Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up

Efficacy of retrograde revascularization in diabetic patients with chronic limb-threatening ischemia after a failed antegrade approach

BACKGROUND

Chronic limb-threatening ischemia is the end stage of peripheral arterial disease. The revascularization of patients suffering from diabetes mellitus who present chronic total occlusions of below-the-knee vessels can be technically very difficult and sometimes impossible to achieve by performing only an antegrade approach. As regards retrograde recanalization, several studies have investigated the efficacy and safety of this technique in the femoropopliteal axis or in the infrageniculate arterial vessels in patients with advanced atherosclerotic disease. Currently in the literature there are still few studies analyzing the effectiveness of the retrograde approach in the treatment of occlusions of below-the-knee vessels in patients suffering from diabetes mellitus.

OBJECTIVES

The purpose of the study was to retrospectively evaluate safety, technical success, and clinical outcome of retrograde transpedal/transtibial recanalization in patients suffering from diabetes mellitus.

RESEARCH DESIGN

This is a retrospective observational monocentric study.

SUBJECTS

We retrospectively analyzed data over a three-year period (August 2019-September 2022) of patients that underwent revascularization of one or more below-the-knee vessels for chronic limb-threatening ischemia and had a retrograde transpedal/transtibial approach after a failed antegrade transfemoral revascularization. We identified and included in the study 28 out of 352 patients.

MEASURES

We evaluated clinical comorbidities, Rutherford-Becker classification, Texas classification, and the occluded vessels (only below-the-knee or multi-level occlusions); we then analyzed technical, procedural and clinical success, survival rate, and procedural complications. All patients included in the study underwent a 6 months follow-up.

RESULTS

Patients belonged to Rutherford-Becker stage V (18) or VI (10), Texas wound classification IIC: 7 IID: 8 IIIC: 4 IIID: 9, all suffering from diabetes, and five were on dialysis. Treatment of a femoropopliteal lesion was performed during the same procedure in 6 of 28 patients (28.6%). Technical success was obtained in 25 out of 28 patients (89.3%), and procedural success was achieved in 23 of 28 patients (82.1%). No complications occurred at the pedal/tibial access. One minor complication at the femoral access was observed. The cure rate 6 months after the procedure was 57.1% (16/28 patients), and the 6-month survival rate was 96.4%. Three major amputations (10.7%) and four minor amputations (14.2%) were performed after revascularization procedures. Two patients were readmitted for vascular causes (7.1%).

CONCLUSIONS

Retrograde approach for revascularization of below-the-knee vessels in diabetic patients is safe and effective with high procedural and clinical success rates in the absence of significant complications. It should be considered when revascularization cannot be achieved with an antegrade transfemoral approach.

The Dutch chronic lower limb-threatening ischemia registry (THRILLER): A study protocol for popliteal and infrapopliteal endovascular interventions

INTRODUCTION

Chronic limb-threatening ischemia (CLTI) is the end stage of peripheral arterial disease (PAD) and is associated with high amputation rates, mortality and disease-related health care costs. In infrapopliteal arterial disease (IPAD), endovascular revascularization should be considered for the majority of anatomical and clinical subgroups of CLTI. However, a gap of high-quality evidence exists in this field. The aim of the Dutch Chronic Lower Limb-Threatening Ischemia Registry (THRILLER) is to collect real world data on popliteal and infrapopliteal endovascular interventions.

METHODS

THRILLER is a clinician-driven, prospective, multicenter, observational registry including all consecutive patients that undergo a popliteal or infrapopliteal endovascular intervention in seven Dutch hospitals. We estimate that THRILLER will include 400-500 interventions annually. Standardized follow-up visits with wound monitoring, toe pressure measurement and duplex ultrasonography will be scheduled at 6-8 weeks and 12 months after the intervention. The independent primary endpoints are primary patency, limb salvage and amputation free survival. Patients must give informed consent before participation and will be included according to predefined reporting standards. A data log of patients who meet the inclusion criteria but are not included in the registry will be maintained. We intend to conduct the first interim analysis two years after the start of inclusion. The results will be published in a scientific journal.

DISCUSSION

Despite innovations in medical therapy and revascularization techniques, patients with CLTI undergoing endovascular revascularization still have a moderate prognosis. Previous prospective cohort studies were hampered by small sample sizes or heterogeneous reporting. Randomized controlled trials (RCTs) have high costs, potential conflicts of interest and give a limited reflection of daily practice. THRILLER aims to provide the largest prospective well phenotyped up-to-date dataset on treatment outcomes in CLTI patients to answer multiple underexplored research questions regarding diagnostics, medication, patient selection, treatment strategies and post intervention follow-up.

Safety and Efficacy of Drug-Coated Balloon in the Treatment of Below-The-Knee Artery: A Meta-analysis

INTRODUCTION

Chronic limb threat ischemia is associated with cardiovascular events, resulting in high amputation, morbidity and mortality rates. This study aims to accomplish a comprehensive summary of randomized controlled trials and single-center trials related to drug-coated balloons (DCBs) in the treatment of below-the-knee (BTK) artery disease, and to provide a recommendation for the application of DCBs in BTK artery disease.

METHODS

Five electronic databases were used to retrieve relevant articles on the safety and effectiveness of DCBs in the treatment of BTK artery disease. A random-effects model was applied to calculate the standard mean deviation, odds ratio (OR) and their 95% of confidence interval (CI).

RESULTS

As of April 8, 2021, a total of 241 articles were retrieved, but only 13 articles were finally included for meta-analysis. The 12 mo follow-up study found that major adverse events , all-cause mortality, major amputation ,and target lesion revascularization had no statistically significant difference between the DCBs group and the control group (target lesion revascularization: OR = 0.68, 95% CI: 0.36, 1.31; all-cause mortality: OR = 1.30, 95% CI: 0.69, 2.46; major amputation: OR = 1.34, 95% CI: 0.64, 2.79; target lesion revascularization: OR = 0.72, 95% CI: 0.35, 1.45).

