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Yoon YH, Lee JH, Hwang WM, Park HW, Roh JH, Lee SJ, Ko YG, Ahn CM, Yu CW, Lee SW, Youn YJ, Park JK, Yoon CH, Rha SW, Min PK, Choi SH, Chae IH, Choi D, On Behalf OTKVI. Treatment extent of femoropopliteal disease and clinical outcomes following endovascular therapy. EUROINTERVENTION 2024; 20:e1154-e1162. [PMID: 39279516 PMCID: PMC11384224 DOI: 10.4244/eij-d-24-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2024]
Abstract
BACKGROUND Endovascular therapy (EVT) has become the preferred treatment modality for femoropopliteal disease. However, there is limited evidence regarding its procedural and clinical outcomes according to the affected area. AIMS The aim of this study is to investigate clinical outcomes and device effectiveness according to treatment extent in the superficial femoral artery (SFA), popliteal artery (PA), or both. METHODS In this study, we analysed EVT for SFA (2,404 limbs), PA (155 limbs), SFA/PA (383 limbs) using the population in the K-VIS ELLA (Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Diseases) registry. The primary endpoint was target lesion revascularisation (TLR) at 2 years. RESULTS The SFA/PA group exhibited a higher prevalence of anatomical complexity, characterised by long lesions, moderate to severe calcification, and total occlusion. The procedures were successful in 97.2% of SFA, 92.9% of PA, and 95.6% of SFA/PA EVTs. The 2-year TLR rates were 21.1%, 18.6%, and 32.7% in the SFA, PA, and SFA/PA groups, respectively. SFA/PA EVT was associated with a significantly increased risk for TLR compared to the SFA group (adjusted hazard ratio [HR] 1.48 [1.09-2.00]; p=0.008) and a trend towards an increased risk compared to the PA group (adjusted HR 1.80 [1.00-3.27]; p=0.052). After overlap weighting, the use of a drug-coated balloon (DCB) was shown to be beneficial, with the lowest TLR rate after SFA and SFA/PA EVT. CONCLUSIONS In this large real-world registry, SFA/PA EVT was associated with an increased risk for TLR at 2 years compared to the SFA or PA EVT groups, with favourable outcomes when using a DCB or drug-eluting stent in the SFA/PA EVT group.
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Affiliation(s)
- Yong-Hoon Yoon
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Republic of Korea
| | - Jae-Hwan Lee
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Republic of Korea
| | - Won-Mook Hwang
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Republic of Korea
| | - Hyun-Woong Park
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Republic of Korea
| | - Jae-Hyung Roh
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Republic of Korea
| | - Seung-Jun Lee
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Guk Ko
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chul-Min Ahn
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Woong Yu
- Department of Cardiology, Cardiovascular Center, Korea University, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jong Kwan Park
- Division of Cardiology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Chang-Hwan Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Pil-Ki Min
- Division of Cardiology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - In-Ho Chae
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Donghoon Choi
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Nugteren MJ, Welling RHA, Bakker OJ, Ünlü Ç, Hazenberg CEVB. Vessel Preparation in Infrapopliteal Arterial Disease: A Systematic Review and Meta-Analysis. J Endovasc Ther 2024; 31:191-202. [PMID: 36062761 PMCID: PMC10938478 DOI: 10.1177/15266028221120752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Infrapopliteal lesions are generally complex to treat due to small vessel diameter, long lesion length, multilevel disease, and severe calcification. Therefore, different vessel preparation devices have been developed to contribute to better peri- and postprocedural outcomes. This systematic review aims to compare different vessel preparation techniques prior to plain old balloon angioplasty (POBA) or drug-coated balloon (DCB) angioplasty with POBA or DCB alone in infrapopliteal arterial disease. METHODS Medline, EMBASE, and Cochrane databases were searched for studies published between 2000 and 2022 assessing the value of adjunctive vessel preparation in infrapopliteal arterial disease. The primary outcomes were 12-month primary patency and limb salvage. RESULTS A total of 1685 patients with 1913 lesions were included in 11 POBA studies. Methodological quality was assessed as poor to moderate in these studies. Only 2 studies with 144 patients assessed vessel preparation in conjunction with DCB angioplasty. These randomized trials were assessed as high quality and found no significant benefit of adjunctive atherectomy to DCB angioplasty. The pooled Kaplan-Meier estimates of 12-month primary patency and limb salvage in the POBA studies were 67.8% and 80.9% for POBA, 62.1% and 86.4% for scoring balloons, 67.9% and 79.6% for mechanical atherectomy (MA), and 79.7% and 82.6% for laser atherectomy, respectively. Within the pooled data only scoring balloons and MA demonstrated significantly improved 12-month limb salvage compared to POBA. CONCLUSIONS Different forms of adjunctive vessel preparation demonstrate similar 12-month outcomes compared to POBA and DCB angioplasty alone in infrapopliteal disease, with the exception of improved 12-month limb salvage in scoring balloons and MA. However, since the included studies were heterogeneous and assessed as poor to moderate methodological quality, selection bias may have played an important role. Main conclusion is that this systematic review found no additional value of standard use of vessel preparation. CLINICAL IMPACT Infrapopliteal arterial disease is associated with chronic limb-threatening ischemia (CLTI) and generally complex to treat due to small vessel diameter, long lesion length, multilevel disease and severe calcification. A wide range of vessel preparation devices have been developed to contribute to improved peri- and postprocedural outcomes in these complex lesions. This systematic review aims to compare different vessel preparation techniques prior to plain old balloon angioplasty (POBA) or drug coated balloon (DCB) angioplasty with POBA or DCB angioplasty alone in infrapopliteal arterial disease. Different forms of adjunctive vessel preparation demonstrate similar 12-month outcomes compared to POBA and DCB angioplasty alone in infrapopliteal disease, with the exception of improved 12-month limb salvage in scoring balloons and mechanical atherectomy (MA). However, since the included studies were heterogeneous and assessed as poor to moderate methodological quality, selection bias may have played an important role. Main conclusion is that this systematic review found no additional value of standard use of vessel preparation.
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Affiliation(s)
- Michael J. Nugteren
- Department of Vascular Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rutger H. A. Welling
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Olaf J. Bakker
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
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Zilinyi RS, Alsaloum M, Snyder DJ, Raja A, Mintz AJ, Sethi SS, Bajakian D, Parikh SA. Surgical and Endovascular Therapies for Below-the-Knee Peripheral Arterial Disease: A Contemporary Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101268. [PMID: 39131787 PMCID: PMC11308828 DOI: 10.1016/j.jscai.2023.101268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 08/13/2024]
Abstract
Peripheral arterial disease (PAD) represents one of the most prevalent cardiovascular disease processes and carries a high burden of morbidity and mortality. Patients with chronic limb-threatening ischemia (CLTI), the most severe manifestation of PAD, have the highest rates of cardiovascular morbidity and mortality of the overall PAD population. Patients with below-the-knee (BTK) PAD have an increased propensity toward CLTI due to small-vessel caliber and the frequently comorbid conditions of end-stage renal disease and diabetes mellitus, which tend to affect small artery beds preferentially. For those with BTK PAD with CLTI, the standard of care is revascularization. Early revascularization was performed using surgical bypass. However, endovascular techniques, starting with percutaneous transluminal angioplasty and expanding to the modern armamentarium of adjunctive devices and therapies, have become standard of care for most patients with CLTI due to BTK PAD. In this review, we will discuss the modern surgical and endovascular approaches to revascularization, as well as devices that are currently in development or preapproval study for the treatment of BTK PAD.
