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Scatena A, Apicella M, Mantuano M, Liistro F, Ventoruzzo G, Petruzzi P, Miranda C, Monge L, Ragghianti B, Silverii A, Ferraro I, Uccioli L, Vermigli C, Mannucci E, Scevola G, Stabile E, Gargiulo M, Monami M. Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome. Acta Diabetol 2024; 61:19-28. [PMID: 37792028 DOI: 10.1007/s00592-023-02185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023]
Abstract
To report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients. Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up.
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Affiliation(s)
- Alessia Scatena
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy.
| | - Matteo Apicella
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Michele Mantuano
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Francesco Liistro
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Giorgio Ventoruzzo
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Pasquale Petruzzi
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | | | - Luca Monge
- AMD - Italian Association of Clinical Diabetologists, Rome, Italy
| | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Antonio Silverii
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | - Luigi Uccioli
- Diabetes Section CTO Hospital and Dept of Biomedicine and Prevention Tor Vergata, University of Rome, Rome, Italy
| | | | - Edoardo Mannucci
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | | | - Mauro Gargiulo
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Lee JH, Jeon HS, Lee JW, Youn YJ, Ahn SG, Kim H, Bae Y, Kim U, Ahn CM, Ko YG. Impact of guideline-directed medical therapy on 5-year mortality in patients with newly diagnosed peripheral artery disease. J Vasc Surg 2023; 78:1471-1478.e3. [PMID: 37597591 DOI: 10.1016/j.jvs.2023.08.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Current guidelines recommend that patients with peripheral artery disease (PAD) should be treated with antithrombotic agents, renin-angiotensin-system blockers, and statins. However, the clinical impact of guideline-directed medical therapy (GDMT) on long-term mortality in patients with newly diagnosed PAD remains unclear. We aimed to investigate the prevalence of GDMT and evaluate 5-year mortality according to GDMT after PAD diagnosis. METHODS This retrospective cohort study, using nationwide health insurance claims data in Korea, included patients newly diagnosed with PAD between 2006 and 2015. GDMT was defined as the use of all drugs, including antithrombotic agents, renin-angiotensin-system blockers, and statins, within 3 months of PAD diagnosis. The primary endpoint was all-cause mortality. RESULTS We investigated 19,561 newly diagnosed patients with PAD without proven cardiovascular disease. Among the study population, 4378 patients (22.4%) were categorized in the GDMT and 15,183 (77.6%) in the non-GDMT groups. During the 5-year follow-up, GDMT showed a lower incidence of all-cause mortality than that of non-GDMT (2.8% vs 4.8%; adjusted hazard ratio, 0.329; 95% confidence interval, 0.257-0.421; P < .001). Even in the propensity-matched population, GDMT showed a lower mortality rate than non-GDMT (hazard ratio, 0.283; 95% confidence interval, 0.217-0.370; P < .001). As the number of guideline-recommended drugs increased, the mortality rate decreased proportionately. CONCLUSIONS After PAD diagnosis, GDMT was associated with a lower incidence of mortality regardless of proven cardiovascular disease. This retrospective analysis showed an insufficient prevalence of GDMT among patients with PAD in real-world practice.
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Affiliation(s)
- Jung-Hee Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Ho Sung Jeon
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Young Jin Youn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Sung Gyun Ahn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Hoseob Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Yoonjong Bae
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Fransson T, Gottsäter A, Abdulrasak M, Malina M, Resch T. Randomized clinical Trial Comparing drug Eluting Stent Zilver PTX® Versus Bare Metal Stent Zilver Flex® for Treatment of Lesions in Femoral and Popliteal Arteries in Chronic Limb Threatening Ischemia. Vasc Endovascular Surg 2023; 57:706-716. [PMID: 37085152 DOI: 10.1177/15385744231171746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
OBJECTIVE Drug eluting stents (DES) might improve the results of stenting in the femoropopliteal (FP) segment, but randomized data between DES and BMS in the treatment of patients with chronic limb threatening ischemia (CLTI) is lacking. The aim of this study was to perform a randomized comparison, between DES and bare metal stent (BMS) implantation in a subgroup of CLTI patients with lesions in the superficial femoral artery (SFA) and the P1-P2 portion of the popliteal artery. METHODS Patients presenting with CLTI scheduled for endovascular treatment of FP lesions were randomly assigned by blinded envelopes 1:1 in a single blinded, parallel group design to DES or BMS after lesion crossing. Primary endpoints were target lesion revascularization (TLR) at 12 and 24 months and primary patency at 12 and 24 months. Secondary endpoints were technical success (TS), clinical success, secondary patency at 12 and 24 months, limb salvage, serious adverse events (SAE) at 24 month and survival at five years. RESULTS A total of 48 CLTI patients and 49 limbs, were enrolled, 22 in the BMS group and 27 in the DES group. Demographics, comorbidities, and Rutherford class were similar in both treatment arms. The overall rate of total occlusions was 96% and the corresponding overall median lesion length was 240 mm. No patients were lost to follow up. No significant differences were detected between groups regarding TLR and primary patency. The overall primary patency at 12 and 24 months was 42.9% and 36.7% respectively and the overall freedom from TLR was 67.3% and 61.2% respectively. The results in the two groups were also similar regarding secondary outcomes. CONCLUSIONS This single centre, randomized study could not demonstrate superiority of DES compared to BMS when treating long FP lesions in patients with CLTI but was limited by insufficient patient inclusion.
