Endovascular treatment of the common femoral artery in the Vascular Quality Initiative

Predictive Modeling for One-Year Lower Extremity Endovascular Revascularization Failure in Black Persons

INTRODUCTION

Black persons bear a disproportionate burden of peripheral artery disease (PAD) and experience higher rates of endovascular revascularization failure (ERF) when compared with non-Hispanic White persons. We aimed to identify predictors of ERF in Black persons using predictive modeling.

METHODS

This retrospective study included all persons identifying as Black who underwent an initial endovascular revascularization procedure for PAD between 2011 and 2018 at a midwestern tertiary care center. Three predictive models were developed using (1) logistic regression, (2) penalized logistic regression (least absolute shrinkage and selection operator [LASSO]), and (3) random forest (RF). Predictive performance was evaluated under repeated cross-validation.

RESULTS

Of the 163 individuals included in the study, 113 (63.1%) experienced ERF at 1 y. Those with ERF had significant differences in symptom status (P < 0.001), lesion location (P < 0.001), diabetes status (P = 0.037), and annual procedural volume of the attending surgeon (P < 0.001). Logistic regression and LASSO models identified tissue loss, smoking, femoro-popliteal lesion location, and diabetes control as risk factors for ERF. The RF model identified annual procedural volume, age, PAD symptoms, number of comorbidities, and lesion location as most predictive variables. LASSO and RF models were more sensitive than logistic regression but less specific, although all three methods had an overall accuracy of ≥75%.

CONCLUSIONS

Black persons undergoing endovascular revascularization for PAD are at high risk of ERF, necessitating need for targeted intervention. Predictive models may be clinically useful for identifying high-risk patients, although individual predictors of ERF varied by model. Further exploration into these models may improve limb salvage for this population.

Long-term outcomes of staged iliofemoral endoconduits prior to complex endovascular aortic aneurysm repair

OBJECTIVE

Adverse iliofemoral anatomy may preclude complex endovascular aortic aneurysm repair (EVAR). In our practice, staged iliofemoral endoconduits (ECs) are planned prior to complex EVAR to improve vascular access and decrease operative time while allowing the stented vessel to heal. This study describes the long-term results of iliofemoral ECs prior to complex EVAR.

METHODS

Between 2012 and 2023, 59 patients (44% male; median age, 75 ± 6 years) underwent ECs before complex EVAR using self-expanding covered stents (Viabahn). For common femoral artery (CFA) disease, ECs were delivered percutaneously from contralateral femoral access and extended into the CFA to preserve the future access site for stent graft delivery. Internal iliac artery patency was maintained when feasible. During complex EVAR, the EC extended into the CFA was directly accessed and sequentially dilated until it could accommodate the endograft. Technical success was defined as successful access, closure, and delivery of the endograft during complex EVAR. Endpoints were vascular injury or EC disruption, secondary interventions, and EC patency.

RESULTS

Unilateral EC was performed in 45 patients (76%). ECs were extended into the CFA in 21 patients (35%). Median diameters of the native common iliac, external iliac, and CFA were 7 mm (interquartile range [IQR], 6-8 mm), 6 mm (IQR, 5-7 mm), and 6 mm (IQR, 6-7 mm), respectively. Internal iliac artery was inadvertently excluded in 10 patients (17%). Six patients (10%) had an intraoperative vascular injury during the EC procedure, and six patients (10%) had EC disruption during complex EVAR, including five EC collapses requiring re-stenting and one EC fracture requiring open cut-down and reconstruction with patch angioplasty. In 23 patients (39%), 22 Fr OD devices were used; 20 Fr were used in 22 patients (37%), and 18 Fr in 14 patients (24%). Technical success for accessing EC was 89%. There was no difference in major adverse events at 30 days between the iliac ECs and iliofemoral ECs. Primary patency by Kaplan-Meier estimates at 1, 3, and 5 years were 97.5%, 89%, and 82%, respectively. There was no difference in primary patency between iliac and iliofemoral ECs. Six secondary interventions (10%) were required. The mean follow-up was 34 ± 27 months; no limb loss or amputations occurred during the follow-up.

CONCLUSIONS

ECs improve vascular access, and their use prior to complex EVAR is associated with low rates of vascular injury, high technical success, and optimal long-term patency. Complex EVAR procedures can be performed percutaneously by accessing the EC directly under ultrasound guidance and using sequential dilation to avoid EC disruption.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Open Surgical Therapy for Peripheral Artery Disease

PURPOSE OF REVIEW

The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD.

RECENT FINDINGS

The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.

Anatomic patterns in claudicants who fail supervised exercise therapy

OBJECTIVE

Patients with intermittent claudication (IC) from peripheral arterial disease (PAD) have significant improvement with supervised exercise therapy (SET). However, many patients have progressive disease that will ultimately require revascularization. We sought to determine whether the anatomic patterns of PAD were associated with response to SET.

METHODS

We prospectively enrolled patients with IC at the West Haven, Connecticut Veterans Health Administration between June 2019 and June 2022. Patients were classified based on the level of their arterial disease with >50% obstruction. SET failure was defined as progressive symptoms or development of critical limb-threatening ischemia (CLTI) requiring revascularization.

RESULTS

Thirty-eight patients with PAD were included. Thirteen patients (34.2%) had significant common femoral artery (CFA) disease, and 25 (65.8%) had non-CFA disease. Over a median follow-up of 1407 days, 11 patients (84.6%) with CFA disease failed SET as compared with three patients (12.0%) with non-CFA disease (P < .001). Patients with CFA disease were more likely to develop CLTI (46.2% vs 4.0%; P = .001) and have persistent symptoms (38.5% vs 8.0%; P = .02). Patients with CFA disease had significantly lower post-SET ankle-brachial index (0.58 ± 0.14 vs 0.77 ± 0.19; P = .03). In multivariate analysis, the only variable associated with SET failure was CFA disease location (odds ratio, 68.75; 95% confidence interval, 5.05-936.44; P = .001).

