Placement of a flexible endovascular stent across the femoral joint: an in vivo study in the swine model

Midterm Results of Intravascular Lithotripsy for Severely Calcified Common Femoral Artery Occlusive Disease: A Single-Center Experience

PURPOSE

Common femoral artery (CFA)-occlusive disease has traditionally been treated with open surgery, yet nowadays the frailty of patients has induced to find new techniques of revascularisation by endovascular means. So far, intravascular lithotripsy (IVL) has shown promising results in several lower limbs arterial districts. The purpose of this article is to report our experience with IVL for severely calcified peripheral arterial disease (PAD) of the CFA.

METHODS

From November 2018 and October 2020, 10 consecutive patients (12 limbs) treated with IVL were prospectively enrolled in a dedicated database. Inclusion criteria were CFA localization of PAD, with a severe degree of calcification, a lesion length ≥10 mm, and a degree of stenosis ≥70% (severe). The only admitted adjunctive treatment was drug-coated balloon (DCB) angioplasty. Primary outcomes were technical and procedural success, clinical success, and target lesion revascularisation (TLR). Secondary outcomes were target extremity revascularisation (TER) and major adverse events (MAEs).

RESULTS

All patients underwent IVL with associated DCB angioplasty. The median percentage of achieved stenosis reduction was 55.5% (interquartile range [IQR] 50-60.75), with a technical and procedural success of 100%. Over the study period, TLR only occurred in one limb (8.3%), with a mean upgrade in Rutherford class of 2.7 ± 0.77. No target vessel and access site complications were reported, as well as no distal embolization. One death and one major amputation occurred over the follow-up period, both in the same patient.

CONCLUSIONS

Based on our experience, IVL for selected cases of severely calcified CFA disease, associated with DCB angioplasty, may be considered a safe and effective technique. Of course, a long-term follow-up and a larger series of patients are needed to validate our results.

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.

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.

The impact of venous stenting across the inguinal ligament on primary patency: a systematic review

INTRODUCTION

Iliac venous stenting is an established treatment option for both post-thrombotic and non-thrombotic iliac venous obstructions. Nonetheless, there is still no consensus on the best medical practice regarding some of these interventions. One area of debate is the safety of extending venous stents across the inguinal ligament (IL), with contradictory results from various authors and overall poor-quality research. This review aims to summarise current knowledge on the effect of venous stent placement across the IL on primary patency.

EVIDENCE ACQUISITION

A literature search was performed on the MEDLINE, Scopus and Web of Science databases, which returned 531 studies. Eleven studies were included. Data were extracted using piloted forms, and, if necessary, authors were contacted to obtain further information.

EVIDENCE SYNTHESIS

Two studies were prospective cohorts, whereas the remaining 9 were retrospective cohorts. Overall study quality was weak. Four studies showed a statistically significant association between stent placement across the IL and decreased primary patency. A multivariate analysis was performed in two of those studies, yet only one maintained statistical significance after multivariate analysis. Two studies reported 4 cases of stent fracture in total, and one study reported 5 cases of stent compression. All cases of stent fracture or compression occurred at the inguinal ligament.

CONCLUSIONS

Although current expert opinion favours stent placement across the IL, there is still insufficient evidence to recommend for or against venous stenting across the IL. Further research is required on comparing alternatives for the treatment of iliac venous lesions that extend into the common femoral vein.

WHAT THIS PAPER ADDS

Despite the establishment of venous stenting as a viable treatment option for both post-thrombotic and non-thrombotic iliac venous obstructions, there is an ongoing debate on the safety of extending such stents across the inguinal ligament. There are several publications on this subject, with conflicting results and overall poor-quality research. This is the first systematic review of published clinical evidence on the impact of venous stent placement across the IL on primary patency.

Retrograde deep femoral artery puncture for the treatment of an iatrogenic dissection flap of the common femoral artery bifurcation

The authors report on a diabetic patient with tissue loss, previously treated with a femoral-tibial bypass, which occluded shortly after construction. A combination of antegrade contralateral femoral and retrograde tibial access was used for revascularization. Angiogram demonstrated a dissection flap occluding the deep femoral artery flow, which was unable to be crossed from an antegrade approach. A retrograde deep femoral artery access was used to perform “kissing” angioplasty of the origins of the superficial and deep femoral arteries, thus successfully reestablishing flow to both vessels. This represents an unconventional endovascular technique that can be safely performed as a bailout maneuver.

