoil translates into superior long-term clinical outcomes.
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Affiliation(s)
- Arash Fereydooni
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Venita Chandra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA, USA
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Budak AB, Altınay L, Günertem OE, Sağlam MS, Külahçıoğlu E, Tümer NB, Yağız BK, Terzioğlu SG, Saba T, Özışık K, Günaydın S. Evaluation of endovascular treatment of chronic limb-threatening ischemia for patients in the PLAN gray zone. J Int Med Res 2023; 51:3000605231211768. [PMID: 38000011 PMCID: PMC10676071 DOI: 10.1177/03000605231211768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/17/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE To compare the results of endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients categorized under the gray and yellow zones of the patient risk, limb severity, and anatomic pattern (PLAN) concept over a 2-year follow-up period. METHODS Patients who underwent endovascular therapy for peripheral artery disease and presented with CLTI from February 2017 to February 2019 were retrospectively reviewed. The patients were grouped into yellow and gray zones based on the PLAN concept. Preoperative and postoperative walking distances, Rutherford classes, and postoperative target vessel patency rates were recorded and compared between the groups. Follow-up evaluations were performed at 1, 6, 12, and 24 months post-procedure. RESULTS Of the 387 patients evaluated, the yellow and gray groups comprised 88 patients each. The overall patency rates were similar between the groups (84 (95.45%) vs. 81 (92.05%), respectively). The occlusion-/stenosis-free survival times, amputation-free survival time, and mean survival time were not significantly different. However, the gray group had a significantly higher number of atherectomy interventions (74 vs. 59) and crosser devices used (62 vs. 42). CONCLUSION Endovascular therapy is an effective treatment option for patients in the gray zone of the PLAN color coding system.
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Affiliation(s)
- Ali Baran Budak
- Department of Cardiovascular Surgery, Ulus Liv Hospital, Beşiktaş-İstanbul, Türkiye
| | - Levent Altınay
- Department of Cardiovascular Surgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Türkiye
| | - Orhan Eren Günertem
- Department of Cardiovascular Surgery, Batıkent Medical Park Hospital, Batıkent, Türkiye
| | - Muhammet Sefa Sağlam
- Department of Cardiovascular Surgery, Niğde Training and Research Hospital, Niğde, Türkiye
| | - Emre Külahçıoğlu
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | - Naim Boran Tümer
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | | | | | - Tonguç Saba
- Department of Cardiovascular Surgery, Baskent University Hospital Alanya, Alanya-Antalya, Türkiye
| | - Kanat Özışık
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | - Serdar Günaydın
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
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Sarkar A, Nagarsheth KH. Deep Venous Arterialization for Limb Salvage. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Guetl K, Muster V, Schweiger L, Tang WC, Patel K, Brodmann M. Standard Balloon Angioplasty Versus Serranator Serration Balloon Angioplasty for the Treatment of Below-the-Knee Artery Occlusive Disease: A Single-Center Subanalysis From the PRELUDE-BTK Prospective Study. J Endovasc Ther 2022:15266028221134891. [PMID: 36408609 DOI: 10.1177/15266028221134891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Endovascular interventions in infrapopliteal occlusive artery disease are becoming more complex, and this frequently tests the standard method of treatment, plain old balloon angioplasty (POBA). The potential that serration angioplasty could produce a more acceptable tibial artery lumen was assessed in this study. AIM The aim of this single-center subgroup analysis was to compare acute angiographic results after endovascular treatment using the Serranator serration balloon catheter in patients participating in the PRELUDE-BTK trial with POBA of the infrapopliteal arteries. A secondary objective was to assess post-treatment hemodynamic improvements. METHODS Our center enrolled 15 subjects and treated 17 lesions within the multicenter prospective core laboratory-adjudicated PRELUDE-BTK study. A 25 lesions analyzed separately were treated with POBA and then compared with the Serranator subset. In both cohorts, lesions were treated with either plain angioplasty or Serranator as a stand-alone therapy; subsequent methods, such as drug elution technologies, were not used. Acute angiographic results were analyzed by the SynvaCor angiographic core laboratory. To assess volumetric flow rates, data were analyzed with a fluid flow simulation software and compared against Poiseuille's Law. RESULTS Final residual stenosis was 17.2%±8.2% in the Serranator group versus 33.7%±15.7% in the POBA group. The mean lumen diameter (MLD) gain for the Serranator group and the POBA group was 1.64±0.41 mm and 1.33±0.63 mm, respectively. The average atmospheric balloon inflation pressure was 5 ATM in the Serranator group versus 9 ATM in the POBA group. Neither group required a bailout stent; however, it was notable that there were significantly more chronic total occlusions (CTOs) treated in the Serranator group at 41.2% versus 12% in the POBA group. Regarding the effectiveness in improving hemodynamic blood flow for non-CTO lesions, the calculated average ratio of post-treatment to pre-treatment flow rates in the Serranator group was 238% than that for the POBA group. For CTO cases where pre-treatment flow rate was zero, final residual stenosis was used as the parameter for comparison. The Serranator group showed a 62% improvement in final residual stenosis over POBA. CONCLUSION Endovascular treatment of the infrapopliteal arteries by use of the Serranator serration balloon provides a novel and promising method of action compared with standard balloon angioplasty and, thus, may have a leading role in complex below-the-knee arterial lesions. CLINICAL IMPACT The Serranator device might help to adequately address issues with conventional routine techniques for the treatment of complex lesions in infrapopliteal arteries in patients with advanced stages of PAD and critical limb ischemia. Integrating modern technologies such as the Serranator balloon catheter into clinical routine is mandatory in order to gain a more favorable outcome in these severely diseased patients and, particularly, to reduce mortality and morbidity.
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Affiliation(s)
- Katharina Guetl
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Viktoria Muster
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Leyla Schweiger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - William C Tang
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Kaushal Patel
- Department of Mechanical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Mortality Risk Assessment in Peripheral Arterial Disease-The Burden of Cardiovascular Risk Factors over the Years: A Single Center's Experience. Diagnostics (Basel) 2022; 12:diagnostics12102499. [PMID: 36292188 PMCID: PMC9600417 DOI: 10.3390/diagnostics12102499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/10/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Atherosclerosis is the basis of the cardiovascular continuum in peripheral artery disease (PAD) patients. Limiting functional decline and increasing quality of life are the main objectives for these patients. We conducted a prospective cohort study on 101 patients with PAD admitted to a single center in Northeast Romania. We used an index score to evaluate the 10-year mortality risk assessment and based on the scores we divided the patients into two groups: a low and low-intermediate risk mortality group (49 cases, 48.5%) and a high-intermediate and high-risk mortality group (52 cases, 51.5%). We analyzed demographics, comorbidities, clinical and paraclinical parameters and we aimed to identify the parameters associated with an unfavorable prognosis. Patients in the high-intermediate and high-risk mortality group were associated more with cardiovascular risk factors. Hypertension (p = 0.046), dyslipidemia (p < 0.001), diabetes mellitus (p < 0.001), and tobacco use (p = 0.018) were statistically significant factors. Lipid profile (low-density lipoprotein cholesterol, p = 0.005) and fasting blood glucose (p = 0.013) had higher mean serum values in the high-intermediate and high-risk mortality group, with a positive correlation between them and the ankle-brachial index value (p = 0.003). A multidisciplinary assessment and, especially, correction of associated cardiovascular risk factors prevent complications, and thus, improve the prognosis in the medium and long term.
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Zeller T, Giannopoulos S, Brodmann M, Werner M, Andrassy M, Schmidt A, Blessing E, Tepe G, Armstrong EJ. Orbital Atherectomy Prior to Drug-Coated Balloon Angioplasty in Calcified Infrapopliteal Lesions: A Randomized, Multicenter Pilot Study. J Endovasc Ther 2022; 29:874-884. [PMID: 35086385 DOI: 10.1177/15266028211070968] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Optimal balloon angioplasty for infrapopliteal lesions is often limited by severe calcification, which has been associated with decreased procedural success and lower long-term patency. MATERIALS AND METHODS This was a prospective, randomized, multicenter pilot trial that included adult subjects with calcified lesions located from the popliteal segment below the knee (BTK) joint to within 5 cm above the ankle with ≥70% diameter stenosis by angiography. Patients were randomized 1:1 to undergo orbital atherectomy (OA) with adjunctive drug-coated balloon (DCB) angioplasty versus plain balloon angioplasty (BA) and DCB angioplasty (control). The periprocedural and 12 month outcomes of both procedures were compared. RESULTS Overall, 66 subjects (OA + DCB = 32 vs control = 34) were included in an intention to treat analysis. Baseline demographics and lesion characteristics were well-balanced. The mean lesion length was 101.3 mm (SD = 72.8 mm) and 78.8 (SD = 61.0 mm) in the OA + DCB and control groups, respectively, with almost all lesions having severe calcification per the Peripheral Academic Research Consortium (PARC) criteria. Chronic total occlusions (CTOs) were present in 43.8% and 35.3% of the patients in the OA + DCB and control groups, respectively. The technical success of OA + DCB versus DCB was 81.8% and 89.2%, respectively, with 3 slow flow/no reflow, 1 perforation, 1 severe dissection occurred in OA + DCB group, and one distal embolization occurred in the control group. The target lesion primary patency rate was numerically higher in the OA + DCB versus control group at 6 (88.2% vs 50.0%, p=0.065) and 12 month follow-up (88.2% vs 54.5%, p=0.076). The 12 month freedom from major adverse events, clinically-driven target lesion revascularization, major amputation, and all-cause mortality rates were similar between both groups. CONCLUSION The results of the Orbital Vessel PreparaTIon to MaximIZe Dcb Efficacy in Calcified BTK (OPTIMIZE BTK) pilot study indicated that utilization of OA + DCB is safe for infrapopliteal disease. Further prospective adequately powered studies should investigate the potential benefit of combined OA + DCB for BTK lesions.