CONCLUSIONS

Patients with IC from high-grade CFA atherosclerosis are overwhelmingly likely to fail SET, potentially identifying a subset of patients who benefit from upfront revascularization.

Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome

To report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients. Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up.

Surgical, Endovascular, and Multimodal Approaches to the Management of Atherosclerotic Common Femoral Artery Disease

Common femoral artery disease is at the heart of nearly all treatment algorithms and decisions for patients with symptomatic peripheral arterial disease. Surgical endarterectomy has been the mainstay of common femoral treatment with a wealth of data supporting its safety, efficacy, and durability. Advances in endovascular technology and techniques for the management of iliac and superficial femoral artery disease has resulted in a paradigm shift in management. The common femoral artery has been aptly named a "no stent zone" due to anatomic and disease-specific challenges that have limited the role for endovascular techniques. New technology and techniques in the endovascular management of common femoral disease seek to change our treatment strategies. A multimodal approach utilizing a combination of angioplasty, atherectomy, and stenting has been shown most beneficial, although limited long-term data leave durability an unanswered question. While surgical treatment remains the gold standard, advances in the endovascular approach will certainly continue to improve outcomes. As truly isolated common femoral disease is a rarity, a collaborative approach combining all benefits of open and endovascular techniques in the treatment of peripheral arterial disease is essential.

A novel endovascular method of atherectomy for calcified common femoral and popliteal disease using the crosser system: Crossbow and Rambow techniques

OBJECTIVES

This study aims to report the efficacy and safety of new atherectomy methods using the Crosser system for calcified lesions in the common femoral and popliteal artery: the Crosser system supported by bended 0.014 wire (Crossbow) technique and retrograde approach of sheathless Crosser system supported by bended 0.014 wire (Rambow) technique.

MATERIALS AND METHODS

This report describes a single-center, retrospective study. A total of 23 patients (mean ± SD age, 73 ± 10 years; 19 men) with symptomatic peripheral artery disease received the Crossbow technique and Rambow technique for treatment of calcified common femoral and popliteal disease; these patients were enrolled between October 2013 and October 2015. The primary efficacy outcome was acute technical success, defined as achievement of residual stenosis < 30% for stenting and < 50% for angioplasty or atherectomy. The primary safety outcome was assessed on the basis of angiographic complications.

RESULTS

The Crossbow and Rambow techniques were undertaken in 100% and 17% of the patients, respectively. Acute technical success was achieved in 96% of the patients. There were two embolic events.

CONCLUSION

Crossbow and Rambow techniques could be effective atherectomy methods of calcified common femoral and popliteal disease. Regarding safety, embolic protection devices may be needed for our atherectomy methods.

Open Surgical Thrombendarterectomy Versus Endovascular Treatment in Occlusive Processes of the Femoral Artery Bifurcation

BACKGROUND

The standard treatment of occlusive processes of the femoral artery bifurcation is thrombendarterectomy (TEA). Endovascular techniques (ENDO) have recently been put forward as a potential alternative. It is unclear so far which modality yields better outcomes with respect to long-term revascularization and periprocedural complications. Method: Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD. Results: 42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO. Conclusion: In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation.

METHODS

Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD.

RESULTS

42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO.

CONCLUSION

In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation.

Statins and statin intensity in peripheral artery disease

Background: Peripheral artery disease (PAD) affects more than 202 million people worldwide. Several studies have shown that patients with PAD are often undertreated, and that statin utilization is suboptimal. European and American guidelines highlight statins as the first-line lipid-lowering therapy to treat patients with PAD. Our objective with this meta-analysis was to further explore the impact of statins on lower extremities PAD endpoints and examine whether statin dose (high vs. low intensity) impacts outcomes. Patients and methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. Any study that presented a comparison of use of statins vs. no statins for PAD patients or studies comparing high vs. low intensity statins were considered to be potentially eligible. We excluded studies with only critical limb threatening ischemia (CLTI) patients. The Medline (PubMed) database was searched up to January 31, 2021. A random effects meta-analysis was performed. Results: In total, 39 studies and 275,670 patients were included in this meta-analysis. In total, 136,025 (49.34%) patients were on statins vs. 139,645 (50.66%) who were not on statins. Statin use was associated with a reduction in all cause-mortality by 42% (HR: 0.58, 95% CI: 0.49-0.67, p<0.01) and cardiovascular death by 43% (HR: 0.57, 95% CI: 0.40-0.74, p<0.01). Statin use was associated with an increase in amputation-free survival by 56% (HR: 0.44, 95% CI: 0.30-0.58, p<0.01). The risk of amputation and loss of patency were reduced by 35% (HR: 0.65, 95% CI: 0.41-0.89, p<0.01) and 46% (HR: 0.54, 95% CI: 0.34-0.74, p<0.01), respectively. Statin use was also associated with a reduction in the risk of major adverse cardiovascular events (MACE) by 35% (HR: 0.65, 95% CI: 0.51-0.80, p<0.01) and myocardial infarction rates by 41% (HR: 0.59, 95% CI: 0.33-0.86, p<0.01). Among patients treated with statins, the high-intensity treatment group was associated with a reduction in all cause-mortality by 36% (HR: 0.64, 95% CI: 0.54-0.74, p<0.01) compared to patients treated with low intensity statins. Conclusions: Statin treatment among patients with PAD was associated with a statistically significant reduction in all-cause mortality, cardiovascular mortality, MACE, risk for amputation, or loss of patency. Higher statin dose seems to be associated with improved outcomes.

