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Kinariwala D, Taylor AC, Wilkins LR. Percutaneous Intentional Extraluminal Recanalization of Chronic Total Occlusions: A Review of Reentry Devices. Semin Intervent Radiol 2023; 40:144-150. [PMID: 37333749 PMCID: PMC10275678 DOI: 10.1055/s-0043-57260] [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: 06/20/2023]
Abstract
Percutaneous intentional extraluminal recanalization (PIER) is an endovascular subintimal crossing technique used to treat chronic total occlusions (CTOs) of the peripheral arteries. Intraluminal revascularization remains the standard over PIER when technically feasible; however, when intraluminal approaches fail, PIER may be preferred prior to pursuit of surgical bypass grafting. The major cause of failure of PIER is inability to reenter the true lumen after crossing the CTO. Therefore, several reentry devices and endovascular techniques have been developed to allow for the operators to safely and quickly access the true lumen distal to the occlusion. Reentry devices currently available on the market include the Pioneer Plus catheter, Outback Elite catheter, OffRoad catheter, Enteer catheter, and GoBack catheter. These devices have unique methods of use and specific advantages with regard to their technical success along with reduced procedural and fluoroscopic time. In addition, there are other endovascular techniques available that may facilitate true lumen reentry and these will also be reviewed.
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Affiliation(s)
- Dhara Kinariwala
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - Amy C. Taylor
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - Luke R. Wilkins
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
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Kuntz S. Subintimal Angioplasty in the Superficial Femoral Artery: A Real Long Term Option Demonstrated by Histology. EJVES Vasc Forum 2021; 52:49-50. [PMID: 34522909 PMCID: PMC8424509 DOI: 10.1016/j.ejvsvf.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- Salomé Kuntz
- Corresponding author: Department of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, France, Nouvel Hôpital Civil, 1 Place de l'hôpital, 67091 Strasbourg Cedex, France.
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Lund T, Svindland A, Bay D, Sundhagen JO, Hisdal J, Flørenes T. Histological Analysis of a Long Term Patent Subintimal Canal in the Superficial Femoral Artery. EJVES Vasc Forum 2020; 50:19-23. [PMID: 33511376 PMCID: PMC7815991 DOI: 10.1016/j.ejvsvf.2020.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/01/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Subintimal angioplasty (SIA) was introduced in the late 1980s and is a supplement to bypass surgery. Adaptation of the technique has been hampered by high rates of early intervention to maintain patency, but the long term assisted patency is good. Report The superficial femoral and popliteal artery containing a patent subintimal canal were explanted from a patient who died in the authors' ward. Histological analysis indicated that the lumen was created in the medial layer of the vessel wall. A collagen rich neointima and fragmented internal elastic lamina were observed, presumably as a result of activated smooth muscle cells. The luminal surface was partly covered by a single layer of CD31, von Willebrand factor, and partly CD144 positive cells. An early atherosclerotic lesion was observed distally in the subintimal canal. Discussion Remodelling and neo-cellularisation of the vascular wall after SIA are described. Notably, hallmarks of early and late stage atherosclerotic disease were evident throughout the subintimal canal. These observations require confirmation in a larger number of specimens but underscore the need for surveillance after SIA.
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Affiliation(s)
- Tormod Lund
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Aud Svindland
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Dag Bay
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Jon O Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tor Flørenes
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
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Kokkinidis DG, Katsaros I, Jonnalagadda AK, Avner SJ, Chaitidis N, Bakoyiannis C, Kakkar A, Secemsky EA, Giri JS, Armstrong EJ. Use, Safety and Effectiveness of Subintimal Angioplasty and Re-Entry Devices for the Treatment of Femoropopliteal Chronic Total Occlusions: A Systematic Review of 87 Studies and 4,665 Patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:34-45. [DOI: 10.1016/j.carrev.2019.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/30/2022]
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Ghoneim B, Younis S, Elmahdy H, Elwan H, Khairy H. Endovascular intervention in flush superficial femoral artery occlusive disease: challenges and outcome. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.18.01368-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Akesson M, Riva L, Ivancev K, Uher P, Lundell A, Malina M. Subintimal Angioplasty of Infrainguinal Arterial Occlusions for Critical Limb Ischemia: Long-Term Patency and Clinical Efficacy. J Endovasc Ther 2016; 14:444-51. [PMID: 17696617 DOI: 10.1177/152660280701400403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To evaluate long-term patency and clinical efficacy of subintimal angioplasty (SAP) of occluded infrainguinal arteries 3 years post procedure. Methods: One hundred eighty-one patients (92 men; median age 79 years) underwent attempted SAP in 193 limbs with occluded infrainguinal arteries during the period 1999 to 2001. Nearly half (83, 46%) of the patients had diabetes. Most (172, 95%) had critical ischemia (Fontaine classification >II). All patients surviving at least 3 years after the procedures were followed in January 2005 with questionnaires, clinical examinations, ankle-brachial index measurements, and duplex ultrasonography. All data were collected prospectively and analyzed retrospectively. Results: The primary technical success in the entire cohort was 77% (148/193). Thirty-day mortality was 10% (19/181); 113 (62%) patients died before the 3-year follow-up. In the 68 (38%) survivors (71 limbs), patency at 49.2 months (IQR 40.8–57.6) was 40% (26/65 limbs imaged by duplex). The TASC classification did not affect technical or clinical outcomes. Forty-six (68%) of the survivors presented with clinical improvement (lower Fontaine classification at postoperative follow-up versus baseline). The limb salvage at >3 years was 86% in the 58 primarily successful SAPs and 38% in the 13 procedures that failed initially. Conclusion: SAP is a minimally invasive option for patients with critical limb ischemia. A primary technical success is essential for good clinical outcome and primary technical failure is more devastating than late occlusion. TASC classification and length of the SAP are of poor predictive value. More data are needed to confirm the efficacy of SAP.