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Affiliation(s)
- Thomas Zeller
- Universitäts-Herzzentrum Bad Krozingen, Bad Krozingen, Germany
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | | | | | | | - Erwin Blessing
- SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Gunnar Tepe
- RoMed Klinikum Rosenheim, Rosenheim, Germany
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Lotfy H, El-Nadar AA, Shaalan W, Emam AE, Ibrahim A, Naga A. Evaluation of Tissue Perfusion by Wound Blush and 2D Color-Coded Digital Subtraction Angiography During Endovascular Intervention and Its Impact on Limb Salvage in Critical Limb Ischemia. J Endovasc Ther 2021; 29:763-772. [PMID: 34964396 DOI: 10.1177/15266028211065957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI. MATERIALS AND METHODS 198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow). RESULTS 176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001). CONCLUSIONS WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.
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Affiliation(s)
- Hassan Lotfy
- Department of Vascular Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Wael Shaalan
- Department of Vascular Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ali El Emam
- Department of Vascular Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Akram Ibrahim
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmad Naga
- Department of Vascular Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Adams G, Soukas PA, Mehrle A, Bertolet B, Armstrong EJ. Intravascular Lithotripsy for Treatment of Calcified Infrapopliteal Lesions: Results from the Disrupt PAD III Observational Study. J Endovasc Ther 2021; 29:76-83. [PMID: 34380334 DOI: 10.1177/15266028211032953] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the safety and effectiveness of the Shockwave S4 intravascular lithotripsy (IVL) catheter in an "all-comers" cohort of patients with calcified infrapopliteal lesions. MATERIALS AND METHODS The Disrupt PAD III Observational Study (NCT02923193) is a prospective, nonrandomized, multicenter single-arm study designed to assess the "real-world" acute safety and effectiveness of the Shockwave Peripheral IVL System for the treatment of de novo calcified, stenotic peripheral arteries. Patients were eligible for enrollment if they had claudication or critical limb ischemia (CLI) and at least moderate calcification as assessed by angiography. This subanalysis includes consecutive patients enrolled with angiographic core lab-assessed treatment of infrapopliteal arteries using the Shockwave S4 IVL catheter. RESULTS From July 2018 to August 2020, 101 patients with 114 calcified infrapopliteal arteries treated with the S4 IVL catheter were enrolled at 15 sites in 3 countries. CLI was present in 69.3% of patients. The anterior tibial and tiboperoneal trunk were the most commonly treated vessels with an overall mean reference vessel diameter (RVD) of 3.1±0.8 mm, minimum lumen diameter (MLD) of 0.5±0.6 mm, and a corresponding diameter stenosis of 83.4%±15.8% by core lab assessment. Mean lesion length was 64.7±54.7 mm with moderate to severe calcification in 69.3% of lesions by the Peripheral Academic Research Consortium (PARC) criteria. Adjunctive calcium-modifying technology, defined as scoring or cutting balloon and/or atherectomy, was used in 22.7% of procedures. The average acute gain at the end of the procedure was 2.0±0.7 mm with a residual stenosis <50% achieved in 99.0% of lesions and a mean residual stenosis of 23.3±12.5%. There were no flow-limiting dissection, embolization, slow flow/no-reflow, or abrupt closure events at the end of the procedure. CONCLUSION This subanalysis of the PAD III Observational Study represents the largest report to-date of IVL treatment of heavily calcified below-the-knee (BTK) lesions in a "real-world" patient cohort. The use of S4 IVL demonstrated consistent acute safety and effectiveness outcomes consistent with prior IVL peripheral studies. These consistent outcomes were achieved with the initial use of the S4 IVL catheter for treatment of complex BTK lesions.
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Affiliation(s)
- George Adams
- Department of Cardiology, North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Peter A Soukas
- Lifespan Cardiovascular Institute, The Miriam Hospital, Providence, RI, USA
| | - Anderson Mehrle
- Department of Internal Medicine, Cardiovascular Division, University of Mississippi Medical Center, Jackson, MS, USA
| | - Barry Bertolet
- Cardiology Associates Research, LLC, North Mississippi Medical Center, Tupelo, MS, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Del Giudice C, Galloula A, Tiercelin C, Vilfaillot A, Alsac JM, Messas E, Déan CL, Larger E, Sapoval M. "Ranger BTK" a Prospective Single-Centre Cohort Study on a New Drug-Coated Balloon for Below the Knee Lesions in Patients with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2021; 44:1017-1027. [PMID: 33948700 DOI: 10.1007/s00270-021-02833-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/24/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Restenosis remains a limitation of endovascular angioplasty with a patency of 30% in BTK at 12 months. Several studies on drug-coated balloons have not demonstrated any improvements in terms of patency and target lesions revascularization in BTK lesions. This prospective single-centre cohort study evaluates the safety and efficacy of a new generation low-dose drug-coated balloon (DCB) with a reduced crystalline structure to treat below the knee (BTK) lesions in patients with critical limb ischemia (CLI). MATERIALS AND METHODS Between November 2016 and November 2017, 30 consecutive patients (mean 68.8 ± 12.7 years, 6 female) with BTK lesions and CLI were included in this single-centre, prospective non-randomized cohort study. All patients with rest pain and/or ischemic wound associated with BTK lesions were included in the study. Mean lesion length was 133.6 ± 94.5 mm and 18(60%) were chronic total occlusions. The primary safety outcome parameter was a composite of all-cause mortality and major amputation at 6 months. The primary efficacy outcome parameter was the primary angiographic patency at 6 months (defined as freedom from clinically driven target lesion revascularization and the absence of significant restenosis (> 50%) as determined by core laboratory angiography assessment. Immediate technical success, late lumen loss (LLL), clinical target lesion revascularization (TLR) and ulcer healing rates at 12 months were also evaluated. RESULTS Immediate technical success was 97%(29/30): one patient had an acute thrombosis at the completion of index procedure. Primary safety outcome parameter was 94%(28/30): one patient underwent major amputation and one patient died of other comorbidities at 2 months. Another patient had a major amputation at 7.5 months. Angiographic follow-up was available in 20 patients. Primary angiographic patency was 57%(12/21 lesions), and LLL was 0.99 ± 0.68 mm at 6 months. Freedom from TLR was 89% at 12 months. The rate of ulcer healing was 76% at 12 months. CONCLUSION Ranger DCB balloons to treat CLI patients demonstrated a positive trend with good safety outcomes parameters. Further randomized studies are needed to understand the usefulness compared to POBA.
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Affiliation(s)
- Costantino Del Giudice
- Department of Radiology, Interventional Radiology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.
| | - Alexandre Galloula
- Department of Vascular Medicine, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Clarisse Tiercelin
- Diabetology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Aurélie Vilfaillot
- Clinical Investigation Unit, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Jean Marc Alsac
- Vascular Surgery, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France.,Université de Paris, INSERM U970, 75015, Paris, France
| | - Emmanuel Messas
- Department of Vascular Medicine, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France.,Université de Paris, INSERM U970, 75015, Paris, France
| | - Carole L Déan
- Vascular and Oncological Interventional Radiology, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Etienne Larger
- Diabetology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Marc Sapoval
- Université de Paris, INSERM U970, 75015, Paris, France.,Vascular and Oncological Interventional Radiology, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
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Kim KG, Meshkin DH, Tirrell AR, Bekeny JC, Tefera EA, Fan KL, Akbari CM, Evans KK. A systematic review and meta-analysis of endovascular angiosomal revascularization in the setting of collateral vessels. J Vasc Surg 2021; 74:1406-1416.e3. [PMID: 33940077 DOI: 10.1016/j.jvs.2021.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Endovascular procedures for targeted treatment of lower extremity wounds can be subdivided as direct revascularization (DR), indirect revascularization (IR), and IR via collateral flow (IRc). Although previous systematic reviews assert superiority of DR when compared with IR, the role of collateral vessels in clinical outcomes remains to be defined. This systematic review and meta-analysis aims to define the usefulness of DR, IR, and IRc in treatment of lower extremity wounds with respect to (1) wound healing, (2) major amputation, (3) reintervention, and (4) all-cause mortality. METHODS A meta-analysis was performed in accordance with PRISMA guidelines. Ovid MEDLINE was queried for records pertaining to the study question using appropriate Medical Subject Heading terms. Studies were limited to those using DR, IR, or IRc as a primary intervention and reporting information on at least one of the primary outcomes of interest. No limitation was placed on year of publication, country of origin, or study size. Studies were assessed for validity using the Newcastle-Ottawa Scale. Study characteristics and patient demographics were collected. Data representing the primary outcomes-wound healing, major amputation, reintervention, and all-cause mortality-were collected for time points ranging from one month to four years following intervention. A meta-analysis on sample size-weighted data assuming a random effects model was performed to calculate odds ratios (ORs) for the four primary outcomes at various time points. RESULTS We identified 21 studies for a total of 4252 limbs (DR, 2231; IR, 1647; IRC, 270). Overall wound healing rates were significantly superior for DR (OR, 2.45; P = .001) and IRc (OR, 8.46; P < .00001) compared with, IR with no significant difference between DR and IRc (OR, 1.25; P = .23). The overall major amputation rates were significantly superior for DR (OR, 0.48; P < .00001) and IRc (OR, 0.44; P = .006) compared with IR, with DR exhibiting significantly improved rates compared with IRc (OR, 0.51; P = .01). The overall mortality rates showed no significant differences between DR (OR, 0.89; P = .37) and IRc (OR, 1.12; P = .78) compared with IR, with no significant difference between DR and IRc (OR, 0.54; P = .18). The overall reintervention rates showed no significant difference between DR and IR (OR, 1.05; P = .81), with no studies reporting reintervention outcomes for IRc. CONCLUSIONS Both DR and IRc offer significantly improved wound healing rates and major amputation rates compared with IR when used to treat critical limb ischemia. Although DR should be the preferred method of revascularization, IRc can offer comparable outcomes when DR is not possible. This analysis was limited by a small sample size of IRc limbs, a predominance of retrospective studies, and variability in outcome definitions between studies.
