Angioplasty or bypass for superficial femoral artery disease? A randomised controlled trial

Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome

To report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients. Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up.

Indications for a "Surgery-First" Approach for the Treatment of Lower Extremity Arterial Disease

BACKGROUND

In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization.

METHODS

A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models.

RESULTS

We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis.

CONCLUSIONS

Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm.

Discrete Event Simulation Model for Cost-Effectiveness Evaluation of Screening for Asymptomatic Patients with Lower Extremity Arterial Disease

Lower limb ischemic disease (LEAD) affects a significant portion of the population, with most patients being asymptomatic. Patient screening is necessary because LEAD patients have an increased risk of occurrence of other cardiovascular events and manifestations of disease, in terms of leg symptoms such as intermittent claudication, critical limb ischemia, or amputation. The aim of this work was to evaluate the cost-effectiveness of screening using ABI diagnostics in asymptomatic patients and its impact on limb symptoms associated with LEAD. A discrete event simulation model was created to capture lifetime costs and effects. Costs were calculated from the perspective of the health care payer, and the effects were calculated as QALYs. A cost-effectiveness analysis was performed to compare ABI screening examination and the situation without such screening. A probabilistic sensitivity analysis and scenario analysis were carried out to evaluate the robustness of the results. In the basic setting, the screening intervention was a more expensive intervention, at a cost of CZK 174,010, compared to CZK 70,177 for the strategy without screening. The benefits of screening were estimated at 14.73 QALYs, with 14.46 QALYs without screening. The final ICER value of CZK 389,738 per QALY is below the willingness to pay threshold. Likewise, the results of the probabilistic sensitivity analysis and of the scenario analysis were below the threshold of willingness to pay, thus confirming the robustness of the results. In conclusion, ABI screening appears to be a cost-effective strategy for asymptomatic patients aged 50 years when compared to the no-screening option.

Impact of Anticoagulation/Antiplatelet Therapy on Femoropopliteal Bypass Graft Outcomes

INTRODUCTION

Anticoagulant and antiplatelet (AC/AP) medications have been reported to improve bypass graft patency, however, the optimal AC/AP strategy remains unclear in the heterogenous peripheral artery disease population.

METHODS

A multi-institutional retrospective review utilizing the Research Patient Data Registry (RPDR) database from 1995-2020 was performed for all patients who underwent femoropopliteal bypass procedures. Electronic medical records were used to obtain demographic information, comorbidities, smoking status, operative details (bypass target), postoperative AC/AP medications, postoperative complications, and long-term outcomes were reviewed for the cohort. Cox proportional hazards model was used to determine independent risk factors for major adverse limb events (MALE) following bypass. MALE was defined as reintervention for patency or major amputation of index limb (above- or below-knee amputation).

RESULTS

A total of 1421 patients underwent femoropopliteal bypass between 1995-2020 throughout five institutions included in this study. Complete data was available for 1292/1421 (90.9%) patients. Indications for bypass included intermittent claudication (21.4%), rest pain (30.3%), tissue loss (33.5%), and non-atherosclerotic disease (14.8%). Distal bypass targets comprised above-knee (38.6%) and below-knee (61.4%) popliteal arteries. Patients were divided into six groups based on postoperative AC/AP use including none (n=57, 4.4%), mono-antiplatelet therapy (MAPT) (n=587, 45.4%), dual antiplatelet therapy (DAPT) (n=214, 16.6%), AC alone (n=73, 5.7%), AC+MAPT (n=319, 24.7%), and AC+DAPT (n=42, 3.3%). Postoperative bleeding complications were low for both hematoma (3.7%) and pseudoaneurysm (0.7%). There was no difference in bleeding complications across AC/AP groups (hematoma p=0.61, pseudoaneurysm p=0.31). After adjusting for patient factors, below-knee bypass target (HR 1.25 [1.04-1.52], p=0.019) and bypass for tissue loss (HR 1.40 [1.04-1.88], p=0.028) were independent predictors for MALE. Great saphenous vein conduit trended towards protection for MALE, compared with prosthetic grafts (HR 0.84 [0.70-1.01], p=0.06). No AC/AP regimen was associated with of MALE, even stratifying by above-knee and below-knee bypass cohorts. Median follow-up period was two years.

CONCLUSIONS

Among patients undergoing femoropopliteal bypass grafting, no combination of anticoagulation or antiplatelet medications was associated with improved graft patency, however, a below-knee target and tissue loss were associated with adverse limb events. Anticoagulation and antiplatelet regimen may be individualized post-bypass with regard to other concomitant medical comorbidities.

Risk Factors and Consequences of Graft Infection after Femoropopliteal Bypass: A 25-year Experience

INTRODUCTION

In this multi-institutional series, we aimed to determine the incidence, risk factors, and long-term outcomes of graft infection in patients post-femoropopliteal bypass.

METHODS

A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures from 1995-2020. Cumulative incidence function estimated the long-term rate of bypass graft infection (BGI) and Fine-Gray model was used to determine independent risk factors for BGI to account for death as a competing risk.

RESULTS

Over the 25-year period, 1315 femoral popliteal bypasses were identified with a median follow-up of 2.89 years (IQR 0.75-6.55). BGI was diagnosed in 34 (2.6%) patients. BGI occurred between 9 days and 11.2 years postoperatively, with a median 109 days. Estimated 1- and 5-year incidence of BGI was 2.1% (95% CI, 1.4-3.1%) and 2.8% (95% CI, 1.9-3.9%) respectively. Medical comorbidities, indications for bypass, and popliteal bypass targets (above- vs below-knee) were similar between BGI patients and all patients (p=NS each). Patients with BGI were more frequently complicated by postoperative hematoma (14.7% vs 3.7%), superficial wound infection (38.2% vs 19.2%), lymphocele/lymphorrhea (8.8% vs 2.1%), and 30-day readmission rates (47.1% vs 21.3%) (p<0.05 each). Most commonly isolated pathogens were Staphylococcus aureus (n=19, 55.9%) and polymicrobial cultures (n=5, 14.7%). Reoperation for BGI involved incision and drainage (n=7, 20.6%), graft excision without reconstruction (n=12, 35.3%), graft excision with in-line reconstruction (n=11, 32.4%), and graft excision with extra-anatomic reconstruction (n=2, 5.9%). Nine BGI patients (26.5%) ultimately required major amputation. Prosthetic bypass (subdistribution hazard ratio [SHR] 3.73 [1.64-8.51], p=0.002), postoperative hematoma (SHR 3.44 [1.23-9.61], p=0.018), and 30-day readmission (SHR 2.75 [1.27-5.44], p=0.010) were independently associated with BGI. One-year amputation-free survival was 50% (95% CI, 31.9-65.7%) after BGI.

CONCLUSIONS

BGI is a rare complication of femoral-popliteal bypass with significant morbidity. Graft infection is associated with the use of prosthetic grafts, postoperative hematoma, and unplanned hospital readmission. Mitigation of these risk factors may decrease the risk of this dreaded complication.

Ten-Year Clinical Follow-Up Following Bare-Nitinol Stent Implantation for Femoropopliteal Artery Disease

Aim: More than 5-year clinical outcomes after femoropopliteal (FP) stenting with bare-nitinol stent (BNS) have not yet been unclear. We investigate the long-term patency and mortality following FP stenting with BNS.

Methods: This study was a multicenter retrospective study of a prospectively maintained database. From April 2004 to December 2011, 1824 consecutive patients (2211 limbs) who underwent FP stenting with BNS for de novo lesions were selected and analyzed. Primary endpoint was primary patency which was defined as treated vessel without restenosis and reintervention and its associated factors.

Results: The prevalence of diabetes mellitus and dialysis was 60.5% and 23.8%, respectively. Chronic limb-threatening ischemia (CLTI) accounted for 30.8%. Chronic total occlusion (CTO) was found in 52.7%, and lesion length was more than 20 cm in 22.6%. During the median follow-up of 3.8 years (interquartile range, 1.4 to 7.4 years), 1049 cases lost patency, whereas 355 cases were dead without experiencing loss of patency. The primary patency (95% CI) was estimated to be 74.8%, 47.3% and 29.1% at 1-, 5- and 10-year. On multivariate analysis, female sex, age ≥ 80 years, diabetes, dialysis, CLTI, CTO, arterial calcification, long lesion (＞20 cm), and small vessel (≤ 4 mm) were the independent predictors of primary patency after FP stenting. In addition, the prognostic impact of age ≥ 80 years, CLTI, and arterial calcification was significantly attenuated afterwards (P＜0.05).

