Percutaneous angioplasty and stenting of the superficial femoral artery

Study on mid-term outcomes of atherectomy for patients with femoral popliteal artery lesions with different Global Limb Anatomic Staging System grades

Objective

To investigate the mid-term efficacy and patency rate of TurboHawk peripheral plaque excision system in the treatment of femoral popliteal artery lesions with different Global Limb Anatomic Staging System (GLASS) grades.

Methods

The clinical data of 141 patients with femoral popliteal arteriosclerosis obliterans who were treated with TurboHawk from January 2018 to July 2022 in our institution were retrospectively analyzed. There were 109 male patients and 32 female patients. Recordings were made of the patient's symptoms of limb ischemia, technical success rate, primary patency rate of target vessels, ankle brachial index (ABI), GLASS grades, postoperative complications, and a statistical analysis with the patient's preoperative treatment was conducted.

Results

All patients had improved limb ischemia symptoms to varying degrees after surgery, with a technical success rate of 100% (femoral artery puncture and superficial femoral artery recanalization) without bleeding, hematoma, pseudoaneurysm, arteriovenous fistula or other complications. The follow-up period was 1-24 months, during which the severity of claudication, resting pain, and toe ulcers significantly improved. The primary patency rate of the target vessel was 98.58% (139/141), and the ABI significantly increased on the second day, three months, and six months after surgery compared to before surgery. No major adverse events were found during follow-up. The patency rates at 1, 6, 12 and 24 months after intervention were 100%, 80%, 75% and 60% respectively.

Conclusion

The mid-term efficacy and patency rate of TurboHawk in the treatment of femoral popliteal artery lesions with GLASS I patients have the best mid-term prognosis, the highest mid-term survival rate, and the highest vascular patency. The plaque removal system has proven to be an effective treatment for individual localized chronic total occlusion lesions. Additionally, the TurboHawk system provides a safe and minimally invasive treatment alternative for superficial femoral artery conditions, achieving significant therapeutic results within a brief period.

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

Purpose

This retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting.

Methods

This treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1-P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter.

Results

Forty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period.

Conclusion

The endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Surveillance After Surgical and Endovascular Treatment for Peripheral Artery Disease: a Dutch Survey

OBJECTIVE

At present, there is no clear, optimal approach to surveillance after invasive treatment of peripheral artery disease (PAD) in terms of modality, duration, clinical benefit, and cost effectiveness. The ongoing debate on the clinical benefit and cost effectiveness of standard surveillance creates a clear knowledge gap and may result in overtreatment or undertreatment. In this study, a survey was conducted among vascular surgeons in the Netherlands to assess the currently applied surveillance programmes.

METHODS

All vascular surgeons from the Dutch Society for Vascular Surgery received an online survey on follow up after open and endovascular revascularisation in patients with PAD. Surveillance was defined as at least one follow up visit after intervention with or without additional imaging or ankle brachial index (ABI) measurement. Ten types of PAD intervention were surveyed.

RESULTS

Surveys were returned by 97 (46.2%) of 210 vascular surgeons, and 76% reported using a routine follow up protocol after an invasive intervention. Clinical follow up only is most commonly performed after femoral endarterectomy (53%). After peripheral bypass surgery, clinical follow up only is applied rarely (4 - 8%). In six of the 10 interventions surveyed, duplex ultrasound (DUS) was the most used imaging modality for follow up. After bypass surgery, 76 - 86% of vascular surgeons perform DUS with or without ABI measurement. After endovascular interventions, 21 - 60% performed DUS surveillance. Lifelong surveillance is most often applied after aortobifemoral bypass (57%). Surveillance frequency and duration vary greatly within the same intervention. Frequencies range from every three or six months to annually. Duration ranges from one time surveillance to lifelong follow up.

CONCLUSION

There is significant practice variation in surveillance after surgical and endovascular treatment of patients with PAD in the Netherlands. Prospective studies to evaluate treatment outcomes and to define the clinical need and cost effectiveness of standardised surveillance programmes for patients with PAD are recommended.

Prognostic Factors for Restenosis of Superficial Femoral Artery after Endovascular Treatment

High incidence of superficial femoral artery (SFA) restenosis after percutaneous transluminal angioplasty (PTA) poses a persistent challenge in peripheral arterial disease (PAD) treatment. We studied how the patients' and lesions' characteristics, thrombin generation, overall haemostatic potential (OHP), and single nucleotide polymorphisms (SNPs) of the NR4A2 and PECAM1 genes affected the likelihood of restenosis. In total, 206 consecutive PAD patients with limiting intermittent claudication due to SFA stenosis who were treated with balloon angioplasty with bailout stenting when necessary were included. Patients' clinical status and patency of the treated arterial segment on ultrasound examination were assessed 1, 6, and 12 months after the procedure. Restenosis occurred in 45% of patients, with less than 20% of all patients experiencing symptoms. In the multivariate analysis, predictors of restenosis proved to be poor infrapopliteal runoff, higher lesion complexity, absence of treated arterial hypertension, delayed lag phase in thrombin generation, and higher contribution of plasma extracellular vesicles to thrombin concentration. Poor infrapopliteal runoff increased the risk of restenosis in the first 6 months, but not later. The negative effect of poor infrapopliteal runoff on SFA patency opens questions about the potential benefits of simultaneous revascularisation of below-knee arteries along with SFA revascularisation.

Comparison of Clinical Outcomes in Patients Undergoing Common Femoral Thromboendarterectomy With or Without Patch Angioplasty

OBJECTIVE

Surgical thromboendarterectomy (TEA) is the standard treatment for an occlusive lesion of the common femoral artery (CFA). However, there is limited knowledge on the need for patch angioplasty in CFA TEA. The objective of this study was to compare the peri-operative and two year results of CFA TEA with or without patch angioplasty.

METHODS

A multicentre retrospective observational study was performed at 34 Japanese centres. Comparisons were made between patients undergoing CFA TEA with or without patch angioplasty after propensity score matching (PSM). The primary endpoints were primary patency and freedom from target lesion revascularisation (TLR) of the TEA lesion. The secondary endpoints were hospital outcomes, limb salvage, and overall survival.

RESULTS

Between 2018 and 2020, 428 TEA procedures (237 with patch angioplasty and 191 with primary closure) were performed. PSM extracted 151 pairs with no significant intergroup differences in baseline characteristics. Peri-operative death and complications occurred in 0.7% vs. 1.3% (p = 1.0) and 6.0% vs. 6.6% (p = 1.0), respectively. The follow up rate was 96% over a median follow up of 14.9 months (interquartile range 8.3, 24.3). Loss of primary patency occurred in 18 patients. The two year primary patency of patch angioplasty cases was statistically significantly higher than that of primary closure cases (97.0% vs. 89.9%; p = .021). TLR was performed in 14 patients. The two year freedom from TLR in patch angioplasty cases was also statistically significantly higher than in primary closure cases (98.6% vs. 92.9%; p = .003). During follow up, seven limbs required major amputation and 40 patients died. There was no statistically significant difference in limb salvage and survival between the two groups after PSM.

CONCLUSIONS

This is the first report to show that patch angioplasty may decrease re-stenosis and target lesion revascularisation of CFA TEA lesions.

Bare metal stent in the area of drug eluting devices for long femoropopliteal lesions

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.

Diabetic foot ulcers: Retrospective comparative analysis from Sicily between two eras

Aim

The aim of this study was to analyze changes in the incidence, management and mortality of DFU in Sicilian Type 2 diabetic patients hospitalized between two eras, i.e. 2008–2013 and 2014–2019.

Methods

We compared the two eras, era1: 2008–13, era2: 2014–19. In era 1, n = 149, and in era 2, n = 181 patients were retrospectively enrolled.

Results

In the population hospitalized for DFU in 2008–2013, 59.1% of males and 40.9% of females died, whilst in 2014–2019 65.9% of males and 34.1% of females died. Moderate chronic kidney disease (CKD) was significantly higher in patients that had died than in ones that were alive (33% vs. 43%, p < 0.001), just as CKD was severe (14.5% vs. 4%, p < 0.001). Considering all together the risk factors associated with mortality, at Cox regression multivariate analysis only moderate-severe CKD (OR 1.61, 95% CI 1.07–2.42, p 0.021), age of onset greater than 69 years (OR 2.01, 95% CI 1.37–2.95, p <0.001) and eGFR less than 92 ml/min (OR 2.84, 95% CI 1.51–5.34, p 0.001) were independently associated with risk of death.