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Affiliation(s)
- Torbjörn Fransson
- Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Mohammad Abdulrasak
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- Department of Internal Medicine, Section of Gastroenterology, Skåne University Hospital, Malmö, Sweden
| | - Martin Malina
- West London Vascular and Interventional Centre, Northwick Park University Hospital, Harrow, UK
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Dubosq-Lebaz M, Fels A, Chatellier G, Gouëffic Y. Systematic Review and Meta-analysis of Clinical Outcomes After Endovascular Treatment in Patients With Femoropopliteal Lesions Greater Than 150 mm. J Endovasc Ther 2023:15266028231202709. [PMID: 37776300 DOI: 10.1177/15266028231202709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
OBJECTIVE Indications for endovascular treatment of femoropopliteal (FP) lesions have steadily increased over the past decade. Accordingly, the number of devices has also increased but the choice of the best endovascular treatment remains to be defined. The aim of this meta-analysis was to summarize all studies investigating endovascular treatment of FP lesions greater than 150 mm from 2010 to 2021. METHODS Articles were searched using PubMed, Scopus, and Cochrane. Included studies were randomized controlled trials (RCTs), cohort studies, and case series (prospective and retrospective) that evaluated any endovascular procedure in patients with long FP lesions classified TASC (Trans-Atlantic Inter-Society Consensus document II on management of peripheral arterial disease) C and/or D, and a mean length >150 mm, primary outcome had to be the 1-year primary patency. Overall estimate of primary patency, secondary patency, and freedom from target lesion revascularization (TLR) at 1 year depending on the different devices were investigated. The meta-analysis was conducted following the requirements of the MOOSE (Meta-analysis of Observational Studies in Epidemiology) checklist. RESULTS Forty-four papers comprising 4847 patients and 5282 treated limbs were included. Mean lesions length ranged from 150.5 to 330 mm. The pooled 1-year primary and secondary patencies, and freedom from TLR rates were 0.71 (95% CI: 0.67-0.74), 0.87 (95% CI: 0.83-0.91), and 0.79 (95% CI: 0.74-0.84), respectively. Primary permeability at 1 year were 0.68 (95% CI: 0.62-0.73), 0.67 (95% CI: 0.60-0.74), 0.74 (95% CI: 0.64-0.84), and 0.83 (95% CI: 0.78-0.88) for bare metal stents, covered stents (CSs), drug-eluting stents, and drug-coated balloons (DCBs), respectively. Lesions treated with DCB had the highest 1-year primary patency rate. CONCLUSIONS At 1-year, endovascular procedures for FP lesions greater than 150 mm obtain satisfactory results. High primary patency rates were obtained with drug-coated devices, while CSs obtained less favorable results. Randomized studies comparing different devices in the treatment of long FP lesions remain necessary to determine the most optimal approach for the management of these patients. CLINICAL IMPACT This paper highlights on the one hand the satisfactory results of endovascular treatment on complex femoropopliteal lesions formerly reserved for conventional surgery. On the other hand, among the available devices, paclitaxel-eluting devices seem to show superior results which should make them recommended as first-line treatment.
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Affiliation(s)
- Maxime Dubosq-Lebaz
- Vascular & Endovascular Surgery, Aortic Center, Institut Coeur-Poumon, CHU de Lille, Lille, France
| | - Audrey Fels
- Clinical Research Department, Groupe Hospitalier Paris St Joseph, Paris, France
| | - Gilles Chatellier
- Clinical Research Department, Groupe Hospitalier Paris St Joseph, Paris, France
| | - Yann Gouëffic
- Department of Vascular and Endovascular Surgery, Groupe Hospitalier Paris St Joseph, Paris, France
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Enzmann FK, Nierlich P, Hölzenbein T, Aspalter M, Kluckner M, Hitzl W, Opperer M, Linni K. Vein Bypass Versus Nitinol Stent in Long Femoropopliteal Lesions: 4-Year Results of a Randomized Controlled Trial. Ann Surg 2023; 277:e1208-e1214. [PMID: 35185122 DOI: 10.1097/sla.0000000000005413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to compare technical success, patency rates and clinical outcomes of vein bypass (VBP) with angioplasty and nitinol stents (NS) in femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) II C and D lesions. SUMMARY BACKGROUND DATA Guidelines widely recommend an endovas-cular-first strategy for long femoropopliteal lesions without sufficient data comparing it with vein bypass surgery. METHODS A single-center prospective, randomized controlled trial (RCT) was performed, after approval of the local ethics committee, with technical success, primary and secondary patency as primary endpoints. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS Between 2016 and 2020, 218 limbs (109 per group) in 209 patients were included. Baseline and lesion characteristics were similar in both groups with a mean lesion length of 268 mm. The indication for treatment was chronic limb threatening ischemia in 53% of limbs in both groups. Technical success was feasible in 88% in the stent group. During a 4-year follow-up, primary patency, freedom from target lesion revascularizations, limb salvage, survival and complications showed no significant differences between the groups. At 48 months secondary patency for the bypass group was 73% versus 50% in the stent group ( P = 0.021). Clinical improvement was significantly superior in the bypass group with 52% versus 19% reaching a Rutherford 0 category ( P < 0.001). CONCLUSIONS This is the largest RCT comparing angioplasty with NS and vein bypass in femoropopliteal TASC II C and D lesions and the first to report 4-year results. The data underline the feasibility of endovascular treatment in long lesions but also emphasize the advantages of VBP.
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Affiliation(s)
- Florian K Enzmann
- Department of Vascular Surgery, Medical University of Innsbruck, Austria
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Austria
| | - Patrick Nierlich
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Austria
| | - Thomas Hölzenbein
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Austria
| | - Manuela Aspalter
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Austria
| | - Michaela Kluckner
- Department of Vascular Surgery, Medical University of Innsbruck, Austria
| | - Wolfgang Hitzl
- Research and Innovation (FMTT) (biostatistics), Paracelsus Medical University Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Austria
- Department of Anesthesiology, Paracelsus Medical University, Salzburg, Austria
| | - Mathias Opperer
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Austria; and
| | - Klaus Linni
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Austria
