Endovascular treatment of long lesions of the superficial femoral artery: results from a multicenter registry of a spiral, covered polytetrafluoroethylene stent

Sex Differences in Peripheral Artery Disease

Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.

[Endovascular treatment for critical limb ischemia in patients with diabetes mellitus: new opportunities and prospects]

Diabetes mellitus (DM) is still one of the most common endocrine diseases despite all available technologies in modern medicine. In recent years, it was shown that severity and duration of DM are closely associated with vascular wall lesions (the called micro-and macroangiopathy). One of severe clinical signs is damage to lower limb arteries followed by trophic and purulent-necrotic lesions of soft tissues (diabetic foot syndrome) and risk of amputation. The authors review the possibilities of endovascular treatment of critical limb ischemia in patients with diabetes mellitus. The features of endovascular interventions depending on clinical and morphological peculiarities of vascular lesions are discussed. The authors compared the results of open and endovascular treatment of lower limb ischemia and determined further prospects for improving the treatment of these patients.

Acute Outcomes With a Novel Plaque Modification System in Real-World Femoropopliteal Lesions

Purpose:

To report outcomes of a multicenter feasibility study using the FLEX Vessel Prep (VP) System, a novel technology that facilitates plaque incision and lumen gain in stenosed or occluded femoropopliteal arteries prior to balloon angioplasty.

Materials and Methods:

Two hundred fifty-five patients (mean age 71.8±9.1 years) were treated with the FLEX VP System at 38 centers between December 2015 and November 2017. Average lesion length was 133±88 mm. Average baseline stenosis was 92%±11%; 112 (44.3%) of 253 patients presented with a chronic total occlusion. Conventional or drug-coated balloon (DCB) angioplasty was performed in all patients after vessel preparation. Vessel measurements were derived from angiograms acquired at baseline, after FLEX passage, and after subsequent ancillary procedures. Logistic regression analyses were performed to identify baseline or procedure variables that predicted the need for provisional stenting.

Results:

Average percent reduction in vessel stenosis following treatment with the FLEX VP System was 27%±17%. No flow-limiting dissection, vessel perforation, or embolization was observed; 15 (5.9%) patients had minor (type A or B) dissections. Provisional stenting was performed in 49 (19.2%) patients. Average stenosis following angioplasty ± stenting was 9.1%±7.4%; 9 (3.6%) patients had significant residual stenosis ≥30%. Logistic regression analyses found that patients with dissections, longer lesions, and those receiving conventional balloon dilation alone were most likely to undergo stenting.

Conclusion:

In a real-world patient population with long, complex femoropopliteal lesions, use of the FLEX VP System as vessel preparation for angioplasty improved acute outcomes compared to historical controls. The rate of provisional stenting was low, and no serious vessel complications were observed.

[Efficacy of using loop endarterectomy]

Endarterectomy is considered to be the most physiological technique of correcting arterial blood flow, since it does not require implantation of a synthetic material, with blood flow restored through its own bed. However, surgeons have long sought to work out the most effective modification of endarterectomy, which eventually resulted in creation of a method known as loop endarterectomy. Mention should be made that some researchers report patency which may be comparable to that of autovenous bypass grafting, while others report negative results of using loop endarterectomy. Such ambiguous findings have impelled the authors to carry out a scrupulous study of the data available in scientific literature. The presented review discusses advantages and shortcomings of loop endarterectomy, also analysing possible complications in loop endarterectomy (causes, probability of occurrence, etc.). Also discussed herein is the problem concerning a combination of loop endarterectomy and roentgen-endovascular stenting.

Integrated application of antegrade and retrograde recanalization for femoral-popliteal artery chronic total occlusions: outcomes compared with antegrade recanalization

Background

To investigate the efficacy of retrograde recanalization for chronic total occlusion (CTO) of femoral-popliteal artery in patients with peripheral arterial disease.

Methods

In this single-center retrospective study, all patients who had undergone endovascular recanalization for femoral-popliteal CTOs at our center from June 2011 to October 2014 were included. Patients' demographics, immediate and follow-up outcomes were analyzed.

