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Cheun TJ, Davies MG. Influence of a Novel Morphology-Driven Classification on Limb Salvage after Isolated Tibial Intervention for Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00234-6. [PMID: 38815911 DOI: 10.1016/j.avsg.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI. METHODS A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated Infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300mm (1 point) and poor pedal runoff score (1 point). Patients were then divided into three groups: low-risk (0 or 1 points), moderate-risk (2 points), and high-risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-orientated outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated. RESULTS 1607 patients (55% male, average age 60 years, 3846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic. origin Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day Major Amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate-risk and high-risk exceeded the goal threshold. For the OPG. Freedom from MALE was 60±5%, 46±5%, and 22±9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± SEM; p =0.008. Overall amputation-free survival (AFS) was 55±5%, 37±6%, and 18±7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± SEM; p=0.003). CONCLUSIONS Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.
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Affiliation(s)
- Tracey J Cheun
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, Texas; Department of Anesthesia, Long School of Medicine, San Antonio, Texas
| | - Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, Texas; Department of Vascular/Endovascular Surgery, Ascension Health, Waco, Texas.
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Liu P, Zheng LH, He XQ, Yang Y, Zhang LK, Zhang L, Zhang F. Mid-Term Outcomes of Endovascular Therapy for TASC II D Femoropopliteal Lesions with Critical Limb Ischaemia: A Retrospective Analysis. Ann Vasc Surg 2022; 88:182-190. [PMID: 36007776 DOI: 10.1016/j.avsg.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/17/2022] [Accepted: 08/07/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Peng Liu
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Li-Hua Zheng
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Xin-Qi He
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Yan Yang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Li-Ke Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Lei Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Feng Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China.
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Significance of Distal Runoff Score as a Key Influencer on Clinical Outcomes after Endovascular Interventions for Superficial Femoral Artery Disease. Ann Vasc Surg 2020; 73:234-243. [PMID: 33359690 DOI: 10.1016/j.avsg.2020.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Endovascular therapy (EVT) is being adopted by many surgeons as a suitable first choice in the treatment of most femoropopliteal disease when clinically indicated. However, there are multiple factors affecting the outcome of EVT including the anatomy of lesions and distal runoff status. The evidence of runoff effect on the outcome of superficial femoral artery (SFA) interventions is still scarce and not well studied in the current literature. The aim of this study was to investigate the effect of runoff score on the outcomes of SFA endovascular interventions. METHODS Retrospective analysis was carried out on prospectively collected data on patients who underwent SFA endovascular intervention for critical limb ischemia (CLI) in a single tertiary center. Patients with Rutherford categories 4, 5, and 6 who did not have any previous vascular interventions were included in the study. The modified SVS runoff score was used after calculating scores from popliteal and all tibial vessels. Runoff was stratified into good (score <5), compromised (score 5-10), and poor (score >10). Amputation-free survival, patency rates, and overall survival were compared between all groups at 5 years. RESULTS Between 2011 and 2018, 254 procedures were performed in 220 patients. Technical success was >92%; 66 patients required SFA stents, and 55 had concomitant tibial angioplasty. There was no significant difference between good, compromised, or poor runoff groups regarding complication rates, with 3.5% overall perioperative mortality (5 cases in the compromised group and 4 in the poor runoff group). A runoff score of <5 was associated with significantly marked clinical improvement (P < 0.001). Patency rates were significantly worse in the compromised and poor runoff groups, with 5-year cumulative primary patency rates of 80%, 50%, and 22% in the good, compromised, and poor runoff groups, respectively (P < 0.001). Amputation-free survival worsened as the runoff got poorer with 98%, 91%, and 78% in the good, compromised, and poor runoff groups, respectively, at 5 years (P < 0.001). SFA stenting and concomitant tibial angioplasty led to slight improvement in patency rates in the poor runoff group. CONCLUSIONS Poor runoff with a score of >10 was associated with significantly reduced amputation-free survival and patency rates at 5 years in patients undergoing SFA endovascular intervention for CLI. Patients with a runoff score of <5 showed marked clinical improvement postoperatively when compared with patients with a runoff score of ≥5.