Conclusions: Ten-year patency after BNS implantation for FP disease has been continuously reducing up to 10 years and the prognostic impact of risk factors was changed over time.

Critical appraisal of evidence on bypass surgery versus endovascular treatment for intermittent claudication: a systematic review and meta-analysis

INTRODUCTION

Intermittent claudication (IC) stage of peripheral artery disease (PAD) is associated with significant impairment of quality of life. In the subset of patients with disabling IC refractory to best medical treatment (BMT), revascularization procedures may be considered. However, evidence comparing open revascularization surgery, endovascular treatment and BMT focussing on the impact on quality of life is very sparse. We aim to review clinical, anatomical and hemodynamic outcomes after bypass surgery compared to BMT and/or endovascular treatment in IC patients.

EVIDENCE ACQUISITION

We systematically reviewed controlled trials and comparative cohort studies assessing quality of life, walking performance, clinical/symptomatic improvement, symptom recurrence, patency rates, ankle-brachial index (ABI) improvement and adverse events after bypass surgery versus endovascular treatment/BMT in IC patients.

EVIDENCE SYNTHESIS

Eleven studies involving 16,608 patients were included. Compared to BMT, bypass surgery was associated with a significantly greater improvement on Short-Form 36 (SF-36) physical functioning score (mean difference (MD), -14.0; 95% confidence interval (CI), -21.2 to -6.8), Walking Impairment Questionnaire (WIQ) walking distance score (MD, -0.23; 95% CI, -0.29 to -0.16) and SF-36 bodily pain score (MD, -13.0; 95% CI, -20.2 to -5.8). There were no significant differences between bypass and endovascular treatment regarding the three scores. Bypass surgery presented better primary patency rates at 1 (odds ratio (OR), 0.47; 95% CI, 0.29 to 0.76) and 5 years (OR, 0.44; 95% CI, 0.34 to 0.57) and better ABI improvement (MD, -0.07; 95% CI, -0.12 to -0.03) when compared to endovascular treatment. There were no statistically significant differences between bypass and endovascular patients regarding secondary patency rates, 30-day mortality and major amputation.

CONCLUSIONS

Lower limb revascularization may be beneficial in patients with disabling and refractory IC when the primary goal is to improve quality of life and walking capacity. Bypass surgery is associated to better symptomatic status, long-term primary patency and ABI improvement when compared to endovascular surgery, especially in anatomically extensive disease. Further studies addressing patient-reported outcomes and including a BMT group are paramount for more robust evidence on IC treatment and, consequently, better decision making.

Outcomes of bypass and endovascular interventions for advanced femoropopliteal disease in patients with premature peripheral artery disease

OBJECTIVE

Patients with premature peripheral artery disease (PAD), defined as age ≤50 years at presentation, have had poor outcomes with open and endovascular lower extremity revascularization. It is unclear whether either strategy is associated with better outcomes because comparative studies have been limited to case series in this patient population. The aim of the present study was to compare the outcomes of patients with premature PAD who had undergone bypass or endovascular revascularization for advanced femoropopliteal disease. Our hypothesis was that open bypass would provide superior long-term outcomes compared with endovascular intervention for patients with premature advanced femoropopliteal PAD.

METHODS

All the patients with premature PAD who had undergone isolated femoropopliteal lower extremity revascularization and included in the Vascular Quality Initiative infrainguinal bypass and peripheral vascular intervention files were reviewed from 2003 through 2019. Propensity score matching (1:1) was performed between patients who had undergone femoropopliteal bypass and endovascular interventions for isolated femoropopliteal Trans-Atlantic Classification System C or D lesions. The 1-year outcomes, including reintervention, patency, major amputation, and mortality, were analyzed.

RESULTS

Of the 2538 included patients, 902 had undergone isolated femoropopliteal endovascular intervention and 1636 had undergone femoropopliteal bypass. The endovascular intervention group were more likely to have diabetes (68.9% vs 54.0%; P < .001), coronary artery disease (31.0% vs 23.0%; P < .001), renal failure requiring dialysis (14.2% vs 7.2%; P < .001), and claudication (45.1% vs 36.6%; P < .001) compared with the bypass group. After propensity score matching, 466 patients were in each group with no significant differences in the baseline characteristics. Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention (12.0% vs 7.9%; P = .038); however, the rates of major amputation and mortality were not different. At 1 year, patients who had undergone femoropopliteal bypass were less likely to require reintervention (17.0% vs 25.2%; P = .012). However, no differences were found in major amputation (7.7% vs 7.9%; P = .928) or mortality (5.2% vs 5.2%; P = 1.00). Propensity score matching was also performed between femoropopliteal bypass with the great saphenous vein and isolated femoropopliteal endovascular interventions, and the outcomes were similar.

CONCLUSIONS

For patients with premature PAD and advanced femoropopliteal disease, bypass surgery decreased the reintervention rate at 1 year but was associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy. No differences were found in major amputation or mortality between the two strategies.

Smaller Superficial Femoral Artery is Associated with Worse Outcomes after Percutaneous Transluminal Angioplasty for De Novo Atherosclerotic Disease

BACKGROUND

With the exponential increase in the use of endovascular techniques in the treatment of peripheral artery disease, our understanding of factors that affect intervention failures continues to grow. We sought to assess the outcomes of percutaneous transluminal angioplasty for isolated de novo superficial femoral artery (SFA) disease based on balloon diameter.

METHODS

The Vascular Quality Initiative database was queried for patients undergoing percutaneous balloon angioplasty for isolated de novo atherosclerotic SFA disease. Based on the diameter of the angioplasty balloon as a surrogate measure of arterial diameter, patients were stratified into 2 groups: group 1, balloon diameter <5 mm (354 patients) and group 2, balloon diameter ≥5 mm (1,550 patients). The primary patency and major adverse limb event (MALE) were estimated by the Kaplan-Meier method and compared with the log-rank test, based on vessel diameter. Multivariable Cox regression analysis was used to determine factors associated with the primary patency.

RESULTS

From January 2010 through December 2018, a total of 1,904 patients met criteria for analysis, with a mean follow-up of 13.3 ± 4.5 months. The mean balloon diameters were 3.92 ± 0.26 mm and 5.47 ± 0.55 mm in group 1 and 2, respectively (P < 0.001). The mean length of treatment and distribution of TASC lesions were not statistically different between the groups. Primary patency at 18 months was significantly lower in group 1, compared with group 2 (55% vs. 67%; log-rank P < 0.001). The MALE rate was higher in group 1 than group 2 (33% vs. 26%; log-rank P < 0.001). Among patients with claudication, there was no significant difference in the primary patency (61% vs 68%; log-rank P = 0.073) and MALE (27% vs. 22%; log-rank P = 0.176) at 18 months between groups 1 and 2, respectively. However, in patients with CLTI, group 1 had significantly lower 18-month primary patency (47% vs. 64%; log-rank P < 0.014) and higher MALE rates (41% vs. 35%; log-rank P = 0.012) than group 2. Cox proportional hazard analysis confirmed that balloon diameter < 5 mm was independently associated with increased risks of primary patency loss (HR 1.35; 95% CI, 1.04-1.72; P = 0.021) and MALE (HR 1.29; 95% CI, 1-1.67; P = 0.048) at 18-months.

CONCLUSIONS

In patients undergoing isolated SFA balloon angioplasty for CLTI, smaller SFA (<5 mm) was associated with worse primary patency and MALE. Using balloon size as a surrogate, our findings suggest that patients with a smaller SFA diameter appear to be at increased risk for treatment failure and warrant closer surveillance. Furthermore, these patients may also be considered for alternative approaches, including open revascularization.

A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia

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.

Factors associated with long-term graft patency after lower extremity arterial bypasses

Purpose

This study was conducted to determine factors associated with long-term graft patency after lower extremity arterial bypass (LEAB).