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Eskelinen E, Lepäntalo M. Role of Infrainguinal Angioplasty in the Treatment of Critical Limb Ischaemia. Scand J Surg 2016; 96:11-6. [PMID: 17461306 DOI: 10.1177/145749690709600103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: To review the published papers reporting on the use of infrainguinal angioplasty in the treatment of critical limb ischaemia (CLI). Methods: A MEDLINE (1966–2005) and Cochrane library search for articles relating to the use of infrainguinal angioplasty in the treatment of CLI. Results: Recent papers reporting on the results of infrainguinal angioplasty as treatment for CLI patients show excellent limb salvage rates regardless of the patency rates. The Cochrane Database of systematic reviews has accepted two prospective randomised trials comparing bypass operations and angioplasty among CLI patients. Pooling both trials showed no overall significant difference in amputation rates between the surgery and PTA groups. A multicentre, randomised controlled trial, the BASIL (bypass versus Angioplasty in Severe Ischaemia of the Leg) trial showed that in the medium term (after six months), the outcomes after angioplasty or surgery among CLI patients did not differ significantly with respect to amputation-free survival, all-cause mortality and quality of life. Conclusions: Infrainguinal PTA is feasible in CLI patients. Data from the BASIL trial show the similar ability of bypass surgery and balloon angioplasty in preserving both life and limb in short term. These results are, however, not applicable for the majority of CLI patients as only 15% (70/456) of the patients with severe limb ischaemia were considered candidates for the trial.
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Affiliation(s)
- E Eskelinen
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Torres-Blanco Á, Edo-Fleta G, Gómez-Palonés F, Molina-Nácher V, Ortiz-Monzón E. Mid-Term Outcomes of Endovascular Treatment for TASC-II D Femoropopliteal Occlusive Disease with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2015. [DOI: 10.1007/s00270-015-1175-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Shammas NW. Subintimal angioplasty and stenting of chronic total femoropopliteal occlusions: is distal protection needed? J Endovasc Ther 2014; 21:482-4. [PMID: 25101574 DOI: 10.1583/14-4703c.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Subintimal Recanalization Plus Stenting or Bypass for Management of Claudicants with Femoro-popliteal Occlusions. Eur J Vasc Endovasc Surg 2013; 46:347-52. [DOI: 10.1016/j.ejvs.2013.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 06/10/2013] [Indexed: 11/15/2022]
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Davies RSM, Rashid SH, Adair W, Bolia A, Fishwick G, McCarthy MJ, Sayers RD. Isolated Percutaneous Transluminal Angioplasty of the Profunda Femoris Artery for Limb Ischemia. Vasc Endovascular Surg 2013; 47:423-8. [DOI: 10.1177/1538574413491636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To compare the outcome of endovascular profunda femoral artery revascularization (ePFR) with ePFR and concurrent endovascular femoropopliteal revascularization (eFPR). Methods: A retrospective review of the consecutive patients with PFA and femoropopliteal vaso-occulsive disease who underwent ePFR or ePFR + eFPR for severe limb ischemia was performed. Results: A total of 18 ePFRs and 26 ePFR + eFPRs were performed; 17 (94%) ePFRs and 22 (85%) ePFR + eFPRs were technically successful. The 12-month survival free from amputation and reintervention rates following isolated ePFR were 78% and 72%, respectively, and following ePFR + eFPR were 96% and 81%, respectively. There was no significant difference in the survival free from amputation ( P = .4) or reintervention ( P = .91) rates between the 2 groups. Conclusion: These contemporary data suggest isolated ePFRs and ePFR + eFPRs are associated with good and comparable early limb salvage rates.
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Affiliation(s)
- Robert S. M. Davies
- Department of Radiology, Leicester Royal Infirmary, Leicester, United Kingdom
- The Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Sidi H. Rashid
- Department of Radiology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - William Adair
- Department of Radiology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Amman Bolia
- Department of Radiology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Guy Fishwick
- Department of Radiology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Mark J. McCarthy
- The Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Robert D. Sayers
- The Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom
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Jenssen EK, Brosstad F, Pedersen T, Bjørnsen S, Jørgensen JJ, Sandbæk G. Thrombin generation and platelet activation related to subintimal percutaneous transluminal angioplasty. Scandinavian Journal of Clinical and Laboratory Investigation 2011; 72:23-8. [DOI: 10.3109/00365513.2011.616220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ikushima I, Hirai T, Ishii A, Iryo Y, Yamashita Y. Confluent Two-Balloon Technique: An Alternative Method for Subintimal Recanalization of Peripheral Arterial Occlusion. J Vasc Interv Radiol 2011; 22:1139-43. [DOI: 10.1016/j.jvir.2011.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 04/06/2011] [Accepted: 04/07/2011] [Indexed: 11/25/2022] Open
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Subintimal angioplasty for femoro-popliteal occlusive disease. J Vasc Surg 2010; 52:1410-6. [DOI: 10.1016/j.jvs.2010.03.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 03/18/2010] [Accepted: 03/20/2010] [Indexed: 11/20/2022]
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Boufi M, Dona B, Orsini B, Auquier P, Hartung O, Alimi YS. A comparison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions. J Vasc Surg 2010; 52:1211-7. [DOI: 10.1016/j.jvs.2010.05.107] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 05/21/2010] [Accepted: 05/27/2010] [Indexed: 10/19/2022]
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Resultados clínicos del tratamiento endovascular sobre el sector fémoro-poplíteo en pacientes con isquemia crítica de la extremidad. ANGIOLOGIA 2010. [DOI: 10.1016/s0003-3170(10)70027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Köcher M, Cerna M, Utikal P, Kozak J, Sisola I, Thomas RP, Bachleda P, Drac P, Sekanina Z, Langova K. Subintimal angioplasty in femoropopliteal region—Mid-term results. Eur J Radiol 2010; 73:672-6. [DOI: 10.1016/j.ejrad.2008.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2008] [Revised: 12/14/2008] [Accepted: 12/23/2008] [Indexed: 11/30/2022]