Toward Data-Driven Learning Healthcare Systems in Interventional Radiology: Implementation to Evaluate Venous Stent Patency

We developed a code and data-driven system (learning healthcare system) for gleaning actionable clinical insight from interventional radiology (IR) data. To this end, we constructed a workflow for the collection, processing and analysis of electronic health record (EHR), imaging, and cancer registry data for a cohort of interventional radiology patients seen in the IR Clinic at our institution over a more than 20-year period. As part of this pipeline, we created a database in REDCap (VITAL) to store raw data, as collected by a team of clinical investigators and the Data Coordinating Center at our university. We developed a single, universal pre-processing codebank for our VITAL data in R; in addition, we also wrote widely extendable and easily modifiable analysis code in R that presents results from summary statistics, statistical tests, visualizations, Kaplan-Meier analyses, and Cox proportional hazard modeling, among other analysis techniques. We present our findings for a test case of supra versus infra-inguinal ligament stenting. The developed pre-processing and analysis pipelines were memory and speed-efficient, with both pipelines running in less than 2 min. Three different supra-inguinal ligament veins had a statistically significant improvement in vein diameters post-stenting versus pre-stenting, while no infra-inguinal ligament veins had a statistically significant improvement (due either to an insufficient sample size or a non-significant p value). However, infra-inguinal ligament stenting was not associated with worse restenosis or patency outcomes in either a univariate (summary-statistics and Kaplan-Meier based) or multivariate (Cox proportional hazard model based) analysis.

Outcomes of Drug-Coated Balloon Angioplasty vs. Conventional Balloon Angioplasty for Endovascular Treatment of Common Femoral Artery Atherosclerotic Disease

BACKGROUND

Atherosclerotic disease of the common femoral artery (CFA), commonly associated with multilevel disease affecting the femoropopliteal segment, can cause claudication or contribute to critical limb ischemia. Although endovascular therapy for the management of peripheral arterial disease (PAD) has been increasingly utilized, its role in CFA lesions remains controversial. The aim of this study was to investigate the safety and efficacy of drug (DCB) vs non drug coated balloon angioplasty (BA) at the CFA segment.

METHODS

In this two-center study, we identified 154 patients treated either with DCB (n = 47) or BA (n = 107) for CFA lesions. Hazard ratios (HR) and the respective 95% confidence interval (CI) were synthesized to examine the association between the two groups in terms of target lesion revascularization (TLR), limb loss, and major adverse limb event (MALE) at 12 and 24 months of follow up.

RESULTS

This real-world population included a high percentage of patients with critical limb ischemia (43%) and moderate to severe lesion calcification (75%). Adjunctive atherectomy was performed in 97.9% of DCB cases (N = 46/47) and 44.7% of BA cases (N = 51/114). The overall procedural success rate was 95% without any differences between the two groups. Post-angioplasty dissections were observed in 15 cases [DCB: 8.5% (N = 4/47) vs BA: 9.7% (N = 11/113); p = .81], while distal embolization occurred in one patient in the DCB group and one in the BA group (p = .52). Provisional stenting was more commonly necessary in BA vs. DCB cases (12.3% vs 2.13%, p = .044). Physiologic assessment during follow up demonstrated a better mean 2-year ABI for the DCB group (mean: 0.9; SD: 0.2) vs BA group (mean: 0.6; SD: 0.4), although statistical significance was not reached (p = .06). No difference between the two groups was detected in terms of freedom from TLR (DCB: 75.5% vs BA: 86.8%; HR: 1.31; 95% CI: 0.46-3.67; p = .61), freedom from limb loss (DCB: 83.8% vs BA: 83.6%; HR: 1.04; 95% CI: 0.36-2.99; p = .94) or freedom from MALE (DCB: 83.5% vs BA: 78%; HR: 0.73; 95% CI: 0.26-1.99; p = .53) at 24 m of follow up. However, at the end of follow up more deaths were observed in patients treated with BA than DCB (DCB: 14.9% vs BA: 31.7%; p = .03). Patients who required provisional stenting were at higher risk for limb loss 2 years after the initial procedure (multivariate: HR: 4.54; 95% CI: 1.09-18.85; p = .04).

CONCLUSIONS

Both DCB and non-DCB strategies are effective modalities for revascularization of patients with CFA lesions. Larger prospective studies are necessary to determine the relative benefit, if any, of drug-eluting technologies for the treatment of common femoral artery disease.

The Advantage of Common Femoral Endarterectomy Alone or Combined with Endovascular Treatment

Purpose

Although common femoral artery endarterectomy (CFAE) is regarded as the standard treatment modality for common femoral artery (CFA) disease, availability of advanced endovascular techniques has resulted in an increased number of CFA disease being treated. We evaluated clinical outcomes in a contemporary series of patients who were treated for CFA disease using endarterectomy alone or combined with endovascular treatment.

Materials and Methods

We retrospectively reviewed 46 patients from November 2001 through December 2007. The treated lesions were divided into 4 groups based on operative procedure: group I (n=11), CFAE alone; group II (n=15), CFAE and iliac artery (IA) endovascular treatment; group III (n=6), CFAE and superficial femoral artery (SFA) endovascular treatment; group IV (n=14), CFAE and IA and SFA endovascular treatment or bypass surgery.