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Affiliation(s)
- Kevin G Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Dean H Meshkin
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, DC
| | - Abigail R Tirrell
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu A Tefera
- Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, MD
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
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11
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Futchko J, Friedmann P, Phair J, Trestman EB, Denesopolis J, Shariff S, Scher LA, Lipsitz EC, Porreca F, Garg K. A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2021; 75:194-204. [PMID: 33819581 DOI: 10.1016/j.avsg.2021.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention. METHODS We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models. RESULTS A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization. CONCLUSIONS An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.
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Affiliation(s)
- John Futchko
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Patricia Friedmann
- Department of Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - John Phair
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Eric B Trestman
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - John Denesopolis
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Saadat Shariff
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Larry A Scher
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Evan C Lipsitz
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Francis Porreca
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Karan Garg
- Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York.
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12
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AMBANI RN, CHO JS. When open surgery is needed: maximizing the blood flow to the foot - the distal gold standard. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01488-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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13
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Kobayashi T, Hamamoto M, Okazaki T, Hasegawa M, Fujiwara T, Takahashi S. 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. Vascular 2020; 29:905-912. [PMID: 33349196 DOI: 10.1177/1708538120981224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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14
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Percutaneous Transluminal Ballooning Angioplasty for Flap Salvage in a Complex Lower Extremity Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3077. [PMID: 33133936 PMCID: PMC7544395 DOI: 10.1097/gox.0000000000003077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient’s foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.
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15
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Kobayashi T, Hamamoto M, Okazaki T, Hasegawa M, Takahashi S. Long Term Outcomes of Endovascular Therapy for Failing Distal Bypass Vein Grafts. Eur J Vasc Endovasc Surg 2020; 61:121-127. [PMID: 33060028 DOI: 10.1016/j.ejvs.2020.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/29/2020] [Accepted: 09/22/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although distal bypass using vein has been established with acceptable outcomes for chronic limb threatening ischaemia (CLTI), the major issue affecting long term outcomes is vein graft disease. This study aimed to analyse the peri-procedural results and long term outcomes of endovascular therapy (EVT) for failing vein grafts after distal bypass. METHODS A retrospective analysis of 113 failing vein grafts (94 patients, 113 limbs) after distal bypass between 2009 and 2019 at the study hospital. RESULTS The mean age was 74 ± 9 years and 72% of the patients were men. Of the 113 grafts, 54 grafts (48%) were detected in asymptomatic patients, 41 grafts (36%) in patients with recurrent ulcer or gangrene, and 18 grafts (16%) in patients with rest pain. The failing grafts were treated by low pressure long inflation balloon angioplasty with a mean balloon size of 3.0 ± 0.8 mm. The mean procedural time was 60 ± 29 min and procedural success was 98% (111 grafts). During the mean follow up period of 34 months, EVT was performed a median frequency of two times (range 1-11 times). The primary and assisted primary patency of the EVT revised grafts were 41% and 80% at one year, 34% and 68% at three years, 31% and 58% at five years, respectively. Of 41 limbs with recurrent ulcer or gangrene, the wound healed in 34 limbs (85%). The complete healing rate was 71% at three months and 84% at 12 months. Eight patients required major amputation, and the freedom from major amputation rate was 96% at one year and 80% at five years. CONCLUSION Long term outcomes including patency, wound healing rate, and amputation free survival after EVT for failing vein grafts were acceptable. EVT could be a viable alternative to surgical revascularisation in patients with a failing distal bypass graft for CLTI.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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16
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Kobayashi T, Hamamoto M, Okazaki T, Honma T, Takahashi S. Long-Term Results of Distal Bypass for Intermittent Claudication. Vasc Endovascular Surg 2020; 55:5-10. [PMID: 32869709 DOI: 10.1177/1538574420954956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Distal bypass (DB) is the optimal treatment for patients with critical limb ischemia (CLI). However, effectiveness of DB for patients with intermittent claudication (IC) remains uncertain. This study aimed to analyze long-term results of DB for IC patients (IC-DB) compared with those of DB for CLI patients (CLI-DB). METHODS Patients undergoing DB from January 2009 to July 2018 at a single institution were retrospectively reviewed. Operative details, primary and secondary patency, amputation free survival rate (AFS), and long-term exercise capacity using Barthel index were analyzed. RESULTS Out of 302 DB (245 patients), 49 IC-DB were performed in 43 patients: 38 males, mean age 70.3 ± 8.0 years, diabetes mellitus 51%, chronic renal failure with hemodialysis 7%. The Great saphenous vein was used in 47 limbs, the small saphenous vein in 1, and the arm vein in 1. These grafts were bypassed in a non-reversed fashion for 35 limbs, in an in-situ fashion in 9, and in a reversed fashion in 5. The mean operative time was 173 min. The mean follow-up was 25 ± 26 months. Primary and secondary patency of IC-DB was 79% and 94% at 1 year, 71% and 90% at 3 years, 65% and 90% at 5 years, which were significantly higher than those of CLI-DB (primary patency: P = .007, secondary patency: P = .025). AFS of IC-DB and CLI-DB was 100% and 77% at 1 year, 93% and 52% at 3 years, and 90% and 43% at 5 years (IC-DB vs. CLI-DB, p < .0001). Barthel index of IC-DB unchanged at discharge (median 100) and at the last visit (median 100), showing daily activity was maintained adequately. CONCLUSIONS DB could offer a promising approach for patients with IC because of durable graft patency, acceptable AFS, and maintenance of daily activity.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, 13754JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, 13754JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, 13754JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Tomoaki Honma
- Department of Rehabilitation, 13754JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, 12803Hiroshima University, Hiroshima, Japan
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17
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Giannopoulos S, Varcoe RL, Lichtenberg M, Rundback J, Brodmann M, Zeller T, Schneider PA, Armstrong EJ. Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy. J Endovasc Ther 2020; 27:547-564. [DOI: 10.1177/1526602820931488] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endovascular revascularization has been increasingly utilized to treat patients with chronic limb-threatening ischemia (CLTI), particularly atherosclerotic disease in the infrapopliteal arteries. Lesions of the infrapopliteal arteries are the result of 2 different etiologies: medial calcification and intimal atheromatous plaque. Although several devices are available for endovascular treatment of infrapopliteal lesions, balloon angioplasty still comprises the mainstay of therapy due to a lack of purpose-built devices. The mechanism of balloon angioplasty consists of adventitial stretching, medial necrosis, and dissection or plaque fracture. In many cases, the diffuse nature of infrapopliteal disease and plaque complexity may lead to dissection, recoil, and early restenosis. Optimal balloon angioplasty requires careful attention to assessment of vessel calcification, appropriate vessel sizing, and the use of long balloons with prolonged inflation times, as outlined in a treatment algorithm based on this systematic review. Further development of specific devices for this arterial segment are warranted, including devices for preventing recoil (eg, dedicated atherectomy devices), treating dissections (eg, tacks, stents), and preventing neointimal hyperplasia (eg, novel drug delivery techniques and drug-eluting stents). Further understanding of infrapopliteal disease, along with the development of new technologies, will help optimize the durability of endovascular interventions and ultimately improve the limb-related outcomes of patients with CLTI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ramon L. Varcoe
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, University of New South Wales, The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | | | - John Rundback
- Advanced Interventional & Vascular Services LLP, Teaneck, NJ, USA
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Bad Krozingen, Germany
| | - Peter A. Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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18
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Giannopoulos S, Ghanian S, Parikh SA, Secemsky EA, Schneider PA, Armstrong EJ. Safety and Efficacy of Drug-Coated Balloon Angioplasty for the Treatment of Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis. J Endovasc Ther 2020; 27:647-657. [PMID: 32508220 DOI: 10.1177/1526602820931559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the safety and efficacy of drug-coated balloons (DCB) for the treatment of femoropopliteal or infrapopliteal lesions in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: A systematic literature search was conducted in PubMed, Scopus, and Cochrane Central up to January 2020 to identify randomized trials and observational studies presenting data on the effectiveness and safety of DCBs in the treatment of femoropopliteal or infrapopliteal lesions. A meta-analysis utilizing random effects modeling was conducted to investigate primary patency and all-cause mortality at 12 months; the results are reported as the odds ratios (ORs) and 95% confidence intervals (CIs). Secondary outcomes were procedural success, bailout stenting, target lesion revascularization (TLR), reocclusion, major amputation, wound healing, and major adverse limb events. Results: Twenty-six studies, 12 retrospective and 14 prospective, comprising 2108 CLTI patients treated with DCBs for femoropopliteal (n=1315) or infrapopliteal (n=793) lesions were analyzed. The average lesion lengths were 121±44 and 135±53 mm, respectively. The overall 12-month all-cause mortality and major amputation rates were 9% (95% CI 6% to 13%) and 5% (95% CI 2% to 8%), respectively. Primary patency rates were 82% (95% CI 76% to 87%) and 64% (95% CI 58% to 70%), respectively. A sensitivity analysis of the infrapopliteal lesions demonstrated no difference between DCB and balloon angioplasty in terms of primary patency, TLR, major amputation, or mortality over 12 months. However, patients with infrapopliteal lesions undergoing DCB angioplasty did have a significantly lower risk for reocclusion (10% vs 25%; OR 0.38, 95% CI 0.21 to 0.70, p=0.002). Conclusion: DCB angioplasty of femoropopliteal and infrapopliteal lesions in patients with CLTI results in acceptable 12-month patency rates, although comparative data have not shown a patency benefit for infrapopliteal lesions. The 12-month mortality rate of DCB vs balloon angioplasty was not significantly different, but studies with longer-term outcomes are necessary to determine any association between DCB use and mortality in patients with CLTI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Sheila Ghanian
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Sahil A Parikh
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, NY, USA
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Medical Center, Boston, MA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Mustapha JA, Anose BM, Martinsen BJ, Pliagas G, Ricotta J, Boyes CW, Lee MS, Saab F, Adams G. Lower extremity revascularization via endovascular and surgical approaches: A systematic review with emphasis on combined inflow and outflow revascularization. SAGE Open Med 2020; 8:2050312120929239. [PMID: 32551113 PMCID: PMC7278295 DOI: 10.1177/2050312120929239] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 05/03/2020] [Indexed: 11/15/2022] Open
Abstract
This review is intended to help clinicians and patients understand the present state of peripheral artery disease, appreciate the progression and presentation of critical limb ischemia/chronic limb-threatening ischemia, and make informed decisions regarding inflow and outflow endovascular revascularization and surgical treatment options within the context of current debates in the medical community. A controlled literature search was performed to obtain research on outcomes of critical limb ischemia patients undergoing complete leg revascularization for peripheral artery disease inflow and outflow disease. Data for this review were identified by queries of medical and life science databases, expert referral, and references from relevant papers published between 1997 and 2019, resulting in 48 articles. The literature review herein indicates that endovascular revascularization-including ballooning, stenting, and atherectomy-is an effective peripheral artery disease therapy for both above the knee and below the knee disease, and can safely and effectively treat both inflow and outflow disease. As such, it plays a leading role in the therapy of lower extremity artery disease.
