Infrainguinal vein graft stenosis: Cutting balloon angioplasty as the first-line treatment of choice

Five-Year Experience of Interwoven Self-Expanding Stent Implantation in Stenotic Kinking of Below the Knee Prosthetic Bypasses

PURPOSE

The purpose of this study was to evaluate the 5-year real-world results of Supera stent implantation in below the knee prosthetic bypasses (BKPBs). All the procedures were performed because of a history of recurrent thrombosis of the graft and significant stenotic kinking of the prosthesis during knee flexion. A Supera stent was implanted to prevent the next potential BKPB thrombosis.

MATERIALS AND METHODS

Fourteen patients were included in this single-center, retrospective observational cohort study. All patients underwent Supera stent implantation in infrainguinal prosthetic bypass between 2012 and 2017, due to a history of recurrent thrombosis and kinking of the prosthetic bypass.

RESULTS

Prior to Supera stent implantation procedure, all the patients had more than one episode of acute limb ischemia caused by thrombosis of the BKPB. The median number of BKPB thromboses prior to Supera stent implantation was 3 and ranged from 2 to 6. Technical success was achieved in all cases. Primary patency rates at 12, 24, 36 and 60 months were 71.4%, 57.1%, 57.1% and 14.3%, respectively. Secondary patency rates at 12, 24, 36 and 60 months were 78.6%, 64.3%, 64.3% and 35.7%, respectively. One stent fracture was reported during 60-month follow-up. Major amputation was performed in 6 patients in 5-year follow-up.

CONCLUSION

Supera stent in treatment of recurrent thrombosis of BKBP is a safe procedure with acceptable mid-term results. However, larger and comparable prospective studies are needed for broader analysis of this procedure.

Predictors of infrapopliteal vein bypass graft revision in patients with chronic limb-threatening ischemia

PURPOSE

Surgical revascularization is the standard treatment for chronic limb-threatening ischemia (CLTI). However, some patients may require reintervention. The Global Anatomic Staging System (GLASS), which evaluates the complexity of infrainguinal lesions, was proposed. This study aimed to identify predictors for graft revision and evaluate whether GLASS impacts vein graft revision.

METHODS

Between 2011 and 2018, CLTI patients who underwent de novo infrapopliteal bypass using autogenous veins were retrospectively analyzed. To assess anatomic complexity with GLASS, femoropopliteal, infrapopliteal, and inframalleolar/pedal (IM) disease grades were determined. The outcomes of patients with or without graft revision were compared. Cox regression analysis was performed.

RESULTS

Thirty-six of the 80 patients underwent reintervention for graft revision. Compared to the non-graft revision group, the graft revision group exhibited significantly higher rates of GLASS stage III (66% vs 81%, p = 0.046) and grade P2 IM disease (25% vs 58%, p = 0.009). Multivariate analysis revealed that IM grade P2 (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.66-6.75; p = 0.001) and spliced vein grafts (HR, 3.18; 95% CI, 1.43-7.06; p = 0.005) were significantly associated with graft revision.

CONCLUSIONS

This study demonstrated that IM grade P2 and spliced vein grafts were predictors of graft revision. The GLASS stratification of IM disease grade may be useful in optimizing treatment for CLTI.

Angiographic and Clinical Impact of Novel Revascularization for Occluded Femoropopliteal Prosthetic Bypass Graft: A Combination of Surgical Thrombectomy and Drug-Coated Balloon Angioplasty

Background

Previous reports have revealed various endovascular intervention techniques for prosthetic femoropopliteal bypass occlusion (PFPBO); however, treatment for PFPBO remains challenging for most interventionalists and vascular surgeons because the procedure is complicated. Most of the reported techniques involve device implantation. In the present study, we performed a combination of surgical graft thrombectomy and drug-coated balloon angioplasty for PFPBO without implanting any additional devices. Furthermore, we determined the favorable long-term results of this treatment using follow-up angiography. Case Presentation. A 77-year-old man with a history of chronic kidney disease and coronary artery disease presented to our clinic with rest pain on his left leg. Seven years prior to the current consult, he underwent femoropopliteal bypass (FPB) surgery using a prosthetic graft due to in-stent occlusion of the left superficial femoral artery (SFA). Four years after surgery, a duplex ultrasound scan revealed stenosis of the proximal anastomosis site; hence, medical therapy was continued. On the current consult, diagnostic angiography revealed occlusion of the FPB and infrapopliteal vessels. In the first attempt at recanalization, the guidewire was unable to pass through the occluded SFA. Therefore, another technique was performed to revascularize the FPBO and infrapopliteal vessels. We obtained an angiography of the left leg after inserting the guiding sheath via the right common femoral artery (CFA). First, surgical thrombectomy using a Fogarty catheter via the exposed left CFA was performed. Following endovascular therapy via the right CFA, we performed drug-coated balloon angioplasty for anastomotic stenosis and recanalized occlusive infrapopliteal vessels. Restenosis was not observed on follow-up angiograms. On further follow-up angiography, there was notable regression of the residual stenosis at the proximal anastomosis of the prosthetic graft.