Conclusions

Patients with DFU have high mortality and reduced life expectancy. Age at onset of diabetic foot ulcer, eGFR values and CKD are the principal risk factors for mortality.

Superficial femoral artery stent extrusion

The superficial femoral artery is a common location for endovascular treatment of occlusive arterial disease. Stent extrusion is an uncommon complication of stent placement. In the present case report, we sought to raise awareness of this rare complication and have described the management of a single unique case. Although rare, the complication of stent extrusion should be considered in patients with abnormal symptoms after endovascular treatment of superficial femoral artery disease.

Adverse Prognosis of Peripheral Artery Disease Treatments Associated With Diabetes: A Comprehensive Meta-Analysis

Many studies have investigated the influence of diabetes mellitus (DM) on outcomes in patients with peripheral artery disease (PAD). We performed a meta-analysis of the outcomes of PAD treatments in DM patients compared with those without DM. Long-term mortality was the primary endpoint. Secondary endpoints were in-hospital/30-day mortality, primary/secondary patency, amputation, and limb salvage. Thirty-one studies reporting 58113 patients were eligible for enrollment. The mean follow-up duration ranged from 1 to 89 months. DM was significantly associated with long-term mortality (relative risk (RR) = 1.67; 95% confidence intervals (CI), 1.43-1.94; P < .001). DM was also associated with significantly lower primary patency (RR = 0.74; 95% CI, 0.58-0.95; P = .001) and secondary patency (RR = 0.80; 95% CI, 0.67-0.96; P = .009). DM is associated with worse outcomes and adverse prognosis of treatment in patients with PAD, and may therefore be a modifiable risk factor for poor prognosis in PAD patients.

The association of healthcare disparities and patient-specific factors on clinical outcomes in peripheral artery disease

BACKGROUND

PAD increases the risk of cardiovascular mortality and limb loss, and disparities in treatment and outcomes have been described. However, the association of patient-specific characteristics with variation in outcomes is less well known.

METHODS

Patients with PAD from Duke University Health System (DUHS) between January 1, 2015 and March 31, 2016 were identified. PAD status was confirmed through ground truth adjudication and predictive modeling using diagnosis codes, procedure codes, and other administrative data. Symptom severity, lower extremity imaging, and ankle-brachial index (ABI) were manually abstracted from the electronic health record (EHR). Data was linked to Centers for Medicare and Medicaid Services data to provide longitudinal follow up. Primary outcome was major adverse vascular events (MAVE), a composite of all-cause mortality, myocardial infarction (MI), stroke, lower extremity revascularization and amputation.

RESULTS

Of 1,768 patients with PAD, 31.6% were asymptomatic, 41.2% had intermittent claudication (IC), and 27.3% had chronic limb-threatening ischemia (CLTI). At 1 year, patients with CLTI had higher rates of MAVE compared with asymptomatic or IC patients. CLTI and Medicaid dual eligibility were independent predictors of mortality. CLTI and Black race were associated with amputation.

CONCLUSIONS

Rates of MAVE were highest in patients with CLTI, but patients with IC or asymptomatic disease also had high rates of adverse events. Black and Medicaid dual-eligible patients were disproportionately present in the CLTI subgroup and were at higher risk of amputation and mortality, respectively. Future studies must focus on early identification of high-risk patient groups to improve outcomes in patients with PAD.

Smaller Superficial Femoral Artery is Associated with Worse Outcomes after Percutaneous Transluminal Angioplasty for De Novo Atherosclerotic Disease

BACKGROUND

With the exponential increase in the use of endovascular techniques in the treatment of peripheral artery disease, our understanding of factors that affect intervention failures continues to grow. We sought to assess the outcomes of percutaneous transluminal angioplasty for isolated de novo superficial femoral artery (SFA) disease based on balloon diameter.

METHODS

The Vascular Quality Initiative database was queried for patients undergoing percutaneous balloon angioplasty for isolated de novo atherosclerotic SFA disease. Based on the diameter of the angioplasty balloon as a surrogate measure of arterial diameter, patients were stratified into 2 groups: group 1, balloon diameter <5 mm (354 patients) and group 2, balloon diameter ≥5 mm (1,550 patients). The primary patency and major adverse limb event (MALE) were estimated by the Kaplan-Meier method and compared with the log-rank test, based on vessel diameter. Multivariable Cox regression analysis was used to determine factors associated with the primary patency.

RESULTS

From January 2010 through December 2018, a total of 1,904 patients met criteria for analysis, with a mean follow-up of 13.3 ± 4.5 months. The mean balloon diameters were 3.92 ± 0.26 mm and 5.47 ± 0.55 mm in group 1 and 2, respectively (P < 0.001). The mean length of treatment and distribution of TASC lesions were not statistically different between the groups. Primary patency at 18 months was significantly lower in group 1, compared with group 2 (55% vs. 67%; log-rank P < 0.001). The MALE rate was higher in group 1 than group 2 (33% vs. 26%; log-rank P < 0.001). Among patients with claudication, there was no significant difference in the primary patency (61% vs 68%; log-rank P = 0.073) and MALE (27% vs. 22%; log-rank P = 0.176) at 18 months between groups 1 and 2, respectively. However, in patients with CLTI, group 1 had significantly lower 18-month primary patency (47% vs. 64%; log-rank P < 0.014) and higher MALE rates (41% vs. 35%; log-rank P = 0.012) than group 2. Cox proportional hazard analysis confirmed that balloon diameter < 5 mm was independently associated with increased risks of primary patency loss (HR 1.35; 95% CI, 1.04-1.72; P = 0.021) and MALE (HR 1.29; 95% CI, 1-1.67; P = 0.048) at 18-months.

CONCLUSIONS

In patients undergoing isolated SFA balloon angioplasty for CLTI, smaller SFA (<5 mm) was associated with worse primary patency and MALE. Using balloon size as a surrogate, our findings suggest that patients with a smaller SFA diameter appear to be at increased risk for treatment failure and warrant closer surveillance. Furthermore, these patients may also be considered for alternative approaches, including open revascularization.

Outcomes of open and hybrid treatments in below the knee pathology for critical limb threatening ischemia

INTRODUCTION

The optimal management of below the knee pathology remains one of the most challenging areas for revascularization in patients presenting with critical limb threatening ischemia. Patients commonly have multilevel lesions and have a high amputation rate and associated mortality. This review aimed to assess the outcomes of below the knee revascularization strategies.

EVIDENCE ACQUISITION

An online literature search of medical databases for original articles or review articles was conducted using mesh terms.

EVIDENCE SYNTHESIS

Bypass surgery remains the gold standard for revascularization with good long-term outcomes with regards to patency, limb salvage, and quality of life but is associated with a higher morbidity than the endovascular approach. Given the increasing frailty of our patients, endovascular treatments have become the preferred strategy with results that are now equal to bypass. Hybrid surgery is an increasingly popular option as it combines the benefits of both endovascular and open surgery and although the evidence base is small the outcomes are encouraging.

CONCLUSIONS

Hybrid surgery offers promising results and could be considered in the treatment of multi-level lower limb arterial disease especially in high-risk patients or those who are not suitable for either open or endovascular techniques as a sole treatment modality.

Wound outcomes and factors associated with wound healing after first-time femoropopliteal artery intervention in patients with ischemic tissue loss

BACKGROUND/OBJECTIVE

This study's goal is to describe wound outcomes at 2 years following intervention for atherosclerotic femoropopliteal lesions in patients with ischemic tissue loss.

METHODS

A retrospective review of 135 first-time endovascular procedures for chronic femoropopliteal atherosclerotic lesions related to ischemic tissue loss was performed. The final wound outcomes were categorized according to the initial wound healing, recurrence and the need of major/minor amputation.

RESULTS

At 2-years of follow up, 76 limbs (56.3%) showed complete wound healing without recurrence, however, wound development occurred at other sites on the same foot following complete primary healing in 11 limbs (8.1%). Tolerable wounds persisted or wounds recurred at the same site in 30 limbs (22.2%), and 18 limbs (13.3%) needed major amputations. Independent factors that prevented wound healing without recurrence at 2 years were renal insufficiency (HR = 0.225, 95% C.I. = 0.091-0.556, p = 0.001), ankle pressure < 50 mmHg or flat forefoot PVR (HR = 0.328, 95% C.I. = 0.124-0.867, p = 0.025) and functional performance < 4 metabolic equivalents (MET) (HR = 0.150, 95% C.I. = 0.063-0.360, p < 0.001).

