Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: Early results with a new approach to avoid radiation exposure and contrast material

Feasibility and impact of extra-vascular ultrasound-guided endovascular treatment for infrapopliteal artery occlusive disease

PURPOSE

This study aimed to examine the feasibility and impact of extra-vascular ultrasound (EVUS)-guided intervention for infrapopliteal (IP) artery occlusive disease.

MATERIALS AND METHODS

A retrospective analysis was performed using data collected from patients who underwent endovascular treatment (EVT) for IP artery occlusive disease between January 2018 and December 2020 at our institution. A total of 63 consecutive de novoocclusive lesions were compared according to the recanalization method utilized. Propensity score matching analysis was performed to compare the clinical outcomes of the methods utilized. The prognostic value was analyzed based on the technical success rate, distal puncture rate, radiation exposure, amount of contrast media, postprocedural skin perfusion pressure (SPP), and procedural complication rate.

RESULTS

Eighteen matched pairs of patients were analyzed using propensity score-matched analysis. Radiation exposure was significantly lower in the EVUS-guided group than in the angio-guided group, with 135 and 287 mGy (p = 0.04) exposure on average, respectively. There were no significant differences between the two groups in terms of technical success rate, distal puncture rate, the amount of contrast media, postprocedural SPP, and procedural complication rate.

CONCLUSION

EVUS-guided EVT for IP occlusive disease achieved a feasible technical success rate and significantly reduced radiation exposure.

Comparison of ultrasound-guided versus angiography-guided endovascular treatment for femoropopliteal artery occlusive disease

PURPOSE

This study aimed to compare the efficacy of ultrasound-guided and angiography-guided intraluminal approach for femoropopliteal (FP) artery occlusive disease.

METHODS

A retrospective analysis was performed using the data collected regarding patients that underwent endovascular treatment (EVT) for FP artery occlusive disease between January 2010 and April 2018 at two centers. A total of 221 consecutive de novo lesions were analyzed according to the method of recanalization. Propensity score-matched analysis was performed to compare the clinical outcomes of recanalization methods for FP occlusive lesions. The prognostic value was analyzed based on the number of guidewires, wire cross time, distal puncture rate, radiation exposure, the amount of contrast media, primary patency, and clinically driven-target lesion revascularization (CD-TLR) at 1 year.

RESULTS

A total of 44 matched pairs of patients were analyzed after propensity score-matched analysis. The number of guidewires, distal puncture rate, wire passage time, radiation exposure, and the amount of contrast media were significantly lower in the ultrasound-guide group, with 3.4 vs. 4.7, 9.1% vs. 54.5%, 47 min vs. 83 min, 207 mGy vs. 821 mGy, 66 ml vs. 109 ml, respectively (p < .01), but there were no significant differences between the two groups in terms of primary patency and CD-TLR.

CONCLUSIONS

The ultrasound-guided EVT for FP occlusive disease significantly reduced the number of guidewires, wire cross time, the rate of distal puncture, radiation exposure, and the amount of contrast media used.

Roboterbasierte Ultraschallsteuerung

Hintergrund

Die periphere endovaskuläre Chirurgie ist nach wie vor durch die Anwendung von Röntgenstrahlen und Röntgenkontrastmittel für die intraprozedurale Navigation der Instrumentarien ein Verfahren mit potenziellen Risiken und Nebenwirkungen.

Projektziel

Ziel des RoGUS-PAD (Robotic-Guided Ultrasound System for Peripheral Arterial Disease)-Projektes ist die Entwicklung eines roboterbasierten ultraschallgesteuerten Assistenzsystems für periphere endovaskuläre Interventionen zur Verringerung und ggf. Vermeidung von Röntgenstrahlung und Röntgenkontrastmittel sowie Verbesserung der Echtzeitvisualisierung.

Material und Methoden

Für die Bildgebung wurde ein 2‑D-Ultraschall-Lineartastkopf (L12‑3, Philips Healthcare, Best, Niederlande) am Endeffektor eines Roboterarms (LBR iiwa 7 R800, KUKA, Augsburg, Deutschland) montiert. Die ersten Versuche wurden an einem eigens für dieses Projekt entwickelten ultraschallfähigen Phantom durchgeführt. Die Bildverarbeitung und Robotersteuerung erfolgten durch ein speziell entwickeltes Programm in C++.