Results

A total of 205 patients with 238 CTOs were enrolled. In total, successful recanalization was achieved in 228 CTOs (95.8%). The antegrade procedure was successful in 196 CTOs. The retrograde procedure was successfully performed in 32 CTOs after failed antegrade procedure. Ankle-brachial index increased from 0.48±0.18 to 0.79±0.16 in antegrade group vs. 0.41±0.13 to 0.76±0.13 in retrograde group (P=0.438). Pulse score increased from 0.48±0.50 to 2.30±0.76 in antegrade group vs. 0.48±0.51 to 2.30±0.79 in retrograde group (P=0.771). At 12 and 24 months, primary patency rate was 86.2% (169/196) and 51.5% (101/196) in the antegrade group, and 75.0% (24/32) and 43.8% (14/32) in the retrograde group, respectively (P=0.346). Kaplan-Meier analysis showed limb salvage rates of 85.7% in the antegrade group vs. 78.1% in the retrograde group (P=0.198).

Conclusions

Retrograde recanalization is effective for CTO of femoral-popliteal artery after the failure of an antegrade procedure; immediate outcomes and mid-term patency and limb salvage rate are comparable with that of antegrade procedure.

VEGF secreted by mesenchymal stem cells mediates the differentiation of endothelial progenitor cells into endothelial cells via paracrine mechanisms

Stem cell therapy is a promising treatment strategy for ischemic diseases. Mesenchymal stem cells (MSCs) and endothelial progenitor cells (EPCs) adhere to each other in the bone marrow cavity and in in vitro cultures. We have previously demonstrated that the adhesion between MSCs and EPCs is critical for MSC self-renewal and their multi-differentiation into osteoblasts and chondrocytes. In the present study, the influence of the indirect communication between EPCs and MSCs on the endothelial differentiation potential of EPCs was investigated, and the molecular mechanisms underlying MSC-mediated EPC differentiation were explored. The effects of vascular endothelial growth factor (VEGF), which is secreted by MSCs, on EPC differentiation via paracrine mechanisms were examined via co-culturing MSCs and EPCs. Reverse transcription-quantitative polymerase chain reaction and western blot analysis were used to detect the expression of genes and proteins of interest. The present results demonstrated that co-culturing EPCs with MSCs enhanced the expression of cluster of differentiation 31 and von Willebrand factor, which are specific markers of an endothelial phenotype, thus indicating that MSCs may influence the endothelial differentiation of EPCs in vitro. VEGF appeared to be critical to this process. These findings are important for the understanding of the biological interactions between MSCs and EPCs, and for the development of applications of stem cell-based therapy in the treatment of ischemic diseases.

Clinical and morphological features of patients who underwent endovascular interventions for lower extremity arterial occlusive diseases

Introduction

Patients with peripheral arterial disease (PAD) are at increased risk for all-cause mortality and cardiovascular mortality.

Aim

To present anatomical and morphological characteristics of patients who underwent endovascular stenting with laboratory and our mid-term results.

Material and methods

One hundred fifty-three patients (mean age: 62.8, 86% male) who underwent percutaneous intervention of lower extremity arteries were included in the study. Demographic characteristics, medical history, physical examination and laboratory findings of patients were analyzed. Patients’ lesions were classified according to the TransAtlantic Inter-Society Consensus (TASC). Clinical outcomes included complications and mortality, 6-minute walking distance, functional class (NYHA) and patency rates.

Results

Seventy percent of patients had hypertension, 42% were smokers, 78% had coronary artery disease, 20% had coronary artery bypass grafting, 55% had diabetes mellitus and 71% had dyslipidemia. Six patients with diabetes mellitus and poor wound healing despite medical therapy were treated with stenting leading to alleviation of pain and avoidance of amputation. The initial technical success rate of revascularization was 95.6% (153/160). Our mid-term results show that percutaneous procedures in lower extremity arterial diseases can be performed with low complication and high success rates. Patients’ 6-minute walk distance, ankle/brachial index values, functional class and the status of foot ulcers were evaluated.

Conclusions

Especially in patients with distal vascular disease, poor wound healing and no chance of surgical revascularization, percutaneous endovascular revascularization may provide good blood flow and prevent amputation.

Atheromatous occlusive lesions of the popliteal artery treated with stent grafts: predictive factors of midterm patency

BACKGROUND

Because of its location, the popliteal artery is exposed to important biomechanical constraints, inducing a specific risk of thrombosis of stents, little studied in the literature. The objective of this monocentric retrospective study was to evaluate the patency of stents implanted in the popliteal artery to treat atheromatous lesions and the risk factors predisposing to thrombosis.