CONCLUSION

Wound outcome classifications showed detailed information regarding clinical outcomes in patients with ischemic tissue loss. Renal insufficiency, ischemia grade 3 and poor functional performance were independent risk factors that prevented wound healing.

Endovascular Intervention for the Treatment of Trans-Atlantic Inter-Society Consensus (TASC) D Femoropopliteal Lesions: A Systematic Review and Meta-Analysis

PURPOSE

Advancements in the endovascular treatment of femoropopliteal atherosclerotic lesions have led to treatment of more complex lesions, particularly long lesions. The aim of this study was to determine the meta-analytic primary patency and need for re-intervention among patients treated for very long lesions (>200 mm) at the femoropopliteal segment and to identify potential risk factors for loss of patency.

METHODS

This study was performed according to the PRISMA guidelines. A random effects model meta-analysis was conducted, and the I-square was used to assess heterogeneity.

RESULTS

Fifty-one studies comprised of 3029 patients were included. The mean lesion length was 269 mm. The primary patency rate at 30 days, 6 m, 1-, 2- and 5-years of follow-up was 98%, 76%, 62%, 55%, and 39% respectively. The incidence of TLR was 16% at one year and 32% at two years. The secondary patency rate at 1, 2, 3 and 5 years was 85%, 71%, 64%, and 64% respectively. Heparin bonded ePTFE covered stents (69%) and paclitaxel eluting stents (73%) demonstrated higher 1-year primary patency rates than self-expanding nitinol stents (55%) or uncoated percutaneous transluminal angioplasty (PTA) with provisional stenting (54%). Lesions treated with a heparin bonded ePTFE covered stent had statistically significant higher odds of remaining patent at 1-year of follow-up (OR: 2.74; 95%CI: 1.63-4.61; p < 0.001) than lesions treated with BMS or PTA. Patients with long femoropopliteal lesions causing critical limb ischemia (CLI) developed restenosis or occlusion more often than patients treated for claudication (HR: 1.63; 95%CI: 1.06-2.49; p = 0.026) during an average follow-up of 26 months.

CONCLUSION

Primary stenting of femoropopliteal TASC D lesions using drug eluting stents or covered stents results in sustained patency over time. PTA or uncoated nitinol stents demonstrated lower patency rates. However, additional comparative studies are needed to determine the efficacy of newer technologies for the treatment of complex femoropopliteal lesions and provide evidence for the most optimal treatment approach.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Systematic Review and Proportional Meta-Analysis of Endarterectomy and Endovascular Therapy with Routine or Selective Stenting for Common Femoral Artery Atherosclerotic Disease

Introduction

Common femoral endarterectomy (CFE) has been the therapy of choice for common femoral artery atherosclerotic disease (CFA-ASD). In the past, there was inhibition to treat CFA-ASD endovascularly with stents due to fear of stent fracture and compromise of future vascular access site. However, recent advances and new evidence suggest that CFA may no longer be a ‘stent-forbidden zone'. In the light of new evidence, we conducted a meta-analysis to determine the use of endovascular treatment for CFA-ASD and compare it with common femoral endarterectomy in the present era.

Methods

Using certain MeSH terms we searched multiple databases for studies done on endovascular and surgical treatment of CFA-ASD in the last two decades. Inclusion criteria were randomized control trials, observational, prospective, or retrospective studies evaluating an endovascular treatment or CFE for CFA-ASD. For comparison, studies were grouped based on the treatment strategy used for CFA-ASD: endovascular treatment with selective stenting (EVT-SS), endovascular treatment with routine stenting (EVT-RS), or common femoral endarterectomy (CFE). Primary patency (PP), target lesion revascularization (TLR), and complications were the outcomes studied. We did proportional meta-analysis using a random-effect model due to heterogeneity among the included studies. If confidence intervals of two results do not overlap, then statistical significance is determined.

Results

Twenty-eight studies met inclusion criteria (7 for EVT-RS, 8 for EVT-SS, and 13 for CFE). Total limbs involved were 2914 (306 in EVT-RS, 678 in EVT-SS, and 1930 in CFE). The pooled PP at 1 year was 84% (95% CI 75-92%) for EVT-RS, 78% (95% CI 69-85%) for EVT-SS, and 93% (95% CI 90-96%) for CFE. PP at maximum follow-up in EVT-RS was 83.7% (95% CI 74-91%) and in CFE group was 88.3% (95% CI 81-94%). The pooled target lesion revascularization (TLR) rate at one year was 8% (95% CI 4-13%) for EVT-RS, 19% (95% CI 14-23%) for EVT-SS, and 4.5% (95% CI 1-9%) for CFE. The pooled rate of local complications for EVT-RS was 5% (95% CI 2-10%), for EVT-SS was 7% (95% CI 3 to 12%), and CFE was 22% (95% CI 14-32%). Mortality at maximum follow-up in CFE group was 23.1% (95% CI 14-33%) and EVT-RS was 5.3% (95% CI 1-11%).

Conclusion

EVT-RS has comparable one-year PP and TLR as CFE. CFE showed an advantage over EVT-SS for one-year PP. The complication rate is lower in EVT RS and EVT SS compared to CFE. At maximum follow-up, CFE and EVT-RS have similar PP but CFE has a higher mortality. These findings support EVT-RS as a management alternative for CFA-ASD.

Long-term results of the heparin-bonded Viabahn stent graft in femoropopliteal TASC C and D lesions with a covered stent length of minimum 25 cm

Background

Heparin-bonded covered stent grafts (Viabahn) are used to treat femoropopliteal long-segment arteriosclerotic lesions. The aim of this study was to evaluate the long-term outcome of Viabahn grafts with a covered stent length of minimum 25 cm.

Methods

We conducted a retrospective analysis of patients receiving a heparin-bonded stent graft in our clinic who met the length criteria between July 2010 and March 2018. Primary endpoints were patency rates, limb salvage and survival after five years. Secondary endpoint was the 30-day outcome including early complications.

Results

A total of 62 patients (45 male, median age 70.5 years) were included. The median arteriosclerotic lesion length was 25 cm (22.0–41.3 cm), the minimum covered stent length was 25 cm (25–46 cm). All lesions were TASC C and D lesions. The 30-day mortality was 0%, an early stent graft occlusion occurred in 8.1%. A major amputation was performed in 1.6%. Primary patency, primary assisted patency, secondary patency, limb salvage and survival were 38.5%, 45.7%, 52.4%, 92.8% and 68.9% after five years. Distal stent graft end below the femoral condyles and critical limb ischemia was associated with a significant decreased survival. The diameter of the stent had no influence on the outcome.

Conclusion

The Viabahn stent graft for long segment arteriosclerotic lesions is a feasible treatment with adequate long-term results.

A Comparative Cost-Effectiveness Analysis of Percutaneous Transluminal Angioplasty With Optional Stenting and Femoropopliteal Bypass Surgery for Medium-Length TASC II B and C Femoropopliteal Lesions

Purpose: To evaluate the total midterm costs and cost-effectiveness of percutaneous transluminal angioplasty with optional stenting (PTA/S) as initial treatment compared with femoropopliteal bypass (FPB) surgery in patients with medium-length TransAtlantic Inter-Society Consensus II (TASC) B and C femoropopliteal lesions. Materials and Methods: Over a period of 3 years, all hospital health care costs for 226 consecutive patients were calculated: 170 patients with a TASC B lesion and 56 patients with a TASC C lesion. In the 135-patient PTA/S group (mean age 69.9±10.9 years; 83 men), 108 (63.5%) patients had TASC B lesions and 27 (48.2%) patients had TASC C lesions. Ninety-one patients (mean age 68.4±10.9 years; 60 men) were treated with FPB for 62 TASC B and 29 TASC C femoropopliteal lesions. The main outcome measure was the primary patency rate at 3-year follow-up. Multiple imputation and bootstrapping techniques were used to analyze the data. The adjusted incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in total costs by the difference in 3-year primary patency rate. Costs were expressed in euros (€), and cost differences are presented with the 95% confidence interval (CI). Results: Mean total costs per patient were €29,058 in the PTA/S treatment group vs €42,437 in the FPB group (mean adjusted difference –€14,820, 95% CI –€29,044 to −€5976). Differences in 3-year primary patency between PTA/S and FPB were small and nonsignificant (68.9% and 70.3%, respectively). An ICER of 563,716 was found, indicating that FPB costs €563,716 more per one extra patient reaching 3-year primary patency in comparison with PTA/S treatment. Conclusion: FPB in medium-length femoropopliteal lesions involved higher total costs when evaluated over a 3-year follow-up period. An endovascular-first approach is recommended, as this will result in cost minimization for patients with medium-length femoropopliteal disease.

