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Matsumoto Y, Shimada R, Morioka H, Morino Y. Repeated thrombus occlusion in superficial femoral artery at the gap between two stents: a case report. Eur Heart J Case Rep 2023; 7:ytad542. [PMID: 38025124 PMCID: PMC10664413 DOI: 10.1093/ehjcr/ytad542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
Background In recent years, endovascular treatment has emerged as a preferred option for treating long lesions in the superficial femoral artery (SFA), including those classified as Trans-Atlantic Inter-Society Consensus IIC and D. This approach may involve the use of multiple stents to ensure adequate coverage of the entire lesion, as maintaining primary patency is a key consideration in the treatment strategy. Case summary An 82-year-old woman underwent endovascular treatment with two stents for a chronic total occlusion lesion in the left SFA. Six months later, she was admitted to our hospital with acute limb ischaemia (ALI). Angiography revealed significant thrombus within the stents and a gap between the stents, while intravascular ultrasounds showed neointimal hyperplasia at the gap. Initially, the patient was treated with a cutting balloon for the gap, but experienced another episode of ALI the following day. Subsequently, a stent was placed to cover the gap, resulting in the resolution of ALI without further recurrence. Discussion Superficial femoral arteries expose the stent to high stresses due to the unique external forces. When multiple stents are implanted, there must be sufficient overlap. If a stent gap occurs, stent deployment is unavoidable due to the neointimal hyperplasia as well as the coronary stent gap. Further research and clinical expertise are needed to optimize stent placement strategies and minimize stent-related complications in SFA lesions.
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Affiliation(s)
- Yuki Matsumoto
- Division of Cardiology, Ofunato Hospital, Ofunato City, Iwate, Japan
| | - Ryutaro Shimada
- Division of Cardiology, Ofunato Hospital, Ofunato City, Iwate, Japan
| | - Hidemi Morioka
- Division of Cardiology, Ofunato Hospital, Ofunato City, Iwate, Japan
| | - Yoshihiro Morino
- Division of Cardiology, Iwate Medical University, Morioka, Iwate, Japan
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Angel de Gregorio M, Brodmann M, Ruiz EM, Manteca JC, Salmeron RR, Munoz Ruiz-Canela JJ, Trujillo IG, Tepe G. Drug-Coated Balloon for the Treatment of Long-Segment Femoropopliteal Artery Disease: Pooled Analysis from the BIOLUX P-III SPAIN and BIOLUX P-III All-Comers Registry Long Lesion Subgroup. J Vasc Interv Radiol 2023; 34:1707-1715.e7. [PMID: 37422253 DOI: 10.1016/j.jvir.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/13/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023] Open
Abstract
PURPOSE To investigate the clinical performance and safety of the Passeo-18 Lux drug-coated balloon (DCB) in complex femoropopliteal Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions in an all-comers patient population. MATERIAL AND METHODS Data from BIOLUX P-III SPAIN, a prospective, national, multicenter, postmarket all-comers registry conducted from 2017 to 2019, and a matching long lesion subgroup from the BIOLUX P-III All-Comers global registry conducted from 2014 to 2018 were pooled for analysis. The primary safety end point was freedom from major adverse events (MAEs) at 6 months, and the primary performance end point was freedom from clinically driven target lesion revascularization (fCD-TLR) at 12 months, both adjudicated by an independent clinical events committee. RESULTS A total of 159 patients, of whom 32.7% had critical limb ischemia, were included in the Passeo-18 Lux long lesion cohort. The mean lesion length was 248.5 mm ± 71.6, and the majority were occluded (54.1%), calcified (87.4%), and of type TASC C (49.1%) or TASC D (50.9%). Freedom from MAEs was 90.6% (95% CI, 84.6-94.3) at 6 months and 83.9% (95% CI, 76.7-89.0) at 12 months. fCD-TLR was 84.4% (95% CI, 77.3-89.5) at 12 months. Freedom from target limb major amputation was 98.6% (95% CI, 94.6-99.7), and all-cause mortality was 5.3% (95% CI, 2.7-10.4) at 12 months. There were no device- or procedure-related deaths or amputations up to the 12-month follow-up. CONCLUSION Passeo-18 Lux DCB is safe and effective for the treatment of long femoropopliteal lesions in a real-word setting.
