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Fresilli M, Oddi FM, Morosetti D, Di Girolamo A, Micali R, Ippoliti A, Gandini R. Recanalization of Chronic Femoropopliteal Total Occlusions after Failed Anterograde Attempt: Use of an Intravascular Ultrasound-Guided Re-entry Catheter versus the Bidirectional Approach. J Vasc Interv Radiol 2024; 35:377-383. [PMID: 38008377 DOI: 10.1016/j.jvir.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 10/21/2023] [Accepted: 11/16/2023] [Indexed: 11/28/2023] Open
Abstract
PURPOSE To analyze the feasibility and effectiveness of the use of an intravascular ultrasound (IVUS)-guided re-entry catheter (IGRC) for femoropopliteal chronic total occlusions (FP-CTOs) after a failed anterograde approach compared with the bidirectional approach without the IGRC. MATERIALS AND METHODS Between June 2019 and December 2022, an IGRC (Pioneer Plus; Philips Volcano, San Diego, California) was used in 52 patients after failure of conventional recanalization techniques (Group A). In the same period, 48 patients who were also eligible for IGRC use were treated without IGRC using the bidirectional approach (Group B). In Groups A and B, 12 (23.1%) and 3 (6.2%) patients experienced claudication, and 40 (76.9%) and 45 (93.7%) patients experienced critical limb-threatening ischemia, respectively. Clinical and procedural records, angiographic imaging findings, and follow-up data were collected, analyzed, and reviewed. RESULTS Technical success was achieved in 49 (94.2%) patients in Group A and 44 (91.7%) patients in Group B (P = .616). Use of the IGRC was associated with a reduction of procedural time (120 vs 133 minutes; P < .001), radiation exposure (47 vs 59 Gy cm2; P < .001), iodinated contrast medium use (98 vs 138 mL; P = .028), and intraprocedural discomfort (numerical rating scale score, 4 vs 6; P < .001). CONCLUSIONS Use of the IGRC was equivalently successful for FP-CTO recanalization compared with the use of the bidirectional approach, but it reduced radiation exposure, iodinated contrast medium used, patient discomfort, and procedural time. These advantages suggest that IGRC could be favored as the next-choice option for FP-CTOs after failure of anterograde recanalization.
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Affiliation(s)
- Mauro Fresilli
- Vascular Surgery Unit, Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy.
| | - Fabio Massimo Oddi
- Vascular Surgery Unit, Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Daniele Morosetti
- Diagnostic Neuroradiology Unit, Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Alessia Di Girolamo
- Vascular Surgery Unit, Cardio-Toraco-Vascular Department, Policlinico Umberto I, La Sapienza University of Rome, Rome, Italy
| | - Rosario Micali
- Vascular Surgery Unit, Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Arnaldo Ippoliti
- Vascular Surgery Unit, Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Roberto Gandini
- Diagnostic Neuroradiology Unit, Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
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Tsitsiou Y, Ekpe J, Harris L, Kashef E, Hamady M. Use and effectiveness of Pioneer re-entry device for subintimal true lumen re-entry: single-centre data and a review of the literature. CVIR Endovasc 2021; 4:81. [PMID: 34854997 PMCID: PMC8637523 DOI: 10.1186/s42155-021-00268-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION During subintimal angioplasty (SIA), it is not always possible to re-enter the vessel lumen due to a variety of factors. Recanalization using hydrophilic wires and catheters alone, apart from its potential technical failure, is also limited by minimal control over the re-entry point. This is frequently well beyond the point of occlusion, thus often compromising important collaterals. In order to bypass the obstruction and attain controlled re-entry into the lumen of the diseased vessel, a re-entry device (RED) may be required. This paper assesses our centre's experience with the safety and efficacy of the Pioneer re-entry system and systematically reviews the pertinent literature. METHOD A single centre retrospective study of subintimal angioplasty involving the use of the Pioneer Plus intravascular guided reentry catheter was performed. Patient demographics including age, gender, risk factors, comorbidities clinical indication and complications were recorded. Lesion characteristics, including location and severity of calcification were also assessed. A systematic literature review of all reported studies where the Pioneer RED was used for iliac and lower limb revascularization was conducted by 2 of the authors using the PubMed (MEDLINE) and EMBASE databases. RESULTS The study comprised 30 cases. Technical success was 97%. A small, quickly resolved extravasation was the only device related complication. These results are in line with the systematic review which identified 16 studies using the Pioneer RED, reporting a technical success rate of 87.4-100% (median = 100%) and complication rate of 0-25.8% (median = 0%). However, due to heterogeneity in definitions of technical success, data was not pooled.
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Affiliation(s)
- Yvonne Tsitsiou
- Department of Interventional Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jadesola Ekpe
- Department of Interventional Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Laura Harris
- Department of Interventional Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Elika Kashef
- Department of Interventional Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Department of Interventional Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College, London, UK
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Kurata N, Iida O, Takahara M, Asai M, Masuda M, Okamoto S, Ishihara T, Nanto K, Mano T. Predictive Factors for Restenosis Following Stent-Supported Endovascular Therapy with Intravascular Ultrasound Evaluation for Femoropopliteal Chronic Total Occlusion. J Vasc Interv Radiol 2021; 32:712-720.e1. [PMID: 33933251 DOI: 10.1016/j.jvir.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To determine the predictive factors for in-stent restenosis (ISR) following stent-supported endovascular therapy (EVT) with intravascular ultrasound (US) evaluation for femoropopliteal chronic total occlusion. MATERIALS AND METHODS This was a single-center, retrospective, observational study. The study included 276 lesions in 251 patients who underwent stent-supported EVT with intravascular ultrasound evaluation for femoropopliteal chronic total occlusion from July 2012 to June 2019. The wire passage route was assessed using intravascular US, and lesions were classified accordingly into 2 groups: intraluminal and subintimal passage. In this study, the intraluminal group was further divided into 3 subgroups by severity of calcification: none, <180°, and ≥180° circumferential. The subintimal group was further divided into 2 subgroups: subintimal passage without or with calcification. The primary outcome measure was ISR. Cox proportional hazards regression was used to determine the association of clinical characteristics with ISR rates. RESULTS The mean follow-up period was 19 months ±16, during which time ISR was observed in 31% of lesions. After multivariate analysis, an increased degree of plaque burden (hazard ratio [HR] = 1.101) and subintimal passage with calcification (HR = 3.408) were associated with an increased risk of ISR; a larger distal external elastic membrane area (HR = 0.898) and use of a stent graft (HR = 0.130) were significantly associated with a reduced risk of ISR. CONCLUSIONS This study revealed that factors associated with ISR after stent-supported EVT with intravascular US evaluation were distal external elastic membrane area, plaque burden, subintimal passage with calcification, and use of a stent graft.