Comparative Analysis of Endovascular Intervention and Endarterectomy in Patients with Femoral Artery Disease: A Systematic Review and Meta-Analysis

Peripheral artery disease is a prevalent illness affecting more than 200 million people worldwide. A commonly used technique to manage the condition has been open endarterectomy. However, in recent times, a shift towards minimally invasive techniques has resulted in endovascular intervention as a popular alternative. This review aims to assess the safety and efficacy of endovascular intervention when compared with endarterectomy. A systematic review of the articles published in PubMed, Ovid, Embase, and Scopus within the last 10 years was conducted. The PRISMA guidelines were adhered to, and the Newcastle-Ottawa and NICE quality assessment scales were used. A meta-analysis of proportions was performed using the RStudio software (RStudio Team (2021). RStudio: Integrated Development Environment for R, PBC, Boston, MA, USA). Twenty-six studies were included, with a total of 7126 patients (endovascular, 2496; endarterectomy, 4630). Technical success was greater for endarterectomy than endovascular intervention with an odds ratio of 0.38; 95% CI [0.27–0.54]. In terms of safety as well endovascular intervention was better than endarterectomy with an odds ratio of 0.22; 95% CI [0.15 to 0.31] for wound infection. Endovascular intervention is a safe and effective procedure; however, it cannot be considered superior to endarterectomy.

A systematic review of racial/ethnic disparities in pharmacotherapy and surgical treatment outcomes in peripheral arterial disease among African American/non-Hispanic Black, non-Hispanic White and Hispanic patients

Background

Lower extremity peripheral arterial disease (PAD) is associated with significant morbidity and mortality in racial/ethnic diverse populations. However, limited data exist on treatment outcome disparities in racial/ethnic diverse populations, particularly in AA/NHB populations.

Objective

The aim of this systematic review is to analyze disparities in the outcomes of PAD treatments, particularly pharmacotherapy and surgery, among racial/ethnic groups in the US.

Methods

A comprehensive search of original investigations pertaining to PAD treatments between 2015 and 2021 was performed. Quality assessment of the studies was also completed.

Results

Fourteen studies were included. Thirteen studies reported differences in treatment outcomes for surgical intervention, and one study reported differences for concurrent surgical and pharmacotherapy. NHB and Hispanic/Latinx ethnicities were associated with decreased overall and perioperative mortality in four studies. Six studies noted increased amputation risk among racial/ethnic diverse populations. Only one study noted significant survival benefit by race/ethnicity. Three studies noted increased risk of major adverse limb events and post-operative complications. One study noted increased limb patency after intervention in racial/ethnic cohorts. Overall, all studies reported high methodological quality with adequate assessment of outcomes and follow-up of cohort.

Conclusion

In this analysis, the predominant intervention reported is surgical. Overall, racial/ethnic populations are less likely to experience PAD-associated mortality but are more likely to experience adverse events. Further studies are necessary to include all racial/ethnic diverse populations in assessing PAD therapeutic intervention outcomes. Moreover, targeted public health efforts are necessary to increase PAD educational awareness, community-driven risk modification, and patient-centered care planning.

SUPERA Stenting in the Common Femoral Artery: Early Experience and Practical Considerations

Purpose

Endovascular therapy in the management of de novo common femoral disease remains controversial. Considerable interest has been generated in recent years due to recent technological advancement in the design of vascular stents. In particular, SUPERA (Abbot Vascular Inc, Santa Clara USA) stents are designed to offer increased flexibility and less adverse interactions with the arterial wall, thus making it potentially better suited for common femoral lesions. However, despite such theoretical advantages, there is lack of data in its use in clinical practice. This study provides illustrative examples of SUPERA stents in different clinical settings and contributes to important clinical data for the overall efficacy and safety profile of endovascular interventions in common femoral artery (CFA) disease.

Materials and Methods

Retrospective analysis of all endovascular CFA procedures between January 1, 2011, and December 31, 2019, was conducted. Data collected included demographics, clinical symptoms, medical comorbidities, procedural characteristics, and immediate and short-term complications. Detailed analysis was performed on the stenting cohort.

Results

During our study period, a total of 69 patients underwent endovascular interventions involving the CFA at our institution, of which 16 patients had stenting procedures for a total of 18 stent deployments. Technical success was achieved in all stenting procedures. A total of 15 SUPERA stents were placed in 13 patients. No stent fractures were observed. Overall primary patency rate of SUPERA stents at the time of 12-month follow-up was 100% in patients who had a follow-up assessment (n = 12 stents).

Conclusion

Endovascular intervention of the CFA is an evolving topic in the interventional radiology and vascular surgery community. Recent development of newer generation of devices such as SUPERA peripheral stents offers significant potential benefits given their inherent design. Despite the theoretically promising design of the SUPERA, there is a lack of data to support its use. This study contributes important patient-level data for SUPERA stent deployments.

Systematic review of atherectomy of inguinal arteries for atherosclerotic lesions

INTRODUCTION

Surgical endarterectomy represents the gold standard for the treatment of atherosclerotic lesions of the groin vessels. Endovascular treatment such as atherectomy with or without drug coated angioplasty (DCA) of the so called no stenting zones, i.e. inguinal and popliteal vessels, is gaining growing acceptance as alternative option to open surgery. This systematic review aims to scrutiny the current clinical evidence regarding atherectomy and DCA for the common artery (CFA).

EVIDENCE ACQUISITION

We conducted an exhaustive research in multiple platforms (Medline, PubMed, Cochrane, Google Scholar, Embase) on studies over atherectomy and angioplasty for inguinal atherosclerotic lesions published between 2000 and 2021. As search strategy we used a wide list of MeSH items, words, synonyms. Bibliographies of review articles were checked for further relating studies regarding atherectomy of CFA. A qualitative and quantitative data analysis was carried out.