Methods

Database of LEABs for patients with chronic arterial occlusive disease (CAOD) at a single institution was retrospectively reviewed. To determine the factors we compared demographic, clinical, and procedural variables between 2 patient groups; group I (graft patency < 2 years) and group II (graft patency ≥ 5 years after LEAB) using univariable and multivariable analyses.

Results

Among 957 LEABs, 259 limbs (group I, 125 limbs and group II, 134 limbs) in 213 patients were included for the analysis. On a univariable analysis, younger age (69 years vs. 66 years, P = 0.024), hypertension (60.8% vs. 74.6%, P = 0.017), claudication (51.2% vs. 70.9%, P = 0.001), absence of prior intervention (50.4% vs. 73.9%, P < 0.001), common femoral artery based bypass (57.6% vs. 70.1%, P = 0.035), above-the knee bypass (36.8% vs. 64.2%, P < 0.001), postoperative graft salvage procedure (3.2% vs. 14.8%, P = 0.001), and statin use (75.2% vs. 88.8, P = 0.004) were associated with long-term patency. On a multivariate analysis hypertension (odds ratio [OR], 1.91; P = 0.038), claudication (OR, 2.08; P = 0.032), no prior intervention (OR, 2.48; P = 0.001), vein graft (OR, 4.36; P = 0.001), above-the knee bypass (OR, 4.68; P < 0.001), and graft salvage procedures (OR, 7.70; P < 0.001) were identified as independent factors.

Conclusion

These factors can be considered in decision making before treatment of patients with CAOD.

Comparison of Long Term Outcomes After Endovascular Treatment Versus Bypass Surgery in Chronic Limb Threatening Ischaemia Patients with Long Femoropopliteal Lesions

OBJECTIVE

There are currently two treatments available for patients with chronic limb threatening ischaemia (CLTI): open surgical bypass (OSB) and percutaneous transluminal angioplasty with/without stenting (PTA/S). The aim of this study was to compare short and long term outcomes between PTA/S and OSB in CLTI patients with long (GLASS grade III and IV) femoropopliteal disease.

METHODS

This was a two centre retrospective study including all consecutive patients with CLTI undergoing first time lower extremity intervention at two distinct vascular surgical centres. Between 1 January 2012 and 1 January 2018, 1 545 CLTI consecutive limbs were treated for femoropopliteal GLASS grade III and IV lesions at two vascular surgical centres. Using covariables from baseline and angiographic characteristics, a propensity score was calculated for each limb. Thus, comparable patient cohorts (235 in PTA/S and 235 in OSB group) were identified for further analysis. The primary outcomes were freedom from re-intervention in the treated extremity and major amputation. Secondary outcomes were all hospital complications among the two patient groups.

RESULTS

Total overall complication rates were significantly higher in the OSB group (20.42% vs. 5.96%, p < .001), especially wound infection/seroma rate that required prolonged hospitalisation and further treatment (7.65% vs. 0%, p < .001). After the median follow up of 61 months, re-intervention rates were significantly higher in the PTA/S group (log rank test, 44.68% vs. 29.79%, p = .002), but there was no significant difference in terms of major amputation rates between the two group of patients (log rank test, PTA/S 27.23% vs. OSB 22.13%, p = .17).

CONCLUSION

Bypass surgery seems to be superior to PTA/S for GLASS grade III and IV femoropopliteal lesions in patients with CLTI in terms of long term re-intervention rates, but with considerably higher rates of post-operative complications. A larger cohort of patients in currently ongoing randomised trials, as well as prospective cohort studies are necessary to confirm these findings.

Resurrection of Chronically Occluded Prosthetic Bypass Grafts in a Single Stage with Suction Thrombectomy and Intervention

BACKGROUND

Peripheral arterial occlusive disease (PAOD) continues to be a vexing problem despite the advent of endovascular techniques augmenting traditional open repair. At our institution, we have found there is a growing number of patients with PAOD who are vein-challenged and have undergone prosthetic bypass previously for infrainguinal arterial reconstruction. When occluded, these grafts have been abandoned for a new bypass strategy or amputation. We present a novel technique of reestablishing flow through chronically occluded prosthetic bypass grafts.

METHODS

A retrospective review of a prospectively maintained database compiled at 2 institutions between 2016 and 2019 was performed. Six patients had previous prosthetic bypass grafts with 4 patients having femoral to popliteal grafts, 1 patient with a femoral to femoral graft, and 1 with a femoral to posterior tibial bypass graft. All patients had an attempted single-stage intervention to clear chronically occluded grafts.

RESULTS

A total of 6 patients were included in the study. Indications for intervention were chronic, critical limb ischemia with tissue loss (3), severe claudication (2), and acute on chronic limb ischemia (1). Average time from bypass to suction thrombectomy was 29 months (6-60 months). Mean patency duration is 13 months (1-28 months). Adjunctive procedures include overnight lysis to improve outflow in 1 patient (16.6%), drug-coated balloon angioplasty (83.3%), or stents (83.3%). There were no embolic complications during these procedures. All (2) wounds healed and all are maintained on full-dose anticoagulation and/or antiplatelet therapy.

CONCLUSIONS

Often, the timing of bypass graft occlusion is unknown, and the risk of embolism with lysis for chronically occluded bypass grafts is concerning with traditional peripheral intervention techniques. We report a new and unique minimally invasive approach to resurrect chronically occluded prosthetic bypass grafts often successful in just one stage. This tool offers an alternative technique for limb salvage in complex patients and as use increases, requires further interrogation.

Failed Prior Endovascular Interventions Do Not Affect 30-day Cardiovascular or Limb-related Outcomes of Infrainguinal Bypasses for Chronic Limb Threatening Ischemia

BACKGROUND

It is often hypothesized that failed prior endovascular intervention could adversely affect the outcome of subsequent infrainguinal bypass in the corresponding limb. However, this perception is not well supported in the literature because of conflicting data. The aim of this study is to address this controversial issue via analysis of a multicenter prospectively collected database.

METHODS

Patients who underwent infrainguinal bypass for chronic limb threatening ischemia (CLTI) were identified in the targeted American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2017. These patients were stratified into 4 groups: first time femoral-popliteal bypass, femoral-popliteal bypass after failed prior endovascular revascularization, first time femoral-tibial bypass, and femoral-tibial bypass after failed prior endovascular revascularization. Thirty-day outcomes including mortality, graft patency, major amputations, and major organ dysfunction were measured.

RESULTS

We identified 7,044 patients who underwent surgical bypasses for CLTI. Patients were mostly well matched among the 4 groups except for differences in sex, hypertension, and preoperative renal function. In terms of major adverse cardiovascular events and major adverse limb events, femoral-popliteal or femoral-tibial bypasses after failed prior endovascular intervention had comparable 30-day outcomes to first-time bypasses. However, patients with failed prior endovascular intervention had increased rates of postoperative wound infection, required significantly more blood transfusions, and had longer operative time.

CONCLUSIONS

Failed prior endovascular intervention does not adversely affect 30-day outcomes of subsequent infrainguinal bypass surgery in mortality, limb salvage, or other major cardiovascular complications.

Optical Coherence Tomography Contribution Assessment in the Revascularization of Long Femoropopliteal Occlusive Lesions (TASC C and D): A Randomized Trial

BACKGROUND

Endovascular treatment has become the first-line revascularization technique for femoropopliteal lesions. This technique lacks reliable and accurate morphological control of the arterial segment treated. Intraoperative 2-dimensional angiogram consumes iodinated contrast media and increases X-ray exposure; this subsequently provides no 3-dimensional information on the quality of the revascularization completed, what could explain some of the early and late failures of the technique. We evaluated whether intraoperative optical coherence tomography (OCT) control in addition to standard angiogram could improve the primary patency rate at 12 months in comparison to standard angiogram alone in patients with occlusive femoropopliteal lesions.

METHODS

The tomography by optical coherence in femoral artery trial is a multicentric, prospective, randomized, controlled, and single-blind study including patients with long de novo occlusive femoropopliteal lesions. The randomization will be achieved in 2 balanced groups of patients after crossing successfully the lesion: group 1 with intraoperative OCT control in addition to standard angiogram and group 2 with standard angiogram alone. The randomization will be stratified by center. The protocol has been submitted and approved by a French ethic's committee under reference number CPP2019-12-098. The study has been registered under the reference number NCT04434586 on the Web site of clinicaltrials.gov.