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Bradbury AW, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, Chetter I, Diamantopoulos A, Ganeshan A, Hall J, Hobbs S, Houlind K, Jarrett H, Lockyer S, Malmstedt J, Patel JV, Patel S, Rashid ST, Saratzis A, Slinn G, Scott DJA, Zayed H, Deeks JJ. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet 2023; 401:1798-1809. [PMID: 37116524 DOI: 10.1016/s0140-6736(23)00462-2] [Citation(s) in RCA: 98] [Impact Index Per Article: 98.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Chronic limb-threatening ischaemia is the severest manifestation of peripheral arterial disease and presents with ischaemic pain at rest or tissue loss (ulceration, gangrene, or both), or both. We compared the effectiveness of a vein bypass first with a best endovascular treatment first revascularisation strategy in terms of preventing major amputation and death in patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. METHODS Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-2 was an open-label, pragmatic, multicentre, phase 3, randomised trial done at 41 vascular surgery units in the UK (n=39), Sweden (n=1), and Denmark (n=1). Eligible patients were those who presented to hospital-based vascular surgery units with chronic limb-threatening ischaemia due to atherosclerotic disease and who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. Participants were randomly assigned (1:1) to receive either vein bypass (vein bypass group) or best endovascular treatment (best endovascular treatment group) as their first revascularisation procedure through a secure online randomisation system. Participants were excluded if they had ischaemic pain or tissue loss considered not to be primarily due to atherosclerotic peripheral artery disease. Most vein bypasses used the great saphenous vein and originated from the common or superficial femoral arteries. Most endovascular interventions comprised plain balloon angioplasty with selective use of plain or drug eluting stents. Participants were followed up for a minimum of 2 years. Data were collected locally at participating centres. In England, Wales, and Sweden, centralised databases were used to collect information on amputations and deaths. Data were analysed centrally at the Birmingham Clinical Trials Unit. The primary outcome was amputation-free survival defined as time to first major (above the ankle) amputation or death from any cause measured in the intention-to-treat population. Safety was assessed by monitoring serious adverse events up to 30-days after first revascularisation. The trial is registered with the ISRCTN registry, ISRCTN27728689. FINDINGS Between July 22, 2014, and Nov 30, 2020, 345 participants (65 [19%] women and 280 [81%] men; median age 72·5 years [62·7-79·3]) with chronic limb-threatening ischaemia were enrolled in the trial and randomly assigned: 172 (50%) to the vein bypass group and 173 (50%) to the best endovascular treatment group. Major amputation or death occurred in 108 (63%) of 172 patients in the vein bypass group and 92 (53%) of 173 patients in the best endovascular treatment group (adjusted hazard ratio [HR] 1·35 [95% CI 1·02-1·80]; p=0·037). 91 (53%) of 172 patients in the vein bypass group and 77 (45%) of 173 patients in the best endovascular treatment group died (adjusted HR 1·37 [95% CI 1·00-1·87]). In both groups the most common causes of morbidity and death, including that occurring within 30 days of their first revascularisation, were cardiovascular (61 deaths in the vein bypass group and 49 in the best endovascular treatment group) and respiratory events (25 deaths in the vein bypass group and 23 in the best endovascular treatment group; number of cardiovascular and respiratory deaths were not mutually exclusive). INTERPRETATION In the BASIL-2 trial, a best endovascular treatment first revascularisation strategy was associated with a better amputation-free survival, which was largely driven by fewer deaths in the best endovascular treatment group. These data suggest that more patients with chronic limb-threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion should be considered for a best endovascular treatment first revascularisation strategy. FUNDING UK National Institute of Health Research Health Technology Programme.
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Affiliation(s)
- Andrew W Bradbury
- University Department of Vascular Surgery, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Solihull, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Matthew Popplewell
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lewis Meecham
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Gareth R Bate
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lisa Kelly
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Chetter
- Hull York Medical School, University of Hull and University of York, York, UK
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guy's and St Thoma's NHS Foundation Trust, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Arul Ganeshan
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jack Hall
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Simon Hobbs
- Department of Vascular Surgery, Dudley Group NHS Foundation Trust, Dudley, UK
| | - Kim Houlind
- Lillebaelt Hospital, University of Southern Denmark, Odense, Denmark
| | - Hugh Jarrett
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Suzanne Lockyer
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Division of Vascular Surgery, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Jai V Patel
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Smitaa Patel
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - S Tawqeer Rashid
- Department of Vascular Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Athanasios Saratzis
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - D Julian A Scott
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thoma's NHS Foundation Trust, London, UK
| | - Jonathan J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Nasr B, Gouailler F, Marret O, Guillou M, Chaillou P, Guyomarc'h B, Maurel B, Gouëffic Y. Treatment of Long Femoropopliteal Lesions With Self-Expanding Interwoven Nitinol Stent: 24 Month Outcomes of the STELLA-SUPERA Trial. J Endovasc Ther 2023; 30:98-105. [PMID: 35114841 DOI: 10.1177/15266028221075227] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The performance of self-expanding interwoven nitinol stent (Supera) in femoropopliteal interventions has been proven through trials with short lesions and with relatively low proportion of occlusions. There is limited evidence of Supera stent in long lesions. The aim of this study was to assess the clinical safety and efficiency of the Supera stent in the treatment of long femoropopliteal lesions (Trans-Atlantic Inter-Society Consensus [TASC] C/D) in patients with symptomatic peripheral arterial disease (PAD). METHODS The STELLA SUPERA (STEnting Long de L'Artère fémorale superficielle par le stent métallique Supera) is a prospective, 2-center, single-arm study. Patients with symptomatic (Rutherford stages 2-6) de novo and TASC C/D lesions of the femoropopliteal segment were treated with Supera stent. The primary endpoint was the primary sustained clinical improvement at 12 months. Follow-up included clinical examination, duplex scan, and biplane X-ray up to 24 months. RESULTS Between December 2016 and October 2018, 48 symptomatic patients with 49 femoropopliteal lesions (TASC D = 32, 65%) were treated. The mean lesion length was 234 ± 123 mm, and 78% were total occlusion. The mean stented lesion length was 273 ± 127 mm. At 12 and 24 months, the primary sustained clinical improvement rate was 87.2% and 79.7%, respectively. The Rutherford category assessment was significantly improved at 24 months compared with baseline (p=0.02). At 24 months, the primary patency and freedom from target lesion revascularization (TLR) rates were 77.9% and 86.9%, respectively. The ankle-brachial pressure index increased from 0.62 ± 0.15 at baseline to 0.93 ± 0.15 at 24 months (p<0.0001). There were no stent fractures at 24 months. CONCLUSION The use of Supera stent in long lesions (TASC C/D) is a safe and effective endovascular alternative. These results reinforce the need for randomized clinical trials to assess the value of interwoven stents for long femoropopliteal lesions.