Conclusion

This novel revascularization strategy may be a viable treatment option for PFPBO.

Drug-Eluting Stents are Associated with Superior Mid-Term Outcomes for the Treatment of Infrainguinal Bypass Graft Stenoses

BACKGROUND

We previously demonstrated that everolimus drug-eluting stents (eDES) have reasonable short-term patency for the treatment of infrainguinal bypass stenoses. The aim of this study is to compare mid-term outcomes of eDES, plain balloon angioplasty (PTA), percutaneous cutting balloon (PCB), and drug-coated balloon (DCB) interventions for failing infrainguinal bypasses.

METHODS

We conducted a retrospective review of patients with infrainguinal bypass stenoses treated by endovascular intervention (August 2010-August 2021). The primary outcome was primary patency (PP). Secondary outcomes were primary-assisted patency (PAP), secondary patency (SP), limb salvage (LS), and mortality. Outcomes were compared by treatment using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models adjusting for baseline differences between groups.

RESULTS

Seventy-two consecutive patients with 152 discrete infrainguinal bypass graft stenoses were identified. Mean age was 65.1 ± 10.6 years, 55.6% were male, and 48.6% were Black. In total, 81.9% of patients were originally treated for chronic limb-threatening ischemia, and 57.2% of distal anastomoses were to tibial or pedal targets. Of 152 lesions, 44.1% (n = 67) were treated with PTA, 17.8% (n = 27) with PCB, 20.4% (n = 31) with DCB, and 17.8% (n = 27) with eDES. Median follow-up was 28.5 months (interquartile range 11.5-51.9). There was no difference in bypass configuration, conduit choice, or stenosis location (proximal anastomosis, mid-bypass, distal anastomosis) between groups. At 24 months postintervention, PP was significantly better for eDES (72.9%, 95% confidence interval [CI] 49.8-85.6), followed by PCB (55.9%, 95% CI 34.2-72.9), PTA (34.4%, 95% CI 21.7-47.4), and DCB (33.6%, 95% CI 14.5-53.9) (P = 0.03). PAP, LS, and mortality did not significantly differ between modalities (P > 0.05). After risk adjustment, eDES was associated with the lowest risk of PP loss (hazard ratio versus PTA 0.15, 95% CI 0.05-0.47).

CONCLUSIONS

eDES is associated with superior 24-month patency rates compared to other endovascular technologies, and should be considered a primary therapy modality for the treatment of infrainguinal bypass graft stenoses.

Efficacy of Balloon Angioplasty for Infrainguinal Vein Graft Stenosis

BACKGROUND

Vein graft stenosis is a critical complication of lower-limb bypass surgery. For vein graft stenosis, balloon angioplasty has been performed instead of surgical revision in recent years. We therefore investigated the effectiveness of the balloon angioplasty for vein graft stenosis.

METHODS AND RESULT

We conducted a retrospective analysis of prospectively collected data for 115 vein graft stenoses performed via balloon angioplasty from August 2011 to January 2018. The rate of freedom from reintervention after balloon angioplasty was 54.3%, 44.4%, and 38.0% at 1, 2, and 3 years, respectively. The rate of freedom from graft occlusion after balloon angioplasty was 79.9%, 71.9%, and 61.3% at 1, 2, and 3 years, respectively. Predictors of freedom from graft occlusion after balloon angioplasty by a multivariate analysis were a single treated lesion (hazard ratio [HR]: 0.38; 95% confidence interval [CI]: 0.17-0.85; P = 0.0189), balloon angioplasty within 90 days after bypass surgery (HR: 3.59; 95% CI: 1.56-8.07; P = 0.0033), and using a cutting balloon (HR: 0.42; 95% CI: 0.17-0.97; P = 0.0426).

