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Suzuki R, Dannoura Y, Makino T, Yokoshiki H. Outcomes of revascularization of stenotic inframalleolar lesions in chronic limb-threatening ischemia. Catheter Cardiovasc Interv 2024. [PMID: 39189067 DOI: 10.1002/ccd.31204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 07/23/2024] [Accepted: 08/16/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND For chronic limb-threatening ischemia, revascularization has been reported for occlusions but not for stenosis in the inframalleolar (IM) lesions. We investigated the clinical outcomes of balloon dilation for stenotic IM lesions distal to the treatment target in the infrapopliteal (IP) legion. METHODS We conducted a retrospective analysis of patients who had chronic limb-threatening ischemia and underwent revascularization of stenotic IM lesions distal to the target IP lesions between January 2015 and August 2022. The outcome measures were amputation-free survival, wound healing rate, and freedom from target IM reintervention. RESULTS The 87 patients had a mean age of 72.7 ± 10.7 years and comprised 67.8% men, 74.7% with diabetes mellitus, 55.2% on dialysis, 33.3% who had Rutherford six classification. The amputation-free survival (AFS), wound healing, and freedom from target IM reintervention rates at 1 year were 82.9%, 53.3%, and 58.4%, respectively. On Cox proportional multivariate analysis, the predictors were Wound, Ischemia, and foot Infection (WIfI) ≥3 and diffuse stenosis in the target IM vessels for delayed wound healing and Global Limb Anatomic Staging System stage Ⅲ and ≥3 diseased IM vessels before endovascular therapy for target IM reintervention. At the time of reintervention, the lesion morphology had progressed from stenosis to occlusion in 50% of cases. CONCLUSIONS In patients with chronic limb-threatening ischemia, revascularization of stenosis in IM lesions showed a high reintervention rate and progression of lesion morphology, although AFS and wound-healing rates were acceptable.
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Affiliation(s)
- Riho Suzuki
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Yutaka Dannoura
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Takao Makino
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Hisashi Yokoshiki
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
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Suzuki R, Horiuchi K, Iida O, Takahara M, Dannoura Y, Asakawa N, Makino T, Yokoshiki H. Comparison of Subsequent Inframalleolar Bypass Surgery and Repeat Endovascular Therapy for Infrapopliteal Restenosis in Patients With Chronic Limb-Threatening Ischemia Undergoing Primary Endovascular Therapy. J Endovasc Ther 2024:15266028241267735. [PMID: 39091096 DOI: 10.1177/15266028241267735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
PURPOSE Although endovascular therapy (EVT) is considered a vital strategy for treating infrapopliteal lesions in chronic limb-threatening ischemia (CLTI), the recurrence rate after EVT exceeds that after bypass surgery (BSX). The optimal approach for managing infrapopliteal lesion recurrence in patients with CLTI and unhealed ulcers remains uncertain. This study aimed to evaluate the clinical outcomes of repeat EVT and subsequent inframalleolar BSX for CLTI with infrapopliteal lesion recurrence. MATERIALS AND METHODS We conducted a retrospective analysis of 140 patients with CLTI (mean age, 70±10 years; male, 71.4%; diabetes mellitus, 73.6%; dialysis, 74.3%; Rutherford 5, 79.3%; and Rutherford 6, 20.7%) who had an unhealed wound due to the recurrence of infrapopliteal lesions between January 2015 and May 2020. We compared the clinical outcomes of 40 patients who underwent the subsequent inframalleolar BSX with those of 100 patients who underwent repeat EVT. The outcome measures were amputation-free survival (AFS) and wound healing rate. Propensity score matching analysis was conducted to minimize differences in baseline characteristics. RESULTS Propensity score matching extracted 38 pairs (38 patients in the subsequent BSX group and 83 patients in the repeat EVT group). AFS was not significantly different between the repeat EVT and subsequent BSX groups (81.9% vs 82.6% at 1 year, p=0.97). Neither was cumulative wound healing (42.8% vs 43.3% at 1 year, p=0.55). No baseline characteristics had any significant interaction effect on the association between repeat EVT, subsequent BSX, and failure of AFS. CONCLUSION This study using propensity score matching revealed that the clinical outcomes following repeat EVT were comparable with those following subsequent inframalleolar BSX, indicating that repeat EVT may be a viable treatment option for CLTI with infrapopliteal lesion recurrence. CLINICAL IMPACT Although endovascular therapy (EVT) has expanded the treatment options for chronic limb-threatening ischemia (CLTI), the recurrence rate after EVT is higher than that after bypass surgery (BSX). This retrospective study compared the clinical outcomes of repeat EVT with those of subsequent BSX for CLTI with infrapopliteal lesion recurrence. After propensity score matching, amputation-free survival (AFS) was not significantly different between the repeat EVT and subsequent BSX groups (81.9% vs 82.6% at 1 year, p=0.97). Neither was cumulative wound healing (42.8% vs 43.3% at 1 year, p=0.55). There was no difference between the 2 revascularization strategies when treating infrapopliteal restenosis lesions.
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Affiliation(s)
- Riho Suzuki
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Katsumi Horiuchi
- Department of Plastic Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Osamu Iida
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yutaka Dannoura
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Naoya Asakawa
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Takao Makino
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Hisashi Yokoshiki
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
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Xue S, Zhang X, Peng Z, Wu X, Peng Z, Qin J, Lu X. Assessment of atherectomy treatment for Thromboangiitis Obliterans: A single center experience. Catheter Cardiovasc Interv 2023; 102:713-720. [PMID: 37706639 DOI: 10.1002/ccd.30801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/29/2023] [Accepted: 07/28/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND AND AIMS Endovascular recanalizaiton (ER) has been proven to be a feasible method for Thromboangiitis Obliterans (TAO). The aims of this study were to evaluate the effectiveness and safety of atherectomy for TAO compared to nonatherectomy ER in our center. METHODS Patients diagnosed as TAO were reviewed from January 2016 to June 2021 in our center. Basic characteristics of patients before ER and perioperative data were collected and compared between the atherectomy and nonatherectomy groups. The vascular event-free survival and limb salvage were calculated to evaluate the prognosis of TAO patients after ERs. Logistic Regression and Cox Regression were used to identify the risk factors for technical failure and prognosis, respectively. RESULTS Seventy-two TAO patients with 79 lower limbs who met the criteria were included in this report. Compared with the nonatherectomy group, no significant improvement was identified in ER technical success, vascular event-free survival, or limb salvage in the atherectomy group. The total technical success rate was 91.1% (atherectomy group, 95.2%; nonatherectomy group, 89.7%), and the multiple limb involvement (p = 0.005; odds ratio [OR], 28.16; confidence interval [CI], 3.28-241.55) was the independent risk factor for technical failure. The total vascular event-free survival proportion was 66.05% and 58.40% at 1 and 3 years, respectively. Technical failure (OR, 5.61; 95% CI, 1.57-20.04; p = 0.008), and runoff grade 0 (OR, 3.28; 95% CI, 1.09-9.85; p = 0.034) were independent risk factors for vascular events. The total limb salvage proportion at 1 and 3 years was 95.84% and 92.53%, respectively. Technical failure (OR, 8.54; 95% CI, 1.71-40.73; p = 0.02) was identified as an independent risk factor for above ankle amputation. CONCLUSIONS No significant difference in prognosis was found between the atherectomy group and the nonatherectomy group during a midterm follow-up. The technical success of ER was crucial for TAO prognosis.