Endovascular therapy versus femoropopliteal bypass surgery for medium-length TASC II B and C lesions of the superficial femoral artery: An observational propensity-matched analysis

Objectives

This study was designed to compare clinical outcomes of percutaneous transluminal angioplasty with optional stenting (PTA/s) and femoropopliteal bypass (FPB) surgery as primary invasive treatment in patients with medium-length superficial femoral artery (SFA) lesions.

Methods

We performed a single-center retrospective, observational analysis in all consecutive patients who had undergone initial invasive treatment for medium-length, TASC II B and TASC II C, SFA lesions from 2004 to 2015. Primary endpoints were primary and secondary clinical patency. Secondary endpoints were complication rates and number of amputations. Kaplan–Meier curves were used to compare patency rates in the two treatment groups. Multivariate Cox regression analysis was performed to adjust for confounding variables and propensity score matching analysis was used to balance treatment groups.

Results

A total of 362 patients with a mean observation period of 4.0 years (SD ± 2.6) were analyzed. In this group, 231 patients (64%) underwent PTA/s and 131 patients (36%) FPB surgery. There was no difference in primary clinical patency at one-, three- and five-year follow-up between the PTA/s and FPB group, with rates of 79% vs. 63%, 53% vs. 78% and 71% vs. 66%, respectively ( P = 0.46). Secondary clinical patency estimates were comparable, resulting in one-, three- and five-year secondary clinical patency rates of 88%, 76% and 67% in the PTA/s group versus 88%, 80% and 79% in the bypass group ( P = 0.40). Multivariate analysis revealed no significant differences between the PTA/s and FPB groups in terms of primary clinical patency (HR 1.4; 95% CI 0.9–2.2) and secondary clinical patency (HR 1.7; 95% CI 0.9–2.9). This was confirmed in the propensity score analysis. Hospital stay (4.8 vs. 10.3 days) and complication rate (2.6% vs. 18.3%) were significantly lower in the PTA/s group ( P = 0.00). The number of amputations was comparable ( P = 0.75).

Conclusions

The clinical success of endovascular therapy and surgery for medium-length SFA lesions is comparable. Taking into account the lower morbidity rate, shorter length of hospital stay and the less invasive character of PTA/s compared with bypass surgery, patients with medium-length SFA lesions are ideally treated by an endovascular-first approach.

Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia in insulin-dependent diabetic patients

OBJECTIVE

Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limb-threatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood.

METHODS

We reviewed the records of all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as use of chronic insulin administration at baseline to control blood glucose levels and recorded the most recent glycated hemoglobin value available within 3 months before the procedure and fasting blood glucose level on the day of the procedure. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S in our population using χ², Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S.

RESULTS

Of 2869 infrainguinal revascularizations from 2005 to 2014, 655 limbs (316 BPG, 339 PTA/S) in 580 patients fit our criteria and underwent a first-time revascularization for CLTI. Patients undergoing BPG, compared with PTA/S, were similar in age (69 vs 68 years; P = .55), had similar rates of tissue loss (87% vs 91%; P = .07) and dialysis dependence (26% vs 28%; P = .55), were less likely to be hypertensive (84% vs 92%; P < .001), and were more likely to be current smokers (21% vs 14%; P = .02). There were no differences between BPG and PTA/S patients in mean glycated hemoglobin levels (8.1% vs 8.0%; P = .51) or mean fasting blood glucose levels (158 vs 150 mg/dL; P = .18). Although total hospital length of stay was significantly longer among BPG patients (11 vs 8 days; P < .001), perioperative complications did not differ, including acute kidney injury (19% vs 23%; P = .24), hematoma (6.0% vs 3.8%; P = .20), acute myocardial infarction (1.3% vs 2.1%; P = .43), and mortality (3.8% vs 3.0%; P = .55). BPG-first patients had significantly lower unadjusted 6-month rates of incomplete wound healing (49% vs 57%) and 5-year rates of restenosis (53% vs 72%) and reintervention (47% vs 58%; all P < .05). After adjustment, multivariable analysis suggested PTA/S-first intervention to be significantly associated with higher risk of restenosis (hazard ratio, 1.9; 95% confidence interval, 1.3-2.7) and reintervention (1.9 [1.2-2.7]). These results remained robust after inverse probability weighting.

CONCLUSIONS

Among patients with IDDM and CLTI, a bypass-first strategy is associated with similar 30-day outcomes and lower restenosis and reintervention rates. These data suggest that a bypass-first approach may best serve appropriately selected, anatomically suitable patients with IDDM and pedal ischemia that requires revascularization.

Midterm results with drug-coated balloons for SFA lesions in patients with CLI: comparison with conventional bypass surgery

BACKGROUND

Endovascular treatment of symptomatic peripheral artery disease has gained widespread acceptance. The efficacy and safety of drug-coated balloon (DCB) angioplasty in the setting of critical limb ischemia in comparison to conventional surgery has not been demonstrated. We have compared our results with DCB angioplasty to conventional bypass surgery in patients with critical limb ischemia (CLI).

METHODS

A total of 187 patients with CLI treated over a 6-year period between 2006 and 2012 by a single operative team constituted the study population. Between 2006 and 2009, all patients underwent conventional surgery. Between 2009 and 2012, the investigators adopted endovascular approach with the use of IN.PACT Admiral (Medtronic Inc., Santa Rosa, CA, USA). Data collection was achieved prospectively.

RESULTS

A total 210 procedures (100 surgery, 110 endovascular) were performed over a 6-year period. A 72% of all bypasses were performed using saphenous vein grafts with above-the-knee bypass as the technique of choice in 80% of the cases. 6-mm DCB was used in 41% of the patients. Procedural success rates (98% vs. 99%, NS) as well as clinical success rates (99% vs. 99%, P=NS) and operative mortality (3.7% vs. 2%, NS) was similar in both groups. Primary patency for DCB vs. bypass groups 91.8% vs. 88.9%, respectively (P=0.31) at 12 months and 82.7% vs. 82.8% at 24 months, respectively (P=0.28). Freedom from clinically-driven target lesion revascularization at 12 months was similar in both groups (87.6% vs. 85%, P=0.33). Primary patency for DCB vs. bypass groups at 24 months was 82.7% vs. 82.8%, respectively (P=0.28).

CONCLUSIONS

DCB angioplasty yields comparable results to surgery in the setting of critical ischemia. The efficacy and the safety of DCBs in more complex lesions is to be investigated with randomized trials.

Impact of Tibial Runoff on Outcomes of Endovascular Treatment for Femoropopliteal Atherosclerotic Lesions

Objectives:

The aim of this study is to investigate the impact of tibial runoff on outcomes of femoropopliteal interventions for atherosclerotic lesions.

Methods:

A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed.

Results:

The distribution rates of good tibial runoff (runoff score <7) and poor tibial runoff (runoff score ≥7) were 37.0% and 63.0%, respectively. In the poor tibial runoff group, the patients were older ( P = .019), and the proportion of male was lower ( P = .014). There was a significantly higher proportion of rest pain or tissue loss ( P < .001), and the prevalence of stroke ( P = .031) and renal insufficiency ( P = .005) was significantly higher in the poor runoff group. After femoropopliteal intervention, the amputation-free survival ( P = .03) and freedom from ischemia ( P = .003) were significantly lower in the poor runoff group. The interventions targeting below-the-knee (BTK) lesions performed concomitantly for critical limb ischemia or tissue loss with poor tibial runoff did not show a significant advantage in terms of freedom from ischemia; however, minor trends of longer lasting freedom from ischemia were observed when BTK intervention was combined.