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Affiliation(s)
- Naoya Kurata
- Department of Clinical Engineering, Kansai Rosai Hospital, Amagasaki, Japan.
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Mitusyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mitsutoshi Asai
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Masaharu Masuda
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Shin Okamoto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Kiyonori Nanto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
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Tadano Y, Kotani JI, Haraguchi T, Watanabe T, Sugie T, Kaneko U, Kobayashi K, Kanno D, Kashima Y, Fujita T. Factors contributing to efficient recanalization procedures for chronic total occlusion of the superficial femoral artery. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 37:43-49. [PMID: 34266771 DOI: 10.1016/j.carrev.2021.06.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/29/2021] [Accepted: 06/28/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND This study aimed to clarify the factors for efficient procedures (EP) in superficial femoral artery (SFA) chronic total occlusion (CTO). METHODS We retrospectively analyzed 200 consecutive limbs that underwent treatment for SFA CTO. The patients were divided into three groups according to the main strategies: subintimal angioplasty (SIA) (n = 123), Crosser use (n = 50), and 0.014″ CTO guidewire (CTO-GW) (n = 27). To determine the factors for an EP (EP; contrast volume <130 mL and procedure time <20 min; derived from non-CTO [control] procedures), the variables (P < 0.2) underwent multivariate analysis. RESULTS SIA included more Trans-Atlantic Inter-Society Consensus C/D lesions and contralateral femoral approaches, and additional GW use (P < 0.05). CTO-GW presented a shorter occlusion length and elapsed time, and used less retrograde approach than the other strategies (P < 0.05). Crossers had a higher incidence of perforation (P = 0.002). The prompt retrograde approach had a similar actual retrograde procedure time, but a shorter total procedure time, compared to that of the delayed adoption (P < 0.001). EP was achieved in 14 limbs (7.0%). Multivariate analysis revealed that occlusion length (adjusted odds ratio [OR], 0.89; 95% CI, 0.81-0.96; P = 0.004) and SIA (OR, 8.71; 95% CI, 1.32-175.27; P = 0.02) were associated with EP. CONCLUSIONS SIA contributed to EP. The timing of the retrograde approach was crucial because its delay resulted in an excessive procedure time.
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Affiliation(s)
- Yutaka Tadano
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
| | - Jun-Ichi Kotani
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Takuya Haraguchi
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | | | - Takuro Sugie
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
| | - Umihiko Kaneko
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
| | - Ken Kobayashi
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
| | - Daitaro Kanno
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
| | | | - Tsutomu Fujita
- Asia Medical Group, Sapporo Cardio Vascular Clinic, Sapporo, Japan
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Ko YG. SFA Intervention: Intraluminal or Subintimal? Korean Circ J 2018; 48:685-691. [PMID: 30073806 PMCID: PMC6072663 DOI: 10.4070/kcj.2018.0216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 11/21/2022] Open
Abstract
Subintimal angioplasty (SA) is an endovascular technique to recanalize an occluded arterial segment through an extraluminal channel between the intima and media. Since its introduction in 1989, the technical success rate has improved with the accumulation of procedural experience and the development of retrograde approaches and re-entry devices. To date, no randomized trial has compared SA with intraluminal angioplasty (IA) for chronic total occlusion (CTO) of the superficial femoral artery (SFA). Based on limited data from several registry studies, SA appears to achieve a higher technical success rate than IA, whereas mid-term primary patency rates are comparable for both endovascular wiring strategies for SFA CTO. Additional clinical data are needed to confirm that SA is as effective as IA. The optimal stenting strategy and role of drug-eluting technologies also need to be defined to improve SA outcomes.
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Affiliation(s)
- Young Guk Ko
- Division of Cardiology and Cardiovascular Research Institute, Severance, Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Kaushal A, Roche-Nagle G, Tan KT, Liao E, Eisenberg N, Oreopoulos GD, Rajan DK. Outcomes at a single center after subintimal arterial flossing with antegrade-retrograde intervention for critical limb ischemia. J Vasc Surg 2018; 67:1448-1454. [DOI: 10.1016/j.jvs.2017.08.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/30/2017] [Indexed: 12/01/2022]
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Kim K, Ko YG, Ahn CM, Min PK, Lee JH, Yoon CH, Yu CW, Lee SW, Lee SR, Choi SH, Koh YS, Chae IH, Choi D. Clinical Outcomes of Subintimal vs. Intraluminal Revascularization Approaches for Long Femoropopliteal Occlusions in a Korean Multicenter Retrospective Registry Cohort. Circ J 2018; 82:1900-1907. [PMID: 29681585 DOI: 10.1253/circj.cj-17-1464] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are limited data comparing the outcomes of subintimal vs. intraluminal approach in the treatment of long femoropopliteal artery occlusions. The objective of this study was to investigate the efficacy and safety of the subintimal approach for long femoropopliteal artery occlusions.Methods and Results:From a multicenter retrospective registry cohort, we included a total of 461 patients with 487 femoropopliteal artery occlusions classified as Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II C/D for this analysis. We compared the immediate and mid-term outcomes of subintimal vs. intraluminal approaches. There were 228 patients with 243 limbs in the subintimal group, and 233 patients with 244 limbs in the intraluminal group. Baseline clinical and lesion characteristics were comparable between the 2 groups. The technical success rate was significantly higher in the subintimal group than in the intraluminal group (95.1% vs. 89.8%, P=0.041). The clinical primary patency (67.5% vs. 73.4% at 12 months, 54.0% vs. 61.3% at 24 months; P=0.086) and target lesion revascularization (TLR)-free survival (89.5% vs. 86.3% at 12 months, 77.6% vs. 76.0% at 24 months; P=0.710) did not differ significantly between the subintimal and the intraluminal groups. CONCLUSIONS In long femoropopliteal occlusions, the subintimal approach achieved a higher technical success rate and similar mid-term primary patency and TLR-free survival compared with intraluminal approach.