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Affiliation(s)
- Song Xue
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Xing Zhang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Zhaoxi Peng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Xiaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Zhiyou Peng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai, China
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Yang YP, Lin TH, Chou CY, Lee CL, Huang HK, Wu XN, Chen CP. Effect of Limb Salvage by Excimer Laser Angioplasty Plus Low-Pressure Balloon Inflation in Chronic Limb-Threatening Ischemia Patients with Infrapopliteal Vessel Disease. ACTA CARDIOLOGICA SINICA 2023; 39:765-772. [PMID: 37720405 PMCID: PMC10499955 DOI: 10.6515/acs.202309_39(5).20230115a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/15/2023] [Indexed: 09/19/2023]
Abstract
Background Patients with chronic limb-threatening ischemia (CLTI) often exhibit long, diffuse, totally occluded and heavily calcified infrapopliteal (IP) lesions. This study evaluated limb salvage after peripheral excimer laser atherectomy (PELA) plus low-pressure balloon inflation (LPBI) without stent deployment in CLTI patients with severe IP disease. Methods We retrospectively evaluated 70 consecutive patients with 109 IP vessels who underwent PELA plus LPBI from 2010 to 2013. Technical success was defined as at least one IP straight-line flow being achieved below the malleolus. Binary logistic regression was performed to identify factors associated with 6-month limb salvage. Results Of the 109 IP vessels, 100 (91.7%) were totally occluded, and none of the patients received a stent. Of the 70 patients, 20% were octogenarians, and 85.8% had a Rutherford-Becker class 5 and 6. The technical success rate was 87.1% and 6-month limb salvage rate was 78.6%. Rutherford score was negatively correlated with clinical success (adjusted odds ratio 0.24; p = 0.028). No immediate major cardiovascular events were recorded during admission. Conclusions PELA plus LPBI may be a treatment option for complex IP lesions in patients with CLTI. Higher Rutherford class was correlated with a lower 6-month limb salvage rate. However, a large-scale study with a control group is needed to clarify our results.
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Affiliation(s)
- Yuan-Po Yang
- Department of Cardiology, Changhua Christian Hospital
- PhD Program in Tissue Engineering and Regenerative Medicine, National Chung-Hsing University and National Health Research Institutes, Taichung
- Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Zhunan, Miaoli, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Kaohsiung Medical University Hospital
- Faculty of Medicine, Kaohsiung Medical University, Kaohsiung
| | | | | | | | - Xian-Nin Wu
- Department of Cardiology, Changhua Christian Hospital
| | - Ching-Pei Chen
- Department of Cardiology, Changhua Christian Hospital
- Department of Post-Baccalaureate College Medicine, National Chung-Hsing University, Taichung
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Jiang X, Li X, Chen B, Jiang J, Shi Y, Ma T, Lin C, Guo D, Xu X, Ju S, Fu W, Dong Z. Results of Excimer Laser Ablation Combined with Drug-Coated Balloon for Atherosclerotic Obliterans of Lower Extremity and Risk Factors for Loss of Primary Patency. Ann Vasc Surg 2023; 91:223-232. [PMID: 36584966 DOI: 10.1016/j.avsg.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/12/2022] [Accepted: 11/24/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The results of excimer laser ablation (ELA) combining with drug-coated balloon (DCB) in the treatment for atherosclerotic obliterans (ASO) remains unclear. METHODS Retrospectively enrolled patients who underwent ELA combined with DCB in 2 centers. The primary endpoint was primary patency, and secondary endpoints included technical success, procedure-related complications, major amputation, clinically driven target lesions reintervention (CD-TLR), measurements of ankle-brachial index (ABI), and quality of life (QoL). RESULTS 102 patients were enrolled. The primary patency was 86.7% (95% confidence interval [CI]: 72.9%-89.0%) at 12 months and 82.6% (95% CI: 78.2%-92.1%) at 24 months. The freedom from reintervention was 87.8% (95% CI: 79.5%-92.9%) at 12 months and 86.6% (95% CI: 78.1%-92.0%) at 24 months. The ABI measurement and QoL were significantly improved at each follow-up point. Sixteen (15.7%) patients lost the primary patency. Patients losing the primary patency demonstrated higher Rutherford class (P = 0.004), worse runoff (P < 0.001), higher Peripheral Arterial Calcium Scoring System (PACSS) (P < 0.001), and smaller ratio of tube diameter to reference vessel diameter (TD/RVD) (P < 0.001) compared with patients without losing it. The run-off ≥7 (adjusted odds ratio [aOR]: 34.3; 95% CI: 2.9-398.3; P = 0.005) and TD/RVD <4.9 (aOR: 24.7; 95% CI: 1.7-359.5; P = 0.019) were independent risk factors for loss of primary patency. CONCLUSIONS ELA combined with DCB seemed an effective and safe treatment for ASO of lower extremity, and it could not only reduce the implantation of stent but significantly improve QoL. The run-off ≥7 and TD/RVD <4.9 were independent risk factors for loss of primary patency.
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Affiliation(s)
- Xiaolang Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiaoyan Li
- Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Junhao Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yun Shi
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Tao Ma
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Changpo Lin
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Daqiao Guo
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xin Xu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shuai Ju
- Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Zhihui Dong
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai, China.
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Kleiss SF, van Mierlo-van den Broek PAH, Vos CG, Fioole B, Bloemsma GC, de Vries-Werson DAB, Bokkers RPH, de Vries JPPM. Outcomes and Patency of Endovascular Infrapopliteal Reinterventions in Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2023:15266028221147457. [PMID: 36609175 DOI: 10.1177/15266028221147457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Endovascular revascularization is the preferred treatment to improve perfusion of the lower extremity in patients with chronic limb-threatening ischemia (CLTI). Patients with CLTI often present with stenotic-occlusive lesions involving the infrapopliteal arteries. Although the frequency of treating infrapopliteal lesions is increasing, the reintervention rates remain high. This study aimed to determine the outcomes and patency of infrapopliteal endovascular reinterventions. METHODS This retrospective, multicenter cohort study of 3 Dutch hospitals included patients who underwent an endovascular infrapopliteal reintervention in 2015 up to 2021 after a primary infrapopliteal intervention for CLTI. The outcome measures after the reintervention procedures included technical success rate, the mortality rate and complication rate (any deviation from the normal postinterventional course) at 30 days, overall survival, amputation-free survival (AFS), freedom from major amputation, major adverse limb event (MALE), and recurrent reinterventions (a reintervention following the infrapopliteal reintervention). Cox proportional hazard models were used to determine risk factors for AFS and freedom from major amputation or recurrent reintervention. RESULTS Eighty-one patients with CLTI were included. A total of 87 limbs underwent an infrapopliteal reintervention in which 122 lesions were treated. Technical success was achieved in 99 lesions (81%). The 30-day mortality rate was 1%, and the complication rate was 13%. Overall survival and AFS at 1 year were 69% (95% confidence interval [CI], 55%-79%) and 54% (95% CI, 37%-67%), respectively, and those at 2.5 years were 45% (95% CI, 33%-56%) and 21% (95% CI, 11%-33%), respectively. Freedom from major amputation, MALE, and recurrent reinterventions at 1 year and 2.5 years were 59% (95% CI, 46%-70%) and 41% (95% CI, 25%-56%); 54% (95% CI, 41%-65%) and 36% (95% CI, 21%-51%); and 68% (95% CI, 55%-78%) and 51% (95% CI, 33%-66%), respectively. A Global Limb Anatomic Staging System score of III showed an increased hazard ratio of 2.559 (95% CI, 1.078-6.072; p=0.033) for freedom of major amputation or recurrent reintervention. CONCLUSIONS The results of this study indicate that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, outcomes and patency were moderate to poor, with low AFS, high rates of major amputations, and recurrent reinterventions. CLINICAL IMPACT This multicenter retrospective study evaluating outcome and patency of endovascular infrapopliteal reinterventions for CLTI, shows that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, the short- and mid-term outcomes of the infrapopliteal reinterventions were moderate to poor, with low rates of AFS and a high need for recurrent reinterventions. While the frequency of performing infrapopliteal reinterventions is increasing with additional growing complexity of the disease, alternative treatment options such as venous bypass grafting or deep venous arterialization may be considered and should be studied in randomized controlled trials.