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Affiliation(s)
- Bahaa Nasr
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Flora Gouailler
- Service de Chirurgie Vasculaire, Clinique Océane, Vannes, France
| | - Olivier Marret
- Service de Chirurgie Vasculaire, CH de la Roche sur Yon, La Roche-sur-Yon, France
| | - Marie Guillou
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Philippe Chaillou
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Béatrice Guyomarc'h
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Blandine Maurel
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France.,Laboratoire de Physiopathologie de la Résorption Osseuse, Inserm-UN UMR-957, Nantes, France
| | - Yann Gouëffic
- Laboratoire de Physiopathologie de la Résorption Osseuse, Inserm-UN UMR-957, Nantes, France.,Service de Chirurgie Vasculaire et Endovasculaire, Groupe Hospitalier Paris St Joseph, Paris, France
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8
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Farhan S, Enzmann FK, Bjorkman P, Kamran H, Zhang Z, Sartori S, Vogel B, Tarricone A, Linni K, Venermo M, van der Veen D, Moussalli H, Mehran R, Reijnen MMPJ, Bosiers M, Krishnan P. Revascularization Strategies for Patients With Femoropopliteal Peripheral Artery Disease. J Am Coll Cardiol 2023; 81:358-370. [PMID: 36697136 DOI: 10.1016/j.jacc.2022.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND No adequately powered studies exist to compare major clinical outcomes after endovascular therapy (EVT) with stent implantation vs bypass surgery (BSx) for symptomatic femoropopliteal peripheral artery disease. OBJECTIVES This study sought to perform a pooled analysis of individual patient data from all randomized controlled trials comparing EVT vs BSx. METHODS Principal investigators of 5 of 6 available randomized controlled trials agreed to pool individual patient data. The primary endpoint was major adverse limb events, a composite of all-cause death, major amputation, or target limb reintervention. Secondary endpoints included amputation-free survival, individual major adverse limb event components, and primary patency. Early complications were bleeding, infection, or all-cause death within 30 days. RESULTS A total of 639 patients were analyzed with a mean age of 68.1 ± 9.1 years and 29.0% women. Baseline characteristics were comparable between groups. At 2 years, there were no significant differences between patients who received EVT and those who received BSx regarding major adverse limb events (40.1% vs 36.4%; log-rank P = 0.447; adjusted HR [aHR]: 1.04; 95% CI: 0.80-1.36), amputation-free survival (88.1% vs 90.0%; log-rank P = 0.455; aHR for death or amputation: 1.04; 95% CI: 0.63-1.71) and the other secondary endpoints except for primary patency, which was lower in patients who received EVT vs those who received BSx (51.2% vs 61.3%; log-rank P = 0.024; aHR for loss of primary patency: 1.31; 95% CI: 1.02-1.69). EVT was associated with significantly lower rates of early complications (6.8% vs 22.6%; P < 0.001) and shorter hospital stay (3.1 ± 4.2 days vs 7.4 ± 4.9 days; P < 0.001). CONCLUSIONS These findings further support the efficacy and safety of EVT as an alternative to BSx in patients with symptomatic femoropopliteal peripheral artery disease.
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Affiliation(s)
- Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Florian K Enzmann
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Bjorkman
- Department of Cardiac, Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Haroon Kamran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arthur Tarricone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Klaus Linni
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Maarit Venermo
- Department of Cardiac, Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Herve Moussalli
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Marc Bosiers
- A.Z. Sint-Blasius Hospital, Dendermonde, Belgium
| | - Prakash Krishnan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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9
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Nasr B, Dubosq M, Gouëffic Y. Bare metal stent in the area of drug eluting devices for long femoropopliteal lesions. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:581-586. [PMID: 35687067 DOI: 10.23736/s0021-9509.22.12374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The advancement in the endovascular treatment and the introduction of novel techniques allowed treatment of more complex and longer femoropopliteal lesions. However, the optimal treatment modality is still a source of controversy. The use of bare metal stents (BMS) showed good results for long femoropopliteal lesions. In this review, we summarized all available data on the different treatment strategies of long femoro-popliteal lesions using BMS. Nevertheless, RCTs with head-to-head comparison between BMS strategies are still needed to have more clarification on the best strategy for the endovascular treatment of long femoropopliteal occlusive lesions.
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Affiliation(s)
- Bahaa Nasr
- Department of Vascular and Endovascular Surgery, Brest University Hospital, Brest, France -
- INSERM UMR 1101, LaTIM, Brest, France -
| | - Maxime Dubosq
- Aortic Center, Institut Cœur-Poumon, CHU Lille, Lille, France
| | - Yann Gouëffic
- Department of Vascular and Endovascular Surgery, Paris St. Joseph Hospital, Paris, France
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10
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Gouëffic Y. Insights into endovascular treatment of long femoropopliteal lesions. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:541-542. [PMID: 35758090 DOI: 10.23736/s0021-9509.22.12419-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Yann Gouëffic
- Department of Vascular and Endovascular Surgery, Groupe Hospitalier Paris St Joseph, Paris, France -
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11
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Nierlich P, Hoelzenbein T, Enzmann F. Is open surgery still the first line of treatment for long femoropopliteal lesions? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:575-580. [PMID: 35687065 DOI: 10.23736/s0021-9509.22.12347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Treatment of long femoropopliteal lesions remains a challenge for vascular physicians as patients often present with multilevel complex pathologies and consequently face a high amputation risk and associated mortality. This review aimed to assess the current state of optimal revascularizations for the treatment of long femoropopliteal lesions. EVIDENCE ACQUISITION An online literature research of medical databases for original articles and review articles on open and endovascular revascularization of femoropopliteal lesions was conducted using mesh terms. EVIDENCE SYNTHESIS There has been an accumulation of evidence over the last years that endovascular treatment is a feasible and enduring alternative to open surgery for treatment of long femoropopliteal lesions if the lesions are restricted to the superficial femoral artery. But when disease extends to the infragenual level venous bypass remains superior with regards to long-term patency, clinical improvement and limb-salvage. CONCLUSIONS While the role of venous bypass as a first-line treatment might be declining, especially in frail patients or claudicants, the superior clinical improvement and amputation-free survival highlighted in several trials, demonstrate the relevance of bypass surgery. More randomized clinical trials are needed to verify the non-inferiority of endovascular treatment options to open surgery, especially when arterial disease extends below the knee.