METHODS

Between January 2009 and July 2013, all the patients receiving stents for a residual stenosis or a complication of angioplasty in the popliteal artery or the distal anastomosis of a femoropopliteal bypass were included retrospectively and in an intention to treat. Forty-six patients (17 women), with a 71.5 years median age (range, 45-90 years), including 17 diabetic patients (37%) and 7 hemodialysis patients (15%), were operated in 51 limbs for claudication (n = 25, 49%), critical ischemia (n = 18, 35%), or acute ischemia (n = 8, 16%). Thirty stenoses >70% (59%) and 21 thromboses (41%) were treated with 56 autoexpandable stents, with an average diameter of 6 mm (range, 5-8 mm) and an average length of 5 cm (range, 4-15 cm), including 39 lesions in P1 (above the patella), 8 in P2 (articular), and 4 in P3 (distal popliteal artery). The following factors were analyzed according to univariate and multivariate models: age, gender, Society for Vascular Surgery score, symptomatology, type and location of lesion, number of stents deployed, and dimension of stents.

RESULTS

Technical success was of 98% (n = 50), including 1 insufficient result of the endovascular treatment. At 30 days, one patient treated for critical ischemia died (2%) and one residual popliteal stenosis was treated by bypass (2%). After a 27.6 ± 10.07 month follow-up, restenosis (>50%) was detected in 5 cases including 4 asymptomatic and a popliteal thrombosis occurred in 9 cases, including 3 asymptomatic cases. Eight secondary interventions were necessary, including 4 endovascular procedures, 3 bypasses, and only 1 major amputation (thigh). The primary and secondary patencies at 12 months and 24 months were 80% and 65%, and 90% and 74%, respectively. The multivariate analysis showed that the type of lesion (stenosis versus occlusion; odds ratio [OR], 5.1; 95% confidence interval [CI], 1.2-22.9, P = 0.032) and the number of stents implanted (1 vs. 2 stents; OR [95% CI], 12.7 [1.8-88.5]; P = 0.011) were independent predictive factors of secondary thrombosis.

CONCLUSIONS

The endovascular treatment of the atheromatous popliteal lesions appears to be a satisfactory alternative. The implantation of 1 stent in the popliteal artery is recommended in the event of popliteal occlusion, whereas for a stenosis, it must be reserved for patients with residual stenosis or in the event of complications of angioplasty, such as dissection or elastic recoil. Stent must be single, with deployment of a long stent in the event of long lesion.

12-month primary patency rates of contemporary endovascular device therapy for femoro-popliteal occlusive disease in 6,024 patients: beyond balloon angioplasty

BACKGROUND

Endovascular approach to superficial femoral artery (SFA) disease, the most common cause of symptomatic peripheral arterial disease, remains fraught with high failure rates. Newer devices including second-generation nitinol stents, drug-coated stents, drug-coated balloons, covered stents, cryo-therapy, LASER, and directional atherectomy have shown promising results. Clinical equipoise still persists regarding the optimal selection of devices, largely attributable to the different inclusion criteria, study population, length of lesions treated, definition of "patency" and "restenosis," and follow-up methods in the pivotal trials.

METHODS

A prospective protocol was developed. We performed a literature search using PubMed from January 2006 to November 2013. Published articles including endovascular interventions in SFA or popliteal arteries with reported 12-month "primary patency" or "binary restenosis" rates as endpoints were included.

RESULTS

We identified 6,024 patients in 61 trials reporting 12-month primary patency rates in patients with femoropoliteal disease. Primary patency rates were (weighted average) 77.2% for nitinol stents, 68.8% for covered stents, 84% for drug eluting stents, 78.2% for drug eluting/coated balloon, 60.7% for cryoballoon, 51.1% for LASER atherectomy, 63.5% for directional atherectomy and 70.2% with a combination of endovascular devices.

CONCLUSION

The most frequently used endovascular devices yielded various 12-month primary patency rates ranging from 51% to 85%. The increased variation in inclusion criteria, length, and complexity of lesions between studies does not allow direct comparison between them. Larger randomized trials in specific patient populations comparing those modalities is needed before we can make safe recommendation of the superiority of one device over the other.