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Soga Y, Yokoi H, Urakawa T, Tosaka A, Iwabuchi M, Nobuyoshi M. Long-Term Clinical Outcome After Endovascular Treatment in Patients With Intermittent Claudication due to Iliofemoral Artery Disease. Circ J 2010; 74:1689-95. [DOI: 10.1253/circj.cj-10-0077] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Flørenes T, Sandbaek G, Stranden E, Jørgensen JJ. [Surgical treatment of atherosclerosis in the lower limbs]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2252-5. [PMID: 19898577 DOI: 10.4045/tidsskr.09.0181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Walking exercise, smoking cessation and best medical therapy are cornerstones in all treatment of atherosclerosis. For patients with intermittent claudication or critical limb ischemia, endovascular therapy (which has developed substantially during the last decade) has become the first line treatment (when feasible). The aim of this article is to provide an overview of options for surgical treatment of peripheral atherosclerosis in the lower limbs. MATERIAL AND METHODS The article is based on literature identified through a non-systematic search in PubMed, vascular textbooks and the authors' own clinical experience. RESULTS When endovascular therapy has failed or is not feasible, open surgical techniques are used, such as endarterectomy and bypass surgery to the popliteal or distal arteries. Hybrid procedures, with femoral endarterectomy and distal or proximal endovascular intervention, are often used. Increased use of endovascular treatment reduces the procedural time, length of hospital stay and the rate of complications. In patients with extreme disease progression, primary amputation may still be the treatment of choice. INTERPRETATION Surgical treatment of peripheral artery disease requires competence both within radiological intervention and open surgical treatment modalities.
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Affiliation(s)
- Tor Flørenes
- Oslo vaskulaere senter, Oslo universitetssykehus, Aker, 0514 Oslo, Norway
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Keeling AN, Khalidi K, Leong S, Given MF, McGrath FP, Athanasiou T, Lee MJ. Subintimal Angioplasty: Predictors of Long-term Success. J Vasc Interv Radiol 2009; 20:1013-22. [DOI: 10.1016/j.jvir.2009.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 05/06/2009] [Accepted: 05/06/2009] [Indexed: 11/24/2022] Open
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Bown MJ, Bolia A, Sutton AJ. Subintimal angioplasty: meta-analytical evidence of clinical utility. Eur J Vasc Endovasc Surg 2009; 38:323-37. [PMID: 19570689 DOI: 10.1016/j.ejvs.2009.05.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/22/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to determine accurate estimates of the success rate of subintimal angioplasty in terms of ability to recanalise occluded vessels, patency over time and limb salvage rates. DESIGN A meta-analysis of published literature. MATERIALS All studies reporting unique patient data published in English language between 1989 and 2008. METHODS Separate meta-analyses were performed for immediate technical success, 12-month patency rates and 12-month limb salvage rates. Longer-term outcomes were analyzed in separate meta-analyses. Meta-regression was applied to determine whether any of these outcomes had improved over time. RESULTS Pooled estimates for technical success, primary patency at 12 months and limb salvage at 12 months were 85.7% (95% confidence interval: 83.3%-87.7%, 2810 limbs), 55.8% (95% confidence interval: 47.9%-63.4%, 1342 limbs), and 89.3% (95% confidence interval: 85.5%-92.2%, 2810 limbs), respectively. Regression analysis demonstrated no significant change in outcomes over time. There was some evidence of publication bias, however, after adjusting for this there was little change in the pooled outcome estimates. CONCLUSIONS This study demonstrates that the outcomes for subintimal angioplasty are good and that this method should be considered as an alternative to surgical bypass.
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Affiliation(s)
- M J Bown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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Setacci C, Chisci E, de Donato G, Setacci F, Iacoponi F, Galzerano G. Subintimal angioplasty with the aid of a re-entry device for TASC C and D lesions of the SFA. Eur J Vasc Endovasc Surg 2009; 38:76-87. [PMID: 19427245 DOI: 10.1016/j.ejvs.2009.03.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
Abstract
AIM The aim of this prospective study was to assess the clinical effectiveness and related midterm patency of subintimal angioplasty (SAP) in patients suffering from critical limb ischaemia (CLI) in a single tertiary care university centre. The secondary aim was to evaluate the safety and clinical effectiveness of using a re-entry device when re-canalisation by SAP was unsuccessful. METHODS From January 2005 to December 2007, consecutive patients suffering from CLI (Rutherford clinical categories: 4-6) were treated with SAP. All patients included in the study had occluded SFA (TASC C and D) and underwent clinical and ultrasound follow-up examinations at day 30 and at 3, 6, 9 and 12 months, and then yearly. A re-entry device (Outback, Cordis Corporation, Miami Lakes, Florida, USA in all cases) was only used when re-canalisation by simple SAP was unsuccessful, and stenting was used when residual stenosis was >30% or there was a flow-limiting dissection. Factors that could modify the outcome were analysed. RESULTS In this study, 145 patients were treated, with a technical success rate of 83.5% (121 of 145) for simple SAP. Stenting was performed in 43% (n=62) of successful SAP procedures. No death occurred in the perioperative period, while the 30-day mortality was 4.8% (7 of 145). The re-entry device (Outback) was used in 24 cases (16.5%). The technical success of the re-entry device was 79% (19 of 24), with a 90% success rate of stent placement at the site of re-entry. Complications occurred in 6.2% of all procedures (n=9) (three arterial perforations (2.1%), three distal embolisations (2.1%), two femoral artery pseudo-aneurysms (1.4%) and one arterio-venous fistula (0.7%)). Factors capable of independently affecting the patency were renal insufficiency (p=0.03), current smoking (p=0.01) and diabetes (p=0.04). The primary patency at 1 and 3 years was 70% and 34% and the secondary patency at 1 and 3 years was 77% and 43%, respectively. At the same time intervals, the limb-salvage rate was 88% and 49%. CONCLUSIONS SAP with the aid of a re-entry device for TASC C and D lesions of the SFA seems to be safe and clinically effective in patients suffering from CLI, according to the experience at our centre. Further follow-up and more data are necessary to confirm these findings.
