Efficacy of Hemobahn® in the Treatment of Superficial Femoral Artery Lesions in Patients with Acute or Critical Ischemia: A Comparative Study with Claudicants

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ipsilateral Antegrade Angioplasty for Flush Superficial Femoral Artery Occlusion versus Open Bypass Surgery

BACKGROUND

Management of superficial femoral artery flush occlusion using the ipsilateral antegrade approach is challenging. The study aimed to assess technical feasibility, patency, and limb salvage of ipsilateral antegrade angioplasty versus surgery for this lesion in patients with lifestyle-limiting claudications and critical limb ischemia.

METHODS

Between June 2015 and March 2018, 53 patients were randomized to either ipsilateral antegrade angioplasty (n = 28) or surgical bypass (n = 25). We included patients with Trans-Atlantic Inter-Society Consensus IIB, C, or D lesions, having a patent popliteal artery. Technical success, patency, limb salvage, and major adverse events were assessed during the 12-month follow-up.

RESULTS

The technical success was 100% and 89.3% in the surgical and endovascular groups, respectively (P = 0.238). At 12 months, the primary, assisted, and secondary patency rates were 72% vs. 64.5%, 78.2% vs. 74.7%, and 81.6% vs. 74.2% in the surgical versus the endovascular groups, respectively, without significant differences between both groups. Limb salvage was 88% vs. 92% in the surgical versus the endovascular group, respectively (P = 0.564). The length of hospital stay was longer in the surgical versus the endovascular group (6.24 ± 0.37 vs. 1.84 ± 0.19 days, respectively, P = 0.001). Local complications were higher in the surgical group (P = 0.046).

CONCLUSIONS

Technical success, patency, and limb salvage of endovascular approach were comparable to surgical bypass. The endovascular approach had the advantages of reduced local complications and hospitalization.

Viabahn stent graft compared with prosthetic surgical above-knee bypass in treatment of superficial femoral artery disease: Long-term results of a retrospective analysis

The prosthetic surgical above-knee bypass (pAKB) is a standard therapy in superficial femoral artery (SFA) occlusive disease in absence of suitable vein. Viabahn graft has been established as a promising alternative. Since limited comparative data are available, we conducted a retrospective study to compare long-term outcomes of these 2 therapies in a real-world setting.Records of 52 patients (60 limbs), who were treated by pAKB (29 limbs) or Viabahn (31 limbs) were reviewed. Patients were followed up by clinical assessment, physical examination, and resting ankle brachial index (ABI) after 3, 6, 12 months and yearly thereafter. Long-term data were available for 97% in the Viabahn and 93% for pAKB after 73 ± 3.7 months (mean ± standard error [SE]).Long-term primary and secondary patencies in Viabahn group were 40% and 70%, respectively, after 63 ± 2.8 months (mean ± SE). Total lesion length was 19 ± 11.06 cm (mean ± SE), graft size was 6 ± 0.72 mm (mean ± SE). Hospital stay was 4.8 ± 0.72 days (mean ± SE). Limb salvage was achieved in 90%. Patients in the pAKB group showed a total lesion length of 24.39 ± 1.97 cm (mean ± SE), graft size was 7 ± 0.99 mm (mean ± SE). Long-term analysis after 83 ± 6.8 months (mean ± SE) revealed a primary patency of 78% with a secondary patency of 94%. Hospital stay was 10.4 ± 1.27 days (mean ± SE). Limb salvage was ensured in 97%. Long-term primary patency was lower for Viabahn (P = .044), secondary patency (P = .245), and leg salvage (P = .389) were not significantly different. However, hospital stay was shorter (P = .0002) for Viabahn.Long-term analysis of Viabahn revealed a significantly lower primary patency, a similar secondary patency, limb salvage, and significantly shorter hospital stay when compared with pAKB. Our data suggest that pAKB is still a valuable option in patients suitable for an open operation. However, Viabahn can be used as a less invasive treatment in high risk patients.