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Affiliation(s)
| | | | - Esau Martinez Ruiz
- Department of Angiology and Vascular Surgery, Hospital de Mataro, Barcelona, Spain
| | - Jorge Cuenca Manteca
- Department of Angiology and Vascular Surgery, Hospital Universitario San Cecilio, Granada, Spain
| | | | | | | | - Gunnar Tepe
- Department of Radiology, Klinikum Rosenheim, Rosenheim, Germany
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3
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Colombo M, Corti A, Gallo D, Colombo A, Antognoli G, Bernini M, McKenna C, Berceli S, Vaughan T, Migliavacca F, Chiastra C. Superficial femoral artery stenting: Impact of stent design and overlapping on the local hemodynamics. Comput Biol Med 2022; 143:105248. [PMID: 35124437 DOI: 10.1016/j.compbiomed.2022.105248] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Superficial femoral arteries (SFAs) treated with self-expanding stents are widely affected by in-stent restenosis (ISR), especially in case of long lesions and multiple overlapping devices. The altered hemodynamics provoked by the stent is considered as a promoting factor of ISR. In this context, this work aims to analyze the impact of stent design and stent overlapping on patient-specific SFA hemodynamics. METHODS Through a morphing technique, single or multiple stents were virtually implanted within two patient-specific, post-operative SFA models reconstructed from computed tomography. The stented domains were used to perform computational fluid dynamics simulations, quantifying wall shear stress (WSS) based descriptors including time-averaged WSS (TAWSS), oscillatory shear index (OSI), transverse WSS (transWSS), and WSS ratio (WSSRATIO). Four stent designs (three laser-cut - EverFlex, Zilver and S.M.A.R.T. - and one prototype braided stent), and three typical clinical scenarios accounting for different order of stent implantation and overlapping length were compared. RESULTS The main hemodynamic differences were found between the two types of stent designs (i.e. laser-cut vs. braided stents). The braided stent presented lower median transWSS and higher median WSSRATIO than the laser-cut stents (p < 0.0001). The laser-cut stents presented comparable WSS-based descriptor values, except for the Zilver, exhibiting a median TAWSS ∼30% higher than the other stents. Stent overlapping provoked an abrupt alteration of the WSS-based descriptors. The overlapping length, rather than the order of stent implantation, highly and negatively impacted the hemodynamics. CONCLUSION The proposed computational workflow compared different SFA stent designs and stent overlapping configurations, highlighting those providing the most favorable hemodynamic conditions.
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Affiliation(s)
- Monika Colombo
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy; Institute for Chemical and Bioengineering, ETH Zurich, Zurich, Switzerland
| | - Anna Corti
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Diego Gallo
- PoliTo(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Andrea Colombo
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Giacomo Antognoli
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Martina Bernini
- Biomechanics Research Centre (BioMEC), National University of Ireland Galway, Ireland
| | - Ciara McKenna
- Biomechanics Research Centre (BioMEC), National University of Ireland Galway, Ireland
| | - Scott Berceli
- Department of Surgery, University of Florida, Gainesville, FL, USA; Malcom Randall VAMC, Gainesville, FL, USA
| | - Ted Vaughan
- Biomechanics Research Centre (BioMEC), National University of Ireland Galway, Ireland
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Claudio Chiastra
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy; PoliTo(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.