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Affiliation(s)
- C Setacci
- Department of Surgery, University of Siena, Siena, Italy.
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Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease. J Vasc Surg 2008; 48:1166-74. [DOI: 10.1016/j.jvs.2008.06.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 05/30/2008] [Accepted: 06/02/2008] [Indexed: 11/24/2022]
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Subintimal angioplasty: Our experience in the treatment of 506 infrainguinal arterial occlusions. J Vasc Surg 2008; 48:878-84. [DOI: 10.1016/j.jvs.2008.05.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/10/2008] [Accepted: 05/13/2008] [Indexed: 11/18/2022]
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Antusevas A, Aleksynas N, Kaupas R, Inciura D, Kinduris S. Comparison of Results of Subintimal Angioplasty and Percutaneous Transluminal Angioplasty in Superficial Femoral Artery Occlusions. Eur J Vasc Endovasc Surg 2008; 36:101-6. [DOI: 10.1016/j.ejvs.2008.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 02/12/2008] [Indexed: 12/01/2022]
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Met R, Van Lienden KP, Koelemay MJW, Bipat S, Legemate DA, Reekers JA. Subintimal angioplasty for peripheral arterial occlusive disease: a systematic review. Cardiovasc Intervent Radiol 2008; 31:687-97. [PMID: 18414946 PMCID: PMC2515568 DOI: 10.1007/s00270-008-9331-7] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 02/27/2008] [Accepted: 02/28/2008] [Indexed: 12/02/2022]
Abstract
The objective of this study was to summarize outcomes of subintimal angioplasty (SA) for peripheral arterial occlusive disease. The Cochrane Library, Medline and Embase databases were searched to perform a systematic review of the literature from 1966 through May 2007 on outcomes of SA for peripheral arterial occlusive disease of the infrainguinal vessels. The keywords “percutaneous intentional extraluminal revascularization,” “subintimal angioplasty,” “peripheral arterial disease,” “femoral artery,” “popliteal artery,” and “tibial artery” were used. Assessment of study quality was done using a form based on a checklist of the Dutch Cochrane Centre. The recorded outcomes were technical and clinical success, primary (assisted) patency, limb salvage, complications, and survival, in relation to the clinical grade of disease (intermittent claudication or critical limb ischemia [CLI] or mixed) and location of lesion (femoropopliteal, crural, or mixed). Twenty-three cohort studies including a total of 1549 patients (range, 27 to 148) were included in this review. Methodological and reporting quality were moderate, e.g., there was selection bias and reporting was not done according to the reporting standards. These and significant clinical heterogeneity obstructed a meta-analysis. Reports about length of the lesion and TASC classification were too various to summarize or were not mentioned at all. The technical success rates varied between 80% and 90%, with lower rates for crural lesions compared with femoral lesions. Complication rates ranged between 8% and 17% and most complications were minor. After 1 year, clinical success was between 50% and 70%, primary patency was around 50% and limb salvage varied from 80% to 90%. In conclusion, taking into account the methodological shortcomings of the included studies, SA can play an important role in the treatment of peripheral arterial disease, especially in the case of critical limb ischemia. Despite the moderate patency rates after one year, SA may serve as a “temporary bypass” to provide wound healing and limb salvage.
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Affiliation(s)
- Rosemarie Met
- Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Verta MJ, Schneider JR, Alonzo MJ, Hahn D. Percutaneous Viabahn-assisted Subintimal Recanalization for Severe Superficial Femoral Artery Occlusive Disease. J Vasc Interv Radiol 2008; 19:493-8. [DOI: 10.1016/j.jvir.2007.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 11/27/2007] [Accepted: 11/28/2007] [Indexed: 10/22/2022] Open
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Vogel TR, Symons RG, Flum DR. A Population-Level Analysis: The Influence of Hospital Type on Trends in Use and Outcomes of Lower Extremity Angioplasty. Vasc Endovascular Surg 2008; 42:12-8. [DOI: 10.1177/1538574407308203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The use of infrainguinal percutaneous transluminal angioplasty (PTA) has increased, but patterns of use have not been well studied. Academic institutions (AIs) and nonacademic institutions (NAIs) may have developed different practice patterns and may have different associated outcomes. Methods A retrospective statewide population-based administrative database was evaluated for patients undergoing PTA (1997-2004). Results A total of 1718 patients underwent PTA for claudication (51.9%), rest pain (12.1%), and ulceration or gangrene (23.1%). The use of infrainguinal stents (62.4% vs 60.8%), elective procedures (76.3% vs 79.8%), in-hospital death (1.6% vs 2.2%), 30-day mortality (2.1% vs 3.3%), readmission rates (17.1% vs 15.9%), and reintervention rates after readmission (38.5% vs 42.9%) were similar between groups. Increased use of PTA was noted in AIs versus NAIs (239.5% vs 53.9%). AIs were significantly less likely to perform PTA for rest pain (7.5% vs 14.4%, P < .05). Conclusion AIs had a more recent increase in the use of PTA, but less often used PTA for patients with rest pain compared with NAIs. Both center types had higher than expected 30-day readmission and reintervention rates. Further understanding of the implementation and associated outcomes of PTA is required.