Gender-specific risk factors for peripheral artery disease in a voluntary screening population

Background

Women have high rates of peripheral artery disease (PAD) despite fewer cardiovascular disease (CVD) risk factors, compared to men. We sought to determine the gender‐specific prevalence of low ankle brachial index (ABI) and the relationship to C‐reactive protein (CRP) levels and CVD risk factors in the Life Line Screening population.

Methods and Results

Between April 2005 and August 2011, 133 750 women and 71 996 men had ABI and CRP measured at a Life Line Screening Center. Women were slightly older than men, whereas men were more likely to be current smokers, have diabetes mellitus (DM), and coronary artery disease (CAD) (P<0.001 for each). Women were more likely to have ABI≤1.0, compared to men (26.6% versus 14.4%, respectively; P<0.001), as well as ABI≤0.9 (4.1% women versus 2.6% men; P<0.001). Women had higher median CRP levels (1.94 mg/L; interquartile range [IQR], 0.89, 4.44 mg/L), compared to men (1.35 mg/L; IQR, 0.73, 2.80 mg/L; P<0.001). Men and women shared similar risk factors for ABI≤0.9, including older age, black race, smoking, DM, hypertension, hypercholesterolemia, CAD, and elevated CRP levels. In an adjusted model, there were significant interactions between gender and age (P<0.001), CRP (P<0.001), CAD (P=0.03), and DM (P=0.06) with ABI as the outcome. The associations between age, CRP, CAD, and DM with ABI≤0.9 were stronger in men than in women.

Conclusions

Women participating in the Life Line Screening had higher CRP levels and a higher prevalence of PAD, compared to men. Neither higher CRP levels nor conventional CVD risk factors explained the excess prevalence of PAD in women.

A review of surgically treated patients with obstruction after stenting in the femoropopliteal artery region

In this study, we retrospectively reviewed 36 cases that required surgical treatment in the femoropopliteal regions (46 regions) because of the development of obstructions after stent placement in these patients. Of the 46, stents were placed in 37 involved regions (80.4%) that included the common femoral and popliteal arteries; such as the common femoral, entire length of superficial femoral, or popliteal arteries, and the anastomosis site created during femoropopliteal (prosthetic graft) bypass surgeries (Group A). In contrast, 9 involved regions (19.6%) did not include the common femoral or popliteal arteries; the stents were primarily localized in the superficial femoral artery (Group B). Symptoms of stent occlusion were more severe in the former group of patients, who subsequently required peripheral artery bypass surgery. These results indicate that placement of stents in the common femoral artery and popliteal arteries should be avoided. (English translation of J Jpn Coll Angiol 2012; 52: 19-23).

Is There an Alternative to the Surgical Above-Knee Bypass in Treatment of Superficial Femoral Artery Disease? Experiences With Viabahn Stent Graft

Objective:

We conducted a retrospective study to compare short- and mid-term patencies of Viabahn with surgical above-knee prosthetic bypass (pAKB).

Methods:

The records of 52 patients with either pAKB (n = 25) or Viabahn (n = 27) were reviewed. The majority had Rutherford clinical grade 3. Patients were followed after 3, 6, and 12 months and yearly thereafter.

Results:

For Viabahn, the short-term (1-16 months) primary patency rate was 60% with a secondary patency rate of 90%, and mid-term (1-68 months) patencies of 47% and 83.3%, respectively. In pAKB, the short-term results revealed a primary patency rate of 78% with a secondary patency of 91% and mid-term results of 65% and 90%, respectively. No statistical difference was found concerning short-term patencies. Mid-term primary patency was lower for Viabahn ( P < .05) and secondary patency proved no significant difference.

Conclusion:

Viabahn revealed similar short-term primary and secondary patencies but lower mid-term primary patency. It provides a good alternative therapy to pAKB.

Endovascular stents: a review of their use in peripheral arterial disease

Technological advances in the past decade have shifted revascularization strategies from traditional open surgical approaches toward lower-morbidity percutaneous endovascular treatments for patients with lower extremity peripheral arterial disease (PAD). The continuing advances in stent design, more than any other advances, have fueled the growth of catheter-based procedures by improving the safety, durability, and predictability of percutaneous revascularization. Although the 2007 TransAtlantic Inter-Society Consensus (TASC) guidelines recommend endovascular therapy for type A and B aortoiliac and femoropopliteal lesions, recent developments in stent technology and increased experience of interventionists have suggested that a strategy of endovascular therapy first is appropriate in experienced hands for TASC type D lesions. The role of endovascular interventions is also expanding in the treatment of limb-threatening ischemia.