Effectiveness of Viabahn in the Treatment of Superficial Femoral Artery Occlusive Disease

Purpose: To evaluate the effectiveness of the Viabahn stent-graft in the treatment of superficial femoral artery (SFA) occlusive disease. Methods: A systematic review and meta-analysis of published studies was performed to evaluate the efficacy of the Viabahn for SFA lesions. Studies were stratified according to controlled vs uncontrolled design and analyzed using random-effects models. Outcomes are reported as the risk ratio (RR) and 95% confidence interval (CI). Four prospective randomized controlled trials, one retrospective controlled study, and 9 uncontrolled studies were identified. Results: In controlled studies, primary patency with the Viabahn was superior to other interventions at 1 year (RR 0.63, 95% CI 0.49 to 0.82, p<0.001) and ankle-brachial index (ABI) improvement was greater at 6 months (mean difference 0.05, 95% CI 0.01 to 0.09, p=0.01) compared with other interventions. Subgroup analysis demonstrated a lower incidence of stent fracture in lesions with >15-cm stented lengths. In uncontrolled studies, ABI improvement was consistently superior at all measurement points during follow-up. Conclusions: Current evidence suggests that the Viabahn stent-graft is a safe and effective option for symptomatic SFA lesions. Prospective multicenter randomized controlled trials with long-term follow-up are needed to confirm the sustained efficacy of the Viabahn device.

The impact of prolonged lower limb ischemia on amputation, mortality, and functional status: the FRIENDS registry

BACKGROUND

Peripheral artery disease (PAD) is a major cause of cardiovascular ischemic events and amputation. Knowledge gaps exist in defining and measuring key factors that predict these events. The objective of this study was to assess whether duration of limb ischemia would serve as a major predictor of limb and patient survival.

METHODS

The FReedom from Ischemic Events: New Dimensions for Survival (FRIENDS) registry enrolled consecutive patients with limb-threatening peripheral artery disease at a single tertiary care hospital. Demographic information, key clinical care time segments, functional status and use of revascularization, and pharmacotherapy data were collected at baseline, and vascular ischemic events, cardiovascular mortality, and all-cause mortality were recorded at 30 days and 1 year.

RESULTS

A total of 200 patients with median (interquartile range) age of 76 years (65-84 years) were enrolled in the registry. Median duration of limb ischemia was 0.75 days for acute limb ischemia (ALI) and 61 days for chronic critical limb ischemia (CLI). Duration of limb ischemia of <12, 12 to 24, and >24 hours in patients with ALI was associated with much higher rates of first amputation (P = .0002) and worse amputation-free survival (P = .037). No such associations were observed in patients with CLI.

CONCLUSIONS

For individuals with ischemic symptoms <14 days, prolonged limb ischemia is associated with higher 30-day and 1-year amputation, systemic ischemic event rates, and worse amputation-free survival. No such associations are evident for individuals with chronic CLI. These data imply that prompt diagnosis and revascularization might improve outcomes for patients with ALI.

Is There an Alternative to the Surgical Above-Knee Bypass in Treatment of Superficial Femoral Artery Disease? Experiences With Viabahn Stent Graft

Objective:

We conducted a retrospective study to compare short- and mid-term patencies of Viabahn with surgical above-knee prosthetic bypass (pAKB).

Methods:

The records of 52 patients with either pAKB (n = 25) or Viabahn (n = 27) were reviewed. The majority had Rutherford clinical grade 3. Patients were followed after 3, 6, and 12 months and yearly thereafter.

Results:

For Viabahn, the short-term (1-16 months) primary patency rate was 60% with a secondary patency rate of 90%, and mid-term (1-68 months) patencies of 47% and 83.3%, respectively. In pAKB, the short-term results revealed a primary patency rate of 78% with a secondary patency of 91% and mid-term results of 65% and 90%, respectively. No statistical difference was found concerning short-term patencies. Mid-term primary patency was lower for Viabahn ( P < .05) and secondary patency proved no significant difference.