RESULTS

The primary outcome of the study is the primary patency at 12 months. The number of patients who need to be treated is 166 (83 in each group) considering 5% of no workable data. Symptoms' improvement, target lesion revascularization, target vessel revascularization, quality-of-life questionnaires, cost utility, and cost effectiveness will be analyzed as secondary end-point variables at 12 months.

CONCLUSIONS

The present study is to evaluate the potential benefit for patients on the result of endovascular revascularization of long occlusive femoropopliteal lesion at 12 months when using intraoperative OCT control.

Outcomes after Open Lower Extremity Revascularization in Patients with Critical Limb Ischemia

BACKGROUND

For decades, open intervention was the treatment of choice in patients requiring lower extremity revascularization. In the endovascular era, however, open and endovascular revascularization are options. The implications of prior revascularization on the outcomes for subsequent revascularization are not known. In the present study, we evaluated 30-day outcomes after open lower extremity revascularization for critical limb ischemia (CLI) in those who had previous interventions.

METHODS

The 2012-2017 open lower extremity bypass Participant User Data Files from the National Surgical Quality Improvement Program were used to identify a cohort of patients with CLI. Patients whose operation was considered emergent were excluded from the analysis. Patients were stratified on whether they had a previous open or endovascular intervention or undergoing a primary revascularization. The primary outcome measure was 30-day major adverse limb events (MALEs). Secondary outcomes included major adverse cardiac events (MACEs) and wound complications.

RESULTS

A total of 12,668 patients met study criteria with 59.6% (n = 7,549) undergoing a primary open revascularization, 22.4% (n = 2,839) having a prior endovascular intervention, and 18.0% (n = 2,280) having a prior open revascularization. There were notable differences in the baseline characteristics between the 3 groups. In addition, there were differences in the reason for intervention (rest pain versus tissue loss), type of revascularization, and type of conduit used between the 3 groups. After adjustment, a prior open revascularization was significantly associated with 30-day MALE when compared with a primary revascularization (adjusted odds ratio, 1.69; 95% confidence interval, 1.47-1.94; P < 0.001) and prior endovascular intervention (adjusted odds ratio, 1.76; 95% confidence interval, 1.46-2.12; P < 0.001). There were no differences in outcomes between primary revascularization and prior endovascular patients. There were no differences between MACEs or wound complications between the 3 groups.

CONCLUSIONS

A prior endovascular intervention does not seem to accrue any additional short-term risk when compared with primary revascularization, suggesting an endovascular-first approach may be a safe strategy in patients with CLI. However, a prior open intervention is significantly associated with 30-day MALE in patients undergoing redo open revascularization, which may be related to the rapid decline in patients once they have exhausted their best open revascularization option.

Changes in rates of vascular procedure types and lower extremity amputations in Finland for 2007-2017 inclusive, a population cohort study of 69,523 revascularizations

INTRODUCTION

Since 2000 the numbers of both open and endovascular revascularization procedures have increased. Despite these increases, the number of major lower extremity amputations (LEAs) has remained relatively constant. The aim of the present study was to assess the number of vascular procedures in relation to the frequency of major LEAs in Finland.

METHODS

The Finnish National Institute for Health and Welfare (THL) administers a national registry of all procedures conducted by official healthcare providers in Finland. Data regarding all revascularization procedures and major LEAs between 2007 and 2017 inclusive, were collected from the THL registry. The rates of both open and endovascular procedures were analyzed.

RESULTS

A total of 69,523 revascularization procedures were registered over the 11-year period. Of all revascularizations, 22.6% were endovascular in 2007, which rose to 60.5% in 2017. The annual rates of vascular procedures per 100,000 inhabitants increased from 66 in 2007 to 172 in 2017 (increase 10 procedures per year, 95% CI 8.6-12.3, P < 0.01) There was a significant increase (by 141 per year, 95% CI 110-174, P < 0.01) for open revascularizations (2705 operations in 2007, 3992 operations in 2017) and (by 491 per year, 95% CI 433-550, P < 0.01) for endovascular revascularizations (791 in 2007-5514 in 2017). Open aorto-iliac segment revascularization decreased, whereas the numbers of procedures increased for all other arterial segments. The overall frequency of amputations was 18-20 per 100,000. The frequency of amputations in the subpopulation over 65 years old decreased from 93 in 2007 to 72 in 2017 (P < 0.01).

CONCLUSION

The present study demonstrated increases in vascular surgery procedures over the 11-year study-period. The increase was greatest for endovascular procedures. During the same period, there was a significant decrease in the frequency of major LEAs in the >65-year-old subpopulation.

Endovascular therapy versus femoropopliteal bypass surgery for medium-length TASC II B and C lesions of the superficial femoral artery: An observational propensity-matched analysis

Objectives

This study was designed to compare clinical outcomes of percutaneous transluminal angioplasty with optional stenting (PTA/s) and femoropopliteal bypass (FPB) surgery as primary invasive treatment in patients with medium-length superficial femoral artery (SFA) lesions.

Methods

We performed a single-center retrospective, observational analysis in all consecutive patients who had undergone initial invasive treatment for medium-length, TASC II B and TASC II C, SFA lesions from 2004 to 2015. Primary endpoints were primary and secondary clinical patency. Secondary endpoints were complication rates and number of amputations. Kaplan–Meier curves were used to compare patency rates in the two treatment groups. Multivariate Cox regression analysis was performed to adjust for confounding variables and propensity score matching analysis was used to balance treatment groups.

Results

A total of 362 patients with a mean observation period of 4.0 years (SD ± 2.6) were analyzed. In this group, 231 patients (64%) underwent PTA/s and 131 patients (36%) FPB surgery. There was no difference in primary clinical patency at one-, three- and five-year follow-up between the PTA/s and FPB group, with rates of 79% vs. 63%, 53% vs. 78% and 71% vs. 66%, respectively ( P = 0.46). Secondary clinical patency estimates were comparable, resulting in one-, three- and five-year secondary clinical patency rates of 88%, 76% and 67% in the PTA/s group versus 88%, 80% and 79% in the bypass group ( P = 0.40). Multivariate analysis revealed no significant differences between the PTA/s and FPB groups in terms of primary clinical patency (HR 1.4; 95% CI 0.9–2.2) and secondary clinical patency (HR 1.7; 95% CI 0.9–2.9). This was confirmed in the propensity score analysis. Hospital stay (4.8 vs. 10.3 days) and complication rate (2.6% vs. 18.3%) were significantly lower in the PTA/s group ( P = 0.00). The number of amputations was comparable ( P = 0.75).

Conclusions

The clinical success of endovascular therapy and surgery for medium-length SFA lesions is comparable. Taking into account the lower morbidity rate, shorter length of hospital stay and the less invasive character of PTA/s compared with bypass surgery, patients with medium-length SFA lesions are ideally treated by an endovascular-first approach.

Pro-resolving lipid mediators in the resolution of neointimal hyperplasia pathogenesis in atherosclerotic diseases

INTRODUCTION

Despite advances in drug eluting technologies, neointimal hyperplasia (NIH) and restenosis still plagues endovascular therapy in atherosclerotic diseases. By appreciating atherosclerosis and NIH as complex inflammatory processes, specialized pro-resolving mediators (SPMs) are a superfamily of endogenous unsaturated fatty-acid derived lipids with the potential for inflammatory resolution. Areas covered: Inquiry into SPMs in this context is a novel approach and is the focus of this review, with emphasis on our understanding with NIH. Prior mechanistic understandings of SPM deficiency with atherosclerosis has offered insight, as well as the complexity and diversity of the SPM superfamily. Therapeutic investigation using SPMs to combat NIH is also evaluated here. Expert commentary: Endogenous deficiency of SPMs synthesis by 12/15-lipoxygenase underlies resolution deficits in atherosclerosis and NIH. Upstream PDGF inhibition by SPMs, most notably RvD1 and LXA4, confers a multifactorial attenuation of NIH that involves interconnected anti-inflammatory efforts, most notably switch pro-resolving smooth muscle cells (vSMCs) and macrophages. The ALX/FPR2 is one receptor system identified on vSMCs that interacts with these SPMs to promote NIH resolution. Therapeutically, while shown to be promising with less stent burden or cytotoxicity, SPMs must be balanced by necessary mechanistic, pharmacokinetic and anatomical considerations.