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Affiliation(s)
| | - Bynthia M Anose
- Department of Clinical and Scientific Affairs, Cardiovascular Systems, Inc., St. Paul, MN, USA
| | - Brad J Martinsen
- Department of Clinical and Scientific Affairs, Cardiovascular Systems, Inc., St. Paul, MN, USA
| | - George Pliagas
- Vascular Division, Premier Surgical Associates, Knoxville, TN, USA
| | - Joseph Ricotta
- Tenet Florida Cardiovascular Care, Delray Beach, FL, USA
| | - Christopher W Boyes
- Carolinas Medical Center and Sanger Heart & Vascular Institute, Vascular Surgery, Charlotte, NC, USA
| | | | - Fadi Saab
- Advanced Cardiac & Vascular Centers, Grand Rapids, MI, USA
| | - George Adams
- North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
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20
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Giannopoulos S, Armstrong EJ. Diabetes mellitus: an important risk factor for peripheral vascular disease. Expert Rev Cardiovasc Ther 2020; 18:131-137. [PMID: 32129693 DOI: 10.1080/14779072.2020.1736562] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Bunch F, Nair P, Aggarwala G, Dippel E, Kassab E, Khan MA, LeCroy C, McClure JM, Tolleson T, Walker C. A universal drug delivery catheter for the treatment of infrapopliteal arterial disease using liquid therapy. Catheter Cardiovasc Interv 2020; 96:393-401. [PMID: 32017374 PMCID: PMC7496530 DOI: 10.1002/ccd.28739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/20/2019] [Accepted: 01/11/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the safety and feasibility of treating infrapopliteal lesions using a novel drug delivery catheter locally delivering liquid paclitaxel. BACKGROUND Balloon angioplasty is currently the Gold Standard to treat below-the-knee disease; however, restenosis continues to be a great challenge following these percutaneous revascularization procedures. METHODS The Occlusion Perfusion Catheter for Optimal Delivery of Paclitaxel for the Prevention of Endovascular Restenosis (COPPER-A) study-Below-the-Knee Cohort was a prospective, nonrandomized, multicenter, feasibility, and safety study that enrolled 35 patients at 11 participating sites. The safety endpoints at 1, 3, and 6 months were freedom from thrombosis, major amputation in the target limb and target limb related death. The efficacy endpoints were primary patency and freedom from clinically driven target lesion revascularization at 6 months. RESULTS All patients tolerated the procedure well with no reports of adverse procedural events. Thirty-five patients were treated with a mean lesion length of 112 ± 81.2 mm with the lesion length range of 20-286 mm. At 6-month follow-up, primary patency was 89.3% and freedom from clinically driven target lesion revascularization was 96.4%. No patients demonstrated thrombosis, major amputation in the target limb and target limb related death at the 1-, 3- and 6-months follow-up intervals. CONCLUSIONS The results of this multi-center study demonstrated that infrapopliteal arteries can be safely and effectively treated with liquid paclitaxel using the occlusion perfusion catheter.
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Affiliation(s)
- Frank Bunch
- Interventional Cardiology and Peripheral Vascular Disease, South Baldwin Regional Medical Center, Foley, Alabama
| | - Pradeep Nair
- Interventional Cardiology and Peripheral Vascular Disease, Cardiovascular Institute of the South, Houma, Louisiana
| | - Gaurav Aggarwala
- Interventional Cardiology and Peripheral Vascular Disease, Pulse Physician Organization, Huntsville, Texas
| | - Eric Dippel
- Interventional Cardiology and Peripheral Vascular Disease, Vascular Institute of the Midwest, Davenport, Iowa
| | - Elias Kassab
- Interventional Cardiology and Peripheral Vascular Disease, Michigan Outpatient Vascular Institute, Dearborn, Michigan
| | - Muhammad A Khan
- Interventional Cardiology and Peripheral Vascular Disease, North Dallas Research Associates, Cardiac Center of Texas, McKinney, Texas
| | - Christopher LeCroy
- Department of Vascular Surgery, Coastal Vascular & Interventional, Peripheral Vascular Disease, Pensacola, Florida
| | - John M McClure
- Interventional Cardiology and Peripheral Vascular Disease, Mid-Michigan Heart and Vascular Center, Saginaw, Michigan
| | - Thaddeus Tolleson
- Interventional Cardiology and Peripheral Vascular Disease, Tyler Cardiovascular Consultants, Tyler, Texas
| | - Craig Walker
- Interventional Cardiology and Peripheral Vascular Disease, Cardiovascular Institute of the South, Houma, Louisiana
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22
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Barillà D, Spinelli D, Stilo F, Derone G, Pipitò N, Spinelli F, Benedetto F. Simultaneous Superficial Femoral Artery Angioplasty/Stent Plus Popliteal Distal Bypass for Limb Salvage. Ann Vasc Surg 2020; 63:443-449. [DOI: 10.1016/j.avsg.2019.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 10/06/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
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Frank U, Nikol S, Belch J, Boc V, Brodmann M, Carpentier PH, Chraim A, Canning C, Dimakakos E, Gottsäter A, Heiss C, Mazzolai L, Madaric J, Olinic DM, Pécsvárady Z, Poredoš P, Quéré I, Roztocil K, Stanek A, Vasic D, Visonà A, Wautrecht JC, Bulvas M, Colgan MP, Dorigo W, Houston G, Kahan T, Lawall H, Lindstedt I, Mahe G, Martini R, Pernod G, Przywara S, Righini M, Schlager O, Terlecki P. ESVM Guideline on peripheral arterial disease. VASA 2019; 48:1-79. [DOI: 10.1024/0301-1526/a000834] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Tsay C, Luo J, Zhang Y, Attaran R, Dardik A, Ochoa Chaar CI. Perioperative Outcomes of Lower Extremity Revascularization for Rest Pain and Tissue Loss. Ann Vasc Surg 2019; 66:493-501. [PMID: 31756416 DOI: 10.1016/j.avsg.2019.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the clinical manifestation of severe peripheral artery disease presenting as rest pain (RP) and tissue loss (TL). Most studies compare CLI as a homogenous group with claudication with limited database studies specifically studying these differences. We hypothesize that CLI should be stratified into RP and TL because of significant differences in disease severity, comorbidities, and outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 was reviewed. All patients with a postoperative diagnosis of CLI undergoing femoral to popliteal bypass (FPB) with vein or graft were identified. Patients were stratified into cohorts based on International Classification of Disease (ICD)-9 or ICD-10 codes for RP or TL (gangrene or ulcer). Univariate and multivariate analyses were performed to examine 30-day mortality, morbidity, major amputation, and readmission adjusting for demographics, comorbidities, and procedural details. RESULTS There were 5,304 patients. Compared to RP, patients with TL were older (P < 0.0001) and more likely to be dependent (P < 0.0001). TL patients were also more likely to have diabetes (P < 0.0001), congestive heart failure (P < 0.0001), renal failure (P = 0.004), dialysis (P < 0.0001), history of wound infection (P < 0.0001), and sepsis (P < 0.0001). TL patients had higher American Society of Anesthesiologists class (P < 0.0001), were less likely to be transferred from home (P < 0.0001), and more likely to receive an FPB with vein (P = 0.03). Patients with TL had worse perioperative outcomes compared with RP in terms of pneumonia (P = 0.004), unplanned intubation (P = 0.009), cardiac arrest requiring cardiopulmonary resuscitation (P = 0.003), bleeding requiring transfusions (P < 0.0001), sepsis (P < 0.0001), septic shock (P = 0.02), and reoperation (P < 0.0001). TL was associated with significantly higher 30-day morbidity (P < 0.0001), 30-day mortality (P < 0.0001), major amputation (P = 0.0004), and readmission rates (P = 0.005). Patients with TL compared with those with RP also had longer hospital stays (P < 0.0001) and days between operation to discharge (P < 0.0001). TL was independently associated with increased 30-day morbidity (OR: 1.16 [1.00-1.35]) and major amputation (OR: 2.48 [1.29-4.76]) compared with RP. CONCLUSIONS Patients with RP and TL have drastic differences that impact perioperative mortality and readmissions. TL is an independent predictor of 30-day morbidity and major amputation. The stratification of CLI into RP and TL can provide insight into variations in outcomes and provide a means to quantify the risks associated with the 2 manifestations of the disease.