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Affiliation(s)
| | | | - Florian Enzmann
- Department of Vascular Surgery, University Innsbruck, Innsbruck, Austria
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12
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Gray WA, Cardenas J, Teigen CL. Evaluation of safety and efficacy of the S.M.A.R.T.® Flex Vascular Stent System (OPEN study). Catheter Cardiovasc Interv 2022; 100:1078-1087. [PMID: 36177491 DOI: 10.1002/ccd.30414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/23/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The OPEN study evaluated the safety and efficacy of the S.M.A.R.T.® Flex Vascular Stent System in patients with femoropopliteal arterial disease. BACKGROUND Long-term data on endovascular treatments of femoropopliteal arterial disease are required to establish the repair durability. METHODS The OPEN study was a multicenter, single-arm, prospective study comparing primary safety and efficacy outcomes to performance goals (PG) developed for bare nitinol stents. Patients with symptoms due to a single, ≤180 mm length, de novo femoropopliteal arterial lesion with >70% stenosis were enrolled were enrolled and followed for 36 months. Subjects with lesions ≤150 mm served as the initial comparison cohort for the PG (other cohorts were analyzed if the PG was met). RESULTS 257 subjects with lesions ≤180 mm were enrolled. The mean lesion length was 71 ± 46, and 52.5% had severe claudication. The primary safety endpoint (freedom from all-cause death, index limb amputation, and target lesion revascularization [TLR] through 30 days) was met in 98.8% (96.5%, 99.6%) of subjects in the comparison cohort, meeting the PG (88.0%). The primary efficacy endpoint (comparison cohort vessel patency at 12 months) was 68.4% (61.1%, 74.8%), where the lower limit of the 95% confidence interval did not meet the 66.0% PG. Freedom from TLR in the per-protocol cohort at 12-, 24-, 36-month was 84.7%, 74.6%, and 72.8%, respectively. The 24-month stent fracture rate was 4.3%, with no new fractures identified at 36 months. CONCLUSION The results show promising long-term safety and effectiveness for the S.M.A.R.T.® Flex Vascular Stent System in patients with femoropopliteal arterial disease.
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Affiliation(s)
- William A Gray
- Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
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13
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Algorithm of Femoropopliteal Endovascular Treatment. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091293. [PMID: 36143968 PMCID: PMC9501396 DOI: 10.3390/medicina58091293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 12/04/2022]
Abstract
Background and Objectives: Indications for the endovascular treatment of femoropopliteal lesions have steadily increased over the past decade. Accordingly, the number of devices has also increased, but the choice of the best endovascular treatment remains to be defined. Many devices are now available for physicians. However, in order to obtain a high success rate, it is necessary to respect an algorithm whose choice of device is only one step in the treatment. Materials and Methods: The first step is, therefore, to define the approach according to the lesion to be treated. Anterograde approaches (femoral, radial, or humeral) are distinguished from retrograde approaches depending on the patient’s anatomy and surgical history. Secondarily, the lesion will be crossed intraluminally or subintimally using a catheter or an angioplasty balloon. The third step corresponds to the preparation of the artery, which is essential before the implantation of the device. It has a crucial role in reducing the rate of restenosis. Several tools are available and are chosen according to the lesion requiring treatment (stenosis, occlusion). Among them, we find the angioplasty balloon, the atherectomy probes, or intravascular lithotripsy. Finally, the last step corresponds to the choice of the device to be implanted. This is also based on the nature of the lesion, which is considered short, up to 15 cm and complex beyond that. The choice of device will be between bare stents, covered stents, drug-coated balloons, and drug-eluting stents. Currently, drug-eluting stents appear to be the treatment of choice for short lesions, and active devices seem to be the preferred treatment for more complex lesions, although there is a lack of data. Results: In case of failure to cross the lesion, the retrograde approach is a safe and effective alternative. Balloon angioplasty currently remains the reference method for the preparation of the artery, the aim of which is to ensure the intraoperative technical success of the treatment (residual stenosis < 30%), to limit the risk of dissection and, finally, to limit the occurrence of restenosis. Concerning the treatment, the drug-eluting devices seem to present the best results, whether for simple or complex lesions. Conclusions: Endovascular treatment for femoropopliteal lesions needs to be considered upstream of the intervention in order to anticipate the treatment and the choice of devices for each stage.
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14
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Kluckner M, Nierlich P, Hitzl W, Aschacher T, Gratl A, Wipper S, Aspalter M, Moussalli H, Linni K, Enzmann FK. Long-Term Results of Endovascular Treatment with Nitinol Stents for Femoropopliteal TASC II C and D Lesions. Medicina (B Aires) 2022; 58:medicina58091225. [PMID: 36143902 PMCID: PMC9500608 DOI: 10.3390/medicina58091225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/21/2022] [Accepted: 09/03/2022] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives: The feasibility of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) II C and D femoropopliteal artery lesions has been described, but no prospective study has performed a long-term follow-up. The aim of this study was to report the long-term results of nitinol stents (NS) for the treatment of long femoropopliteal lesions. Materials and Methods: A single-center prospective, randomized controlled trial (RCT) comparing EVT with NS and vein bypass surgery was previously performed. The EVT group’s follow-up was extended and separately analyzed with primary patency as the primary endpoint. The secondary endpoints were technical success, secondary patency, reinterventions, limb salvage, survival, complications, and clinical improvement. Results: Between 2016 and 2020, 109 limbs in 103 patients were included. A total of 48 TASC II C and 61 TASC II D lesions with a mean lesion length of 264 mm were reported. In 53% of limbs, the indication for treatment was chronic limb-threatening ischemia. The median follow-up was 45 months. Technical success was achieved in 88% of cases, despite 23% of the lesions being longer than 30 cm (retrograde popliteal access in 22%). At four-year follow-up, primary patency, secondary patency, and freedom from target lesion revascularizations were 35%, 48%, and 58%, respectively. Limb salvage and survival were 90% and 80% at 4 years. Clinical improvement of at least one Rutherford category at the end of follow-up was achieved in 83% of limbs. Conclusions: This study reports the longest follow-up of endovascular treatment with nitinol stents in femoropopliteal TASC II C and D lesions. The results emphasize the feasibility of an endovascular-first strategy, even in lesions beyond 30 cm in length, and clarify its acceptable long-term durability and good clinical outcomes. Large multicenter RCTs with mid- and long-term follow-up are needed to investigate the role of different endovascular techniques in long femoropopliteal lesions.
