Results of endovascular superficial femoral endarterectomy

An Update on Endovascular Therapy of the Lower Extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Remote Superficial Femoral Artery A Endarterectomy: Early Results for TASC D Lesions in Patients With Severe Ischemia

Endovascular treatment for Transatlantic Inter-Society Consensus (TASC) D lesions of the superficial femoral artery has been disappointing. This has been attributed to a bulking atheromatous plaque. Debulking the superficial femoral artery allows for a larger lumen, whereas covering the lumen with an endograft provides in-line flow. We evaluated the intermediate results of remote superficial femoral artery endarterectomy with covered endograft placement in 18 patients. Patient demographic, vascular laboratory, and preoperative data were gathered retrospectively. The procedure was technically successful in all the patients. The mean age was 62.2 ± 9.9 years. Ankle brachial index improved from 0.35 ± 0.1 to 0.86 ± 0.1. The cumulative 12-month primary patency was 42.2%, whereas assisted primary or secondary patency was 70.8%. Five endografts occluded within the 12 months. Two of those patients underwent subsequent femoral-to-below-knee bypass, whereas 2 had major amputations. Remote superficial femoral artery endarterectomy can be reasonably offered if an autogenous conduit is not available for revascularization of the superficial femoral artery.

Current state of endovascular treatment of femoro-popliteal artery disease

Considerable advances have been made over the last decade in percutaneous technology for the treatment of atherosclerotic diseases in the femoro-popliteal arteries. While treatment strategies are well defined in the iliac segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoro-popliteal lesions continues. Whereas balloon angioplasty (PTA) is the accepted therapy for short lesions, long diffuse lesions are still recommended for surgical treatment. However, attractive new technologies ranging from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and placement of drug-eluting stents to simple angioplasty with drug-coated balloons may have the potential to replace femoro-popliteal bypass surgery as a treatment of choice for complex lesions. This article reviews the status of percutaneous endovascular techniques for the treatment of femoro-popliteal artery occlusive disease.

Randomized controlled trial of remote endarterectomy versus endovascular intervention for TransAtlantic Inter-Society Consensus II D femoropopliteal lesions

OBJECTIVE

This study evaluated outcomes of remote endarterectomy (RE) vs endovascular (ENDO) interventions on TransAtlantic Inter-Societal Consensus (TASC)-II D femoropopliteal lesions and identified factors predictive of restenosis.

METHODS

From October 2004 to December 2008, 95 patients with TASC-II D lesions were randomized 1:1 to receive RE of the superficial femoral artery (SFA) with end point stenting (51 patients) or ENDO, consisting of subintimal angioplasty with stenting (44 patients). The groups were balanced for age, sex, atherosclerotic risk factors, and comorbidities. Categoric data were analyzed with χ2 tests, and time to event provided two-sided P values with a level of significance at .05 and 95% confidence intervals (CIs). Survival curves for primary patency were plotted using the Kaplan-Meier method. Univariate analysis for diabetes, hypertension, dyslipidemia, smoking, and critical ischemia was performed according to the Cox proportional hazards model.

RESULTS

The mean follow-up was 52.5 months (range, 35-75 months). Five RE patients and four ENDO patients were lost to follow-up (censored). Primary patency was 76.5% (39 of 51) in RE and 56.8% (25 of 44) in ENDO (hazard ratio [HR], 2.6; 95% CI, 0.99-4.2; P=.05) at 24 months and was 62.7% (32 of 46) in RE and 47.7% (21 of 40) in ENDO (HR, 1.89; 95% CI, 0.94-3.78; P=.07) at 36 months. Assisted primary patency was 70.6% (36 of 51) in RE and 52.3% (23 of 44) in ENDO (HR, 2.45; 95% CI, 1.20-5.02; P=.01). Secondary patency overlapped the primary comparison data at 12 and 24 months; at 36 months, there was a slight but significative advantage for RE (HR, 2.26; 95% CI, 1.05-4.86; P=.03). Univariate analysis demonstrated that hypercholesterolemia and critical limb ischemia (CLI) were significantly related to patency failure, whereas diabetes was significant only in ENDO. These factors (hypercholesterolemia and CLI) were independent predictors of patency on Cox multivariate analysis.