Conclusion:

Viabahn revealed similar short-term primary and secondary patencies but lower mid-term primary patency. It provides a good alternative therapy to pAKB.

The BioStent: novel concept for a viable stent structure

OBJECTIVES

Percutaneous stenting of occluded peripheral vessels is a well-established technique in clinical practice. Unfortunately, the patency rates of small-caliber vessels after stenting remain unsatisfactory. The aim of the BioStent concept is to overcome in-stent restenosis by excluding the diseased vessel segment entirely from the blood stream, in addition to providing an intact endothelial cell layer.

DESIGN

The concept combines the principles of vascular tissue engineering with a self-expanding stent: casting of the stent within a cellularized fibrin gel structure, followed by bioreactor conditioning, allows complete integration of the stent within engineered tissue.

MATERIALS AND METHODS

Small-caliber BioStents (Ø=6 mm; n=4) were produced by casting a nitinol stent within a thin fibrin/vascular smooth muscle cell (vSMC) mixture, followed by luminal endothelial cell seeding, and conditioning of the BioStent within a bioreactor system. The potential remodeling of the fibrin component into tissue was analyzed using routine histological methods. Scanning electron microscopy was used to assess the luminal endothelial cell coverage following the conditioning phase and crimping of the stent.

RESULTS

The BioStent was shown to be noncytotoxic, with no significant effect on cell proliferation. Gross and microscopic analysis revealed complete integration of the nitinol component within a viable tissue structure. Hematoxylin and eosin staining revealed a homogenous distribution of vSMCs throughout the thickness of the BioStent, while a smooth, confluent luminal endothelial cell lining was evident and not significantly affected by the crimping/release process.

CONCLUSIONS

The BioStent concept is a platform technology offering a novel opportunity to generate a viable, self-expanding stent structure with a functional endothelial cell lining. This platform technology can be transferred to different applications depending on the luminal cell lining required.

Excimer laser with adjunctive balloon angioplasty and heparin-coated self-expanding stent grafts for the treatment of femoropopliteal artery in-stent restenosis: twelve-month results from the SALVAGE study

OBJECTIVES

The aim of the study is to evaluate the safety and effectiveness of treating femoropopliteal in-stent restenosis (ISR) with debulking with excimer laser followed by implantation of a VIABAHN endoprosthesis.

BACKGROUND

The optimal treatment strategy for femoropopliteal ISR is unclear.

METHODS

The SALVAGE study is a multicenter prospective registry involving nine US centers. Patients with femoropopliteal ISR with moderate to severe intermittent claudication or critical limb ischemia (Rutherford categories 2-5) and an ankle-brachial index (ABI) =0.8 were treated with excimer laser and the VIABAHN endoprosthesis. The primary efficacy endpoint is primary patency at 12 months as measured by duplex ultrasonography. The primary safety endpoint is the major adverse event (MAE) rate at 30 days.

RESULTS

Twenty-seven patients were enrolled. The mean lesion length was 20.7 ± 10.3 cm. The majority of lesions were TASC (TASC I) C and D (81.4%). All lesions were pretreated with excimer laser and percutaneous transluminal angioplasty (PTA) prior to VIABAHN implantation. Technical success was achieved in 100% of cases. There were no MAE at 30 days. Primary patency at 12 months was 48%. The ankle brachial index increased from 0.58 ± 0.24 at baseline to 0.90 ± 0.17 at 12 months. There was improvement in all quality-of-life parameters. The 12-month TLR rate was 17.4%.

CONCLUSIONS

The strategy of excimer laser atherectomy and PTA followed by implantation of a self-expanding stent graft for the treatment of femoropopliteal ISR is safe and associated with high procedural success. Primary patency rate at 12-months was suboptimal; however, the TLR rate was low.

