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

Trends in Lower Extremity Artery Disease Repair Incidence, Comorbidity, and Mortality: A Danish Nationwide Cohort Study, 1996-2018

Background

The prevalence of occlusive lower extremity artery disease (LEAD) is rising worldwide while European epidemiology data are scarce. We report incidence and mortality of LEAD repair in Denmark from 1996 through 2018, stratified on open aorto-iliac, open peripheral, and endovascular repair.

Methods

A nationwide cohort study of prospective data from population-based Danish registers covering 1996 to 2018. Comorbidity was assessed by Charlson's Comorbidity Index (CCI). Incidence rate (IR) ratios and mortality rate ratios (MRR) were estimated by multivariable Poisson and Cox regression, respectively.

Results

We identified 41,438 unique patients undergoing 46,236 incident first-time LEAD repairs by either aorto-iliac- (n=5213), peripheral surgery (n=18,665) or percutaneous transluminal angioplasty (PTA, n=22,358). From 1996 to 2018, the age- and sex-standardized IR for primary revascularization declined from 71.8 to 50.2 per 100,000 person-years (IRR, 0.70; 95% CI, 0.66-0.75). Following a 2.5-fold IR increase of PTA from 1996 to 2010, all three repair techniques showed a declining trend after 2010. The declining IR was driven by decreasing LEAD repair due to claudication, and by persons aged below 80 years, while the IR increased in persons aged above 80 years (p interaction<0.001). LEAD repair was more frequent in men (IRRfemale vs male, 0.78; 95% CI, 0.77-0.80), which was consistent over calendar time (p interaction=0.41). Crude mortality decreased following open/surgical repair, and increased following PTA, but all three techniques trended towards lower adjusted mortality comparing the start and the end of the study period (MRRaorto-iliac, 0.71; 95% CI, 0.54-0.93 vs MRRperipheral, 0.76; 95% CI, 0.69-0.83 vs MRRPTA, 0.96; 95% CI, 0.86-1.07). Increasing age and CCI, male sex, smoking, and care dependency associated with increased mortality.

Conclusion

The incidence rate of LEAD repair decreased in Denmark from 1996 to 2018, especially in persons younger than 80 years, and primarily due to reduced revascularization for claudication. Adjusted mortality rates decreased following open surgery, but seemed unaltered following PTA.

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.

Focused Ultrasound, an Emerging Tool for Atherosclerosis Treatment: A Comprehensive Review

Focused ultrasound (FUS) has emerged as a promising noninvasive therapeutic modality for treating atherosclerotic arterial disease. High-intensity focused ultrasound (HIFU), a noninvasive and precise modality that generates high temperatures at specific target sites within tissues, has shown promising results in reducing plaque burden and improving vascular function. While low-intensity focused ultrasound (LIFU) operates at lower energy levels, promoting mild hyperthermia and stimulating tissue repair processes. This review article provides an overview of the current state of HIFU and LIFU in treating atherosclerosis. It focuses primarily on the therapeutic potential of HIFU due to its higher penetration and ability to achieve atheroma disruption. The review summarizes findings from animal models and human trials, covering the effects of FUS on arterial plaque and arterial wall thrombolysis in carotid, coronary and peripheral arteries. This review also highlights the potential benefits of focused ultrasound, including its noninvasiveness, precise targeting, and real-time monitoring capabilities, making it an attractive approach for the treatment of atherosclerosis and emphasizes the need for further investigations to optimize FUS parameters and advance its clinical application in managing atherosclerotic arterial disease.

A narrative review on the application of high-intensity focused ultrasound for the treatment of occlusive and thrombotic arterial disease

Objectives

High-intensity focused ultrasound (HIFU) is a noninvasive therapeutic modality with a variety of applications. It is approved for the treatment of essential tremors, ablation of prostate, hepatic, breast, and uterine tumors. Although not approved for use in the treatment of atherosclerotic arterial disease, there is a growing body of evidence investigating applications of HIFU. Currently, percutaneous endovascular techniques are predominant for the treatment of arterial pathology; however, there are no endovascular techniques of HIFU available. This study aims to review the state of current evidence for the application of HIFU in atherosclerotic arterial disease.