Primary stenting for femoropopliteal peripheral arterial disease: analysis up to 24 months

Background

Primary stenting is a well-established treatment option for femoropopliteal arterial obstructive disease. There is a shortage of Brazilian studies of the subject.

Objectives

To evaluate short and mid-term clinical and radiological outcomes in patients classified as Rutherford 3-6 and treated with stenting of femoropopliteal lesions.

Methods

Analysis based on a prospectively populated database of patients treated from July 2012 to July 2015. The primary endpoint was primary patency. Secondary endpoints were clinical and ankle/brachial index changes. Target Vessel Revascularization, limb salvage rate and death, within a 24-month follow-up period.

Results

64 patients were enrolled, including 61 TASC II A / B lesions (95%). The primary patency rates at 6, 12, and 24 months were 95.2%, 79.1% and 57.9%, respectively. Cox regression analysis revealed lower patency rates in patients with occlusive disease (hazard ratio [HR], 6.64; 95% confidence interval [CI], 1.52-28,99, p = 0.02), as well as patency loss about 6 times higher in TASC B than in TASC A patients ([HR], 5.95, 95% CI, 1.67-21.3, p = 0.0061). At 12 months, 90.38% of the patients remained asymptomatic. The limb salvage rate at 24 months was 94.3% (95% CI, 87.9-100%). Freedom from TVR at 24 months was 90.5% (95% CI 82.8-98.9%).

Conclusions

Results of primary patency were compatible with international studies, despite the more advanced stage of the vascular disease observed in our group. Occlusive disease and complex lesions were both associated with worse outcomes.

[Operative treatment of diabetics with vascular complications : Secondary data analysis of diagnosis-related groups statistics from 2005 to 2014 in Germany]

BACKGROUND

In Germany approximately 40,000 amputations per year are performed on patients with diabetes mellitus, often with accompanying vascular complications.

OBJECTIVE

The aim of this study was to present the various degrees of severity of the vascular complications and the temporal changes of the treatment options in diabetics with vascular complications in Germany.

MATERIAL AND METHODS

The microdata of the diagnosis-related groups (DRG) statistics of the Federal Statistical Office were analyzed over the period from 2005 to 2014. All cases were included in which the main or secondary diagnosis of diabetes mellitus with concurrent vascular complications (diabetic angiopathy and peripheral arterial disease) was encrypted.

RESULTS

The median age of the 1,811,422 cases was 73 years and 62% were male. While the total number of amputations remained stable over time, there was a 41% reduction in knee-preserving and a 31% reduction in non-knee preserving major amputations with an 18% increase in minor amputations. Revascularization increased by 33% from 36 procedures in 2005 to 48 procedures per 100,000 inhabitants. The increase in revascularization was evident in the area of endovascular therapy alone where there was an increase of 78%.

CONCLUSION

Due to the significant increase in endovascular revascularization measures, there was a significant increase in the proportion of diabetes patients with vascular pathologies in whom revascularization was carried out. As a result, improved limb preservation was achieved despite equally high amputation rates due to increasing minor amputation rates.

When Are Endovascular and Open Bypass Treatments Preferred for Femoropopliteal Occlusive Disease?

Several meta-analyses and multicenter trials have shown that chronic limb ischemia did not occur for up to 5 years in 50%–70% of patients who underwent saphenous vein grafts, with limb salvage and perioperative mortality rates of >80% and 3%, respectively. However, open surgical bypass can have limitations, including postoperative morbidity/wound complications of 10%–20% and prolonged length of hospital stay and outpatient care. Several studies have analyzed clinical outcomes for patients with critical limb ischemia treated with endovascular therapies, but they have been mainly retrospective with significant heterogeneity or were single center. Only few randomized trials have compared surgical vs. endovascular therapy. These included the Bypass vs. Angioplasty in Severe Ischemia of the Leg (BASIL) trial, with no differences found in amputation-free or overall survival rates at 1 year; however, late outcomes favored the surgical group. The Bypass or Angioplasty in Severe Intermittent Claudication (BASIC) trial concluded that the 1-year patency rates were 82% and 43% for bypass and angioplasty, respectively. The BEST Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial is currently enrolling patients. This review analyzed studies comparing open vs. endovascular therapy in patients with femoropopliteal disease. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)

Safety and Outcomes of Ipsilateral Antegrade Angioplasty for Femoropopliteal Disease

Purpose:

Previous reports have suggested higher periprocedural complications after ipsilateral antegrade femoral arterial access (AA). We looked at a contemporary series comparing complication rates between AA and contralateral retrograde femoral arterial access (RA) for femoropopliteal angioplasty.

Method:

A prospective review of all cases between 2010 and 2015 in a United Kingdom tertiary vascular center. Demographical and procedural data were obtained for those undergoing percutaneous femoropopliteal angioplasty. The primary outcome looked at periprocedural complications including retroperitoneal hematoma, pseudoaneurysm, hematoma requiring transfusion, arteriovenous fistulation, and surgical intervention. Secondary outcomes included contrast and radiation doses in addition to procedural failure leading to major amputation.

Results:

A total of 556 (66% male) patients underwent femoropopliteal angioplasty, 461 (82%) via AA. Groups were of comparable age, sex, comorbidity, and symptomatology. AA patients had a lower body mass index, 26 versus 29 ( P = .005). No significant difference was seen in periprocedural (15.8% AA vs 11.6% RA; P = 0.292) or access site complications (3.7% AA vs 1.1% RA; P = 0.186). There was less need for a closure device, 40.3% AA vs 73% RA ( P < .01), less contrast, 94 mL AA: 114 mL RA ( P < .001), and less radiation, 3487 cGy cm2 AA: 9697 cGy cm2 RA ( P < .001). Arterial access was also associated with greater technical success of 83.8%: 73.3% RA ( P = .002).

Conclusions:

Arterial access is associated with higher technical success and reduced contrast/radiation doses with no significant difference in complications compared to RA contrary to previous reports.

Patient selection and perioperative outcomes of bypass and endovascular intervention as first revascularization strategy for infrainguinal arterial disease

OBJECTIVE

The optimal initial revascularization strategy remains uncertain for patients with peripheral arterial disease. The purpose of this study was to evaluate current nationwide selection and perioperative outcomes of patients undergoing bypass or endovascular intervention for infrainguinal disease in those with no prior ipsilateral revascularization.

METHODS

Patients undergoing nonemergent first-time infrainguinal revascularization were identified in the Targeted Vascular module of the National Surgical Quality Improvement Program (NSQIP) for 2011 to 2014 and stratified by symptom status (chronic limb-threatening ischemia [CLTI] or claudication). Patients treated with endovascular intervention were compared with those who underwent bypass. Multivariable logistic regression was used to evaluate current selection of patients and to establish independent associations between first-time procedures and postoperative outcomes.

RESULTS

Of 5998 first-time infrainguinal revascularizations performed, 3193 were bypass procedures (63% for CLTI) and 2805 were endovascular interventions (64% for CLTI). Current patient characteristics associated with an endovascular-first approach as opposed to bypass-first in CLTI patients were age ≥80 years, tissue loss, nonsmoking, functional dependence, diabetes, dialysis, and tibial lesions, whereas age ≥80 years, nonwhite race, nonsmoking, diabetes, and tibial lesions were associated with an endovascular approach for claudication. In comparing first-time endovascular intervention with bypass, there was no difference in 30-day mortality in CLTI patients (univariate: 2.1% vs 2.2%; adjusted: odds ratio [OR], 0.7; 95% confidence interval [CI], 0.4-1.1) or claudication patients (0.3% vs 0.6%). Among CLTI patients, endovascular-first intervention was associated with lower rates of major adverse cardiovascular event (3.6% vs 4.7%; OR, 0.6; 95% CI, 0.4-0.9), surgical site infection (0.9% vs 7.7%; OR, 0.1; 95% CI, 0.1-0.2), bleeding (8.5% vs 17%; OR, 0.4; 95% CI, 0.3-0.5), unplanned reoperation (13% vs 17%; OR, 0.7; 95% CI, 0.5-0.8), and unplanned readmission (17% vs 18%; OR, 0.8; 95% CI, 0.7-0.9). Patients with claudication undergoing endovascular-first intervention also had lower rates of major adverse cardiovascular event (0.8% vs 1.6%; OR, 0.4; 95% CI, 0.2-0.95), surgical site infection (0.7% vs 6.6%; OR, 0.1; 95% CI, 0.04-0.2), bleeding (2.3% vs 6.0%; OR, 0.3; 95% CI, 0.2-0.5), unplanned reoperation (4.3% vs 6.6%; OR, 0.6; 95% CI, 0.4-0.9), and unplanned readmission (5.9% vs 9.0%; OR, 0.6; 95% CI, 0.4-0.8). Conversely, endovascular-first intervention was associated with a higher rate of secondary revascularizations within 30 days for CLTI (4.3% vs 3.1%; OR, 1.6; 95% CI, 1.04-2.3) but not for claudication (2.6% vs 1.9%; OR, 1.7; 95% CI, 0.9-3.4).