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Affiliation(s)
- Todd R. Vogel
- Robert Wood Johnson Medical School, Division of Vascular Surgery, New Brunswick, New Jersey,
| | - Rebbecca G. Symons
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
| | - Dave R. Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
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Increased Endovascular Interventions Decrease the Rate of Lower Limb Artery Bypass Operations without an Increase in Major Amputation Rate. Ann Vasc Surg 2008; 22:195-9. [DOI: 10.1016/j.avsg.2007.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 11/12/2007] [Accepted: 12/20/2007] [Indexed: 11/19/2022]
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Wester T, Jørgensen JJ, Stranden E, Sandbæk G, Tjønnfjord G, Bay D, Kollerøs D, Kroese AJ, Brinchmann JE. Treatment with Autologous Bone Marrow Mononuclear Cells in Patients with Critical Lower Limb Ischaemia. A Pilot Study. Scand J Surg 2008; 97:56-62. [DOI: 10.1177/145749690809700108] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Aims: Treatment with autologous, bone marrow mononuclear stem cells has shown effects in patients with chronic limb ischaemia in one randomized clinical study. The aim of the study was to test the potential effect of stem cell treatment in a strict defined group of patients with stable critical limb ischaemia (CLI). Design: A prospective, combined-centre pilot study. Material: Eight patients with CLI of the lower extremities, and without any other treatment options. Methods: Bone marrow cells were harvested from the patient's iliac crest and, after separation, injected into the calf muscles of the affected leg. Outcome was evaluated by digital subtraction angiography (DSA), visual analogue scale (VAS) and several non-invasive circulatory physiological tests. Results: There were no complications from the procedures. Two patients were amputated two months after cell injection. Five patients reported pain relief after four months. Five patients could be evaluated at eight months. According to VAS and physiological tests, they were all either stable or showed improvement. Conclusion: This method seems to be a safe option for treating patients with CLI. Inclusion of patients took a long time, mainly because many patients with CLI are offered endovascular treatment in our institution. While symptomatic improvement was found in individual patients, larger trials are required to investigate efficacy. This will probably require multi-centre participation.
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Affiliation(s)
- T. Wester
- Department of Vascular Surgery, Aker University Hospital
| | | | - E. Stranden
- Department of Vascular Diagnosis and Research, Aker University Hospital
| | - G. Sandbæk
- Department of Radiology, Oslo Vascular Centre, Aker University Hospital
| | - G. Tjønnfjord
- Department of Immunology, Rikshospitalet-Radiumhospitalet Medical Centre, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - D. Bay
- Department of Radiology, Oslo Vascular Centre, Aker University Hospital
| | - D. Kollerøs
- Department of Anaesthesiology, Aker University Hospital
| | - A. J. Kroese
- Department of Vascular Surgery, Aker University Hospital
| | - J. E. Brinchmann
- Department of Immunology, Rikshospitalet-Radiumhospitalet Medical Centre, Faculty of Medicine, University of Oslo, Oslo, Norway
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Tartari S, Zattoni L, Rizzati R, Aliberti C, Capello K, Sacco A, Mollo F, Benea G. Subintimal Angioplasty as the First-Choice Revascularization Technique for Infrainguinal Arterial Occlusions in Patients with Critical Limb Ischemia. Ann Vasc Surg 2007; 21:819-28. [DOI: 10.1016/j.avsg.2007.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 05/29/2007] [Accepted: 07/16/2007] [Indexed: 10/21/2022]
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Scott EC, Biuckians A, Light RE, Scibelli CD, Milner TP, Meier GH, Panneton JM. Subintimal angioplasty for the treatment of claudication and critical limb ischemia: 3-year results. J Vasc Surg 2007; 46:959-64. [PMID: 17905560 DOI: 10.1016/j.jvs.2007.06.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 06/11/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Subintimal angioplasty (SIA) is an increasingly used method of lower extremity revascularization for patients with chronic arterial occlusions. To assess the technical feasibility, safety, and 3-year outcomes of patients treated with SIA, we performed a retrospective review of our early experience. METHODS Patient information-including demographics, indications, procedures, noninvasive arterial studies, and postprocedural events-was recorded in a database. Outcomes were determined on an intention-to-treat basis, as well as by technical success, by using Kaplan-Meier survival analysis. Continuous data were compared by using the Student t test, and survival curves were compared by log-rank testing. RESULTS From December 2002 through December 2003, 104 patients (105 limbs) underwent SIA of 159 occlusive lesions involving the iliac (n = 10), superficial femoral (n = 85), popliteal (n = 48), or tibial (n = 16) arteries. Sixty-six (62.9%) patients were treated for critical limb ischemia, and 39 patients (37.1%) were treated for disabling claudication. Technical success was achieved in 91 procedures (86.7%) and resulted in a mean increase in ankle-brachial index of 0.36 +/- 0.16. The mean follow-up was 23.4 months (range, 0-46 months). During this period, 18 patients (17.0%) died, and 15 amputations (14.3%) were performed, 6 of which were performed for patients on whom SIA had been unsuccessful. In patients undergoing successful SIA, the primary patency was 55%, 43%, and 35% at 12, 24, and 36 months, respectively. Twenty-one patients underwent a total of 23 percutaneous procedures to maintain or restore patency of the SIA during the study period. This resulted in secondary patency rates of 71%, 63%, and 51% at 12, 24, and 36 months, respectively. Multivariate analysis revealed critical limb ischemia to be the only predictor of reduced primary patency. Fifteen patients with inoperable critical limb ischemia underwent successful SIA. Limb salvage in this group was 54% and 43% at 12 and 36 months, respectively. Limb salvage in operative candidates was 100% and 88% at the same intervals. In patients with disabling claudication, 94% experienced improvement in symptoms 3 months after the procedure, and 68% of patients reported sustained improvement at 36 months. In all operative candidates successfully treated with SIA, freedom from surgical bypass was 83% and 73% at 12 and 36 months, respectively. CONCLUSIONS SIA for the treatment of lower extremity chronic arterial occlusions is technically feasible, results in minimal morbidity, and provides satisfactory revascularization without surgical bypass. Secondary patency is comparable to that of autologous vein bypass and is achieved with a low rate of reintervention. When used as first-line therapy, SIA provides most patients with limb salvage and freedom from surgical bypass at 3 years.