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Affiliation(s)
- Robert S. Zilinyi
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Marissa Alsaloum
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Daniel J. Snyder
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Aishwarya Raja
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Ari J. Mintz
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Sanjum S. Sethi
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Danielle Bajakian
- Division of Vascular Surgery, Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Sahil A. Parikh
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
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Jamil Y, Nanna MG, Chaar CIO, Mena-Hurtado C, Attaran RR. Comparative Analysis of Mortality and Amputation Rates in Patients Undergoing Atherectomy for Infra-Popliteal Peripheral Arterial Disease: Insight From the VQI. J Endovasc Ther 2023:15266028231208895. [PMID: 37919968 DOI: 10.1177/15266028231208895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Infra-popliteal peripheral arterial disease (IPPAD) poses challenges due to high restenosis and occlusion rates. The BASIL-2 trial demonstrated the superiority of endovascular treatment compared with surgical bypass in patients with IPPAD. However, the association between different endovascular modalities and clinical outcomes has not been conclusive. HYPOTHESIS Combining plain old balloon angioplasty (POBA) with atherectomy is associated with improved clinical outcomes compared with POBA alone. METHODS Patients who underwent POBA vs POBA+atherectomy for IPPAD from the Vascular Quality Initiative database were identified. To mitigate potential selection bias, we employed propensity score matching (PSM) to balance the distribution of confounding variables for mortality identified on multivariable logistic regression. Subsequently, we compared patient characteristics and long-term outcomes between the 2 treatment groups. RESULTS Among patients who underwent endovascular intervention for IPPAD, 19 979 individuals (80.8%) were treated with POBA alone, while 4747 (19.2%) were treated with both POBA+atherectomy after PSM. Propensity score matching ensured minimal differences in baseline characteristics, such as indication for lower extremity revascularization (LER) and history of LER. After PSM, patients receiving POBA+atherectomy experienced higher rates of technical success and lower perioperative complications, such as renal complications and hematoma, compared with POBA alone. During long-term follow-up, patients who underwent atherectomy had lower rates of major amputation and major adverse limb events (MALE) but slightly lower freedom from reintervention. Nonetheless, there were no differences in mortality. CONCLUSION Combining POBA with atherectomy appears to be a safe approach in patients with IPPAD, with lower rates of long-term amputation and MALE at the cost of a higher risk of reintervention. CLINICAL IMPACT The use of adjunctive atherectomy is associated with improved long-term outcomes in patients with infra-popliteal disease.
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Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Michael G Nanna
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Ramak Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Sanon O, Carnevale M, Indes J, Gao Q, Lipsitz E, Koleilat I. Incidence of Procedure-Related Complications in Patients Treated With Atherectomy in the Femoropopliteal and Tibial Vessels in the Vascular Quality Initiative. J Endovasc Ther 2023; 30:693-702. [PMID: 35466788 DOI: 10.1177/15266028221091900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare procedural complications in patients undergoing atherectomy plus angioplasty (A+A) and plain balloon angioplasty (POBA). MATERIALS AND METHODS Patients in the Vascular Quality Initiative (VQI) registry undergoing first-time peripheral vascular intervention (PVI) were included. Those undergoing aortoiliac or pedal interventions, primary stenting, or hybrid procedures were excluded. Patients were stratified by lesion location (femoropopliteal [FP] or tibial [TIB]). The primary outcomes were target vessel dissection, distal embolization, and provisional stent placement. Secondary outcomes included postoperative complications and the need for subsequent interventions. RESULTS 12 499 patients undergoing FP (49.6% A+A) and 6736 patients undergoing TIB (17.0% A+A) interventions were identified. In the FP group, A+A was associated with greater intraoperative target vessel dissection (4.5% vs 2.6%, p<0.001), distal embolization (1.5% vs 0.7%, p =0.001), and provisional stent placement (1.5% vs 0%, p<0.001); and greater postoperative target vessel dissection (4.2% vs 2.0%, p<0.001) and distal embolization (0.9% vs 0.4%, p=0.034). In the TIB group, A+A was associated with fewer intraoperative vessel dissection (0.8% vs 2.3%, p=0.011) but greater provisional stent placement (0.3% vs 0%, p<0.001). TIB A+A was also associated with higher rates of technical success (97.6% vs 95.1%, p<0.001). CONCLUSIONS Atherectomy was associated with increased procedural-related complications in femoropopliteal, but not in tibial vessels. Future studies addressing lesion morphology, device design, and technique may help define its role in peripheral vascular interventions.
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Affiliation(s)
- Omar Sanon
- Department of Vascular Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Matthew Carnevale
- Division of Vascular and Endovascular Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Jeffrey Indes
- Division of Vascular and Endovascular Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Qi Gao
- Division of Vascular and Endovascular Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Evan Lipsitz
- Department of Vascular Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Issam Koleilat
- Department of Surgery, Community Medical Center, RWJBarnabas Health, Tom's River, NJ, USA
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Benfor B, Sinha K, Lumsden AB, Roy TL. Scoping review of atherectomy and intravascular lithotripsy with or without balloon angioplasty in below-the-knee lesions. J Vasc Surg Cases Innov Tech 2023; 9:101185. [PMID: 37274435 PMCID: PMC10238458 DOI: 10.1016/j.jvscit.2023.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/28/2023] [Indexed: 06/06/2023] Open
Abstract
Objective We evaluated how contemporary data on infrapopliteal vessel preparation have been reported to identify knowledge gaps and opportunities for future research. Methods A literature search was performed on Web of Science, PubMed, and Google Scholar to identify clinical research studies reporting on the outcomes of vessel preparation in below-the-knee lesions between 2006 and 2021. Studies were excluded if they were case reports or case series with a sample size of <10. Results A total of 15 studies comprising 5450 patients were included in this review, with vessel preparation performed in 2179 cases (40%). Of the 15 studies, 2 were randomized controlled trials, 6 were prospective cohort studies, and 7 were retrospective studies. Only 2 of the 15 studies evaluated intravascular lithotripsy devices, and 6 were noncomparative studies. The mean diameter stenosis treated was 86.7% ± 12.6%, and the lesion length was 71.7 ± 55.3 mm. Large heterogeneity was found in the choice and definitions of end points and lesion characterization. Procedural success ranged between 84% and 90%, and bailout stenting was performed in 0.8% to 15% of cases. Of the five studies comparing procedural success of atherectomy with or without balloon angioplasty to balloon angioplasty alone, only one was in favor of the former (99% vs 90%; P < .001). The remaining studies did not show any statistically significant differences. Similarly, atherectomy had a significantly superior limb salvage rate in only one of seven studies (91% vs 73%; P = .036). In contrast, the seven studies evaluating target lesion revascularization reported conflicting outcomes, with two in favor of atherectomy, two against atherectomy, and three reporting similar outcomes between atherectomy and balloon angioplasty alone. None of the studies evaluating intravascular lithotripsy was comparative. Conclusions The current body of evidence on vessel preparation in tibial arteries is largely based on observational studies with a large amount of heterogeneity and a number of inconsistencies. Further clinical and experimental studies with more robust study designs are warranted to investigate the comparative efficacy and safety of vessel preparation in calcified tibial arteries.