CONCLUSIONS

An endovascular-first approach as a revascularization strategy for infrainguinal disease was associated with substantially lower early morbidity but not mortality, at the cost of higher rates of postoperative secondary revascularizations. As a national representation of first-time revascularizations, this study highlights the early endovascular perioperative benefit, although more robust long-term data are needed to adopt either one strategy or the other in select patients with peripheral arterial disease.

Mid-Term Outcomes of Stent Overlap in Long Total Occluded Lesions of Superficial Femoral Artery

Background

Superficial femoral artery chronic total occlusion (SCTO) is a common type of peripheral arterial disease (PAD). Endovascular therapy is a treatment approach that has a poor long-term success rate in this group. The aim of this study was to compare the mid-term results of two different uses of nitinol stents in long SCTO lesions (>100 mm): the use of one long stent or two shorter stents.

Material/Methods

Of 154 patients who underwent percutaneous infrainguinal interventions from 2011 to 2014, a total of 170 CTO lesions were selected for this retrospective study analysis. The mean age of the study population was 63.4±10.4 years (range 29–89 years); 71.8% of the patients were male.

Results

Patients were divided into two groups according to the number of stents used. Patients treated with a single stent were placed into group A and patients treated with two stents were placed into group B. The stent fracture rate was significantly higher in group B compared to group A (29.2% vs. 42%). Type 1 and 2 fracture rates were higher in group A, but type 3 and 5 fracture rates were significantly higher in group B. The rate of stent restenosis was significantly higher in group B compared to group A (45.1% vs. 54.5%, p=0.05).

Conclusions

Mid-term patency rate was low in patients with long totally occluded superficial femoral artery (SFA) lesions. Using a long single stent had an acceptable mid-term patency rate compared to using a two stent strategy. Stent fracture seemed to be the main reason for in-stent restenosis in cases of multiple stenting. A long single stent strategy may be more appropriate and reasonable than a two stent strategy in the treatment of long SFA lesions.

Bypass surgery for chronic lower limb ischaemia

BACKGROUND

Bypass surgery is one of the mainstay treatments for patients with critical lower limb ischaemia (CLI). This is the second update of the review first published in 2000.

OBJECTIVES

To assess the effects of bypass surgery in patients with chronic lower limb ischaemia.

SEARCH METHODS

For this update, the Cochrane Vascular Group searched its trials register (last searched October 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (last searched Issue 9, 2016).

SELECTION CRITERIA

We selected randomised controlled trials of bypass surgery versus control or any other treatment. The primary outcome parameters were defined as early postoperative non-thrombotic complications, procedural mortality, clinical improvement, amputation, primary patency, and mortality within follow-up.

DATA COLLECTION AND ANALYSIS

For the update, two review authors extracted data and assessed trial quality. We analysed data using odds ratio (OR) and 95% confidence intervals (CIs). We applied fixed-effect or random-effects models.

MAIN RESULTS

We selected 11 trials reporting a total of 1486 participants. Six trials compared bypass surgery with percutaneous transluminal angioplasty (PTA), and one each with remote endarterectomy, thromboendarterectomy, thrombolysis, exercise, and spinal cord stimulation. The quality of the evidence for the most important outcomes of bypass surgery versus PTA was high except for clinical improvement and primary patency. We judged the quality of evidence for clinical improvement to be low, due to heterogeneity between the studies and the fact that this was a subjective outcome assessment and, therefore, at risk of detection bias. We judged the quality of evidence for primary patency to be moderate due heterogeneity between the studies. For the remaining comparisons, the evidence was limited. For several outcomes, the CIs were wide.Comparing bypass surgery with PTA revealed a possible increase in early postinterventional non-thrombotic complications (OR 1.29, 95% CI 0.96 to 1.73; six studies; 1015 participants) with bypass surgery, but bypass surgery was associated with higher technical success rates (OR 2.26, 95% CI 1.49 to 3.44; five studies; 913 participants). Analyses by different clinical severity of disease (intermittent claudication (IC) or CLI) revealed that peri-interventional complications occurred more frequently in participants with CLI undergoing bypass surgery than PTA (OR 1.57, 95% CI 1.09 to 2.24). No differences in periprocedural mortality were identified (OR 1.67, 95% CI 0.66 to 4.19; five studies; 913 participants). The primary patency rate at one year was higher after bypass surgery than after PTA (OR 1.94, 95% CI 1.20 to 3.14; four studies; 300 participants), but this difference was not shown at four years (OR 1.15, 95% CI 0.74 to 1.78; two studies; 363 participants). No differences in clinical improvement (OR 0.65, 95% CI 0.03 to 14.52; two studies; 154 participants), amputation rates (OR 1.24, 95% CI 0.82 to 1.87; five studies; 752 participants), reintervention rates (OR 0.76, 95% CI 0.42 to 1.37; three studies; 256 participants), or mortality within the follow-up period (OR 0.94, 95% CI 0.71 to 1.25; five studies; 961 participants) between surgical and endovascular treatment were identified. No differences in subjective outcome parameters, indicated by quality of life and physical and psychosocial well-being, were reported. The hospital stay for the index procedure was reported to be longer in participants undergoing bypass surgery than in those treated with PTA.In the single study (116 participants) comparing bypass surgery with remote endarterectomy of the superficial femoral artery, the frequency of early postinterventional non-thrombotic complications was similar in the treatment groups (OR 1.11, 95% CI 0.53 to 2.34). No mortality within 30 days of the index treatment or during stay in hospital in either group was recorded. No differences were identified in patency (OR 1.66, 95% CI 0.79 to 3.46), amputation (OR 1.70, 95% CI 0.27 to 10.58), and mortality rates within the follow-up period (OR 1.66, 95% CI 0.61 to 4.48). Information regarding clinical improvement was unavailable.No differences in major complications (OR 0.66, 95% CI 0.34 to 1.31) or mortality (OR 2.09, 95% CI 0.67 to 6.44) within 30 days of treatment between surgery and thrombolysis (one study, 237 participants) for chronic lower limb ischaemia were identified. The amputation rate was lower after bypass surgery (OR 0.10, 95% CI 0.01 to 0.80). No differences in late mortality were found (OR 1.56, 95% CI 0.71 to 3.44). No data regarding patency rates and clinical improvement were reported.Technical success resulting in blood flow restoration was higher after bypass surgery than thromboendarterectomy for aorto-iliac occlusive disease (one study, 43 participants) (OR 0.01, 95% CI 0 to 0.17). The periprocedural mortality (OR 0.33, 95% CI 0.01 to 8.65), follow-up mortality (OR 3.29, 95% CI 0.13 to 85.44), and amputation rates (OR 0.47, 95% CI 0.08 to 2.91) did not differ between treatments. Clinical improvement and patency rates were not reported.Comparing surgery and exercise (one study, 75 participants) did not identify differences in early postinterventional complications (OR 7.45, 95% CI 0.40 to 137.76) and mortality (OR 1.55, 95% CI 0.06 to 39.31). The remaining primary outcomes were not reported. There was no difference in maximal walking time between exercise and surgery (1.66 min, 95% CI -1.23 to 4.55).Regarding comparisons of bypass surgery with spinal cord stimulation for CLI, there was no difference in amputation rates after 12 months of follow-up (OR 4.00, 95% CI 0.25 to 63.95; one study, 12 participants). The remaining primary outcome parameters were not reported.