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Affiliation(s)
- Eric C Scott
- Division of Vascular Surgery, Eastern Virginia Medical School, Vascular & Transpalnt Specialists, Sentara Heart Hospital, Norfolk, VA 23507, USA
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Kakani N, Travis S, Hancock J. Recanalization of an Occluded Infrainguinal Vein Graft Complicated by Graft Aneurysm. Cardiovasc Intervent Radiol 2007; 30:1271-3. [PMID: 17671811 DOI: 10.1007/s00270-007-9106-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The technique of subintimal angioplasty has been described for the recanalisation of native vessels after occlusion of infrainguinal vascular bypass grafts. We report a case in which an attempt at such treatment resulted in inadvertent but successful recanalisation of the occluded vein graft instead. This was complicated by graft perforation and subsequent graft aneurysm which was successfully treated with a covered stent.
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Affiliation(s)
- Nirmal Kakani
- Department of Clinical Imaging, Royal Cornwall Hospital, Cornwall, UK
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Åkesson M, Riva L, Ivancev K, Uher P, Lundell A, Malina M. Subintimal Angioplasty of Infrainguinal Arterial Occlusions for Critical Limb Ischemia:Long-term Patency and Clinical Efficacy. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[444:saoiao]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ko YG, Kim JS, Choi DH, Jang Y, Shim WH. Improved Technical Success and Midterm Patency with Subintimal Angioplasty Compared to Intraluminal Angioplasty in Long Femoropopliteal Occlusions. J Endovasc Ther 2007; 14:374-81. [PMID: 17723006 DOI: 10.1583/06-1983.1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare the efficacy of subintimal angioplasty combined with primary stenting to intraluminal angioplasty with stenting for revascularization of long (>10 cm) femoropopliteal arterial occlusions. METHODS Baseline characteristics and outcomes of 52 patients (40 men; mean age 65.6+/-9.7 years) with superficial femoral artery (SFA) occlusions in 61 limbs (mean occlusion length 22.7+/-9.9 cm) treated with subintimal angioplasty and primary stenting were compared with a 54-patient control group (46 men; mean age 64.8+/-8.2 years) from our registry database who had intraluminal angioplasty with stenting in 60 limbs (mean occlusion length 22.0+/-8.5 cm). RESULTS All baseline clinical and angiographic characteristics showed no differences. In all patients, at least 1 self-expanding nitinol stent was implanted. Subintimal angioplasty was successful in 58 (95.1%) of 61 limbs, whereas technical success for the conventional approach was 86.7% (52/60 limbs; p = 0.11). In both groups, there were no major complications requiring surgery. Primary patency at 12 months for successful cases was 76.4% for subintimal angioplasty and 59.2% for conventional angioplasty (p = 0.06); on an intention-to-treat basis, including technical failures, the rates were 72.4% and 50.9%, respectively (p = 0.02). CONCLUSION Subintimal angioplasty combined with stenting was feasible, with a high technical success rate and better short and midterm results for revascularization of long femoropopliteal occlusions than the conventional intraluminal approach.
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Affiliation(s)
- Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea
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Lower extremity angioplasty for claudication: A population-level analysis of 30-day outcomes. J Vasc Surg 2007; 45:762-7. [DOI: 10.1016/j.jvs.2006.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 12/01/2006] [Indexed: 11/21/2022]
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Myers SI, Myers DJ, Ahmend A, Ramakrishnan V. Preliminary results of subintimal angioplasty for limb salvage in lower extremities with severe chronic ischemia and limb-threatening ischemia. J Vasc Surg 2006; 44:1239-46. [PMID: 17145425 DOI: 10.1016/j.jvs.2006.08.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 08/09/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study examined the hypothesis that superficial femoral artery (SFA) subintimal angioplasty (SI-PTA) can maintain limb salvage with minimal complications in patients with symptomatic occlusive arterial disease. METHODS From March 1, 2004, until April 28, 2006, 78 patients with rest pain (62.2%), gangrene (25.6%), or severe progressive claudication (12.2%) were treated consecutively with 82 SFA SI-PTAs (4 bilateral). The mean age was 59 +/- 1.2 years, and 21 (27%) of the patients were female. All patients were treated in the operating room under local anesthesia by using fluoroscopic guidance, and the percentage SFA that was occluded was measured during the diagnostic portion of the procedure. Selective stent placement was performed after successful recanalization of the occluded arterial segments. Patients were treated with chronic aspirin and clopidogrel bisulfate for 3 months and followed up at 30 days and then every 3 months with physical examination and arterial duplex scan. RESULTS Of the 82 SFA SI-PTA attempts, 76 (92%) were initially successful, with an increase in the ankle-brachial index from 0.46 +/- 0.02 to 0.88 +/- 0.01 (P < .001). Five of the six patients with a failed SFA SI-PTA were female, two of the six had had previous bypass attempts, and one of the six had had a previous SFA SI-PTA attempt by another physician. Forty-nine (64%) of the 76 initially successful SFA SI-PTAs required placement of a stent, and 43 (56.5%) of the successful 76 SFA SI-PTAs required additional PTA of 1 or more arterial segments. The group treated with a successful SFA SI-PTA had 42.5% +/- 3.5% SFA occlusion, compared with 82% +/- 10% (P < .05) in the group with a failed attempt at SFA SI-PTA. Two of the six patients with initial SI-PTA failure underwent leg amputation within 30 days, three were treated with successful leg bypass surgery, and one was lost to follow-up. Of the 76 successful SFA SI-PTAs, 5 (6.5%) failed within 90 days, and the patients were treated successfully with leg bypass surgery. Of the 71 limbs with patent SI-PTAs at 90 days, 68 have remained patent with a mean follow-up 10.4 +/- 0.7 months (range, 2-24 months). Three of the 71 SFA SI-PTAs failed between 4 and 7 months (mean, 5 +/- 0.7 months): 1 patient was treated with successful bypass surgery, 1 patient is currently considering further intervention, and 1 patient was treated with amputation. Ten (14%) of the 71 successful SFA SI-PTAs required limited PTA for asymptomatic restenosis, as identified by the arterial duplex scan (7.4 +/- 1.4 months; range, 2-16 months). There were no perioperative deaths, and three patients have died during follow-up with patent SFA SI-PTAs (9.3 +/- 1.4 months). CONCLUSIONS These data suggest that SFA SI-PTA can be successfully used for limb salvage with minimal morbidity and mortality in a group of patients with severe lower extremity occlusive vascular disease.
