Current Role of Atherectomy for Treatment of Femoropopliteal and Infrapopliteal Disease

Comparative Analysis of Mortality and Amputation Rates in Patients Undergoing Atherectomy for Infra-Popliteal Peripheral Arterial Disease: Insight From the VQI

INTRODUCTION

Infra-popliteal peripheral arterial disease (IPPAD) poses challenges due to high restenosis and occlusion rates. The BASIL-2 trial demonstrated the superiority of endovascular treatment compared with surgical bypass in patients with IPPAD. However, the association between different endovascular modalities and clinical outcomes has not been conclusive.

HYPOTHESIS

Combining plain old balloon angioplasty (POBA) with atherectomy is associated with improved clinical outcomes compared with POBA alone.

METHODS

Patients who underwent POBA vs POBA+atherectomy for IPPAD from the Vascular Quality Initiative database were identified. To mitigate potential selection bias, we employed propensity score matching (PSM) to balance the distribution of confounding variables for mortality identified on multivariable logistic regression. Subsequently, we compared patient characteristics and long-term outcomes between the 2 treatment groups.

RESULTS

Among patients who underwent endovascular intervention for IPPAD, 19 979 individuals (80.8%) were treated with POBA alone, while 4747 (19.2%) were treated with both POBA+atherectomy after PSM. Propensity score matching ensured minimal differences in baseline characteristics, such as indication for lower extremity revascularization (LER) and history of LER. After PSM, patients receiving POBA+atherectomy experienced higher rates of technical success and lower perioperative complications, such as renal complications and hematoma, compared with POBA alone. During long-term follow-up, patients who underwent atherectomy had lower rates of major amputation and major adverse limb events (MALE) but slightly lower freedom from reintervention. Nonetheless, there were no differences in mortality.

CONCLUSION

Combining POBA with atherectomy appears to be a safe approach in patients with IPPAD, with lower rates of long-term amputation and MALE at the cost of a higher risk of reintervention.

CLINICAL IMPACT

The use of adjunctive atherectomy is associated with improved long-term outcomes in patients with infra-popliteal disease.

CIRSE Standards of Practice on Below-the-Knee Revascularisation

The CIRSE Standards of Practice Committee established a writing group that was tasked with producing up-to-date recommendations for performing below-the-knee revascularisation, taking into account data on novel techniques, devices, and long-term outcomes that have emerged over the last decade. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature. This document is not intended to impose a standard of clinical patient care but recommends a reasonable approach to and best practices for performing below-the-knee revascularisation.

Prediction of restenosis based on hemodynamical markers in revascularized femoro-popliteal arteries during leg flexion

Endovascular therapy in patients suffering from peripheral arterial disease shows high rates of restenosis. The poor clinical outcomes are commonly explained by the demanding mechanical environment due to leg movements, but the mechanisms responsible for restenosis remain unknown. In this study, we hypothesized that restenosis following revascularization is associated with hemodynamical markers derived from blood flow during leg flexion. Therefore, we performed personalized computational fluid dynamics (CFD) analyses of 20 patients, who underwent routine endovascular femoro-popliteal interventions. The CFD analyses were conducted using 3D models of the arterial geometry in straight and flexed positions, which were reconstructed from 2D angiographic images. Based on restenosis rates reported at 6-month follow-up, logistic regression analyses were performed to predict restenosis from hemodynamical parameters. Results showed that severe arterial deformations, such as kinking, induced by leg flexion in stented arteries led to adverse hemodynamic conditions that may trigger restenosis. A logistic regression analysis based solely on hemodynamical markers had an accuracy of 75%, which showed that flow parameters are sufficient to predict restenosis (p = 0.031). However, better predictions were achieved by adding the treatment method in the model. This suggests that a more accurate image acquisition technique is required to capture the localized modifications of blood flow following intervention, especially around the stented artery. This approach, based on the immediate postoperative configuration of the artery, has the potential to identify patients at increased risk of restenosis. Based on this information, clinicians could take preventive measures and more closely follow these patients to avoid complications.

Antithrombotic Therapy After Revascularization in Patients With Peripheral Arterial Disease: What Is Here, What Is Next

Objective:

The optimal antithrombotic regimen in peripheral arterial disease (PAD) is not known, leading to significant variations in antithrombotic treatment protocols in randomized trials and clinical practice. In device trials, antithrombotic regimens in patients receiving peripheral vascular interventions have not been clearly reported on. This review summarizes and discusses the most recent evidence on this topic to provide a potential guide to clinical practice.

Methods:

A search of the literature was done for publications that reported outcomes of major PAD device trials. Reported outcomes and various antithrombotic regimens were studied.

Results:

Use of antithrombotic therapy varied significantly between various device trials. Reporting of antithrombotic regimens at the time of follow-up is lacking.

Conclusion:

Outcome data on optimal antithrombotic regimens are presently lacking largely due to the significant heterogeneity and underreporting of antithrombotic regimens at follow-up among prior clinical trials. Standardization and reporting of precise antithrombotic regimens at various points of follow-up in device trials of patients with PAD should be attempted so as to minimize differences in treatment patterns when evaluating new devices.