Results

The degree of CFA steno-occlusion was not different among the groups. The 3-year primary patency rates of each group were 88.9±10.5%, 60.0±14.5%, 62.5±21.3%, and 83.9±10.4%, respectively. The 3-year primary assisted patency rates were 100%, 70.0±13.0%, 62.5±21.3%, and 89.3±10.4%, while 3-year secondary patency rates were 100%, 80.0±13.0%, 62.5±21.3%, and 92.3±7.4%, respectively. There was no procedure-related mortality. Significant improvement of ankle-brachial index was achieved in all groups.

Conclusion

CFAE alone is the treatment of choice for excellent patency and clinical improvement in steno-occlusive lesions confined to the CFA. In multiple steno-occlusive diseases, this procedure could be combined with endovascular procedures to reduce the operative risk in conditions with high morbidity.

Femoral Bifurcation Endarterectomy with Transection-Eversion of the Superficial Femoral Artery: Technique and Results

BACKGROUND

We evaluated the results of femoral bifurcation endarterectomy using the eversion technique with transection of the superficial femoral artery (femoral bifurcation endarterectomy with eversion [FBEE]).

METHODS

We included all patients who underwent a femoral revascularization using the eversion technique, with or without antegrade or retrograde revascularization, from January 2006 to December 2015. Data were retrospectively collected. Primary and primary assisted patency (PAP) of the femoral bifurcation were analyzed. Secondary outcomes were 30-day postoperative complications.

RESULTS

A total of 129 patients (143 limbs) underwent consecutive FBEE (86.8% men, with a mean age of 69.7 years). Patients presented with claudication (93, 65%) and critical ischemia (46, 32.2%). Primary patency was 96.3%, 94.6%, and 93% at 1, 2, and 5 years, respectively. PAP was 99% at 3 time points. Reintervention was necessary in 8 patients during follow-up. The 30-day mortality was 0.7% (1 patient), and the access complication rate was 18.8% (n = 27), of which only 2.8% (n = 4) were major complications.

CONCLUSIONS

This retrospective study confirmed the efficiency and the reproducibility of this technique for the treatment of femoral bifurcation lesions. This technique allowed treating extensive atherosclerotic lesions of the deep femoral artery and may be associated with antegrade and retrograde revascularizations.

Investigation of adverse events associated with an off-label use of arterial stents and CE-marked iliac vein stents in the iliac vein: insights into developing a better iliac vein stent

We analyzed the adverse events associated with an off-label use of arterial stents and CE-marked iliac vein stents for the treatment of iliac venous thromboembolism and investigated their relationships with the anatomical features of the iliac vein, to gain insights into the development of a better iliac vein stent. Reports of adverse events following the use of stents in the iliac vein were retrieved from the Manufacturer and User Facility Device Experience (MAUDE) database that contain suspected device-associated complications reported to the Food and Drug Administration. Data from 2006 to 2016 were investigated. The literature analysis was also conducted using PubMed, Cochrane Library, EMBASE, and Web of Science focusing on English articles published up to 4 October 2016. The analysis of 88 adverse events from the MAUDE database and 182 articles from the literature revealed that a higher number of adverse events had been reported following the use of arterial stents in the iliac vein compared to CE-marked iliac vein stents. While stent migration and shortening were reported only for the arterial stents, stent fracture and compression occurred regardless of the stent type, even though a vein does not pulsate. A study of the anatomical features of the iliac vein implies that bending, compression, and kink loads are applied to the iliac vein stents in vivo. For designing, developing, and pre-clinical testing of stents intended for use in the iliac vein, the above mechanical load environments induced by the anatomical features should be considered.

Outcome of Stent Graft Implantation for Treatment of Access Site Bleeding After Transfemoral Transcatheter Aortic Valve Replacement

Vascular complications are common after transcatheter aortic valve replacement (TAVR) and are associated with increased morbidity and mortality. Stent graft implantation enables percutaneous treatment of access site bleeding; however, the efficacy and durability and of this approach are unknown. We studied the immediate outcome of stent graft implantation for control of access site bleeding and the need for repeat vascular interventions after stenting, in a cohort of consecutive patients with severe symptomatic aortic stenosis who underwent transfemoral TAVR. Predictors of access site complications requiring percutaneous or surgical vascular repair were identified. Transfemoral TAVR was performed in 194 patients. Access site complications requiring urgent vascular repair occurred in 34 patients (18%). Stent graft implantation was performed in 31 patients and vascular surgery in 3 patients. When patients who required surgical or percutaneous vascular repair were compared with those who did not, increased body mass index (30 ± 6 vs 28 ± 5, p = 0.035) and reduced activated clotting time (233 ± 47 vs 252 ± 47, p = 0.030) were the only predictors of need for vascular repair. Stenting achieved adequate hemostasis in all patients with a single minor vascular complication. During median follow-up of 797 days (interquartile range 585 to 1,173), no clinically significant vascular complications were detected after stenting. In conclusion, control of bleeding was achieved in all patients who underwent stent graft implantation for treatment of access site vascular complications after transfemoral TAVR. None of these patients needed further vascular interventions during follow-up.