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Affiliation(s)
- Simone F Kleiss
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Gijs C Bloemsma
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Debbie A B de Vries-Werson
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Oh K, O'Brien-Irr MS, Montross BC, Khan SZ, Dryjski ML, Dosluoglu HH, Rivero M, Harris LM. Comparison of outcomes for balloon angioplasty, atherectomy, and stenting in the treatment of infrapopliteal disease for chronic limb-threatening ischemia. J Vasc Surg 2023; 77:241-247. [PMID: 36031169 DOI: 10.1016/j.jvs.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI). METHODS All index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS. RESULTS The 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P = .006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P = .08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P = .001; HR, 0.73; 95% CI, 0.60-0.90; P = .003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P = .11) and for stenting and atherectomy (87.6% vs 84.8%; P = .23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P = .07; HR, 0.71; 95% CI, 0.50-1.017; P = .062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P = .005; HR, 0.69; 95% CI, 0.54-0.89; P = .005). No significant differences were found between stenting and atherectomy (P = .21 for atherectomy; and P = .34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P = .001; stenting vs atherectomy, 13.5 months vs 6.8 months; P < .001). CONCLUSIONS Stenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment.
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Affiliation(s)
- Kenny Oh
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - Monica S O'Brien-Irr
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - Brittany C Montross
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - Sikandar Z Khan
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - Maciej L Dryjski
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - H Hasan Dosluoglu
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - Mariel Rivero
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY
| | - Linda M Harris
- Division of Vascular Surgery, Jacobs School of Medicine, University of Buffalo, State University of New York, Buffalo, NY.
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Aygun MS, Tureli D, Deniz S, Oguzkurt L. Ultrasound-guided retrograde tibial access through chronically occluded tibial arteries: a last resort recanalization technique. Diagn Interv Radiol 2022; 28:621-626. [PMID: 36550764 PMCID: PMC9885662 DOI: 10.5152/dir.2022.21844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE We aimed to demonstrate the feasibility of ultrasound (US)-guided retrograde tibial access through chronically occluded tibial arteries as a bailout endovascular recanalization procedure in patients with critical limb ischemia (CLI). METHODS Fifty-one CLI patients with failed conventional antegrade tibiopedal recanalization required retrograde tibiopedal access in the same session. In all of these patients, the target tibial artery was chronically occluded in at least the distal half of the cruris. Access attempts were made under real-time US by a single operator experienced in image-guided vascular access procedures. Fluoroscopy was used only as an adjunct during advancement of a 0.018 inch guidewire. If access to the artery was successful by the retrograde route, the occluded artery was usually predilated with a 2 mm balloon, and the standard endovascular treatment was mostly performed through the antegrade route. RESULTS Patients had athereosclerosis (n=35) or Buerger's disease (n=32) and presented with Rutherford category IV and category V. Successful placement of a guidewire in the occluded artery lumen was achieved in 81% of all patients, whereas, treatment success, i.e. angiographic demonstration of in-line flow at the end of procedure, was achieved in 49%. No significant procedure-related complications were observed. Of 33 limbs with initially successful endovascular treatment, 6 required minor and 1 required major amputation during follow-up. CONCLUSION US-guided retrograde access through completely occluded tibial arteries is difficult but feasible. Half of the tibial arteries that could not be recanalized otherwise were converted to successful recanalization by this method.
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Affiliation(s)
| | - Derya Tureli
- Department of Radiology, Marmara University, İstanbul, Turkey
| | - Sinan Deniz
- LMU Klinikum der Universität München, München, Germany
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Abdelmonem M, Shahat M, Elashry M, Ali H. Retrograde tibiopedal access for chronic limb-threatening ischemia: A real-world experience report of 178 consecutive patients. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_123_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Korosoglou G, Schmidt A, Stavroulakis K, Pollert D, Giusca S, Lichtenberg M, Scheinert D, Torsello G, Andrassy M, Blessing E. Retrograde Access for the Recanalization of Lower-Limb Occlusive Lesions: A German Experience Report in 1,516 Consecutive Patients. JACC Cardiovasc Interv 2021; 15:348-351. [PMID: 34922890 DOI: 10.1016/j.jcin.2021.09.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
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Therasse E, Benko A, Brodmann M, Hadziomerovic A. A Multinational, Single-Arm Pivotal Study Assessing the Performance of the SoundBite Crossing System for Peripheral Chronic Total Occlusions (The PROSPECTOR Study). J Vasc Interv Radiol 2021; 33:50-59. [PMID: 34628039 DOI: 10.1016/j.jvir.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/08/2021] [Accepted: 07/10/2021] [Indexed: 12/28/2022] Open
Abstract
PURPOSE This study aimed to demonstrate the efficacy and safety of the SoundBite Crossing System‒Peripheral (SCS-P) to facilitate crossing chronic total occlusions (CTOs) of infrainguinal arteries. MATERIALS AND METHODS This clinical trial was approved by the Ethics Committees of all 4 participating centers and enrolled 52 patients with symptomatic de novo infrainguinal CTOs. Technical device success, the primary efficacy endpoint, was defined as the ability to facilitate the treatment of the target lesion by crossing a portion or the whole length of the CTO. Freedom from SCS-P-related major adverse events (MAEs) at 30 days after the procedure was the primary safety endpoint. RESULTS The SCS-P met the primary efficacy and safety endpoints in 92.3% (48/52) and 100% (52/52) of subjects, respectively. Technical device success with postprocedural patency and freedom from SCS-P-related MAEs was achieved in 88.5% (46/52) of subjects. The mean CTO crossing time was 20.0 minutes ± 30.8, and the SCS-P was able to traverse the whole CTO and enter the distal true lumen without the need of any other device in 59.6% (31/52) of subjects. The mean Rutherford category and ankle-brachial index improvement at the 30-day follow-up was 2.4 ± 1.17 and 0.23 ± 0.22, respectively. CONCLUSIONS The SCS-P demonstrated a satisfactory safety and performance profile to cross peripheral CTOs and enter the distal true lumen of infrainguinal CTOs.