EVIDENCE SYNTHESIS

Fifteen studies were included in the qualitative review. Not all studies were focused only on atherectomy of inguinal vessels, despite including such treatment. Hence, data regarding this treatment were not exhaustive. A fairly homogeneous data analysis was possible in 7 of 15 studies. The remaining 8 studies were qualitatively analyzed but not included in the statistical analysis. In all 7 included studies directional atherectomy and DCA under filter protection were carried out. In this subgroup, overall, 497 patients were treated with atherectomy. Sixty-eight percent of the patients were males. Rutherford class from 1-3 dominated against 4-6 (63% vs. 37%). Mean technical success rate was 96%, with a primary and secondary patency rate of 92% and 98% respectively at one year. Procedure related vascular complications ranged from 1% to 6%.

CONCLUSIONS

Current literature about atherectomy for inguinal arteries is scant, data are inhomogeneous and so are treatment modalities. Nevertheless, the results of this systematic review suggest that this endovascular strategy is feasible with good short and midterm results. Prospective trials with larger patient cohorts are necessary to confirm these preliminary results.

Antegrade dissection of external iliac artery after failed attempt of common femoral artery chronic total occlusion angioplasty

Introduction. Endovascular treatment of chronic total occlusion (CTO) represents a true challenge even for experienced interventional radiologists. We are presenting a case of hidden antegrade dissection of the external iliac artery (EIA) after a failed attempt to recanalize CTO of the common femoral artery (CFA). Case outline. A 52-year-old male patient was admitted for multidetector computed tomography (CT) angiography. Left common iliac artery (CIA) stenting was performed, followed by ?crossover? attempt of recanalization of right CFA CTO that failed. The next day, left femoral superficial artery angioplasty was performed and after one month, angioplasty of the left popliteal and the bellow-knee arteries. A month later, the patient was readmitted for surgical reconstruction of the CFA. After desobstruction, excellent inflow was obtained and a Dacron graft was inserted. A few hours postoperatively, Fogarty catheter thrombectomy was performed. The next morning, pulsations were weakened again and CT angiography showed antegrade dissection of the EIA. Stenting of the EIA was performed with two stents and a favorable outcome was achieved. After a detailed analysis of the CT, hidden thrombosed antegrade dissection of the EIA was noted in the lateral view, which was not seen in the posterior/anterior view and was presented as fibrous plaque with mural thrombosis. Dissection occurred after failed attempt of CFA recanalization and was clinically silent until flow was established triggering opening of the false lumen and the release of thrombotic masses. Conclusion. In patients with failed angioplasty of CTO of the CFA and CT characteristics of fibrous plaque proximal to the site of attempted angioplasty, thrombosed antegrade dissection should be considered.

Statins and Peripheral Arterial Disease: A Narrative Review

Peripheral arterial disease (PAD) is a highly prevalent atherosclerotic condition. In patients with PAD, the presence of intermittent claudication leads to a deterioration in quality of life. In addition, even in asymptomatic cases, patients with PAD are at high risk of cardiac or cerebrovascular events. Treatment of PAD is based on lifestyle modifications; regular exercise; smoking cessation; and control of cardiovascular risk factors, including hypercholesterolemia. A growing number of studies have shown that statins reduce cardiovascular risk and improve symptoms associated with PAD. Current guidelines recommend the use of statins in all patients with PAD in order to decrease cardiovascular events and mortality. However, the prescribing of statins in patients with PAD is lower than in those with coronary heart disease. This review provides relevant information from the literature that supports the use of statins in patients with PAD and shows their potential benefit in decreasing lower limb complications as well as cardiovascular morbidity and mortality.

Simultaneous Hybrid Treatment of Multilevel Peripheral Arterial Disease in Patients with Chronic Limb-Threatening Ischemia

Background: Hybrid treatments (HT) aim to reduce conventional open surgery invasiveness and address multilevel peripheral arterial disease (PAD). Herein, the simultaneous HT treatment in patients with chronic limb-threatening ischemia (CLTI) is reported. Methods: Retrospective analysis, for the period from May 2012 to April 2018, of patients presenting multilevel PAD with CLTI addressed with simultaneous HT. The outcomes of these interventions were measured the following metrics: early technical successes (within 30 days following treatment) and late technical successes (30 days or more following treatment) and included mortality, morbidity symptoms recurrence, and amputation. Survival and patencies were estimated. The median follow-up was 43.77 months. Results: In the 45 included patients, the HT consisted of femoral bifurcation patch angioplasty followed by an endovascular treatment in 38 patients (84.4%) and endovascular treatment followed by a surgical bypass in 7 patients (15.6%). Technical success was 100% without perioperative mortality. Eight (17.8%) patients presented early complications without major amputations. During the follow-up, seven (15.6%) deaths occurred and six patients (13.3%) experienced symptoms recurrence, with five of those patients requiring major amputation. An estimated survival time of 5 years, primary patency, and secondary patency was 84.4%, 79.2%, and 83.3% respectively. Conclusions: Hybrid treatments are effective in addressing patients presenting with multilevel PAD and CLTI. The common femoral artery involvement influences strategy selection. Larger studies with longer-term outcomes are required to validate the hybrid approach, indications, and results.

Systematic review and meta-analysis of endovascular versus open repair for common femoral artery atherosclerosis treatment

BACKGROUND

Encouraging recent reports on endovascular treatment of common femoral artery (CFA) atherosclerotic disease has rendered the question regarding the place of this technique evermore pertinent and legitimizes the performance of randomized trials. The present comprehensive review focused on the early and midterm outcomes to help assess the benefit/risk balance of endovascular vs open repair for CFA treatment.

METHODS

Embase and Medline searches were conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) standards to identify studies from 2000 to 2018 reporting on endovascular repair (ER), open surgery (OS), and comparisons of both techniques for CFA atherosclerosis treatment. The outcomes measured were 30-day mortality, morbidity, reintervention rates, midterm patency, late reintervention, and restenosis rates.