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Affiliation(s)
- Kyu Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Pil-Ki Min
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Jae-Hwan Lee
- Division of Cardiology, Chungnam National University Hospital
| | - Chang-Hwan Yoon
- Division of Cardiology, Seoul National University Bundang Hospital
| | | | - Seung Whan Lee
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan
| | - Sang-Rok Lee
- Division of Cardiology, Chonbuk National University Hospital
| | - Seung Hyuk Choi
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yoon Seok Koh
- Division of Cardiology, Seoul St. Mary's Hospital, the Catholic University of Korea
| | - In-Ho Chae
- Division of Cardiology, Seoul National University Bundang Hospital
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
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Kokkinidis DG, Alvandi B, Cotter R, Hossain P, Foley TR, Singh GD, Waldo SW, Laird JR, Armstrong EJ. Long-term outcomes after re-entry device use for recanalization of common iliac artery chronic total occlusions. Catheter Cardiovasc Interv 2018. [PMID: 29521465 DOI: 10.1002/ccd.27583] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the impact of re-entry device (RED) use on 1- and 5-year outcomes after endovascular treatment of common iliac artery (CIA) chronic total Occlusions (CTOs). BACKGROUND There are not enough data regarding the long-term safety and efficacy of RED. METHODS We performed a two-center retrospective study of 115 patients (140 lesions) undergoing CIA CTO endovascular intervention between 2006 and 2016. Baseline characteristics and long-term outcomes were described. A Cox proportional hazard model was developed to determine if REDs were associated with target lesion revascularization (TLR) or major adverse limb events (MALE) after 1 and 5 years. RESULTS Among 140 lesions, 43 (31%) required use of a RED. The mean age was 63.9 years and the majority (n = 80) of patients were male. An antegrade crossing approach and treatment of restenotic lesions were less common in the RED group (10% vs. 29%, P < .05 and 0% vs. 21%, P < .05, respectively). There were no significant differences in Rutherford class, pre-procedure ABI, or patient presentation. The procedural complication rates were similar between the two groups. The 1- and 5-year TLR rates for lesions treated with re-entry device vs. standard approaches were 11% vs. 9%; P = 0.8 and 29% vs. 29%; P = 0.9 respectively. The 1 and 5-year MALE rates for lesions treated with re-entry device were 5% vs. 6%; P = 0.8 and 11% vs. 11%; P = 0.9 respectively. CONCLUSIONS This retrospective analysis found that recanalization of CIA occlusions using a RED is safe and is associated with long-term clinical outcomes similar to that of standard crossing techniques.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Denver VA Medical Center and University of Colorado, Denver, Colorado
| | - Bejan Alvandi
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, California
| | - Ryan Cotter
- Division of Cardiology, Denver VA Medical Center and University of Colorado, Denver, Colorado
| | - Prio Hossain
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, California
| | - T Raymond Foley
- Division of Cardiology, Denver VA Medical Center and University of Colorado, Denver, Colorado
| | - Gagan D Singh
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, California
| | - Stephen W Waldo
- Division of Cardiology, Denver VA Medical Center and University of Colorado, Denver, Colorado
| | - John R Laird
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, California
| | - Ehrin J Armstrong
- Division of Cardiology, Denver VA Medical Center and University of Colorado, Denver, Colorado
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Diamantopoulos A, Santonocito S, Thulasidasan N, Gkoutzios P, Ahmed I, Zayed H, Katsanos K. Initial Experience With the Outback Catheter for Targeted Reentry During Subintimal Angioplasty of the Infragenicular Arteries. J Endovasc Ther 2018; 25:178-182. [DOI: 10.1177/1526602818757409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Athanasios Diamantopoulos
- Department of Radiology, Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
- Kings College London, School of Medicine, London, UK
| | - Serafino Santonocito
- Department of Radiology, Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
| | - Narayanan Thulasidasan
- Department of Radiology, Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
| | - Panos Gkoutzios
- Department of Radiology, Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
| | - Irfan Ahmed
- Department of Radiology, Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
| | - Hany Zayed
- Kings College London, School of Medicine, London, UK
- Department of Vascular Surgery, Guy’s and St. Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
| | - Konstantinos Katsanos
- Department of Radiology, Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
- Kings College London, School of Medicine, London, UK
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Babaev A, Hari P, Gokhale R, Zavlunova S. A single-center retrospective analysis of patency rates of intraluminal versus subintimal endovascular revascularization of long femoropopliteal occlusions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:399-404. [PMID: 28347605 DOI: 10.1016/j.carrev.2017.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/11/2017] [Accepted: 03/16/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The evaluation of patency rates of intraluminal versus subintimal endovascular revascularization of long femoropopliteal (FP) lesions. BACKGROUND Chronic total occlusions (CTO) of the FP artery in peripheral interventions are crossed either with a support catheter-guidewire based technique or subintimal dissection and re-entry device assisted approach. Both techniques have a high procedural success rate, but their long term patency is not well studied. There is also lack of comparative data addressing the patency of long non-CTO vs. CTO occlusions. METHODS We performed a single center retrospective analysis, studying the patency rates in 215 patients (254 limbs) with TASC C and D FP lesions treated with stents. There were 3 patient groups: without CTO (non-CTO); CTO crossed using support catheter and guide-wire (CTO-SW) and CTO crossed with a re-entry device (CTO-RE). RESULTS There were 155 limbs in CTO-SW group; 50 in CTO-RE group and 49 in non-CTO. Lesion length (mean±SD) was 251.81±7.48mm in CTO-SW group; 280±13.18mm in CTO-RE group and 248.77±13.31 in non-CTO group (p=non-significant). In-stent restenosis (ISR) at a mean follow-up of 19.26±16.14months did not differ between groups occurring in 23 (47%) limbs in non-CTO; 66 (42%) in CTO-SW; and 24 (48%) in CTO-RE. Smoking and stent fracture were predictors of ISR by multivariate analysis. CONCLUSION In patients with long FP lesions, ISR rates were similar between patients with and without CTO. In the CTO group mid-term vessel patency was not affected by the crossing technique utilized.