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Affiliation(s)
- Cynthia Tsay
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jiajun Luo
- Department of Statistics, Yale School of Public Health, New Haven, CT
| | - Yawei Zhang
- Department of Statistics, Yale School of Public Health, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Robert Attaran
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
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Jung HW, Ko YG, Hong SJ, Ahn CM, Kim JS, Kim BK, Choi D, Hong MK, Jang Y. Editor's Choice - Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 58:854-863. [PMID: 31653609 DOI: 10.1016/j.ejvs.2019.07.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 06/23/2019] [Accepted: 07/05/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study investigated the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with critical limb ischaemia (CLI). METHODS This retrospective analysis of a single centre cohort included 239 patients who underwent endovascular revascularisation of infrapopliteal arteries for a chronic ischaemic wound. PAR was attempted in 141 patients during the procedure. After propensity score matching, there were 87 pairs of patients with and without PAR. RESULTS After the matching, the two groups showed balanced baseline clinical and lesion characteristics. PAR was achieved in 60.9% of the PAR group. Direct angiosome flow was more frequently obtained in the PAR group than in the non-PAR group (81.6% vs. 34.5%; p < .001). Subintimal angioplasty (47.1% vs. 29.9%; p = .019) and pedal-plantar loop technique (18.4% vs. 0%; p < .001) were more frequent in the PAR group. At the one year follow up, the PAR group showed greater freedom from major amputation (96.3% vs. 84.2%; p = .009). The wound healing rate, overall survival, major adverse limb event, and freedom from re-intervention did not differ significantly between the two groups. However, the patient subgroup with successful PAR showed a higher wound healing rate than the non-PAR group (76.0% vs. 67.0%; p = .031). In a multivariable Cox proportional hazards regression model, successful PAR (hazard ratio [HR] 1.564, 95% confidence interval [CI] 1.068-2.290; p = .022) was identified as an independent factor associated with improved wound healing, whereas gangrene (HR 0.659, 95% confidence interval [CI] 0.471-0.923; p = .015), C reactive protein >3 mg/dL (HR 0.591, 95% CI 0.386-0.904; p = .015), and pre-procedural absence of pedal arch (HR 0.628, 95% CI 0.431-0.916; p = .016) were associated with impaired wound healing. CONCLUSION Successful PAR significantly improved wound healing in patients with CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.
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Affiliation(s)
- Hae Won Jung
- Department of Cardiology, Daegu Catholic University Medical Centre, Daegu, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Ghoneim BM, Karmota AG, Abuhadema AM, Shaker AA, Abdelmawla HM, Nasser MM, Elmahdy HY, Mostafa HA, Khairy HM. Management of Buerger's Disease in Endovascular Era. Int J Angiol 2019; 28:173-181. [PMID: 31452585 DOI: 10.1055/s-0039-1685200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
This study was aimed to report data on the feasibility, safety, and effectiveness of endovascular procedures in a thromboangiitis obliterans diagnosed patients presenting with critical limb ischemia (CLI). Prospective study conducted on patients affected by Buerger's disease who presented to our center along 2 years. Clinical, radiological, and patient-based outcomes were recorded at 3, 6, and 12 months after the intervention. Total 39 patients were included in the study. Fifteen (38.5%) patients underwent percutaneous transluminal angioplasty, another 15 patients (38.5%) underwent follow-up on medical treatment, there are four other patients (10.3%) underwent surgical bypass, and five (12.8%) patients underwent lumbar sympathectomy. The 12 months' outcome showed 66.7% technical success in endovascular group with 46.7% patency rate ( p -value = 0.06), 86.7% limb salvage rate (LSR; p -value < 0.04), and 66.7% clinical improvement ( p -value = 0.005). The endovascular management of Buerger's disease is feasible, save, and effective with high rate of LSR and clinical improvement.
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Affiliation(s)
- Baker M Ghoneim
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Ahmed G Karmota
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Ahmed M Abuhadema
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Ahmed A Shaker
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Hany M Abdelmawla
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Mahmoud M Nasser
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Hossam Y Elmahdy
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Hesham A Mostafa
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
| | - Hussein M Khairy
- Vascular Surgery Department, Faculty of Medicine, Cairo University, Egypt
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Hicks CW, Canner JK, Kirkland K, Malas MB, Black JH, Abularrage CJ. Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures. J Surg Res 2018; 226:72-81. [PMID: 29661291 DOI: 10.1016/j.jss.2018.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/14/2017] [Accepted: 01/12/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hemodialysis (HD) has been shown to be an independent predictor of poor outcomes after femoropopliteal revascularization procedures in patients with chronic limb-threatening ischemia. However, HD patients tend to have isolated infrageniculate disease, an anatomic risk factor for inferior patency. We aimed to compare outcomes for HD versus non-HD patients after infrageniculate open lower extremity bypass (LEB) and endovascular peripheral vascular interventions (PVIs). METHODS Data from the Society for Vascular Surgery Vascular Quality Initiative database (2008-2014) were analyzed. All patients undergoing infrageniculate LEB or PVI for rest pain or tissue loss were included. One-year primary patency (PP), secondary patency (SP), and major amputation outcomes were analyzed for HD versus non-HD patients stratified by treatment approach using both univariable and multivariable analyses. RESULTS A total of 1688 patients were included, including 348 patients undergoing LEB (HD = 44 versus non-HD = 304) and 1340 patients undergoing PVI (HD = 223 versus non-HD = 1117). Patients on HD more frequently underwent revascularization for tissue loss (89% versus 77%, P < 0.001) and had ≥2 comorbidities (91% versus 76%, P < 0.001). Among patients undergoing LEB, 1-y PP (66% versus 69%) and SP (71% versus 78%) were similar for HD versus non-HD (P ≥ 0.25) groups, but major amputations occurred more frequently in the HD group (27% versus 14%; P = 0.03). Among patients undergoing PVI, 1-y PP (70% versus 78%) and SP (82% versus 90%) were lower and the frequency of major amputations was higher (27% versus 10%) for HD patients (all, P ≤ 0.02). After correcting for baseline differences between the groups, outcomes were similar for HD versus non-HD patients undergoing LEB (P ≥ 0.21) but persistently worse for HD patients undergoing PVI (all, P ≤ 0.006). CONCLUSIONS HD is an independent predictor of poor patency and higher risk of major amputation after infrageniculate endovascular revascularization procedures for the treatment of chronic limb-threatening ischemia. The use of endovascular interventions in these higher risk patients is not associated with improved limb salvage outcomes and may be an inappropriate use of healthcare resources.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kevin Kirkland
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mahmoud B Malas
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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Baer-Bositis HE, Hicks TD, Haidar GM, Sideman MJ, Pounds LL, Davies MG. Outcomes of reintervention for recurrent symptomatic disease after tibial endovascular intervention. J Vasc Surg 2018. [PMID: 29525414 DOI: 10.1016/j.jvs.2017.11.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Tibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remain barriers to durability after intervention. The aim of this study was to examine the patient-centered outcomes of open and endovascular reintervention for symptomatic recurrent disease after a primary isolated tibial endovascular intervention. METHODS A database of patients undergoing isolated primary lower extremity tibial endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with recurrent critical ischemia (Rutherford 4 and 5) were identified. Outcomes in this cohort were analyzed, and three groups were defined: endovascular reintervention (ie, a repeated tibial or pedal endovascular intervention), bypass (bypass to a tibial or pedal vessel), and primary amputation (ie, above- or below-knee amputation) on the ipsilateral leg. Patient-oriented outcomes of clinical efficacy (absence of recurrent signs or symptoms of critical ischemia, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention, such as new bypass graft or jump or interposition graft revision) were evaluated after the reintervention. RESULTS There were 1134 patients (56% male; average age, 59 years) who underwent primary tibial intervention for critical ischemia, and 54% presented with symptomatic restenosis and occlusion. Of the 513 patients with recurrent disease, 58% presented with rest pain and the remainder with ulceration. A repeated tibial endovascular intervention was performed in 64%, open bypass in 19%, and below-knee amputation in 17%. Bypass was employed in patients with a good target vessel, venous conduit, and good pedal runoff. Patient-centered outcomes were better in the bypass group compared with the reintervention group (amputation-free survival, 45% ± 9% vs 27% ± 9% [P < .01]; major adverse limb events, 50% ± 9% vs 31% ± 9% [P < .05]; clinical efficacy, 60% ± 7% vs 30% ± 9% [P < .01], mean ± standard error of the mean at 5 years). CONCLUSIONS Tibial interventions for critical ischemia are associated with a high rate of reintervention. In patients with good target vessel, venous conduit, and good pedal runoff, bypass appears more durable than repeated tibial endovascular intervention.
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Affiliation(s)
- Hallie E Baer-Bositis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Taylor D Hicks
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Georges M Haidar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Matthew J Sideman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Lori L Pounds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Mark G Davies
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex.
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Mii S, Guntani A, Kawakubo E, Shimazoe H. Barthel Index and Outcome of Open Bypass for Critical Limb Ischemia. Circ J 2018; 82:251-257. [DOI: 10.1253/circj.cj-17-0247] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital
| | - Eisuke Kawakubo
- Department of Vascular Surgery, Saiseikai Yahata General Hospital
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Decision-Making in Critical Limb Ischemia: A Markov Simulation. Ann Vasc Surg 2017; 45:1-9. [PMID: 28739455 DOI: 10.1016/j.avsg.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/08/2017] [Accepted: 07/17/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes. METHODS We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses. RESULTS In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values. CONCLUSIONS For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.