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Affiliation(s)
- Bright Benfor
- Correspondence: Bright Benfor, MD, Department of Vascular Surgery, Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin St, Ste B5-022, Houston, TX 77030
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Goodney P, Shah S, Hu YD, Suckow B, Kinlay S, Armstrong DG, Geraghty P, Patterson M, Menard M, Patel MR, Conte MS. A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia. J Vasc Surg 2022; 75:1762-1775. [PMID: 35085747 PMCID: PMC9524582 DOI: 10.1016/j.jvs.2021.11.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/08/2021] [Indexed: 01/23/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.
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Affiliation(s)
- Philip Goodney
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
| | - Samir Shah
- Vascular Surgery, University of Florida, Gainesville, Fla
| | - Yiyuan David Hu
- Geisel School of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Bjoern Suckow
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Scott Kinlay
- Cardiovascular Medicine, Boston Medical Center, Boston, Mass
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, Calif
| | - Patrick Geraghty
- Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
| | | | - Matthew Menard
- Vascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Michael S Conte
- Vascular Surgery, University of California, San Francisco, San Francisco, Calif
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Böhme T, Romano L, Macharzina RR, Noory E, Beschorner U, Jacques B, Bürgelin K, Flügel PC, Zeller T, Rastan A. Outcomes of directional atherectomy for common femoral artery disease. EUROINTERVENTION 2021; 17:260-266. [PMID: 32176618 PMCID: PMC9724908 DOI: 10.4244/eij-d-19-00693] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Endovascular therapy is the first-line strategy for femoropopliteal obstructive disease. However, for lesions involving the common femoral artery (CFA) surgical endarterectomy is still the gold standard. AIMS The aim of this study was to evaluate the safety and efficacy of directional atherectomy (DA) for the treatment of CFA lesions. METHODS A retrospective analysis of patients who underwent DA of the CFA between March 2009 and June 2017 was performed. The primary efficacy endpoint was the incidence of clinically driven target lesion revascularisation (cdTLR). Secondary endpoints included the overall procedural complication rate at 30 days, change in ankle-brachial index (ABI), and Rutherford-Becker class (RBC) during follow-up. RESULTS This analysis included 250 patients. The mean follow-up period was 31.03±21.56 months (range 1-88, median follow-up period 25 months). The procedural complication rate including access-site complications, target lesion perforation, and outflow embolisation was 10.4% (n=26). All but one complication could be treated conservatively or endovascularly. One surgical revision was necessary. Freedom from major adverse events (death, cdTLR, myocardial infarction and major target limb amputation) at 30 days was 99.6%. The rate of cdTLR during follow-up was 13.6% (n=34). A significant improvement of the mean ABI and the RBC was observed. Multivariate logistic regression analysis revealed residual target lesion stenosis >30% (p=0.005), and heavy calcification of the target lesion (p=0.033) to be independent predictors for cdTLR. CONCLUSIONS The use of DA for the treatment of CFA lesions leads to promising midterm results with an acceptable complication rate.
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Affiliation(s)
- Tanja Böhme
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Rastan A, Brodmann M, Böhme T, Macharzina R, Noory E, Beschorner U, Flügel PC, Bürgelin K, Neumann FJ, Zeller T. Atherectomy and Drug-Coated Balloon Angioplasty for the Treatment of Long Infrapopliteal Lesions: A Randomized Controlled Trial. Circ Cardiovasc Interv 2021; 14:e010280. [PMID: 34092093 DOI: 10.1161/circinterventions.120.010280] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Aljoscha Rastan
- Medizinische Universitätsklinik, Angiologie, Kantonsspital Aarau, Switzerland (A.R.)
| | - Marianne Brodmann
- Angiologische Abteilung, LKH-Universitäts-Klinikum Graz, Austria (M.B.)
| | - Tanja Böhme
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Roland Macharzina
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Elias Noory
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Ulrich Beschorner
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Peter-Christian Flügel
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Karlheinz Bürgelin
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Franz-Josef Neumann
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
| | - Thomas Zeller
- Universitäts-Herzzentrum Freiburg, Kardiologie und Angiologie II, Bad Krozingen, Germany (T.B., R.M., E.N., U.B., P.F., K.B., F.N., T.Z.)
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Kwon Y, Kim J, Won JH, Kim SH, Kim JE, Park SJ. [Atherectomy in Peripheral Artery Disease: Current and Future]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:551-561. [PMID: 36238795 PMCID: PMC9432436 DOI: 10.3348/jksr.2021.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/22/2021] [Accepted: 04/02/2021] [Indexed: 11/15/2022]
Abstract
Atherectomy has become a promising treatment option for peripheral artery disease caused by diabetes mellitus or end-stage renal disease. Atherectomy refers to the removal of atheromatous tissue by mechanical method, resulting in an enlarged lumen of the treated blood vessel. Based on this method, the term is limited to the percutaneous minimally invasive approach, and there are currently two types of atherectomy devices available in Korea. The increased prevalence of atherectomy has led to the concept of "vascular preparation" and a new treatment concept of "leave nothing behind." Various studies have proven the safety and effectiveness of atherectomy; however, there are some limitations. We need to remain focused on patient selection and subsequent large-scale research.
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Infrapopliteal Artery Occlusive Disease: An Overview of Vessel Preparation and Treatment Options. J Clin Med 2020; 9:jcm9103321. [PMID: 33081117 PMCID: PMC7602832 DOI: 10.3390/jcm9103321] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/28/2020] [Accepted: 10/12/2020] [Indexed: 01/01/2023] Open
Abstract
Critical limb ischemia (CLI) is defined as chronic rest pain and/or the presence of tissue loss (ulcers or gangrene) in the lower extremities secondary to ischemia. CLI is a limb and potentially life-threatening disease associated with a poor prognosis with only 50% of patients being able to preserve both limbs within 12 months of diagnosis. CLI related to diabetes is often more extensive with multi-level long segmental arterial disease resulting in a 5–30-fold increased rate of amputation. As the incidence and prevalence of diabetes mellitus increases within our aging society, the rate of infrapopliteal artery occlusive disease (IPOD) and the need for intervention rises with it. The aim of this manuscript is to provide the reader with an overview of the various devices available for vessel preparation (VP) and treatment of IPOD in order to optimize patency rates, symptom resolution, healing of wounds, and minimize complications.