CONCLUSIONS

The meta-analysis results of randomized controlled trials focusing on comparing DCBs and other treatments suggest that DCBs do not have significant advantages in the treatment of BTK artery disease when compare with percutaneous transluminal angioplasty (PTA), but better than control intervention except PTA in both safety and efficacy end points. However, the results of meta-analysis of single-arm trial reported DCBs in treating BTK artery lesions are significantly improved compared with the meta-analysis concentrating on PTA.

"Ranger BTK" a Prospective Single-Centre Cohort Study on a New Drug-Coated Balloon for Below the Knee Lesions in Patients with Critical Limb Ischemia

PURPOSE

Restenosis remains a limitation of endovascular angioplasty with a patency of 30% in BTK at 12 months. Several studies on drug-coated balloons have not demonstrated any improvements in terms of patency and target lesions revascularization in BTK lesions. This prospective single-centre cohort study evaluates the safety and efficacy of a new generation low-dose drug-coated balloon (DCB) with a reduced crystalline structure to treat below the knee (BTK) lesions in patients with critical limb ischemia (CLI).

MATERIALS AND METHODS

Between November 2016 and November 2017, 30 consecutive patients (mean 68.8 ± 12.7 years, 6 female) with BTK lesions and CLI were included in this single-centre, prospective non-randomized cohort study. All patients with rest pain and/or ischemic wound associated with BTK lesions were included in the study. Mean lesion length was 133.6 ± 94.5 mm and 18(60%) were chronic total occlusions. The primary safety outcome parameter was a composite of all-cause mortality and major amputation at 6 months. The primary efficacy outcome parameter was the primary angiographic patency at 6 months (defined as freedom from clinically driven target lesion revascularization and the absence of significant restenosis (> 50%) as determined by core laboratory angiography assessment. Immediate technical success, late lumen loss (LLL), clinical target lesion revascularization (TLR) and ulcer healing rates at 12 months were also evaluated.

RESULTS

Immediate technical success was 97%(29/30): one patient had an acute thrombosis at the completion of index procedure. Primary safety outcome parameter was 94%(28/30): one patient underwent major amputation and one patient died of other comorbidities at 2 months. Another patient had a major amputation at 7.5 months. Angiographic follow-up was available in 20 patients. Primary angiographic patency was 57%(12/21 lesions), and LLL was 0.99 ± 0.68 mm at 6 months. Freedom from TLR was 89% at 12 months. The rate of ulcer healing was 76% at 12 months.

CONCLUSION

Ranger DCB balloons to treat CLI patients demonstrated a positive trend with good safety outcomes parameters. Further randomized studies are needed to understand the usefulness compared to POBA.

[Current Strategy in Endovascular Management for Below-the-Knee Arterial Lesions]

The below-the-knee arterial tree is the thinnest of all the leg vessels and is an important path for blood flow to the foot. Hence, lesions including stenosis, especially obstruction, may lead to critical limb ischemia which represents the most severe clinical manifestation of peripheral arterial disease. It is characterized by the presence of ischemic rest pain, ischemic lesions, or gangrene attributable to the objectively proven arterial occlusive disease. Typically, the atherosclerotic disease process involving the below-the-knee arterial tree is diffuse in the majority of patients. The cornerstone of therapy is vascular reconstruction and limb salvage. Revascularization should be attempted whenever technically possible, without delay, in patients presenting critical limb ischemia and when the clinical status is not hopelessly non-ambulatory. Therefore, endovascular treatment can become the gold standard for the full range of patients including below-the-knee, limiting the clinical role of the classically trained surgeons.

[Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]

Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee

BACKGROUND

Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.

OBJECTIVES

The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.

METHODOLOGY

A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.

RESULTS

A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

A model for predicting the time of early symptomatic restenosis after infrapopliteal angioplasty in patients with critical limb ischemia

The objective of this study is to develop a model for predicting the time of early symptomatic (delayed or nonhealing wound) restenosis after infrapopliteal angioplasty in patients with critical limb ischemia (CLI). This is a single-center retrospective cohort study evaluating 60 de novo infrapopliteal lesions of 38 limbs in 35 patients with CLI, who underwent successful endovascular treatment (EVT) from October 2016 to December 2018 and follow-up angiography within 3 months from the procedure. Outcome measures were binary restenosis at follow-up angiography and clinical outcome at 3 months. Patient/limb/lesion characteristics were compared between the restenosis and non-restenosis groups. Angiographic restenosis predictors were assessed to develop a model for predicting the time of restenosis using multinomial logistic regression. The restenosis rate at follow-up angiography (median time, 41 days [IQR 27-58 days]) was 38% (23/60). After adjustment for covariables, longer period between EVT and follow-up angiography and lower C-reactive protein (CRP) were the predictors of angiographic restenosis. We developed a model for predicting the time of early symptomatic restenosis with a probability of 70%: "Days = 200 - 2.1 age - 13 CTO + 3.3 CRP" (R² = 0.81, RMSE = 0.27), e.g., 80 years old, CTO (+), CRP 4.4 mg/dl: 32.2 days. The predictive model including age, CTO, and CRP might allow estimation of the period for the angiographic restenosis development.

Lower extremity revascularization via endovascular and surgical approaches: A systematic review with emphasis on combined inflow and outflow revascularization

This review is intended to help clinicians and patients understand the present state of peripheral artery disease, appreciate the progression and presentation of critical limb ischemia/chronic limb-threatening ischemia, and make informed decisions regarding inflow and outflow endovascular revascularization and surgical treatment options within the context of current debates in the medical community. A controlled literature search was performed to obtain research on outcomes of critical limb ischemia patients undergoing complete leg revascularization for peripheral artery disease inflow and outflow disease. Data for this review were identified by queries of medical and life science databases, expert referral, and references from relevant papers published between 1997 and 2019, resulting in 48 articles. The literature review herein indicates that endovascular revascularization-including ballooning, stenting, and atherectomy-is an effective peripheral artery disease therapy for both above the knee and below the knee disease, and can safely and effectively treat both inflow and outflow disease. As such, it plays a leading role in the therapy of lower extremity artery disease.