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4
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Kostanyan GM, Khramykh TP, Gaygiev TI, Ermolaev PA, Kolbina MV, Memus KP. [Endovascular treatment for critical limb ischemia in patients with diabetes mellitus: new opportunities and prospects]. Khirurgiia (Mosk) 2022:99-104. [PMID: 36223156 DOI: 10.17116/hirurgia202210199] [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: 06/16/2023]
Abstract
Diabetes mellitus (DM) is still one of the most common endocrine diseases despite all available technologies in modern medicine. In recent years, it was shown that severity and duration of DM are closely associated with vascular wall lesions (the called micro-and macroangiopathy). One of severe clinical signs is damage to lower limb arteries followed by trophic and purulent-necrotic lesions of soft tissues (diabetic foot syndrome) and risk of amputation. The authors review the possibilities of endovascular treatment of critical limb ischemia in patients with diabetes mellitus. The features of endovascular interventions depending on clinical and morphological peculiarities of vascular lesions are discussed. The authors compared the results of open and endovascular treatment of lower limb ischemia and determined further prospects for improving the treatment of these patients.
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Affiliation(s)
- G M Kostanyan
- Omsk State Medical University, Omsk, Russia
- Clinical Medical and Sanitary Unit No. 9, Omsk, Russia
| | | | - T I Gaygiev
- Clinical Medical and Sanitary Unit No. 9, Omsk, Russia
| | | | | | - K P Memus
- Omsk State Medical University, Omsk, Russia
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Colombo M, He Y, Corti A, Gallo D, Ninno F, Casarin S, Rozowsky JM, Migliavacca F, Berceli S, Chiastra C. In-Stent Restenosis Progression in Human Superficial Femoral Arteries: Dynamics of Lumen Remodeling and Impact of Local Hemodynamics. Ann Biomed Eng 2021; 49:2349-2364. [PMID: 33928465 PMCID: PMC8455500 DOI: 10.1007/s10439-021-02776-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/31/2021] [Indexed: 12/17/2022]
Abstract
In-stent restenosis (ISR) represents a major drawback of stented superficial femoral arteries (SFAs). Motivated by the high incidence and limited knowledge of ISR onset and development in human SFAs, this study aims to (i) analyze the lumen remodeling trajectory over 1-year follow-up period in human stented SFAs and (ii) investigate the impact of altered hemodynamics on ISR initiation and progression. Ten SFA lesions were reconstructed at four follow-ups from computed tomography to quantify the lumen area change occurring within 1-year post-intervention. Patient-specific computational fluid dynamics simulations were performed at each follow-up to relate wall shear stress (WSS) based descriptors with lumen remodeling. The largest lumen remodeling was found in the first post-operative month, with slight regional-specific differences (larger inward remodeling in the fringe segments, p < 0.05). Focal re-narrowing frequently occurred after 6 months. Slight differences in the lumen area change emerged between long and short stents, and between segments upstream and downstream from stent overlapping portions, at specific time intervals. Abnormal patterns of multidirectional WSS were associated with lumen remodeling within 1-year post-intervention. This longitudinal study gave important insights into the dynamics of ISR and the impact of hemodynamics on ISR progression in human SFAs.
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Affiliation(s)
- Monika Colombo
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Yong He
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Anna Corti
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Diego Gallo
- PoliToBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Federica Ninno
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
- Department of Medical Physics and Biomedical Engineering, University College of London, London, UK
| | - Stefano Casarin
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Center for Computational Surgery, Houston Methodist Research Institute, Houston, TX, USA
- Houston Methodist Academic Institute, Houston, TX, USA
| | - Jared M Rozowsky
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Scott Berceli
- Department of Surgery, University of Florida, Gainesville, FL, USA
- Malcom Randall VAMC, Gainesville, FL, USA
| | - Claudio Chiastra
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy.
- PoliToBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.