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12
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Drug-Coated Balloon Angioplasty and Debulking for the Treatment of Femoropopliteal In-Stent Restenosis: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3076346. [PMID: 32596293 PMCID: PMC7303732 DOI: 10.1155/2020/3076346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 03/31/2020] [Accepted: 04/18/2020] [Indexed: 11/25/2022]
Abstract
The purpose of this article was to compare the efficiency and safety of drug-coated balloon angioplasty (DCB) and atherectomy with percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal in-stent restenosis (ISR). Pubmed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) (all up to March 2019) were searched systematically. Trial sequential analysis (TSA) was conducted. 5 studies with 599 participants were included. Compared with PTA, DCB significantly increased the rate of patency (6 months: RR 1.65, 95% CI 1.30 to 2.09, P < 0.01; 12 months: RR 2.38, 95% CI 1.71 to 3.30, P < 0.01) and the rate freedom from target lesion revascularization (TLR) (6 months: RR 1.18, 95% CI 1.09 to 1.28, P < 0.01; 12 months: RR 1.56, 95% CI 1.33 to 1.82, P < 0.01) at 6 and 12 months follow-up, and the TSA results showed these outcomes were reliable. The rate of clinical improvement by ≥1 Rutherford category in the DCB group was higher than that in the PTA group (6 months: RR 1.35, 95% CI 1.03 to 1.75, P = 0.03; 12 months: RR 1.46, 95% CI 1.17 to 1.82, P < 0.01) at 6 and 12 months. There is no statistically difference of ABI, all-cause mortality, and incidence of amputation between DCB group and PTA group (MD 0.03, 95% CI -0.03 to 0.08, P = 0.40; RR 1.24, 95% CI 0.46 to 3.34, P = 0.67; RR 0.32, 95% CI 0.01 to 7.61, P = 0.48). Compared with PTA, the rate of patency and freedom from TLR in the laser atherectomy (LD) group was higher than that in the PTA group (patency: 6 months: RR 1.28, 95% CI 1.01 to 1.64, P < 0.05, 12 months: RR 2.25, 95% CI 1.14 to 4.44, P < 0.05; freedom from TLR: 6 months: RR 1.27, 95% CI 1.05 to 1.53, P = 0.01, 12 months: RR 1.59, 95% CI 1.12 to 2.25, P = 0.01) at 6 and 12 months follow-up. In conclusion, DCB and LD had superior clinical (freedom from TLR and clinical improvement) and angiographic outcomes (patency rate) compared with PTA for the treatment of femoropopliteal ISR. Moreover, DCB and LD had a low incidence of amputation and mortality and were relatively safe methods.
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Giannopoulos S, Varcoe RL, Lichtenberg M, Rundback J, Brodmann M, Zeller T, Schneider PA, Armstrong EJ. Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy. J Endovasc Ther 2020; 27:547-564. [DOI: 10.1177/1526602820931488] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endovascular revascularization has been increasingly utilized to treat patients with chronic limb-threatening ischemia (CLTI), particularly atherosclerotic disease in the infrapopliteal arteries. Lesions of the infrapopliteal arteries are the result of 2 different etiologies: medial calcification and intimal atheromatous plaque. Although several devices are available for endovascular treatment of infrapopliteal lesions, balloon angioplasty still comprises the mainstay of therapy due to a lack of purpose-built devices. The mechanism of balloon angioplasty consists of adventitial stretching, medial necrosis, and dissection or plaque fracture. In many cases, the diffuse nature of infrapopliteal disease and plaque complexity may lead to dissection, recoil, and early restenosis. Optimal balloon angioplasty requires careful attention to assessment of vessel calcification, appropriate vessel sizing, and the use of long balloons with prolonged inflation times, as outlined in a treatment algorithm based on this systematic review. Further development of specific devices for this arterial segment are warranted, including devices for preventing recoil (eg, dedicated atherectomy devices), treating dissections (eg, tacks, stents), and preventing neointimal hyperplasia (eg, novel drug delivery techniques and drug-eluting stents). Further understanding of infrapopliteal disease, along with the development of new technologies, will help optimize the durability of endovascular interventions and ultimately improve the limb-related outcomes of patients with CLTI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ramon L. Varcoe
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, University of New South Wales, The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | | | - John Rundback
- Advanced Interventional & Vascular Services LLP, Teaneck, NJ, USA
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Bad Krozingen, Germany
| | - Peter A. Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Clinical Impact and Predictors of the Slow-Flow Phenomenon after Endovascular Treatment of Infrapopliteal Lesions Using the Crosser Catheter in Patients with Critical Limb Ischemia. J Vasc Interv Radiol 2020; 31:141-149. [DOI: 10.1016/j.jvir.2019.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 11/19/2022] Open
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15
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Zia S, Juneja A, Shams S, Faheem B, Shariff MA, Singh K, Schor J, Deitch J. Contemporary outcomes of infrapopliteal atherectomy with angioplasty versus balloon angioplasty alone for critical limb ischemia. J Vasc Surg 2019; 71:2056-2064. [PMID: 31727459 DOI: 10.1016/j.jvs.2019.08.254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/16/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Limited data exist comparing atherectomy (At) with balloon angioplasty for infrapopliteal peripheral arterial disease. The objective of this study was to compare the outcomes of infrapopliteal At with angioplasty vs angioplasty alone in patients with critical limb ischemia. METHODS This is a retrospective, single-center, longitudinal study comparing patients undergoing either infrapopliteal At with angioplasty or angioplasty alone for critical limb ischemia, between January 2014 and October 2017. The primary outcome was primary patency rates. Secondary outcomes were reintervention rates, assisted primary patency, secondary patency, major adverse cardiac events, major adverse limb events, amputation-free survival, overall survival, and wound healing rates. Data were analyzed in multivariate generalized linear models with log rank tests to determine survival in Kaplan-Meier curves. RESULTS There were 342 infrapopliteal interventions, 183 percutaneous balloon angioplasty (PTA; 54%), and 159 atherectomies (At) with PTA (46%) performed on 290 patients, with a mean age of 67 ± 12 years; 61% of the patients were male. The PTA and At/PTA groups had similar demographics, tissue loss (79% vs 84%; P = .26), ischemic rest pain (21% vs 16%; P = .51), mean follow-up (19 ± 9 vs 20 ± 9 months; P = .32), mean number of vessels treated (1.7 ± 0.8 vs 1.9 ± 0.8; P = .08) and the mean lesion length treated (6.55 ± 5.00 cm vs 6.02 ± 4.00 cm; P = .08), respectively. Similar 3-month (96 ± 1% vs 94 ± 1%), 6-month (85 ± 2% vs 86 ± 3%), 12-month (68 ± 3% vs 69 ± 4%), and 18-month (57 ± 4% vs 62 ± 4%) primary patency rates were seen in the two groups (P = .87). At/PTA patients had significantly higher reintervention rates as compared with the PTA patients (28% vs 16%; P = .02). Similar assisted primary patency rates (67 ± 4% vs 69 ± 4%; P = .78) and secondary patency rates (61 ± 4% vs 66 ± 4%; P = .98) were seen in the PTA and At/PTA groups at 18 months. The 30-days major adverse cardiac event rates (3% vs 2%; P = .13) and 30-day major adverse limb event rates (5% vs 4%; P = .2) were similar in both groups. Wound healing rates (72 ± 3% vs 75 ± 2%; P = .12), 1-year amputation-free survival (68 ± 4.1% vs 70 ± 2%; P = .5), and 1-year overall survival (76 ± 4% vs 78 ± 4%; P = .39) rates did not differ in the PTA and At/PTA groups. THE At/PTA group had higher local complication rates (7 [4%] vs 1 [0.5%]; P = .03) CONCLUSIONS: At with angioplasty provides similar patency rates compared with angioplasty alone for infrapopliteal peripheral arterial disease, but associated with higher reintervention and local complication rates. Further appropriately designed studies are required to determine the exact role of At in this subset of patients.
