Primary balloon expandable polytetrafluoroethylene-covered stenting of focal infrarenal aortic occlusive disease

Efficacy and Safety of Atherectomy Combined With Balloon Angioplasty vs Balloon Angioplasty Alone in Patients With Femoro-Popliteal Lesions: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Balloon angioplasty (BA), including drug-coated balloons (DCBs) and percutaneous transluminal angioplasty (PTA), has traditionally been used to treat femoral-popliteal lesions. However, in recent years, atherectomy (ATH) has been proposed as a complementary approach. To assess the effectiveness of ATH compared with BA alone in patients with femoral-popliteal artery lesions, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We included RCTs that focused on patients with femoral-popliteal artery lesions and reported data on the use of ATH and BA therapy. Two reviewers conducted a literature search, refined the data, and assessed the risk of bias.

RESULTS

We included a total of 6 RCTs involving 399 patients with femoral-popliteal artery lesions. The use of ATH in combination with BA appeared to improve the patency rate at 12 months (odds ratio [OR]=2.04, 95% confidence interval [CI]=1.14-3.62). In addition, ATH with BA was associated with lower major amputation rates (MD=2.01, 95% CI=0.06-0.77, p=0.02) and a decreased likelihood of bailout stenting (OR=0.07, 95% CI=0.02-0.25, p=0.001). However, there were no statistically significant differences between the groups in terms of target lesion revascularization (TLR) at 12 months, major adverse cardiovascular events (MACEs), and distal embolization events. In addition, we performed subgroup analysis for different ATH devices and BA types.

CONCLUSIONS

Based on this meta-analysis, it can be concluded that the use of ATH in combination with BA is a safe and effective method for treating femoral-popliteal artery lesions. In addition, the patency rate at 1 year is superior to treatment with BA alone. Atherectomy also reduces the likelihood of amputation and bailout stenting. Clinicians should consider these findings when designing future RCTs and developing clinical practice guidelines.

CLINICAL IMPACT

This meta-analysis summarises a number of existing studies to advance understanding of the atherectomy devices and to reveal its potential. This new technique, when compared with drug coated balloon, shows the possibility of obtaining better clinical outcomes in femoro-popliteal lesions than drug-coated balloon alone, such as higher 12-month primary patency rates as shown in some studies. Currently, it is important to consider the appropriate technology applicable for individualised treatment. atherectomy devices seem to provide clinicians with additional options in clinical practice and to benefit patients in the future. This requires more high quality studies to explore the role and benefits of atherectomy devices in femoro-popliteal lesions.

Early and long-term results of the endovascular treatment of patients with isolated infrarenal aortic stenosis

OBJECTIVE

The purpose of this study was to report our results of patients' characteristics, procedural complications, and long-term patency in treatment of isolated infrarenal aortic stenosis (IIAS).

METHODS

Forty symptomatic patients (28 female, 12 male; median age, 60 years [54.8-68 years]) with IIAS who underwent endovascular intervention between 2001 and 2017 were retrospectively analyzed. Patient, lesion, procedure, and balloon/stent characteristics were assessed. Follow-up included clinical status evaluation and color Doppler ultrasound examination.

RESULTS

The cause of IIAS was atherosclerosis in all patients. Twenty percent of the patients were younger than 50 years; 85% had hypertension, 80% were smokers, 38% had hyperlipidemia, 23% had diabetes mellitus, 15% were obese (body mass index ≥30 kg/m²), and 8% had chronic kidney disease. The median stenosis grade was 80% (70%-80%), and the median lesion length was 19.9 mm (13-29.4 mm). Severe calcification was present in 8% of the patients. Percutaneous transluminal angioplasty was performed in four cases (10%), whereas stenting was performed in 36 (90%). One complication, an aortic rupture requiring surgical repair, occurred. The median follow-up was 61 months (17-101 months). The primary patency rate was 100% at 6 months, 97% at 12 and 24 months, and 88% at 60 and 96 months. Restenosis developed in three patients (8%); reintervention was carried out in two cases (5%).

CONCLUSIONS

Endovascular therapy for IIAS provides a safe and effective long-term treatment strategy.

Outcomes of covered expandable stents for the treatment of TASC D aorto-iliac occlusive lesions

INTRODUCTION

Aortoiliac arterial occlusive disease is frequently encountered in the management of lower limb vascular insufficiency. We report our experience with covered balloon-expandable stents for treatment of TASC D lesions of the abdominal aorta and common iliac arteries.

METHODS

A retrospective study of 30 patients who underwent aortoiliac stenting with the Atrium Advanta V12 from March 2010 to September 2012 was conducted. Patient demographic data, clinical signs and symptoms and procedural details were recorded. Outcomes assessed were primary patency, secondary patency, technical success, complications, limb salvage and survival.

RESULTS

Median age was 67 years (range 48-84) and 40% of patients underwent treatment for critical limb ischaemia. Median follow-up was 13 months (range 3-38 months). Stent configuration comprised of long iliac stents in 20 patients, a large diameter aortic stent with iliac stenting in six patients, and aortic stent alone in four patients. Radiological success was achieved in 100% and the complication rate was 6%. Primary patency at 6, 12 and 24 months was 97%, 90% and 79%, respectively. Four cases of in-stent stenosis were reported, with three of these undergoing re-interventions resulting in a secondary patency rate of 97% at the end of follow-up. One patient death occurred within the follow-up period.

DISCUSSION

This case series demonstrates that treatment of complex aortoiliac occlusive disease with covered balloon-expandable stents can have acceptable results with good patency and good clinical outcome. Secondary patency rates are comparable to open surgical revascularisation, with lower morbidity.

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication

Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.

Primary infrarenal aortic stenting with or without iliac stenting for isolated and aortoiliac stenoses: single-centre experience with long-term follow-up

PURPOSE

The purpose of this study was to evaluate the technical success, complications, long-term clinical outcome, and patency after primary infrarenal aortic stenting for aortic and aortoiliac stenosis. Between January 1999 and January 2006, 22 consecutive patients underwent endovascular treatment because of infrarenal aortic stenosis with and without common iliac stenosis (10 men; mean age 64 ± 14 years). Eleven (11 of 22) patients had an isolated aortic stenosis, whereas 11 of 22 had aortic stenosis that extended into the common iliac arteries (CIAs). Thirteen patients were Rutherford classification type 3, and 9 patients were type 4. Statistical analysis included paired Student t test and Kaplan-Meier life table analysis; p < 0.05 was considered significant. Technical and initial clinical success was achieved in all patients. There were three (14 %) procedure-related complications, which included two access-point pseudoaneurysms and one non-flow-limiting left external iliac dissection. Patients were followed-up for a mean period of 88 months (range 60-132). Mean preprocedure ankle brachial pressure indexes (ABPI) were 0.60 ± -0.15 (right) and 0.61 ± -0.16 (left). After the procedure they were 0.86 ± -0.07 (right) and 0.90 ± -0.09 (left). The increase in ABPI was significant (p < 0.05), and this continued throughout follow-up. Four (18 %) patients had recurrence of symptoms during follow-up. These occurred at 36, 48, 48, and 50 months after the original procedure. All four patients were successfully treated with repeat angioplasty procedures. There was a significant difference in primary patency between isolated aortic stenosis (100 %) and aortoiliac stenosis (60 %) (p = 0.031). Cumulative follow-up was 1920 months yielding a reintervention rate of 0.025/events/year.

CONCLUSION

Primary stenting of infrarenal stenosis is safe and successful with a low reintervention rate. It should be considered as first-line treatment for patients with infrarenal aortic stenotic disease.