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Affiliation(s)
- Michaela Kluckner
- Department of Vascular Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria
| | - Patrick Nierlich
- Chirurgie Nierlich, Vienna Private Hospital, A-1090 Vienna, Austria
| | - Wolfgang Hitzl
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
- Research and Innovation Management, Paracelsus Medical University, A-5020 Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, A-5020 Salzburg, Austria
| | - Thomas Aschacher
- Department of Cardiovascular Surgery, Clinic Floridsdorf and Karl Landsteiner Institute for Cardio-Vascular Research, A-1210 Vienna, Austria
| | - Alexandra Gratl
- Department of Vascular Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria
| | - Sabine Wipper
- Department of Vascular Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria
| | - Manuela Aspalter
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, A-5020 Salzburg, Austria
| | - Herve Moussalli
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, A-5020 Salzburg, Austria
| | - Klaus Linni
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, A-5020 Salzburg, Austria
| | - Florian K. Enzmann
- Department of Vascular Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria
- Correspondence:
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Mosarla RC, Armstrong E, Bitton-Faiwiszewski Y, Schneider PA, Secemsky EA. State-of-the-Art Endovascular Therapies for the Femoropopliteal Segment: Are We There Yet? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1. [PMID: 36268042 PMCID: PMC9581461 DOI: 10.1016/j.jscai.2022.100439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Peripheral arterial disease is an increasingly prevalent condition with significant associated morbidity, mortality, and health care expenditure. Endovascular interventions are appropriate for most patients with either ongoing symptoms of intermittent claudication despite lifestyle and medical optimization or chronic limb-threatening ischemia. The femoropopliteal segment is the most common arterial culprit responsible for claudication and the most commonly revascularized segment. Endovascular approaches to revascularization of the femoropopliteal segment are advancing with an evolving landscape of techniques for arterial access, device-based therapies, vessel preparation, and intraprocedural imaging. These advances have been marked by debate and controversy, notably related to the safety of paclitaxel-based devices and necessity of atherectomy. In this review, we provide a critical overview of the current evidence, practice patterns, emerging evidence, and technological advances for endovascular intervention of the femoropopliteal arterial segment.
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Affiliation(s)
| | - Ehrin Armstrong
- Adventist Heart and Vascular Institute, St Helena, California
| | | | | | - Eric A. Secemsky
- Harvard Medical School, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Corresponding author: (E.A. Secemsky)
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Gostev AA, Osipova OS, Saaya SB, Bugurov SV, Cheban AV, Rabtsun AA, Ignatenko PV, Karpenko AA. Bypass Versus Interwoven Nitinol Stents for Long Femoro-Popliteal Occlusions: A Propensity Matched Analysis. Cardiovasc Intervent Radiol 2022; 45:929-938. [PMID: 35581472 DOI: 10.1007/s00270-022-03134-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/23/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE To compare femoro-popliteal bypass and interwoven nitinol stenting for long occlusions of the femoro-popliteal segment. MATERIALS AND METHODS Single center retrospective propensity matching analysis of the symptomatic patients with long occlusion of the femoro-popliteal segment (> 20 cm), who underwent stenting with interwoven nitinol stent or femoro-popliteal bypass from 2012 to 2020. PRIMARY ENDPOINTS primary patency, primary-assisted patency, secondary patency. Secondary endpoints: major adverse cardiovascular events, major adverse limb events, primary sustained clinical improvement, survival. RESULTS A total of 437 patients were enrolled: 294 in the bypass group and 143 in the endovascular therapy (EVT) group. After propensity score matching, 264 and 113 patients remained in the groups, respectively. A median occlusion length was 250 mm. One-year and two-year primary and secondary patency rates were comparable in both groups (two-year primary patency: 68.5% for bypass vs. 68.9% for EVT, p = 1.00). In the "above the knee" subgroup analysis, two-year secondary patency was higher in the EVT group than in the bypass group (90.9% vs. 77.5%, p = 0.048). In "below-the-knee" subgroup analysis, primary and primary assisted patency were statistically significantly higher in the EVT group than in artificial bypass subgroup (66.7% vs. 42.4%, p = .046 and 76.7% vs. 45.5%, p = .011, respectively). However, compared to autovenous bypass, the EVT group showed lower primary patency rates, although the differences are not significant. CONCLUSION A nonselective endovascular strategy can allow for regular successful treatment of femoro-popliteal lesions longer than 25 cm.
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Affiliation(s)
- Alexander A Gostev
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055.
| | - Olesya S Osipova
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
| | - Shoraan B Saaya
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
| | - Savr V Bugurov
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
| | - Alexey V Cheban
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
| | - Artem A Rabtsun
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
| | - Pavel V Ignatenko
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
| | - Andrey A Karpenko
- Department of Vascular Pathology and Hybrid Technologies, Meshalkin National Medical Research Center of the Ministry of Healthcare of the Russian Federation, Novosibirsk Area, Rechkunovskaya 15'th st., Novosibirsk, Russia, 630055
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17
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Kluckner M, Gratl A, Wipper SH, Hitzl W, Nierlich P, Aspalter M, Linni K, Enzmann FK. Comparison of Prosthetic and Vein Bypass with Nitinol Stents in Long Femoropopliteal Lesions. Ann Vasc Surg 2021; 78:272-280. [PMID: 34437960 DOI: 10.1016/j.avsg.2021.05.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/28/2021] [Accepted: 05/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Guidelines for the treatment of long femoropopliteal lesions are not based on a high level of evidence and recent randomized controlled trials (RCTs) challenge vein bypass (VBP) as the recommended therapy. This study compared prosthetic (PTFE) bypass, VBP and angioplasty with nitinol stents in long femoropopliteal lesions. METHODS Pooled data from a RCT and a retrospective database with the same inclusion criteria were analyzed with primary and secondary patency as well as freedom from target lesion revascularization (TLR) as primary endpoints. RESULTS Between 2016 and 2018 a total of 172 lesions were treated in three groups (PTFE: n = 62, VBP: n = 55, stent: n = 55). Clinical and lesion characteristics were similar with mean lesion lengths between 260 and 279mm. Technical success rate in the stent group was 87%. There were no significant differences between the groups in patency rates, freedom from TLR, limb salvage and survival during 2-year follow-up. The primary patency rates for the PTFE, VBP and stent groups were 50%, 56% and 60% at 2 years. The PTFE group had significantly less complications compared to the other groups and a shorter hospital-stay compared to the VBP group. Clinical improvement was significantly better in the PTFE and VBP group compared to the stent group. CONCLUSIONS The 2-year results indicate that the role of VBP as the recommended therapy for long femoropopliteal lesions may not be unchallenged due to the similar results in all three groups. Further RCTs are needed to determine the best revascularization modality for long femoropopliteal lesions.
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Affiliation(s)
- Michaela Kluckner
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Alexandra Gratl
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Sabine H Wipper
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Wolfgang Hitzl
- Research Office (biostatistics), Paracelsus Medical University Salzburg, Salzburg, Austria; Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria; Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Patrick Nierlich
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Manuela Aspalter
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Klaus Linni
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Florian K Enzmann
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria; Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria.