Inflammatory burden predicts long-term outcomes in endovascular therapy in peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is a systemic inflammatory disorder that affects the entire vascular system. Endovascular therapy (EVT) is the first surgical treatment choice in a large number of patients who suffer from this disease. However, late clinical failure after primarily successful interventions, with the need of a new reintervention, is the major drawback of this technique. The aim of this study is to determine the possible association between serum high sensitivity C-reactive protein (hsCRP) and fibrinogen levels both preintervention and during follow-up, and the outcomes of EVT and their association with the incidence of cardiovascular events or death in these patients.

METHODS

This is a prospective cohort study in patients diagnosed with PAD in the iliac, femoral, popliteal, or distal sectors, within Rutherford category 3-5 who underwent EVT de novo. We determined levels of hsCRP and fibrinogen before surgery and during the follow-up period (at 1, 3, 6, and 12 months). We analyzed the possible association among inflammatory markers levels before EVT, during 1 year of follow-up and its variation during that year, and the incidence of reintervention, reintervention-free survival, and the occurrence of cardiovascular events or death.

RESULTS

Over the course of 1 year, 246 patients underwent a revascularizing treatment of the lower limbs; 64 patients qualified for inclusion in this study. In these 64 patients, a significant increase between basal hsCRP and fibrinogen levels and the incidence of reintervention (P=0.002 and 0.013, respectively) and death (P=0.001 and 0.013, respectively) during follow-up was found. A significant increase between higher hsCRP basal levels and the incidence of cardiovascular events during the follow-up period was also noted (P=0.004). Levels of basal hsCRP were related to reintervention-free survival after EVT (P=0.04). On the basis of the rate of hsCRP variation and its association with reintervention-free survival, we observed a progressive reduction of the levels of hsCRP until 12 months after the primary procedure.

CONCLUSIONS

Basal levels of inflammatory markers and their variation during follow-up allowed us to identify a subgroup of patients with PAD that will require a greater number of (and earlier) reinterventions after EVT and who will have higher rates of cardiovascular morbidity and mortality.

Endovascular brachytherapy using liquid Beta-emitting rhenium-188 for the treatment of long-segment femoropopliteal in-stent stenosis

PURPOSE

To evaluate the efficacy and safety of endovascular brachytherapy with liquid beta-emitting rhenium-188 (Re-188) in patients with long-segment in-stent stenosis in the femoropopliteal segment.

METHODS

From July 2009 to April 2011, 90 consecutive patients (59 men; mean age 68.3±10.3 years, range 43-86) with symptomatic in-stent stenosis/occlusion (24.6-cm mean lesion length) of the femoropopliteal segment underwent angioplasty and subsequent endovascular brachytherapy. The liquid beta-emitting Re-188 was applied to the target lesion within an angioplasty balloon using a dose of 13 Gy at a depth of 2 mm into the vessel wall. Clinical and angiographic follow-up data were collected up to 2 years. The main study endpoints were the 6- and 12-month primary patency rates defined as <50% in-stent stenosis as detected by duplex ultrasound. Clinical endpoints were the cumulative rates of death, amputation, and bypass surgery, as well as improvement in the Rutherford category and the ankle-brachial index. Results were correlated with patient and lesion characteristics.

RESULTS

Primary technical success was achieved in all patients, with 1 early stent thrombosis, but no other complications related to the irradiation. Eighty-eight patients reached the 6-month and 82 the 12-month examinations; the primary patency was 95.2% and 79.8%, respectively. In-stent stenosis occurred in 9 patients, while 10 patients had reocclusion of the treated segment. During follow-up, there were 2 late acute thrombotic occlusions, both after discontinuation of clopidogrel. The clinical status improved in 67.0% and 62.2% of the patients after 6 and 12 months, respectively. No patient, lesion, or procedure variables were predictive of restenosis after EVBT.