RESULTS

Twenty-eight studies were eligible: 14 OS (1920 patients), 12 ER (1900 patients), and 2 comparative randomized trials (197 patients). The meta-analysis of the comparative studies revealed no differences in 30-day mortality or reintervention rates but improved 30-day morbidity after ER. At 1 year, the primary patency rates did not differ between ER and OS, nor did the late reintervention rate. In the noncomparative studies, with a mean follow-up period of 23.8 months for ER and 66 months for OS, the restenosis rate was 14.4% and 4.7%, respectively. The reported stent fracture rate was 3.6%. In the ER cohort, the overall primary patency at 1, 2, and 3 years was 81.9%, 77.8%, and 75.1%, respectively. For the OS cohort, the overall primary patency rate at 1, 2, and 3 years was 93.4%, 91.4%, and 90.5%, respectively.

CONCLUSIONS

Despite expectations, our analysis of the reported data suggests that the perioperative mortality is not in favor of ER; however, the perioperative morbidity showed an advantage for ER compared with OS. Also, although comparable in the first year, the long-term primary patency rate was much greater after OS. At present, the place of ER for CFA treatment still requires further definition. Additional clarification of the indications and more research are both required to determine the optimal endovascular technology and femoral bifurcation reconstruction with stenting.

Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis

AIMS

Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes.

METHODS AND RESULTS

This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations.

CONCLUSION

Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

Intermittent claudication treatment patterns in the commercially insured non-Medicare population

OBJECTIVE

Despite published guidelines and data for Medicare patients, it is uncertain how younger patients with intermittent claudication (IC) are treated. Additionally, the degree to which treatment patterns have changed over time with the expansion of endovascular interventions and outpatient centers is unclear. Our goal was to characterize IC treatment patterns in the commercially insured non-Medicare population.

METHODS

The IBM MarketScan Commercial Database, which includes more than 8 billion US commercial insurance claims, was queried for patients newly diagnosed with IC from 2007 to 2016. Patient demographics, medication profiles, and open/endovascular interventions were evaluated. Time trends were modeled using simple linear regression and goodness-of-fit was assessed with coefficients of determination (R²). A patient-centered cohort sample and a procedure-focused dataset were analyzed.

RESULTS

Among 152,935,013 unique patients in the database, there were 300,590 patients newly diagnosed with IC. The mean insurance coverage was 4.4 years. The median patients age was 58 years and 56% of patients were male. The prevalence of statin use was 48% among patients at the time of IC diagnosis and increased to 52% among patients after one year from diagnosis. Interventions were performed in 14.3%, of whom 20% and 6% underwent two or more and three or more interventions, respectively. The median time from diagnosis to intervention decreased from 230 days in 2008 days to 49 days in 2016 (R² = 0.98). There were 16,406 inpatient and 102,925 ambulatory interventions for IC over the study period. Among ambulatory interventions, 7.9% were performed in office-based/surgical centers. The proportion of atherectomies performed in the ambulatory setting increased from 9.7% in 2007 to 29% in 2016 (R² = 0.94). In office-based/surgical centers, 57.6% of interventions for IC used atherectomy in 2016. Atherectomy was used in ambulatory interventions by cardiologists in 22.6%, surgeons in 15.2%, and radiologists in 13.6% of interventions. Inpatient atherectomy rates remained stable over the study period. Open and endovascular tibial interventions were performed in 7.9% and 7.8% of ambulatory and inpatient IC interventions, respectively. Tibial bypasses were performed in 8.2% of all open IC interventions.

CONCLUSIONS

There has been shorter time to intervention in the treatment of younger, commercially insured patients with IC, with many receiving multiple interventions. Statin use was low. Ambulatory procedures, especially in office-based/surgical centers, increasingly used atherectomy, which was not observed in inpatient settings.

Efficacy of Multichannel Balloon Angioplasty in Calcified Common Femoral Artery Lesions

This report describes 7 cases in which multichannel balloon angioplasty was performed for severely calcified common femoral artery stenosis. After the successful passage of a guidewire through the stenosis, another guidewire with a tip load of 12g or 14 g was passed through a different channel inside the calcified plaques, followed by balloon angioplasty via each route. After the procedure, ankle brachial index improved from 0.49 ± 0.23 to 0.89 ± 0.05 on an average, and 6 of the 7 patients had patent arteries at a median follow-up period of 13 months. Multichannel balloon angioplasty offers the promise of being an effective endovascular intervention to expand calcified lesions.

Comparative Analysis of Outcomes in Patients Undergoing Femoral Endarterectomy plus Endovascular (Hybrid) or Bypass for Femoropopliteal Occlusive Disease

INTRODUCTION

The gold-standard for management of combined common femoral artery (CFA) and superficial femoral artery (SFA) atherosclerotic occlusive disease has traditionally been open femoral endarterectomy and femoral-popliteal bypass. Hybrid approaches involving an open and endovascular component are increasingly common. The aim of this study was to compare perioperative outcomes in patients who underwent an open versus hybrid revascularization.

METHODS

NSQIP data, years 2012-2017, were queried for patients who underwent nonemergent CFA endarterectomy with either SFA transluminal intervention or bypass. The primary outcome of interest was a composite of cardiovascular, pulmonary, and renal complications (systemic) and mortality. Two propensity-weight adjusted analyses were performed: 1) comparing hybrid and prosthetic bypass 2) comparing hybrid and vein bypass.