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Affiliation(s)
- Eric Therasse
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
| | - Andrew Benko
- Department of Radiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | - Adnan Hadziomerovic
- Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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12
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Validation of the correlation between angiosome-based target arterial path, mid-term limb-based patency, and the global limb anatomical staging system. Heart Vessels 2021; 37:496-504. [PMID: 34491392 DOI: 10.1007/s00380-021-01937-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022]
Abstract
This study aimed to validate the correlation between the Global Limb Anatomical Staging System (GLASS) and limb-based patency (LBP) and angiosome-based target arterial path (TAP) and to detect the predictors of LBP loss. After the publication of the Global Vascular Guidelines in 2019, the evaluation of GLASS and identification of TAP have been recommended. However, there are few reports regarding GLASS. Eighty-three patients with chronic limb-threatening ischemia (CLTI) and tissue loss from 2016 to 2020 were evaluated. The correlation between GLASS and LBP and successful revascularization of angiosome-based TAP was analyzed. We also investigated the predictors of LBP loss. The number of patients in each GLASS stage was as follows: GLASS I, 6 patients; GLASS II, 15 patients; GLASS III, 62 patients. At 6 months, the Kaplan-Meier estimate of LBP was 66.7% in GLASS I, 41.6% in GLASS II, and 16.4% in GLASS III, respectively (p = 0.034). The rate of successful revascularization of angiosome-based TAP was 100% in GLASS I, 86.7% in GLASS II, and 46.8% in GLASS III, respectively (p = 0.002). Multivariate analysis showed that the Wound, Ischemia, and foot Infection (WIfI) stage [hazard ratio (HR) 1.58; 95% confidence interval (CI) 1.07-2.33; p = 0.021] and GLASS infrapopliteal (IP) grade (HR 1.96; 95% CI 1.31-2.95; p = 0.001) were the independent predictors of LBP loss. The GLASS stage was significantly correlated with successful revascularization of angiosome-based TAP and mid-term LBP. The WIfI stage and GLASS IP grade were the independent predictors of loss of LBP.
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Steiner S, Schmidt A. Repeat BTK revascularization: when, how and what are the results? THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:118-123. [PMID: 33635043 DOI: 10.23736/s0021-9509.21.11679-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Owing to the ageing of the population and rising rates of diabetes, more patients suffering from chronic limb threatening ischemia (CLTI) need revascularization for often complex, multilevel peripheral arterial occlusive disease. Below the knee (BTK) lesions are common in CLTI and short-term outcomes of BTK endovascular revascularizations have improved substantially over the last decade as a consequence of improved techniques and dedicated low profile devices. EVIDENCE ACQUISITION The manuscript summarized the information identified through a limited literature review conducted on key resources including MEDLINE and EMBASE databases as well as conference proceedings. The keywords were "angioplasty," "endovascular intervention," "infrapopliteal," "tibial arteries" and "below the knee." The search was limited to contemporary English-language documents published between 2000 and 2020. EVIDENCE SYNTHESIS Rates of re-stenosis and re-occlusion are high after infrapopliteal interventions limiting long-term success and necessitating frequent repeat procedures. CONCLUSIONS In this article we aimed to summarize current knowledge regarding the need, options and outcome of repeat BTK interventions through a limited literature review and presentation of own data.
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Affiliation(s)
- Sabine Steiner
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany -
| | - Andrej Schmidt
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
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Bekeny JC, Alfawaz A, Day J, Naz I, Attinger CE, Fan KL, Evans KK, Akbari CM. Indirect Endovascular Revascularization via Collaterals: A New Classification to Predict Wound Healing and Limb Salvage. Ann Vasc Surg 2020; 73:264-272. [PMID: 33373768 DOI: 10.1016/j.avsg.2020.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization. METHODS Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected. RESULTS Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively. The mean age was 65.8 years old (standard deviation (SD) 11.9) with 81 males (77.1%) and 24 females (22.9%). Average follow-up was 21.0 months (SD 14.0). Overall wound healing rates were 80.0%, 92.1%, and 63.6% for DR, IR-C, and IR, respectively (P = 0.009). Significant differences were found between all 3 group comparisons, DR versus IR-C (P = 0.010), DR versus IR (P = 0.013), IR-C versus IR (P = 0.008). Overall major amputation-free survival was 85.7%, 89.5%, and 69.7% in DR, IR-C, and IR groups, respectively, with statistically significant differences between the IR-C and IR groups (P = 0.036). CONCLUSIONS Treating diseased infra-popliteal arteries and improving blood flow via arterial-arterial connections as per the angiosome model improved wound healing and amputation-free survival in this cohort. Although DR is still the gold standard, revascularization using IR-C may give superior healing results even in highly comorbid patients. This offers an additional avenue for treatment, especially when DR is not possible.
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Affiliation(s)
- Jenna C Bekeny
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Abdullah Alfawaz
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jonathan Day
- Georgetown University School of Medicine; Washington, DC
| | - Iram Naz
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Kenneth L Fan
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Cameron M Akbari
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC.
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Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 61:270-279. [PMID: 33358346 DOI: 10.1016/j.ejvs.2020.11.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Antegrade crossing techniques via transfemoral access are often challenging and may be associated with technical and clinical failure when treating patients with critical limb ischaemia (CLI). The objective of this study was to summarise all available literature regarding retrograde endovascular treatment of patients with CLI and to investigate the technical success and complication rate of retrograde access. METHODS A systematic literature search was performed in PubMed, Scopus, and Cochrane Central until May 2020. A meta-analysis of 31 observational studies (29 retrospective and two prospective; 26 and five studies with low and moderate risk of bias, respectively) was conducted with random effects modelling. The incidence of adverse events peri-procedurally and during follow up were calculated. RESULTS The 31 studies enrolled 1 910 patients who were treated endovascularly for femoropopliteal and/or infrapopliteal lesions causing CLI. Most of the patients had diabetes while more than half of the overall population had coronary artery disease and dyslipidaemia. All lesions were located in the infra-inguinal segment and most were chronic total occlusions (96%; 95% CI 85%-100%). Seven studies reported moderate or severe calcification in approximately half of the cases (45%; 95% CI 30%-60%). The overall technical success of the retrograde approach was 96% (18 studies; 95% CI 92%-100%). Perforation, flow limiting dissection, distal embolisation, and local haematoma at the retrograde access site were infrequent and observed in 2.1%, 0.6%, 0.1%, and 1.3% of the patients, respectively. The six month primary patency rate was 78% (five studies; 95% CI 46%-99%), the six month limb salvage rate was 77% (four studies; 95% CI 70%-84%). CONCLUSION The results indicated that the retrograde or bidirectional antegrade/retrograde approach is safe and effective and facilitates angioplasty when antegrade treatment fails. However, prospective studies with standardised wound care and surveillance protocols are needed to investigate retrograde techniques in patients with CLI who failed antegrade revascularisation, to improve long term limb salvage and survival.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA
| | - Luis M Palena
- Endovascular Surgery Unit, Endovascular Interventions & Research, Foot & Ankle Clinic, Maria Cecilia Hospital, Cotignola, Italy
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA.