CONCLUSIONS

The freedom from graft occlusion rate after balloon angioplasty remained relatively high. Furthermore, better results can be expected in single treated lesions and cases of balloon angioplasty occurring 90 days after bypass surgery or in which a cutting balloon was used. Balloon angioplasty for lower-limb bypass graft stenosis was shown to be a useful treatment.

Drug-eluting stents are associated with improved outcomes for the treatment of infrainguinal bypass graft stenoses

BACKGROUND

Existing endovascular therapies for failing infrainguinal bypass grafts are associated with modest patency rates. The use of everolimus drug-eluting stents (eDESs) for endovascular bypass graft revision has not yet been reported. The objective of this study was to describe and to compare clinical outcomes of eDESs vs percutaneous cutting balloons (PCBs) vs percutaneous transluminal angioplasty (PTA) for the treatment of infrainguinal bypass graft stenoses.

METHODS

A multicenter, single-institution retrospective analysis of patients with infrainguinal bypass graft stenoses treated by endovascular intervention (August 2010-December 2017) was conducted. The primary study outcome was primary patency of the treated lesion. The secondary outcome was limb salvage. Outcomes are described overall and stratified by endovascular treatment modality using Kaplan-Meier curves and log-rank tests.

RESULTS

During the 7-year study period, 43 patients with 78 infrainguinal bypass stenoses were treated by endovascular intervention (eDES, 15; PCB, 23; PTA, 40). Mean age was 63.3 ± 1.7 years, 53.5% were male, and 55.8% were black. The majority of patients were diabetic (60.5%) with a history of smoking (74.4%), and nearly all (83.7%) had two or more comorbidities. Half (48.7%) of bypasses treated were femoral-popliteal bypasses, followed by popliteal-distal (25.6%) and femoral-tibial (25.6%) configurations. The location of revision was the proximal anastomosis in 37.2%, midbypass in 25.6%, and distal anastomosis in 37.2%. There were no significant differences in baseline characteristics, bypass configuration, or revision location between treatment groups (P ≥ .19). Technical success for endovascular bypass intervention was 100%. At 2 years after intervention, primary patency was significantly better for patients treated with eDES (81.8%) compared with PCB (54.7%) or PTA (33.2%; log-rank, P = .03). Limb salvage was achieved in 93.6% of patients, including 86.7%, 91.3%, and 97.5% for eDES, PCB, and PTA, respectively (P = .30).

CONCLUSIONS

This is the first study reporting the results of eDESs for the treatment of infrainguinal bypass graft stenoses. Use of eDESs for endovascular bypass graft revision not only is feasible but may have better primary patency than other endovascular therapies. These data suggest that eDESs may be considered a safe and efficacious endovascular technique in the armamentarium for treatment of infrainguinal bypass graft stenoses.

Endovascular Reintervention for Failing Infrainguinal Bypass Grafts

OBJECTIVE

Patients with lower extremity bypass grafts that develop stenosis commonly undergo endovascular treatment (EVT) procedures. This study was performed to evaluate the outcomes of EVT procedures for infrainguinal grafts with bypass at risk (BAR).

METHODS

We performed a retrospective review of 24 grafts in 22 patients from July 2010 to June 2016. The demographic information of the patients and the characteristics of lesions were examined, and the outcomes with regard to the patency and survival rates were calculated.

RESULTS

Twenty-four grafts were evaluated; the initial technical success rate of EVT procedure was 91.7%. Sixteen of 24 bypass grafts (66.7%) required multiple EVT procedures due to graft restenosis. Inflow vessels from the superficial femoral artery were associated with significantly higher rates of single EVT procedures (P = 0.0206). At 2 years, the primary, assisted primary, and secondary patency rates were 30.3%, 69.5%, and 78.0%, respectively.

CONCLUSIONS

The EVT procedure is one of the treatment options for the treatment of grafts with BAR and might be associated with an acceptable medium-term patency rate.

The use of a cutting balloon in contemporary reverse controlled antegrade and retrograde subintimal tracking (reverse CART) technique

The key concept of reverse controlled antegrade and retrograde tracking (CART) technique is retrograde puncture with a tapered wire to an antegrade balloon (contemporary reverse CART) or new connections between the antegrade and retrograde subintimal space (classical reverse CART). In our case, a 75-year-old man with severe chronic total occlusion of the right coronary artery, reverse CART with conventional balloons could not be accomplished. Externalization wiring was completed by contemporary reverse CART using a cutting balloon as an antegrade balloon to improve the fenestration force of the retrograde guidewire. Thus, the use of a cutting balloon for contemporary reverse CART might be promising.