RESULTS

There were 4,478 patients included (1,537 hybrid, 1,408 prosthetic, 1,533 vein); 64.8% were men, and the mean age was 67.8 ± 9.7 years; 29.9% had claudication, 38.8% had tissue loss, and 31.3 were unspecified. In the propensity-weighted analysis comparing hybrid to prosthetic bypass, there was no difference in systemic complications (OR = 1.29 for prosthetic vs. hybrid; 95% CI: 0.95-1.76; P = 0.107) or mortality (OR = 1.54; 95% CI: 0.71-3.33; P = 0.275). Prosthetic bypass was associated with more deep surgical-site infections (OR = 2.02; 95% CI: 1.19-3.45; P = 0.010), postoperative sepsis (OR = 2.07; 95% CI: 1.13-3.76; P = 0.018), unplanned 30-day readmission (OR = 1.28; 95% CI: 1.04-1.58; P = 0.021), and the composite of any complication (OR = 1.38; 95% CI: 1.18-1.61; P < 0.001). In the propensity-weighted analysis comparing hybrid to vein bypass, there was no difference in systemic complications (OR = 1.10 for vein vs. hybrid; 95% CI: 0.81-1.49; P = 0.552) or mortality (OR = 0.91; 95% CI: 0.42-2.00; P = 0.819). Vein bypass was associated with more superficial surgical-site infections (OR = 1.45; 95% CI: 1.04-2.02; P = 0.028), and the composite of any complication (OR = 1.32; 95% CI: 1.13-1.54; P = 0.001). Overall mortality was significantly higher patients with systemic complications (13.9% vs 0.1%; P < 0.001). Systemic complications were less common in patients with claudication undergoing hybrid revascularization than vein or prosthetic bypass.

CONCLUSIONS

Claudicants undergoing bypass experienced more systemic complications than those undergoing hybrid procedures, but there appears to be no increased risk of systemic complications or mortality with open reconstruction when compared to hybrid procedures for other indications. Other complications, such as infection, postoperative transfusion, and readmission, were more common in the bypass groups.

WITHDRAWN: One-Year Freedom from Amputation, Survival, and Cost of Care following Tibial and Pedal Endovascular Interventions for Critical Limb Ischemia: The Role of Atherectomy and Drug-Eluting Stents

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Device Selection in Femoral-Popliteal Arterial Interventions

Endovascular intervention devices for femoral-popliteal arterial disease have evolved in the last decade to more effectively treat patients with symptoms of claudication, improve tissue healing, and prevent amputation in patients with critical limb ischemia. Drug-eluting stents and drug-coated balloon therapies have demonstrated significant improvements in short- and mid-term patency and decreases in future target vessel interventions over uncoated balloon angioplasty. Adjunctive lesion preparation options including atherectomy devices are available to treat more complex and calcified lesions, but comparative data are still required.

Long-Term Outcome of Common Femoral Artery Endarterectomy In Octogenarians and Non-Octogenarians

OBJECTIVE

Arteriosclerotic disease of the common femoral artery can be treated by surgical or endovascular intervention. Elderly patients are said to have a worse outcome if treated by surgical means; however, data to support this theory are missing.

METHODS

Retrospective analysis of all patients who underwent common femoral artery endarterectomy between March 2007 and July 2018 in our clinic. Group 1 included all patients <80 years and Group 2 included all patients ⩾80 years. Endpoints were patency rates, limb salvage, and overall survival.

RESULTS

During this time period, 977 common femoral artery endarterectomies were performed. Indication was claudication in 61.5% and critical limb ischemia in 38.5%. Group 1 included 805 cases (82.4%) and Group 2 included 172 cases (17.6%). Thirty-day mortality was 2.7% (Group 1 = 1.6% versus Group 2 = 7.6%; p < 0.001) and 30-day major amputation was 1.1% (Group 1 = 0.7% versus Group 2 = 2.9%; p = .043). Primary patency and secondary patency were 84.2% and 96.8%, respectively, after 7 years. Limb salvage (93.7%, Group 1 = 94.1% versus Group 2 = 91.8%; p = .088) and overall survival (52.0%, Group 1 = 59.1% versus Group 2 = 15.7%; p = .006) were significantly different after the same time period. Multivariable analysis showed female gender to be a risk factor for loss of primary patency. Age ⩾ 80 years and ulcer or gangrene were risk factors for death. Statin use was beneficial to survival.

CONCLUSIONS

Common femoral artery endarterectomy is a safe procedure with excellent long-term results. Octogenarians have an increased risk for perioperative mortality and major amputation.

An Overview of the Treatment of Symptomatic Common Femoral Artery Lesions with a Focus on Endovascular Therapy

Endarterectomy of common femoral artery lesions (CFA) carries favorable long-term results and is currently still considered the gold standard for treating these lesions. Although routine stenting has been considered an option for treating the CFA, it has yielded conflicting results and is currently reserved for a bailout of suboptimal endovascular results. Newer therapies with atherectomy or lithoplasty in conjunction with pharmacologic anti-proliferative therapies are promising with less bailout stenting and dissections but randomized trials are needed to confirm their effectiveness and safety.

Directional Atherectomy of the Common Femoral Artery: Complications and Outcomes

BACKGROUND

The use of directional atherectomy (DA) with or without drug-coated balloon (DCB) may be considered for the management of common femoral artery (CFA) occlusive disease because of its minimally invasive nature with early mobilization, reduced incision complications, and infection rates. However, it has recognized complications, which may be related to the learning curve. We present our initial experience using DA and suggest changes that may, based on our practice, improve outcomes.

METHODS

Retrospective analysis with a prospective data collection from 2 centers to analyze outcomes in all consecutive patients treated during 1 year (n = 25). Patients who underwent CFA DA with/without DCB for CFA >70% stenosis. Primary end points include technical success, primary patency of the CFA, morbidity, and mortality. Secondary end points include change in Rutherford-Becker class, length of stay, and target lesion revascularization rate.