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Affiliation(s)
- Saqib Zia
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY.
| | - Amandeep Juneja
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY
| | - Sara Shams
- Department of Radiology, Stanford University School of Medicine, Stanford, Calif
| | - Beenish Faheem
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY
| | - Masood A Shariff
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY
| | - Kuldeep Singh
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY
| | - Jonathan Schor
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY
| | - Jonathan Deitch
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital Northwell Health, Staten Island, NY
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16
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Long-term Outcomes of an Endovascular-First Approach for Diabetic Patients With Predominantly Tibial Disease Treated in a Multidisciplinary Setting. Ann Vasc Surg 2019; 60:315-326.e2. [DOI: 10.1016/j.avsg.2019.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 01/18/2023]
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 756] [Impact Index Per Article: 151.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Ramkumar N, Martinez‐Camblor P, Columbo JA, Osborne NH, Goodney PP, O'Malley AJ. Adverse Events After Atherectomy: Analyzing Long-Term Outcomes of Endovascular Lower Extremity Revascularization Techniques. J Am Heart Assoc 2019; 8:e012081. [PMID: 31165658 PMCID: PMC6645635 DOI: 10.1161/jaha.119.012081] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The long-term effectiveness of atherectomy treatment for peripheral arterial disease is unknown. We studied 5-year clinical outcomes by endovascular treatment type among patients with peripheral arterial disease. Methods and Results We queried the Medicare-linked VQI (Vascular Quality Initiative) registry for endovascular interventions from 2010 to 2015. The exposure was treatment type: atherectomy (with or without percutaneous transluminal angioplasty [ PTA] ), stent (with or without PTA ), or PTA alone. The outcomes were major amputation, any amputation, and major adverse limb event (major amputation or any reintervention). We used the center-specific proportions of atherectomy procedures performed in the 12 months before a patient's procedure as the instruments to perform an instrumental-variable Cox model analysis. Among 16 838 eligible patients (median follow-up: 1.3-1.5 years), 11% underwent atherectomy, 40% received PTA alone, and 49% underwent stenting. Patients receiving atherectomy commonly underwent femoropopliteal artery treatment (atherectomy: 65%; PTA : 49%; stenting: 43%; P<0.001) and had worse disease severity (Trans-Atlantic Inter-Society Consensus score [TASC] B and greater; atherectomy: 77%; PTA : 68%; stenting: 67%; P<0.001). The 5-year rate of major adverse limb events was 38% in patients receiving atherectomy versus 33% for PTA and 32% for stenting (log rank P<0.001). Controlling for unmeasured confounding using instrumental-variable analysis, patients treated with atherectomy experienced outcomes similar to those of patients treated with PTA , except for a higher risk of any amputation (hazard ratio: 1.51; 95% CI , 1.08-2.13). However, compared with stenting, atherectomy patients had a higher risk of major amputation (hazard ratio: 3.66; 95% CI , 1.72-7.81), any amputation (hazard ratio: 2.73; 95% CI , 1.60-4.76), and major adverse limb event (hazard ratio: 1.61; 95% CI , 1.10-2.38). Conclusions Atherectomy is used to treat severe femoropopliteal and tibial peripheral arterial disease even though long-term adverse outcomes occur more frequently after this treatment modality.
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical PracticeLebanonNH
| | | | - Jesse A. Columbo
- Section of Vascular SurgeryDepartment of SurgeryDartmouth‐Hitchcock Medical CenterLebanonNH
| | | | - Philip P. Goodney
- The Dartmouth Institute for Health Policy and Clinical PracticeLebanonNH
- Section of Vascular SurgeryDepartment of SurgeryDartmouth‐Hitchcock Medical CenterLebanonNH
| | - A. James O'Malley
- The Dartmouth Institute for Health Policy and Clinical PracticeLebanonNH
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19
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 730] [Impact Index Per Article: 146.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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20
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Korosoglou G, Giusca S, Andrassy M, Lichtenberg M. The Role of Atherectomy in Peripheral Artery Disease: Current Evidence and Future Perspectives. VASCULAR AND ENDOVASCULAR REVIEW 2019. [DOI: 10.15420/ver.2018.16.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An ageing population and the increasing prevalence of cardiovascular risk factors have aggravated the burden of peripheral artery disease (PAD). Despite advances in the pharmacological treatment of atherosclerosis, many patients with symptomatic PAD require invasive procedures to reduce the symptoms of claudication, salvage tissue and prevent amputation and subsequent disability in those with critical limb ischaemia. After significant advances in endovascular treatment over the past two decades, these techniques are widely accepted as first-choice treatment in the majority of patients with PAD. However, in patients with severely calcified lesions, standard endovascular treatment such as plain or drug-coated balloon (DCB) angioplasty may fail due to vessel recoil or severe dissection in the acute setting, and intimal hyperplasia in the long term. With the use of percutaneous plaque modification and debulking techniques based on atherectomy, such calcified lesions can be tackled more easily after removal or fragmentation of atherosclerotic plaque. More homogeneous balloon expansion at lower pressures can be achieved after atherectomy, which reduces barotrauma while allowing better drug delivery to the vessel wall during DCB angioplasty avoids the need for stent placement. There are four principal methods of direct atherectomy available at the present time: directional atherectomy, rotational atherectomy, orbital atherectomy and hybrid atherectomy. In this article, we provide a short overview of these techniques and the current evidence from clinical trials to support their use.
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Affiliation(s)
- Grigorios Korosoglou
- Department of Cardiology, Vascular Medicine and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Sorin Giusca
- Department of Cardiology, Vascular Medicine and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Martin Andrassy
- Department of Cardiology, Vascular Medicine and Diabetology, Fuerst-Stirum Hospital Bruchsal, Bruchsal, Germany
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21
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Khalili H, Jeon-Slaughter H, Armstrong EJ, Baskar A, Tejani I, Shammas NW, Prasad A, Abu-Fadel M, Brilakis ES, Banerjee S. Atherectomy in below-the-knee endovascular interventions: One-year outcomes from the XLPAD registry. Catheter Cardiovasc Interv 2018; 93:488-493. [PMID: 30499198 DOI: 10.1002/ccd.27897] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/31/2018] [Accepted: 08/29/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Use of atherectomy for the treatment of peripheral arterial disease (PAD) is increasing as an adjunctive treatment to either conventional or drug-coated balloon angioplasty. There is limited data on atherectomy outcomes in below-the-knee (BTK) endovascular interventions. METHODS Data from the multicenter Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) were analyzed to examine predictors of atherectomy use and its associated 1-year patency rate. We analyzed 518 BTK procedures performed between January 2005 and December 2016. RESULTS Overall a total of 518 BTK procedures were treated in 430 patients, and 43% of interventions used atherectomy. African American patients were less likely (13% vs 25%; |standard residual| = 3.41) to be treated with atherectomy. Use of atherectomy was lower in chronic total occlusive (CTO) lesions (48% vs 58%; P = 0.02). There were no significant associations of baseline comorbidities, critical limb ischemia (CLI), ankle-brachial index, number of BTK vessel run-off, or vessel location with atherectomy use. Compared with patients without atherectomy, use of atherectomy was associated with lower incidence of repeat target limb intervention at 1 year after adjusting for age, CLI, in-stent restenosis, heavy calcification, presence of diffuse disease, and CTO lesion traits (Hazard Ratio 0.41, 95% confidence interval 0.23-0.72; P < 0.01). CONCLUSIONS Compared with no atherectomy, use of atherectomy in BTK interventions is associated with lower rates of 1-year repeat target limb revascularization. These findings require confirmation in prospective, randomized clinical studies.