Ergebnisse

Zur Testung der technischen Umsetzbarkeit des Projektes konnten wir einen semiautomatischen 2‑D-Ultraschallscan einer peripheren Arterie am Phantom durchführen. In 27 von 30 Durchläufen zeigte sich ein erfolgreicher Scanvorgang.

Schlussfolgerung

Unsere ersten Ergebnisse bestätigten, dass die Entwicklung eines roboterbasierten Assistenzsystems für ultraschallgesteuerte periphere endovaskuläre Interventionen technisch umsetzbar ist. Dies stützt unsere Ambitionen einer Translation des Systems in die tägliche klinische Praxis.

Comparison of the OUTBACK® Elite Reentry Catheter and the Bi-directional Approach after Failed Antegrade Approach for Femoro-popliteal Occlusive Disease

Aim: A successful antegrade wire crossing for femoro-popliteal chronic total occlusion (FP-CTO) is still a technical challenge. We attempted to demonstrate the safety and feasibility of the OUTBACK^® Elite reentry catheter and the bi-directional approach for failed FP-CTO cases with the antegrade approach.

Methods: Endovascular therapy for FP-CTO was performed in 219 lesions from May 2013 to December 2016 at Morinomiya Hospital. We retrospectively analyzed the data of 43 consecutive lesions which underwent endovascular therapy using the bi-directional approach with distal access and the mono-directional approach with the OUTBACK^® Elite reentry catheter for FP-CTO lesions. The antegrade success using a combination of traditional and Intravascular Ultrasound (IVUS) -guided techniques was achieved in 170 lesions out of a total of 219 lesions. From May 2013 to June 2016 (phase 1), the bi-directional approach with distal access was applied to 22 lesions after failed antegrade approaches. From July 2016 to December 2016 (phase 2), the mono-directional approach with the OUTBACK^® Elite reentry catheter was applied to 21 lesions.

Results: Clinical and lesion characteristics in phase 1 were not significantly different from those in phase 2. The overall initial technical success rate was 100% in both phases. The total wire number and amount of contrast media were significantly less, and the total procedure time and the total fluoroscopic time were significantly shorter in phase 2 than in phase 1 (p < 0.01).

Conclusions: Endovascular therapy for FP-CTO using the OUTBACK^® Elite reentry catheter is feasible and safe after a failed antegrade approach.

Use of duplex guided stent graft placement to prevent bleeding from previously thrombosed pseudo-aneurysms during thrombolytic therapy for acute popliteal artery occlusion

We present a 68-year-old female who developed multiple pseudo-aneurysms (PSAs) following cardiac catheterization via the right groin. During subsequent thrombin injection of PSAs, the patient developed acute occlusion of the popliteal artery. A covered stent was placed to obliterate the PSAs and allow for successful endovascular treatment of the occlusion without hemorrhage from the previous arteriotomy sites. This report demonstrates a safe and successful method to treating high surgical risk patients with recent PSA's and a necessity for thrombolysis.

Chapter V: Diabetic foot

Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.

Practical use of duplex echo-guided recanalization of chronic total occlusion in the iliac artery

Although endovascular therapy for peripheral arterial disease has undergone tremendous changes, chronic total occlusion (CTO) remains a significant challenge for interventionalists. Failed CTO recanalization is predominately due to unsuccessful guidewire crossing. In particular, the unique characteristics of tortuous and deeply located large vessels in the retroperitoneal cavity create challenging endovascular procedures. Real-time guidance based on external direct vessel visualization might be a promising tool for successful recanalization of noncalcific CTO. Here, we describe the practical use of duplex echo-guidance during the procedural course of iliac CTO recanalization.

Predictive factors of femoropopliteal patency after suboptimal duplex-guided balloon angioplasty and stenting: is recoil a bad sign?

Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex-guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex-guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/ or recoil caused diameter reduction > or = 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 +/- 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 +/- 4.2 months and 5.6 +/- 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p<.04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.