Current review with evolving management strategies in critical limb ischemia

Critical limb ischemia represents the end stage of peripheral artery disease, which is associated with impaired quality of life and considerable morbidity and mortality. Economical impact of the disease is huge with a substantial burden on patients, healthcare providers, and resources. Varied therapeutic strategies have been employed in the management of these patients. These patients usually have complex multilevel occlusive arteriopathy with significant comorbidities, rendering surgical interventions undesirable in many cases. Recent therapeutic advances with evolving endovascular techniques and gene or cell-based therapies have the potential to dramatically change the therapeutic outlook in these patients.

Inflammatory Cytokines Associated With Failure of Lower-Extremity Endovascular Revascularization (LER): A Prospective Study of a Population With Diabetes

OBJECTIVE

Peripheral artery disease (PAD) is one of the most relevant complications of diabetes. Although several pharmacological and revascularization approaches are available for treating patients with diabetes and PAD, an endovascular approach is often associated with postprocedural complications that can increase the risk for acute limb ischemia or amputation. However, no definitive molecular associations have been described that could explain the difference in outcomes after endovascular treatment in patients with diabetes, PAD, and chronic limb-threatening ischemia (CLTI).

RESEARCH DESIGN AND METHODS

We evaluated the relationship between the levels of the main cytokines associated with diabetic atherosclerosis and the outcomes after endovascular procedures in patients with diabetes, PAD, and CLTI.

RESULTS

A total of 299 patients with below-the-knee occlusive disease who were undergoing an angioplasty procedure were enrolled. The levels of key cytokines-osteoprotegerin (OPG), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and C-reactive protein (CRP)-were measured, and major adverse limb events (MALE) and major adverse cardiovascular events (MACE) were assessed 1, 3, 6, and 12 months after the procedure. There was a linear trend from the lowest to the highest quartile for each cytokine at baseline and incident MALE. A linear association was also observed between increasing levels of each cytokine and incident MACE. Receiver operating characteristics models were constructed using clinical and laboratory risk factors, and the inclusion of cytokines significantly improved the prediction of incident events.

CONCLUSIONS

We demonstrated that elevated OPG, TNF-α, IL-6, and CRP levels at baseline correlate with worse vascular outcomes in patients with diabetes, PAD, and CLTI undergoing an endovascular procedure.

Vein Harvest Wound Healing after Bypass Surgery for Critical Limb Ischemia

BACKGROUND

Lower-limb revascularization surgery, especially when performed using the great saphenous vein, predisposes patients to major surgical trauma on initially ischemic tissue. Vein harvest wounds (VHWs) after infrainguinal revascularization heal slowly. This study's aim was to assess the factors associated with VHW healing after infrainquinal bypass surgery for critical limb ischemia (CLI).

METHODS

A retrospective patient record study was conducted. All patients with CLI who underwent infrainguinal bypass surgery with autologous vein graft between January 1, 2015, and December 31, 2017, in the Turku University Hospital, were included. Follow-up data were collected until February 28, 2018. The following data was collected from the patient files; risk factors, ankle-brachial indices (ABIs), systolic toe pressures (STPs), the presence of an ischemic ulcer, VHW dehiscence, and the time when the VHW was completely healed. Procedures with outflow vessels at either popliteal or tibial artery were analyzed separately. Descriptive and univariate statistical analyses were performed.

RESULTS

Altogether, 195 patients were operated on for CLI, of whom 133 (68.2%) patients had ischemic ulcers. The mean follow-up time was 535.0 days (range 3.0-1143.0 days). The mean ABI improvement was 0.49 (P = 0.00), and STP improvement, 39.9 mm Hg (P = 0.00). The median time taken when VHW was healed was 48.0 days (95% confidence interval [CI], 39.4-56.6) in patients without ischemic ulcers and 82.0 days (95% CI, 59.7-104.3) in patients with ischemic ulcers, P = 0.03. VHW in patients who underwent popliteal artery bypass (62 days, 95% CI, 12.9-93.0) healed faster than VHW in those who underwent tibial artery bypass (132 days, 95% CI, 48.0-93.0), P = 0.02. Risk factors and the preoperative or postoperative ABIs or STPs had no effect on VHW healing time.

CONCLUSIONS

VHW healing was remarkably slower after revascularization surgery in patients with an ischemic foot ulcer than in those without ischemic ulcers.

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.

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.

Preferential Use of Infrapopliteal Angioplasty for Critical Limb Ischemia: Vascular Surgeons' Perspective

The purpose of this study was to describe the vascular surgeons' experience with an endovascular-first approach for critical limb ischemia (CLI) due to arteriosclerotic disease involving infrapopliteal vessels. From April 2006 to September 2013, 55 limbs with CLI in 45 consecutive patients who had undergone infrapopliteal percutaneous transluminal angioplasty (PTA) were evaluated. All limbs presented with ulcers or gangrenes (Rutherford 5 or 6), and were treated with infrapopliteal PTA as the initial treatment. Clinical outcomes of major adverse limb event (MALE) + perioperative death (POD), amputation-free survival (AFS), limb salvage, and survival were analyzed with the Kaplan–Meier method. Multivariable perioperative predictors of MALE + POD and AFS were identified using the stepwise Cox proportional hazards regression model. The technical success rate was 95% (52/55). Clinical success was attained in 37 of 55 limbs (67%). Freedom from MALE + POD, AFS, limb salvage, and survival were 89%, 84%, 92%, and 92% at 6 months, respectively, and 82%, 68%, 89%, and 78% at 12 months, respectively. Clinical success (HR, 0.06; 0.01–0.50; P = 0.009) was associated with freedom from MALE + POD. Rutherford 6 (HR, 3.0; 95% CI, 1.1–8.3; P < 0.004) and clinical success (HR, 0.19; 95% CI, 0.07–0.49; P < 0.0007) were associated with AFS. These results suggest that infrapopliteal PTA can be offered as a first therapeutic option for a significant proportion of patients with CLI. Vascular surgeons must embrace and validate endovascular technology if they are to remain competitive in treatment of peripheral artery disease.