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Giannopoulos S, Armstrong EJ. WIRION™ embolic protection system for carotid artery stenting and lower extremity endovascular intervention. Future Cardiol 2020; 16:527-538. [PMID: 32253940 DOI: 10.2217/fca-2020-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Aim: To summarize all available literature regarding the Wirion™ embolic protection system (EPS) and present examples from our center. Materials & methods: A review of literture was performed about the utilization of Wirion EPS. Results: One study was identified investigating the outcomes of Wirion during carotid artery stenting. The study demonstrated 98.3% procedural success with stroke occurring in only 2.5%. Two single arm studies were identified investigating the efficacy of the Wirion filter during lower extremity endovascular interventions. The reported device success ranged from 95.1 to 97.3%. Conclusion: While carotid artery stenting should always be performed with adjunctive EPS in order to decrease the risk of cerebrovascular accidents, the routine use of EPS in femorpopliteal interventions remains an active area of investigation.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO 80045, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO 80045, USA
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Kokkinidis DG, Strobel A, Jawaid O, Haider MN, Alvandi B, Singh GD, Laird JR, Waldo SW, Armstrong EJ. Development and validation of a predictive score for anterograde crossing of infrapopliteal chronic total occlusions: (The Infrapop‐CTO Score). Catheter Cardiovasc Interv 2020; 95:748-755. [DOI: 10.1002/ccd.28693] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/23/2019] [Accepted: 12/20/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Damianos G. Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Aaron Strobel
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Omar Jawaid
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Moosa N. Haider
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis California
| | - Bejan Alvandi
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis California
| | - Gagan D. Singh
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis California
| | - John R. Laird
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis California
| | - Stephen W. Waldo
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
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18
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Clinical Impact and Predictors of the Slow-Flow Phenomenon after Endovascular Treatment of Infrapopliteal Lesions Using the Crosser Catheter in Patients with Critical Limb Ischemia. J Vasc Interv Radiol 2020; 31:141-149. [DOI: 10.1016/j.jvir.2019.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 11/19/2022] Open
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19
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Chaudhari H, Sumanthraj KB, Anand V, Motukuru V, Rodney SR, Sravan CPS, Sivakrishna K, Suresh KR. Comparative study of outcomes between single-vessel versus multiple-vessel infrapopliteal angioplasties in patients with chronic limb-threatening ischemia. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_64_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Lavingia KS, Tran K, Dua A, Itoga N, Deslarzes-Dubuis C, Mell M, Chandra V. Multivessel tibial revascularization does not improve outcomes in patients with critical limb ischemia. J Vasc Surg 2019; 71:2083-2088. [PMID: 31685281 DOI: 10.1016/j.jvs.2019.08.251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/15/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Multivessel tibial revascularization for critical limb ischemia (CLI) remains controversial. The purpose of this study was to evaluate single vs multiple tibial vessel interventions in patients with multivessel tibial disease. We hypothesized that there would be no difference in amputation-free survival between the groups. METHODS Using the Vascular Quality Initiative registry, we reviewed patients undergoing lower extremity endovascular interventions involving the tibial arteries. Patients with CLI were included only if at least two tibial vessels were diseased and adequate perioperative data and clinical follow-up were available for review. The primary outcome was amputation-free survival. RESULTS There were 10,849 CLI patients with multivessel tibial disease evaluated from 2002 to 2017; 761 limbs had adequate data and follow-up available for review. Mean follow-up was 337 ± 62 days. Of these, 473 (62.1%) underwent successful single-vessel tibial intervention (group SV), whereas 288 (37.9%) underwent successful multivessel (two or more) intervention (group MV). Patients in group MV were younger (69.1 vs 73.2 years; P < .001), with higher tobacco use (29.5% vs 18.2%; P < .001). Group SV more commonly had concurrent femoral or popliteal inflow interventions (83.7% vs 78.1%; P = .05). Multivessel runoff on completion was significantly greater for group MV (99.9% vs 39.9%; P < .001). No differences were observed between group SV and group MV for major amputation (9.0% and 7.6%; P = .6), with similar amputation-free survival at 1 year (90.6% vs 92.9%; P = .372). In a multivariate Cox model, loss of patency was the only significant predictor of major amputation (hazard ratio, 5.36 [2.7-10.6]; P = .01). A subgroup analysis of 355 (46.6%) patients with tissue loss data showed that tissue loss before intervention was not predictive of future major amputation. CONCLUSIONS In the Vascular Quality Initiative registry, patients with CLI and occlusive disease involving multiple tibial vessels did not appear to have a limb salvage benefit from multiple tibial revascularization compared with single tibial revascularization.
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Affiliation(s)
- Kedar S Lavingia
- Division of Vascular Surgery, Stanford University, Stanford, Calif.
| | - Kenneth Tran
- Division of Vascular Surgery, Stanford University, Stanford, Calif
| | - Anahita Dua
- Division of Vascular Surgery, Stanford University, Stanford, Calif
| | - Nathan Itoga
- Division of Vascular Surgery, Stanford University, Stanford, Calif
| | | | - Matthew Mell
- Division of Vascular Surgery, Stanford University, Stanford, Calif
| | - Venita Chandra
- Division of Vascular Surgery, Stanford University, Stanford, Calif
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21
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Schmidt A, Bausback Y, Piorkowski M, Wittig T, Banning-Eichenseer U, Thiele H, Aldmour S, Branzan D, Scheinert D, Steiner S. Retrograde Tibioperoneal Access for Complex Infrainguinal Occlusions. JACC Cardiovasc Interv 2019; 12:1714-1726. [DOI: 10.1016/j.jcin.2019.06.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/08/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
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22
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 739] [Impact Index Per Article: 147.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 710] [Impact Index Per Article: 142.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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Shimada Y, Kino N, Tonomura D, Yamanaka Y, Nishiura S, Yano K, Ito K, Yoshida M, Tsuchida T, Fukumoto H. Efficacy of Cutting Balloon Angioplasty for Chronic Total Occlusion of Femoropopliteal Arteries. Ann Vasc Surg 2019; 58:91-100. [PMID: 30769058 DOI: 10.1016/j.avsg.2018.10.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/27/2018] [Accepted: 10/31/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion subset where maintaining long-term patency after endovascular treatment is challenging. We evaluated the efficacy of cutting balloon angioplasty (CBA) for de novo FP-CTOs in patients with symptomatic lower limb ischemia. METHODS Seventy-three limbs of 67 symptomatic patients with de novo FP-CTOs successfully recanalized using CBA alone were enrolled in this study. Primary patency was defined as the absence of recurrent symptoms and no deterioration of the ankle-brachial index (ABI) >0.10 from the immediate postinterventional value. RESULTS The mean age was 73.5 ± 7.3 years, and 59.7% of patients had diabetes mellitus. Most lesions were classified as Trans-Atlantic Inter-Society Consensus II type C (n = 18; 24.7%) or type D (n = 44; 60.3%), with mean lesion and occluded lengths of 24.8 ± 11.4 and 17.8 ± 11.2 cm, respectively. No procedure-related adverse events occurred, except one distal embolization. The ABI significantly increased after intervention from 0.52 ± 0.12 to 0.80 ± 0.15 (P < 0.0001), with marked improvement in clinical symptoms (Rutherford stage: 2.7 ± 1.0 to 1.1 ± 1.2, P < 0.0001). The mean follow-up period was 31.2 ± 18.0 months, and the primary patency rates at 12 and 24 months were 75.3% and 60.6%, respectively. The independent predictive factors of failed patency were baseline hemoglobin A1c (P = 0.031, hazard radio [HR] 1.51 per 1%), occluded length ≥15 cm (P = 0.036, HR 2.90), and severe dissection (P = 0.033, HR 2.85). Vessel calcification and diameter did not affect primary patency. CONCLUSIONS CBA is a feasible option for endovascular treatment of FP-CTOs. Diabetic status, occlusion length, and severe dissection after CBA are independent negative predictors of long-term patency.