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18
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Lin Y, Li W, Liu W, Liu M, Li Y, Chen Y. Mid-term outcomes of endovascular treatment and risk factors for recurrence in patients with Trans-Atlantic-Inter-Society II C/D femoropopliteal lesions. Quant Imaging Med Surg 2021; 11:2028-2039. [PMID: 33936984 DOI: 10.21037/qims-20-221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The purpose of this study was to determine the efficacy of interventional endovascular treatment (EVT) and the risk factors for postoperative restenosis in patients with Trans-Atlantic Inter-Society Consensus (TASC) II C/D femoropopliteal lesions. Methods A total of 55 patients who received EVT for TASC II C/D femoropopliteal lesions (64 affected limbs) from October 2014 to September 2017 were examined. The mean lesion length was 19.6±5.3 (range, 15.5-26.4 cm). The femoropopliteal lesions were classified as TASC II C and TASC II D in 39 and 16 cases, respectively. The ankle-brachial index (ABI), primary patency rate, secondary patency rate, and limb salvage rate were monitored in follow-up evaluations for up to 24 months. A Cox regression model was used to evaluate the correlation between each of these factors and the restenosis rate after EVT. Results Patent TASC II C/D femoropopliteal lesions were present in 59 of the 64 limbs. The mean ABI values for the dorsal pedal artery and posterior tibial artery increased 1 month after treatment from a baseline level of 0.35±0.12 to 0.89±0.10 and from 0.43±0.15 to 0.90±0.13, respectively (P<0.01). The mean follow-up time was 19.3 (range, 6-24) months. The cumulative primary patency rates at 1, 3, 6, 12, 18, and 24 months were 98.3%, 91.5%, 84.3%, 61.1%, 53.1%, and 31.1%, respectively. The secondary patency rates at 12 and 24 months were 70.4% and 60.0%, respectively. Factors with a high hazard ratio included male sex, TASC II D, smoking, and diabetes mellitus (DM). Conclusions EVT had a safe and satisfactory mid-term therapeutic effect on TASC II C/D femoropopliteal lesions. Male sex, TASC II D (compared to TASC II C), smoking, and DM were risk factors for restenosis. EVT has a secondary patency rate comparable to that of open surgery and can be considered a first-line treatment for TASC II C/D femoropopliteal lesions.
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Affiliation(s)
- Yisheng Lin
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Weihao Li
- Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Wendao Liu
- Department of Interventional Radiology, Guangdong Province Traditional Chinese Medical Hospital, Guangzhou, China
| | - Min Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Yin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yong Chen
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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19
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Altable García M, Chiriboga Granja JI, Reviriego Eíros M, Zaragozá García JM, Plaza Martinez Á, Martinez Perelló I, Gómez Palonés FJ. Could prior endovascular interventions affect the results of lower extremity below the knee autologous vein bypasses? INT ANGIOL 2021; 40:315-322. [PMID: 33870675 DOI: 10.23736/s0392-9590.21.04542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Performing a non-selective primary endovascular approach involves risk of performing ineffective procedures and could compromise future treatments. The objective of this research is to determine if previous failed endovascular intervention could affect bypass results. METHODS Retrospective cohort study including 77 below the knee (BTK) bypasses with great saphenous vein (GSV) in patients with critical limb ischemia, carried out between 2008-2018. Primary bypasses (P-BP) were compared with bypasses with history of previous failed endovascular intervention (Secondary bypasses [S-BP]). Primary outcomes included: primary, primary-assisted, and secondary patency, and major amputation-free survival (AFS). The quality of GSV used was evaluated as a potential confounding factor. RESULTS Forty-six procedures were P-BP (59.7%) and 31 S-BP (40.3%). The mean follow-up was 35.4 (SD: 31) and 28 (DS: 30) months respectively. Univariate results showed an increased risk of loss of primary patency (HR=2.7), primary-assisted patency (HR=3.1) and secondary patency (HR=3.26) in S-BP (P<0.05). This group also presented a trend towards an increased risk of major amputation (HR=1.6; P>0.05). Suboptimal GSV was used in 29% of S-BP and 15% of P-BP. This factor was identified as confounding partially, as it decreased the influence assumed by the history of prior endovascular intervention in the analyzed variables. CONCLUSIONS Secondary bypasses show inferior results to primary bypasses in our series. Although the cause could be a prior failed endovascular intervention, the frequent use of suboptimal GSV in this type of patients may also contribute to this effect.
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Affiliation(s)
- Mario Altable García
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain -
| | - Jose I Chiriboga Granja
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain
| | - Mario Reviriego Eíros
- Department of Biodiversity, Ecology and Evolution, Complutense University of Madrid, Madrid, Spain.,Smart Intelligence Services (SAITS), Madrid, Spain
| | - José M Zaragozá García
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain
| | - Ángel Plaza Martinez
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain
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20
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Enzmann FK, Metzger P, Martin JES, Dabernig W, Akhavan F, Hölzenbein T, Nierlich P. The Upper-Arm Basilic-Cephalic Loop: A Valueable Alternative for Below-Knee Arterial Reconstruction. Vasc Endovascular Surg 2021; 55:348-354. [PMID: 33478360 DOI: 10.1177/1538574420980610] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Despite advances of endovascular interventions, bypass surgery remains the gold standard for treatment of long and complex arterial occlusions in the lower limb. Autologous vein is regarded superior to other options. As the graft of first choice, the great saphenous vein (GSV) is often not available due to previous bypass, stripping or poor quality. Other options like arm veins (AV) are important alternatives. As forearm portions of AVs are often unusable, a graft created from the upper arm basilic and cephalic veins provides a valuable alternative. PATIENTS AND METHODS We analyzed consecutive patients treated at an academic tertiary referral center between 01/1998 and 07/2018 using arm veins as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage and survival. RESULTS In the observed time period 2702 bypass procedures were performed at our institution for below-knee arterial reconstructions. Vein grafts used included the ipsilateral GSV (iGSV; n = 1937/71.7%), contralateral GSV (cGSV; 192/7.1%), small saphenous vein (SSV; 133/4.9%), prosthetic conduits (61/2.3%) and different configurations of AV (379/14%). In the majority of patients receiving AV grafts a complete continuous cephalic or basilic vein (CAV) was used (n = 292/77%). If it was not possible to use major parts of these 2 veins, either spliced arm vein grafts (SAV) (42/11%) or an upper arm basilic-cephalic loop graft (45/12%) were used. Median follow-up was 27 (interquartile range: 8-50) months. After 3 years secondary patency (CAV: 85%; SAV: 62%; loop: 66%; p = 0.125) and limb salvage rates (CAV: 79%, SAV: 68%; loop: 79%; p = 0.346) were similar between the 3 bypass options. CONCLUSION The encouraging results of alternative AV configurations highlight their value in case the basilic or cephalic veins are not useable in continuity. Especially for infragenual redo-bypass procedures, these techniques should be considered to offer patients durable revascularization options.