CONCLUSIONS

RE is a safe, effective, and durable procedure for TASC-II D lesions. Our data demonstrate a significantly higher primary, assisted primary, and secondary patency of RE vs ENDO procedures. Furthermore, overall secondary patency rates remain within the standard limits, although preoperative CLI and dyslipidemia continue to be associated with worse outcomes. Taken together, these data suggest that RE should be considered better than an endovascular procedure in SFA long-segment occlusion treatment.

Current approach to the diagnosis and treatment of femoral-popliteal arterial disease. A systematic review

Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis affecting 5 million adults in the United States, with an age-adjusted prevalence of 4% to 15% and increasing up to 30% with age and the presence of cardiovascular risk factors. In this article we focus on lower extremity PAD and specifically on the superficial femoral and proximal popliteal artery (SFPA), which are the most common anatomic locations of lower extremity atherosclerosis. We summarize current evidence and perform a systematic review on the diagnostic evaluation as well as the medical, endovascular and surgical management of SFPA 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.

Remote endarterectomy for long segment superficial femoral artery occlusive disease. A systematic review

BACKGROUND

Remote endarterectomy is a minimally invasive procedure which combines open and endovascular surgery for the treatment of long segment superficial femoral artery (SFA) occlusive disease. We conducted a systematic review of the medical literature to analyze the indications, technical limitations and the outcome of remote SFA endarterectomy (RSFAE).

METHODS

The English literature was searched using the MEDLINE electronic database up to February 2008. We considered studies comprising at least 10 patients treated with RSFAE and reporting on the primary and/or secondary patency rates. Average primary and secondary patency rates were obtained by weighting the data of each study by the number of limbs treated.

RESULTS

Our search identified 19 retrospective or prospective case series; no randomized controlled trials comparing RSFAE with another treatment modality were identified. The average technical success rate was 94% and the procedure-related complication rate was 14.7%. The weighted mean cumulative primary patency rates were 60%, 57% and 35% at 1, 2 and 5 years, respectively. The weighted mean assisted primary patency rates were 75%, 77% and 50% at 1, 2 and 5 years, respectively. The weighted mean secondary patency rates were 88% and 62% at 1 and 2 years, respectively.

CONCLUSIONS

RSFAE has acceptable short-, medium- and long-term results but patients should undergo intensive surveillance postoperatively. Randomized controlled trials are needed to assess the durability of this procedure as compared to conventional open bypass surgery.

Endovascular treatment of long lesions of the superficial femoral artery: results from a multicenter registry of a spiral, covered polytetrafluoroethylene stent

OBJECTIVE

Information on outcome of patients with long superficial femoral artery (SFA) obstruction undergoing endovascular treatment is scarce. The present study reports results from a prospective multicenter registry designed to evaluate the safety, effectiveness, and patency of the aSpire self-expanding polytetrafluoroethylene covered stent (Vascular Architects Inc, San Jose, Calif) in patients with femoropopliteal occlusive disease.

METHOD

The aSpire Registry included 150 patients (166 limbs) enrolled in 16 centers during a 28-month period (2003 to 2005) for medium/long (>3 cm) occlusion (n = 115) or stenosis (n = 51) of the SFA (n = 51) or of the proximal popliteal (n = 115) arteries. Procedures were performed for intermittent claudication in 92, for rest pain in 33, and for limb savage in 41. The mean length of arterial segment covered was 107.35 +/- 73.7 mm. Indications for treatment included 44 type B1, 57 type B2, 47 type C1, and 18 type D lesions according to TransAtlantic Inter-Society Consensus classification. Clinical and ultrasound evaluation was performed at discharge and at 1, 6, 12 months, and yearly thereafter. Mean follow-up was 13 months (range, 1 to 36). Primary end points were immediate technical success (vessel recanalization with residual stenosis < or =30%) and stent patency.