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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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Watanabe Y, Hozawa K, Hiroyoshi K, Naganuma T, Ishiguro H, Nakamura S. The Importance of Patency of Tibial Run Off Arteries on Clinical Outcomes After Stenting for Chronic Total Occlusions in the Superficial Femoro-popliteal Artery. Eur J Vasc Endovasc Surg 2018; 56:857-863. [DOI: 10.1016/j.ejvs.2018.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 08/01/2018] [Indexed: 12/28/2022]
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Morphological characteristics of chronic total occlusion: predictors of different strategies for long-segment femoral arterial occlusions. Eur Radiol 2017; 28:897-909. [DOI: 10.1007/s00330-017-5003-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/16/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
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Abstract
The estimated prevalence of diabetes is 9.78% in Taiwan. The lifetime risk for patients with diabetes to have foot ulcers might be as high as 25%. About 15% of these patients require major limb amputation because of ischemia and infection. Peripheral artery disease is still a major problem involved in diabetic foot disease and the cause for major amputation despite an increase in the prevalence of revascularization surgery and new revascularization techniques over the past 20 years. We investigated the major limb amputation rates in patients with diabetic foot and critical limb ischemia who had undergone revascularization surgery in our hospital. The records of 42 patients who had undergone revascularization surgery for diabetic foot were retrospectively reviewed. Nineteen patients (45%) required major limb amputation despite revascularization. The affected limbs of only 15 patients (36%) were salvaged. Four patients died soon after surgery because of comorbidities, and another 4 were lost to follow-up. Two patients died from procedure-related sepsis, and overall perioperative mortality was 4.8%. Ten predictive risk factors (duration of diabetes, history of smoking, coronary artery disease, congestive heart failure, cerebral vascular accident, contralateral amputation, end-stage renal disease, fever episode, wound infection severity score, and arterial obstruction level) were included for analysis. Although none was significant, long-duration diabetes (OR: 1.13), end-stage renal disease (OR: 10.02), wound infection (OR: 1.56), and infrapopliteal lesions (OR: 3.00) tended to be unfavorable predictive risk factors of limb amputation. Revascularization surgery is still potentially beneficial for these patients--eg, it decreases the contralateral limb amputation rate by 7.5%--if done early in high-risk patients.
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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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Mathur K, Ayyappan MK, Hodson J, Hopkins J, Tiwari A, Duddy M, Vohra R. Factors Affecting Medium-Term Outcomes After Crural Angioplasty in Critically Ischemic Legs. Vasc Endovascular Surg 2015; 49:63-8. [DOI: 10.1177/1538574415591001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To study factors affecting patency and medium-term outcomes after crural angioplasty. Materials and Methods: All crural angioplasties between March 2003 and September 2010 were reviewed from a prospective database to analyze primary patency, amputation-free survival, and limb salvage. Results: Five hundred and twenty-seven limbs in 478 patients (58.7% male, mean age 73.9 ± 0.53 years) were treated. In all, 49.1% were diabetic patients and 7.4% were dialysis dependent. Primary patency was 65.5%, 57.8%, 48.5%, and 32.9% at 1, 6, 12, and 36 months, respectively. Amputation-free survival was 75.2% at 1 year and 59.0% at 3 years. Limb salvage at 3 years was 92.7%. Rutherford categories 5 and 6 had a consistent adverse effect on patency. This led to an adverse amputation-free survival and limb salvage at 3 years. Conclusion: Crural angioplasty is an effective treatment for limb salvage. Its outcomes are adversely affected by diabetes, renal disease, coronary disease, and worsening Rutherford grade.
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Affiliation(s)
- K. Mathur
- Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - M. K. Ayyappan
- Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - J. Hodson
- Wolfson Computer Laboratory, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - J. Hopkins
- Department of Interventional Vascular Radiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - A. Tiwari
- Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - M. Duddy
- Department of Interventional Vascular Radiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Rajiv Vohra
- Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Guo X, Xue G, Huang X, Xie H, Liang W, Zhang J, Lin F, Yao T. Outcomes of endovascular treatment for patients with TASC II D femoropopliteal occlusive disease: a single center study. BMC Cardiovasc Disord 2015; 15:44. [PMID: 26022244 PMCID: PMC4453767 DOI: 10.1186/s12872-015-0025-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 04/21/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Advances in endovascular technology led to an alternative treatment option for TASC II D (TransAtlantic Inter-Society Consensus II class D) lesions. This study was aimed to evaluate the outcomes of endovascular treatment for TASC II D femoropopliteal lesions. METHODS Endovascular intervention with bare nitinol stent implantation was performed on 58 limbs (53 patients) with TASC II D femoropopliteal lesions from January 2011 to March 2013. Kaplan-Meier curves of primary patency, assisted patency and second patency were performed. Predictive factors of re-stenosis/occlusion were evaluated by univariate methods. RESULTS Total 53 patients with mean age of 74.2 ± 8.2 (range, 58.0-91.0 years) and mean lesion length of 314.8 ± 64.3 mm (188.2-400.4 mm) were enrolled. The mean follow-up time was 12.2 ± 6.1 months (5-38 months). Revascularization was successfully on 95% lesions by bare nitinol stent implantation. Primary patency rates at 1, 2 and 3 years were 63%, 12% and 12%, respectively. Assisted primary patency rates at 1, 2 and 3 years were 77%, 31% and 31%, respectively. Secondary patency rates at 1, 2 and 3 years were 96%, 63% and 63%. During one-year follow-up, no major amputation was occurred. Univariate analysis revealed that number of run-off vessels was a potential predictor of re-stenosis/occlusion. CONCLUSION Endovascular treatment of TASC II D femoropopliteal artery occlusion has a high technical success rate with acceptable one-year patency rate. The long-term outcomes are poor, but endovascular intervention could be a good alternative for patients unsuitable for surgical bypass.