CONCLUSION

EVBT with liquid beta-emitting Re-188 was safe and effective in preventing restenosis in long-segment femoropopliteal ISS.

Endovascular nitinol stenting for long occlusive disease of the superficial femoral artery in critical limb ischemia: a single-center, mid-term result

BACKGROUND

The aim of the present study was to assess the mid-term patency rate of nitinol stent implantation in patients with long superficial femoral artery (SFA) stenosis or occlusion. This is a retrospective, single-center study.

METHODS

The data of 138 patients were retrospectively assessed in our center to determine the patency rate after nitinol stenting of the SFA.

MATERIALS

Data for 165 limbs from 138 patients were collected. Each limb showed a long lesion with a total occlusion of >10 cm and mean lesion length of 20.35 ± 9.46 cm (range, 10-32 cm). Nitinol self-expanding stent implantations were performed in each limb. A total of 258 stents were implanted into 165 limbs (average, 1.56 stents/limb). Each patient received clinical and ultrasound/computerized tomographic angiography/magnetic resonance angiography evaluations before the procedure and underwent clinical status evaluation and an ankle-brachial index test at discharge and at 12, 24, and 36 months thereafter.

RESULTS

The initial technical success rate of revascularization was 91.51% (151/163). During follow-up, nine patients died because of myocardial infarction, cerebral infarction, and pneumonia, and 14 patients were lost to follow-up. The mean follow-up period for 150 limbs from 124 patients was 25.46 months (range, 6-51). During follow-up, 19 in-stent restenoses and 15 occlusions were diagnosed. In all, 30 re-interventions were performed, including six balloon angioplasties, three secondary cutting balloon angioplasties, 10 restenting procedures, four bypass surgeries, two bone marrow stem cell transplantations, and five limb amputations. Analysis showed the primary patency rates at 12, 24, and 36 months were 92.4%, 78.3%, and 62.1%, respectively, and the overall assisted-primary patency rates were 94.4%, 84.6%, and 75.8%, respectively.

CONCLUSIONS

Nitinol self-expanding stent implantation seems to be a good choice for older patients with long SFA occlusions. Although the short- and mid-term patency results were good, more observations are needed to assess its long-term efficiency.

Massive coronary perforation and shock: From appropriate labeling to appropriate calls

Coronary perforation is a rare, unpredictable and dreaded complication of percutaneous coronary Intervention. With Ellis Grade 3 perforations the only effective treatment includes temporary balloon occlusion of the perforated coronary artery and placement of JOSTENT GraftMaster stent to cover the perforation. The authors describe coronary perforation during proximal right coronary artery (RCA) stenting, resulting in immediate cardiogenic shock. The patient was treated with temporary balloon occlusion of the RCA, reversal of anti-coagulation, sealing of the perforation with a GraftMaster stent, inotropes, intra-aortic balloon counterpulsation (IABC) and surgical drainage the pericardial space. The authors describe the rational of their therapeutic strategy. The methodology and pitfalls of GraftMaster deployment, in patients with massive coronary perforation are discussed. This report also emphasizes, that as opposed to manufactures instructions and all previous manuscripts, GraftMaster can be easily deployed via conventional 6F guiding catheters with internal diameter 0.070 inch (1.8 mm).

Prognostic values of C-reactive protein levels on clinical outcome after endovascular therapy in hemodialysis patients with peripheral artery disease

PURPOSE

Endovascular therapy (EVT) has been widely performed for peripheral artery disease. However, the high restenosis rate after EVT remains a major problem in patients on hemodialysis. Recent studies suggest that C-reactive protein (CRP) reflects vascular wall inflammation and can predict adverse events. We evaluated the possible prognostic values of CRP on outcomes in hemodialysis patients undergoing EVT.

METHODS

A total of 234 hemodialysis patients undergoing EVT for peripheral artery disease were enrolled and followed-up for up to 5 years. They were divided into tertiles according to serum CRP levels (lowest tertile, < 1.4 mg/L; middle tertile, 1.4-6.0 mg/L; highest tertile, ≥ 6.0 mg/L). We analyzed the incidence of any reintervention or above-ankle amputation of the limb index (RAO) and any-cause death.