RESULTS

Initial technical success was obtained in 162 (97.6%) of 166 procedures. More than one stent was applied in 48 procedures, for a total of 214 stents. No periprocedural deaths occurred. Procedure-related complications occurred in 22 of 166 procedures, including 6 peripheral embolizations, 7 thromboses, 2 hemorrhages requiring revision, 1 vessel rupture, and 6 vessel dissections. Life-table estimates of primary patency at 12, 24, and 36 months were 64%, 59%, and 59%, respectively. Thirty-two reinterventions were performed during follow-up, resulting in secondary patency rates at 12, 24, and 36 months of 74.2%, 67%, and 67%, respectively. Amputation was required in six of 41 patients treated for limb salvage. At multivariate analysis, critical limb ischemia was the only significant predictor of late failure.

CONCLUSION

Endovascular treatment of SFA occlusive lesions provides interesting results. Length of lesion and clinical symptoms influence negatively the patency. The aSpire covered stent showed good mid-term results, but a number of reinterventions were necessary to obtain an optimal secondary patency. Risk of patency failure was related to critical limb ischemia as an indication for the procedure. Technologic and pharmacologic improvement and longer follow-up are needed to define the indications for the aSpire stent.

Remote endarterectomy for occlusive iliac and superficial femoral artery disease

Today's patients increasingly desire a low-risk procedure with rapid return to functional status following surgery. Many patients actively seek a minimally invasive option. During the last decade, minimally invasive surgical and radiological procedures emerged from their infancy to become an integral part of the treatment strategy in both peripheral arterial occlusive disease and aneurysmal arterial disease. The trend towards restoration of luminal patency, using the vessel itself as a conduit, can also be termed restorative intervention. As radiological percutaneous transluminal angioplasty has thus far proven unsuccessful in the long term for iliac and femoropopliteal occlusive lesions exceeding 10 cm, a new endovascular surgical procedure has been developed. A modification to the original ringstripper, used in semiclosed endarterectomy, was made to enable the technique of remote endarterectomy.

Biological coating for arterial stents: the next evolutionary change in stents

PURPOSE

To describe the in vivo results of a promising new stent-graft lined with peritoneum.

METHODS

Eighteen dogs underwent balloon angioplasty injury to the bilateral iliac arteries followed by placement of either an 8-mm x 5-cm glutaraldehyde-fixed bovine peritoneum- lined balloon-expandable stent (PLS) or a similarly sized, commercially prepared, polyester-lined self-expanding stent (DLS) as a control. Animals were sacrificed at 1 and 6 months. Biplanar arteriography and intravascular ultrasound were done at the time of sacrifice, and the vessels were harvested after perfusion fixation for histology/morphometry. Immunofluorescence with CD34 and factor VIII staining was used to evaluate endothelialization, while alpha-actin was used to quantify smooth muscle cell (SMC) deposition.

RESULTS

At 1 month, all vessels were patent in both groups. At 6 months, 8 of 9 vessels were open in the PLS group versus 6 of 9 in the control DLS group. Vessel lumen diameter at 1 month was significantly greater in the PLS vessels compared to the DLS group at 1 cm above the stent (35.9 +/- 4.4 versus 29.4 +/- 4.7 mm2; p = 0.02) and 1 cm below the stent (37.2 +/- 7.1 versus 25.2 +/- 3.2 mm2; p = 0.005); these results persisted to 6 months. Histological morphometry demonstrated progression of neointimal hyperplasia in the DLS stent between 30 and 180 days (8.3 +/- 1.79 versus 14.9 +/- 6.6 mm2; p = 0.03), whereas the peritoneum-lined stent had no change during the same time period (4.62 +/- 0.98 versus 4.72 +/- 0.97 mm2; p = 0.85). The same patterns were true for the intima:media ratio. Immunohistochemistry demonstrated complete endothelialization at 6 months in both DLS and PLS. However, SMC staining with alpha-actin demonstrated more smooth muscle actin-positive cells in the DLS compared to the PLS (327 +/- 87 versus 262 +/- 73 counts/5 high-powered fields; p = 0.04).

CONCLUSION

Peritoneum-lined stents offer a novel method to improve patency of lower extremity arterial stents.