Stenting as a bail-out option after failed percutaneous transluminal angioplasty in infrainguinal vein bypass grafts

OBJECTIVES

To study the safety and efficacy of bare and covered stents in infrainguinal vein grafts after failure of PTA for treating graft stenoses.

METHODS

An analysis of a prospective database of all patients who underwent stenting of infrainguinal vein bypass grafts at this institution between 1 January 2008 and 31 December 2012 was carried out. The main outcome considered was primary patency, which was reported at 1, 6 and 12 months.

RESULTS

A total of 18 patients with a mean age of 73 years (range: 56 to 86) were included. The indications for stent placement were significant recoil (7, 39%), graft rupture (6, 33%), residual vein cusps (3, 17%) and aneurysmal degeneration (2, 11%). There was a high overall technical success rate of 94% (17/18) and arrest of haemorrhage was achieved in all cases of graft rupture. The primary patency at 1, 6 and 12 months was 89%, 71% and 59%, respectively.

CONCLUSION

The use of bare and covered stents in infrainguinal vein grafts appears safe and effective. They are an excellent bail-out option for the treatment of graft rupture and give acceptable short-term results.

Cutting Balloon Angioplasty in the Treatment of Short Infrapopliteal Bifurcation Disease

PURPOSE

To evaluate the safety, feasibility, and effectiveness of cutting balloon angioplasty in the management of infrapopliteal bifurcation disease.

METHODS

Between November 2010 and March 2013, 23 patients (mean age 69.6±9.01 years, range 56-89; 16 men) suffering from critical limb ischemia were treated using cutting balloon angioplasty (single cutting balloon, T-shaped double cutting balloon, or double kissing cutting balloon technique) for 47 infrapopliteal artery bifurcation lesions (16 popliteal bifurcation and 9 tibioperoneal bifurcation) in 25 limbs. Follow-up consisted of clinical examination and duplex ultrasonography at 1 month and every 3 months thereafter.

RESULTS

All treatments were technically successful. No 30-day death or adverse events needing treatment were registered. No flow-limiting dissection was observed, so no stent implantation was necessary. The mean postprocedure minimum lumen diameter and acute gain were 0.28±0.04 and 0.20±0.06 cm, respectively, with a residual stenosis of 0.04±0.02 cm. Primary and secondary patency rates were estimated as 89.3% and 93.5% at 6 months and 77.7% and 88.8% at 12 months, respectively; 1-year primary and secondary patency rates of the treated bifurcation were 74.2% and 87.0%, respectively. The survival rate estimated by Kaplan-Meier analysis was 82.5% at 1 year.

CONCLUSION

Cutting balloon angioplasty seems to be a safe and effective tool in the routine treatment of short/ostial infrapopliteal bifurcation lesions, avoiding procedure-related complications, overcoming the limitations of conventional angioplasty, and improving the outcome of catheter-based therapy.

Balloon angioplasty for revision of failing lower extremity bypass grafts

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of balloon angioplasty as the primary method of intervention in patients with color duplex ultrasound documented failing bypass grafts and to determine factors that may affect the patency of lower extremity bypass grafts revised by percutaneous transluminal angioplasty (PTA).

METHODS

All consecutive patients who underwent lower extremity bypass grafts from January 2009 to December 2013 were enrolled in a graft surveillance program. Patients identified as having failing grafts underwent arteriography to confirm the diagnosis with a view to concomitant treatment of the lesion using balloon angioplasty. Procedural success was defined as <30% residual stenosis. Treatment failure was defined as target lesion restenosis or graft occlusion. Descriptive and life-table analyses were performed.

RESULTS

PTA was used to revise 96 failing grafts in 90 patients. Mean age was 65.8 years (range, 50-88 years), 64% were male, and 66% were symptomatic. Mean follow-up was 18.5 months (range, 3-24 months). Twenty-four grafts (25%) underwent repeat angioplasty for restenosis. Grafts with multiple lesions (P = .009) and grafts aged <6 months from the index operation (P = .004) were the only graft-related variables that showed a significant effect on the longevity of the endovascular revision. The PTA-revised grafts had primary, assisted primary, and secondary patency rates of 56.9%, 83.2%, and 90%, respectively, at 2 years.

CONCLUSIONS

Primary balloon angioplasty of failing lower extremity bypass grafts, notwithstanding the higher restenosis rate and the need for reintervention, appears to be safe and is associated with acceptable early and medium-term patency rates. Grafts with multiple lesions and those revised ≤6 months of the index operation showed a significant association with the need for a second revision at the same site.