Conclusion:

The patients with poor runoff showed significantly lower amputation-free survival and freedom from ischemia. In poor tibial runoff limbs with critical limb ischemia or tissue loss, BTK intervention did not demonstrate additional significant beneficial outcomes; however, there was a minor trend of longer lasting freedom from ischemia after concomitant BTK intervention.

Neutrophil-lymphocyte ratio is a marker of survival and cardiac complications rather than patency following revascularization of lower extremities

The neutrophil-lymphocyte ratio (NLR), as a marker of inflammation, is associated with the severity of peripheral artery disease (PAD). The role of the NLR on predicting future complications after elective revascularization for patients with PAD remains unknown. We aimed to examine the role of the NLR in the development of major adverse limb events (MALE) and the long-term mortality of these patients. We evaluated 1708 revascularization procedures from May 2001 to December 2015 at the Veterans Affairs Western New York Healthcare System from a prospectively maintained vascular database that included demographics, comorbidities and pre-procedural medications. Peri-procedural laboratory findings including complete blood cell count and metabolic panel were further retrieved from the electronic health record. The NLR was calculated, and the patients were categorized into tertiles according to NLR cut-off points. Multivariate Cox regression analysis was performed to determine MALE and 10-year mortality. The primary endpoint of the study was MALE, and the secondary endpoint included 10-year mortality. A total of 1228 patients were included for final analyses. Patients in the third NLR tertile were more likely to experience MALE during the follow-up period ( p<0.001). In addition, fewer patients in tertile 3 survived over the follow-up period compared to tertiles 1 and 2 ( p<0.0001). Patients in tertile 3 tended to be older with a higher frequency of hypertension, diabetes, chronic kidney disease, coronary artery disease and congestive heart failure. Our multivariate analysis demonstrated that the NLR was independently associated with higher rates of MALE in the affected vessels following revascularization procedures. Similarly, the NLR was revealed to be an independent predictor of higher long-term mortality in these patients.

Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia between patients with and without diabetes

OBJECTIVE

The effect of diabetes type and insulin dependence on short- and long-term outcomes after lower extremity revascularization for chronic limb-threatening ischemia (CLTI) warrants additional study and more targeted focus. We sought to address this paucity of information by evaluating outcomes in insulin-dependent and noninsulin-dependent patients after any first-time revascularization.

METHODS

We reviewed all limbs undergoing first-time infrainguinal bypass grafting (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. Based on preoperative medication regimen, patients were categorized as having insulin-dependent diabetes (IDDM), noninsulin-dependent diabetes (NIDDM), or no diabetes (NDM). Outcomes included wound healing; major amputation; RAS events (reintervention, major amputation, or stenosis); major adverse limb events; and mortality. Outcomes were evaluated using χ², Kaplan-Meier, and Cox regression analyses.

RESULTS

Of 2869 infrainguinal revascularizations from 2005 to 2014, 1294 limbs (646 BPG, 648 PTA/S) fit our criteria. Overall, our analysis included 703 IDDM, 262 NIDDM, and 329 NDM limbs. IDDM patients, compared with NIDDM and NDM patients, were younger (69 vs 73 vs 77 years; P < .001) and more often presented with tissue loss (89% vs 77% vs 67%; P < .001), coronary artery disease (57% vs 48% vs 43%; P < .001), and end-stage renal disease (26% vs 13% vs 12%; P < .001). Perioperative complications, including mortality (3% vs 2% vs 5%; P = .07), did not differ between groups; however, complete wound healing at 6-month follow-up was significantly worse among IDDM patients (41% vs 49% vs 61%; P < .001). IDDM patients had significantly higher 3-year major amputation rates (23% vs 11% vs 8%; P < .001). Multivariable analyses illustrated that compared with NDM, IDDM was associated with significantly higher risk of both major amputation and RAS events after any first-time intervention (hazard ratio, 2.0 [95% confidence interval, 1.1-4.1] and 1.4 [1.1-1.8], respectively). Similar associations between IDDM and both major amputation and RAS events were found in patients undergoing a PTA/S-first intervention (4.1 [1.3-12.6] and 1.5 [1.1-2.2], respectively), whereas IDDM in BPG-first patients was associated with only incomplete wound healing (2.0 [1.4-4.5]). Last, compared with NDM, NIDDM was associated with lower late mortality (0.7 [0.5-0.9]).

CONCLUSIONS

Compared with NDM, IDDM is associated with similar perioperative and long-term mortality but a higher risk of incomplete wound healing, major amputation, and future RAS events, especially after a PTA/S-first approach. NIDDM, on the other hand, is associated with lower long-term mortality and few adverse limb events. Overall, these data demonstrate both the importance of distinguishing between diabetes types and the potential long-term benefit of a BPG-first strategy in appropriately selected IDDM patients with CLTI.

Retrograde Popliteal Access to Percutaneous Peripheral Intervention for Chronic Total Occlusion of Superficial Femoral Arteries

Objective:

The aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with chronic total occlusions of superficial femoral artery (SFA).

Method:

From July 2012 to May 2014, a total of 28 patients (20 men, mean age 61.2 ± 11.5 years) with total occlusion of the SFA and good distal runoff were treated with percutaneous atherectomy, balloon angioplasty, and stenting (mean length 165.3 ± 57.5 mm, range 72-336 mm). All patients had severe claudication or critical limb ischemia, and most of the lesions were TransAtlantic Inter-Society Consensus classification type D (n = 21).

Results:

Technical success was achieved in all cases. In majority (26, 92.8%) of the patients, endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. During a mean follow-up of 12.9 ± 2.5 months, claudication, severity, rest pain, and toe ulcers improved significantly. Ankle–brachial index changed from 0.54 ± 0.11 to 0.91 ± 0.2 at 1 year after intervention ( P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 92.8%, and 85.7%, respectively. One pseudoaneurysm and 1 arteriovenous fistula were found in the popliteal region on duplex examinations. There were 2 in-stent restenosis and 3 occlusions during the 12-month follow-up. These occlusions were treated with reendovascular procedures. Our secondary patency rate was 96.4%. No stent fracture was observed.

Conclusion:

The retrograde popliteal artery approach under duplex guidance can be considered as safe, efficient, and the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and mid-term results.

Results of common femoral artery thromboendarterectomy evaluation of a traditional surgical management in the endovascular era

OBJECTIVE

The aim of this study was to investigate the long-term outcome of common femoral artery thromboendarterectomy in patients with peripheral arterial occlusive disease.

METHODS

The study retrospectively evaluated 713 vessels in 655 patients (75% male; mean age, 69.4 ± 9.5 years) who underwent common femoral thromboendarterectomy from January 2006 until May 2012 in two high-volume vascular centers. Critical limb ischemia was present in 221 patients, and intermittent claudication was present in 434. Three patent tibial arteries, described as runoff vessels, were available in 33% of the cohort, two were present in 28.3%, one runoff vessel was present in 23.4%, and 15.2% (n = 102) showed no runoff option. Hybrid procedures were used to treat 255 limbs (35.8%). The primary end point was primary patency (PP). Secondary patency (SP), limb salvage, and survival were the secondary end points.

RESULTS

Survival rates were 93.9%, 83.0%, 74.1%, and 60.1% at 1, 3, 5, and 7 years, respectively. PP was 78.5% and SP was 89.1% at 7 years. Patency rates were 97.3% (PP) and 97.8% (SP) at 6 months and 90.2% (PP) and 98.3% (SP) at 3 years, respectively, with 76 target lesion revascularizations. No significant difference was demonstrated for PP rates stratified for nonhybrid procedures and hybrid procedures (78.1% vs 78.6%; P = .22) and for critical limb ischemia vs intermittent claudication (76.3% vs 79.4%; P = .20) at 7 years. The mean ± standard deviation ankle-brachial index increased from 0.46 ± 0.3 preoperatively to 0.81 ± 0.2 postoperatively and to 0.77 ± 0.3 at 7 years (P < .001). A total of 20 major amputations were performed, achieving a limb salvage rate of 92.6%. Procedure-related complications occurred in 11.5% during 7 years of follow-up.

CONCLUSIONS

Open surgery for common femoral artery stenosis is safe and effective in the long-term. Endovascular therapy will need to compete with these excellent results.