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.

A pooled analysis of common femoral and profunda femoris endovascular interventions

Background

Atherosclerotic disease of common femoral and profunda femoris arteries has been historically treated with surgical endarterectomy. Endovascular treatment of common femoral artery and profunda femoris artery disease is increasingly reported in the recent literature. This review summarizes short- and mid-term outcomes of endovascular interventions to the common femoral artery and common femoral artery.

Methods

All published series in the English language were identified through a systematic PubMed search. Standard descriptive statistics, reported as mean ± SD, were applied to perform the pooled analysis and calculate the overall outcome measures. Combined overall effect sizes were calculated using fixed-effect meta-analysis.

Results

The analysis included 20 studies with a total of 836 patients (897 limbs, mean age of 70.5 ± 4.3 years, critical limb ischemia 39.6%). Technical success was 95%. Angioplasty alone was undertaken in 68.8% of cases and stenting in 22.3%. Access complications occurred in 2.4% of cases. Post-operative major adverse limb events occurred in 2% and major adverse cardiovascular events in 1% of cases. Primary patency at 6, 12 and 24 months was 87%, 77% and 73%, respectively. Subgroup analysis revealed a significantly higher mean primary patency at 12 months for routine stenting compared to a selective stenting strategy (91.4% versus 75%; p < 0.05).

Conclusions

Endovascular interventions to the common femoral artery and common femoral artery can be performed safely with high technical success. Endovascular therapy may be a favored approach over endarterectomy for highly selected patients of poor surgical risk, with limited life expectancy and those with wound-healing considerations such as re-operative fields or prone to infection.

Angioplasty of the common femoral artery and its bifurcation

BACKGROUND

To evaluate the efficacy of percutaneous transluminal angioplasty (PTA) of atherosclerotic lesions of the common femoral artery (CFA) and its bifurcation.

METHODS

From 2009 to 2013, 53 patients (43 men, average age, 68 years) were included in a single-center, nonrandomized, prospective study. Indication was disabling intermittent claudication (n = 36) or chronic critical limb ischemia (n = 17). Thirty-four procedures (64%) were isolated CFA PTA, whereas 7 of 53 (13%) involved inflow (including 4 iliac occlusions) and 12 of 53 (23%) involved outflow vessels. Primary stenting was performed in 50 cases (95%). CFA occlusions were recanalized in 4 of 53. Lesions involved the bifurcation in 22 cases (40%). Follow-up consisted of clinical examination and duplex scanning with ankle-brachial index measurement at 1, 6, and 12 months. A biplane X-ray was performed at 1 year. The primary end point was the absence of binary restenosis (>50% reobstruction of the CFA). Secondary end points were freedom from target lesion revascularization (TLR) and stent fracture rate.

RESULTS

Procedural success was achieved in 96% of cases. At a mean follow-up of 24 months (with 1 patient lost of follow-up), the absence of binary restenosis was 92.5%. At the end of follow-up, 82% of patients continued to show clinical improvement. Freedom from TLR was 97%. Stent fracture rate at 1 year was 9%.

CONCLUSIONS

PTA of the CFA and its bifurcation is a reliable technique with good midterm functional results. These results justify performing a randomized study comparing surgery and endovascular treatment.

Stent strut protrusion--an uncommon complication of stent placement in a fistula

Stent strut protrusion through the skin is a rare and a potentially dangerous complication from the cannulation of stents placed within arterio-venous fistulas and grafts. Such cases are usually managed surgically. We present a case wherein strut penetration of an arterio-venous fistula was noted at the distal (uncovered) end of a Fluency Plus(®) tracheo bronchial stent graft. After analyzing the various reasons why this may have happened, a nonsurgical approach was taken to preserve the access and manage strut protrusion.

Assessing the Perioperative Safety of Common Femoral Endarterectomy in the Endovascular Era

Introduction:

Common femoral endarterectomy (CFE) has historically been the preferred treatment for atherosclerotic lesions involving the common femoral artery. The objectives of this study are to delineate the safety of this open procedure in the endovascular era, establish contemporary benchmarks for morbidity and mortality after CFE, and identify the subgroup of patients at increased risk of postoperative adverse events.

Methods:

Patients undergoing elective CFE in the 2007 to 2010 National Surgical Quality Improvement Project database were examined. Univariate analyses were used to identify the factors associated with major morbidity and mortality. Significant variables by univariate analysis were used to create multivariate logistic regression models for morbidity and mortality.