Limitations of and Lessons Learned from Clinical Experience of 1,020 Duplex Arteriography

Objective: Due to the inherent risks, deficiencies and cost associated with contrast arteriography (CA), our group has been utitilizing duplex arteriography (DA) for evaluating the arteries of the lower extremity for patients undergoing lower extremity revascularization. In an effort to further explore the strengths and weaknesses of DA, we reviewed our evolving experience with DA from January 1, 1998, to January 1, 2005.

Patients and Methods: The arterial segments starting from mid-abdominal aorta to the pedal arteries were studied in cross-sectional and longitudinal planes using a variety of scanheads of 7–4, 10–5, 12–5, 5–2 and 3–2 MHz extended operative frequency range to obtain high-quality B-mode, color and power Doppler images as well as velocity spectra. In 906 patients, 1,020 duplex arteriograms were obtained. The ages ranged from 30–98 years old with a mean of 73±11 (SD) years. Fifty percent of the patients were diabetics. Indications for the examination included: tissue loss (409), rest pain (221), claudication (310), acute ischemia (74), popliteal aneurysm (45), SFA aneurysm (2), abdominal aortic aneurysms (AAA) (10) and failing bypass (55). Prior procedures had been performed in 262. DA was performed by six technologists (4 of whom are MDs). In all, 207 DA were performed intraoperatively and the remainder, preoperatively.

Results: The resultant procedures based upon DA included: bypass to the popliteal artery (262) and bypass to an infrapopliteal artery (325), endovascular procedures (363), thrombectomy (11), embolectomy (9), inflow bypass procedures to the femoral arteries (46), débridment (4), amputation (8) and no intervention (75). The areas not visualized well included: iliac (73), femoral (26), popliteal (17), and infrapopliteal (221). Additional imaging after DA was deemed necessary in 102 cases to obtain enough information to plan lower extremity revascularization. Factors associated with increased need to obtain CA included: DM ( p<.001), infrapopliteal calcification ( p<.001), older age ( p = .01) and limb threatening ischemia ( p<.001). Factors not associated with the need to obtain CA included: which technologist performed the exam, whether the technologist has a medical degree and whether the patient underwent prior revascularization.

Conclusions: In 90% of patients reviewed, DA is able to obtain the needed information to plan lower extremity revascularization. Severe tibial vessel calcification is the most common cause of an incomplete DA exam and determines when alternative imaging modalities need to be obtained.

Intravascular ultrasound-guided central vein angioplasty and stenting without the use of radiographic contrast agents

Patients with contraindications to iodinated radiographic contrast agents present a significant challenge during endovascular intervention. A 46-year-old man with end-stage renal disease and a normally functioning left upper extremity arteriovenous fistula presented with severe left arm edema. The patient's history included repeated severe anaphylactoid reactions with severe respiratory distress upon exposure to iodinated contrast. In an attempt to avoid the use of iodinated contrast, angioplasty and stent placement of a severe central venous stenosis were performed using only fluoroscopy and intravascular sonography. In patients unable to receive iodinated contrast secondary to anaphylactoid reactions, intravascular sonography can be used to guide angioplasty and stenting of central venous stenosis.

Lesion severity and treatment complexity are associated with outcome after percutaneous infra-inguinal intervention

OBJECTIVES

Percutaneous revascularization has become increasingly utilized for the treatment of lower extremity ischemia. Patients with limb-threat have been shown to be at increased risk of failure, although the reasons for this remain unclear. This study analyzed factors associated with percutaneous treatment failure, focusing specifically on lesion characteristics and treatment complexity.

METHODS

We retrospectively reviewed percutaneous infra-inguinal interventions performed for peripheral occlusive disease between 2002 and 2005 using a prospectively maintained database. Lesion characteristics were assessed by angiography, and lesions were graded according to the TransAtlantic InterSociety Consensus (TASC) criteria. Patency was expressed by Kaplan-Meier method and compared by log-rank analysis. Multivariate Cox-regression analysis was used to assess significant factors on univariate analysis. Mean follow-up was 11.8 months.