Endovascular therapy is effective treatment for focal stenoses in failing infrapopliteal vein grafts

BACKGROUND

To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts.

METHODS

We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3- to 6-month intervals for graft surveillance.

RESULTS

Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% of the patients were free from graft restenosis at 12 months and 31% were at 24 months. Receiver-operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P = 0.03), patency without reintervention (P = 0.01), and assisted patency with secondary intervention (P = 0.02) rates were superior for short lesions compared with long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions.

CONCLUSIONS

In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow-up with vascular laboratory surveillance is essential.

Treatment of failing vein grafts in patients who underwent lower extremity arterial bypass

PURPOSE

We attempted to determine risk factors for the development of failing vein graft and optimal treatment in patients with infrainguinal vein grafts.

METHODS

We retrospectively reviewed a database of patients who underwent infrainguinal bypass using autogenous vein grafts due to chronic atherosclerotic arterial occlusive disease of lower extremity (LE) at a single institute between September 2003 and December 2011. After reviewing demographic, clinical, and angiographic features of the patients with failing grafts, we analyzed those variables to determine risk factors for the development of failing grafts. To determine an optimal treatment for the failing vein grafts, we compared results of open surgical repair (OSR), endovascular treatment (EVT) and conservative treatment.

RESULTS

Two hundred and fifty-eight LE arterial bypasses using autogenous vein grafts in 242 patients were included in this study. During the follow-up period of 39 ± 25 months (range, 1 to 89 months), we found 166 (64%) patent grafts with no restenosis, 41 (15.9%) failing grafts, 39 (15.1%) graft occlusions, and 12 (4.7%) grafts lost in follow-up. In risk factor analysis for the development of a failing graft, no independent risk factors were identified. After 50 treatments of the 41 failing grafts (24 OSR, 18 EVT, 8 conservative management), graft occlusion was significantly more common in conservative treatment group and severe (>75%) restenosis was significantly more common following EVT than OSR (P = 0.001). Reintervention-free graft patency was also superior in the OSR group to that of the EVT group (87% vs. 42%, P = 0.015).

CONCLUSION

OSR of failing grafts has better outcomes than EVT or conservative management in treating failing grafts.

Therapeutic strategies to combat neointimal hyperplasia in vascular grafts

Neointimal hyperplasia (NIH) in bypass conduits such as veins and prosthetic grafts is an important clinical entity that limits the long-term success of vascular interventions. Although the development of NIH in the conduits shares many of the same features of NIH that develops in native arteries after injury, vascular grafts are exposed to unique circumstances that predispose them to NIH, including surgical trauma related to vein handling, hemodynamic changes creating areas of low flow, and differences in biocompatibility between the conduit and the host environment. Multiple different approaches, including novel surgical techniques and targeted gene therapies, have been developed to target and prevent the causes of NIH. Recently, the PREVENT trials, the first molecular biology trials in vascular surgery aimed at preventing NIH, have failed to produce improved clinical outcomes, highlighting the incomplete knowledge of the pathways leading to NIH in vascular grafts. In this review, we aim to summarize the pathophysiologic pathways that underlie the formation of NIH in both vein and synthetic grafts and discuss current and potential mechanical and molecular approaches under investigation that may limit NIH in vascular grafts.

Revision of vein bypass grafts: factors affecting durability of interventions

Once the failing vein graft is identified and characterized, the clinician must choose the appropriate intervention to maintain graft patency. Limited by the single-institution, retrospective studies that are pervasive in this area, definitive data to guide these decisions are limited. In general, open surgical revisions appear to offer a modest benefit in primary patency, but likely at the cost of increased periprocedural morbidity. Although endovascular revisions are more prone to failure, these recurrent lesions are often amenable to reintervention so that the secondary patency rates for both endovascular and open interventions may be similar. Given this, endovascular intervention as an initial treatment modality seems a reasonable approach for favorable lesions. Factors associated with poor outcome for endovascular revision include longer lesions (stenosis >2 cm in length), multiple stenoses, lesions occurring within 3 months of graft placement, or interventions for graft thrombosis, where endovascular failures are high and open surgery as an initial approach is warranted. The optimum method for percutaneous intervention remains a shifting landscape. No techniques as of yet appear clearly superior to standard balloon angioplasty, but initial investigations would suggest that cutting balloons offer a modest improvement and are worthy of consideration.