Results:

A total of 1513 patients underwent elective CFE. The 30-day mortality rate was 1.5%. Postoperative morbidities included cardiac (1.0%), pulmonary (1.9%), renal (0.4%), urinary tract infection (1.7%), thromboembolic (0.5%), neurologic (0.4%), sepsis (2.7%), superficial (6.3%), and deep surgical site complications (2.0%). At least 1 complication, including major and minor, was seen in 7.9% of the patients. By multivariate analysis, partial- and total-dependent functional status (odds ratio [OR] 9.0, 95% confidence interval [CI] 2.8-28.4 and OR 21.3, 95% CI 3.3-139.4) and dyspnea at rest (OR 8.2, 95% 1.2-58.8) predicted mortality. Independent predictors of morbidity include steroid use (OR 2.4, 95% 1.4-4.1), diabetes (OR 1.8, 95% CI 1.3-2.4), and obesity (OR 1.6, 95% CI 1.1-2.4).

Discussion:

Overall, CFE is tolerated well by the majority of patients with peripheral arterial disease. These results affirm the safety of CFE and can still be used as standard first-line therapy in most patients. Long-term results for endovascular interventions need to be studied to see whether high-risk patients that we identified for CFE would benefit more from an endovascular approach.

Endovascular Treatment of the Common Femoral Artery for Limb Ischemia

Objective:

To determine the short- and mid-term outcomes of percutaneous endovascular common femoral artery (CFA) revascularization (eCFR) of the CFA.

Methods:

A review of patients who underwent eCFR for limb ischemia between 2006 and 2012 was performed. Limb salvage, patient survival, survival free from reintervention, and survival free from amputation rates were determined. Median (range) follow-up was 28 (1-71) months.

Results:

In all, 115 patients underwent 121 eCFR for CFA occlusion (n = 13) or stenosis (n = 108); 109 (90%) were technically successful and 7 (6%) had significant perioperative complications; access site hematoma (n = 2) and thromboembolism (n = 5). Thirty-day mortality and amputation rates were 2.5% and 0.8%, respectively. The 1- and 3-year limb salvage rates were 97% and 97%, respectively. The 1- and 3-year survival free from reintervention rates were 77% and 57%, respectively. The 1- and 3-year survival free from amputation rates were 84% and 70%, respectively.

Conclusion:

These novel data demonstrate that eCFR is a durable treatment for patients with limb ischemia associated with CFA disease.

External iliac artery stenting: high incidence of concomitant revascularization procedures

OBJECTIVES

To review immediate results, patency rates, hemodynamic success, and incidence of concomitant procedures with external iliac artery stenting (EIAS).

METHODS

Demographic features, category and clinical grade, Trans-Atlantic Inter-Society Consensus II classification lesion type, pre- and postprocedure ankle-brachial indices, and primary patency were compared between group 1 (EIAS without distal revascularization) and group 2 (EIAS with concomitant distal revascularization).

RESULTS

No mortality and a 100% immediate technical success rate was recorded in group 1 (n = 12) and group 2 (n = 24). Eleven patients (30.6%) also had stenting of the adjacent common iliac artery. Two thirds of group 2 patients required concomitant femoral or distal revascularization.

CONCLUSIONS

No difference in stent patency rates was found between patients in group 1 versus group 2. Patients requiring EIAS tend to have more diffuse arterial disease necessitating complicated open reconstruction and/or distal revascularization, as well as more proximal iliac stenting.

Combined common femoral artery endarterectomy with superficial femoral artery stenting plus Shuxuening Injection infusion for chronic lower extremity ischemia: 3-year results

OBJECTIVE

To investigate the efficacy and safety of combined common femoral artery (CFA) endarterectomy with superficial femoral artery (SFA) stenting plus Shuxuening Injection infusion in patients with complex multifocal arterial steno-obstructive lesions of the lower extremities.

METHODS

From March 2006 to March 2011, 104 lower limbs in 96 patients with multilevel peripheral arterial steno-occlusive disease, involving SFA as well as CFA and deep femoral artery (DFA) orifice, were treated by combined surgical with endovascular therapy, such as SFA stenting as an adjunct to CFA endarterectomy and patch angioplasty with the great saphenous vein. Before the end of the operation, 20 mL of Shuxuening Injection was infused through the catheter located in the treated artery. Technical and hemodynamic success, as well as primary and primary-assisted patency, was determined according to the Society for Vascular Surgery Guidelines. During follow-up, clinical status assessment, ankle-brachial index (ABI) test, and duplex Doppler ultrasound were administered every 6 months, and computed tomography angiography or magnetic resonance angiography was performed at 12, 24, and 36 months after discharge.

RESULTS

All patients underwent successful combined CFA endarterectomy with SFA stenting treatment. The average ABI after the combination treatment increased from pretreatment of 0.32±0.21 to 0.82±0.24 (P<0.01). No perioperative death and major limb amputations occurred. The mean duration of follow-up for 104 limbs from 96 patients was 1,180 days (range, 196-2,064 days). During follow-up, 5 patients died due to myocardial infarction, cerebral infarction, or pneumonia, and 5 patients were lost to follow-up. There were 21 cases (21.4%) of restenosis, with 15 that occurred in-stent and 6 near the distal end of the stent. A total of 18 (18.3%) reinterventions were performed, including 6 balloon angioplasty, 8 restenting procedures, 2 bypass surgeries, and 2 major limb amputations. The primary patency rates were 92.2%, 76.8%, and 61.3% at 12, 24, and 36 months, respectively, while the primary-assisted patency rates were 94.4%, 83.2%, and 75.6% at 12, 24, and 36 months, respectively.