RESULTS

Between July 2017 and December 2018, 25 patients underwent CFA DA. Two had an occluded CFA, and 23 had >70% CFA stenosis as determined by ultrasound scan (USS) and/or computed tomography angiogram (CTA) preoperatively. There were no deaths within 30 days. Procedure-related complications included 2 cases of CFA pseudoaneurysm (one of them repaired by open surgery) and 1 CFA perforation (repaired with covered stent). No distal embolization or limb loss occurred. Mean length of stay was 1.9 days. Primary and secondary patency at 3 and 6 months was 100%. At 12 months, it was 96%.

CONCLUSIONS

Early results suggest that CFA DA with/without DCB is safe and effective. Previous CTA, focused USS, and/or intravascular USS may be useful to minimize the risk of pseudoaneurysm or perforation by excessive thinning of the media. Experience is required to prevent localized dilatation over time.

A systematic review of the diagnosis, management, and outcomes of true profunda femoris artery aneurysm

OBJECTIVE

True profunda femoris artery aneurysm (TPFAA) is rare. Most cases of profunda femoris artery aneurysm are classified as pseudoaneurysms. TPFAAs are mostly asymptomatic, but some are manifested with pain, swelling, paresthesia, gait and movement disturbances, thrombosis, and rupture. There is a paucity of evidence on the effectiveness of diagnostic and therapeutic measures for management of TPFAA. The aim of this paper was to systematically review the incidence, diagnosis, and management of TPFAA.

METHODS

A comprehensive systematic review on the diagnosis and management of TPFAAs was conducted by a search through PubMed, Cochrane, Embase, and Google Scholar databases to identify and to evaluate publications on TPFAA since 2012. Only publications on TPFAA were included in this review.

RESULTS

A total of 19 publications published from 2012 were included in the review. The studies were 18 case reports and a cadaver study reporting 27 TPFAAs in 26 patients with a mean age of 69.6 years. Rupture was reported in 18.5% of the cases (n = 5); the conventional clinical presentation of unruptured TPFAA was reported in 48% of cases (n = 13), with 40.9% of unruptured aneurysms being asymptomatic (n = 9). Computed tomography angiography was used as a diagnostic tool in 85.2% of the cases (n = 23); Doppler ultrasound was applied in 33.3% of cases (n = 9). The common therapeutic approaches were resection and revascularization (n = 13 [48.1%]) and ligation or resection without reconstruction (n = 6 [22.2%]). Cumulative analysis for cases reported before and after 2012 yielded similar results.

CONCLUSIONS

Review of the current literature supports that computed tomography angiography and Doppler ultrasound are the mainstay diagnostic approaches for TPFAA. Surgical repair through ligation, resection, and revascularization remains the most common and effective therapeutic procedure. Endovascular embolization is recommended for aneurysms when surgery is not tenable because of the patient's comorbidities and the aneurysm's anatomy.

A Hybrid Technique to Treat Iliofemoral Lesions Using a Covered Stent Associated with Open Femoral Repair

BACKGROUND

To describe a hybrid approach for complex iliofemoral lesions and report short-term and mid-term results.

METHODS

In this single-center retrospective study, all consecutive patients (n = 32, 36 limbs) who underwent hybrid repair of complex iliofemoral lesions between 2012 and 2017 using a conformable self-expandable covered stent for external iliac artery lesions and open repair of the common femoral artery were included. Lesions were responsible for claudication in 13 (36%) limbs, rest pain in 13 (36%) limbs and tissue loss in 10 (28%) limbs. Over a wire crossing the iliac lesion, the covered stent was deployed, externalized through the femoral arteriotomy, and cut at the iliofemoral junction in such a way that no untreated transition zone remained between the stent and the open reconstruction of the femoral artery.

RESULTS

Two elderly patients with critical limb ischemia died during the postoperative course, giving in-hospital mortality of 6.2%. Four (12.5%) presented with moderate to severe complications, including one transtibial amputation in a patient who presented with tissue loss at admission. The median follow-up period was 24.1 months (range: 0.8-64 months). One-year and two-year Kaplan-Meier estimates of overall survival were 91% (95% CI: 97-74) and 76% (95% CI: 89-53). One-year and two-year estimates of freedom from major amputation were 96% (95% CI: 99-76) and 91% (95% CI: 97-66). Estimates of primary patency, assisted primary patency, and secondary patency were: 93.7 (95% CI: 77.1-98.4) at 1 year, and 93.7 (95% CI: 77.1-98.4) at 2 years; 96.7% (95% CI: 78.6-99.6) at 1 year, and 96.7% (95% CI: 78.6-99.6) at 2 years; 96.7% (95% CI: 78.6-99.6) at 1 year and 96.7% (95% CI: 78.6-99.6) at 2 years, respectively.

CONCLUSIONS

Our hybrid approach for iliofemoral lesions provided acceptable mortality and good mid-term patency rates. Further studies with long-term followup are needed to evaluate the safety and durability of this technique.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

BACKGROUND

The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence.

METHODS

We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies.

RESULTS

We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low.

CONCLUSIONS

There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

BACKGROUND

The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence.

METHODS

We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies.

RESULTS

We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low.

CONCLUSIONS

There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

Safety and Feasibility of Intravascular Lithotripsy for Treatment of Common Femoral Artery Stenoses

Purpose: To evaluate the safety and feasibility of treating calcified, stenotic common femoral arteries (CFAs) using the Peripheral Intravascular Lithotripsy (IVL) System. Methods: An analysis was performed of 21 patients (mean age 71.9±10.1 years; 16 men) across 3 sites with calcified CFA stenoses treated with the Peripheral IVL System. The outcomes of interest were the ability to deliver IVL to the target lesion, the increase in acute gain, the reduction in diameter stenosis, the rate of provisional stenting, and angiographically defined complications. Results: Access to the target lesion and delivery of treatment by the IVL catheter were successful in all 21 patients. Post treatment mean diameter stenosis was 21.3%, representing an acute mean lumen gain of 3.1±1.3 mm (range 0.7–5.2). Vascular complications were minimal, with only 5 type B (non-flowing-limiting) dissections reported. The profunda femoris artery was patent in all patients following IVL, and none of the subjects experienced a perforation, distal embolization, thrombus, no reflow, or abrupt closure. Conclusion: These early results demonstrate that calcified, stenotic CFA lesions can be safely and successfully treated using the Peripheral IVL System.

