Predictive Factors for Restenosis Following Stent-Supported Endovascular Therapy with Intravascular Ultrasound Evaluation for Femoropopliteal Chronic Total Occlusion

ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg: 2023 Update

Acute onset of a cold, painful leg, also known as acute limb ischemia, describes the sudden loss of perfusion to the lower extremity and carries significant risk of morbidity and mortality. Acute limb ischemia requires rapid identification and the management of suspected vascular compromise and is inherently driven by clinical considerations. The objectives of initial imaging include confirmation of diagnosis, identifying the location and extent of vascular occlusion, and preprocedural/presurgical planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Factors in Sufficient Endovascular Vessel Preparation for Severely Calcified Femoropopliteal Lesions

BACKGROUND

Vessel preparation for endovascular treatment (EVT) is important but because the contributory factors for favorable outcomes are not yet known, we conducted the present study to elucidate the factors associated with sufficient vessel preparation for severely calcified femoropopliteal (FP) lesions.Methods and Results: This was a single-center retrospective observational study of 97 patients (mean age, 75±8 years, 76% male) with 106 de novo severely calcified FP lesions who underwent EVT under intravascular ultrasound (IVUS) evaluation. The lesion definition was 360° of superficial calcification on IVUS. The primary outcome measure was sufficient vessel preparation, which was defined as successful cracking of severely calcified lesions evaluated by IVUS after predilation. The mean lesion length was 200±103 mm, and chronic total occlusion was present in 38% of patients. According to the greater difference between the preballoon size and the lumen diameter of the severely calcified lesion, the frequency of sufficient vessel preparation increased (odds ratio, 4.68; 95% confidence interval, 2.09-10.49; P<0.01). Balloon type (noncompliant, P=0.80; scoring: P=0.25) and pressure (P=0.27) were non-contributory.

CONCLUSIONS

The difference between the lumen diameter at the severely calcified FP lesion site and the preballoon dilatation diameter was the sole factor contributing to sufficient vessel preparation.

Vascular Pathology and Impact of Stent Eccentricity for Stent Restenosis in Femoropopliteal Endovascular Therapy

PURPOSE

To explore the clinical features associated with stent eccentricity and reveal the impact of stent eccentricity on 1-year restenosis risk after femoropopliteal stent implantation for symptomatic atherosclerotic peripheral artery disease (PAD).

MATERIALS AND METHODS

The effect of stent asymmetry expansion immediately after treatment on long-term patency has not been fully investigated. We used the clinical database of a multicenter prospective study registering 2,018 limbs of 1,766 patients in whom intravascular ultrasound (IVUS)-supported femoropopliteal endovascular therapy (EVT) for symptomatic atherosclerotic PAD was planned from November 2015 to June 2017. We included 1,233 limbs of 1,088 patients implanted with either a bare nitinol stent, drug-eluting stent (DES), or stent graft, and administered two or more antithrombotic drugs. Stent eccentricity was evaluated using IVUS calculated as ((maximum diameter)/(minimum diameter) - 1) at the cross-section segment with the lowest lumen area after stent implantation.

RESULTS

Chronic total occlusion and bilateral arterial calcification (peripheral artery calcification scoring system grades 3 and 4) were positively associated with stent eccentricity, whereas renal failure on dialysis, DES, and stent graft use were negatively associated with stent eccentricity (all p<0.05). Stent eccentricity was associated with an increased risk of 1-year restenosis (odds ratio (OR) 1.18, 95% confidence interval (CI) 1.01-1.37; p=0.034). However, after adjustment for the lesion severity and implanted stent types, the association was no longer significant (OR 1.07, 95% CI 0.91-1.24; p=0.43).

CONCLUSION

Stent eccentricity was not significantly associated with 1-year restenosis risk after femoropopliteal EVT.

Diabetes and restenosis

Restenosis, defined as the re-narrowing of an arterial lumen after revascularization, represents an increasingly important issue in clinical practice. Indeed, as the number of stent placements has risen to an estimate that exceeds 3 million annually worldwide, revascularization procedures have become much more common. Several investigators have demonstrated that vessels in patients with diabetes mellitus have an increased risk restenosis. Here we present a systematic overview of the effects of diabetes on in-stent restenosis. Current classification and updated epidemiology of restenosis are discussed, alongside the main mechanisms underlying the pathophysiology of this event. Then, we summarize the clinical presentation of restenosis, emphasizing the importance of glycemic control in diabetic patients. Indeed, in diabetic patients who underwent revascularization procedures a proper glycemic control remains imperative.