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Affiliation(s)
- Anvar Babaev
- New York University Department of Medicine, Division of Cardiology.
| | - Pawan Hari
- New York University Department of Medicine, Division of Cardiology
| | - Rohit Gokhale
- New York University Department of Medicine, Division of Cardiology
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Kearney K, Hira RS, Riley RF, Kalyanasundaram A, Lombardi WL. Update on the Management of Chronic Total Occlusions in Coronary Artery Disease. Curr Atheroscler Rep 2017; 19:19. [DOI: 10.1007/s11883-017-0655-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
BACKGROUND In recent years subintimal angioplasty (SIA) has become an established percutaneous procedure for the treatment of symptomatic lower limb arterial chronic total occlusions. However, the clinical benefits of this practice remain unclear. The aim of the review was to determine the effectiveness of SIA on clinical outcomes. This is an update of a review first published in 2013. OBJECTIVES To assess the effectiveness of SIA versus other treatment for people with lower limb arterial chronic total occlusions, determined by the effects on clinical improvement, technical success rate, patency rate, limb salvage rate, and morbidity rates. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched January 2016) and Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 12). We also searched clinical trials registries. SELECTION CRITERIA We included data from randomized controlled trials comparing the effectiveness of SIA and any other management method in the treatment of lower limb arterial chronic total occlusions. The primary intervention of interest was SIA, with or without a stent, for the restoration of vessel patency in people with occlusions of a lower limb artery. We compared SIA against alternative modalities used to restore vessel patency, including conventional percutaneous transluminal angioplasty, surgical bypass, or any other treatments. We compared different SIA devices and techniques against each other. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. The third review author resolved disagreements. MAIN RESULTS Two studies, involving a total of 147 participants with TransAtlantic Inter-Society Consensus (TASC)-II D femoropopliteal lesions, met our inclusion criteria and were included in the review. Both studies were small but otherwise of high methodological quality. However, the treatment techniques and control groups of the two studies differed, precluding the combining of study results and resulting in the evidence being less applicable. We therefore considered the quality of the evidence to be low.In one study, participants with TASC-II D lesions were randomized to receive either SIA with stenting of the superficial femoral artery or remote endarterectomy (RE) with stenting of the superficial femoral artery. Three-year follow-up results showed a Rutherford classification improvement of 64% in the SIA group compared to 80% in the RE group (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.61 to 1.03; 95 participants; P = 0.079). Postexercise ankle brachial index improvements (defined as an increased value of 0.2) were reported in 70% of participants in the SIA group compared to 82% in the RE group (RR 0.86, 95% CI 0.68 to 1.08; 95 participants; P = 0.18). The study reported the technical success rate was 93% for the SIA group and 96% for the RE group (RR 0.97, 95% CI 0.88 to 1.07; 95 participants; P = 0.91). Primary patency at 12 months was 59.1% in the SIA group compared to 78.4% in the RE group (RR 0.75, 95% CI 0.57 to 1.00; 95 participants; P = 0.05). Primary patency at 24 months was 56.8% in the SIA group compared to 76.5% in the RE group (RR 0.74, 95% CI 0.55 to 1.00; 95 participants; P = 0.05) and 47.7% in the SIA group and 62.7% in the RE group at 36 months (RR 0.76, 95% CI 0.52 to 1.11; 95 participants; P = 0.15). Assisted primary patency was 52.3% in the SIA group compared to 70.6% in the RE group (P = 0.01) at 36 months. Secondary patency was better for the RE group (P = 0.03) at 36 months. Limb salvage at three years' follow-up was 95% in the SIA group and 98% in the RE group (RR 0.97, 95% CI 0.90 to 1.05; 95 participants; P = 0.4). There were no perioperative deaths, but complications occurred in two SIA participants (femoral pseudoaneurysm and pulmonary edema) and in three RE participants (seroma, femoral pseudoaneurysm, superficial femoral artery acute occlusion).In the second study, the effects of the SIA OUTBACK re-entry catheter device in people affected by TASC-II D superficial femoral artery chronic total occlusion were compared with the SIA manual re-entry technique. This study did not report clinical improvement and limb salvage. Technical success was achieved in all cases in both the OUTBACK device and manual groups. The primary 6-month patency rate was 100% in the OUTBACK group (26 of 26 participants) compared to 96.2% in the manual group (25 of 26 participants) (RR 1.04, 95% CI 0.94 to 1.15). The primary 12-month patency rate was 92.3% in the OUTBACK group (24 of 26 participants) compared to 84.6% in the manual group (22 of 26 participants) (RR 1.09, 95% CI 0.90 to 1.33). Patency rates at 24 and 36 months were not reported. The study reported that there were no complications. AUTHORS' CONCLUSIONS Using the GRADE approach, we classified the quality of the evidence presented by both studies in this review as low due to small study size and the small number of studies. In addition, the two included trials differed from each other in the techniques and control used, and we were therefore unable to combine the data. Consequently there is currently insufficient evidence to support SIA over other techniques. Evidence from more randomized controlled trials is needed to assess the role of SIA in people with chronic lower limb arterial total occlusions.