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Bunch F, Walker C, Kassab E, Carr J. A universal drug delivery catheter for the treatment of infrapopliteal arterial disease: Results from the multi-center first-in-human study. Catheter Cardiovasc Interv 2017; 91:296-301. [PMID: 28707423 DOI: 10.1002/ccd.27176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/26/2017] [Accepted: 06/08/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The objective of this study was to assess the feasibility, safety and initial efficacy of paclitaxel administration using a novel drug delivery catheter for the prevention of restenosis in infrapopliteal de novo and restenotic lesions. BACKGROUND Restenosis continues to be a great challenge after percutaneous revascularization procedures for peripheral arterial disease, particularly for below-the-knee applications. METHODS A prospective, multicenter first-in-human registry of a novel delivery catheter delivering liquid paclitaxel was conducted in 10 patients. The primary efficacy endpoint at 6 months was freedom from clinically driven target lesion revascularization (CD-TLR) and the primary safety endpoint at 1, 3, and 6 months were thrombosis, major amputation in the target limb and target limb related death. RESULTS All patients tolerated the procedure well with no reports of adverse procedural events. Twelve (n = 12) lesions in ten patients were treated with a mean lesion length of 83.3 ± 49.2 mm, with the lesion length range of 30mm to 182 mm. At 6-month follow-up, the rate of CD-TLR was 30% (3 of 10 patients). Zero patients (0 out of 10) demonstrated thrombosis, major amputation in the target limb and target limb related death at the 1, 3, and 6 month follow-up intervals. CONCLUSIONS This first in-human experience obtained in a multicenter study of real-world de novo and restenotic lesions demonstrates a favorable safety and efficacy profile at 6 months. Randomized comparison to current drug coated balloons should be performed to further validate this approach and positive experience.
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Affiliation(s)
- Frank Bunch
- Cardiology Associates, Interventional Cardiologist and Peripheral Interventionalist, 188 Hospital Drive, Suite 100, Fairhope, AL, 36532
| | - Craig Walker
- Cardiovascular Institute of the South, President and Founder, Interventional Cardiologist and Peripheral Interventionalist, 225 Dunn Street, Houma, LA, 70360
| | - Elias Kassab
- Michigan Outpatient Vascular Institute, Interventional Cardiologist and Peripheral Interventionalist, 5500 Auto Club Drive, Dearborn, MI, 48126
| | - Jeffrey Carr
- Cardiovascular Associates of East Texas, Interventional Cardiologist and Peripheral Interventionalist, 1783 Troup Hwy, Tyler, TX, 75701
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Popplewell MA, Davies HOB, Narayanswami J, Renton M, Sharp A, Bate G, Patel S, Deeks J, Bradbury AW. A Comparison of Outcomes in Patients with Infrapopliteal Disease Randomised to Vein Bypass or Plain Balloon Angioplasty in the Bypass vs. Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial. Eur J Vasc Endovasc Surg 2017; 54:195-201. [PMID: 28602580 DOI: 10.1016/j.ejvs.2017.04.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 04/20/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim was to compare outcomes in a subgroup of patients with infrapopliteal (IP) disease randomised to infrapopliteal vein bypass (VB) or plain balloon angioplasty (PBA) in the original BASIL trial. METHODS A comparison of outcomes from patients randomised to VB or PBA undergoing revascularisation for severe limb ischaemia (SLI) because of IP disease with or without femoropopliteal disease. Data were extracted from case report forms from the BASIL trial. The primary outcome was amputation free survival (AFS); secondary outcomes included overall survival (OS), 30 day mortality and morbidity, freedom from arterial re-intervention, immediate technical success, repeat and crossover interventions, length of hospital stay, and quality of revascularisation. RESULTS A total of 104 patients were identified in the BASIL study with IP disease, 56 randomised to IP VB, and 48 to IP PBA. Groups were similar at baseline except for more chronic kidney disease and non-steroidal anti-inflammatory drug use in the VB group, and more previous surgical arterial intervention and antihypertensive use in the PBA group. There were no statistically significant differences in AFS or OS; however, clinically important trends were apparent in favour of a VB first strategy. Patients allocated to VB demonstrated significantly quicker relief of rest pain when compared with PBA (p = .005), but no significant differences in improved tissue healing. Median length of index hospital admission was significantly greater in the VB than in the PBA group (18 vs. 10 days, p < .0001) but there was no difference between the two groups in median total hospital stay between randomisation and the primary endpoint (VB 43.5 vs. PBA 42 days). CONCLUSIONS Further randomised trials, like BASIL-2 and BEST-CLI, are required to determine whether patients with severe limb ischaemia who require IP revascularisation and who are suitable for VB should have bypass or endovascular intervention as their primary revascularisation procedure.
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Affiliation(s)
- M A Popplewell
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK.
| | - H O B Davies
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - J Narayanswami
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - M Renton
- Heart of England Foundation Trust, Birmingham, UK
| | - A Sharp
- Heart of England Foundation Trust, Birmingham, UK
| | - G Bate
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - S Patel
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Deeks
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
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Xiao Y, Chen Z, Yang Y, Kou L. Network meta-analysis of balloon angioplasty, nondrug metal stent, drug-eluting balloon, and drug-eluting stent for treatment of infrapopliteal artery occlusive disease. Diagn Interv Radiol 2017; 22:436-43. [PMID: 27559766 DOI: 10.5152/dir.2016.15430] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE We aimed to conduct a network meta-analysis of mixed treatments for the infrapopliteal artery occlusive disease. METHODS We searched randomized controlled trials (RCTs) regarding balloon angioplasty (BA), nondrug metal stent (NDMS), drug-eluting balloon (DEB), or drug-eluting stent (DES) in PubMed, Embase, CENTRAL, Ovid, Sinomed, and other relevant websites. We selected and assessed the trials that met the inclusion criteria and conducted a network meta-analysis using the ADDIS software. RESULTS We included 11 relevant trials. We analyzed data of 1322 patients with infrapopliteal artery occlusive disease, of which 351 were in the NDMS vs. DES trials, 231 in the NDMS vs. BA trials, 490 in the BA vs. DEB trials, 50 in the DEB vs. DES trials, and 200 in the BA vs. DES trials. The network meta-analysis indicated that with NDMS as the reference, DES had a better result with respect to restenosis (odds ratio [OR], 5.16; 95% credible interval [CI], 1.58-18.41; probability of the best treatment, 84%) and amputation (OR, 2.50; 95% CI, 0.81-7.11; probability of the best treatment, 61%) and DEB had a better result with respect to target lesion revascularization (TLR; OR, 3.74; 95% CI, 0.78-17.05; probability of the best treatment, 57%). Moreover, with BA as the reference, NDMS had a better result with respect to technical success (OR, 0.10; 95% CI, 0.00-1.15; probability of the best treatment, 86%). CONCLUSION Our meta-analysis revealed that DES is a better treatment with respect to short-term patency and limb salvage rate, NMDS may provide a better technical success, and DEB and DES are good choices for reducing revascularization.
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Affiliation(s)
- Yaowen Xiao
- Department of Vascular Surgery, Beijing Anzhen Hospital Affiliated to Capital Medical University and Beijing Institution of Heart Lung and Vessel Disease, Beijing, China.
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Karles-Ernotte AJ, Bermúdez-Posada A, Rincón-Sánchez HM, Padilla-Castro AT, Drews-Elger K, Novoa-Leal M, Hiller-Correa HG. Efecto terapéutico del alprostadil en pacientes con isquemia crítica terminal de los miembros inferiores. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2016.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Patel SD, Biasi L, Paraskevopoulos I, Silickas J, Lea T, Diamantopoulos A, Katsanos K, Zayed H. Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with infrapopliteal peripheral artery disease. Br J Surg 2016; 103:1815-1822. [PMID: 27650636 DOI: 10.1002/bjs.10292] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/08/2016] [Accepted: 07/07/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Both infrapopliteal (IP) bypass surgery and percutaneous transluminal angioplasty have been shown to be effective in patients with critical limb ischaemia (CLI). The most appropriate method of revascularization has yet to be established, as no randomized trials have been reported. The aim of this study was to compare the outcomes of patients with similar characteristics treated using either revascularization method. METHODS Consecutive patients undergoing IP bypass and IP angioplasty for CLI (Rutherford 4-6) at a single institution were compared following propensity score matching. The study endpoints were primary, assisted primary and secondary patency, and amputation-free survival at 12 months, calculated by Kaplan-Meier analysis. RESULTS Some 279 limbs in 243 patients were included in the study. The two groups differed significantly with respect to the incidence of diabetes (P = 0·024), estimated glomerular filtration rate (P = 0·006), total lesion length (P < 0·001) and Rutherford classification (P = 0·008). These factors were used to construct the propensity score model, which yielded a matched cohort of 125 legs in each group. Primary patency (54·4 versus 51·4 per cent; P = 0·014), assisted primary patency (77·5 versus 62·7 per cent; P = 0·003), secondary patency (84·4 versus 65·8 per cent; P < 0·001) and amputation-free survival (78·7 versus 74·1 per cent; P = 0·043) were significantly better after bypass than angioplasty. However, limb salvage was similar (90·4 versus 94·2 per cent; P = 0·161), and overall complications (36·0 versus 21·6 per cent; P = 0·041) as well as length of hospital stay (18(4-134) versus 5(0-110); P = 0·001) were worse in the surgical bypass group. CONCLUSION There was no difference in limb salvage rates, but patency and amputation-free survival rates were better 1 year after bypass surgery.