Lower extremity computed tomography angiography can help predict technical success of endovascular revascularization in the superficial femoral and popliteal artery

OBJECTIVE

Preprocedural computed tomography angiography (CTA) assists in evaluating vascular morphology and disease distribution and in treatment planning for patients with lower extremity peripheral artery disease (PAD). The aim of the study was to determine the predictive value of radiographic findings on CTA and technical success of endovascular revascularization of occlusions in the superficial femoral artery-popliteal (SFA-pop) region.

METHODS

Medical records and available imaging studies were reviewed for patients undergoing endovascular intervention for PAD between January 2013 and December 2015 at a single academic institution. Radiologists reviewed preoperative CTA scans of patients with occlusions in the SFA-pop region. Radiographic criteria previously used to evaluate chronic occlusions in the coronary arteries were used. Technical success, defined as restoration of inline flow through the SFA-pop region with <30% stenosis at the end of the procedure, and intraoperative details were evaluated.

RESULTS

From 2013 to 2015, there were 407 patients who underwent 540 endovascular procedures for PAD. Preprocedural CTA scans were performed in 217 patients (53.3%), and 84 occlusions in the SFA-pop region were diagnosed. Ten occlusions were excluded as no endovascular attempt to cross the lesion was made because of extensive disease or concomitant iliac intervention. Of the remaining 74 occlusions in the SFA-pop region, 59 were successfully treated (80%) and 15 were unsuccessfully crossed (20%). The indications for revascularization were claudication in 57% of patients and critical limb ischemia in the remaining patients. TransAtlantic Inter-Society Consensus A, B, and C occlusions were treated with 87% success, whereas D occlusions were treated with 68% success (P = .047). There were nine occlusions with 100% vessel calcification that was associated with technical failure (P = .014). Longer lengths of occlusion were also associated with technical failure (P = .042). Multiple occlusions (P = .55), negative remodeling (P = .69), vessel runoff (P = .56), and percentage of vessel calcification (P = .059) were not associated with failure. On multivariable analysis, 100% calcification remained the only significant predictor of technical failure (odds ratio, 9.0; 95% confidence interval, 1.8-45.8; P = .008).

CONCLUSIONS

Analysis of preoperative CTA shows 100% calcification as the best predictor of technical failure of endovascular revascularization of occlusions in the SFA-pop region. Further studies are needed to determine the cost-effectiveness of obtaining preoperative CTA for lower extremity PAD.

A single-center retrospective analysis of patency rates of intraluminal versus subintimal endovascular revascularization of long femoropopliteal occlusions

OBJECTIVE

The evaluation of patency rates of intraluminal versus subintimal endovascular revascularization of long femoropopliteal (FP) lesions.

BACKGROUND

Chronic total occlusions (CTO) of the FP artery in peripheral interventions are crossed either with a support catheter-guidewire based technique or subintimal dissection and re-entry device assisted approach. Both techniques have a high procedural success rate, but their long term patency is not well studied. There is also lack of comparative data addressing the patency of long non-CTO vs. CTO occlusions.

METHODS

We performed a single center retrospective analysis, studying the patency rates in 215 patients (254 limbs) with TASC C and D FP lesions treated with stents. There were 3 patient groups: without CTO (non-CTO); CTO crossed using support catheter and guide-wire (CTO-SW) and CTO crossed with a re-entry device (CTO-RE).

RESULTS

There were 155 limbs in CTO-SW group; 50 in CTO-RE group and 49 in non-CTO. Lesion length (mean±SD) was 251.81±7.48mm in CTO-SW group; 280±13.18mm in CTO-RE group and 248.77±13.31 in non-CTO group (p=non-significant). In-stent restenosis (ISR) at a mean follow-up of 19.26±16.14months did not differ between groups occurring in 23 (47%) limbs in non-CTO; 66 (42%) in CTO-SW; and 24 (48%) in CTO-RE. Smoking and stent fracture were predictors of ISR by multivariate analysis.

CONCLUSION

In patients with long FP lesions, ISR rates were similar between patients with and without CTO. In the CTO group mid-term vessel patency was not affected by the crossing technique utilized.

Results for primary bypass versus primary angioplasty/stent for lower extremity chronic limb-threatening ischemia

BACKGROUND

Long-term results comparing percutaneous transluminal angioplasty with or without stenting (PTA/S) and open surgical bypass for chronic limb-threatening ischemia (CLTI) in patients who have had no prior intervention are lacking.

METHODS

All patients undergoing a first-time lower extremity revascularization for CLTI by vascular surgeons at our institution from 2005 to 2014 were retrospectively reviewed. Outcomes included perioperative complications, wound healing, restenosis, primary patency, reintervention, major amputation, RAS events (ie, reintervention, major amputation, or stenosis), and mortality. Outcomes were evaluated using χ², Kaplan-Meier, and Cox regression analyses.

RESULTS

Of the 2869 total lower extremity revascularizations performed between 2005 and 2014, there were 1336 that fit our criteria of a first-time lower extremity intervention for CLTI (668 bypass procedures and 668 PTA/S procedures). Bypass patients were younger (71 vs 72 years; P = .02) and more often male (62% vs 56%; P < .02). Total mean hospital length of stay (LOS) was significantly longer after a first-time bypass (10 vs 8 days; P < .001), as were mean preoperative LOS (4 vs 3 days; P < .01) and postoperative LOS (7 vs 5 days; P < .001). There was no difference in perioperative mortality (3% vs 3%; P = .63). Surgical site infection occurred in 10% of bypass patients. Freedom from reintervention was significantly higher in patients undergoing a first-time bypass procedure (62% vs 52% at 3 years; P = .04), as was freedom from restenosis (61% vs 45% at 3 years; P < .001). Complete wound healing at 6-month follow-up was significantly better after an initial bypass (43% vs 36%; P < .01). A Cox regression model of all patients showed that reintervention was predicted by a first-time PTA/S (hazard ratio, 1.6; 95% confidence interval, 1.3-2.1) and both preoperative femoropopliteal TransAtlantic Inter-Society Consensus (TASC) C and TASC D lesions (2.0 [1.3-3.1] and 1.8 [1.3-2.7], respectively). Major amputation among all patients was predicted by an initial presentation of gangrene (2.5 [1.3-5.0]), dialysis dependence (1.9 [1.3-2.9]), diabetes (2.0 [1.1-3.8]), and preoperative femoropopliteal TASC D lesions (2.1 [1.1-4.0]) and was not predicted by procedure type.

CONCLUSIONS

In this retrospective analysis, bypass for the primary treatment of CLTI showed improved 6-month wound healing, higher freedom from restenosis, improved patency rates, significantly fewer reinterventions, and higher survival than PTA/S within 3 years; however, a bypass-first approach was associated with increased total hospital LOS and wound infection. Perioperative mortality and amputation rates were similar between procedure types.

One-year results of primary stenting for TASC II D lesions of the superficial femoral and popliteal arteries

Objective This study aimed to evaluate the safety and the efficacy of primary stenting to treat Trans-Atlantic Inter-Society Consensus II (TASC) D femoropopliteal lesions. Background Advances in wire, balloon and stent design have been reported to improve the durability of stenting of longer femoropopliteal lesions. Methods A total of 57 limbs of 53 patients with Rutherford stage 3 to 6 due to TASC D femoropopliteal lesions were treated with a self-expanding nitinol stent in a prospective, single-centre, observational study. End points of interest included primary and secondary patency, target lesion revascularization, in-stent restenosis, major adverse cardiovascular events, Rutherford class improvement and change in walking capacity at 1 year. Results A total of 53 patients (57 lesions) were treated with a self-expanding nitinol stent and final procedural success was 91.2%. The median length of the treated segment was 330 ± 96 mm. The median stented segment was 366 ± 71 mm and the mean number of the stents was 2.1 ± 0.9. At 1 year, primary and secondary patency rates were 63.9% and 82.1%, respectively. Major adverse cardiovascular events occurred in 11 patients (22.9%), and[[strike_start]] [[strike_end]]significant benefits were observed in Rutherford class and walking distance (both P < 0.001). Conclusions Primary implantation of self-expanding nitinol stents for the treatment of TASC D femoropopliteal lesions appears to be safe and effective, especially in patients who have multiple co-morbidities and a high risk for surgical bypass. The risk of restenosis was higher when long stenting was extended to the popliteal artery.