RESULTS

A total of 324 interventions for claudication (55.8%), rest pain (18.4%), or tissue loss (25.8%) were analyzed, including 284 primary interventions and 40 re-interventions in 258 patients (mean age 72.1 +/- 10 years, 51.0% male). TASC lesion grades included: A (4.9%), B (29.3%), C (37.7%), and D (28.1%). Isolated single-level interventions (femoral, popliteal, or tibial) were performed in 38.9%, while two-level interventions were performed in 46.2% and three-level interventions in 14.9%. Overall primary patency (+/- SD) at 6, 12, and 18 months was 87 +/- 2%, 66 +/- 2% and 59 +/- 4%, respectively. Secondary patency at 6, 12, and 18 months was 89 +/- 2%, 76 +/- 3%, and 69 +/- 5%. One-year limb salvage rate (limb-threat patients) was 85 +/- 3%. Limb-threatening ischemia as the indication for intervention was most highly associated with failure of both primary and secondary patency and was associated with four indicators of lesion severity and treatment complexity, including increasing TASC grade, multilevel intervention, tibial intervention, and reduced tibial outflow. One-year primary patency was inversely correlated with TASC severity (TASC A-C: 67 +/- 6%, D: 61 +/- 4%; P < .05), multilevel intervention (76 +/- 5% and 49 +/- 9% for single vs multilevel, P = .002), distal interventions (74 +/- 5% and 57 +/- 7% for femoral vs tibial, P < .05), and decreased tibial runoff (83 +/- 6% and 52 +/- 6% for three- vs < three-vessels, P < .02). No differences in secondary patency or limb-salvage rates existed for these lesion- and treatment-related variables. Multilevel intervention and tibial intervention remained significant independently associated with primary patency on multivariate analysis.

CONCLUSIONS

Patients with limb-threatening ischemia are at increased risk of initial failure compared with claudicants, likely as a result of the increased prevalence of advanced lesion severity and treatment complexity, which are associated with decreased primary patency. However, this finding did not extend to secondary patency or limb-salvage in the overall patient population. Although additional studies with longer follow-up are needed, these findings argue that percutaneous intervention may still be considered as a primary treatment modality with the understanding that these patients may have higher re-intervention rates and may ultimately require salvage open surgical bypass for persistent failures of percutaneous therapy.

Recanalization of infrainguinal vessels: silverhawk, laser, and the remote superficial femoral artery endarterectomy

There are multiple endovascular options to achieve percutaneous revascularization of chronic superficial femoral artery (SFA) stenoses and occlusions. Most rely on forceful displacement of plaque via balloon angioplasty, either as a stand-alone therapy or supplemented by cold thermal injury (cryoplasty), microtome assistance (cutting balloon angioplasty), nitinol stent deployment, or expanded polytetrafluoroethylene-lined nitinol stent deployment. Excellent technical success rates are routinely described in the literature. The essential problem associated with these techniques is the predictable compromise of the initial result by neointimal hyperplasia leading to poor long-term results. An alternative to forceful displacement techniques is use of directional atherectomy or excimer laser to debulk the atheromatous lesion, with the addition of low-pressure angioplasty or stent deployment as needed. Currently, directional atherectomy is performed using the Silverhawk Plaque Excision System (FoxHollow, Redwood City, CA), while laser atherectomy is frequently performed with the CLIRpath Excimer Laser (Spectranetics Corp., Colorado Springs, CO). While both techniques can be utilized for de novo atherosclerotic lesions, even eccentric lesions or ostial lesions, proponents of these devices have also shown good short-term results in the treatment of restenoses. Remote SFA endarterectomy with the Aspire stent (Vascular Architects, San Jose, CA) is a hybrid surgical and endovascular technique that is useful for debulking plaque from the SFA with adjunctive stenting of the distal SFA. We present a review of various alternative techniques to forceful balloon dilation used in the recanalization of the SFA with potential pitfalls and complications, along with a review of literature associated with each of these techniques.