Results With Viabahn-Assisted Subintimal Recanalization for TASC C and TASC D Superficial Femoral Artery Occlusive Disease

Objectives: Many investigators including TransAtlantic Inter-Society Consensus (TASC) recommend against primary endovascular treatment for severe (TASC C and D) superficial femoral artery (SFA) disease. Vein bypass is preferable but may not be appropriate due to comorbidities or lack of suitable vein. This study reviews our results with Viabahn stent graft-assisted subintimal recanalization (VASIR) for TASC C and D SFA atherosclerosis. Methods: In all, 13 males and 14 females, mean age 72 ± 11 years underwent 28 VASIR for severe (TASC C 8 of 28, TASC D 20 of 28, and 5 of 28 no continuous infrapopliteal runoff artery) SFA disease. Indications were claudication (14 of 28 limbs), ischemic rest pain (6 of 28), and tissue loss (8 of 28). Viabahn stent graft-assisted subintimal recanalization was chosen instead of bypass due to comorbidities or lack of vein. Patients received aspirin and, if not already taking warfarin, they also received clopidogrel. Patients were examined with Ankle-brachial Index (ABI) and duplex scan at 1 month, then every 3 months after VASIR. Results Viabahn stent graft-assisted subintimal recanalization was technically successful in all. Ankle-brachial Index averaged 0.47 ± 0.17 preprocedure, 0.89 ± 0.20 postprocedure, and increased by 0.15 or more in every case. Median follow-up is 20 months. There were 3 perioperative (<30 days) and 7 later failures including revision prior to any thrombosis. One patient required amputation. Four have died, 2 with patent grafts, none from causes related to VASIR, all more than 30 days post-VASIR. Estimated 1-year primary and secondary patency were 70% ± 11% and 73% ± 10%. Failure was not significantly associated with indications, comorbidities, or runoff status. There was a clear distinction between patients with early failure and the rest of the patients. None of the 8 patients with failure in the first 8 months after surgery has a patent graft. However, of 17 grafts primarily patent at 8 months, only 2 have failed (1 thrombosed and 1 required preemptive balloon angioplasty). There was a strong trend toward better patency with 6 and 7 mm diameter compared to 5 mm diameter stent grafts. Furthermore, although warfarin was not prescribed as part of the protocol, no patient taking warfarin before and who resumed warfarin after VASIR (n = 4) suffered failure. Conclusions: Despite significant early failures, we found VASIR to be durable in those who did not have early failure. Viabahn stent graft-assisted subintimal recanalization is an acceptable alternative to vein bypass in selected patients with severe SFA disease. Smaller arterial or stent graft diameter may be associated with poorer results. Warfarin may be valuable to reduce the risk of failure after VASIR.

Evolving modalities for femoropopliteal interventions

Despite technical advances in balloon design and technique, there has been little improvement of primary patency rates after balloon-based endovascular interventions for all but focal femoropopliteal lesions. Improving on stainless steel models, nitinol stents have been associated with favorable short- and midterm primary patency rates; studies with longer-term follow-up will be required to learn whether restenosis is ongoing, with continued loss of primary patency. Studies in recent years have shown varying incidences of mechanical fatigue leading to nitinol stent fracture. Covered stents are designed to prevent the tissue infiltration and intimal hyperplasia that can lead to bare metal in-stent restenosis. Several clinical studies, mainly single-center registries, have demonstrated a general effectiveness of the Hemobahn/Viabahn polytetrafluoroethylene-covered stent-grafts, approved for femoral arterial occlusive disease, and have helped to distinguish indications for use and to delineate possible failure modes. A multicenter randomized trial, which has completed enrollment, will compare the Viabahn with self-expanding bare nitinol stents. The primary use of drug-eluting stents (DES) has become routine clinical practice for coronary artery disease. The 2-phase multicenter randomized double-blind SIROCCO trials have been completed, with results published through 24 months. Follow-up demonstrated the feasibility and safety of deploying sirolimus-eluting stents in the femoropopliteal segment but failed to show superior efficacy for DES versus bare nitinol stents. However, the restenosis rates with bare metal stents were unexpectedly low. A paclitaxel-eluting stent without a polymer coating is currently being evaluated in the recently enrolled Zilver PTX randomized trial and international registry. A polymer-based everolimus-eluting stent is being evaluated for femoropopliteal use in the nonrandomized European STRIDES trial. Balloons coated with paclitaxel have recently been evaluated for simple femoropopliteal disease with encouraging results through 2 years of follow-up. The bioabsorbable stent concept emerged in response to the potential issues with metal stents, but to date no investigational device has successfully overcome issues such as relatively low radial force and variable degradation rates.