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Affiliation(s)
- Xiangjiang Guo
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai, 200127, China.
| | - Guanhua Xue
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai, 200127, China.
| | - Xiaozhong Huang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai, 200127, China.
| | - Hui Xie
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai, 200127, China.
| | - Wei Liang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai, 200127, China.
| | - Jiwei Zhang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Pujian Road 160, Shanghai, 200127, China.
| | - Feng Lin
- Shanghai Testing & Inspection center for Medical Devices, Shanghai, China.
| | - Tianping Yao
- Shanghai Testing & Inspection center for Medical Devices, Shanghai, China.
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Baumann F, Ozdoba C, Gröchenig E, Diehm N. The Importance of Patency in Patients with Critical Limb Ischemia Undergoing Endovascular Revascularization for Infrapopliteal Arterial Disease. Front Cardiovasc Med 2015; 1:17. [PMID: 26664867 PMCID: PMC4668862 DOI: 10.3389/fcvm.2014.00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/16/2014] [Indexed: 12/02/2022] Open
Abstract
Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease (PAD) and frequently occurs in medically frail patients. CLI patients frequently exhibit multi-segmental PAD commonly including the tibial arterial segment. Endovascular therapy has been established as first-line revascularization strategy for most CLI patients. Restenosis was reported to occur in up to more than two-thirds of CLI patients undergoing angioplasty of complex tibial arterial obstructions. Nevertheless, favorable clinical outcomes were observed for infrapopliteal angioplasty when compared with bypass surgery, despite higher patency rates for the latter. Based on these observations, infrapopliteal patency was considered to be only of secondary importance upon clinical outcomes in CLI patients. In contrast to these earlier observations, however, recent findings from two randomized clinical trials indicate that infrapopliteal patency does impact on clinical outcomes in CLI patients. The purpose of the present manuscript is to provide a critical reappraisal of the present literature on the clinical importance of tibial arterial patency in CLI patients undergoing endovascular revascularization and to discuss utility and limitations of currently available anti-restenosis technologies.
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Affiliation(s)
- Frederic Baumann
- Miami Cardiac and Vascular Institute, Baptist Hospital , Miami, FL , USA
| | - Christoph Ozdoba
- Clinical and Interventional Neuroradiology, University Hospital Bern , Bern , Switzerland
| | - Ernst Gröchenig
- Clinical and Interventional Angiology, Kantonsspital Aarau , Aarau , Switzerland
| | - Nicolas Diehm
- Clinical and Interventional Angiology, Kantonsspital Aarau , Aarau , Switzerland ; University of Applied Sciences Furtwangen , Villingen-Schwenningen , Germany
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Baker AC, Humphries MD, Noll RE, Salhan N, Armstrong EJ, Williams TK, Clouse WD. Technical and early outcomes using ultrasound-guided reentry for chronic total occlusions. Ann Vasc Surg 2015; 29:55-62. [PMID: 25449989 PMCID: PMC9886056 DOI: 10.1016/j.avsg.2014.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 09/28/2014] [Accepted: 10/18/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Subintimal angioplasty is a common treatment for chronic total occlusions (CTOs) in the iliac and infrainguinal arteries. Although technical success has been described using intravascular ultrasound-guided reentry devices (IVUS-RED), outcomes are still not well defined. This report describes the technical aspects and longitudinal follow-up after intravascular ultrasound-guided reentry of iliac and infrainguinal CTOs. METHODS A retrospective review was performed of 20 patients with lower extremity CTO treated with IVUS-RED from 2011 to 2013. A matched cohort of patients who underwent lower extremity interventions without the use of IVUS-RED was also identified. Procedural success, patency estimates, ankle-brachial indices (ABIs), complications, and limb salvage were analyzed. RESULTS Twenty patients (mean age, 69 ± 13 years), including 11 men and 9 women, underwent attempted IVUS-RED-guided recanalization. Median follow-up was 4.3 months (range, 0.4-24). Eleven patients presented with critical limb ischemia (CLI), and 9 presented with claudication. Technical success was achieved in 18 (90%) patients. Ten common iliac arteries, 3 external iliac arteries, and 5 superficial femoral arteries (SFA) were treated. No intraoperative complications resulted from device use. After procedure, ABIs significantly increased (0.5-0.9; P < 0.01) in the 13 patients with follow-up. Primary patency for the entire cohort was 62% at 12 months. No patient treated for claudication required reintervention, whereas 3 (27%) of those treated for CLI required repeat interventions. During follow-up, 2 patients died unrelated to the procedure, 1 patient required an amputation, and 1 patient eventually required open revascularization. When the IVUS-RED group was compared with a cohort matched on Trans-Atlantic Inter-Society Consensus and age, no difference was found in runoff scores and patency between the 2 groups during follow-up (P > 0.05). CONCLUSIONS Recanalization of CTO using IVUS-RED is safe and effective. Use of IVUS-RED does not adversely impact outcomes in conjunction with other endovascular techniques. Early follow-up demonstrates acceptable patency, especially in patients with claudication, and freedom from reintervention.