Computed Tomography Fractional Flow Reserve Can Identify Culprit Lesions in Aortoiliac Occlusive Disease Using Minimally Invasive Techniques

BACKGROUND

Currently, the gold standard diagnostic examination for significant aortoiliac lesions is angiography. Fractional flow reserve (FFR) has a growing body of literature in coronary artery disease as a minimally invasive diagnostic procedure. Improvements in numerical hemodynamics have allowed for an accurate and minimally invasive approach to estimating FFR, utilizing cross-sectional imaging. We aim to demonstrate a similar approach to aortoiliac occlusive disease (AIOD).

METHODS

A retrospective review evaluated 7 patients with claudication and cross-sectional imaging showing AIOD. FFR was subsequently measured during conventional angiogram with pull-back pressures in a retrograde fashion. To estimate computed tomography (CT) FFR, CT angiography (CTA) image data were analyzed using the SimVascular software suite to create a computational fluid dynamics model of the aortoiliac system. Inlet flow conditions were derived based on cardiac output, while 3-element Windkessel outlet boundary conditions were optimized to match the expected systolic and diastolic pressures, with outlet resistance distributed based on Murray's law. The data were evaluated with a Student's t-test and receiver operating characteristic curve.

RESULTS

All patients had evidence of AIOD on CT and FFR was successfully measured during angiography. The modeled data were found to have high sensitivity and specificity between the measured and CT FFR (P = 0.986, area under the curve = 1). The average difference between the measured and calculated FFRs was 0.136, with a range from 0.03 to 0.30.

CONCLUSIONS

CT FFR successfully identified aortoiliac lesions with significant pressure drops that were identified with angiographically measured FFR. CT FFR has the potential to provide a minimally invasive approach to identify flow-limiting stenosis for AIOD.

Remote Superficial Femoral Artery A Endarterectomy: Early Results for TASC D Lesions in Patients With Severe Ischemia

Endovascular treatment for Transatlantic Inter-Society Consensus (TASC) D lesions of the superficial femoral artery has been disappointing. This has been attributed to a bulking atheromatous plaque. Debulking the superficial femoral artery allows for a larger lumen, whereas covering the lumen with an endograft provides in-line flow. We evaluated the intermediate results of remote superficial femoral artery endarterectomy with covered endograft placement in 18 patients. Patient demographic, vascular laboratory, and preoperative data were gathered retrospectively. The procedure was technically successful in all the patients. The mean age was 62.2 ± 9.9 years. Ankle brachial index improved from 0.35 ± 0.1 to 0.86 ± 0.1. The cumulative 12-month primary patency was 42.2%, whereas assisted primary or secondary patency was 70.8%. Five endografts occluded within the 12 months. Two of those patients underwent subsequent femoral-to-below-knee bypass, whereas 2 had major amputations. Remote superficial femoral artery endarterectomy can be reasonably offered if an autogenous conduit is not available for revascularization of the superficial femoral artery.

OUTBACK catheter for treatment of superficial femoral and iliac artery chronic total occlusion: Experience from two centers

PURPOSE

The OUTBACK(®) catheter is a reentry device that enables reentry into a vessel lumen from the subintimal space during subintimal angioplasty. It is reserved for cases where reentry has not been possible using conventional wire and catheter techniques. We report a two-center experience in recanalization of the chronic total occlusions of the common iliac (CIA) and the superficial femoral artery (SFA) using the OUTBACK(®) catheter in cases where other techniques were unsuccessful.

MATERIAL AND METHODS

All cases where recanalization was performed using the OUTBACK(®) reentry catheter between January 2010 to January 2015 were retrospectively identified and included in this study. 21 patients were identified. The indication for intervention in these cases included claudication and critical leg ischemia. In all cases, conventional recanalization could not be successfully achieved.

RESULTS

The OUTBACK(®) catheter was used to recanalize 10 SFA occlusion and 9 CIA occlusions. In 19 patients (90%), reentry into true arterial lumen was successfully achieved. 17 patients had their recanalization through the transfemoral approach whereas 2 patients had a transpopliteal artery approach. In 2 patients, reentry into the true lumen could not be achieved using the OUTBACK(®) catheter due to patient's intolerability for the procedure and severe atherosclerotic calcified plaques. There was 100% patency of the vessel intervened on Duplex ultrasound at 24 months of follow up. 16 patients (84%) remained asymptomatic and 2 patients (10.5%) reported worsening of their symptoms due to the development of new lesions within the arterial system.

CONCLUSION

The OUTBACK(®) catheter is an effective and safe technique for reentry into the vessel lumen when conventional techniques fail.

Minimally Invasive Revascularization Strategies for Chronic Lower Limb Ischemia

Lower extremity wounds resulting from ischemia are increasingly becoming a common indication for surgical revascularization. Techniques in minimally invasive vascular surgery for the treatment of lower extremity chronic ischemia have expanded rapidly in recent years. The current standard of care with which all new modalities should be compared is the restoration of arterial flow via direct arterial revascularization using the autogenous reversed saphenous vein that can yield limb salvage rates of approximately 95%. Percutaneous transluminal angioplasty and stenting (PTA/S), cryoplasty, catheter-directed atherectomy, laser-assisted PTA/S, drug-eluting stents, and subintimal angioplasty are emerging minimally invasive modalities used for the treatment of lower extremity ischemia. Early success rates using many of these techniques have been promising. The outcomes of randomized controlled trials with long-term follow-ups are needed to make confident remarks about the effectiveness of these techniques.

Limitations of Percutaneous Transluminal Angioplasty and Stenting for the Treatment of Disease of the Superficial Femoral and Popliteal Arteries

The long-term primary patency rates for percutaneous transluminal angioplasty (PTA) and stenting in treatment of disease of the superficial femoral and popliteal arteries have been disappointing. Three-year primary patency rates of ∼50% have been reported for PTA and first-generation stents. Early results with newer nitinol stents appear promising; however, long-term data are lacking. One- and 2-year primary patency rates of 76% to 97% and 60% to 84%, respectively, have been reported with nitinol stents. An emerging concern with nitinol stents is the frequency of stent fracture (≥25%) after interventions for long-segment disease. A recent study has shown that stent fractures are associated with in-stent restenosis and with significantly lower primary patency at 1 year.

The therapeutic success of PTA and stenting correlates with the complexity of the underlying disease. The best results are achieved when treating focal stenoses in patients with good distal runoff. Because endovascular interventions are preferred by patients, can be repeated, and preserve the option of bypass surgery, PTA and stenting are increasingly employed for diffuse and complex SFA disease. Clarifying the role of PTA and stenting in the treatment of complex SFA disease will require future studies that stratify results by both lesion anatomy and treatment indication.

Indications and Results with Cryoplasty in the Treatment of Infrainguinal Arterial Occlusive Disease

Percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries has been an accepted therapy for short focal stenosis. Elastic recoil and flow-limiting dissection have limited the durability of angioplasty, especially in long lesions and total occlusions. Cryoplasty couples cold therapy with angioplasty to induce mechanical and biologic effects to reduce elastic recoil and potentially to reduce restenosis. The mechanical and biologic mechanisms of this therapy are discussed. The results of cryoplasty for femoropopliteal lesions from a single-center series and a multicenter registry are reviewed. Cryoplasty appears to improve patency over conventional angioplasty and to reduce the need for bailout stenting in femoropopliteal stenoses and occlusions < 10 cm in length. Cryoplasty appears to be promising to treat critical limb ischemia in patients with tibial disease.

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study

BACKGROUND

Symptomatic femoro-popliteal disease is treated by bypass surgery or angioplasty with or without stenting. The aim of this study was to compare the results of stenting and bypass surgery with regard to limb salvage in patients with severe leg ischaemia.

METHODS

A total of 213 patients with femoro-popliteal disease presenting with severe claudication or critical limb ischaemia between January 2009 and December 2013 were evaluated; 118 patients (139 limbs) had stents placed and 95 patients (104 limbs) had bypass surgery. Most (60%) presented with critical limb ischaemia (rest pain 40%, tissue necrosis 20%), and the remainder with severe claudication. The treatment groups had matching risk factors.