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Affiliation(s)
- Stuart I Myers
- McGuire Research Institute/McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA.
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Cho SK, Do YS, Shin SW, Park KB, Kim DI, Kim YW, Kim DK, Choo SW, Choo IW. Subintimal angioplasty in the treatment of chronic lower limb ischemia. Korean J Radiol 2006; 7:131-8. [PMID: 16799274 PMCID: PMC2667586 DOI: 10.3348/kjr.2006.7.2.131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To present our experience with subintimal angioplasty (SA) for treatment of chronic lower limb ischemia (CLLI) and to assess its effectiveness and durability. Materials and Methods From April 2003 through June 2005, we treated 40 limbs in 36 patients with CLLI by SA. Balloons with or without secondary stent placement appropriate in size to the occluded arteries were used for SA of all lesions, except for iliac lesions where primary stent placement was done. The patients were followed for 1-23 months by clinical examination and color Doppler ultrasound and/or CT angiography. Technical results and outcomes were retrospectively evaluated. The presence of a steep learning curve for performance of SA was also evaluated. Primary and secondary patencies were determined using Kaplan-Meier analysis. Results Technical success was achieved in 32 (80%) of 40 limbs. There was no statistical difference between technical success rates of 75% (18/24) during the first year and 88% (14/16) thereafter. There were four complications (10%) in 40 procedures; two arterial perforations, one pseudoaneurysm at the puncture site, and one delayed hematoma at the SA site. Excluding initial technical failures, the primary patency rates at six and 12 months were 68% and 55%, respectively. Secondary patency rates at six and 12 months were 73% and 59%, respectively. Conclusion Subintimal angioplasty can be accomplished with a high technical success rate. It should be attempted in patients with CLLI as an alternative to more extended surgery, or when surgical treatment is not recommended due to comorbidity or an unfavorable disease pattern.
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Affiliation(s)
- Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Dong-Ik Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Young Wook Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Duk-Kyung Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Sung Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - In Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
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Aarts F, Blankensteijn JD, van der Vliet JA, Kool LJS. Subintimal Angioplasty of Supra- and Infrageniculate Arteries. Ann Vasc Surg 2006; 20:620-4. [PMID: 16802210 DOI: 10.1007/s10016-006-9105-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 04/13/2006] [Accepted: 05/22/2006] [Indexed: 10/24/2022]
Abstract
We retrospectively reviewed our experience with subintimal angioplasty for chronic limb ischemia. Hospital records and films of all subintimal angioplasty procedures performed between October 2002 and December 2004 were reviewed and analyzed for demographic data, clinical data, and comorbid condition status. Thirty-nine subintimal angioplasties were performed in 37 patients (65% male, 35% female), with a median age of 73 years. Median follow-up was 9 months. The 30-day mortality rate was 8%. All-cause mortality was 33% after 24 months. In 23 cases (59%), a subintimal angioplasty of the superficial femoral artery (SFA) alone was performed. Both the SFA and popliteal/crural vessels were used in nine limbs (23%), the popliteal artery alone in three limbs (8%), and the crural arteries alone in four limbs (10%). Initial technical and clinical success rates were 67% and 49%, respectively. The complication rate was 28%. Twenty-four additional surgical interventions were performed after the initial angioplasty procedure, of which 12 were major amputations. Amputation-free survival (limb-salvage rate) was 69% at 12 months [95% confidence interval (CI) 52-85%], and overall survival was 69% (95% CI 52-85%) at 12 months. In patients with critical limb ischemia, subintimal angioplasty is feasible and in most cases technically successful. In these high-risk patients, often with combined cardiac, pulmonary, and diabetic risk and considered unfit for bypass surgery, subintimal angioplasty offers a safe and effective alternative.