The Impact of Decline in Activities of Daily Living (ADL) of Patients With Critical Limb Ischemia (CLI) After Endovascular Treatment

BACKGROUND

Certain patients with critical limb ischemia (CLI) experience significant decline in activities of daily living (ADL) during hospitalization. The prognosis of decline in ADL during hospitalization remains unknown.

METHODS

A retrospective analysis was performed on collected data of patients with CLI treated by endovascular treatment between April 2007 and December 2015. We evaluated CLI in patients ADL at the time of hospitalization and after discharge using the Barthel index. We classified all patients into patients with decline in ADL and stable in ADL and compared clinical outcomes (cumulative incidence of wound healing, amputation-free survival at 1 year) between the 2 groups.

RESULTS

Two hundred and fifty-five consecutive patients with CLI (221 limbs), who underwent successful endovascular intervention, were enrolled in this study. Of all patients, 22 patients were classified into the decline group. The prevalence of wound, Ischemia, foot infection (WIfI) classification high grade was higher in the decline group (30.7% vs 63.6%; P < .01). The wound healing rates were worse in the decline group than in the stable group (40% vs 78% at 1 year; P < .01). The same trends were observed in the amputation-free survival (37% vs 78%; P < .01). After multivariate analysis, decline in ADL was an independent predictor of wound healing and amputation-free survival (odds ratio [OR]: 2.85, 95% confidence interval [CI]: 1.61-3.35, P < .01; OR: 2.46, 95% CI: 1.26-4.53, P = .01).

CONCLUSIONS

Patients with CLI with decline in ADL during hospitalization were found to have a poor prognosis suggesting that a decline in ADL may affect the clinical outcomes.

Endovascular Interventions for Femoropopliteal Peripheral Artery Disease: A Network Meta-Analysis of Current Technologies

PURPOSE

To use network meta-analysis (NMA) to determine the optimal endovascular strategy for management of femoropopliteal peripheral artery disease (PAD) given the lack of multiple prospective randomized trials to guide treatment decisions.

MATERIALS AND METHODS

NMA is a new meta-analytic method that permits comparisons among any 2 therapies by combining results of a collection of clinical trials conducted in the same or similar patient population. NMA was used to analyze data from 15 randomized controlled trials (RCTs) and 10 prospective, multicenter, single-arm trials (combined evidence [CE] NMA) that evaluated target lesion revascularization (TLR) for 5 endovascular strategies: bare metal stent (BMS), polymer-covered metal stent (CMS), drug-eluting stent (DES), drug-coated balloon (DCB) and percutaneous transluminal angioplasty (PTA).

RESULTS

The RCT and CE NMAs included 2,912 (6,091) patients with 3,151 (6,786) person-years of follow-up. In the CE NMA, DCB provided a statistically significant 68% reduction in TLR compared with PTA and a statistically significant 53% reduction in TLR compared with BMS. BMS, CMS, and DES provided reductions in TLR of 33%, 48%, and 58% compared with PTA, with statistical significance achieved for CMS and DES. The significant reductions in TLR for DCB compared with PTA and BMS were replicated in the RCT NMA.

CONCLUSIONS

This NMA demonstrated that DCB provided better reduction in TLR rates compared with PTA and BMS.

Therapeutic Angiogenesis for Peripheral Artery Disease: Lessons Learned in Translational Science

Peripheral arterial disease (PAD) is a major health care problem. There have been limited advances in medical therapies, and a huge burden of symptomatic patients with intermittent claudication and critical limb ischemia who have limited treatment options. Angiogenesis is the growth and proliferation of blood vessels from existing vasculature. For approximately 2 decades, "therapeutic angiogenesis" has been studied as an investigational approach to treat patients with symptomatic PAD. Despite literally hundreds of positive preclinical studies, results from human clinical studies thus far have been disappointing. Here we present an overview of where the field of therapeutic angiogenesis stands today and examine lessons learned from previously conducted clinical trials. The objective is not to second-guess past efforts but to place the lessons in perspective to allow for trial success in the future to improve agent development, trial design, and ultimately, clinical outcomes for new therapeutics for PAD.

One-Year Outcomes of the Paclitaxel-Eluting, Self-Expanding Stentys Stent System in the Treatment of Infrapopliteal Lesions in Patients With Critical Limb Ischemia

Purpose: To investigate the efficacy of the paclitaxel-coated, self-expanding, nitinol Stentys Stent System in tibioperoneal lesions ≤50 mm long. Methods: The prospective, single-arm, multicenter PES-BTK-70 trial ( ClinicalTrials.gov identifier NCT01630070) evaluated the safety and efficacy of the coronary Stentys Stent System in the treatment of a stenotic or occlusive lesion ≤50 mm long in the tibioperoneal arteries of patients with critical limb ischemia (CLI). Between January 2012 and May 2013, 70 patients (mean age 74.6±9.4 years; 45 men) with CLI [Rutherford category 4 (37, 52.9%) or 5 (33, 47.1%)] received a Stentys drug-eluting stent for the treatment of infrapopliteal stenosis (60, 85.7%) or occlusion (10, 14.3%). The mean lesion length was 17.2 mm (4.0–58.5). The primary outcome measures were primary patency at 6 months (duplex ultrasound) and 12 months (angiography). Secondary outcomes included limb salvage and freedom from target lesion revascularization (TLR). Kaplan-Meier estimates of the outcomes are given with the 95% confidence intervals (CI). Results: Technical and procedure success (<30% residual stenosis without major complications) was achieved in 68 (97.1%) of 70 cases. Primary patency was 87.6% (95% CI 83.5% to 91.7%) at 6 months and 72.6% (95% CI 66.9% to 78.3%) at 1 year. Freedom from TLR was 79.1% at 1 year (95% CI 73.9% to 84.3) and limb salvage was 98.5% (95% CI 97.0 to 100.0). No stent fractures were found by core laboratory review of all follow-up imaging data available up to 12 months. Conclusion: In this study, the self-expanding, nitinol, paclitaxel-eluting, coronary Stentys stent was found to be safe and effective in the below-the-knee region, with results similar to the most recent limus-eluting stent trials.

