Endovascular treatment for symptomatic stent failures in long-segment chronic total occlusion of femoropopliteal arteries

An old but still valuable technique for popliteal artery stenosis: Endarterectomy via the posterior approach

Isolated popliteal artery occlusions are rare compared with femoropopliteal occlusive diseases. Although endovascular procedures have gained importance in treatment, conventional surgery remains the gold standard. In this study, we reviewed popliteal endarterectomy and patch plasty using a posterior approach. Fourteen patients who underwent surgery for isolated popliteal artery occlusions were retrospectively examined. Patients were assessed in terms of age, sex, and risk factors, such as accompanying diseases and smoking, surgical method and anesthesia, incision type, preoperative and postoperative pulse examination, ankle-brachial indices, patency, wound infection, postoperative complications, and the treatment applied. Twelve (85.7%) patients were male, and 2 (14.3%) were female. Limb ischemia was critical (ABI < 0.7) in 11 (78.5%) patients. The average duration of postoperative hospitalization was 8 ± 3.7 days on average, and the average length of follow-up was 17 ± 3.4 months. Thrombosis and complications requiring secondary intervention did not develop during the early postoperative period. While the patency rate in the first 6 months of follow-up was 100%, it was 92.8% in the 1st year and 85.7% in the 2nd year. Surgical treatment with the posterior approach in isolated popliteal artery lesions is preferred by vascular surgeons as a prioritized treatment method, with a sufficient recanalization rate and low perioperative morbidity and mortality rates. Furthermore, it is promising because it does not prevent below-knee femoropopliteal bypass, which is the subsequent stage of treatment. Moreover, the great saphenous vein was protected, and the acceptable early- and mid-term results were encouraging.

Systematic review and meta-analysis of drug-coated balloon for in-stent restenosis in femoropopliteal artery disease

PURPOSE

To evaluate the role of drug-coated balloon (DCB) angioplasty for in-stent restenosis (ISR) in femoropopliteal artery disease.

MATERIAL AND METHODS

Cochrane Library, Embase, and PubMed were searched without language restriction from inception to May 10, 2020.The endpoints included target lesion revascularization (TLR), recurrent ISR, clinical improvement, ankle-brachial index (ABI), and death.

RESULTS

There were five randomized controlled trials with 425 patients (218 with DCB angioplasty and 207 with plain old balloon angioplasty [POBA]) included in the meta-analysis. Compared with POBA, DCB angioplasty was associated with lower risk of TLR (odds ratio [OR] 0.21, 95% confidence interval [CI]: 0.09 to 0.49, P<0.001 at 6 months and OR 0.15, 95% CI: 0.08 to 0.30, P<0.001 at 12 months) and recurrent ISR (OR 0.22, 95% CI: 0.13 to 0.38, P<0.001 at 6 months and OR 0.31, 95% CI: 0.16 to 0.61, P<0.001 at 12 months), and superior clinical improvement (OR 1.98, 95% CI: 1.07 to 3.65, P=0.03 at 6months and OR 2.84, 95% CI: 1.50 to 5.35, P=0.001 at 12 months). There were no significant differences between groups in ABI and death. Subgroup analysis for patients with DCB angioplasty showed similar rates of TLR, recurrent ISR, clinical improvement, and death between the short lesion (<15 cm) and long lesion group (≥15 cm) (P>0.05).

CONCLUSIONS

The current meta-analysis suggests hat DCB angioplasty is an improvement over POBA for femoropopliteal ISR. Future studies about the effect of lesion length on DCB performance are still needed.

[Application of Rotarex mechanical thrombectomy system in treating in-stent restenosis of lower extremity arteriosclerosis obliterans]

OBJECTIVE

To evaluate the role of Rotarex mechanical thrombectomy system in treating instent restenosis of peripheral artery disease (PAD).

METHODS

The clinical data of 7 in-stent restenosis (ISR) cases of lower extremity PAD from June 2017 to Dec 2018 were retrospectively analyzed. There were 5 males and 2 females and the mean age was (70.0±7.6) years from 59.0 to 76.0 years. All the cases were treated by Rotarex mechanical thrombectomy system. In the 7 cases, time interval from the previous stent implantation to ischemia recurrence was 1.0 to 72.0 months, and the median time was 6.0 months. The period from ischemia recurrence to endovascular therapy was 3 days to 2 years, and the median time was 62 days. Rotarex mechanical debulking catheter and percutaneous transluminal angioplasty (PTA) were used in all the cases, and the stent was used only when it was necessary. Anticoagulation was used for 24 hours after procedures and then antiplatelet agents were used as usual. Doppler ultrasonography was taken during the followed-up.

RESULTS

All the 7 cases were successful in technology, 3 of which were implanted with new stents for the fracture of the old ones. while for the other four cases, no new stent was implanted. The ankle-brachial index (ABI) increased from 0.31±0.08 to 0.86±0.08 after treatment (t=-12.84, P < 0.001). Thrombectomy was applied urgently in one case because of acute thrombosis in the stent, and the result was good. There was no other complications in hospital. All the patients were followed up for 5.0-22.0 months, and the median time was 14.0 months. No death and amputation occurred during the follow-up. One patient stopped antiplatelet agents because of gastrointestinal bleeding, which resulted in acute thrombosis. in-stent restenosis reappeared in 3 cases.