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Affiliation(s)
- F Aarts
- Department of Vascular Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Kim JS, Kang TS, Ahn CM, Ko YG, Choi D, Jang Y, Chung N, Shim WH, Cho SY. Efficacy of Subintimal Angioplasty/Stent Implantation for Long, Multisegmental Lower Limb Occlusive Lesions in Patients Unsuitable for Surgery. J Endovasc Ther 2006; 13:514-21. [PMID: 16928168 DOI: 10.1583/05-1798mr.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the feasibility and clinical outcomes of subintimal angioplasty combined with stent implantation in patients with long, multisegmental occlusive lesions unsuitable for surgical treatment. METHODS Between 2003 and 2005, 30 patients (23 men; mean age 68 years, range 49-82) with severe claudication (Rutherford category 3, n=12) or critical limb ischemia (CLI; Rutherford category 4 or 5, n=18) underwent subintimal angioplasty with primary stenting for long (mean 28+/-11 cm) total occlusion in the lower limb arteries. Bypass surgery was considered unsuitable owing to inappropriate anatomy or poor distal runoff in 14 (47%) patients, severe coronary artery disease 14 (47%), or poor general condition in 2 (6%). RESULTS Technical success was achieved in 27 (90%) of 30 cases. The 3 technical failures were due to inability to advance the wire, to re-enter the distal lumen, and vessel rupture, respectively. Three (10%) complications occurred (1 perforation, 2 hematomas) but did not require surgery. After a mean follow-up of 13+/-7 months (range 3-28), 10 (37%) cases of restenosis were found in 27 patients. At 12 months, the primary patency rate was 52%, and the limb salvage rate was 83%. CONCLUSION Combined use of subintimal angioplasty and stent implantation was performed safely, with a relatively high success rate and acceptable intermediate-term clinical outcomes in patients with multisegmental, long occlusions of the lower limb arteries. Therefore, this strategy can be considered an option for symptomatic relief and limb salvage in patients unsuitable for bypass surgery due to various reasons.
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Affiliation(s)
- Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea
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Treiman GS, Treiman R, Whiting J. Results of percutaneous subintimal angioplasty using routine stenting. J Vasc Surg 2006; 43:513-9. [PMID: 16520165 DOI: 10.1016/j.jvs.2005.11.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Accepted: 11/10/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the long-term patency and clinical success of subintimal angioplasty in patients with limb-threatening ischemia. METHODS From 1999 through 2004, 29 patients with superficial femoral artery (SFA) or popliteal artery occlusion and rest pain or tissue loss underwent subintimal angioplasty. Patients had subintimal wire placement followed by percutaneous transluminal angioplasty and stent placement. From 1 to 10 stents were placed. Technical success required stenosis less than 30% by arteriography, a velocity ratio less than 1.5 by duplex scan, and improvement of the ankle-brachial index greater than 0.15. Follow-up duplex scanning was performed every 3 months for 2 years and then every 6 months thereafter. RESULTS Initial success was obtained in 26 (90%) of the 29 patients, with an improvement in the mean ankle-brachial index of 0.25. Mean follow-up was 38 months (range, 28-54 months). During follow-up, 16 arteries reoccluded. Six of the 16 patients had recurrent symptoms, four required below-knee amputation, two required above-knee amputation, and four died with an intact limb. After treatment failure, two patients had attempted tissue plasminogen activator (TPA), and four had prosthetic tibial bypass. Overall, 15 patients died, and only 2 of the 14 who lived had a patent artery. One of the two required percutaneous transluminal angioplasty of the recanalized artery. By life-table analysis, success was 85%, 64%, 18%, and 9% at 1, 2, 3, and 4 years, respectively. Periprocedural complications occurred in four patients. Of the 13 patients with wounds, six died (four healed), two were alive with healed wounds, and five had limb loss. Of 16 patients with rest pain, 14 developed recurrent symptoms after reocclusion, 1 was alive without pain, and 1 underwent amputation. CONCLUSIONS Subintimal angioplasty is technically successful in most patients, with few complications. Most procedures provide short-term clinical success and have allowed for successful wound healing and temporary relief of rest pain. However, late arterial patency is poor, with a high rate of symptom recurrence. Many patients will have recurrent pain, and some will require major amputation. Nevertheless, limb-salvage rates are significantly better than arterial patency. Intermediate-term patency is higher than that commonly reported for prosthetic bypass, and despite the lack of durable long-term patency, the procedure offers an additional potentially effective therapeutic option in the treatment of patients with limb-threatening ischemia and femoropopliteal occlusion.
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Affiliation(s)
- Gerald S Treiman
- Department of Surgery, University of Utah School of Medicine, Section of Vascular Surgery, Salt Lake City, Utah, USA.
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Devalia K, Magee TR, Galland RB. Remote Superficial Femoral Endarterectomy: Long-term Results. Eur J Vasc Endovasc Surg 2006; 31:262-5. [PMID: 16359885 DOI: 10.1016/j.ejvs.2005.10.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2005] [Accepted: 10/11/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to determine long-term results following successful remote superficial femoral endarterectomy (RSFE). METHODS RSFE is a minimally invasive technique of revascularising the superficial femoral artery. A single incision was made over the origin of the superficial femoral artery. The endarterectomy was carried out in a closed fashion from above. The cut end of distal atheroma was secured with a stent. Following RSFE patients were followed up with intravenous digital subtraction angiography (IVDSA) and 3-monthly duplex scans. IVDSA was repeated if any abnormality was found. RESULTS RSFE was attempted on 30 patients with 33 symptomatic legs to treat tissue loss (n = 3), rest pain (n = 3) or intermittent claudication (n = 27). In 26 limbs it was possible to complete the RSFE satisfactorily (technical success 79%), but during follow-up 18 later developed stenoses. Of 31 stenoses detected, 27 were treated by angioplasty. Primary patency at 1, 2 and 5 years was 38, 31 and 16%, respectively. Primary-assisted patency at 1, 2 and 5 years was 77, 65 and 60%. CONCLUSIONS Primary-assisted patency following RSFE is reasonable, however, it is only achieved with life-long surveillance and intervention. Until results can be improved the widespread use of RSFE cannot be recommended.
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Affiliation(s)
- K Devalia
- Department of Surgery, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK
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