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Affiliation(s)
- Aaron C. Baker
- Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Misty D. Humphries
- Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Robert E. Noll
- Division of Vascular Surgery, David Grant Medical Center, Travis Air Force Base, CA
| | - Navjeet Salhan
- Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Ehrin J. Armstrong
- Division of Cardiology, VA Eastern Colorado Healthcare System and University of Colorado School of Medicine, Denver, CO
| | - Timothy K. Williams
- Division of Vascular Surgery, David Grant Medical Center, Travis Air Force Base, CA
| | - W. Darrin Clouse
- Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, CA.,Division of Vascular Surgery, David Grant Medical Center, Travis Air Force Base, CA
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Wakassa TB, Benabou JE, Puech-Leão P. Clinical efficacy of successful angioplasty in critical ischemia--a cohort study. Ann Vasc Surg 2013; 28:1143-8. [PMID: 24370502 DOI: 10.1016/j.avsg.2013.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/18/2013] [Accepted: 10/05/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND To evaluate the impact of percutaneous angioplasty (PA), objectively assessed with duplex-ultrasound, on 3-year clinical outcome. METHODS Thirty-nine patients with atherosclerotic disease successfully treated by PA were included (40 limbs). All patients had critical ischemia with rest pain and ischemic ulcers due to infrainguinal obstructions alone. The patients were submitted to duplex ultrasound examination on the day before and on the first or second day after the procedure. Peak systolic velocities (PSV) were recorded in the anterior tibial, posterior tibial, and fibular arteries at the level of distal third of the leg. All patients were followed for 3 years. Comparison between groups with good and bad results were based on perioperative VPS gradient (GPSV) of the mean of the VPS in the 3 arteries. After 3 years, a good result was defined as a patient having no pain and complete healing of a previous ulcer or minor amputations. RESULTS Mean age was 68.5±8.1 years with no difference in demographic characteristics (P>0.05). In 26 cases, the long-term result was good. Healing time ranged from 4 to 130 weeks (median 26.5). Bad long-term results were observed in 12 cases. Two lesions remained unhealed despite patent angioplasty. In 10 cases, a second procedure was carried out (repeat angioplasty in 6 and bypass in 4). TransAtlantic Inter-Society Consensus (TASC) II category A/B registered better clinical success then TASC II category C/D (P<0.05) at 1-year follow-up but not at 3 years (P=0.36). Two-year limb salvage was 92.5%±4.2%. Primary patency was 52.5%±9.5% at 3 years. GVPS was 21.9 cm/sec in the good results group and 24.7 cm/sec in the bad results group (P>0.05). The quality of the initial result, as measured by GPSV, was not associated with long-term success (P>0.05). CONCLUSIONS An initially successful procedure indicated by the degree of increased flow is not related to long-term durability and ulcer healing.
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Affiliation(s)
- Tais Bugs Wakassa
- Division of Vascular and Endovascular Surgery, Department of Surgery and Department of Radiology, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil
| | - Joseph Elias Benabou
- Division of Vascular and Endovascular Surgery, Department of Surgery and Department of Radiology, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil
| | - Pedro Puech-Leão
- Division of Vascular and Endovascular Surgery, Department of Surgery and Department of Radiology, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil.
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Hong SJ, Ko YG, Kim JS, Hong MK, Jang Y, Choi D. Midterm Outcomes of Subintimal Angioplasty Supported by Primary Proximal Stenting for Chronic Total Occlusion of the Superficial Femoral Artery. J Endovasc Ther 2013; 20:782-91. [DOI: 10.1583/13-4398mr.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Sadaghianloo N, Jean-Baptiste E, Declemy S, Mousnier A, Brizzi S, Hassen-Khodja R. Percutaneous Angioplasty of Long Tibial Occlusions in Critical Limb Ischemia. Ann Vasc Surg 2013; 27:894-903. [DOI: 10.1016/j.avsg.2013.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 02/11/2013] [Indexed: 12/01/2022]
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Schneider PA, Caps MT, Nelken N. Re-entry into the true lumen from the subintimal space. J Vasc Surg 2013; 58:529-34. [DOI: 10.1016/j.jvs.2013.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 02/11/2013] [Accepted: 03/02/2013] [Indexed: 10/26/2022]
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Mousnier A, Jean-Baptiste E, Sadaghianloo N, Declemy S, Brizzi S, Hassen-Khodja R. Subintimal Recanalization of Femoropopliteal Occlusive Lesions in Patients With Critical Ischemia: 66 Cases. Ann Vasc Surg 2013; 27:467-73. [DOI: 10.1016/j.avsg.2012.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 10/16/2011] [Accepted: 03/08/2012] [Indexed: 11/30/2022]
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Georgakarakos E, Papanas N, Papadaki E, Georgiadis GS, Maltezos E, Lazarides MK. Endovascular treatment of critical ischemia in the diabetic foot: new thresholds, new anatomies. Angiology 2012; 64:583-91. [PMID: 23129734 DOI: 10.1177/0003319712465172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.