Methods

All English-language articles evaluating the effect of HIFU on arterial occlusive and thrombotic disease until 2021 were reviewed. Both preclinical and human clinical studies were included. Study parameters such as animal or clinical model and outcomes were reviewed. In addition, details pertaining to settings on the HIFU device used were also reviewed.

Results

In preclinical models, atherosclerotic plaque progression was inhibited by HIFU, through decreases in oxidized low-density lipoprotein cholesterol and increases in macrophage apoptosis. Additionally, HIFU promotes angiogenesis in hindlimb ischemic models by the upregulation of angiogenic and antiapoptotic factors, with increased angiogenesis at higher line densities of HIFU. HIFU also promotes thrombolysis and conversely induces platelet activation at low frequencies and higher intensities. Various clinical studies have attempted to translate some of these properties and demonstrated positive clinical outcomes for arterial recanalization after thrombotic stroke, decreased atherosclerotic plaque burden in carotid arteries, increase in tissue perfusion and a decrease in diameter stenosis in patients with atherosclerotic arterial disease.

Conclusions

In current preclinical and clinical data, the safety and efficacy of HIFU shows great promise in the treatment of atherosclerotic arterial disease. Future focused studies are warranted to guide the refinement of HIFU settings for more widespread adoption of this technology.

"Modern Endovascular Therapy"

INTRODUCTION

The past 25 years have been witness to a revolution in how vascular care is delivered. The majority of arterial and venous interventions have converted from open surgery to minimally invasive percutaneous endovascular procedures.

METHODS

This surgical innovations symposium article reviews current endovascular therapy in multiple vascular beds with a primary focus on carotid artery occlusive disease, aortic pathologies, and lower extremity arterial occlusive disease. Mesenteric arterial occlusive disease and lower extremity venous endovascular therapies are also briefly discussed. Indications for intervention, treatment examples and outcomes analysis are presented. While not reviewed in this article, endovascular therapy has also become first line in the treatment of coronary artery disease, chronic mesenteric arterial occlusive disease, superficial venous reflux, central vein occlusion, and acute venous thrombus intervention when indicated.

CONCLUSION

Endovascular therapies are used in all vascular beds to treat the full spectrum of vascular pathologies. Aneurysm disease, atherosclerotic arterial occlusive disease, acute arterial and venous thrombosis, ongoing hemorrhage, and venous reflux are among the issues which can be addressed by endovascular means. The minimally invasive nature of endovascular treatments in what is largely a very co-morbid patient cohort is an attractive method of avoiding major procedural related morbidity and mortality.

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.

[Femoropopliteal angioplasty: Short- and mid-term results]

BACKGROUND

Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease.

METHODS

Femoropopliteal percutaneous transluminal angioplasty was performed on 162 consecutive limbs (160 patients) from January 2006 to January 2016.

RESULTS

In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included angioplasty only in 70 cases (43.2%), and the remaining 92 (56.8%) received at least one stent. Technical success was achieved in 98.7% of patients, with three deaths and a major morbidity rate of 15%. The actuarial primary patency at 12 and 36 month was 65.4% and 40.2%, respectively, 33 peripheral reinterventions were performed after femoropopliteal axis occlusion, resulting in an actuarial primary limb preservation rate of 94.4 at 12 months. Comparison between angioplasty only and the use of stent show no difference in primary patency (P=0.832) and limb salvage (P=0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P<0.001) and TASC D (P<0.001). However, diabetes mellitus (P=0.001) and poor run off (P<0.001) were the principal predictive factors of limb loss.

CONCLUSION

Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization.