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Zeller T, Lopez L, Pigott JP. Acute Outcomes With a Novel Plaque Modification System in Real-World Femoropopliteal Lesions. J Endovasc Ther 2019; 26:333-341. [DOI: 10.1177/1526602819849955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Purpose: To report outcomes of a multicenter feasibility study using the FLEX Vessel Prep (VP) System, a novel technology that facilitates plaque incision and lumen gain in stenosed or occluded femoropopliteal arteries prior to balloon angioplasty. Materials and Methods: Two hundred fifty-five patients (mean age 71.8±9.1 years) were treated with the FLEX VP System at 38 centers between December 2015 and November 2017. Average lesion length was 133±88 mm. Average baseline stenosis was 92%±11%; 112 (44.3%) of 253 patients presented with a chronic total occlusion. Conventional or drug-coated balloon (DCB) angioplasty was performed in all patients after vessel preparation. Vessel measurements were derived from angiograms acquired at baseline, after FLEX passage, and after subsequent ancillary procedures. Logistic regression analyses were performed to identify baseline or procedure variables that predicted the need for provisional stenting. Results: Average percent reduction in vessel stenosis following treatment with the FLEX VP System was 27%±17%. No flow-limiting dissection, vessel perforation, or embolization was observed; 15 (5.9%) patients had minor (type A or B) dissections. Provisional stenting was performed in 49 (19.2%) patients. Average stenosis following angioplasty ± stenting was 9.1%±7.4%; 9 (3.6%) patients had significant residual stenosis ≥30%. Logistic regression analyses found that patients with dissections, longer lesions, and those receiving conventional balloon dilation alone were most likely to undergo stenting. Conclusion: In a real-world patient population with long, complex femoropopliteal lesions, use of the FLEX VP System as vessel preparation for angioplasty improved acute outcomes compared to historical controls. The rate of provisional stenting was low, and no serious vessel complications were observed.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Freiburg–Bad Krozingen, Bad Krozingen, Germany
| | - Louis Lopez
- Allen County Cardiology, Saint Joseph Hospital, Fort Wayne, IN, USA
| | - John P. Pigott
- Jobst Vascular Institute, Promedica Healthcare Systems, Toledo, OH, USA
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Spiliopoulos S, Kitrou P, Galanakis N, Papadimatos P, Katsanos K, Konstantos C, Palialexis K, Reppas L, Kehagias E, Karnabatidis D, Brountzos E, Tsetis D. Incidence and Endovascular Treatment of Isolated Atherosclerotic Popliteal Artery Disease: Outcomes from the IPAD Multicenter Study. Cardiovasc Intervent Radiol 2018; 41:1481-1487. [PMID: 29992345 DOI: 10.1007/s00270-018-2028-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/06/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To report the incidence and long-term outcomes following endovascular treatment of symptomatic, atherosclerotic isolated popliteal artery disease (IPAD). MATERIALS AND METHODS This retrospective, multicenter study included all patients who underwent endovascular treatment of IPAD between January 2010 and December 2016 because of intermittent claudication or critical limb ischemia (CLI), in three tertiary University Hospitals. In total, 4717 peripheral arterial disease (PAD) procedures were analyzed. The study's primary outcome measures were: IPAD incidence, binary restenosis rate and freedom from target lesion revascularization (TLR). Secondary outcome measures included technical success, limb salvage rate and the identification of predictors of outcomes. RESULTS The incidence of IPAD was 0.98% (46/4717 PAD procedures). In total, 46 patients (38 male; mean age 73 ± 12 years) underwent plain balloon (69.5%) or bail-out stenting (30.5%) procedures. Most patients suffered from CLI (65.2%). Mean lesion length was 52.5 ± 32.0 mm and 45.6% of the cases were occlusions. Severe calcifications were noted in 26.1%. Technical success was 100%. Mean time follow-up was 32.6 ± 25.6 months. According to Kaplan-Meier analysis, restenosis was 15.8, 40.9, 45.8% and TLR-free rate was 90.5, 79.0, 74.1%, at 1, 2 and 3 years, respectively. Survival and limb salvage rates were 73.6 and 88.1%, at 5 years, respectively. The major amputation rate for CLI patients was 10.0% (3/29 limbs), while no major amputations occurred in the claudication subgroup. Cox multivariable analysis detected baseline occlusion as an independent predictor of increased restenosis (HR 5.3; 95% CI 0.21-0.66, p = 0.02). CONCLUSIONS Isolated popliteal lesions requiring treatment appear in nearly 1% of patients with PAD. Balloon angioplasty and bail-out stenting resulted in acceptable long-term clinical outcomes. Treatment of occlusions was correlated with increased restenosis rate.