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Affiliation(s)
- Houman Khalili
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Veterans Affairs North Texas Health Care System
| | - Haekyung Jeon-Slaughter
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Veterans Affairs North Texas Health Care System
| | | | | | - Ishita Tejani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Veterans Affairs North Texas Health Care System
| | | | - Anand Prasad
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Mazen Abu-Fadel
- Oklahoma University Health Science Center, Oklahoma City, Oklahoma
| | - Emmanouil S Brilakis
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Veterans Affairs North Texas Health Care System.,Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Veterans Affairs North Texas Health Care System
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22
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Current Role of Atherectomy for Treatment of Femoropopliteal and Infrapopliteal Disease. Interv Cardiol Clin 2018; 6:235-249. [PMID: 28257771 DOI: 10.1016/j.iccl.2016.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Atherectomy improves the acute procedural success of a procedure whether treating de novo or restenotic (including in-stent) disease. Intermediate follow-up results seem to be in favor of atherectomy in delaying and reducing the need for repeat revascularization in patients with femoropopliteal in-stent restenosis. Recent data suggest that avoiding cutting into the external elastic lamina is an important factor in reducing restenosis. The interplay between directional atherectomy and drug-coated balloons is unclear.
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23
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Xu Y, Jia X, Zhang J, Zhuang B, Fu W, Wu D, Wang F, Zhao Y, Guo P, Bi W, Wang S, Guo W. Drug-Coated Balloon Angioplasty Compared With Uncoated Balloons in the Treatment of 200 Chinese Patients With Severe Femoropopliteal Lesions: 24-Month Results of AcoArt I. JACC Cardiovasc Interv 2018; 11:2347-2353. [PMID: 30448170 DOI: 10.1016/j.jcin.2018.07.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/10/2018] [Accepted: 07/24/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The authors sought to investigate the midterm efficacy and safety of drug-coated balloon (DCB) in the treatment of severe femoropopliteal artery disease (FPAD). BACKGROUND The midterm outcome of DCB versus uncoated balloon percutaneous transluminal angioplasty (PTA) for FPAD are still debated. METHODS A total of 200 Chinese patients with FPAD were prospectively randomized into treatment with DCB or with PTA. The primary efficacy endpoints were primary patency of the target lesion, freedom from clinically driven target lesion revascularization, improved ankle-brachial index, and improved Rutherford class at 24 months. The primary safety endpoint was the rate of major adverse events. RESULTS The DCB group and PTA group were comparable in demographic characteristics and clinical severity at baseline. At 24-month follow-up, primary patency was better in the DCB group versus PTA group (64.6% vs. 31.4%; p < 0.001). The DCB group had a higher rate of freedom from clinically driven target lesion revascularization than the PTA group (86.5% vs. 58.9%; p < 0.001). Rutherford class and ankle-brachial index also confirmed more improvements in the DCB group (p < 0.01 and p < 0.05, respectively). There was no significant difference in major adverse events. CONCLUSIONS The superiority of DCB versus PTA in the efficacy of FPAD treatment persists at 24-month follow-up and the safety of DCB is equivalent to that of PTA.
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Affiliation(s)
- Yongle Xu
- Chinese PLA General Hospital, Beijing, China
| | - Xin Jia
- Chinese PLA General Hospital, Beijing, China
| | - Jiwei Zhang
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Baixi Zhuang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Weiguo Fu
- Zhongshan Hospital Fudan University, Shanghai, China.
| | - Danming Wu
- The People's Hospital of Liaoning Province, Shenyang, China
| | - Feng Wang
- The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yu Zhao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Pingfan Guo
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wei Bi
- The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Guo
- Chinese PLA General Hospital, Beijing, China.
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24
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Patel SV, Sonani R, Patel P, Patel M, Bhatt P, Badheka A. Effect of hospital volume on outcomes of percutaneous peripheral atherectomy - An observational analysis from National Inpatient Sample. Vascular 2018; 26:615-625. [PMID: 29973108 DOI: 10.1177/1708538118786596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the published literature has reported an inverse association between hospital volume and outcomes of coronary interventions, sparse data are available for percutaneous peripheral atherectomy (PPA). The aim of our study was to examine the effect of hospital volume on outcomes of PPA. METHODS Using the Nationwide Inpatient Sample (NIS) database of the year 2012, PPA with ICD-9 code of 17.56 was identified. The primary outcomes were mortality and amputation rates; secondary outcomes were peri-procedural complications, cost, and length of hospitalization and discharge disposition of the patient. Multivariate models were generated for predictors of the outcomes. RESULTS We identified a total of 21,015 patients with mean age of 69.53 years, with 56% males. Higher hospital volume centers were associated with a significantly lower mortality (OR 0.42, 95% CI 0.30-0.57, p < 0.0001), amputation rates (5.34% vs. 9.32%, p < 0.0001), combined endpoint of mortality and complications (OR 0.53, 95% CI 0.49-0.58, p < 0.0001), shorter length of hospital stay (LOS) (4.86 vs. 6.79 days, p < 0.0001) and lower hospitalization cost ($23,062 vs. $30,794, p < 0.0001). Subgroup analysis for acute and chronic limb ischemia showed similar results. CONCLUSION Hospital procedure volume is an independent predictor of mortality, amputation rates, complications, LOS, and costs in patients undergoing PPA with an inverse relationship.