CONCLUSION

The combined CFA endarterectomy with SFA stenting plus Shuxuening Injection infusion appears to offer a safe, less invasive, and effective treatment option to patients with chronic lower extremity ischemia due to complex multifocal peripheral artery disease.

Combined Direct Repair and Inline Inflow Stenting in the Management of Aortoiliac Disease Extending Into the Common Femoral Artery

Purpose: Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Methods: Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Results: Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Conclusions: Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Percutaneous balloon fenestration of flow-limiting iatrogenic dissection of the common femoral artery: report of two cases

Acute iatrogenic arterial dissection is a known complication of endovascular techniques and can be treated with prolonged ballooning, stent placement, or balloon fenestration. Treatment of common femoral artery (CFA) dissection needs special attention because of the potential compromise of either the deep or superficial femoral artery origin and the enhanced mechanical stress to arteries in the groin. The authors report two cases with percutaneous balloon fenestration of flow-limiting localized iatrogenic dissection of the CFA with initial technical success in both cases and favorable short- to midterm outcomes.

Atualização sobre endopróteses vasculares (stents): dos estudos experimentais à prática clínica

Atualmente, o tratamento das doenças vasculares periféricas é uma das áreas da medicina de maior expansão. O número de intervenções vasculares aumenta e os resultados das novas técnicas endovasculares estão muito próximos aos das tradicionais cirurgias vasculares. Embora a angioplastia ofereça bons resultados em curto prazo, o implante de stents procura melhorar o sucesso do procedimento e estender o seu uso a um número maior de pacientes com doença vascular periférica. Entretanto, a sua utilização ainda é controversa. O implante de stents no sistema aorto-ilíaco tem bons resultados; porém, a sua indicação para as lesões femoro-poplíteas ainda é discutida. Além disso, o rápido desenvolvimento de stents e sua escolha para uso no sistema vascular periférico têm sido uma difícil tarefa para o cirurgião endovascular. Muitos fatores influenciam a escolha do stent, e um amplo conhecimento desse material é essencial. Tal escolha depende da avaliação pré-operatória, da localização e das características da lesão e também do uso do stent primário ou seletivo. Nesse trabalho, são realizadas revisão do histórico do desenvolvimento dos stents, desde os estudos experimentais até os ensaios clínicos e também discussão sobre a sua aplicação no tratamento das doenças vasculares periféricas.

Common femoral artery occlusive disease: contemporary results following surgical endarterectomy

OBJECTIVE

Proliferation of endovascular techniques with perceived reduction in treatment morbidity repetitively question the precept that surgical endarterectomy is the preferred treatment for occlusive disease of the common femoral artery (CFA). This study details a contemporary experience with common femoral endarterectomy (CFE) with and without concomitantly performed endovascular therapies.

METHODS

Technical, hemodynamic, and clinical success of CFE performed between 2002 and 2005 were determined according to the Society of Vascular Surgery reporting standards. Primary and assisted patencies of the CFA segment, freedom from reintervention in the ipsilateral limb, and survival were assessed using Kaplan-Meier life-table analysis. Multivariate analysis was performed to evaluate factors associated with patency and survival.

RESULTS

CFE was performed on 65 limbs in 58 patients (mean age 71 +/- 10; male 77%; diabetes 28%; creatinine >/= 1.5 mg/dL 19%). Forty-four cases (68%) were performed for claudication, and 21 cases (32%) for critical limb ischemia. Thirty-seven cases (57%) were performed as a hybrid procedure wherein concomitant endovascular interventions were performed. Twenty iliac (TASC II A-30%; B-35%; C-20%; D-15%) and 25 femoropopliteal (TASC II A-24%; B-60%; C-12%; D-4%) lesions were treated. Technical success was achieved in 100% of the cases. Hemodynamic success was achieved in 95% of the cases with mean postoperative increase in ankle-brachial index (ABI) of 0.24 +/- 0.24. All but one patient (98.5%) had improvement in symptoms and/or ABI. Average hospital stay was 3.2 days (range 1-12 days). There were 3 (5%) major complications requiring reintervention (early failure secondary to untreated inflow lesion, hematoma, and wound infection), six (9%) minor complications which were treated conservatively (five wound infections, one lymph leak), and no perioperative mortality. With a mean follow-up period of 27 months (range 1-58 months), 1- and 5-year primary patencies were 93% and 91%, respectively. Assisted patency was 100% at both time points. There was no difference in patencies between CFE performed alone or as a hybrid procedure. Multivariate analysis showed congestive heart failure (CHF) as the only predictor of primary failure (odds ratio [OR] 18.5 [2.6-142.9]; P = .004). Freedom from reintervention in the ipsilateral limb was 82% at 1 year and 78% at 5 years, with CHF again as the only predictor of reintervention (OR 5.3 [1.4-19.6]; P =.012). Survival was 89% at 1 year and 70% at 5 years. There were no amputations.