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Affiliation(s)
- Stavros Spiliopoulos
- Division of Interventional Radiology, 2nd Department of Radiology, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Panagiotis Kitrou
- Department of Interventional Radiology, Patras University Hospitral, Rion, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
| | | | | | - Chrysostomos Konstantos
- Division of Interventional Radiology, 2nd Department of Radiology, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Palialexis
- Division of Interventional Radiology, 2nd Department of Radiology, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Lazaros Reppas
- Division of Interventional Radiology, 2nd Department of Radiology, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
| | | | - Elias Brountzos
- Division of Interventional Radiology, 2nd Department of Radiology, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
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Lindgren HIV, Qvarfordt P, Bergman S, Gottsäter A. Primary Stenting of the Superficial Femoral Artery in Patients with Intermittent Claudication Has Durable Effects on Health-Related Quality of Life at 24 Months: Results of a Randomized Controlled Trial. Cardiovasc Intervent Radiol 2018; 41:872-881. [PMID: 29520431 PMCID: PMC5937864 DOI: 10.1007/s00270-018-1925-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intermittent claudication (IC) is commonly caused by lesions in the superficial femoral artery (SFA), yet invasive treatment is still controversial and longer term patient-reported outcomes are lacking. This prospective randomized trial assessed the 24-month impact of primary stenting with nitinol self-expanding stents compared to best medical treatment (BMT) alone in patients with stable IC due to SFA disease on health-related quality of life (HRQoL). METHODS One hundred patients with stable IC due to SFA disease treated with BMT were randomized to either stent (n = 48) or control (n = 52) group. HRQoL assessed by Short Form 36 Health Survey (SF-36) and EuroQoL 5-dimensions (EQ5D) 24 months after treatment were primary outcome measures. Walking Impairment Questionnaire, ankle-brachial index (ABI), and walking distance were secondary outcomes. RESULTS Significantly better SF-36 Physical Component Summary (P = 0.024) and physical domain scores such as Physical Function (P = 0.012), Bodily Pain (P = 0.002), General Health (P = 0.037), and EQ5D (P = 0.010) were reported in intergroup comparison between the stent and the control group. Both ABI (from 0.58 ± 0.11 to 0.85 ± 0.18; P < 0.001 in the stent group and from 0.63 ± 0.17 to 0.69 ± 0.18; P = 0.036 in the control group) and walking distance (from 170 ± 90 m to 616 ± 375 m; P < 0.001 in the stent group and from 209 ± 111 m to 331 ± 304 m; P = 0.006 in the control group) improved significantly in intragroup comparisons. CONCLUSIONS In patients with IC caused by lesions in the SFA, primary stenting compared to BMT alone was associated with significant improvements in HRQoL, ABI, and walking distance durable up to 24 months of follow-up. Clinical Trial Registration http://www.clinicaltrials.gov . Unique Identifier: NCT01230229.
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Affiliation(s)
- Hans I V Lindgren
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Interventional Radiology and Surgery, Helsingborg Hospital, 251 87, Helsingborg, Sweden.
| | - Peter Qvarfordt
- Department of Interventional Radiology and Surgery, Helsingborg Hospital, 251 87, Helsingborg, Sweden
| | - Stefan Bergman
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Vascular Centre, Skåne University Hospital, 205 02, Malmö, Sweden
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