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Affiliation(s)
- Samir V Patel
- 1 Sparks Regional Medical Center, University of Arkansas Medical Sciences west, Fort Smith, AR, USA
| | | | - Palak Patel
- 3 Massachusetts College of Pharmacy and Health Sciences, Manchester, NH, USA
| | | | - Parth Bhatt
- 5 Texas Tech Health Sciences Center, Amarillo, TX, USA
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25
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Mohan S, Flahive JM, Arous EJ, Judelson DR, Aiello FA, Schanzer A, Simons JP. Peripheral atherectomy practice patterns in the United States from the Vascular Quality Initiative. J Vasc Surg 2018; 68:1806-1816. [PMID: 29937287 DOI: 10.1016/j.jvs.2018.03.417] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/08/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Peripheral atherectomy has been shown to have technical success in single-arm studies, but clinical advantages over angioplasty and stenting have not been demonstrated, leaving its role unclear. We sought to describe patterns of atherectomy use in a real-world U.S. cohort to understand how it is currently being applied. METHODS The Vascular Quality Initiative was queried to identify all patients who underwent peripheral vascular intervention from January 2010 to September 2016. Descriptive statistics were performed to analyze demographics of the patients, comorbidities, indication, treatment modalities, and lesion characteristics. The intermittent claudication (IC) and critical limb ischemia (CLI) cohorts were analyzed separately. RESULTS Of 85,605 limbs treated, treatment indication was IC in 51% (n = 43,506) and CLI in 49% (n = 42,099). Atherectomy was used in 15% (n = 13,092) of cases, equivalently for IC (15%; n = 6674) and CLI (15%; n = 6418). There was regional variation in use of atherectomy, ranging from a low of 0% in one region to a high of 32% in another region. During the study period, there was a significant increase in the proportion of cases that used atherectomy (11% in 2010 vs 18% in 2016; P < .0001). Compared with nonatherectomy cases, those with atherectomy use had higher incidence of prior peripheral vascular intervention (IC, 55% vs 43% [P < .0001]; CLI, 47% vs 41% [P < .0001]), greater mean number of arteries treated (IC, 1.8 vs 1.6 [P < .0001]; CLI, 2.1 vs 1.7 [P < .0001]), and lower proportion of prior leg bypass (IC, 10% vs 14% [P < .0001]; CLI, 11% vs 17% [P < .0001]). There was lower incidence of failure to cross the lesion (IC, 1% vs 4% [P < .0001]; CLI, 4% vs 7% [P < .0001]) but higher incidence of distal embolization (IC, 1.9% vs 0.8% [P < .0001]; CLI, 3.0% vs 1.4% [P < .0001]) and, in the CLI cohort, arterial perforation (1.4% vs 1.0%; P = .01). CONCLUSIONS Despite a lack of evidence for atherectomy over angioplasty and stenting, its use has increased across the United States from 2010 to 2016. It is applied equally to IC and CLI populations, with no identifiable pattern of comorbidities or lesion characteristics, suggesting that indications are not clearly delineated or agreed on. This study places impetus on further understanding of the optimal role for atherectomy and its long-term clinical benefit in the management of peripheral arterial disease.
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Affiliation(s)
- Sathish Mohan
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Julie M Flahive
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Edward J Arous
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Dejah R Judelson
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Francesco A Aiello
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
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- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
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26
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Loffroy R, Chevallier O, Falvo N, Gehin S, Midulla M, Galland C. Combined HawkOne directional atherectomy and paclitaxel-coated balloon angioplasty for isolated calcified popliteal artery lesion: a no-stent approach to lower extremity endovascular revascularization. Quant Imaging Med Surg 2018; 8:364-367. [PMID: 29774189 DOI: 10.21037/qims.2018.03.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Romaric Loffroy
- Department of Vascular Medicine and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- Department of Vascular Medicine and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Nicolas Falvo
- Department of Vascular Medicine and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Sophie Gehin
- Department of Vascular Medicine and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular Medicine and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Christophe Galland
- Department of Vascular Medicine and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
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28
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Kok HK, Asadi H, Sheehan M, McGrath FP, Given MF, Lee MJ. Outcomes of infrapopliteal angioplasty for limb salvage based on the updated TASC II classification. Diagn Interv Radiol 2018; 23:360-364. [PMID: 28774866 DOI: 10.5152/dir.2017.17040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE We aimed to evaluate limb salvage, defined as freedom from major amputation, and to identify predictors of major amputation in patients with infrapopliteal peripheral arterial disease (PAD) based on the updated 2015 TASC II anatomic classification treated by percutaneous transluminal angioplasty (PTA). METHODS This was a retrospective study of infrapopliteal PTA procedures performed for PAD over a 4-year period. Patient demographics, medical comorbidities, risk factors, angiographic imaging, technical details, and clinical follow-up were analyzed to determine limb salvage rates, technical success, and all-cause mortality. Predictors of major amputation following PTA were identified. RESULTS A total of 112 patients were treated by infrapopliteal PTA. Most lesions consisted of TASC C (44%) and D (34%) categories, were over 10 cm in length, and were occlusive and heavily calcified (89%). Overall technical success was 75%, with limb salvage rates of 77% at 1 year and 65% at 3 years following PTA. Smoking, previous stroke or cardiovascular events, and anticoagulation use were associated with an increased risk of major amputation following PTA. CONCLUSION PTA of complex infrapopliteal PAD is associated with good intermediate term limb salvage rates.
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Affiliation(s)
- Hong Kuan Kok
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland.
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29
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Kobayashi N, Hirano K, Yamawaki M, Araki M, Sakai T, Sakamoto Y, Mori S, Tsutsumi M, Honda Y, Tokuda T, Makino K, Shirai S, Ito Y. Characteristics and clinical outcomes of repeat endovascular therapy after infrapopliteal balloon angioplasty in patients with critical limb ischemia. Catheter Cardiovasc Interv 2017; 91:505-514. [DOI: 10.1002/ccd.27238] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/22/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Norihiro Kobayashi
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Keisuke Hirano
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Masahiro Yamawaki
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Motoharu Araki
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Tsuyoshi Sakai
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Yasunari Sakamoto
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Shinsuke Mori
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Masakazu Tsutsumi
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Yohsuke Honda
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Takahiro Tokuda
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Kenji Makino
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Shigemitsu Shirai
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
| | - Yoshiaki Ito
- Department of Cardiology; Saiseikai Yokohama-city Eastern Hospital; Yokohama Kanagawa 230-8765 Japan
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30
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Katsanos K, Spiliopoulos S, Reppas L, Karnabatidis D. Debulking Atherectomy in the Peripheral Arteries: Is There a Role and What is the Evidence? Cardiovasc Intervent Radiol 2017; 40:964-977. [PMID: 28451812 PMCID: PMC5486795 DOI: 10.1007/s00270-017-1649-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/04/2017] [Indexed: 02/05/2023]
Abstract
Traditional percutaneous balloon angioplasty and stent placement is based on mechanical plaque disruption and displacement within the arterial wall. On the contrary, transcatheter atherectomy achieves atherosclerotic plaque clearance by means of directional plaque excision or rotational plaque removal or laser plaque ablation. Debulking atherectomy may allow for a more uniform angioplasty result at lower pressures with consequently less vessel barotrauma and improved luminal gain, thereby decreasing the risk of plaque recoil and dissection that may require permanent metal stenting. It has been also argued that atherectomy may disrupt the calcium barrier and optimize drug transfer and delivery in case of drug-coated balloon applications. The authors discuss the various types of atherectomy devices available in clinical practice to date and critically appraise their mode of action as well as relevant published data in each case. Overall, amassed randomized and observational evidence indicates that percutaneous atherectomy of the femoropopliteal and infrapopliteal arteries may achieve high technical success rates and seems to lessen the frequency of bailout stenting, however, at the expense of increased risk of peri-procedural distal embolization. Long-term clinical outcomes reported to date do not support the superiority of percutaneous atherectomy over traditional balloon angioplasty and stent placement in terms of vessel patency or limb salvage. The combination of debulking atherectomy and drug-coated balloons has shown promise in early studies, especially in the treatment of more complex lesions. Unanswered questions and future perspectives of this continuously evolving endovascular technology as part of a broader treatment algorithm are discussed.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Panepistimiou St., 26504, Rion, Greece.