Retrograde Approach Using Surgical Cutdown Technique for Limb Salvage in a Case of Critical Limb Ischemia With Severely Calcified Tibial Occlusive Disease

We here report a successful angioplasty for tibial artery occlusion using direct tibial puncture and subsequent retrograde approach under surgical cutdown technique. An 82-year-old man with ulcer/gangrene in first and second digits was referred to our hospital for endovascular therapy (EVT) of lower extremity ischemia. Diagnostic angiogram revealed anterior tibial artery (ATA) occlusion with severe calcification. Subintimal angioplasty was attempted using a 0.014-inch hydrophilic guidewire but was unsuccessful. A retrograde approach was subsequently attempted for ATA recanalization. However, because of severe calcification of dorsal pedis artery (DPA), percutaneous distal puncture was also unsuccessful. Direct puncture under surgical cutdown technique for DPA was subsequently performed and was successful. A 0.014-inch hydrophilic wire was advanced in retrograde fashion across the ATA occlusion and was used to access the microcatheter positioned at the proximal ATA via antegrade approach. Angioplasty of the ATA occlusion was performed using a 2.5-/3.0-mm tapered balloon. Completion angiogram revealed restoration of flow without dissection. Skin perfusion pressure was dramatically improved. Complete wound healing was achieved 5 months after EVT.

The Excimer Laser: Science Fiction Fantasy or Practical Tool?

Nearly 20 years ago, in vitro experiments left no doubt about the fact that laser light can ablate atherosclerotic plaque. The initial enthusiastic results with the technology, particularly in coronary arteries, were followed by reports showing unacceptably high restenosis and complication rates. These poor results were due to the premature application of an underdeveloped technology, a lack of understanding of laser/tissue interaction, and the use of incorrect lasing techniques. Consequently, and without discrimination, all lasers were banned from the catheterization laboratories for nearly a decade. Technological enhancements of the excimer laser, combined with refined catheter lasing techniques, resulted in greater debulking of atherosclerotic material in long superficial femoral artery occlusions. These results triggered the application of the excimer laser technique as an atherectomy tool in more complex lesions below the knee. The multicenter Laser Atherectomy for Critical Ischemia study clearly demonstrated that the excimer laser technology resulted in limb salvage rates >90% in patients with critical limb ischemia (CLI). Furthermore, new clinical results indicate that the excimer laser is very effective in dissolving thrombotic obstructions, redirecting this technology to the coronary field.

The results of the excimer laser in CLI validate the role of the cool laser in treating complex peripheral vascular disease. The results suggest a larger indication for this technology and support a more aggressive use of these interventional techniques in the treatment of this large patient cohort. However, all lasers are not equally effective in debulking atherosclerotic material. Only the athermic process associated with the excimer laser produces a safe and effective endovascular ablation of obstructive atherosclerotic and/or thrombotic material. The appropriate and safe utilization of the equipment and lasing techniques, combined with correct indications and patient selection, will contribute to the successful application of laser-assisted atherectomy in complex peripheral and coronary artery obstructive disease. Unfortunately, little consistent scientific data has been generated to convince the interventional community of the usefulness of excimer laser ablation.

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.

Incidence and clinical outcomes of the slow-flow phenomenon after infrapopliteal balloon angioplasty

OBJECTIVE

This study investigated the incidence and clinical relevance of the slow-flow phenomenon after infrapopliteal balloon angioplasty.

METHODS

This retrospective, single-center study included 161 consecutive patients with critical limb ischemia (173 limbs) who underwent endovascular treatment for infrapopliteal lesions between January 2012 and May 2015. The overall technical success rate was 88%. Of these lesions, 30 limbs presented with slow flow after angioplasty.

RESULTS

Total occlusion (90% vs 63%; P < .01) and severe calcification (43% vs 8%; P < .01) were more common in the slow-flow group. Kaplan-Meier curve analysis revealed that freedom from major amputation (60% vs 86%; log-rank, P < .01) and wound healing at 2 years (77% vs 91%; log-rank, P = .03) were significantly less common in the slow-flow group. Univariate Cox proportional hazard analysis identified Rutherford class 6 (hazard ratio [HR], 6.4; 95% confidence interval [CI], 2.8-15.8; P < .01), the slow-flow phenomenon (HR, 3.9; 95% CI, 1.6-8.9; P < .01), and hemodialysis (HR, 3.2; 95% CI, 1.2-11.1; P = .02) as independent predictors of major amputation and Rutherford class 6 (HR, 0.3; 95% CI, 0.2-0.6; P < .01), the slow-flow phenomenon (HR, 0.5; 95% CI, 0.3-0.9; P = .02), and pedal arch (HR, 1.6; 95% CI, 1.0-2.5; P = .04) as predictors of wound healing.

CONCLUSIONS

The slow-flow phenomenon after infrapopliteal balloon angioplasty occurred in 18.6% of limbs. This phenomenon may result in poor outcomes.

The Angiosome Concept Evaluated on the Basis of Microperfusion in Critical Limb Ischemia Patients-an Oxygen to See Guided Study

OBJECTIVES

Aim of this clinical study was to evaluate the angiosome concept with regard to the microcirculation of the foot in patients with CLI and to evaluate its relevance by means of combined laser Doppler flowmetrie and white-light tissue spectrophotometry.

METHODS

Twenty-eight patients who underwent leg revascularization in the stage of CLI were prospectively examined. The microperfusion was assessed by light guided spectrophotometry. The measuring points were set according to the angiosome concept into direct and indirect revascularized areas of the foot. Investigations were performed pre and postinterventionally and after 4 and 12 weeks in baseline-position as well as in an elevated position of the leg.

RESULTS

Microcirculation parameters (oxygen saturation, blood flow, velocity) of the revascularized leg showed a significant increase in elevation and baseline position compared to the preoperative values in most analyses. No significant differences between the direct and indirect revascularized angiosome were apparent.