PTFE bypass or thrupass for superficial femoral artery occlusion? A randomised controlled trial

Early results of a thrupass endograft in the treatment of femoral lesions are promising. Less morbidity and better cost-effectiveness are suggested to be achieved in the treatment of chronic lower limb ischaemia with endovascular treatment compared to surgical treatment.

PATIENTS AND METHODS

This randomised multicentre trial aimed to enroll a group of 60+60 patients for the treatment of 5-25-cm occlusions of superficial femoral artery (SFA) to be followed up for 3 years. Patients were treated either with endoluminal PTFE thrupass (WL Gore & Ass) or with surgical polytetrafluoroethylene (PTFE) bypass to proximal popliteal artery. Primary patency at 3 years was scheduled to be the primary end-point and secondary patency, functional success, costs and quality of life the secondary end-points.

RESULTS

A sample of 100 consecutive SFA occlusions in one of the centres revealed that only 4% of the lesions were amenable for the study. The trial was prematurely terminated due to the results of an interim analysis at the time when 44 patients were recruited: the 1-year primary patency (excluding technical failures) was 48% for thrupass and 95% for bypass (p=0.02). The patency difference in favour of surgical bypass over endovascular thrupass was also sustained after completion of 1-year follow-up, the primary patencies being 46% and 84% at 1 year with grossly equilinear life-table curves thereafter (p=0.18), respectively. The corresponding secondary patencies were 63% and 100% (p=0.05) when excluding technical failures and 58% and 100% (p=0.02) according to intention-to-treat analysis. Secondary outcomes were thus not analysed.

CONCLUSION

Treatment of SFA occlusions (TASC IIB and C or Imelda Ia and II) should be done by PTFE bypass rather than by PTFE thrupass, as thrupass is connected with worse early outcome. These results represent only a small category of femoral disease.

Randomized, multicenter study comparing expanded polytetrafluoroethylene-covered endoprosthesis placement with percutaneous transluminal angioplasty in the treatment of superficial femoral artery occlusive disease

PURPOSE

To compare the safety and effectiveness of the Viabahn endoprosthesis with that of percutaneous transluminal angioplasty (PTA) alone in the treatment of symptomatic peripheral arterial disease (PAD) affecting the superficial femoral artery (SFA).

MATERIALS AND METHODS

From 1998 to 1999, patients with symptomatic SFA PAD were enrolled in a prospective, multicenter randomized study and underwent either PTA alone (n = 100) or PTA followed by stent-graft placement (expanded polytetrafluoroethylene/nitinol self-expanding stent-graft) (n = 97) for stenoses or occlusions of the SFA that were 13 cm long or shorter. At baseline, there were no significant differences between the PTA and stent-graft treatment groups, including chronic limb ischemia status and treated lesion length.

RESULTS

The stent-graft group had a significantly higher technical success rate (95% vs 66%, P < .0001) and 1-year primary vessel patency rate at duplex ultrasonography (65% vs 40%, P = .0003). A patency benefit was seen for lesions at least 3 cm long. At 12 months, chronic limb ischemia status was 15% further improved for the stent-graft group (P = .003). There were no significant differences between treatment groups with regard to the occurrence of early or late major adverse events.

CONCLUSIONS

In this multicenter study, the patency, technical success, and clinical status results obtained with stent-grafts were superior to those obtained with PTA alone.