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Affiliation(s)
- ZhiHui Chang
- ShengJing Hospital of China Medical UniversityRadiology DepartmentNo. 36, SanHao Street, HePing DistrictShenYangLiaoNingChina110004
| | - JiaHe Zheng
- ShengJing Hospital of China Medical UniversityRadiology DepartmentNo. 36, SanHao Street, HePing DistrictShenYangLiaoNingChina110004
| | - ZhaoYu Liu
- ShengJing Hospital of China Medical UniversityRadiology DepartmentNo. 36, SanHao Street, HePing DistrictShenYangLiaoNingChina110004
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Kahn SL, Kaufman JL. Extravascular Revascularization of a Chronic Total Occlusion Using the Dual Bull’s-Eye Technique. J Endovasc Ther 2016; 23:903-906. [DOI: 10.1177/1526602816667307] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To describe the dual bull’s-eye technique to achieve successful extravascular revascularization of an occlusion after vessel perforation when the antegrade and retrograde catheters are too far apart for salvage with a reentry catheter. Technique: The dual bull’s-eye technique, which is an adaptation of the “gun-sight” method for transjugular portosystemic shunt procedures, is demonstrated in a popliteal artery occlusion in which multiple recanalization attempts have produced vessel perforation. Via antegrade femoral and retrograde anterior tibial artery accesses, 10-mm Amplatz GooseNeck snares were advanced in plane from each access to rendezvous in the popliteal fossa to obtain through-and-through wire access. A 15-cm Chiba needle was advanced percutaneously in plane through both snares, and a hydrophilic guidewire was maneuvered across an extravascular tract parallel to the popliteal artery. The tract was carefully predilated, and a 5×100-mm Viabahn stent-graft was deployed across the extravascular tract. Conclusion: Owing to potential complications (limited patency, injury to adjacent structures) and only single-case use, this new technique should be considered a bailout strategy exclusively employed for limb salvage when traditional methods have failed and there are no viable surgical options.
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Hydrodynamic boost: a novel re-entry technique in subintimal angioplasty of below-the-knee vessels. Eur Radiol 2015; 26:2419-25. [DOI: 10.1007/s00330-015-4078-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 09/06/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
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15
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.). Ann Vasc Dis 2015; 8:343-57. [PMID: 26730266 DOI: 10.3400/avd.tasc.15-01000] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | - Christopher J White
- The Ochsner Clinical School-University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Vasc Med 2015; 20:465-78. [DOI: 10.1177/1358863x15597877] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | | | - Christopher J. White
- The Ochsner Clinical School–University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: A supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC steering commi. Catheter Cardiovasc Interv 2015; 86:611-25. [DOI: 10.1002/ccd.26122] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Christopher J. White
- The Ochsner Clinical School-University of Queensland, Ochsner Clinic Foundation; New Orleans LA USA
| | - William R. Hiatt
- Division of Cardiology; University of Colorado School of Medicine, and CPC Clinical Research; Aurora CO USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh; UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital; Amsterdam The Netherlands
| | - Lars Norgren
- Department of Surgery; Faculty of Medicine and Health, Örebro University; Örebro Sweden
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18
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries. J Endovasc Ther 2015; 22:663-77. [DOI: 10.1177/1526602815592206] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | | | - Christopher J. White
- The Ochsner Clinical School–University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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19
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Shimada Y. Commentary: Novel Crossing Devices vs the Skill of Artisans: Is It a Tie Thus Far? J Endovasc Ther 2015; 22:535-7. [PMID: 26187976 DOI: 10.1177/1526602815590971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Yoshihisa Shimada
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
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20
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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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Palena LM, Garcia LF, Brigato C, Sultato E, Candeo A, Baccaglini T, Manzi M. Angiosomes: how do they affect my treatment? Tech Vasc Interv Radiol 2015; 17:155-69. [PMID: 25241316 DOI: 10.1053/j.tvir.2014.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The number of diabetic patients is actually increasing all around the world, consequently, critical limb ischemia and ischemic diabetic foot disorders related to the presence of diabetic occlusive arterial disease will represent in the next few years a challenging issue for vascular specialists. Revascularization represents one step in the treatment for the multidisciplinary team, reestablishing an adequate blood flow to the wound area, essential for healing and avoiding major amputations. The targets of revascularization can be established to obtain a "complete" revascularization, treating all tibial and foot vessels or following the angiosome and wound-related artery model, obtaining direct blood flow for the wound. In this article, we summarize our experience in endovascular treatment of diabetic critical limb ischemia, focusing on the angiosome and wound-related artery model of revascularization and the technical challenges in treating below-the-knee and below-the-ankle vessels.
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Affiliation(s)
| | - Luis Fernando Garcia
- Vascular Surgery Unit, Clinica de Marly-Hospital military central, Clinica Universitaria Colombia, Bogota, Colombia
| | - Cesare Brigato
- Interventional Radiology Unit, Policlinico Abano Terme, Paduva, Italy
| | - Enrico Sultato
- Interventional Radiology Unit, Policlinico Abano Terme, Paduva, Italy
| | - Alessandro Candeo
- Interventional Radiology Unit, Policlinico Abano Terme, Paduva, Italy
| | | | - Marco Manzi
- Interventional Radiology Unit, Policlinico Abano Terme, Paduva, Italy
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22
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Niazi K. Focal stenting versus "metal jacket" for long subintimal recanalization of the femoropopliteal artery. JACC Cardiovasc Interv 2015; 8:481-482. [PMID: 25703880 DOI: 10.1016/j.jcin.2014.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 12/12/2014] [Accepted: 12/18/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Khusrow Niazi
- Division of Cardiovascular Medicine, Emory University, Atlanta, Georgia.