RESULTS

Kaplan-Meier analysis showed that the event-free rate from the composite end point of RAO and any-cause death for 5 years was 60.2% in the lowest tertile, 50.0% in the middle tertile, and 25.1% in the highest tertile (P < .0001). The survival rate from any-cause death for 5 years was 81.5% in the lowest tertile, 65.2% in the middle tertile, and 59.3% in the highest tertile (P = .0078). Even after adjusting for other risk factors at baseline, preprocedural CRP levels were a significant predictive factor for RAO and any-cause death after EVT in a multivariable Cox analysis.

CONCLUSIONS

Elevated preprocedural serum CRP levels were associated with RAO and any-cause death after EVT in hemodialysis patients with peripheral artery disease.

Five-year retrograde transpopliteal angioplasty results compared with antegrade angioplasty

INTRODUCTION

Retrograde transpopliteal angioplasty (PA) is a potentially useful alternative technique for endovascular treatment of infra-inguinal arterial disease when antegrade transfemoral puncture (FA) is technically not possible or appropriate. This study aimed to investigate the outcomes of PA compared with FA during a 5-year period.

PATIENTS AND METHODS

A retrospective study was performed to assess 88 PA and 275 FA performed between January 2003 and January 2008. Assessments of patients, indication for procedure, disease site, stenosis severity, procedure outcomes and time to further intervention were recorded.

RESULTS

FA was used to treat more patients with critical ischaemia (42.2% vs 30.7%; P = 0.014)). PA was used to treat more proximal superficial femoral lesions (P < 0.001) and occlusive lesions (P = 0.001). Overall, 84.1% of PA and 82.5 % of FA were technically successful. There was no difference in local puncture site complication rates. Significantly more FA resulted in distal thrombus/embolism (8.4% vs 3.4%; P = 0.044). Further intervention was required in 27.3% of PA and 36.0% of FA. The time interval to re-intervention was not different between the groups.

CONCLUSIONS

PA is safe with comparable success rates and long-term outcomes to an FA. PA is a useful alternative approach for treating occlusive, proximal disease.

Role of superficial femoral artery stents in the management of arterial occlusive disease: review of current evidence

The objectives of this study were to compare the 1-year patency of superficial femoral artery (SFA) stent placement with percutaneous transluminal angioplasty (PTA) alone and to attempt to define the role of stents in arterial occlusive disease. Literature searches of the Embase, Medline, and Cochrane databases identified relevant articles, which were split into two subgroups: those containing case-controlled matches for stenting and PTA and those considering only stent placement. The review conformed to the QUORUM statement. One-year patency rates were 219 of 383 (57%) in the stented group and 319 of 607 (53%) in the PTA group for matched cases (odds ratio 1.206 [95% CI 0.932-1.559; p = .115]). The patency of stents deployed secondarily was 554 of 909 (61%). The combined 1-year patency of primary and secondary SFA stents for matched and unmatched case series was 816 of 1,282 (64%). One-year patency rates following stent placement or PTA alone in well-matched patient groups demonstrated no significant difference. This would suggest that the routine use of primary SFA stenting should be undertaken only in selected cases and should mainly be used in "bailout" situations or for complex lesions where surgery is precluded. However, the studies used displayed a high degree of heterogeneity, and some used stent technology that is now considered obsolete. Ongoing randomized controlled trials will provide a more definitive answer to this important problem.

Predictive risk factors for restenosis after remote superficial femoral artery endarterectomy

OBJECTIVES

Restenosis following remote superficial femoral artery endarterectomy (RSFAE) remains a challenging problem. The determinants predicting failure are lacking. This study investigated patient characteristics with predictive value for restenosis during the first year after RSFAE.

DESIGN

A prospective cohort study.

MATERIALS AND METHODS

A total of 90 patients post-RSFAE were studied for the occurrence of restenosis (peak systolic velocity ratio >or= 2.5) in the first 12 months postoperatively. At baseline, clinical parameters were recorded. Vessel size was measured on the basis of plaque perimeter in the culprit lesion and lumen diameter on perioperative digital subtraction angiography.