Endovascular treatment of long lesions of the superficial femoral artery: results from a multicenter registry of a spiral, covered polytetrafluoroethylene stent

OBJECTIVE

Information on outcome of patients with long superficial femoral artery (SFA) obstruction undergoing endovascular treatment is scarce. The present study reports results from a prospective multicenter registry designed to evaluate the safety, effectiveness, and patency of the aSpire self-expanding polytetrafluoroethylene covered stent (Vascular Architects Inc, San Jose, Calif) in patients with femoropopliteal occlusive disease.

METHOD

The aSpire Registry included 150 patients (166 limbs) enrolled in 16 centers during a 28-month period (2003 to 2005) for medium/long (>3 cm) occlusion (n = 115) or stenosis (n = 51) of the SFA (n = 51) or of the proximal popliteal (n = 115) arteries. Procedures were performed for intermittent claudication in 92, for rest pain in 33, and for limb savage in 41. The mean length of arterial segment covered was 107.35 +/- 73.7 mm. Indications for treatment included 44 type B1, 57 type B2, 47 type C1, and 18 type D lesions according to TransAtlantic Inter-Society Consensus classification. Clinical and ultrasound evaluation was performed at discharge and at 1, 6, 12 months, and yearly thereafter. Mean follow-up was 13 months (range, 1 to 36). Primary end points were immediate technical success (vessel recanalization with residual stenosis < or =30%) and stent patency.

RESULTS

Initial technical success was obtained in 162 (97.6%) of 166 procedures. More than one stent was applied in 48 procedures, for a total of 214 stents. No periprocedural deaths occurred. Procedure-related complications occurred in 22 of 166 procedures, including 6 peripheral embolizations, 7 thromboses, 2 hemorrhages requiring revision, 1 vessel rupture, and 6 vessel dissections. Life-table estimates of primary patency at 12, 24, and 36 months were 64%, 59%, and 59%, respectively. Thirty-two reinterventions were performed during follow-up, resulting in secondary patency rates at 12, 24, and 36 months of 74.2%, 67%, and 67%, respectively. Amputation was required in six of 41 patients treated for limb salvage. At multivariate analysis, critical limb ischemia was the only significant predictor of late failure.

CONCLUSION

Endovascular treatment of SFA occlusive lesions provides interesting results. Length of lesion and clinical symptoms influence negatively the patency. The aSpire covered stent showed good mid-term results, but a number of reinterventions were necessary to obtain an optimal secondary patency. Risk of patency failure was related to critical limb ischemia as an indication for the procedure. Technologic and pharmacologic improvement and longer follow-up are needed to define the indications for the aSpire stent.

Increasing Endovascular Intervention for Claudication: Impact on Vascular Surgery Resident Training

PURPOSE

To audit the caseloads of vascular surgery residents in the management of disabling claudication and assess the influence of endovascular procedures on overall operative experience.

METHODS

A retrospective review was conducted of vascular surgery resident experience in the open and endovascular management of lower limb claudication during two 3-year periods (January 2000 to December 2002 and January 2003 to December 2005). The time periods differed with regard to number of surgical faculty with advanced endovascular skills (3 in the first period and 4 in the second) and the availability of portable operating room angiography equipment.

RESULTS

During the 6-year period, the operative logs of vascular surgery residents indicated participation in 283 procedures [170 (60%) open surgical interventions, including 146 suprainguinal procedures] performed for claudication. The number of procedures increased by 62% (p<0.05) from the first period (n=108) to the second (n=175). Endovascular intervention to treat aortoiliac occlusive disease increased 4-fold (14 versus 56 interventions, p=0.01) compared to a decrease in open (bypass grafting, endarterectomy) surgical repair (45 to 31 procedures, p=0.22). The greatest change in resident experience was in endovascular intervention of infrainguinal occlusive disease: the case volume increased from 4 to 39 procedures (p=0.07) during the 2 time intervals. By contrast, the number of open surgical bypass procedures was similar (45 versus 49) in each 3-year period.