RESULTS

The average age was 66 years and 73% were male. Tissue necrosis was found in 26% of the stent group and 12% of the bypass group (p = 0.009). In the stent group 26% had adjunctive procedures, compared to 16% in the bypass group (p = 0.138). During the one-year follow up, there were 30 stent occlusions (22%) and 18 graft occlusions (17%) (p = 0.42). There were 14 major amputations (10%) in the stent group, and 13 (13%) in the bypass group (p = 0.68). Limb salvage rate was 90% in the stent group, and 88% in the bypass group (p = 0.68). There were no peri-operative deaths in the stent group, but one in the bypass group (1%). One-year mortality rate was equal (8%) in both groups (p = 1.00).

CONCLUSION

One-year outcome was comparable in both groups with regard to mortality, stent or graft patency and limb salvage rates.

Endovascular Therapy for Femoropopliteal Artery Disease and Association of Risk Factors With Primary Patency

The treatment of femoropopliteal artery disease remains controversial, without clear guidelines specifying the indications for endovascular therapy (EVT). Accordingly, we retrospectively examined our experience of using EVT to treat femoropopliteal artery disease. A total of 91 limbs in 82 patients underwent EVT for the treatment of femoropopliteal artery disease. Percutaneous transluminal angioplasty alone was performed in 20 limbs, and additional stenting was performed in 71 limbs. The 1-year primary patency, primary-assisted patency, limb salvage, and survival rates were 76%, 88%, 96%, and 92%, respectively. Multivariate Cox analysis of primary patency showed that critical limb ischemia (CLI; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.08-5.33; P < .01) and TASC II C/D disease (HR, 2.70; 95% CI, 1.14-6.39; P < .05) were independent predictors of decreased primary patency. In conclusion, patients with CLI or extensive lesions have reduced patency after EVT for femoropopliteal artery disease.

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Our primary objective was to study postprocedural outcomes and hospitalization costs after peripheral endovascular interventions and the multivariate predictors affecting the outcomes with emphasis on hospital volume. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2006 to 2011). Peripheral endovascular interventions were identified using appropriate International Classification of Diseases, Ninth Revision diagnostic and procedural codes. Annual institutional volumes were calculated using unique identification numbers and then divided into quartiles. Two-level hierarchical multivariate mixed models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and postprocedural complications. Amputation rates and hospitalization costs were also assessed. Multivariate analysis (odds ratio, 95% confidence interval, p value) revealed age (1.46, 1.37 to 1.55, p <0.001), female gender (1.28, 1.12 to 1.46, p <0.001), baseline co-morbidity status as depicted by a greater Charlson co-morbidity index score (≥2: 4.32, 3.45 to 5.40, p <0.001), emergent or urgent admissions(2.48, 2.14 to 2.88, p <0.001), and weekend admissions (1.53, 1.26 to 1.86, p <0.001) to be significant predictors of primary outcome. An increasing hospital volume quartile was independently predictive of improved primary (0.65, 0.52 to 0.82, p <0.001 for the fourth quartile) and secondary (0.85, 0.73 to 0.97, 0.02 for the fourth quartile) outcomes and lower amputation rates (0.52, 0.45 to 0.61, p <0.001). A significant reduction hospitalization costs ($-3,889, -5,318 to -2,459, p <0.001) was also seen in high volume centers. In conclusion, a greater hospital procedural volume is associated with superior outcomes after peripheral endovascular interventions in terms of inhospital mortality, complications, and hospitalization costs.

Outcomes of endovascular treatment for patients with TASC II D femoropopliteal occlusive disease: a single center study

BACKGROUND

Advances in endovascular technology led to an alternative treatment option for TASC II D (TransAtlantic Inter-Society Consensus II class D) lesions. This study was aimed to evaluate the outcomes of endovascular treatment for TASC II D femoropopliteal lesions.

METHODS

Endovascular intervention with bare nitinol stent implantation was performed on 58 limbs (53 patients) with TASC II D femoropopliteal lesions from January 2011 to March 2013. Kaplan-Meier curves of primary patency, assisted patency and second patency were performed. Predictive factors of re-stenosis/occlusion were evaluated by univariate methods.

RESULTS

Total 53 patients with mean age of 74.2 ± 8.2 (range, 58.0-91.0 years) and mean lesion length of 314.8 ± 64.3 mm (188.2-400.4 mm) were enrolled. The mean follow-up time was 12.2 ± 6.1 months (5-38 months). Revascularization was successfully on 95% lesions by bare nitinol stent implantation. Primary patency rates at 1, 2 and 3 years were 63%, 12% and 12%, respectively. Assisted primary patency rates at 1, 2 and 3 years were 77%, 31% and 31%, respectively. Secondary patency rates at 1, 2 and 3 years were 96%, 63% and 63%. During one-year follow-up, no major amputation was occurred. Univariate analysis revealed that number of run-off vessels was a potential predictor of re-stenosis/occlusion.

CONCLUSION

Endovascular treatment of TASC II D femoropopliteal artery occlusion has a high technical success rate with acceptable one-year patency rate. The long-term outcomes are poor, but endovascular intervention could be a good alternative for patients unsuitable for surgical bypass.

Comparative Assessment of Guidewire and Microcatheter vs a Crossing Device-Based Strategy to Traverse Infrainguinal Peripheral Artery Chronic Total Occlusions

PURPOSE

To compare success rates of a guidewire and microcatheter strategy vs the use of specialized crossing devices to traverse infrainguinal peripheral artery chronic total occlusions (CTOs).

METHODS

For this analysis, data on 438 consecutive infrainguinal CTO interventions in 438 patients (mean age 63.2 years; 402 men) performed between August 2006 and May 2014 were extracted from the multicenter Excellence in Peripheral Artery Disease (XLPAD) database (ClinicalTrials.gov; identifier NCT01904851). Primary technical success constituted placement of a guidewire in the true lumen, past the distal CTO cap, with the initial crossing strategy.

RESULTS

A wire-catheter strategy was used in 295 (67.4%) and a specialized CTO crossing device in 143 (32.6%) patients (p<0.001). Primary crossing technical success was higher with CTO devices (72.1% vs 51.9%, p<0.001). The primary wire-catheter arm used significantly more secondary CTO devices (28.1% vs 17.5%) and/or provisional re-entry devices (26.7% vs 4.9%) compared with the primary CTO device arm (both p<0.001). Secondary crossing technical success (defined as crossing with an alternate strategy: 67.5% vs 71.4%, p=1.000), provisional crossing technical success (defined as use of a re-entry device: 84.2% vs 87.5%, p=0.768), and procedure success (93.6% vs 90.9%, p=0.332) were similar between the wire-catheter and CTO device strategies, respectively. No differences were observed in periprocedural complications or 30-day adverse events; however, at 12 months, there was a significantly higher surgical revascularization rate in the primary wire-catheter arm (8.8% vs 2.8%, p=0.025).

CONCLUSION

Infrainguinal peripheral artery CTO crossing is frequently attempted with a wire-catheter technique; however, an initial CTO crossing device approach is associated with higher primary technical success. Overall procedure success is similar with both strategies.

[Usefulness of virtual vessel images in ppi for treatment of complete obstruction of leg arteries]

Following recent rapid advances in devices and treatment technology, indications for percutaneous peripheral intervention (PPI) have been expanded to include complex lesions (long-segment lesions, completely obstructed chronic lesions, etc.) and even lesions of the superficial femoral artery and arteries distal to the popliteal artery. However, when PPI is used for treatment of complete obstruction, treatment can take a long time or its outcome can be less satisfactory for reasons such as difficulty in assessing the vascular distribution/arrangement or the direction of calcification in the obstructed area or excessively long lesions. In the present study, we conducted three-dimensional image processing of CT data from leg arteries conventionally used for preoperative diagnosis. Using this processing technique, we created virtual images of the blood vessels of the completely obstructed area and mapped these virtual vessel images onto the fluoroscopic monitor image during catheter treatment. The usefulness of this technique for PPI was then evaluated. We succeeded in creating virtual vessel images of the completely obstructed parts of leg arteries with the use of preoperative CT images of leg arteries that we then mapped onto the fluoroscopic monitor images during treatment. We were successful in mapping virtual images onto the abdominal aorta in 96.8% of cases and in 95.7% with the common iliac artery. This technique is thus able to supply reliable information on vascular distribution/arrangement, suggesting that it can enable the surgeon to advance the treatment device precisely along the vessels, making it useful for treatment with PPI. The study additionally showed that differences in the angle of imaging affect the manual mapping of the CT images onto angiograms.