AUTHORS' CONCLUSIONS

There is limited high quality evidence for the effectiveness of bypass surgery compared with other treatments; no studies compared bypass to optimal medical treatment. Our analysis has shown that PTA is associated with decreased peri-interventional complications in participants treated for CLI and shorter hospital stay compared with bypass surgery. Surgical treatment seems to confer improved patency rates up to one year. Endovascular treatment may be advisable in patients with significant comorbidity, rendering them high risk surgical candidates. No solid conclusions can be drawn regarding comparisons of bypass surgery with other treatments because of the paucity of available evidence. Further large trials evaluating the impact of anatomical location and extent of disease and clinical severity are required.

Results for primary bypass versus primary angioplasty/stent for lower extremity chronic limb-threatening ischemia

BACKGROUND

Long-term results comparing percutaneous transluminal angioplasty with or without stenting (PTA/S) and open surgical bypass for chronic limb-threatening ischemia (CLTI) in patients who have had no prior intervention are lacking.

METHODS

All patients undergoing a first-time lower extremity revascularization for CLTI by vascular surgeons at our institution from 2005 to 2014 were retrospectively reviewed. Outcomes included perioperative complications, wound healing, restenosis, primary patency, reintervention, major amputation, RAS events (ie, reintervention, major amputation, or stenosis), and mortality. Outcomes were evaluated using χ², Kaplan-Meier, and Cox regression analyses.

RESULTS

Of the 2869 total lower extremity revascularizations performed between 2005 and 2014, there were 1336 that fit our criteria of a first-time lower extremity intervention for CLTI (668 bypass procedures and 668 PTA/S procedures). Bypass patients were younger (71 vs 72 years; P = .02) and more often male (62% vs 56%; P < .02). Total mean hospital length of stay (LOS) was significantly longer after a first-time bypass (10 vs 8 days; P < .001), as were mean preoperative LOS (4 vs 3 days; P < .01) and postoperative LOS (7 vs 5 days; P < .001). There was no difference in perioperative mortality (3% vs 3%; P = .63). Surgical site infection occurred in 10% of bypass patients. Freedom from reintervention was significantly higher in patients undergoing a first-time bypass procedure (62% vs 52% at 3 years; P = .04), as was freedom from restenosis (61% vs 45% at 3 years; P < .001). Complete wound healing at 6-month follow-up was significantly better after an initial bypass (43% vs 36%; P < .01). A Cox regression model of all patients showed that reintervention was predicted by a first-time PTA/S (hazard ratio, 1.6; 95% confidence interval, 1.3-2.1) and both preoperative femoropopliteal TransAtlantic Inter-Society Consensus (TASC) C and TASC D lesions (2.0 [1.3-3.1] and 1.8 [1.3-2.7], respectively). Major amputation among all patients was predicted by an initial presentation of gangrene (2.5 [1.3-5.0]), dialysis dependence (1.9 [1.3-2.9]), diabetes (2.0 [1.1-3.8]), and preoperative femoropopliteal TASC D lesions (2.1 [1.1-4.0]) and was not predicted by procedure type.

CONCLUSIONS

In this retrospective analysis, bypass for the primary treatment of CLTI showed improved 6-month wound healing, higher freedom from restenosis, improved patency rates, significantly fewer reinterventions, and higher survival than PTA/S within 3 years; however, a bypass-first approach was associated with increased total hospital LOS and wound infection. Perioperative mortality and amputation rates were similar between procedure types.

Endovascular Versus Open Revascularization for Peripheral Arterial Disease

OBJECTIVE

The aim of this study was to determine whether endovascular or open revascularization provides an advantageous approach to symptomatic peripheral arterial disease (PAD) over the longer term.

SUMMARY OF BACKGROUND DATA

The optimal revascularization strategy for symptomatic lower extremity PAD is not established.

METHODS

We evaluated amputation-free survival, overall survival, and relative rate of subsequent vascular intervention after endovascular or open lower extremity revascularization for propensity-score matched cohorts of Medicare beneficiaries with PAD from 2006 through 2009.

RESULTS

Among 14,685 eligible patients, 5928 endovascular and 5928 open revascularization patients were included in matched analysis. Patients undergoing endovascular repair had improved amputation-free survival compared with open repair at 30 days (7.4 vs 8.9%, P = 0.002). This benefit persisted over the long term: At 4 years, 49% of endovascular patients had died or received major amputation compared with 54% of open patients (P < 0.001). An endovascular procedure was associated with a risk-adjusted 16% decreased risk of amputation or death compared with open over the study period (hazard ratio: 0.84; 95% confidence interval, 0.79-0.89; P < 0.001). The amputation-free survival benefit associated with an endovascular revascularization was more pronounced in patients with congestive heart failure or ischemic heart disease than in those without (P = 0.021 for interaction term). The rate of subsequent intervention at 30 days was 7.4% greater for the endovascular vs the open revascularization cohort. At 4 years, this difference remained stable at 8.6%.

CONCLUSIONS

Using population-based data, we demonstrate that an endovascular approach is associated with improved amputation-free survival over the long term with only a modest relative increased risk of subsequent intervention.

Minimally Invasive Revascularization Strategies for Chronic Lower Limb Ischemia

Lower extremity wounds resulting from ischemia are increasingly becoming a common indication for surgical revascularization. Techniques in minimally invasive vascular surgery for the treatment of lower extremity chronic ischemia have expanded rapidly in recent years. The current standard of care with which all new modalities should be compared is the restoration of arterial flow via direct arterial revascularization using the autogenous reversed saphenous vein that can yield limb salvage rates of approximately 95%. Percutaneous transluminal angioplasty and stenting (PTA/S), cryoplasty, catheter-directed atherectomy, laser-assisted PTA/S, drug-eluting stents, and subintimal angioplasty are emerging minimally invasive modalities used for the treatment of lower extremity ischemia. Early success rates using many of these techniques have been promising. The outcomes of randomized controlled trials with long-term follow-ups are needed to make confident remarks about the effectiveness of these techniques.

Contemporary Endovascular Treatment for Disease of the Superficial Femoral and Popliteal Arteries: An Integrated Device-Based Strategy

Endovascular therapy for disease of the superficial femoral artery (SFA) and the popliteal artery remains controversial. Percutaneous treatment of this arterial segment presents a particular technical challenge, as the extent of disease varies from short, focal, and stenotic to long, diffuse, and occluded lesions. Over the last 2 decades, multiple therapies have been evaluated, including simple balloon angioplasty, directional atherectomy, stenting (both balloon-expandable and self-expanding), and more recently, intra-arterial radiation, laser, and cryotherapy. Regardless of which modality is used, however, endovascular therapy as a revascularization strategy has the potential to improve symptoms and quality of life and, in selected patients, to avoid limb amputation. While percutaneous endovascular treatment has been historically associated with high procedural success and favorable short and intermediate-term patency rates, long-term clinical results have proven disappointing. Conventional balloon angioplasty is limited by elastic recoil, dissection, and restenosis. Balloon-expandable stents (particularly in the distal SFA) are associated with late stent deformation and mechanical compression, with resultant late clinical failure. Newer self-expanding stents have shown improved initial results but have been limited by late mechanical fatigue and associated restenosis. With the development of several newer endovascular techniques in recent years, the possibilities for treating this condition have increased dramatically. Currently, no long-term comparative data exist regarding the role of these alternative technologies. This article summarizes and compares important data about new endovascular options for intervention therapy in SFA and popliteal disease. In addition, based on this analysis, we propose a contemporary treatment strategy, integrating older and newer technologies into a real-world algorithm.

[Indications and results of endovascular therapy of critical limb ischemia]

BACKGROUND

Critical limb ischemia (CLI) is the most severe form of peripheral artery occlusive disease and is characterized by high amputation, morbidity and mortality rates. Therefore, revascularization is the essential step in therapy for retention of the affected limb.

OBJECTIVES

Although for a long time bypass surgery represented the gold standard in the treatment of CLI, in recent years there has been a disproportionate increase of endovascular treatment despite the lack of level-data. In this review the indications and results of endovascular therapy of CLI are presented on the basis of published data.