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Venkatachalam S, Shishehbor MH, Gray BH. Basic Data Related to Endovascular Management of Peripheral Arterial Disease in Critical Limb Ischemia. Ann Vasc Surg 2012; 26:1039-51. [DOI: 10.1016/j.avsg.2012.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
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Pigott JP, Raja ML, Davis T. A multicenter experience evaluating chronic total occlusion crossing with the Wildcat catheter (the CONNECT study). J Vasc Surg 2012; 56:1615-21. [PMID: 22975332 DOI: 10.1016/j.jvs.2012.06.071] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 03/12/2012] [Accepted: 06/03/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Percutaneous techniques for crossing femoropopliteal chronic total occlusions (CTOs) offer an alternative to bypass surgery in patients deemed to be at increased risk due to advanced age or comorbidities. Recent reports document good success rates in catheters designed to reconstitute peripherally occluded arteries following failed guidewire passage. The Wildcat catheter (Avinger, Redwood City, Calif) is a novel device with a rotating distal tip and deployable wedges fashioned for channeling a passage through arterial occlusions. This report describes the results of a prospective, multicenter, nonrandomized trial evaluating the safety and efficacy of the Wildcat device when crossing de novo or restenotic femoropopliteal CTOs. METHODS Between August 2010 and April 2011, patients with peripheral arterial disease due to a femoropopliteal CTO>1 cm and ≤35 cm were evaluated for study enrollment at 15 U.S. sites. During treatment, the physician initially attempted to cross the CTO using conventional guidewires per protocol; if the guidewire successfully crossed, the patient was considered a screen failure and the Wildcat was not deployed. At 30 days, patients were reevaluated. The primary efficacy end point was successful crossing of the Wildcat into the distal true lumen as confirmed by angiography. Primary safety end points included no in-hospital or 30-day major adverse events, no clinically significant perforation or embolization, and no grade C or greater dissection. Additional data collected included lesion length, degree of calcification, and location. RESULTS Eighty-eight patients were enrolled in the trial. Of these, the Wildcat device was used in 84 patients (95%) per protocol. Successful CTO crossing was reported and confirmed by independent review in 89% (75/84) of cases with 5% (4/84) major adverse events as defined in the protocol (predominantly perforations sealed with balloon inflation). There were no clinically relevant events associated with any of the perforations. The mean CTO length was 174±96 mm (range, 15-350 mm). Approximately 57% (n=48) of all lesions were categorized as containing at least moderate calcification. Eighty-nine percent (n=75) of vessels recanalized were superficial femoral arteries. CONCLUSIONS In this multicenter study, the Wildcat catheter demonstrated an 89% crossing success rate with little associated morbidity. The Wildcat catheter is a viable device for crossing moderately calcified femoropopliteal CTOs.