- Guy's and St.Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, ATTIKO Athens University Hospital, 1st Rimini St., Chaidari, 12461, Athens, Greece
| | - Lazaros Reppas
- Interventional Radiology Unit, 2nd Department of Radiology, ATTIKO Athens University Hospital, 1st Rimini St., Chaidari, 12461, Athens, Greece
| | - Dimitris Karnabatidis
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Panepistimiou St., 26504, Rion, Greece
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Peeled Guidewire Coating with Debulked Plaque Obtained by Directional Coronary Atherectomy. Case Rep Cardiol 2017; 2017:2397183. [PMID: 28480081 PMCID: PMC5396424 DOI: 10.1155/2017/2397183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/28/2017] [Indexed: 11/18/2022] Open
Abstract
Percutaneous directional coronary atherectomy (DCA) is a plaque debulking method performed in Japan, and recently a renewed DCA device has been launched. We present a case with a tight left anterior descending lesion undergoing percutaneous coronary intervention with application of DCA. After several sessions of DCA, white plaques accompanied by green, stringed materials were obtained from the device; some materials were considerably long (approximately 15 mm in length). A drug-eluting stent was subsequently implanted, and the procedure was completed successfully without any complications. The extracted plaques and artificial materials were pathologically examined, and no inflammatory changes were detected on plaques adjacent to the material. Assessing pathological findings and structure of the DCA catheter, the obtained artificial materials were considered as peeled guidewire, possibly resulting from the friction between the guidewire and metallic bearing in the housing of DCA catheter. Of note, this phenomenon has been recognized even in other DCA cases in which guidewires of the other kind are used. We report this phenomenon for the first time, warning of theoretically possible distal embolization of artificial materials caused by any debulking devices.
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32
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Soga Y, Tomoi Y, Hiramori S, Murata N, Kobayashi Y, Ichihashi K, Aodo K. New Endovascular Technique to Prevent Distal Embolism for Iliofemoral Occlusive Disease: Reverse Flow Aspiration With Proximal Sheath Blockage. J Endovasc Ther 2017; 24:488-495. [DOI: 10.1177/1526602817707306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yusuke Tomoi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Naotaka Murata
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yohei Kobayashi
- Department of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Kei Ichihashi
- Department of Cardiology, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Kenji Aodo
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
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33
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Stent revascularization versus bypass surgery for peripheral artery disease in type 2 diabetic patients - an instrumental variable analysis. Sci Rep 2016; 6:37177. [PMID: 27857178 PMCID: PMC5114545 DOI: 10.1038/srep37177] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/26/2016] [Indexed: 12/04/2022] Open
Abstract
The objective of this study was to use instrumental variable (IV) analyses to evaluate the clinical effectiveness of percutaneous stent revascularization versus bypass surgery in the treatment of peripheral artery disease (PAD) among type 2 diabetic patients. Type 2 diabetic patients who received peripheral artery bypass surgery (n = 5,652) or stent revascularization (n = 659) for lower extremity arterial stenosis between 2000 and 2007 were identified from the Taiwan National Health Insurance claims database. Patients were followed from the date of index hospitalization for 2 years for lower-extremity amputation, revascularization, and hospitalization for medical treatment. Analysis using treatment year, patients’ monthly income level, and regional difference as IVs were conducted to reduce unobserved treatment selection bias. The crude analysis showed a statistically significant risk reduction in favor of stent placement in lower extremity amputation and in the composite endpoint of amputation, revascularization, or hospitalization for medical treatment. However, peripheral artery stent revascularization and bypass surgery had similar risk of lower limb amputation and composite endpoints in the analyses using calendar year or patients’ monthly income level as IVs. These two treatment modalities had similar risk of lower limb amputation among DM patients with PAD.
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34
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Herten M, Torsello GB, Schönefeld E, Stahlhoff S. Critical appraisal of paclitaxel balloon angioplasty for femoral-popliteal arterial disease. Vasc Health Risk Manag 2016; 12:341-56. [PMID: 27621646 PMCID: PMC5010165 DOI: 10.2147/vhrm.s81122] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peripheral arterial disease, particularly critical limb ischemia, is an area with urgent need for optimized therapies because, to date, vascular interventions often have limited life spans. In spite of initial encouraging technical success after femoropopliteal percutaneous transluminal angioplasty or stenting, postprocedural restenosis remains the major problem. The challenging idea behind the drug-coated balloon (DCB) concept is the biological modification of the injury response after balloon dilatation. Antiproliferative drugs administered via DCBs or drug-eluting stents are able to suppress neointimal hyperplasia, the main cause of restenosis. This article reviews the results of DCB treatments of femoropopliteal and infrapopliteal lesions in comparison to standard angioplasty with uncoated balloons. A systematic literature search was performed in 1) medical journals (ie, MEDLINE), 2) international registers for clinical studies (ie, www.clinicaltrials.gov), and 3) abstracts of scientific sessions. Several controlled randomized trials with follow-up periods of up to 5 years demonstrated the efficacy of paclitaxel –DCB technology. However, calcified lesions seem to affect the efficacy of DCB. Combinations of preconditioning methods with DCBs showed promising results. Although the mechanical abrasion of calcium via atherectomy or laser ablation showed favorable periprocedural results, the long-term impact on restenosis and clinical outcome has to be demonstrated. Major advantages of the DCBs are the rapid delivery of drug at uniform concentrations with a single dose, their efficacy in areas wherein stents have been contraindicated until now (ie, bifurcation, ostial lesions), and in leaving no stent scaffold behind. Reinterventions are easier to perform because DCBs leave no metal behind. Various combinations of DCBs with other treatment modalities may prove to be viable options in future. The follow-up results of clinical studies will evaluate the long-term impact of DCBs.
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Affiliation(s)
- Monika Herten
- Department of Vascular and Endovascular Surgery, University Hospital Münster
| | - Giovanni B Torsello
- Department of Vascular and Endovascular Surgery, University Hospital Münster; Department of Vascular Surgery, St Franziskus Hospital, Münster
| | - Eva Schönefeld
- Institute for Education and Student Affairs, University Hospital Münster, Münster, Germany
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Krishnan P, Tarricone A, Ali Z, Purushothaman KR, Overbey J, Vasquez M, Wiley J, Kapur V, Gujja K, Atallah RT, Nasiadko K, Kini A, Sharma S. Intravascular Ultrasound Is an Effective Tool for Predicting Histopathology-Confirmed Evidence of Adventitial Injury Following Directional Atherectomy for the Treatment of Peripheral Artery Disease. J Endovasc Ther 2016; 23:672-3. [PMID: 27413065 DOI: 10.1177/1526602816647364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Prakash Krishnan
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Arthur Tarricone
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Ziad Ali
- Center for Interventional Vascular Therapy, Division of Cardiology, New York Presbyterian Hospital and Columbia University, New York, NY, USA
| | | | - Jessica Overbey
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Miguel Vasquez
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Jose Wiley
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Vishal Kapur
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Karthik Gujja
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | | | | | - Annapoorna Kini
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Samin Sharma
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
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