Endovascular Treatment of Common Femoral Artery Atherosclerotic Disease

Common femoral artery atherosclerosis is a common cause of claudication and critical limb ischaemia. Surgical endarterectomy with or without patch angioplasty has been considered the gold standard for the treatment of common femoral peripheral artery disease. Endovascular intervention to the common femoral artery has gained popularity in recent years as devices and technical skills have advanced. A systematic review of the literature from 1987 to 2018 for endovascular treatment of common femoral artery disease was conducted. This article summarises the data on acute and long-term outcomes for endovascular treatment of common femoral artery disease.

A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

BACKGROUND

The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence.

METHODS

We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies.

RESULTS

We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low.

CONCLUSIONS

There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

Directional Atherectomy With Antirestenotic Therapy vs Drug-Coated Balloon Angioplasty Alone for Common Femoral Artery Atherosclerotic Disease

Purpose: To report an experience using directional atherectomy (DA) with antirestenotic therapy (DAART) in the form of drug-coated balloon (DCB) angioplasty vs DCB angioplasty alone in common femoral artery (CFA) occlusive lesions. Methods: A retrospective review was conducted of 47 consecutive patients (mean age 71 years; 26 men) treated between October 2011 and July 2016 using either DCB angioplasty alone (n=26) or DAART (n=21) for CFA lesions. The majority of patients had lifestyle-limiting claudication (14 DCB and 15 DAART). Mean lesion length (39±14 mm DCB and 34±16 mm DAART) and vessel calcification (17/26 DCB and 11/21 DAART) were comparable between the groups. There were 4 chronic total occlusions, all in the DAART group. The main outcome measure was primary patency. Key secondary outcomes were technical success, secondary patency, and freedom from clinically-driven target lesion revascularization (TLR). Results: Technical success rates were 89% following DCB angioplasty and 95% for DAART (p=0.41). The 88% 12-month primary patency and 89% freedom from TLR for DAART were higher than the 68% and 75% estimates following DCB angioplasty alone, but neither difference was statistically significant. However, the secondary patency estimate at 12 months was significantly higher in the DAART group (100% vs 81% for DCB, p=0.03). Bailout stenting (1 DCB vs 1 DAART), vessel perforation (1 DCB vs 0 DAART), access site complications (4 DCB vs 3 DAART), and distal embolization (0 DCB vs 1 DAART) were comparable, whereas DCB angioplasty had more non-flow-limiting dissections (8 vs 1 for DAART, p=0.02). Conclusion: Preparation of the atherosclerotic CFA with directional atherectomy was not associated with statistically significantly higher primary patency or freedom from TLR compared to DCB angioplasty alone at 12 months. Nonetheless, both modalities had promising outcomes in a primarily surgically treated vascular territory.

Acute procedural outcomes of orbital atherectomy for the treatment of common femoral artery disease: Sub-analysis of the CONFIRM Registries

This analysis compared the angiographic outcomes of patients treated with orbital atherectomy for calcified common femoral artery (CFA) and superficial femoral artery (SFA) disease. The ideal revascularization strategy for CFA disease is unknown. Endarterectomy has been considered the standard of care for CFA disease for over 50 years. Endovascular intervention is becoming more commonly used to revascularize the CFA given the advances in technology and the less invasive nature of the procedure. Patient demographics, lesion characteristics, and procedure data for all CONFIRM patients with at least one CFA lesion location ( n=147 patients; n=200 lesions) were compared to patients with at least one SFA lesion location ( n=1508 patients; n=2367 lesions). The primary endpoint was angiographic complication, defined as the composite of dissection, perforation, slow flow, closure, spasm, embolism, or thrombosis. The CFA group had more patients with Rutherford class 4 and shorter lesion length. The CFA group had a higher final residual stenosis, shorter total run time, and shorter total inflation time. The primary endpoint was lower in the CFA group compared with the SFA group (17% vs 24%, p=0.02), driven by a lower dissection rate (10% vs 15%, p=0.04). Plaque modification of the CFA with orbital atherectomy was safe and compared favorably with SFA disease. The need for bail-out stenting was low. A randomized trial is needed to determine the ideal treatment strategy for calcified CFA disease.

Infrainguinal open reconstruction: a review of surgical considerations and expected outcomes

Infrainguinal arterial occlusive disease can lead to potentially disabling and limb-threatening conditions. Revascularization may be indicated for claudication, rest pain, or tissue loss. Although endovascular interventions are becoming more prevalent, open surgeries such as endarterectomy and bypass are still needed and performed regularly. Open reconstruction has been associated with postoperative morbidity, both at the local and at the systemic levels. Local complications include surgical site infections (SSIs 0-5.3%), graft failure (12-60%), and amputation (5.7-27%), and more systemic issues include cardiac (2.6-18.4%), respiratory (2.5%), renal (4%), neurovascular (1.5%), and thromboembolic (0.2-1%) complications. While such outcomes present an additional challenge to the postoperative management of surgical patients, it may be possible to minimize their occurrence through careful risk stratification and preoperative assessment. Therefore, individualized selection of candidates for open repair requires weighing the need for intervention against the likelihood of adverse outcomes based on preoperative risk factors. This review provides an overview of open reconstruction, focusing on identifying the clinical indications for surgery and perioperative morbidity and mortality.