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Affiliation(s)
- Florian K Enzmann
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria
| | - Peter Metzger
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria.,Department of Surgery, A.ö. Bezirkskrankenhaus St. Johann, Austria
| | - Julio Ellacuriaga San Martin
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria
| | - Werner Dabernig
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria
| | - Fatema Akhavan
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria
| | - Thomas Hölzenbein
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria.,Department of Surgery, Sozialmedizinisches Zentrum Ost-Donauspital, Vienna, Austria
| | - Patrick Nierlich
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, 31507Paracelsus Medical University, Salzburg, Austria.,Department of Surgery, Hospital of St. John of God, 27271Medical University of Vienna, Austria
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21
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Böhme T, Noory E, Brechtel K, Scheinert D, Bosiers M, Beschorner U, Zeller T. Heparin-Bonded Stent-Graft for the Treatment of TASC II C and D Femoropopliteal Lesions: 36-Month Results of the Viabahn 25 cm Trial. J Endovasc Ther 2020; 28:222-228. [PMID: 33044119 DOI: 10.1177/1526602820965965] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the 36-month technical and clinical outcome after implantation of the 25-cm Viabahn endoprosthesis with Propaten bioactive surface in TransAtlantic Inter-Society Consensus II C and D lesions of the superficial femoral and proximal popliteal arteries. MATERIALS AND METHODS This prospective, multicenter, single-arm trial (ClinicalTrials.gov; identifier NCT01263665) enrolled 71 patients (mean age 66.7±8.3 years; 50 men) with lifestyle-limiting claudication or rest pain (Rutherford category 2-4) and long (>20-cm) lesions of the superficial femoral and proximal popliteal arteries. Primary endpoint was primary patency at 36 months. Secondary endpoints included primary assisted patency; secondary patency; freedom from target lesion revascularization (TLR); freedom from a composite of death, target vessel revascularization (TVR), and amputation; clinical success; and freedom from device fracture. RESULTS Primary patency estimated by Kaplan-Meier analysis was 40.6% at 36 months. Primary assisted patency and secondary patency estimates were 53.0% and 96.9%, respectively. Within 36 months, 27 patients had to undergo a TLR. Twenty-five patients (35.2%) had a TVR. Freedom from the composite of death, TVR, and amputation endpoint was 44.5%. The estimate of the sustained clinical success with stable or improved Rutherford category was 58.5%. No stent fracture was detected during follow-up. CONCLUSION The primary patency rate without reintervention after treatment of long femoropopliteal lesions is low. However, secondary patency after implantation of a Viabahn endoprosthesis is high and seems to be superior to the use of other revascularization techniques, resulting in persistent clinical improvement.
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Affiliation(s)
- Tanja Böhme
- Department Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Elias Noory
- Department Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Klaus Brechtel
- Department Radiology, MVZ GmbH Berlin-Tiergarten, Berlin, Germany
| | | | - Marc Bosiers
- Department Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium
| | | | - Thomas Zeller
- Department Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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22
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Nierlich P, Enzmann FK, Metzger P, Dabernig W, Aspalter M, Akhavan F, Hitzl W, Hölzenbein T. Alternative Venous Conduits for Below Knee Bypass in the Absence of Ipsilateral Great Saphenous Vein. Eur J Vasc Endovasc Surg 2020; 60:403-409. [DOI: 10.1016/j.ejvs.2020.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/19/2020] [Accepted: 06/11/2020] [Indexed: 01/01/2023]
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23
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Nierlich P, Enzmann FK, Metzger P, Dabernig W, Akhavan F, San Martin JE, Hitzl W, Hölzenbein T. Arm Vein versus Small Saphenous Vein for Lower Extremity Bypass in the Absence of Both Great Saphenous Veins. Ann Vasc Surg 2020; 70:341-348. [PMID: 32599110 DOI: 10.1016/j.avsg.2020.06.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bypass surgery remains the gold standard for long and complex arterial occlusions in the lower limb. The vein is regarded superior to prosthetic conduits in peripheral arterial bypass surgery. However, this option is often limited because of previous bypass, stripping, or poor quality of the ipsilateral and/or contralateral great saphenous vein (GSV). Under these circumstances, the arm vein (AV) and small saphenous vein (SSV) are the only alternative autologous vein grafts. METHODS We analyzed all consecutive patients treated at an academic tertiary referral center between January 1998 and July 2018 using either the AV or SSV as the main peripheral bypass graft. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS In total, 416 bypass procedures using exclusively AV (n = 327) or SSV (n = 89) were performed. There was a predominance of male gender. The majority of risk factors were evenly distributed between groups. The mean follow-up period was 2.3 years (0.9 to 13.3 years). Five-year primary and secondary patency rates were 39% (95% CI: 31-47%) and 67% (59-75%) for AV and 53% (41-66%) and 76% (67-86%) for SSV, respectively (P = 0.2 and 0.25). The five-year limb salvage and survival rates were 71% (68-81%) and 84% (77-90%) for AV and 78% (67-88%) and 90% (82-98%) for SSV, respectively (P = 0.52 and 0.11). CONCLUSIONS Both AV and SSV are equally effective alternatives for peripheral bypass if no GSV is available. Although there was a trend toward better results with the SSV, there was no significant difference between the 2 options.
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Affiliation(s)
- Patrick Nierlich
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria.
| | - Florian K Enzmann
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Peter Metzger
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria; Department of Surgery, A.ö. Bezirkskrankenhaus St.Johann, St.Johann, Austria
| | - Werner Dabernig
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Fatema Akhavan
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Julio Ellacuriaga San Martin
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Wolfgang Hitzl
- Research Office (Biostatistics), Paracelsus Medical University, Salzburg, Austria; Department of Ophtalmology and Glaucoma Research, Paracelsus Medical University Salzburg, Salzburg, Austria; Department of Ophtalmology, Research Program Experimental Ophtalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Hölzenbein
- Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
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24
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Menard MT. Defining the Role of Open and Endovascular Therapy in Complex PAD Patients. JACC Cardiovasc Interv 2019; 12:2550-2552. [PMID: 31786213 DOI: 10.1016/j.jcin.2019.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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