CONCLUSIONS

These data suggest CFE should remain the standard of care for occlusive disease of the CFA. Its safety and efficacy establish a standard for comparison with emerging endovascular therapies.

Carotid artery dynamics after carotid angioplasty and stenting

Carotid angioplasty and stenting (CAS) has emerged as an alternative treatment for carotid artery occlusive disease. As initial results in patients with an increased surgical risk appeared promising, the popularity of CAS has increased substantially over the last years and CAS has more often been advocated as an alternative to the gold standard, carotid endarterectomy (CEA). Several controlled trials comparing CAS with CEA are currently being conducted. However, long-term results of CAS are still sparse and several issues regarding the inherent differences between treatment modalities have not yet been elucidated. Interestingly, to date, very little attention has been directed towards the mobile features of the carotid artery and the implications of stent placement on carotid artery dynamics.

Placement of Self-expanding Stents with Different Diameters in the Porcine Venous System: An Experimental Study

PURPOSE

To study the vascular histologic response after placement of oversized self-expanding stents in the porcine venous system.

MATERIALS AND METHODS

Twenty-four oversized stents (range of oversizing, 119.5%-216.0%) were deployed in jugular and iliac veins of six miniature pigs divided into two groups with follow-up times of 1 and 3 months. Necropsy with histologic evaluation of each stent was performed, and the areas of neointimal proliferation were calculated with slices obtained during follow-up from each stent at 5 mm from the proximal and distal edges and at the midpoint.

RESULTS

Neointimal proliferation was observed inside the stent lumen. All segments were patent in both groups. However, one jugular stent in the 1-month group and one jugular stent in the 3-month group had migrated at follow-up and were excluded from analysis. There were no significant differences in neointimal growth between the stent edges (proximal and distal) and middle segments of the stents at follow-up in the 1-month group (P = .970) or in the 3-month group (P = .694). Simple linear regression showed strong positive correlation between stent oversizing and neointimal proliferation in the 1-month model (r = 0.791; P < .001) and the 3-month model (r = 0.718; P < .001). There were no significant differences between 1-month and 3-month groups in the degree of neointimal proliferation (P = .072). Also, branched vessels showed no neointimal proliferation at their intersections with the stent-implanted segments.

CONCLUSION

Stent oversizing showed a strong positive correlation with neointimal growth in each follow-up model in this study.

The Arterial Folding Point During Flexion of the Hip Joint

PURPOSE

Endovascular stents placed in periarticular vessels may be at a greater risk of neointimal hyperplasia and eventual occlusion than those placed in non-periarticular vessels. The purpose of this study was to investigate the location of maximal conformational change along the iliac and femoral artery, the folding point, during flexion of the hip joint and its location relative to the hip joint and the inguinal ligament.

METHODS

Seventy patients undergoing femoral artery catheterization were evaluated. The patients were 47 men and 23 women and ranged in age from 26 to 75 years (mean 54 years). The arteries (right:left=34:36) were measured using a marked catheter for sizing vessels. Fluoroscopic images were obtained in anteroposterior and lateral projections in neutral position, and in the lateral projection in flexed position of the hip joint. The folding point was determined by comparing the lateral projection images in the neutral and flexed positions. The distance from the acetabular roof to the folding point and the distance from the inguinal ligament to the folding point was evaluated.

RESULTS

The folding point was located 42.8 +/- 28.6 mm cranial to the acetabular roof and 35.1 +/- 30.1 mm cranial to the inguinal ligament. As the patient's age increased, the folding point was located more cranially (p < 0.001).

CONCLUSIONS

The folding point during flexion of the hip joint was located 42.8 +/- 28.6 mm cranial to the acetabular roof and 35.1 +/- 30.1 mm cranial to the inguinal ligament. As the patient's age increased, the folding point was located more cranially. When a stent is inserted over this region, more attention may be needed during follow-up to monitor possible occlusion and stent failure.

Impact of head movements on morphology and flow in the internal carotid artery after carotid angioplasty and stenting versus endarterectomy

OBJECTIVE

Because stents can cause vessel angulation during movement, we hypothesized that internal carotid artery (ICA) stents might lead to alterations of cerebropetal blood flow. This study assessed three-dimensional anatomy and volumetric flow rate (VFR) in the ICA in various head positions by comparing patients treated with carotid angioplasty and stenting (CAS) with patients treated with carotid endarterectomy (CEA).