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23
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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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24
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A breakthrough trans-collateral retrograde access for occlusive superficial femoral artery: multi-site access and sheaths insertion (MUSASHI) technique. Cardiovasc Interv Ther 2014; 30:356-61. [PMID: 25332141 DOI: 10.1007/s12928-014-0304-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
A purpose of this article is to describe a breakthrough technique for occlusive superficial femoral artery (SFA) recanalization: multi-site access and sheaths insertion (MUSASHI) technique. Trans-collateral retrograde approach (TCA) for SFA cannot become popular because it needs conventional (crossover or ipsilateral) approach, which might not be suitable for collateral channel tracking. An innovative MUSASHI technique has a possibility to make TCA popular. Inserting two different sheaths into SFA and profunda artery from common femoral artery, we can manipulate both antegrade and retrograde guidewires without losing their trackability and with strong system-stability. Using MUSASHI technique, TCA may become easier and safer.
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Katsanos K, Tepe G, Tsetis D, Fanelli F. Standards of Practice for Superficial Femoral and Popliteal Artery Angioplasty and Stenting. Cardiovasc Intervent Radiol 2014; 37:592-603. [DOI: 10.1007/s00270-014-0876-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 09/04/2013] [Indexed: 11/30/2022]
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Vibrational angioplasty in recanalization of chronic femoropopliteal arterial occlusions: single center experience. Eur J Radiol 2014; 83:155-62. [PMID: 24518192 DOI: 10.1016/j.ejrad.2013.09.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/14/2013] [Accepted: 09/20/2013] [Indexed: 11/22/2022]
Abstract
PURPOSE This prospective study aims to present the overall success rate, safety and long-term outcome of vibrational angioplasty technique, in the treatment of chronic total femoropopliteal occlusions in our institute. METHODS Between October 2000 and December 2008, patients with chronic total femoropoliteal arterial occlusions, treated with vibrational angioplasty during the same session after a failed attempt with conventional recanalization technique, were included. Patient's follow up included serial ankle-brachial index measurements and arterial duplex ultrasound examinations at 1, 3, 6, 12, 24, 36 and 48 months. RESULTS Twenty-seven patients (16 males and 11 females) and twenty-eight lesions were included in our study. Twenty-five lesions (89.3%) were successfully recanalized. Pain relief was noticed in twenty-one cases. From ten lesions with tissue loss (ulcer or gangrene) in successfully recanalized occlusions, six healed without major, or minor amputation. One non-healing amputation stump was healed after recanalization, without further complications. Four limbs underwent amputation (one minor and three major) despite successful recanalization, however all had an excellent healing of the amputation stump without further complications. The Kaplan-Meier test demonstrated 90%, 85% and 70% amputation-free survival rate at 12, 24 and 36 months, respectively. No major or minor complications were encountered. CONCLUSIONS Vibrational angioplasty is a safe, effective and durable endovascular technique for the treatment of chronic total occlusions in patients with limb ischemia that would be difficult to recanalize using conventional intraluminal techniques.
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Chin JA, Sumpio BE. Diabetes mellitus and peripheral vascular disease: diagnosis and management. Clin Podiatr Med Surg 2014; 31:11-26. [PMID: 24296015 DOI: 10.1016/j.cpm.2013.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Diabetes mellitus and peripheral artery disease are prevalent diseases throughout the world and often present simultaneously in the same patient, which has direct implications for their diagnosis and management. Refinements of existing and development of new diagnostic and treatment modalities are changing the management of these diseases. This article reviews the significant pathologic basis, history, and physical examination findings with respect to each disease and their presentation together. Advantages and disadvantages of different diagnostic modalities, including noninvasive studies and imaging technologies, are discussed. General medical management principles and indications, techniques, and efficacy of surgical and endovascular interventions are reviewed.
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Affiliation(s)
- Jason A Chin
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, BB 204, New Haven, CT 06510, USA
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28
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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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29
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Subintimal Recanalization Plus Stenting or Bypass for Management of Claudicants with Femoro-popliteal Occlusions. Eur J Vasc Endovasc Surg 2013; 46:347-52. [DOI: 10.1016/j.ejvs.2013.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 06/10/2013] [Indexed: 11/15/2022]
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30
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Hua WR, Yi MQ, Min TL, Feng SN, Xuan LZ, Xing J. Popliteal versus tibial retrograde access for subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique. Eur J Vasc Endovasc Surg 2013; 46:249-54. [PMID: 23764133 DOI: 10.1016/j.ejvs.2013.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 05/09/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This study aimed to ascertain differences in benefit and effectiveness of popliteal versus tibial retrograde access in subintimal arterial flossing with the antegrade-retrograde intervention (SAFARI) technique. METHODS This was a retrospective study of SAFARI-assisted stenting for long chronic total occlusion (CTO) of TASC C and D superficial femoral lesions. 38 cases had superficial femoral artery lesions (23 TASC C and 15 TASC D). All 38 cases underwent SAFARI-assisted stenting. The ipsilateral popliteal artery was retrogradely punctured in 17 patients. A distal posterior tibial (PT) or dorsalis pedis (DP) artery was retrogradely punctured in 21 patients, and 16 of them were punctured after open surgical exposure. RESULTS SAFARI technical success was achieved in all cases. There was no significant difference in 1-year primary patency (75% vs. 78.9%, p = .86), secondary patency (81.2% vs. 84.2%, p = .91) and access complications (p = 1.00) between popliteal and tibial retrograde access. There was statistical difference in operation time between popliteal (140.1 ± 28.4 min) and tibial retrograde access with PT/DP punctures after surgical vessel exposure (120.4 ± 23.0 min, p = .04). CONCLUSION The SAFARI technique is a safe and feasible option for patients with infrainguinal CTO (TASC II C and D). The PT or DP as the retrograde access after surgical vessel exposure is a good choice when using the SAFARI technique.