Predictive value of skin perfusion pressure after endovascular therapy for wound healing in critical limb ischemia

PURPOSE

To determine the predictive value of skin perfusion pressure (SPP) for wound healing after endovascular therapy (EVT).

METHODS

Between May 2004 and March 2011, 113 consecutive patients (84 men; mean age 71.5±12.5 years) with CLI (123 limbs) underwent successful balloon angioplasty ± stenting (flow from >1 vessel to the foot without bypass) and were physically able to undergo SPP measurement before and within 48 hours after EVT. The status of wound healing was recorded over a mean follow-up of 17.4±12.4 months.

RESULTS

The wound healing rate was 78.9% (97 limbs of 89 patients). SPP values after EVT were significantly higher in these patients than in the 24 patients (26 limbs) without wound healing (44.2±15.6 mmHg vs. 27.5±10.4 mmHg, p<0.001). Receiver operating characteristics analysis of SPP after EVT to predict wound healing had an area under the curve of 0.81 (95% CI 0.723 to 0.899, p<0.001). The optimal cutoff for predicting wound healing was 30 mmHg, with a sensitivity of 81.4% and a specificity of 69.2%. Binary logistic regression analysis demonstrated SPP after EVT to be an independent predictor of wound healing (p<0.001). The probability of wound healing with SPP values >30 mmHg, 40 mmHg, and 50 mmHg were 69.8%, 86.3%, and 94.5%, respectively.

CONCLUSION

SPP after EVT is an independent predictor of wound healing in patients with CLI. In our study, an SPP value of 30 mmHg was shown to be the best cutoff for prediction of wound healing after EVT.

The factors affecting recurrence of symptoms after infrainguinal arterial endovascular angioplasty

Background

This study reports the result of endovascular treatment for arterial occlusive disease limited to femoropopliteal lesions, focusing on the recurrence of symptoms instead of patency.

Methods

This was a retrospective, single-center study. From April 2007 to November 2011, 48 limbs in 38 patients underwent endovascular stenting or balloon angioplasty to treat femoropopliteal arterial occlusive disease. The factors affecting the recurrence of symptoms were analyzed.

Results

The mean age of the patients was 69.60±7.62 years. Among the baseline characteristics of the patients, initial hyperlipidemia was the most important factor affecting the recurrence of symptoms (relative risk=5.810, p=0.031). The presence of a dorsal arch was also a significant factor (relative risk=0.675, p=0.047).

Conclusion

The major factors that affect the recurrence of symptoms after endovascular treatment for femoropopliteal arterial occlusive lesions are hyperlipidemia and the presence of a dorsal arch. Therefore, the usage of lipid-lowering agents after endovascular treatment and taking the presence of a dorsal arch into consideration are important elements of managing the recurrence of symptoms.

The role of infrainguinal bypass surgery in the endovascular era

The current worldwide trend in the treatment of peripheral arterial disease (PAD) is towards an increase in endovascular procedures either in the aorto-iliac area or in the infrainguinal district. However, the role of the open repair with a femoro-popliteal bypass is still debated and in our opinion there still a room for traditional surgery in the presence of complex lesions involving the superficial femoral artery and the popliteal and tibial vessels. In this field, vein bypass provides better results than prosthetic grafts, but in selected cases and not only in the absence of a suitable vein, new modified grafts may be used with satisfactory results. The choice between the two options, open and endovascular, that in some cases can be associated in hybrid procedures, depends on several factors. Only if we are able to take into account all the different preoperative issues, we could choose the right procedure in the right patient.

Clinical efficacy of successful angioplasty in critical ischemia--a cohort study

BACKGROUND

To evaluate the impact of percutaneous angioplasty (PA), objectively assessed with duplex-ultrasound, on 3-year clinical outcome.