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Rigatelli G, Cardaioli P, Dell'avvocata F, Giordan M, Lisato G, Mollo F. Endovascular management of patients with coronary artery disease and diabetic foot syndrome: A long-term follow-up. J Geriatr Cardiol 2012; 8:78-81. [PMID: 22783289 PMCID: PMC3390080 DOI: 10.3724/sp.j.1263.2011.00078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/08/2011] [Accepted: 06/15/2011] [Indexed: 12/05/2022] Open
Abstract
Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients. Methods We retrospectively included 220 diabetic patients (78.5 ± 15.8 years, 107 females, all with Fontaine III or IV class) who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010. Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease (CAD) and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions. Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure (TcPO2) before and after the procedure were performed as well as stress-echocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly. Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography. In the rest of 126 patients, combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients. Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients. For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients (77.7%) and contralateral cross-over in 40/220 patients (18.8%) and popliteal retrograde + femoral antegrade in 10/220 patients (4.5%). Balloon angioplasty was performed in 252 legs (32 patients had bilateral disease): the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcPO2 and ABI with ulcer healing in 233/252 legs (92.4%). Freedom from major amputation was 82.8% at a mean follow-up of 3.1 ± 1.8 years (range 1 to 5 years) whereas survival was 88%. Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Intervention Unit, Rovigo General Hospital, Rovigo 45100, Italy
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Gallagher KA, Meltzer AJ, Ravin RA, Graham A, Shrikhande G, Connolly PH, Aiello F, Dayal R, McKinsey JF. Endovascular Management as First Therapy for Chronic Total Occlusion of the Lower Extremity Arteries:Comparison of Balloon Angioplasty, Stenting, and Directional Atherectomy. J Endovasc Ther 2011; 18:624-37. [DOI: 10.1583/11-3539.1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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CARDAIOLI PAOLO, RIGATELLI GIANLUCA, DELL’AVVOCATA FABIO, GIORDAN MASSIMO, LISATO GIOVANNA, MOLLO FRANCESCO, VASSILEV DOBRIN, NANJUNDAPPA ARAVINDA. Endovascular Treatment of Diabetic Foot Syndrome: Results from a Single Center Prospective Registry Using Mixed Coronary and Peripheral Techniques and Equipment. J Interv Cardiol 2011; 24:562-8. [DOI: 10.1111/j.1540-8183.2011.00676.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Zhu YQ, Zhao JG, Li MH, Liu F, Wang JB, Cheng YS, Wang J, Li J. Retrograde Transdorsal-to-Plantar or Transplantar-to-Dorsal Intraluminal Re-Entry Following Unsuccessful Subintimal Angioplasty for Below-the-Ankle Arterial Occlusion. J Endovasc Ther 2010; 17:712-21. [DOI: 10.1583/10-3207.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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Indes JE, Shah HJ, Jonker FHW, Ohki T, Veith FJ, Lipsitz EC. Subintimal angioplasty is superior to SilverHawk atherectomy for the treatment of occlusive lesions of the lower extremities. J Endovasc Ther 2010; 17:243-50. [PMID: 20426648 DOI: 10.1583/09-2821.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the outcomes of atherectomy versus subintimal angioplasty (SIA) in patients with lower extremity arterial occlusive disease. METHODS From September 2005 through July 2006, 27 patients (17 women; mean age 65 years, range 37-85) underwent atherectomy of 46 lesions (11 TASC C/D occlusions) with the SilverHawk device. Results were compared to 67 patients (34 men; mean age 69 years, range 46-92) undergoing SIA for 67 lower extremity arterial occlusions from July 1999 through June 2004. RESULTS Technical success in the atherectomy cohort was 100%. In the 11 patients with occlusions, symptoms improved in 10 and worsened in 1, but 9 (82.0%) of the 11 patients required reintervention, and 8 (72.7%) patients with occlusive lesions re-occluded. Endovascular reintervention was required to maintain primary patency in only 2 (12.5%) of 16 patients treated for stenotic lesions. At 1 year, the assisted primary patency was 37.7% in the atherectomy group. In the 11 patients with occlusive lesions, the patency rates were 36.8% and 12.3% at 6 and 9 months, respectively, versus 100% and 83.3% at the same time intervals in patients with stenotic lesions. SIA was technically successful in 56 (83.6%) of 67 occlusions. The assisted primary patency and limb salvage rates of the entire group (intention-to-treat) at 12 and 24 months were 59.2% and 45.0%, respectively, while the assisted primary patency of the 56 technically successful SIAs at 12 and 24 months were 70.7% and 53.8%, respectively. Limb salvage for the entire group (intention-to-treat) was 90.6% and 87.9% at 12 and 24 months, respectively. CONCLUSION Atherectomy may yield acceptable primary patency and limb salvage in patients with stenotic lesions. Many of the patients treated for occlusive lesions require reintervention. Based on patency and limb salvage, SIA appears superior to atherectomy for the treatment of lower extremity occlusive disease.
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Affiliation(s)
- Jeffrey E Indes
- Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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27
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Sidhu R, Pigott J, Pigott M, Comerota A. Subintimal Angioplasty for Advanced Lower Extremity Ischemia due to TASC II C and D Lesions of the Superficial Femoral Artery. Vasc Endovascular Surg 2010; 44:633-7. [DOI: 10.1177/1538574410376453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Subintimal angioplasty (SA) has evolved into a viable revascularization procedure for complex lower extremity lesions. Although patency rates are lower than those for autogenous bypass, limb salvage rates are comparable. This study reviewed the 8-year experience of SA in a single center. Methods: Records of patients undergoing SA were reviewed. Clinical presentation and noninvasive exams were used to classify patients. Lesions were categorized by TransAtlantic InterSociety Consensus (TASC) II guidelines. Outcomes included technical success, patency, amputation-free survival, and limb salvage. Results: 120 patients with TASC II C/D lesions underwent SA. Technical success was 91%. Primary patency at 6 and 12 months was 90% and 73%. Secondary patency at 6 and 12 months was 94% and 85%. One-year amputation-free survival was 90%. One-year limb salvage was 98%. Conclusions: SA for TASC C/D lesions is a safe procedure and may be considered an alternative to bypass, especially in high-risk patients.