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Affiliation(s)
- W R Hua
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University, Jinan, China; Department of Vascular Surgery, Jinan Central Hospital, Shandong University, Jinan, China
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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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Abstract
BACKGROUND Subintimal angioplasty (SIA) has become an established percutaneous procedure for the treatment of symptomatic lower limb arterial occlusions in recent years. However, the clinical benefits of this practice remain unclear. The aim of the review was to determine the effectiveness of SIA on clinical outcomes. OBJECTIVES To assess the effectiveness of SIA versus any other treatment for patients with chronic lower limb artery occlusion. This will be determined by the effects on clinical improvement, technical success rate, patency rate, limb salvage rate, and morbidity rates. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). Clinical trials databases were also searched. SELECTION CRITERIA We planned to include data from randomized controlled trials comparing the effectiveness of SIA and any other management method in the treatment of chronic lower limb arterial occlusion. DATA COLLECTION AND ANALYSIS Two authors evaluated the trials identified from the searches for appropriateness of inclusion. MAIN RESULTS There were no randomized controlled trials in which SIA was compared with any other treatment. AUTHORS' CONCLUSIONS Randomized controlled trial evidence for the effectiveness of SIA is lacking. There is a need for high-quality randomized controlled trials comparing SIA with any other treatment.
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Affiliation(s)
- Zhi Hui Chang
- Radiology Department, ShengJing Hospital of China Medical University, ShenYang, China.
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33
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Sumpio BE. Contemporary evaluation and management of the diabetic foot. SCIENTIFICA 2012; 2012:435487. [PMID: 24278695 PMCID: PMC3820495 DOI: 10.6064/2012/435487] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 09/30/2012] [Indexed: 06/02/2023]
Abstract
Foot problems in patients with diabetes remain a major public health issue and are the commonest reason for hospitalization of patients with diabetes with prevalence as high as 25%. Ulcers are breaks in the dermal barrier with subsequent erosion of underlying subcutaneous tissue that may extend to muscle and bone, and superimposed infection is a frequent and costly complication. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Early recognition of the etiology of these foot lesions is essential for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs are the mainstays of therapy. Even when properly managed, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents, and negative pressure wound therapy. While these, increasingly expensive, therapies have shown promising results in clinical trials, the results have yet to be translated into widespread clinical practice leaving a huge scope for further research in this field.
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Affiliation(s)
- Bauer E. Sumpio
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, CT 06510, USA
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Siablis D, Diamantopoulos A, Katsanos K, Spiliopoulos S, Kagadis GC, Papadoulas S, Karnabatidis D. Subintimal angioplasty of long chronic total femoropopliteal occlusions: long-term outcomes, predictors of angiographic restenosis, and role of stenting. Cardiovasc Intervent Radiol 2012; 35:483-90. [PMID: 21833807 DOI: 10.1007/s00270-011-0244-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/15/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this article is to report the results of a prospective single-center study analyzing the long-term clinical and angiographic outcomes of subintimal angioplasty (SIA) for the treatment of chronic total occlusions (CTOs) of the femoropopliteal artery. MATERIALS AND METHODS Patients with severe intermittent claudication or critical limb ischemia (CLI) were enrolled in the study. All lesions were treated with SIA and provisional stenting. Primary end points were technical success, patient survival, limb salvage, lesion primary patency, angiographic binary restenosis (>50%), and target lesion revascularization (TLR). Regular clinical and angiographic follow-up was set at 6 and 12 months and yearly thereafter. Study end points were calculated with life-table survival analysis. Proportional-hazards regression analysis with a Cox-model was applied to adjust for confounding factors of heterogeneity. RESULTS Between May 2004 and July 2009, 98 patients (105 limbs, patient age 69.3±9.9 years) were included in the study. Technical success rate was 91.4% with a lesion length of 121±77 mm. Limb-salvage and survival rates were 88.7% and 84.1% at 3 years, respectively. After 12, 24, and 36 months, primary patency was 80.1%, 42.3%, and 29.0%, angiographic binary restenosis was 37.2%, 68.6%, and 80.0%, and TLR was 84.8%, 73.0%, and 64.5%, respectively. CLI was the only adverse predictor for decreased primary patency (hazard ratio [HR] 0.36; 95% confidence interval [CI] 0.16-0.80, p=0.012), whereas significantly less restenosis was detected after spot stenting of the entry and/or re-entry site (HR 0.31; 95% CI 0.10-0.89, p=0.01 and HR 0.20; 95% CI 0.07-0.56, p=0.002, respectively). CONCLUSIONS Subintimal angioplasty is a safe and effective revascularization technique for the treatment of CTOs of the femoropopliteal artery. Provisional stenting may have a role at the subintimal entry or true lumen re-entry site.
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Affiliation(s)
- Dimitris Siablis
- Department of Radiology, Angiography Suite, Patras University Hospital, and Department of Medical Physics, Patras School of Medicine, 265 00, Rion, Greece.
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Fichelle JM. [Critical ischemia in patients over 80: waiting or evidence-based surgical treatment?]. JOURNAL DES MALADIES VASCULAIRES 2012; 37:124-131. [PMID: 22445556 DOI: 10.1016/j.jmv.2012.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 02/01/2012] [Indexed: 05/31/2023]
Abstract
Critical ischemia is defined by continuous pain, impending sleep, with ankle pressure less than 50mm Hg, and/or first toe pressure less than 30 mm Hg (Dormandy et Rutherford, 2000; Norgren et al., 2007). Treatment of patients aged over 80 requires specific knowledge of arteriopathy at this age and an evaluation of co-morbidity factors (diabetes mellitus, renal failure, ischemic cardiopathy). Assessment should include: the degree of ischemia, the extension of arterial disease, the co-morbidity factors, and the diffusion of the atherosclerotic disease. A transatlantic consensus conference has enabled a classification of arterial lesions determining therapeutic indications. Aorto-iliac lesions may be treated by surgery or angioplasty. Femoro-popliteal or crural lesions may be treated by surgery or angioplasty. Type C or D lesions should be treated by femoro-popliteal or crural bypass. Bypass to the ankle or foot are done on high peripheral resistances. These bypasses require a venous graft. Several authors have shown the utility of short grafts: popliteo-tibial, tibiotibial, tibiopedal artery bypass, tibioplantar artery bypass. In patients over 80, the presence of arteriopathy is an important mortality factor, which is four or five times more important than in the normal population. Twenty-five percent of patients will require amputation.