METHODS

Thirty-nine patients with atherosclerotic disease successfully treated by PA were included (40 limbs). All patients had critical ischemia with rest pain and ischemic ulcers due to infrainguinal obstructions alone. The patients were submitted to duplex ultrasound examination on the day before and on the first or second day after the procedure. Peak systolic velocities (PSV) were recorded in the anterior tibial, posterior tibial, and fibular arteries at the level of distal third of the leg. All patients were followed for 3 years. Comparison between groups with good and bad results were based on perioperative VPS gradient (GPSV) of the mean of the VPS in the 3 arteries. After 3 years, a good result was defined as a patient having no pain and complete healing of a previous ulcer or minor amputations.

RESULTS

Mean age was 68.5±8.1 years with no difference in demographic characteristics (P>0.05). In 26 cases, the long-term result was good. Healing time ranged from 4 to 130 weeks (median 26.5). Bad long-term results were observed in 12 cases. Two lesions remained unhealed despite patent angioplasty. In 10 cases, a second procedure was carried out (repeat angioplasty in 6 and bypass in 4). TransAtlantic Inter-Society Consensus (TASC) II category A/B registered better clinical success then TASC II category C/D (P<0.05) at 1-year follow-up but not at 3 years (P=0.36). Two-year limb salvage was 92.5%±4.2%. Primary patency was 52.5%±9.5% at 3 years. GVPS was 21.9 cm/sec in the good results group and 24.7 cm/sec in the bad results group (P>0.05). The quality of the initial result, as measured by GPSV, was not associated with long-term success (P>0.05).

CONCLUSIONS

An initially successful procedure indicated by the degree of increased flow is not related to long-term durability and ulcer healing.

Current Status of Drug-Eluting Stents and Drug-Eluting Balloons for the Superficial Femoral Artery

The endovascular management of symptomatic atherosclerotic superficial femoral artery disease is challenging and requires consideration of unique anatomic, hemodynamic, and biomechanical factors. For innovative local drug delivery technologies to have a cost-effective and clinically meaningful benefit, they must provide patency rates in more complex lesions equivalent or superior to those currently approved devices are able to provide. Several proof-of-concept trials have either been published or been recently presented and many more are in the pipeline suggesting biologic effectiveness of these hybrid devices in reducing restenosis. Local drug delivery technology has already been commercially introduced in some countries for a variety of clinical settings. However, although these technologies offer promise in improving outcomes following lower extremity intervention, caution and safety are paramount. Adequately powered, multicenter, well-designed, randomized controlled trials with long-term follow-up (3-5 years) are still needed to accurately assess safety and efficacy.

Cryoplasty offers no advantage over standard balloon angioplasty for the treatment of in-stent stenosis

In-stent restenosis is the primary failure mode of endovascular treatment of occlusive disease in the femeropopliteal segment. Cryoplasty has been proposed to reduce intimal hyperplasia through induction of apoptosis. We sought to evaluate the efficacy of cryoplasty for treatment of in-stent restenosis compared to conventional balloon angioplasty (CBA). After IRB approval, a retrospective record review was performed of reinterventions for in-stent restenosis by a single vascular surgery group at a university hospital. Reinterventions involving cryoplasty and CBA were evaluated at 1, 3, 6 and 12 months after intervention with duplex imaging to identify significant recurrent stenosis utilizing established velocity criteria. Data collected included basic demographic information and comorbidities as well as time to restenosis. Statistical analysis was performed using Kaplan–Meier survival curves with the log rank test, Wilcoxon rank test, and Cox proportional hazards models. From December 2004 to November 2007, 76 reinterventions were performed using CBA (n = 39) or cryoplasty (n = 37) for in-stent restenosis without placement of additional stents. Periprocedural technical success (>30% residual stenosis) was 100% for both groups, with no complications. The two cohorts were statistically similar in mean age, gender, comorbidities, tobacco use and use of statins, aspirin and Plavix. However, the mean lesion length was significantly longer in the cryoplasty cohort (CBA: 140.9 mm, Cyro: 191.7 mm; P = 0.032). The mean time to recurrent stenosis or need for additional secondary intervention was significantly shorter for the cyroplasty cohort than for the CBA, 4.09 and 10.79 months, respectively ( P = .0001). Recurrent stenosis-free survival was significantly lower in the cyroplasty cohort at 3 months (CBA: 96.9%, Cyro: 88.9%) and 6 months (CBA: 84.0%, Cyro: 43.8%; P = .0089). Cyroplasty as a modality for treatment of in-stent stenosis in the femoropopliteal segment offers no benefit over CBA.