CONCLUSION

An audit of resident experience demonstrated intervention for claudication has increased during the past 6 years. The increased operative experience reflects more endovascular treatment (atherectomy, angioplasty, stent-graft placement) of femoropopliteal and aortoiliac occlusive disease, but no decrease in open surgical operative experience for claudication. This increase in endovascular intervention may be related to a decrease in the threshold for intervention.

Value of the Hemobahn/Viabahn Endoprosthesis in the Treatment of Long Chronic Lesions of the Superficial Femoral Artery:6 Years of Experience

PURPOSE

To evaluate the long-term efficacy of Hemobahn/Viabahn endoprostheses (HVE) in patients with femoral arterial occlusive disease.

METHODS

During a 6-year period, 57 patients (46 men; mean age 62.7+/-9.3 years, range 44-82) were treated with 82 Hemobahn or Viabahn endoprostheses for stenoses (13%) or occlusions (87%) of the superficial femoral artery (SFA) in 60 limbs. The average length of the treated lesions was 10.7 cm (range 3-34), and the mean length of the HVE was 15.9 cm (3-33). Patients had chronic limb ischemia in Rutherford stages 2/3 (92%), 4 (2%), and 5 (7%). The crossover method was used to deploy the stent-graft in 31 cases and the ipsilateral technique in 29.

RESULTS

Endoprosthesis deployment was technically successful in 59 (98%) of 60 limbs. In 2 cases, major complications (1 deployment failure and 1 thromboembolism) required additional surgery. Early thrombosis (within 30 days) occurred in 6 (10%) femoral arteries. The mean follow-up was 55 months (8-78). Late thrombosis or reocclusion was observed in 22 (37%) arteries up to 5 years after prosthesis placement (14 in the first year). Primary/ secondary patency rates were 90%/95% at 30 days (n=59), 67%/81% at 1 year (n=58), 57%/ 80% after 3 years (n=49), and 45%/69% after 5 years (n=32). In a subgroup analysis of 48 patients with "optimal" conditions for implantation (no heavy calcifications, popliteal obstruction, or complete superficial femoral artery occlusion; minimum 1-vessel runoff; and adequate antiplatelet therapy or anticoagulation), the primary/secondary patency rates were 80%/91% after the first year (n=46), 71%/89% after 3 years (n=38), and 62%/90% after 5 years (n=21).

CONCLUSION

HVE seems to be suitable for femoral arterial occlusive disease so long as ideal indications and prophylaxis against secondary thrombosis are strictly observed.

Stenting in the Femoropopliteal Arterial Segment

In the femoropopliteal arterial segment, balloon angioplasty is a recommended treatment strategy for short lesions. Over the past few years, several reports have emerged on the potential role of self-expanding stents for treating longer, more complex disease segments where the patency following balloon angioplasty is notoriously dismal. This paper will attempt to review the emerging role of nitinol stents for treating patients with chronic lower limb ischemia, secondary to severe femoropopliteal arterial disease.

The Use of Femoropopliteal Stent-Grafts for Critical Limb Ischemia

Peripheral vascular disease of the femoropopliteal segment is one of the most common anatomic locations leading to patient symptoms. Traditional open surgical bypass has started to be supplanted by a surge in lower risk endovascular procedures. Though midterm results of endovascular therapy have been acceptable, longer term results, especially in long diffuse disease, appear to be less durable than their surgical alternatives. Recently the Viabahn, a percutaneously placed PTFE stent-graft, has been approved for use in the femoropopliteal artery. Though the majority of the data for this stent-graft has been derived from patients with complex (>10 cm length) lesions, most of the patients have been claudicants. The population with critical limb ischemia is at particularly high risk for cardiovascular mortality and may benefit from this less invasive approach. However, stent-graft utilization is more complex and many variables must be evaluated before and during the procedure to allow for optimal procedural outcomes.