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Affiliation(s)
- S D Patel
- Departments of Vascular and Endovascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - L Biasi
- Departments of Vascular and Endovascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I Paraskevopoulos
- Departments of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Silickas
- Departments of Vascular and Endovascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - T Lea
- Departments of Vascular and Endovascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Diamantopoulos
- Departments of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Katsanos
- Departments of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - H Zayed
- Departments of Vascular and Endovascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Walker CM, Bunch FT, Cavros NG, Dippel EJ. Multidisciplinary approach to the diagnosis and management of patients with peripheral arterial disease. Clin Interv Aging 2015. [PMID: 26203234 PMCID: PMC4504338 DOI: 10.2147/cia.s79355] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Peripheral arterial disease (PAD) is frequently diagnosed after permanent damage has occurred, resulting in a high rate of morbidity, amputation, and loss of life. Early and ongoing diagnosis and treatment is required for this progressive disease. Lifestyle modifications can prevent or delay disease progression and improve symptoms. Limb-sparing endovascular interventions can restore circulation based on appropriate diagnostic testing to pinpoint vascular targets, and intervention must occur as early as possible to ensure optimal clinical outcomes. An algorithm for the diagnosis and management of PAD was developed to enable a collaborative approach between the family practice and primary care physician or internist and various specialists that may include a diabetologist, endocrinologist, smoking cessation expert, hypertension and lipid specialist, endovascular interventionalist, vascular surgeon, orthopedist, neurologist, nurse practitioner, podiatrist, wound healing expert, and/or others. A multidisciplinary team working together has the greatest chance of providing optimal care for the patient with PAD and ensuring ongoing surveillance of the patient’s overall health, ultimately resulting in better quality of life and increased longevity for patients with PAD.
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Affiliation(s)
- Craig M Walker
- Cardiovascular Institute of the South, Tulane University School of Medicine, New Orleans, LA, USA ; Louisiana State University School of Medicine, New Orleans, LA, USA
| | | | - Nick G Cavros
- Cardiovascular Institute of the South, Lafayette General Medical Center, Lafayette, LA, USA
| | - Eric J Dippel
- Cardiovascular Medicine, PC Genesis Heart Institute, Davenport, IA, USA
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Retrograde Pedal Access Technique for Revascularization of Infrainguinal Arterial Occlusive Disease. J Vasc Interv Radiol 2015; 26:29-38. [DOI: 10.1016/j.jvir.2014.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 11/18/2022] Open
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Shimada Y. Commentary: Another back door to the endovascular future: an antegrade pedal approach for retrograde revascularization. J Endovasc Ther 2014; 21:779-82. [PMID: 25453878 DOI: 10.1583/14-4801c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Yoshihisa Shimada
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
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Hussey K, Chandramohan S. Contemporary treatment for critical ischemia: the evidence for interventional radiology or surgery. Semin Intervent Radiol 2014; 31:300-6. [PMID: 25435654 DOI: 10.1055/s-0034-1393965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article is a review of the evidence regarding the management of patients with critical limb ischemia. The aim of the study is to discuss the definition, incidence, and clinical importance of critical limb ischemia, as well as the aims of treatment in terms of quality of life and limb salvage. Endovascular and surgical treatments should not be viewed as competing therapies. In fact, these are complementary techniques each with strengths and weaknesses. The authors will propose a strategy based on the available evidence for deciding the optimal approach to management of patients with critical limb ischemia.
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Affiliation(s)
- Keith Hussey
- Department of Vascular Surgery, Western Infirmary of Glasgow, Glasgow, Scotland, United Kingdom
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Krishnamurthy V, Munir K, Rectenwald JE, Mansour A, Hans S, Eliason JL, Escobar GA, Gallagher KA, Grossman PM, Gurm HS, Share DA, Henke PK. Contemporary outcomes with percutaneous vascular interventions for peripheral critical limb ischemia in those with and without poly-vascular disease. Vasc Med 2014; 19:491-9. [DOI: 10.1177/1358863x14552013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Given the very ill nature of patients with critical limb ischemia (CLI), the use of percutaneous vascular interventions (PVIs) for limb salvage may or may not be efficacious; in particular, for those with polyvascular arterial disease. Herein, we reviewed large, multi-institutional outcomes of PVI in polyvascular and peripheral arterial disease (PAD) patients with CLI. An 18-hospital consortium collected prospective data on patients undergoing endovascular interventions for PAD with 6-month follow-up from January 2008 to December 2011. The patient cohort included 4459 patients with CLI; of those, 3141 patients had polyvascular (coronary artery disease, cerebrovascular disease and PAD) disease, whereas 1318 patients suffered from only PAD. All patients were elderly and with significant comorbidities. The mean ankle–brachial index (ABI) was 0.44 and was not different between those with and without polyvascular disease. Polyvascular patients had more femoropopliteal and infra-inguinal interventions and less aortoiliac interventions than PAD patients. Pre- and post-procedural cardioprotective medication use was less in the PAD patients as compared with polyvascular patients. Vascular complications requiring surgery were higher in PAD patients whereas other access complications were similar between groups. At 6-month follow-up, death was more common in the polyvascular group (6.7% vs 4.1%, p<0.001) as was repeat PVI, but no difference was found in the amputation rate. Considering the group as a whole at the 6-month follow-up, predictors of amputation/death included age (HR=1.01; 95% CI=1.002–1.02), anemia (HR=2.6; 95% CI=2.1–3.2), diabetes mellitus (HR=1.6; 95% CI=1.3–1.9), congestive heart failure (HR=1.6; 95% CI=1.4–1.9), and end-stage renal failure (HR=1.9; 95% CI=1.5–2.3), while female sex was protective (HR=0.7; 95% CI=0.6–0.8). In conclusion, from examination of this large, multicenter, multi-specialist practice registry, patients with polyvascular disease had higher 6-month mortality than PAD patients, but this was not a factor in 6-month limb amputation outcomes. This study also underscores that PAD patients still lag in cardioprotective medication use as compared with polyvascular patients.
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Affiliation(s)
| | - Kahn Munir
- Department of Medicine, University of Michigan, USA
| | | | | | | | | | | | | | | | | | - Dave A Share
- Department of Medicine, University of Michigan, USA
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Westin GG, Armstrong EJ, Javed U, Balwanz CR, Saeed H, Pevec WC, Laird JR, Dawson DL. Endovascular therapy is effective treatment for focal stenoses in failing infrapopliteal vein grafts. Ann Vasc Surg 2014; 28:1823-31. [PMID: 25106106 DOI: 10.1016/j.avsg.2014.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts. METHODS We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3- to 6-month intervals for graft surveillance. RESULTS Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% of the patients were free from graft restenosis at 12 months and 31% were at 24 months. Receiver-operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P = 0.03), patency without reintervention (P = 0.01), and assisted patency with secondary intervention (P = 0.02) rates were superior for short lesions compared with long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions. CONCLUSIONS In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow-up with vascular laboratory surveillance is essential.
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Affiliation(s)
- Gregory G Westin
- Division of Vascular and Endovascular Surgery, New York University Medical Center, New York, NY.
| | - Ehrin J Armstrong
- Division of Cardiology, University of Colorado Denver and VA Eastern Colorado Healthcare System, Denver, CO
| | - Usman Javed
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - Christopher R Balwanz
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, MO
| | - Haseeb Saeed
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - William C Pevec
- Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - John R Laird
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
| | - David L Dawson
- Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis Medical Center, Sacramento, CA
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Percutaneous transluminal angioplasty versus primary stenting in infrapopliteal arterial disease: a meta-analysis of randomized trials. J Vasc Surg 2014; 59:1711-20. [PMID: 24836770 DOI: 10.1016/j.jvs.2014.03.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/09/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Percutaneous transluminal angioplasty (PTA) and primary stenting are commonly used endovascular therapeutic procedures for the treatment of infrapopliteal arterial occlusive disease. However, which procedure is more beneficial for patients with infrapopliteal arterial occlusive disease is unknown. METHODS AND RESULTS We performed a meta-analysis, searching PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, ISI Web of Knowledge, and relevant websites without language or publication date restrictions for randomized trials that compared primary stenting with PTA in patients with infrapopliteal arterial occlusive disease. The keywords were "stents," "angioplasty," "infrapopliteal," "tibial arteries," and "below knee." We selected immediate technical success, primary and secondary patency, limb salvage, and patient survival as the outcomes of this meta-analysis. On the basis of the inclusion criteria, we identified six prospective randomized trials. One-year outcomes did not show any significant differences between the PTA and primary stenting groups, respectively: technical success (93.3% vs 96.2%; odds ratio [OR], 0.59; 95% confidence interval [CI], 0.24-1.47; P = .25), primary patency (57.1% vs 65.7%; OR, 0.95; 95% CI, 0.35-2.58; P = .92), secondary patency (73.5% vs 57.6%; OR, 2.08; 95% CI, 0.81-5.34; P = .13), limb salvage (82.2% vs 87.5%; OR, 0.64; 95% CI, 0.29-1.41; P = .27), and patient survival (84.0% vs 87.5%; OR, 0.79; 95% CI, 0.40-1.55; P = .49). CONCLUSIONS For infrapopliteal arterial occlusive disease, primary stenting has the same 1-year benefits as PTA. There is insufficient evidence to support the superiority of either method. Primary stenting is associated with a trend toward higher primary patency and lower secondary patency. Further large-scale prospective randomized trials should produce more reliable results.
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Azuma N, Koya A, Uchida D, Saito Y, Uchida H. Ulcer healing after peripheral intervention-can we predict it before revascularization? Circ J 2014; 78:1791-800. [PMID: 24998193 DOI: 10.1253/circj.cj-14-0500] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Complete ulcer healing is one of the most important goals of treatment for critical limb ischemia; however, it is still difficult to inform patients of the time to ulcer healing before performing revascularization. The time to ulcer healing has a great impact on the cost of treatment and patient's quality of life. To predict it, the factors that influence delayed ulcer healing should be explored. According to a review of the literature investigating ulcer healing after revascularization, the influential factors can be classified into 5 categories: (1) systemic factors; (2) clinical state of tissue defect; (3) infection; (4) wound management strategy; and (5) revascularization strategy (endovascular or open repair, the angiosome concept). It is also important to ensure sufficient blood supply to predict ulcer healing probability in the individual patient. Several new methodologies, such as measuring tissue circulation around the tissue defect and intraoperative imaging techniques, have been reported. Because the status of ischemic tissue loss and wound healing ability can affect the decision-making process in selecting the revascularization strategy, understanding the many factors that influence ulcer healing after revascularization is indispensable for physicians performing revascularization. Accumulating ulcer healing data via well-designed clinical research can help to establish a new paradigm for the revascularization strategy from the viewpoint of ulcer healing.