Endovascular management of patients with critical limb ischemia

BACKGROUND

Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined.

METHODS

From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models.

RESULTS

Demographics included age (70 ± 12 years old), diabetes (65.8%), and dialysis dependence (13%). The superficial femoral artery was treated in 58% of the patients, 16% were limited to the crural vessels, 38% had multilevel treatment, and stents were placed in 26%. Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31% ± 0.04 and 75% ± 0.04, respectively. Limb salvage at 5 years was 74% ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39% ± 0.03. Multivariate analysis identified dialysis dependence (P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff (P = .02; 1.5 [1.1-2.0]), and warfarin use (P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence (P = .006; 2.5 [1.3-4.8]), female gender (P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off (P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence (P = .0003; 2.3 [1.5-3.5]), diabetes (P = .04; 1.5 [0.5-2.1]), and poor run-off (P = .04; 1.6 [1.2-2.1]) were predictors of mortality.

CONCLUSION

Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12% annual death rate, validate PTA as first-line therapy in patients with CLI.

Isolated Endarterectomy of Femoral Bifurcation in Critical Limb Ischemia: Is Restoration of Inline Flow Essential?

This retrospective study reviews clinical outcomes of isolated common femoral endarterectomy (CFE) for critical limb ischemia (CLI), in particular whether poor runoff and inability to restore inline flow has negative impact. In 30 patients, runoff was assessed on preoperative angiograms and categorized into groups based on Society of Vascular Surgery criteria. Data were evaluated using Cox Regression survival analysis. Freedom from secondary revascularization was not affected by runoff score (hazard ratio for compromised and poor groups being 1.8 (95% CI 0.16 to 20.8) and 1.47 (95% CI 0.09 to 24.3), respectively; P = .894). Distal inline flow was not achieved in 25 (83%) patients, but this was not associated with significantly worse outcome (P = .295, log-rank test). In conclusion, CFE can be performed in CLI with high technical success and there is no significant effect of runoff score on recurrence of symptoms. Limb salvage can be achieved even if options to restore inline flow are limited.

Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia

OBJECTIVE

We investigated the role of the angiosome concept in endovascular therapy (EVT) for limb salvage.

BACKGROUND

The angiosome concept is clinically useful in bypass surgery for critical limbs ischemia (CLI). However, comparison with direct and indirect flow to the site of ulceration based on angiosome concept regarding freedom from amputation has not been systematically studied for the patient with CLI undergoing EVT.

METHODS

We analyzed 203 limbs in 177 consecutive patients (male = 127, age = 70 +/- 11 years) with ischemic ulceration that was Rutherford 5 or 6 (5 in 145 limbs and 6 in 58 limbs; pretreatment ankle-brachial index = 0.74 +/- 0.27), who underwent EVT alone without bypass surgery. We classified these patients into direct and indirect groups depending on whether feeding artery flow to the site of ulceration was successfully acquired or not acquired based on the angiosome concept. Freedom from amputation was compared between the direct and the indirect groups by Kaplan-Meier analysis.

RESULTS

The overall limb salvage rate was 82% (167/203). Skin perfusion pressure was significantly higher in the direct group (67 +/- 25 mm Hg) than in the indirect group (41 +/- 20 mm Hg, P = 0.002). The limb salvage rate was also significantly (P = 0.03) higher in the direct group (86%) than in the indirect group (69%) for up to 4 years after the procedure. The number of vessels with run-off flow did not influence the limb salvage rate in either the direct group (P = 0.84) or the indirect group (P = 0.90).