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Affiliation(s)
- Yoshihisa Shimada
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan.
| | - Naoto Kino
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Daisuke Tonomura
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Yuki Yamanaka
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Satoshi Nishiura
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Kentaro Yano
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Kazato Ito
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Masataka Yoshida
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Takao Tsuchida
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
| | - Hitoshi Fukumoto
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
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Park UJ, Kim HT, Roh YN. Impact of Tibial Runoff on Outcomes of Endovascular Treatment for Femoropopliteal Atherosclerotic Lesions. Vasc Endovascular Surg 2018; 52:498-504. [DOI: 10.1177/1538574418779466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: The aim of this study is to investigate the impact of tibial runoff on outcomes of femoropopliteal interventions for atherosclerotic lesions. Methods: A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed. Results: The distribution rates of good tibial runoff (runoff score <7) and poor tibial runoff (runoff score ≥7) were 37.0% and 63.0%, respectively. In the poor tibial runoff group, the patients were older ( P = .019), and the proportion of male was lower ( P = .014). There was a significantly higher proportion of rest pain or tissue loss ( P < .001), and the prevalence of stroke ( P = .031) and renal insufficiency ( P = .005) was significantly higher in the poor runoff group. After femoropopliteal intervention, the amputation-free survival ( P = .03) and freedom from ischemia ( P = .003) were significantly lower in the poor runoff group. The interventions targeting below-the-knee (BTK) lesions performed concomitantly for critical limb ischemia or tissue loss with poor tibial runoff did not show a significant advantage in terms of freedom from ischemia; however, minor trends of longer lasting freedom from ischemia were observed when BTK intervention was combined. Conclusion: The patients with poor runoff showed significantly lower amputation-free survival and freedom from ischemia. In poor tibial runoff limbs with critical limb ischemia or tissue loss, BTK intervention did not demonstrate additional significant beneficial outcomes; however, there was a minor trend of longer lasting freedom from ischemia after concomitant BTK intervention.
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Affiliation(s)
- Ui Jun Park
- Division of Transplantation and Vascular Surgery, Department of Surgery, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
| | - Hyoung Tae Kim
- Division of Transplantation and Vascular Surgery, Department of Surgery, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
| | - Young-Nam Roh
- Division of Transplantation and Vascular Surgery, Department of Surgery, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
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26
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Biagioni RB, Biagioni LC, Nasser F, Burihan MC, Ingrund JC, Neser A, Miranda F. Infrapopliteal Angioplasty of One or More than One Artery for Critical Limb Ischaemia: A Randomised Clinical Trial. Eur J Vasc Endovasc Surg 2018; 55:518-527. [DOI: 10.1016/j.ejvs.2017.12.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/18/2017] [Indexed: 12/31/2022]
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27
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Ye K, Shi H, Qin J, Yin M, Liu X, Li W, Jiang M, Lu X. Outcomes of endovascular recanalization versus autogenous venous bypass for thromboangiitis obliterans patients with critical limb ischemia due to tibioperoneal arterial occlusion. J Vasc Surg 2017; 66:1133-1142.e1. [DOI: 10.1016/j.jvs.2017.03.425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/18/2017] [Indexed: 11/17/2022]
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Kobayashi N, Hirano K, Yamawaki M, Araki M, Sakai T, Sakamoto Y, Mori S, Tsutsumi M, Honda Y, Tokuda T, Makino K, Shirai S, Ito Y. Characteristics and clinical outcomes of repeat endovascular therapy after infrapopliteal balloon angioplasty in patients with critical limb ischemia. Catheter Cardiovasc Interv 2017; 91:505-514. [DOI: 10.1002/ccd.27238] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/22/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Norihiro Kobayashi
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Keisuke Hirano
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Masahiro Yamawaki
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Motoharu Araki
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Tsuyoshi Sakai
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Yasunari Sakamoto
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Shinsuke Mori
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Masakazu Tsutsumi
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Yohsuke Honda
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Takahiro Tokuda
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Kenji Makino
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Shigemitsu Shirai
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Yoshiaki Ito
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
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Singh GD, Brinza EK, Hildebrand J, Waldo SW, Foley TR, Laird JR, Armstrong EJ. Midterm Outcomes After Infrapopliteal Interventions in Patients With Critical Limb Ischemia Based on the TASC II Classification of Below-the-Knee Arteries. J Endovasc Ther 2017; 24:321-330. [DOI: 10.1177/1526602817704643] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To analyze the relationship between the new TransAtlantic Inter-Society Consensus (TASC II) infrapopliteal classification and limb outcomes among patients with critical limb ischemia (CLI). Methods: A single-center retrospective study was performed on 166 consecutive CLI patients (mean age 71 years; 113 men) undergoing endovascular treatment of 244 infrapopliteal lesions from 2006 to 2013. Patient, procedural, angiographic, and limb outcomes were compared for the new TASC A/B vs C/D classification for infrapopliteal lesions. Binary restenosis was determined by a peak systolic velocity ratio >2.0 by duplex ultrasound on follow-up at 1, 3, 6, and 12 months. Results: Seventy-two (43.4%) patients had TASC A/B lesions, while 94 (56.6%) had TASC C/D patterns of infrapopliteal disease. Baseline demographics and tissue loss (93% vs 94%, p=0.59) were similar between the groups. TASC A/B lesions were shorter (53±35 vs 170±83 mm, p<0.001), less severely stenosed (77%±24% vs 93%±14%, p<0.001), had a larger target vessel diameter (2.9±0.5 vs 2.6±0.5 mm, p<0.001), and were less frequently chronic total occlusions (24% vs 64%, p<0.001) compared with the TASC C/D group. Three-year freedom from both amputation (85% vs 67%, p=0.02) and major adverse limb events (79% vs 61%, p=0.02) were significantly higher in the TASC A/B group. Technical success rates (95% vs 80%, p<0.001) and 1-year primary patency (58% vs 51%, p=0.04) were higher in the A/B group. Overall 3-year survival was similar between the groups (96% A/B vs 88% C/D, p=0.2). Conclusion: TASC C/D infrapopliteal lesions are associated with higher amputation and major adverse limb events rates and lower primary patency compared with TASC A/B infrapopliteal lesions. Further studies are needed to assess the association between TASC C/D infrapopliteal lesions and clinical outcomes in patients with CLI.