METHODS

Three-dimensional time-of-flight magnetic resonance angiography and magnetic resonance flow quantification were performed on six subjects after CAS (median age, 70 years) and on six subjects after CEA (median age, 67 years). All investigations were performed in five head positions: neutral, bent forward, bent backward, and turned to the treated, ipsilateral side and to the contralateral side. Maximum-intensity projection reconstructions were obtained to measure maximal angulation of the ICA in the forward, backward, ipsilateral, and contralateral positions compared with neutral. Subsequently, the plane perpendicular to the ICA, 1 cm distal to the stent or 4 cm distal to the carotid bifurcation (CEA patients), was established. The VFR through this plane was measured for each position, and the forward, backward, ipsilateral, and contralateral positions were compared with neutral.

RESULTS

In CAS patients, there was a median change in ICA angulation of +10.2 degrees (interquartile range, +7.3 degrees to +17.9 degrees ) in the forward position, compared with +0.2 degrees (-1.0 degrees to +2.4 degrees ) in CEA patients ( P = .016). In all other head positions, there was no statistically significant difference in angulation change. There was no statistically significant difference in VFR change between groups in any of the head positions tested.

CONCLUSIONS

There was a significant increase in ICA angulation in CAS patients if the head was bent forward; this was not observed in CEA patients. This angulation change did not lead to significant acute changes in cerebropetal blood flow, but it might have chronic effects not yet tested.

Early results of external iliac artery stenting combined with common femoral artery endarterectomy

PURPOSE

The endovascular approach to external iliac artery (EIA) disease extending into the common femoral artery (CFA) has been avoided because of problems with stent placement across the inguinal ligament. Surgical treatment for this disease distribution includes extensive endarterectomy or bypass procedures or both. We report our initial experience with a combined open and endovascular approach to these patients.

METHODS

We performed a retrospective analysis of all patients who underwent intraoperative EIA stenting after CFA endarterectomy/patch angioplasty between 1997 and 2000. Stents were positioned to end at the proximal endarterectomy endpoint, without crossing the inguinal ligament. Technical success, hemodynamic success, and clinical success were determined according to Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria. Life-table analysis was performed for patency.

RESULTS

Thirty-four patients (mean age, 68 years; 23 male, 11 female) had combined endovascular and open treatment of iliofemoral occlusive disease. Indications were claudication in 41% and critical limb ischemia in 59%. Femoral reconstruction included endarterectomy with patch angioplasty in all patients. EIA stent deployment incorporated the stenotic iliac segment and the proximal endpoint of the endarterectomy in all patients. Four patients (12%) also needed common iliac angioplasty at the same time for proximal iliac disease, and 14 patients (41%) also needed distal revascularization for associated femoropopliteal or tibial disease. Technical success and hemodynamic success were achieved in 100% of patients. Clinical success was achieved in 97% of patients. The mean postoperative increase in ankle-brachial index in patients with inflow procedures only was 0.36 (range, 0.1 to 0.85). The overall complication rate was 15%. With a mean follow-up period of 13 months (range, 0.5 to 28 months), 1-year primary patency and primary-assisted patency rates were 84% and 97%, respectively. No perioperative mortality was seen.

CONCLUSION

EIA stenting as an adjunct to CFA endarterectomy/patch angioplasty allows for more localized surgery than conventional bypass. This approach also allows a better interface between the stent and endarterectomy than staged preoperative stenting. Technical success and early patency rates are excellent.

Endovascular management of iliac vein compression (May-Thurner) syndrome

PURPOSE

To evaluate the feasibility of endovascular techniques in treating venous outflow obstruction resulting from compression of the iliac vein by the iliac artery of the left lower extremity (May-Thurner syndrome).

MATERIALS AND METHODS

A retrospective analysis of 39 patients (29 women, 10 men; median age, 46 years) with iliac vein compression syndrome (IVCS) was performed. Nineteen patients presented with acute deep vein thrombosis (DVT) and 20 patients presented with chronic symptoms. All patients presented with leg edema or pain. In the acute group, patients were treated with catheter-directed thrombolysis (120,000-180,000 IU urokinase/h) and angioplasty followed by stent placement. In the chronic group, patients were treated with use of angioplasty and stent placement alone (n = 8), or in combination with thrombolysis (n = 12). Patients were then followed-up with duplex ultrasound and a quality-of-life assessment.

RESULTS

Initial technical success was achieved in 34 of 39 patients (87%). The overall patency rate at 1 year was 79%. Symptomatically, 85% of patients were completely or partially improved compared with findings before treatment. Thirty-five of 39 patients received stents. The 1-year patency rate for patients with acute symptoms who received stents was 91.6%; for patients with chronic symptoms who received stents, the 1-year patency rate was 93.9%. Five technical failures occurred. Major complications included acute iliac vein rethrombosis (< 24 hours) requiring reintervention (n = 2). Minor complications included perisheath hematomas (n = 4) and minor bleeding (n = 1). There were no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications.

CONCLUSION

Endovascular reconstruction of occluded iliac veins secondary to IVCS (May-Thurner) appears to be safe and effective.