CONCLUSION

The light-guided spectrophotometry measurement proved to be feasible in terms of measuring changes in the microcirculation after leg revascularization. However, our data do not support the value of the "angiosome concept" concerning the individual changes in microperfusion of the foot in patients with CLI.

Influence of Repeat Intervention on the Risk of Major Amputation After Infrapopliteal Angioplasty for Critical Limb Ischemia

PURPOSE

To assess the influence of repeat intervention on the risk of major amputation after infrapopliteal angioplasty for patients with critical limb ischemia (CLI).

METHODS

A multicenter database of Japanese CLI patients was interrogated to identify patients who underwent balloon angioplasty for isolated infrapopliteal lesions from April 2004 to December 2012. In that time frame, 1298 limbs of 1065 patients (mean age 72±10 years; 739 men) were eligible for this analysis. The prevalence of tissue loss was 76%, with 33% accompanied by infection. The association between repeat intervention and future risk for major amputation was evaluated using a mixed effects logistic regression model. A stratification analysis was also performed with baseline variables. A supplementary analysis compared baseline characteristics between the cases with and without repeat intervention. Hazard ratios (HR) and their 95% confidence intervals (CI) are reported.

RESULTS

Median follow-up was 1.2 years (interquartile range 0.4-2.5), during which time 143 (11.0%) limbs had major amputations and 499 (38.4%) underwent repeat intervention. The mixed effects modeling revealed that repeat intervention was significantly associated with future risk for major amputation (unadjusted HR 3.01, 95% CI 2.05 to 4.41, p=0.001). From the stratification analysis, repeat intervention significantly increased future risk of major amputation in cases with regular dialysis (HR 3.35, 95% CI 2.14 to 5.26, p<0.001), whereas it did not in those without dialysis. The supplemental analysis showed that patients with repeat intervention within 1 year had a higher prevalence of nonambulatory status, regular dialysis, tissue loss, and infection at baseline compared to those without repeat intervention for 1 year.

CONCLUSION

In the patients with CLI due to infrapopliteal lesions, the need for repeat intervention increased the risk of future major amputation. However, this correlation was not applicable to nondialysis patients.

Role of Infrainguinal Angioplasty in the Treatment of Critical Limb Ischaemia

Objective:

To review the published papers reporting on the use of infrainguinal angioplasty in the treatment of critical limb ischaemia (CLI).

Methods:

A MEDLINE (1966–2005) and Cochrane library search for articles relating to the use of infrainguinal angioplasty in the treatment of CLI.

Results:

Recent papers reporting on the results of infrainguinal angioplasty as treatment for CLI patients show excellent limb salvage rates regardless of the patency rates. The Cochrane Database of systematic reviews has accepted two prospective randomised trials comparing bypass operations and angioplasty among CLI patients. Pooling both trials showed no overall significant difference in amputation rates between the surgery and PTA groups. A multicentre, randomised controlled trial, the BASIL (bypass versus Angioplasty in Severe Ischaemia of the Leg) trial showed that in the medium term (after six months), the outcomes after angioplasty or surgery among CLI patients did not differ significantly with respect to amputation-free survival, all-cause mortality and quality of life.

Conclusions:

Infrainguinal PTA is feasible in CLI patients. Data from the BASIL trial show the similar ability of bypass surgery and balloon angioplasty in preserving both life and limb in short term. These results are, however, not applicable for the majority of CLI patients as only 15% (70/456) of the patients with severe limb ischaemia were considered candidates for the trial.

Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies

The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.

The open retrograde approach as an alternative for failed percutaneous access for difficult below the knee chronic total occlusions-A case series

Retrograde puncture via patent pedal vessels can be attempted in failed antegrade approach for infrapopliteal long chronic total occlusion. However in cases where the pedal vessels are unable to be visualized via duplex ultrasonography or fluoroscopy an open approach offers an additional option to a vascular surgeon for successful recanalization. Our case report highlights 3 cases where successful hybrid open retrograde approach was able to achieve recanalization of long chronic total occlusion.

Presentation of cases

The three cases in our series presented with critical limb ischaemia. All three cases had undergone duplex imaging of the affected arterial system. As the antegrade approach to cross the lesion failed a retrograde approach was attempted in all 3 cases. However when the usual modality of retrograde puncture via the use of ultrasound or fluoroscopy failed we proceeded with an open approach.

Discussion

Retrograde approach usually offers a better chance of successfully crossing a chronic total occlusion lesion. However puncturing a distal vessel successfully and traversing a catheter or guidewire across proves to be a challenge. An open approach offers an additional pathway for puncturing the target vessel when duplex imaging or fluoroscopic guidance fails.

Conclusion

Open approach is usually attempted as a last resort by many endovascular surgeons. However procedural time, contrast and radiation usage could have been cut short in cases where the distal target vessels pose a technical challenge for approach via a percutaneous method.

Clinical characteristics of patients with Rutherford category IV, compared with V and VI

Objective:

Patients categorized Rutherford category IV might have different characteristics compared with Rutherford category V and VI. Our study aims were to estimate the clinical differences between Rutherford category IV and Rutherford category V and VI, for those underwent endovascular therapy for isolated infrapopliteal disease, and also to find risk factors for endovascular therapy in Rutherford category IV.

Methods:

Based on the Japanese multi-center registry data, 1091 patients with 1332 limbs (Rutherford category IV: 226 patients with 315 limbs, Rutherford category V and VI: 865 patients with 1017 limbs) were analyzed retrospectively.

Results:

Patients’ backgrounds and lesions’ characteristics had significant differences. Both freedom rate from major adverse limb event with perioperative death and amputation-free survival rate at 1 year were better in Rutherford category IV than Rutherford category V and VI (93.6% vs 78.3%, 87.7% vs 66.7%) and those maintained to 3 years (p < 0.0001). Significant predictors for major adverse limb event/perioperative death were small body mass index (<18.5 kg/m³) and initial endovascular therapy success, and those for amputation-free survival were small body mass index (<18.5 kg/m³), non-ambulatory status, high systematic inflammatory reaction (C-reactive protein > 3.0 mg/dL), chronic obstructive pulmonary disease, and coronary artery disease in Rutherford category IV.