Ultrasonic endarterectomy for long superficial femoral artery atherosclerotic occlusive disease

OBJECTIVE

To report the long term results of ultrasonic superficial femoral artery endarterectomy (USFAE).

DESIGN

Retrospective study.

PATIENTS AND METHODS

From January 1998 to June 2004 218 USFAE were performed in 202 selected patients (178 males, 192 procedures) with a median age of 65 years (46-87 years). Indications for operation were disabling intermittent claudication in 137 procedures (68%), rest pain in 24 procedures (12%), and limb salvage in 41 procedures (20%). The new medical technology of ultrasonic endarterectomy is based on the application of the mechanical vibrations in the range of low frequency ultrasound. The ultrasonic device consists of the ultrasonic generator, acoustic unit and the flexible wave concentrators with special working tips in the shape of a ring. Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning.

RESULTS

The mean follow-up time was 30.1 months. The mean length of the endarterectomised SFAs was 29 cm (range, 15-43 cm). The five year cumulative primary patency rate by means of life table analysis was 45.8 +/- 4.4% (SE). Percutaneous transluminal balloon angioplasty and surgical re-interventions were performed in thirty three and five patients respectively resulting in a primary assisted patency rate of 57.5 +/- 4.1%. The five year secondary patency rate was 65.6 +/- 3.8%. Limb salvage was achieved in 35 of the 41 patients with gangrene.

CONCLUSIONS

The long term results of ultrasonic SFA endarterectomy suggest this is an effective technique.

An update on endovascular therapy of the lower extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Open surgical repair versus endovascular therapy for chronic lower-extremity occlusive disease

Chronic lower-extremity occlusive disease is most often manifested by mild symptoms of claudication that can be managed conservatively. When conservative therapy fails, endovascular procedures may be effective, particularly if the disease extent is minimal. Surgery may be considered for selected patients with claudication who fail endovascular therapy or are not candidates for it. Patients with more severe symptoms of lower-extremity occlusive disease typically have more extensive disease that is treated best with surgery or with a combination of surgery and endovascular therapy. Occasionally, endovascular procedures are performed on patients with more extensive disease who are poor candidates for traditional open surgery because of severe comorbidity. Further advances in endovascular technology may improve patency after endovascular procedures in these patients.

Consultations on Patients with Venous or Arterial Diseases

Advances in vascular biology and drug development, as well as improved interventional techniques, are yielding multiple new treatments for patients with venous and/or arterial thrombosis. Hematologists who are providing consultations for these patients often participate in a multidisciplinary approach to provide optimal care. New anticoagulants, simplified and validated tests for detecting vascular disease, and improved interventional procedures can all reduce the morbidity and mortality that result from venous and arterial thrombosis. In this chapter, different aspects of the diagnosis and treatment of these disorders are addressed by a hematologist, an expert in vascular medicine, and a vascular surgeon.

The key to the prevention and treatment of venous and arterial thrombosis is anticoagulant and antiplatelet therapy. In Section I, Dr. Charles Francis, a hematologist with expertise in thrombosis and hemostasis, describes the clinical trials that have resulted in the approval of newer anticoagulants such as fondaparinux and the thrombin- specific inhibitors. He also reviews the clinical trials that have shown the efficacy of the new oral anticoagulant ximelagatran. Although currently under study primarily for the prevention and treatment of venous thrombosis, these anticoagulants are likely to undergo evaluation for use in arterial thrombosis.

Peripheral arterial disease (PAD), which affects as many as 12% of individuals over the age of 65 years, provides a diagnostic and therapeutic challenge to physicians across multiple subspecialties. Dr. William Hiatt, a specialist in vascular medicine, discusses in Section II the epidemiology and manifestations of PAD, the best ways in which to diagnose this disorder and determine its severity, and the most appropriate pharmacologic treatment.

In Section III, Dr. Mark Jackson, a vascular surgeon, describes interventional procedures that have been developed or are under development to treat arterial thrombosis. He also reviews the status of inferior vena caval filters that are retrievable.