Infrapopliteal Intervention for the Treatment of the Claudicant

As the associated risks of infrainguinal balloon angioplasty and stenting have fallen and the relative success rates have risen in recent years, the threshold for offering endovascular treatment to patients with claudication has significantly decreased. Patients once considered appropriate only for risk-factor modification, exercise therapy, and medical treatment are now increasingly being offered percutaneous revascularization as a primary treatment option. Similarly, occlusive disease of the tibial vessels, once thought to be the exclusive domain of operative bypass, is increasingly being treated percutaneously. Over this same period, results of operative infrainguinal arterial reconstruction have also considerably improved. In modern times, excellent outcomes following bypass grafting with autogenous vein to the tibial level have been demonstrated, with morbidity, mortality, and long-term patency equivalent to that of more proximal bypasses. Evidence supports the view that the anatomic level of the distal anastomosis is less critical to the long-term outcome of the procedure than factors such as operative indication and conduit quality. Within the context of this changing climate, it is an appropriate time to examine and potentially redefine the role of both endovascular and open surgical intervention for a population that has not traditionally been offered revascularization, patients with claudication secondary to infrageniculate occlusive disease.

Contrast-Induced Nephropathy

Contrast-induced nephropathy (CIN) is a well-recognized complication of radiographic contrast administration and is the third leading cause of hospital-acquired renal insufficiency. The use of contrast media is increasing, particularly in the area of endovascular therapy. Vascular interventionists need to be aware of strategies to reduce the risk of CIN. Numerous trials, meta-analyses, and expert guidelines for the prevention of CIN have been published between 1966 and 2006, but the majority of studies have been conducted on patients undergoing coronary interventions; few have involved vascular surgical population. The literature suggests that adequate hydration is essential in all patients due to receive contrast. No pharmacological agents have been shown to conclusively reduce the risk. Forced diuresis is harmful, and there is insufficient evidence to support routine use of hemodialysis or hemofiltration. Well conducted studies of other potential prophylactic techniques are needed in vascular populations.

Popliteal artery volume flow measurement: A new and reliable predictor of early patency after infrainguinal balloon angioplasty and subintimal dissection

OBJECTIVE

We have investigated whether popliteal artery volume flow (PAVF) measured immediately after balloon angioplasties of the superficial femoral artery-popliteal segments (SFA/POP) was predictive of early (30 days) and mid-term (6 months) arterial thrombosis.

METHODS

During the last 24 months, 203 patients (56% men) with a mean age of 73 +/- 9 years had 268 duplex-guided balloon angioplasties of the SFA/POP. Critical ischemia was the indication in 36%. Group I included 176 (66%) with stenoses, and group II had 92 (34%) with occlusions. All patients had completion duplex examinations that included three measurements of PAVF of below-the-knee popliteal artery.

RESULTS

Early (30 days) thrombosis of the treated femoropopliteal arterial segment developed in 10 patients (3.7%), three in group I (1.7%) and seven in group II (7.6%; P < .04). All 10 cases of early thrombosis were in patients with TransAtlantic Inter-Society Consensus (TASC) class C (6/185, 3.2%) and D (4/26, 15%) lesions. Moreover, the 19% incidence (n = 4) of early thrombosis in patients with PAVF <100 mL/min (mean, 73 +/- 24 mL/min; range, 20 to 99 mL/min) was higher compared with the 2.4% rate for patients with higher flows (mean, 176 +/- 60 mL/min; range, 100 to 450 mL/min; P < .01). At 6 months of follow-up, femoropopliteal occlusions had developed in nine more patients, and it became apparent that low PAVF measurements were still predictive of thrombosis (29%) when compared with higher PAVF cases (6%; P < .002). Log-rank comparison of survival curves for cumulative primary stenosis-free patency in group I and group II demonstrated a statistically significant difference (P < .02). PAVF <100 mL/min and TASC classification were significant predictors of early (30 days) and mid-term (6 months) arterial thrombosis after femoropopliteal angioplasties. PAVF was the most powerful predictor of arterial thrombosis. The respective 6-month and 12-month limb salvage rates were 98% and 94% for patients with claudication and 88% and 85% for those with limb-threatening ischemia (P < .0001).

CONCLUSIONS

Our results demonstrate that low PAVF is the most powerful predictor of early (30 days) and mid-term (6 months) arterial thrombosis after femoropopliteal interventions. In the presence of a low postprocedure PAVF (<100 mL/min), one may consider not reversing the heparin or using intermittent calf compression, or both, to augment the arterial flow.

Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: A comparative study in the first 253 cases

OBJECTIVE

The standard technique of balloon angioplasty with or without subintimal dissection of infrainguinal arteries requires contrast arteriography and fluoroscopy. We attempted to perform this procedure with duplex guidance to avoid the use of nephrotoxic contrast material and eliminate or minimize radiation exposure.