Conclusion:

From the present results, Rutherford category IV should be recognized to have quite different backgrounds and better outcome from Rutherford category V and VI.

Use of indigo carmine angiography to qualitatively assess adequate distal perfusion after endovascular revascularization in critical limb ischemia

PURPOSE

To report a novel technique to visualize the efficacy of revascularization in critical limb ischemia patients with ischemic foot ulcers.

TECHNIQUE

An 80-year-old man was admitted with nonhealing ulcers on his left second toe and lateral border of the foot owing to in-stent restenosis of the left popliteal artery. After dilation of the popliteal in-stent restenosis, below-the-knee angiography revealed that the anterior tibial artery (ATA) was occluded, the posterior tibial artery was hypoplastic, and the peroneal artery was enlarged, with 2 plantar arteries. To evaluate the foot circulation before performing additional procedures, a 4-F multipurpose catheter was advanced into the peroneal artery, and 5 mL of indigo carmine was injected. Immediately, the patient's second toe and lateral border ulcers were dyed blue. We concluded that sufficient blood flow had been obtained to the ulcerated area by balloon angioplasty alone, so the procedure was terminated. The ulcers completely healed at 1 month.

CONCLUSION

Indigo carmine angiography provides visual information on foot perfusion, yielding new insights into microcirculation and helping to determine the effectiveness of treatment and procedure endpoint.

Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics

The world is facing an epidemic of diabetes; consequently in the next years, critical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and long occlusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators. Revascularization is a key therapy in these patients as restoring adequate blood supply to the wound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTK arteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascular approaches have been shown to achieve high limb salvage rates with low morbidity and mortality and endovascular interventions one should now consider to be the first line treatment in the majority of CLI patients, especially in those with associated medical comorbidities. To do so, the vascular specialist requires detailed knowledge of the BTK endovascular techniques and devices. The first step decision in tibial endovascular therapy is access. In this context, the anterograde ipsilateral approach is generally preferred. The next critical decision is the choice of the vessel(s) to be approached in order to achieve successful limb salvage. Obtaining pulsatile flow to the correct portion of the foot is the paramount for ulcer healing. As such, a good understanding of the current angiosome model should enhance clinical results. The devices used should be carefully selected and optimal choice of guide wire is also extremely important and should be based on the characteristics of the lesion (location, length, and stenosis/occlusion) together with the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobic coating, flexibility, torque transmission, trackability, and pushability). Passing through chronic total occlusions can be quite challenging. The vascular interventional radiologist needs therefore to master the techniques that have been recently described: anterograde approaches, including the drilling technique, the penetrating technique, the subintimal technique and the parallel technique; subintimal arterial flossing with anterograde-retrograde procedures (Safari); the pedal-plantar loop technique and revascularization through collateral fibular artery vessels.

Contemporary assessment of foot perfusion in patients with critical limb ischemia

Significant progress in limb salvage for patients with peripheral arterial disease and critical limb ischemia has occurred in the past 2 decades. Improved patient outcomes have resulted from increased knowledge and understanding of the disease processes, as well as efforts to improve revascularization techniques and enhance patient care after open and endovascular procedures. An imaging modality that is noninvasive, fast, and safe would be a useful tool for clinicians in assessing lower-extremity perfusion when planning interventions. Among the current and emerging regional perfusion imaging modalities are transcutaneous oxygen monitoring, hyperspectral imaging, indocyanine green dye-based fluorescent angiography, nuclear diagnostic imaging, and laser Doppler. These tests endeavor to delineate regional foot perfusion to guide directed revascularization therapy in patients with critical limb ischemia and foot ulceration.

Treating calf and pedal vessel disease: the extremes of intervention

Recent developments in catheter, balloon, and guidewire technology have increased the scope for endovascular treatments in the management of complex and challenging disease in the calf and foot. The antegrade femoral approach remains the starting point for most interventions, but there is a growing role for procedures performed from unconventional access such as the pedal arteries. This article reviews the indications for intervention, atypical access, and the choice of equipment for these extreme interventions.

Initial experience with ticagrelor in patients with critical limb ischemia and high on-clopidogrel platelet reactivity undergoing complex peripheral endovascular procedures

PURPOSE

To investigate the safety and efficacy of ticagrelor in patients with critical limb ischemia (CLI) and high on-clopidogrel platelet reactivity (HCPR) undergoing complex, limb-salvage, peripheral endovascular procedures (PEP).

MATERIALS AND METHODS

The study included consecutive patients with HCPR undergoing PEP for CLI. HCPR was defined as platelet reaction units (PRU) >234 as assessed by the VerifyNow P2Y12 assay. Patients with HCPR were prescribed ticagrelor, 180/90 mg twice daily, and aspirin, 100 mg daily, for 6 months and ticagrelor, 180/90 mg twice daily, thereafter. Primary safety outcome was total major bleeding, and primary efficacy outcome was the composite of cardiovascular death and major amputation. Secondary outcomes included the level of platelet inhibition achieved and target limb revascularization (TLR)-free survival rate.

RESULTS

In total, 37 CLI patients with 40 limbs were investigated. Mean follow-up period was 11.3 ± 5.0 months (range 6-21). The mean treated lesion length was 229.2 ± 71.4 mm in the femoropopliteal axis and 179.3 ± 83.9 mm in the infrapopliteal arteries. No major or minor bleeding was detected. There were four periprocedural minor adverse events (10.8%), and in two cases (5.6%) ticagrelor was discontinued. In all patients, ticagrelor achieved platelet inhibition lower than the cut-off value. Mean PRU during clopidogrel therapy was 308.4 ± 41.8 (range 257-422) versus 67.0 ± 52.8 (range 2-189) when switched to ticagrelor; p < 0.0001. Kaplan-Meier estimated primary efficacy outcome and TLR-free survival rates were 92.0 and 67.3% at 12 months, respectively.

CONCLUSION

In this series of CLI patients with HCPR undergoing complex PEP, initial experience with ticagrelor was proven safe and efficient because it resulted in sufficient platelet inhibition and satisfactory clinical results without major complications.