CONCLUSION

Debulking using Rotarex catheter is safe and effective in treating in-stent restenosis of PAD, especially in reducing stents implantation, but is not good at dealing with old thrombus and proliferating intima, and can do nothing about fractured stents and hyperplasia of intima, so it needs to be combined with stents and drug coated balloons.

Stent crush: A novel endovascular approach for treatment of complex in-stent femoropopliteal chronic total occlusion

Femoropopliteal in-stent chronic total occlusions (CTOs) remain one of the most challenging subsets of peripheral arterial disease to treat percutaneously. Advances in available CTO crossing technology and operator experience have increased percutaneous intervention success rates. We report a case of critical limb ischemia in a patient with chronically occluded femoropopliteal nonoverlapping stents treated with a novel percutaneous approach of subintimal retrograde angioplasty using high compression resistant nitinol stents to crush the occluded previous stents to create a neo-lumen.

Substent Anchor Technique for Recanalisation of a Full Metal Jacket Femoropopliteal In-Stent Occlusion

Purpose

To report the endovascular treatment of a full metal jacket (FMJ) femoropopliteal chronic total occlusion (CTO) using a new ancillary retrograde technique.

Case report

An 80 year old woman with type 2 diabetes presented to the Diabetic Foot Clinic with critical limb ischaemia with tissue loss in the right leg. Her comorbidities included coronary artery disease, morbid obesity, hypertension, dyslipidaemia, and active smoking habit. The patient had been treated at another hospital by femoropopliteal FMJ stenting six years before this presentation. The duplex ultrasound showed a full length in-stent re-occlusion. An antegrade recanalisation was attempted via contralateral femoral access, but was unsuccessful. An ultrasound guided retrograde puncture of the popliteal artery in the P2 segment was performed very close to the distal occluded stent. A 0.018 guidewire was pushed in the substent plane, functioning as an anchor to achieve a stable system. The FMJ was then retrogradely recanalised with a second guidewire. The procedure was completed by antegrade angioplasty with drug coated balloons.

Conclusion

The substent anchor technique can help to achieve stability even if close to the occluded stents, and spares the distal landing zone for surgical revascularisation if the endovascular approach fails. This technique could be useful in retrograde treatment of long in-stent CTO.

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Recanalisation of in-stent chronic total occlusion is a challenging procedure.

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It is very difficult to treat long in-stent occlusion by an antegrade approach.

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The retrograde route allows for easier access to the stent true lumen.

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The distal landing zone should be spared for further surgical revascularisation.

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The substent anchor technique offers system stability as well as being close to the CTO.

Stenting of femoropopliteal lesions using interwoven nitinol stents

OBJECTIVE

The Supera stent (Abbott Laboratories, Abbott Park, Ill) has a unique biomimetic design allowing axial and longitudinal flexibility and fracture resistance. The aim of this retrospective study was to assess the midterm patency of Supera stents used to treat patients with superficial femoral and popliteal arterial disease by a single practice.

METHODS

From April 2010 to December 2011, 53 patients and 59 limbs with symptomatic femoropopliteal lesions underwent angioplasty and stenting with the Supera stent. Five patients had no follow-up and were excluded. Demographics of the patients, radiographic images, morphologic features of the lesions, procedural reports, reinterventions, and follow-up clinical visit notes were reviewed. Primary patency was defined as clinical resolution of symptoms with no secondary interventions. Primary and secondary patency rates at 12, 24, and 36 months were estimated by Kaplan-Meier analysis.

RESULTS

A total of 48 patients (42 men, six women; 54 limbs; mean age, 64.3 years [range, 51-87]) received Supera stents and had at least one follow-up visit as part of their treatment for femoropopliteal disease. Primary indications for intervention included claudication, rest pain, and tissue loss, at rates of 54% (29 of 54), 26% (14 of 54), and 20% (11 of 54), respectively; 22% of lesions were TransAtlantic Inter-Society Consensus type A or B and 78% were type C or D. Mean lesion length was 24.0 cm (range, 3-51). Mean follow-up was 27.5 months (range, 1-45). The ankle-brachial index increased from 0.58 ± 0.20 preoperatively to 0.77 ± 0.18 postoperatively (P = .00004). Primary, primary assisted, and secondary patency rates at latest follow-up were 79.6%, 88.9%, and 92.3%, respectively. Cumulative primary patency rates by Kaplan-Meier analysis at 12, 24, and 36 months were 85.6%, 83.1%, and 76.7%, respectively. Secondary patency rates by Kaplan-Meier estimates at 12, 24, and 36 months were 93.8%, 93.8%, and 89.3%, respectively. No stent fractures were found at the time of any reinterventions. Long lesions >30 cm (n = 18) showed equivalent patency to lesions of 1 to 15 cm (n = 18) and lesions 15 to 30 cm in length (n = 18).

CONCLUSIONS

Our midterm results show that Supera stents are durable in treating femoropopliteal lesions, with notably high patency rates in patients with long lesion lengths.