METHODS

A literature search was carried out to identify publications that compared the results of endovascular and surgical therapy as well as observational studies about different endovascular techniques.

RESULTS

The BASIL study provided the highest quality data comparing endovascular and surgical treatment of CLI. The long-term data of the BASIL trial showed that apart from patients with a suitable vein and a life expectancy of more than 2 years, first line endovascular therapy is equivalent to surgical treatment. The equivalence could also be demonstrated in a meta-analysis comparing operative and endovascular treatment of CLI.

CONCLUSION

The CLI is a disease with high mortality and morbidity risks. Due to the comparable amputation-free survival times with lower complication rates in the published data, in most patients an endovascular first strategy in experienced centers can be justified.

The role of clinical evidence in emergent therapies: an empirical study on femoropopliteal stent-angioplasty in Europe

RATIONALE, AIMS AND OBJECTIVE

A delayed availability of clinical evidence in rapidly emerging therapies is considered a major problem. In this study, we examined whether evidence from clinical studies has influenced the therapy of a major disease in industrial countries, peripheral arterial disease (PAD), using novel femoropopliteal stent-angioplasty.

METHOD

This analysis of retrospective time series data uses multivariate linear regression to investigate associations between published clinical evidence on femoropopliteal stent-angioplasty from Q3/2004 to Q4/2010 and the demand for femoropopliteal stents in Germany, France, Italy and the UK between Q1/2005 and Q4/2010, controlling for the prevalence of PAD risk factors, cardiovascular drug demand, reimbursement of health care providers for stent implantation, stent selling prices of manufacturers and economic indicators.

RESULTS

We did not observe any association of published clinical evidence with femoropopliteal stent demand in Germany, France, Italy and the UK, while we observed such associations for varying control variables at different time lags respectively.

CONCLUSION

We observed no association between published clinical evidence of femoropopliteal stent-angioplasty and its use in any of the four countries. The country-specific context and practice-related variables at a centre and individual doctor level may have limited the role of published clinical evidence in emerging femoropopliteal stent-angioplasty. More research is needed at this context, centre and individual level.

Relationship Between Primary Patency and Lesion Length Following Bare Nitinol Stent Placement for Femoropopliteal Disease

PURPOSE

To evaluate the relationship between 1-year primary patency and lesion length in patients with femoropopliteal disease treated with bare nitinol stents.

METHODS

The study was a retrospective analysis of a prospectively maintained multicenter database. Between January 2004 and December 2011, 1047 consecutive patients (mean age 72 years; 765 men) underwent femoropopliteal stenting with nitinol stents in 1373 limbs. The mean vessel diameter was 5.3±0.7 mm and the mean lesion length was 142±75 mm. One-year follow-up data were collected and analyzed to ascertain which lesion length would be expected to demonstrate a 1-year primary patency above the established 66% objective performance goal (OPG).

RESULTS

The lower limit of the 95% confidence interval (CI) for the unadjusted 1-year primary patency was >66% when the lesion length was ≤243 mm. After adjustment of the covariates to match those of the OPG-derived population, the 1-year primary patency decreased linearly with longer lesion length. The 1-year primary patency was 83.2% (95% CI 79.8% to 86.1%) for a 100-mm lesion length, 76.4% (95% CI 71.7% to 80.5%) for a 200-mm lesion length, and 70.7% (95% CI 62.4% to 77.7%) for a 300-mm lesion length. The maximum lesion length providing a 1-year primary patency significantly greater than 66% was calculated to be 263 mm.

CONCLUSION

The 1-year primary patency of femoropopliteal lesions treated with bare nitinol stents decreased linearly with longer lesion length. The maximum lesion length providing a higher patency rate than the OPG of 66% was ~25 cm.

Direct Revascularization With the Angiosome Concept for Lower Limb Ischemia: A Systematic Review and Meta-Analysis

The angiosome concept provides practical information regarding the vascular anatomy of reconstructive and vascular surgery for the treatment of peripheral arterial occlusive disease and, particularly, critical lower limb ischemia.The aim of the study was to confirm the efficacy of direct revascularization with the angiosome concept (DR) for lower limb ischemia.Complementary manual searches were performed through the Pubmed, Cochrane Library, and EMBASE databases.We searched all randomized and nonrandomized studies (NRSs) comparing DR with indirect revascularization (IR) (without the angiosome concept) for lower limb ischemia. Only 9 nonrandomized controlled retrospective cohort studies were found and included. Trials published in any language were included.Primary endpoints were time to limb amputation and time to wound healing. Data extraction and trial quality assessment were performed by two authors independently. A third author was consulted for disagreements settlement and quality assurance.Five NRSs involving 779 lower limbs revealed that DR significantly improved the overall survival of limbs (hazard ratio [HR] 0.61; 95% confidence interval [CI] = 0.46-0.80; P < 0.001; I = 0%). In addition, DR significantly improved time to wound healing (HR 1.38; 95% CI = 1.13-1.69; P = 0.002; I = 0%, in 5 studies including 605 limbs).All included studies were retrospective comparative studies, and no consensus was obtained in describing wound conditions in the included studies.Our results suggested that treatment of lower limb ischemia using DR is more effective in salvaging limbs and healing wounds than IR is. Additional randomized controlled studies are necessary to confirm these results.

Percutaneous versus surgical management of lower extremity peripheral artery disease

Lower extremity peripheral artery disease (PAD) is highly prevalent and can manifest as intermittent claudication or, in the most advanced form, critical limb ischemia. Revascularization, which can be accomplished by an endovascular or surgical approach, is performed to improve quality of life or, in severe cases, for limb salvage. Over the past decade, percutaneous catheter-based techniques have improved such that acute procedural success is high even in complex anatomy. Patency rates have also increased with the use of atherectomy devices and drug-eluting stents. Often, patients with PAD have comorbidities that increase the risk of cardiovascular complications with surgical procedures. These factors have led to the adoption of an endovascular first strategy with surgical management reserved for selected patients. This review focuses on the most current clinical trials of endovascular therapy for PAD. In addition, older but relevant studies comparing endovascular and surgical approaches and contemporary surgical trials are presented for reference.

Comparative Assessment of Guidewire and Microcatheter vs a Crossing Device-Based Strategy to Traverse Infrainguinal Peripheral Artery Chronic Total Occlusions

PURPOSE

To compare success rates of a guidewire and microcatheter strategy vs the use of specialized crossing devices to traverse infrainguinal peripheral artery chronic total occlusions (CTOs).

METHODS

For this analysis, data on 438 consecutive infrainguinal CTO interventions in 438 patients (mean age 63.2 years; 402 men) performed between August 2006 and May 2014 were extracted from the multicenter Excellence in Peripheral Artery Disease (XLPAD) database (ClinicalTrials.gov; identifier NCT01904851). Primary technical success constituted placement of a guidewire in the true lumen, past the distal CTO cap, with the initial crossing strategy.

RESULTS

A wire-catheter strategy was used in 295 (67.4%) and a specialized CTO crossing device in 143 (32.6%) patients (p<0.001). Primary crossing technical success was higher with CTO devices (72.1% vs 51.9%, p<0.001). The primary wire-catheter arm used significantly more secondary CTO devices (28.1% vs 17.5%) and/or provisional re-entry devices (26.7% vs 4.9%) compared with the primary CTO device arm (both p<0.001). Secondary crossing technical success (defined as crossing with an alternate strategy: 67.5% vs 71.4%, p=1.000), provisional crossing technical success (defined as use of a re-entry device: 84.2% vs 87.5%, p=0.768), and procedure success (93.6% vs 90.9%, p=0.332) were similar between the wire-catheter and CTO device strategies, respectively. No differences were observed in periprocedural complications or 30-day adverse events; however, at 12 months, there was a significantly higher surgical revascularization rate in the primary wire-catheter arm (8.8% vs 2.8%, p=0.025).

CONCLUSION

Infrainguinal peripheral artery CTO crossing is frequently attempted with a wire-catheter technique; however, an initial CTO crossing device approach is associated with higher primary technical success. Overall procedure success is similar with both strategies.

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication

Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.

Contemporary treatment for critical ischemia: the evidence for interventional radiology or surgery

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.

Contemporary Management of Femoral Popliteal Revascularization

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