Drug eluting devices for critically ill patients: can we apply lessons learned from the treatment of peripheral artery disease?

OBJECTIVE

To review the use of drug-eluting devices in peripheral arteries of critically ill patients

FINDINGS

Drug eluting stents and drug coated balloons are promising technologies and have become an important tool for the endovascular treatment of peripheral artery disease. The concept of local drug delivery to prevent restenosis due to intimal hyperplasia has been proven in several trials for different peripheral vascular beds. Especially for the treatment of patients with critical lower limb ischemia, improved patency could presumably improve wound healing, survival and limb salvage rates. However, until now, there is a paucity of evidence regarding these devices in critically ill patients and lessons learned must be extrapolated from non-critically ill patients at this time.

CONCLUSIONS

Restenosis rates can be reduced by drug eluting devices. Further study of the clinical impact of the use of drug eluting devices in the peripheral arteries will be required to determine if improved patency rates also can be translated into clinical benefit for critically ill patients.

[Usefulness of virtual vessel images in ppi for treatment of complete obstruction of leg arteries]

Following recent rapid advances in devices and treatment technology, indications for percutaneous peripheral intervention (PPI) have been expanded to include complex lesions (long-segment lesions, completely obstructed chronic lesions, etc.) and even lesions of the superficial femoral artery and arteries distal to the popliteal artery. However, when PPI is used for treatment of complete obstruction, treatment can take a long time or its outcome can be less satisfactory for reasons such as difficulty in assessing the vascular distribution/arrangement or the direction of calcification in the obstructed area or excessively long lesions. In the present study, we conducted three-dimensional image processing of CT data from leg arteries conventionally used for preoperative diagnosis. Using this processing technique, we created virtual images of the blood vessels of the completely obstructed area and mapped these virtual vessel images onto the fluoroscopic monitor image during catheter treatment. The usefulness of this technique for PPI was then evaluated. We succeeded in creating virtual vessel images of the completely obstructed parts of leg arteries with the use of preoperative CT images of leg arteries that we then mapped onto the fluoroscopic monitor images during treatment. We were successful in mapping virtual images onto the abdominal aorta in 96.8% of cases and in 95.7% with the common iliac artery. This technique is thus able to supply reliable information on vascular distribution/arrangement, suggesting that it can enable the surgeon to advance the treatment device precisely along the vessels, making it useful for treatment with PPI. The study additionally showed that differences in the angle of imaging affect the manual mapping of the CT images onto angiograms.

Percutaneous transluminal angioplasty versus primary stenting in infrapopliteal arterial disease: a meta-analysis of randomized trials

BACKGROUND

Percutaneous transluminal angioplasty (PTA) and primary stenting are commonly used endovascular therapeutic procedures for the treatment of infrapopliteal arterial occlusive disease. However, which procedure is more beneficial for patients with infrapopliteal arterial occlusive disease is unknown.

METHODS AND RESULTS

We performed a meta-analysis, searching PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, ISI Web of Knowledge, and relevant websites without language or publication date restrictions for randomized trials that compared primary stenting with PTA in patients with infrapopliteal arterial occlusive disease. The keywords were "stents," "angioplasty," "infrapopliteal," "tibial arteries," and "below knee." We selected immediate technical success, primary and secondary patency, limb salvage, and patient survival as the outcomes of this meta-analysis. On the basis of the inclusion criteria, we identified six prospective randomized trials. One-year outcomes did not show any significant differences between the PTA and primary stenting groups, respectively: technical success (93.3% vs 96.2%; odds ratio [OR], 0.59; 95% confidence interval [CI], 0.24-1.47; P = .25), primary patency (57.1% vs 65.7%; OR, 0.95; 95% CI, 0.35-2.58; P = .92), secondary patency (73.5% vs 57.6%; OR, 2.08; 95% CI, 0.81-5.34; P = .13), limb salvage (82.2% vs 87.5%; OR, 0.64; 95% CI, 0.29-1.41; P = .27), and patient survival (84.0% vs 87.5%; OR, 0.79; 95% CI, 0.40-1.55; P = .49).

CONCLUSIONS

For infrapopliteal arterial occlusive disease, primary stenting has the same 1-year benefits as PTA. There is insufficient evidence to support the superiority of either method. Primary stenting is associated with a trend toward higher primary patency and lower secondary patency. Further large-scale prospective randomized trials should produce more reliable results.

SCAI expert consensus statement for femoral-popliteal arterial intervention appropriate use

Successful endovascular intervention for femoral-popliteal (FP) arterial disease provides relief of claudication and offers limb-salvage in cases of critical limb ischemia. Technologies and operator technique have evolved to the point where we may now provide effective endovascular therapy for a spectrum of lesions, patients, and clinical scenarios. Endovascular treatment of this segment offers a significant alternative to surgical revascularization, and may confer improved safety for a wide range of patients, not solely those deemed high surgical risk. Although endovascular therapy of the FP segment has historically been hampered by high rates of restenosis, emerging technologies including drug-eluting stents, drug-coated balloons, and perhaps bio-absorbable stent platforms, provide future hope for more durable patency in complex disease. By combining lessons learned from clinical trials, international trends in clinical practice, and insights regarding emerging technologies, we may appropriately tailor our application of endovascular therapy to provide optimal care to our patients. This document was developed to guide physicians in the clinical decision-making related to the contemporary application of endovascular intervention among patients with FP arterial disease.

Retrograde pedal/tibial artery access for treatment of infragenicular arterial occlusive disease

Endovascular intervention has emerged as an accepted modality for treating patients with critical limb ischemia. However, this therapy poses multiple challenges to the interventionalist due to the presence of widespread multilevel disease, long and complex occlusive lesions, and the common involvement of the tibial vessels. Retrograde pedal/tibial access is a relatively new technique that allows the treatment of tibial occlusive lesions when conventional endovascular techniques fail. This article reviews the technical details and published data regarding this technique and evaluates its use in this difficult-to-treat patient population.