METHODS

From September 2003 to June 2005, 196 patients (57% male) with a mean age of 73 +/- 10 years (range, 42-97 years) had a total of 253 attempted balloon angioplasties of the superficial femoral and/or popliteal artery under duplex guidance in 218 limbs. Critical ischemia was the indication in 38% of cases, and disabling claudication was the indication in 62%. Hypertension, diabetes, chronic renal insufficiency, smoking, and coronary artery disease were present in 78%, 51%, 41%, 39%, and 37% of patients, respectively. The TransAtlantic Inter-Society Consensus (TASC) classification was used for morphologic description of femoral-popliteal lesions. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery, across the diseased segment(s), and parked at the tibioperoneal trunk. The diseased segment(s) were then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Hemodynamically significant defects causing diameter reductions greater than 30% and peak systolic velocity ratios greater than 2 were stented with a variety of self-expandable stents under duplex guidance. Completion duplex examinations and ankle-brachial indices were obtained routinely before hospital discharge.

RESULTS

There were 11 (4%) TASC class A lesions, 31 (12%) TASC class B lesions, 177 (70%) TASC class C lesions, and 34 (14%) TASC class D lesions in this series. The overall technical success was 93% (236/253 cases). Eight of the 17 failed subintimal dissections belonged to TASC class C and the remaining 9 to TASC class D. End-stage renal disease was the only significant predictor of subintimal dissection failure in patients with femoral-popliteal occlusions (5/17 cases; P < .04). Intraluminal stents were placed in 153 (65%) of 236 successful cases. Overall pre-procedure and post-procedure ankle-brachial indices changed from a mean of 0.69 +/- 0.16 (range, 0.2-1.1) to 0.95 +/- 0.14 (range, 0.55-1.3), respectively (P < .0001). The mean duration of follow-up was 10 +/- 7 months (range, 1-29 months). The overall 30-day survival rate was 100%. Overall limb salvage rates were 94% and 90% at 6 and 12 months, respectively. Six-month patency rates for TASC class A, B, C, and D lesions were 89%, 73%, 72%, and 63%, respectively. Twelve-month patency rates for TASC class A, B, C, and D lesions were 89%, 58%, 51%, and 45%, respectively.

CONCLUSIONS

Duplex-guided balloon angioplasty and stent placement seems to be a safe and effective technique for the treatment of infrainguinal arterial occlusive disease. Technical advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, and confirmation of the adequacy of the technique by hemodynamic and imaging parameters. Additional benefits are avoidance of radiation exposure and contrast material.

Duplex Guided Balloon Angioplasty of Failing Infrainguinal Bypass Grafts

OBJECTIVE

To assess the results of angioplasty and stent placement under duplex guidance for failing grafts.

METHODS

Over 22 months, 25 patients (72% males) with a mean age of 74+/-10 years presented to our institution with a failing infrainguinal bypass. The site of the most significant stenotic lesion was in the inflow in four cases, conduit in 18 cases and at the outflow in 11 cases. All arterial (20) or graft (13) entry sites cannulations were performed under direct duplex visualization. Duplex scanning was the sole imaging modality used to manipulate the guide wire and directional catheters from the ipsilateral CFA to a site beyond the most distal stenotic lesion. Selection and placement of balloons and stents were also guided by duplex. In 11 cases (33%), the contralateral CFA was used as the entry site and a standard approach (fluoroscopy and contrast material) was employed. Completion duplex exams were obtained in all cases.

RESULTS

The overall technical success was 97% (32/33 cases). In only one case, the outflow stenotic lesion in the plantar artery could not be traversed with the guidewire due to extreme tortuosity. Overall local complications rate was 6% (two cases). One vein bypass pseudoaneurysm caused by rupture with a cutting balloon was repaired by patch angioplasty and one SFA pseudoaneurysm at the puncture site required open repair. Overall 30-day survival rate was 100%. Overall 6-month limb salvage and primary patency rates were 100 and 69%, respectively.

CONCLUSIONS

Duplex guided endovascular therapy is an effective modality for the treatment of failing infrainguinal arterial bypasses.