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Abstract
Many patients with severe intermittent claudication (IC) or critical limb ischemia (CLI) have chronic total occlusions (CTO) in their lower extremity vascular bed. The successful treatment of these lesions is becoming increasingly more important as the population ages and the prevalence of diseases such as diabetes mellitus and its consequences increases. Many of these patients have significant comorbidities and may benefit from less invasive treatment options. Several endovascular techniques have now become well established in the treatment of these lesions. Additionally, several new adjunctive tools have been developed to enhance the technical success of CTO revascularization. These tools and techniques offer a minimally invasive alternative for limb salvage in this compromised patient population and have become an established practice in many centers. Although some concerns about procedure durability and lower rates of primary patency exist, particularly when compared to surgical bypass, the limb salvage and amputation-free survival rates are much more encouraging. Advantages of these techniques compared to surgical bypass are reduced morbidity and mortality, reduced anesthesia requirements, and potential reductions in length of hospital stay and cost. In addition, bypass options are typically preserved after endovascular treatment. The more conventional and some newer endovascular treatment approaches, some of the adjunctive tools and techniques used in CTO revascularization as well as their clinical results will be discussed in this review.
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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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Kim SJ, Kim W, Kim JB, Hong MJ, Kang WY, Hwang SH, Kim W. Determinants of Procedural Success and Patency Following Subintimal Angioplasty in Patients With TASC C and D Femoropopliteal Arterial Disease. Circ J 2010; 74:1959-64. [DOI: 10.1253/circj.cj-10-0106] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Seung Ju Kim
- The Cardiovascular Center of Gwangju Veterans Hospital
| | - Weon Kim
- Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University
| | - Jong Bum Kim
- The Cardiovascular Center of Gwangju Veterans Hospital
| | - Myung Ju Hong
- The Cardiovascular Center of Gwangju Veterans Hospital
| | - Won Yu Kang
- The Cardiovascular Center of Gwangju Veterans Hospital
| | - Sun Ho Hwang
- The Cardiovascular Center of Gwangju Veterans Hospital
| | - Wan Kim
- The Cardiovascular Center of Gwangju Veterans Hospital
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Angioplasty or Primary Stenting for Infrapopliteal Lesions: Results of a Prospective Randomized Trial. Cardiovasc Intervent Radiol 2009; 33:260-9. [DOI: 10.1007/s00270-009-9765-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 11/06/2009] [Indexed: 10/20/2022]
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Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of critical limb ischemia. J Endovasc Ther 2009; 16:II31-62. [PMID: 19624074 DOI: 10.1583/08-2657.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.
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Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA.
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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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36
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Sultan S, Hynes N. Five-Year Irish Trial of CLI Patients With TASC II Type C/D Lesions Undergoing Subintimal Angioplasty or Bypass Surgery Based on Plaque Echolucency. J Endovasc Ther 2009; 16:270-83. [DOI: 10.1583/08-2581.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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37
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Rabellino M, Zander T, Baldi S, Nielsen LG, Aragon-Sanchez FJ, Zerolo I, Llorens R, Maynar M. Clinical follow-up in endovascular treatment for TASC C-D lesions in femoro-popliteal segment. Catheter Cardiovasc Interv 2009; 73:701-5. [DOI: 10.1002/ccd.21971] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abedi NN, Davenport DL, Karagiorgos N, Minion DJ, Sorial EE, Endean ED, Xenos ES. Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia. Int J Angiol 2009; 18:126-8. [PMID: 22477512 PMCID: PMC2903018 DOI: 10.1055/s-0031-1278338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
CONTEXT Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented. AIMS To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions. METHODS A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time. RESULTS Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI - preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention. CONCLUSION Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.
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Affiliation(s)
- Nick N Abedi
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
| | - Daniel L Davenport
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
| | - Nikolaos Karagiorgos
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
| | - David J Minion
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
| | - Ehab E Sorial
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
| | - Eric D Endean
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
| | - Eleftherios S Xenos
- University of Kentucky Medical Center, Division of Vascular Surgery; Veterans Affairs Medical Center, Lexington, Kentucky, USA
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Beard JD. Which is the best revascularization for critical limb ischemia: Endovascular or open surgery? J Vasc Surg 2008; 48:11S-16S. [DOI: 10.1016/j.jvs.2008.08.036] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Revised: 08/06/2008] [Accepted: 08/12/2008] [Indexed: 11/25/2022]
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Selective stenting in subintimal angioplasty: Analysis of primary stent outcomes. J Vasc Surg 2008; 48:1175-80; discussion 1180-1. [DOI: 10.1016/j.jvs.2008.05.080] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 05/30/2008] [Accepted: 05/30/2008] [Indexed: 11/22/2022]
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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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Abstract
Abstract Chronic critical limb ischemia (CLI) occurs when arterial perfusion is reduced below a threshold level that results in rest pain and/or tissue breakdown in the lower extremities. Importantly, it is associated with high cardiovascular morbidity and mortality. Without prompt revascularization, CLI may result in loss of a limb (i.e. amputation) and/or life. The goal of endovascular therapy is the re-establishment of pulsatile, straight-line flow to the distal extremity. Percutaneous transluminal angioplasty (PTA) has been shown to be effective and safe in the setting of CLI, with limb salvage rates that compare favorably with surgical procedures. Stents are indicated for failed PTA, while adjunctive therapies such as lasers, thermal angioplasty and atherectomy devices lack data demonstrating improved efficacy compared with conventional lower extremity interventions. In addition to successful revascularization, the institution of lifestyle changes, atherosclerotic risk factor modification, and pharmacologic therapies are indicated to reduce cardiovascular morbidity and mortality.