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Affiliation(s)
- Gagan D. Singh
- Division of Cardiovascular Medicine and Vascular Center, University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Justin Hildebrand
- Division of Cardiovascular Medicine and Vascular Center, University of California Davis Medical Center, Sacramento, CA, USA
| | - Stephen W. Waldo
- VA Eastern Colorado Healthcare System, Denver, CO, USA
- Division of Cardiovascular Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - T. Raymond Foley
- VA Eastern Colorado Healthcare System, Denver, CO, USA
- Division of Cardiovascular Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - John R. Laird
- Division of Cardiovascular Medicine and Vascular Center, University of California Davis Medical Center, Sacramento, CA, USA
| | - Ehrin J. Armstrong
- VA Eastern Colorado Healthcare System, Denver, CO, USA
- Division of Cardiovascular Medicine, University of Colorado School of Medicine, Denver, CO, USA
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30
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Singh GD, Armstrong EJ, Waldo SW, Alvandi B, Brinza E, Hildebrand J, Amsterdam EA, Humphries MD, Laird JR. Non-compressible ABIs are associated with an increased risk of major amputation and major adverse cardiovascular events in patients with critical limb ischemia. Vasc Med 2017; 22:210-217. [PMID: 28466753 DOI: 10.1177/1358863x16689831] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Ankle-brachial indices (ABIs) are important for the assessment of disease burden among patients with peripheral artery disease. Although low values have been associated with adverse clinical outcomes, the association between non-compressible ABI (ncABI) and clinical outcome has not been evaluated among patients with critical limb ischemia (CLI). The present study sought to compare the clinical characteristics, angiographic findings and clinical outcomes of those with compressible (cABI) and ncABI among patients with CLI. Consecutive patients undergoing endovascular evaluation for CLI between 2006 and 2013 were included in a single center cohort. Major adverse cardiovascular events (MACE) were then compared between the two groups. Among 284 patients with CLI, 68 (24%) had ncABIs. These patients were more likely to have coronary artery disease ( p=0.003), diabetes ( p<0.001), end-stage renal disease ( p<0.001) and tissue loss ( p=0.01) when compared to patients with cABI. Rates of infrapopliteal disease were similar between the two groups ( p=0.10), though patients with ncABI had lower rates of iliac ( p=0.004) or femoropopliteal stenosis ( p=0.003). Infrapopliteal vessels had smaller diameters ( p=0.01) with longer lesions ( p=0.05) among patients with ncABIs. After 3 years of follow-up, ncABIs were associated with increased rates of mortality (HR 1.75, 95% CI: 1.12-2.78), MACE (HR 2.04, 95% CI: 1.35-3.03) and major amputation (HR 1.96, 95% CI: 1.11-3.45) when compared to patients with cABIs. In conclusion, ncABIs are associated with higher rates of mortality and adverse events among those undergoing endovascular therapy for CLI.
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Affiliation(s)
- Gagan D Singh
- 1 Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Ehrin J Armstrong
- 2 Division of Cardiology, University of Colorado, Denver, CO, USA.,3 VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Stephen W Waldo
- 2 Division of Cardiology, University of Colorado, Denver, CO, USA.,3 VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Bejan Alvandi
- 1 Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Ellen Brinza
- 2 Division of Cardiology, University of Colorado, Denver, CO, USA.,3 VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Justin Hildebrand
- 1 Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Ezra A Amsterdam
- 1 Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Misty D Humphries
- 4 Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - John R Laird
- 1 Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, CA, USA
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31
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Muir KB, Cook PR, Sirkin MR, Aidinian G. Tibioperoneal Occlusive Disease: A Review of below the Knee Endovascular Therapy in Patients with Critical Limb Ischemia. Ann Vasc Surg 2017; 38:64-71. [DOI: 10.1016/j.avsg.2016.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/19/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
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Rundback JH, Armstrong EJ, Contos B, Iida O, Jacobs D, Jaff MR, Matsumoto AH, Mills JL, Montero-Baker M, Pena C, Tallian A, Uematsu M, Wilkins LR, Shishehbor MH. Key Concepts in Critical Limb Ischemia: Selected Proceedings from the 2015 Vascular Interventional Advances Meeting. Ann Vasc Surg 2016; 38:191-205. [PMID: 27569717 DOI: 10.1016/j.avsg.2016.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/01/2016] [Accepted: 08/03/2016] [Indexed: 01/28/2023]
Abstract
Over 500,000 patients each year are diagnosed with critical limb ischemia (CLI), the most severe form of peripheral artery disease. CLI portends a grim prognosis; half the patients die from a cardiovascular cause within 5 years, a rate that is 5 times higher than a matched population without CLI. In 2014, the Centers for Medicare and Medicaid Services paid approximately $3.6 billion for claims submitted by hospitals for inpatient and outpatient care delivered to patients with CLI. Although significant advances in diagnosis, treatment, and follow-up of patients with CLI have been made, many challenges remain. In this article, we summarize selected presentations from the 2015 Vascular Interventional Advances Conference related to the modern demographics, diagnosis, and management of patients with CLI.
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Affiliation(s)
- John H Rundback
- Interventional Institute, Holy Name Medical Center, Teaneck, NJ.
| | - Ehrin J Armstrong
- Department of Vascular Surgery, VA Eastern Colorado Healthcare System and University of Colorado, Denver, CO
| | | | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Donald Jacobs
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Michael R Jaff
- Department of Vascular Medicine, Massachusetts General Hospital, Boston, MA
| | - Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | - Constantino Pena
- Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL
| | | | - Masaaki Uematsu
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Luke R Wilkins
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Mehdi H Shishehbor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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Morisaki K, Yamaoka T, Iwasa K, Ohmine T. Popliteal-Peroneal Artery Bypass via the Posterior Approach: A Case Report. Ann Vasc Surg 2016; 36:292.e1-292.e4. [PMID: 27421203 DOI: 10.1016/j.avsg.2016.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/11/2016] [Accepted: 03/06/2016] [Indexed: 11/25/2022]
Abstract
We report the case of a 65-year-old man with critical limb ischemia treated with popliteal-peroneal bypass via the posterior approach and endarterectomy of the P2 popliteal artery. The posterior approach is useful in a number of situations, such as cases of arteriosclerotic disease of the crural arteries, where the target artery is the distal posterior tibial artery or peroneal artery; where the inflow site is the popliteal artery; in cases of a poor-quality greater saphenous vein, limited length of vein, and a preferable lesser saphenous vein; and in reoperation after failed bypass via a medial approach. Vascular surgeons should consider the posterior approach as an alternative procedure in below-knee revascularization.
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Affiliation(s)
- Koichi Morisaki
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan.
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan
| | - Kazuomi Iwasa
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan
| | - Takahiro Ohmine
- Department of Vascular Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Hiroshima, Japan
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de Athayde Soares R, Matielo MF, Brochado Neto FC, Martins Cury MV, Marques RC, Sacilotto R. Number of infrapopliteal arteries undergoing endovascular treatment is not associated with the limb salvage rate in patients with critical limb ischemia. J Vasc Surg 2016; 64:1344-1350. [PMID: 27288107 DOI: 10.1016/j.jvs.2016.04.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of this study was to determine whether the number of infrapopliteal arteries undergoing endovascular treatment is associated with the limb salvage rate in patients with critical limb ischemia (CLI). METHODS This was a retrospective, consecutive cohort study of CLI patients who underwent infrapopliteal angioplasty at the Vascular and Endovascular Surgery Service of the Hospital do Servidor Público Estadual, São Paulo, between January 2009 and January 2013. The primary outcome variable was the limb salvage rate. The secondary outcome variables were patency, survival, plantar arch quality, and operative mortality rate. RESULTS Overall, 109 infrapopliteal angioplasties were performed in 92 patients, and the initial technical success rate was 95.6%. Based on the analyses of the arteriography of the endovascular procedures, the patients were classified into two groups according to whether they had undergone endovascular treatment of one artery (group 1) or two arteries (group 2). The mean outpatient follow-up time was 430 ± 377.5 days. The analyses were performed at 180 and 360 days. There were 72 angioplasties (66%) in group 1 and 37 (34%) in group 2. Hypertension was more frequent in group 1 (93.1%) than in group 2 (78.4%; P = .03). Other clinical characteristics were similar in both groups. Regarding postoperative complications, the incidence of acute kidney failure was lower in group 1 (0% vs 8.1%, respectively; P = .037). The limb salvage rate at 360 days was similar in groups 1 and 2 (89.4% vs 89.3%, respectively; P = .595). The secondary patency rate at 360 days was also similar in groups 1 and 2 (59.9% vs 60.9%, respectively; P = .571). The perioperative mortality rate was lower in group 1 (4.2% vs 16.2%, respectively; P = .039), but the survival rate at 360 days was similar in both groups (82.1% vs 75.1%, respectively; P = .931). The frequencies of complete, incomplete, and absent plantar arch were similar in both groups. The estimated limb salvage rates for patients with complete plantar arch or incomplete/absent plantar arch were 96.2% and 84.6%, respectively (P = .467), at 360 days. CONCLUSIONS Our results suggest that it is not necessary to treat the largest number of arteries possible in CLI patients. Instead, the most amenable artery for endovascular procedures should be treated to improve limb salvage and secondary patency rates.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil.