CONCLUSION

Acquiring direct flow based on the angiosome concept is important for limb salvage by EVT in patients with CLI.

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.

24-carat gold, 14-carat gold, or platinum standards in the treatment of critical limb ischemia: bypass surgery or endovascular intervention?

Critical limb ischemia (CLI) remains a poorly understood, rarely reported, and inconsistently treated major global healthcare epidemic. The incidence in the US is estimated at 1% of the population aged 50 years and older and at approximately double that rate in the over-70 age group. These frequencies are expected to increase significantly with the aging population and the expected increase in diabetes. Within 1 year of being diagnosed with CLI, 40% to 50% of the now 20 million US diabetics will experience an amputation, and 20% to 25% will die. The estimate for treating CLI in the US alone is $10 to $20 billion per year, but just a 25% reduction in amputations could save $2.9 to $3.0 billion annually. Infrainguinal bypass surgery (IBS) utilizing autogenous saphenous vein has been considered the "24-carat gold standard" treatment for CLI, but over the last decade, endovascular therapy has emerged to seriously challenge IBS, which has created considerable controversy. Despite an overall lack of "hard" level I data, many interventionists are questioning the role of IBS as a first-line CLI therapy or are at least now considering IBS a "tainted" gold standard ("14-carat"). This review will examine the available evidence, but there should be no doubt regarding the huge global clinical and economic impact of CLI and amputations.

Primary stenting of the superficial femoral and popliteal artery

OBJECTIVES

Over the last decade, the number of endovascular procedures performed on the superficial femoral (SFA) and popliteal arteries (PA) has significantly increased. There is no consensus on the optimal form of intervention used in this arterial segment. While some have advocated balloon angioplasty alone, others have championed either selective or primary stenting of these lesions. It is the purpose of this study to determine the efficacy and durability of primary stenting of the superficial femoral and popliteal artery.

METHODS

All patients undergoing peripheral angioplasty by a single vascular surgeon were prospectively enrolled in an Institutional Review Board-approved, primary-stenting protocol. During a 44-month period, all patients undergoing percutaneous transluminal angioplasty of the SFA or PA also received primary arterial stenting with bare, self-expanding nitinol stents. Patient demographics and risk factors were identified. TransAtlantic InterSociety Consensus (TASC) classifications were determined for all lesions. Loss of primary patency was said to have occurred when an occlusion or a 50% or greater stenosis in any treated arterial segment was diagnosed by arterial duplex or angiography. Only time to loss of primary patency was recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log rank method.

RESULTS

Between January 16, 2004 and August 13, 2007, 201 angioplasties with primary stenting were performed on 161 patients. One hundred twenty-three stents were placed for claudication, and 78 for critical limb ischemia. Forty-six segments treated were TASC A, 82 were TASC B, 38 were TASC C, and 35 were TASC D. Patient follow-up ranged from three to 1329 days (mean: 426 days). Primary patency rates for TASC A and B lesions were 79%, 67%, and 57% at 12, 24, and 36 months. For TASC C and D lesions, primary patency rates were 52.7%, 36%, and 19% at the same time intervals. Primary patency rates for TASC A and B lesions were significantly higher than for C and D lesions (P < .001). The limb salvage rate was 88.5% in patients with critical limb ischemia. Distal runoff did not influence patency (P = .827).

CONCLUSIONS

Primary stenting of the SFA and PA provides durable results in patients with TASC A and B lesions and may be an effective treatment strategy. This approach is significantly less effective when used in treating those with TASC C and D disease. Based on the results in this series, the use of primary stenting does not extend the anatomic limits of the current treatment recommendations for catheter-based intervention in patients with infrainguinal occlusive disease.