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Affiliation(s)
- J-M Fichelle
- Clinique Bizet, 21, rue Georges-Bizet, 75116 Paris, France.
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Setacci C, Sirignano P, Setacci F. Commentary: The ENABLER-P Balloon Catheter System: a new and exciting tool for recanalization of femoropopliteal CTOs. J Endovasc Ther 2012; 19:140-3. [PMID: 22545875 DOI: 10.1583/11-3664c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Surgery, University of Siena, Siena, Italy.
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Setacci C, Sirignano P. Commentary. Subintimal angioplasty of femoropopliteal artery occlusions: the long-term results. Eur J Vasc Endovasc Surg 2011; 42 Suppl 1:S16-8. [PMID: 21855013 DOI: 10.1016/j.ejvs.2011.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- C Setacci
- Department of Vascular and Endovascular Surgery, University of Sienna, Viale Bracci 1, Siena, Italy
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Abstract
Critical limb ischemia (CLI) is primarily a disease of advanced atherosclerosis but may occur in the setting of other causes. It is essential for the treating physician to understand the complexity of patients with CLI and the appropriate and emerging treatment approaches in this patient population. The authors provide a comprehensive review of the percutaneous endovascular management of CLI in this article.
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Ikushima I, Hirai T, Ishii A, Iryo Y, Yamashita Y. Confluent Two-Balloon Technique: An Alternative Method for Subintimal Recanalization of Peripheral Arterial Occlusion. J Vasc Interv Radiol 2011; 22:1139-43. [DOI: 10.1016/j.jvir.2011.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 04/06/2011] [Accepted: 04/07/2011] [Indexed: 11/25/2022] Open
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40
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Ko YG, Shin S, Kim KJ, Kim JS, Hong MK, Jang Y, Shim WH, Choi D. Efficacy of stent-supported subintimal angioplasty in the treatment of long iliac artery occlusions. J Vasc Surg 2011; 54:116-22. [DOI: 10.1016/j.jvs.2010.11.127] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 11/29/2010] [Accepted: 11/30/2010] [Indexed: 11/16/2022]
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Subintimal angioplasty of chronic total occlusion in iliac arteries: A safe and durable option. J Vasc Surg 2011; 53:367-73. [DOI: 10.1016/j.jvs.2010.08.073] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 08/18/2010] [Accepted: 08/24/2010] [Indexed: 11/17/2022]
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Laganà D, Carrafiello G, Lumia D, Fontana F, Mangini M, Vizzari FA, Piffaretti G, Fugazzola C. Recanalisation of thrombotic arterial occlusions with rotational thrombectomy. LA RADIOLOGIA MEDICA 2010; 116:932-44. [PMID: 21311991 DOI: 10.1007/s11547-010-0611-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Accepted: 03/26/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE This study sought to assess the effectiveness of rotational thrombectomy (RT) with the Rotarex device in the treatment of thrombotic occlusions in native arteries, by-pass grafts, stents and stent-grafts. MATERIALS AND METHODS Over the last 4 years, 22 patients (14 men and 8 women; mean age 62.6 years) affected by 5 acute (<14 days) thrombotic occlusions of the native arteries (4 plaque thromboses in the common iliac artery and one on a dissection intimal flap of the external iliac artery), 17 subacute and chronic thromboses affecting 4 femoro-popliteal by-pass grafts, 10 stents (7 in the common iliac artery and 3 in the superficial femoral artery) and 3 stents-grafts were studied. Acute thromboses of native arteries were follow-up with colour-Doppler ultrasound (US) examination at 1 and 3 months. Subacute and chronic thrombotic occlusions were follow-up with colour-Doppler US examination at 1, 3, 6 and 12 months and yearly thereafter. RESULTS Immediate technical success was achieved without any need for additional procedures in all acute occlusions of native arteries (4/22 cases). In the subacute and chronic occlusions, the procedure was completed with percutaneous transluminal angioplasty (PTA) (8/22), cutting balloon (6/22) and stenting (5/22). The complication rate was 4.8% (1 rupture of the external iliac artery repaired with a stent-graft). CONCLUSIONS Arterial recanalisation with RT is the treatment of choice for acute thrombosis of healthy native arteries (4-7 mm); the treatment of thrombosis complicating calcified plaques or dissection intimal flaps may cause rupture of the arterial wall. In subacute and chronic occlusions of by-pass grafts, stents and stent grafts, additional procedures are necessary to achieve complete recanalisation.
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Affiliation(s)
- D Laganà
- Department of Radiology, University of Insubria, V.le Borri 57, Varese, Italy.
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Subintimal angioplasty for femoro-popliteal occlusive disease. J Vasc Surg 2010; 52:1410-6. [DOI: 10.1016/j.jvs.2010.03.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 03/18/2010] [Accepted: 03/20/2010] [Indexed: 11/20/2022]
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Bown M, Sutton A. Quality Control in Systematic Reviews and Meta-analyses. Eur J Vasc Endovasc Surg 2010; 40:669-77. [DOI: 10.1016/j.ejvs.2010.07.011] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 07/16/2010] [Indexed: 12/22/2022]
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Biondi-Zoccai GGL, Sangiorgi G. Commentary: Shutting the Door After Antegrade Femoral Arteriotomy: Should You Push, Clip, Tie, or Plug? J Endovasc Ther 2010; 17:376-9. [PMID: 20557178 DOI: 10.1583/09-2960c.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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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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