RESULTS

In 57 patients (63%), a restenotic lesion was diagnosed within 12 months following surgery. Patients with longer time interval between start of ischaemic walking complaints and RSFAE revealed a significantly higher incidence of restenosis (hazard ratio (HR) = 1.3 (1.05-1.52) per 4 years). Small plaque perimeter and small superficial femoral artery (SFA) diameter on angiography were significantly associated with restenosis (HR = 0.54 (0.34-0.88) per 10 mm and HR = 0.46 (0.27-0.78) per 1.5 mm, respectively). In multivariate analysis, age, duration of ischaemic walking complaints and lumen diameter were independently associated with increased risk of restenosis after RSFAE.

CONCLUSIONS

This study provides evidence that age, vessel size and duration of ischaemic walking complaints before RSFAE are predictive values for restenosis after RSFAE.

Evolving modalities for femoropopliteal interventions

Despite technical advances in balloon design and technique, there has been little improvement of primary patency rates after balloon-based endovascular interventions for all but focal femoropopliteal lesions. Improving on stainless steel models, nitinol stents have been associated with favorable short- and midterm primary patency rates; studies with longer-term follow-up will be required to learn whether restenosis is ongoing, with continued loss of primary patency. Studies in recent years have shown varying incidences of mechanical fatigue leading to nitinol stent fracture. Covered stents are designed to prevent the tissue infiltration and intimal hyperplasia that can lead to bare metal in-stent restenosis. Several clinical studies, mainly single-center registries, have demonstrated a general effectiveness of the Hemobahn/Viabahn polytetrafluoroethylene-covered stent-grafts, approved for femoral arterial occlusive disease, and have helped to distinguish indications for use and to delineate possible failure modes. A multicenter randomized trial, which has completed enrollment, will compare the Viabahn with self-expanding bare nitinol stents. The primary use of drug-eluting stents (DES) has become routine clinical practice for coronary artery disease. The 2-phase multicenter randomized double-blind SIROCCO trials have been completed, with results published through 24 months. Follow-up demonstrated the feasibility and safety of deploying sirolimus-eluting stents in the femoropopliteal segment but failed to show superior efficacy for DES versus bare nitinol stents. However, the restenosis rates with bare metal stents were unexpectedly low. A paclitaxel-eluting stent without a polymer coating is currently being evaluated in the recently enrolled Zilver PTX randomized trial and international registry. A polymer-based everolimus-eluting stent is being evaluated for femoropopliteal use in the nonrandomized European STRIDES trial. Balloons coated with paclitaxel have recently been evaluated for simple femoropopliteal disease with encouraging results through 2 years of follow-up. The bioabsorbable stent concept emerged in response to the potential issues with metal stents, but to date no investigational device has successfully overcome issues such as relatively low radial force and variable degradation rates.

PTFE bypass or thrupass for superficial femoral artery occlusion? A randomised controlled trial

Early results of a thrupass endograft in the treatment of femoral lesions are promising. Less morbidity and better cost-effectiveness are suggested to be achieved in the treatment of chronic lower limb ischaemia with endovascular treatment compared to surgical treatment.

PATIENTS AND METHODS

This randomised multicentre trial aimed to enroll a group of 60+60 patients for the treatment of 5-25-cm occlusions of superficial femoral artery (SFA) to be followed up for 3 years. Patients were treated either with endoluminal PTFE thrupass (WL Gore & Ass) or with surgical polytetrafluoroethylene (PTFE) bypass to proximal popliteal artery. Primary patency at 3 years was scheduled to be the primary end-point and secondary patency, functional success, costs and quality of life the secondary end-points.

RESULTS

A sample of 100 consecutive SFA occlusions in one of the centres revealed that only 4% of the lesions were amenable for the study. The trial was prematurely terminated due to the results of an interim analysis at the time when 44 patients were recruited: the 1-year primary patency (excluding technical failures) was 48% for thrupass and 95% for bypass (p=0.02). The patency difference in favour of surgical bypass over endovascular thrupass was also sustained after completion of 1-year follow-up, the primary patencies being 46% and 84% at 1 year with grossly equilinear life-table curves thereafter (p=0.18), respectively. The corresponding secondary patencies were 63% and 100% (p=0.05) when excluding technical failures and 58% and 100% (p=0.02) according to intention-to-treat analysis. Secondary outcomes were thus not analysed.

CONCLUSION

Treatment of SFA occlusions (TASC IIB and C or Imelda Ia and II) should be done by PTFE bypass rather than by PTFE thrupass, as thrupass is connected with worse early outcome. These results represent only a small category of femoral disease.