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Affiliation(s)
- Salman A Arain
- Department of Cardiology, Ochnser Clinic Foundation, New Orleans, LA, USA
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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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Primary Infrainguinal Subintimal Angioplasty in Diabetic Patients. Cardiovasc Intervent Radiol 2008; 31:713-22. [DOI: 10.1007/s00270-008-9366-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 05/07/2008] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
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Romiti M, Albers M, Brochado-Neto FC, Durazzo AES, Pereira CAB, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008; 47:975-981. [DOI: 10.1016/j.jvs.2008.01.005] [Citation(s) in RCA: 401] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 12/20/2007] [Accepted: 01/03/2008] [Indexed: 12/20/2022]
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Paraskevas KI, Baker DM, Pompella A, Mikhailidis DP. Does Diabetes Mellitus Play a Role in Restenosis and Patency Rates Following Lower Extremity Peripheral Arterial Revascularization? A Critical Overview. Ann Vasc Surg 2008; 22:481-91. [DOI: 10.1016/j.avsg.2007.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 12/26/2007] [Indexed: 10/21/2022]
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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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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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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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DeRubertis BG, Faries PL, McKinsey JF, Chaer RA, Pierce M, Karwowski J, Weinberg A, Nowygrod R, Morrissey NJ, Bush HL, Kent KC. Shifting paradigms in the treatment of lower extremity vascular disease: a report of 1000 percutaneous interventions. Ann Surg 2007; 246:415-22; discussion 422-4. [PMID: 17717445 PMCID: PMC1959357 DOI: 10.1097/sla.0b013e31814699a2] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Catheter-based revascularization has emerged as an alternative to surgical bypass for lower extremity vascular disease and is a frequently used tool in the armamentarium of the vascular surgeon. In this study we report contemporary outcomes of 1000 percutaneous infra-inguinal interventions performed by a single vascular surgery division. METHODS We evaluated a prospectively maintained database of 1000 consecutive percutaneous infra-inguinal interventions between 2001 and 2006 performed for claudication (46.3%) or limb-threatening ischemia (52.7%; rest pain in 27.7% and tissue loss in 72.3%). Treatments included angioplasty with or without stenting, laser angioplasty, and atherectomy of the femoral, popliteal, and tibial vessels. RESULTS Mean age was 71.4 years and 57.3% were male; comorbidities included hypertension (84%), coronary artery disease (51%), diabetes (58%), tobacco use (52%), and chronic renal insufficiency (39%). Overall 30-day mortality was 0.5%. Two-year primary and secondary patencies and rate of amputation were 62.4%, 79.3%, and 0.5%, respectively, for patients with claudication. Two-year primary and secondary patencies and limb salvage rates were 37.4%, 55.4%, and 79.3% for patients with limb-threatening ischemia. By multivariable Cox PH modeling, limb-threat as procedural indication (P < 0.0001), diabetes (P = 0.003), hypercholesterolemia (P = 0.001), coronary artery disease (P = 0.047), and Transatlantic Inter-Society Consensus D lesion complexity (P = 0.050) were independent predictors of recurrent disease. For patients that developed recurrent disease, 7.5% required no further intervention, 60.3% underwent successful percutaneous reintervention, 11.7% underwent bypass and 20.5% underwent amputation. Patency rates were identical for the initial procedure and subsequent reinterventions (P = 0.97). CONCLUSION Percutaneous therapy for peripheral vascular disease is associated with minimal mortality and can achieve 2-year secondary patency rates of nearly 80% in patients with claudication. Although patency is diminished in patients with limb-threat, limb-salvage rates remain reasonable at close to 80% at 2 years. Percutaneous infra-inguinal revascularization carries a low risk of morbidity and mortality, and should be considered first-line therapy in patients with chronic lower extremity ischemia.
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Affiliation(s)
- Brian G DeRubertis
- Division of Vascular Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University and Columbia University College of Physicians and Surgeons, New York, New York 10021, USA
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