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Affiliation(s)
- Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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Barnes R, Souroullas P, Lane RA, Chetter I. The Impact of Previous Surgery and Revisions on Outcome after Major Lower Limb Amputation. Ann Vasc Surg 2014; 28:1166-71. [DOI: 10.1016/j.avsg.2013.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/28/2013] [Accepted: 10/29/2013] [Indexed: 10/25/2022]
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Naoum JJ, Arbid EJ. Endovascular techniques in limb salvage: infrapopliteal angioplasty. Methodist Debakey Cardiovasc J 2014; 9:103-7. [PMID: 23805344 DOI: 10.14797/mdcj-9-2-103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Critical limb ischemia (CLI) results from inadequate blood flow to supply and sustain the metabolic needs of resting muscle and tissue. Infragenicular atherosclerosis is the most common cause of CLI, and it is more likely to develop when multilevel or diffuse arterial disease coincides with compromised run-off to the foot. Reports of good technical and clinical outcomes have advanced the endovascular treatment options, which have gained a growing acceptance as the primary therapeutic strategy for CLI, especially in patients with significant risk factors for open surgical bypass. In fact, endovascular recanalization of below-the-knee arteries has proven to be feasible and safe, reduce the need for amputation, and improve wound healing. The distribution of various vascular territories or angiosomes in the foot has been recognized, and it appears advantageous to revascularize the artery supplying the territory directly associated with tissue loss. In addition, the targeted application and local delivery of drugs using drug-coated balloons (DCB) during angioplasty has the potential to improve patency rates compared to balloon angioplasty alone.
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Huang ZS, Schneider DB. Endovascular intervention for tibial artery occlusive disease in patients with critical limb ischemia. Semin Vasc Surg 2014; 27:38-58. [DOI: 10.1053/j.semvascsurg.2014.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Singh GD, Armstrong EJ, Yeo KK, Singh S, Westin GG, Pevec WC, Dawson DL, Laird JR. Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia. J Vasc Surg 2014; 59:1300-7. [PMID: 24393279 DOI: 10.1016/j.jvs.2013.11.061] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 11/11/2013] [Accepted: 11/12/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. METHODS All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. RESULTS A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P < .001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P < .001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P = .02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P = .02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63). CONCLUSIONS Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.
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Affiliation(s)
- Gagan D Singh
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif
| | - Ehrin J Armstrong
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif
| | - Khung-Keong Yeo
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif; Division of Cardiovascular Medicine, National Heart Centre Singapore, Singapore
| | - Satinder Singh
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif
| | - Gregory G Westin
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif
| | - William C Pevec
- Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif
| | - David L Dawson
- Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif
| | - John R Laird
- Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
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Wakassa TB, Benabou JE, Puech-Leão P. Clinical efficacy of successful angioplasty in critical ischemia--a cohort study. Ann Vasc Surg 2013; 28:1143-8. [PMID: 24370502 DOI: 10.1016/j.avsg.2013.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/18/2013] [Accepted: 10/05/2013] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Tais Bugs Wakassa
- Division of Vascular and Endovascular Surgery, Department of Surgery and Department of Radiology, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil
| | - Joseph Elias Benabou
- Division of Vascular and Endovascular Surgery, Department of Surgery and Department of Radiology, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil
| | - Pedro Puech-Leão
- Division of Vascular and Endovascular Surgery, Department of Surgery and Department of Radiology, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil.
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Katsanos K, Spiliopoulos S, Diamantopoulos A, Karnabatidis D, Sabharwal T, Siablis D. Systematic review of infrapopliteal drug-eluting stents: a meta-analysis of randomized controlled trials. Cardiovasc Intervent Radiol 2013; 36:645-58. [PMID: 23435741 DOI: 10.1007/s00270-013-0578-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 01/13/2013] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Drug-eluting stents (DES) have been proposed for the treatment of infrapopliteal arterial disease. We performed a systematic review to provide a qualitative analysis and quantitative data synthesis of randomized controlled trials (RCTs) assessing infrapopliteal DES. MATERIALS AND METHODS PubMed (Medline), EMBASE (Excerpta Medical Database), AMED (Allied and Complementary medicine Database), Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), online content, and abstract meetings were searched in September 2012 for eligible RCTs according to the preferred reporting items for systematic reviews and meta-analyses selection process. Risk of bias was assessed using the Cochrane Collaboration's tool. Primary endpoint was primary patency defined as absence of ≥50 % vessel restenosis at 1 year. Secondary outcome measures included patient survival, limb amputations, change of Rutherford-Becker class, target lesion revascularization (TLR) events, complete wound healing, and event-free survival at 1 year. Risk ratio (RRs) were calculated using the Mantel-Haenszel fixed effects model, and number-needed-to-treat values are reported. RESULTS Three RCTs involving 501 patients with focal infrapopliteal lesions were analyzed (YUKON-BTX, DESTINY, and ACHILLES trials). All three RCTs included relatively short and focal infrapopliteal lesions. At 1 year, there was clear superiority of infrapopliteal DES compared with control treatments in terms of significantly higher primary patency (80.0 vs. 58.5 %; pooled RR = 1.37, 95 % confidence interval [CI] = 1.18-1.58, p < 0.0001; number-needed-to-treat (NNT) value = 4.8), improvement of Rutherford-Becker class (79.0 vs. 69.6 %; pooled RR = 1.13, 95 % CI = 1.002-1.275, p = 0.045; NNT = 11.1), decreased TLR events (9.9 vs. 22.0 %; pooled RR = 0.45, 95 % CI = 0.28-0.73, p = 0.001; NNT = 8.3), improved wound healing (76.8 vs. 59.7 %; pooled RR = 1.29, 95 % CI = 1.02-1.62, p = 0.04; NNT = 5.9), and better overall event-free survival (72.2 vs. 57.3 %; pooled RR = 1.26, 95 % CI = 1.10-1.44, p = 0.0006; NNT = 6.7). CONCLUSION DES for focal infrapopliteal lesions significantly inhibit vascular restenosis and thereby improve primary patency, decrease repeat procedures, improve wound healing, and prolong overall event-free survival.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, Guy's and St. Thomas' Hospitals, NHS Foundation Trust, King's Health Partners, London, SE1 7EH, UK.
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Iida O, Nakamura M, Yamauchi Y, Kawasaki D, Yokoi Y, Yokoi H, Soga Y, Zen K, Hirano K, Suematsu N, Inoue N, Suzuki K, Shintani Y, Miyashita Y, Urasawa K, Kitano I, Yamaoka T, Murakami T, Uesugi M, Tsuchiya T, Shinke T, Oba Y, Ohura N, Hamasaki T, Nanto S. Endovascular Treatment for Infrainguinal Vessels in Patients With Critical Limb Ischemia. Circ Cardiovasc Interv 2013; 6:68-76. [DOI: 10.1161/circinterventions.112.975318] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Recent technical advances have made endovascular treatment (EVT) an alternative first-line treatment for critical limb ischemia.
Methods and Results—
A prospective multicenter study was conducted to evaluate the clinical outcomes of 314 Japanese critical limb ischemia patients (mean age, 73±10 years) with infrainguinal arterial lesions who underwent EVT. Patients were enrolled from December 2009 to July 2011 and were followed-up for 12 months. The primary end point was amputation-free survival (AFS) at 12 months. Secondary end points were anatomic, clinical, and hemodynamic measures, including 12-month freedom from major adverse limb events. The 12-month AFS rate was 74%, with body mass index <18.5 (hazard ratio [HR], 2.22;
P
=0.008), heart failure (HR, 1.73;
P
=0.04), and wound infection (HR, 1.89;
P
=0.03) associated with a poor prognosis for AFS. The 12-month major adverse limb event-free rate was 88%, with hemodialysis (HR, 1.98;
P
=0.005), heart failure (HR, 1.69;
P
=0.02), and Rutherford classification 6 (HR, 2.25;
P
=0.002) associated with a poor prognosis for major adverse limb events. The median time for wound healing was 97 days, with body mass index <18.5 (HR, 0.54;
P
=0.03) and wound infection (HR, 0.60;
P
=0.04) being significant risk factors for unhealed wounds after EVT. At 12 months, 34% had undergone reintervention (bypass surgery, 2.6%; repeat EVT, 31.7%), and 73% were major adverse event–free.
Conclusions—
The high reintervention rate notwithstanding, EVT was an effective treatment for Japanese critical limb ischemia patients with infrainguinal disease, with satisfactory AFS and major adverse limb event-free rates. The results of this study will be helpful for the future evaluation of critical limb ischemia therapy.
Clinical Trial Registration—
URL:
http://www.umin.ac.jp/ctr
. Unique identifier: UMIN000002830.
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Affiliation(s)
- Osamu Iida
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Masato Nakamura
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Yasutaka Yamauchi
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Daizo Kawasaki
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Yoshiaki Yokoi
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Hiroyoshi Yokoi
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Yoshimistu Soga
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Kan Zen
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Keisuke Hirano
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Nobuhiro Suematsu
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Naoto Inoue
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Kenji Suzuki
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Yoshiaki Shintani
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Yusuke Miyashita
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Kazushi Urasawa
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Ikuro Kitano
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Terutoshi Yamaoka
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Takashi Murakami
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Michitaka Uesugi
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Taketsugu Tsuchiya
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Toshiro Shinke
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Yasuhiro Oba
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Norihiko Ohura
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Toshimitsu Hamasaki
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
| | - Shinsuke Nanto
- From the Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan (O.I.); Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo, Japan (M.N.); Cardiovascular Center, Kikuna Memorial Hospital, Kanagawa, Japan (Y. Yamauchi); Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan (D.K.); Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan (Y. Yokoi); Department of Cardiology, Kokura Memorial Hospital, Fukuoka,
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