| | - Marcelo Fernando Matielo
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil
| | | | | | - Régis Campos Marques
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil
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Abstract
Endovascular treatment of infrapopliteal disease is focused on the treatment of patients with rest pain or critical limb ischemia (CLI) due to severe atherosclerotic disease. While the evidence base surrounding the comparative effectiveness of endovascular intervention vs. surgery is lacking, many operators have adopted an "endovascular first" approach to the treatment of infrapopliteal atherosclerotic disease due to the lower morbidity of these procedures. This manuscript reviews current data on the endovascular treatment of CLI, including a comparison of endovascular and surgical approaches, current indications for and outcomes with balloon angioplasty of infrapopliteal PAD, angiosome-guided revascularization, and emerging technologies to improve long-term vessel patency after endovascular intervention.
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Affiliation(s)
- Ehrin J Armstrong
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA.
| | - Kalkidan Bishu
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
| | - Stephen W Waldo
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
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Kakkar AM, Abbott JD. Percutaneous versus surgical management of lower extremity peripheral artery disease. Curr Atheroscler Rep 2015; 17:479. [PMID: 25612856 DOI: 10.1007/s11883-014-0479-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Lower extremity peripheral artery disease (PAD) is highly prevalent and can manifest as intermittent claudication or, in the most advanced form, critical limb ischemia. Revascularization, which can be accomplished by an endovascular or surgical approach, is performed to improve quality of life or, in severe cases, for limb salvage. Over the past decade, percutaneous catheter-based techniques have improved such that acute procedural success is high even in complex anatomy. Patency rates have also increased with the use of atherectomy devices and drug-eluting stents. Often, patients with PAD have comorbidities that increase the risk of cardiovascular complications with surgical procedures. These factors have led to the adoption of an endovascular first strategy with surgical management reserved for selected patients. This review focuses on the most current clinical trials of endovascular therapy for PAD. In addition, older but relevant studies comparing endovascular and surgical approaches and contemporary surgical trials are presented for reference.
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Affiliation(s)
- Amit M Kakkar
- Vascular Medicine and Endovascular Interventions, Jacobi Medical Center, 1400 Pelham Pkwy South Cardiac Cath, Bld 1, 5, West Bronx, NY, 10461, USA,
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Banerjee S, Sarode K, Patel A, Mohammad A, Parikh R, Armstrong EJ, Tsai S, Shammas NW, Brilakis ES. Comparative Assessment of Guidewire and Microcatheter vs a Crossing Device-Based Strategy to Traverse Infrainguinal Peripheral Artery Chronic Total Occlusions. J Endovasc Ther 2015; 22:525-34. [PMID: 25985785 DOI: 10.1177/1526602815587707] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare success rates of a guidewire and microcatheter strategy vs the use of specialized crossing devices to traverse infrainguinal peripheral artery chronic total occlusions (CTOs). METHODS For this analysis, data on 438 consecutive infrainguinal CTO interventions in 438 patients (mean age 63.2 years; 402 men) performed between August 2006 and May 2014 were extracted from the multicenter Excellence in Peripheral Artery Disease (XLPAD) database (ClinicalTrials.gov; identifier NCT01904851). Primary technical success constituted placement of a guidewire in the true lumen, past the distal CTO cap, with the initial crossing strategy. RESULTS A wire-catheter strategy was used in 295 (67.4%) and a specialized CTO crossing device in 143 (32.6%) patients (p<0.001). Primary crossing technical success was higher with CTO devices (72.1% vs 51.9%, p<0.001). The primary wire-catheter arm used significantly more secondary CTO devices (28.1% vs 17.5%) and/or provisional re-entry devices (26.7% vs 4.9%) compared with the primary CTO device arm (both p<0.001). Secondary crossing technical success (defined as crossing with an alternate strategy: 67.5% vs 71.4%, p=1.000), provisional crossing technical success (defined as use of a re-entry device: 84.2% vs 87.5%, p=0.768), and procedure success (93.6% vs 90.9%, p=0.332) were similar between the wire-catheter and CTO device strategies, respectively. No differences were observed in periprocedural complications or 30-day adverse events; however, at 12 months, there was a significantly higher surgical revascularization rate in the primary wire-catheter arm (8.8% vs 2.8%, p=0.025). CONCLUSION Infrainguinal peripheral artery CTO crossing is frequently attempted with a wire-catheter technique; however, an initial CTO crossing device approach is associated with higher primary technical success. Overall procedure success is similar with both strategies.
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Affiliation(s)
- Subhash Banerjee
- Veteran Affairs North Texas Healthcare System, Dallas, TX, USA University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karan Sarode
- Veteran Affairs North Texas Healthcare System, Dallas, TX, USA
| | | | - Atif Mohammad
- Veteran Affairs North Texas Healthcare System, Dallas, TX, USA University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Ehrin J Armstrong
- VA Eastern Colorado Healthcare System and University of Colorado School of Medicine, Denver, CO, USA
| | - Shirling Tsai
- Veteran Affairs North Texas Healthcare System, Dallas, TX, USA University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Emmanouil S Brilakis
- Veteran Affairs North Texas Healthcare System, Dallas, TX, USA University of Texas Southwestern Medical Center, Dallas, TX, USA
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Prognosis of critical limb ischemia patients with tissue loss after achievement of complete wound healing by endovascular therapy. J Vasc Surg 2015; 61:951-9. [DOI: 10.1016/j.jvs.2014.11.065] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/12/2014] [Indexed: 11/19/2022]
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Retrograde Pedal Access Technique for Revascularization of Infrainguinal Arterial Occlusive Disease. J Vasc Interv Radiol 2015; 26:29-38. [DOI: 10.1016/j.jvir.2014.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 11/18/2022] Open
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Shimada Y. Commentary: Another back door to the endovascular future: an antegrade pedal approach for retrograde revascularization. J Endovasc Ther 2014; 21:779-82. [PMID: 25453878 DOI: 10.1583/14-4801c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Yoshihisa Shimada
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
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Huang ZS, Schneider DB. Endovascular intervention for tibial artery occlusive disease in patients with critical limb ischemia. Semin Vasc Surg 2014; 27:38-58. [DOI: 10.1053/j.semvascsurg.2014.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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