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Salahuddin T, Giannopoulos S, Adams G, Armstrong EJ. Anterior, posterior, or all-vessel infrapopliteal revascularization in patients with moderate-severe claudication: Insights from the LIBERTY 360 study. Catheter Cardiovasc Interv 2021; 98:559-569. [PMID: 34057276 DOI: 10.1002/ccd.29780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 04/14/2021] [Accepted: 05/17/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little data guides revascularization of infrapopliteal peripheral arterial disease (PAD) in patients with claudication. We assessed outcomes after infrapopliteal-only intervention for claudication in the LIBERTY 360 observational study. METHODS In this post hoc analysis, LIBERTY 360 patients (N = 128) with claudication and isolated infrapopliteal disease undergoing endovascular revascularization were divided by territory into anterior-vessel, posterior-vessel, or all-vessel groups. Patients were followed for periprocedural, in-hospital, and long-term outcomes. Logistic regression for odds ratios, Cox proportional hazard models, ANOVA, and Kaplan-Meier estimates were utilized to compare outcomes. RESULTS Patients underwent anterior (N = 37), posterior (N = 76), or all-vessel (N = 15) infrapopliteal revascularization. Initial procedural success was 86%, 86%, and 69% for anterior, posterior, and all-vessel groups, respectively. Each group had improvements in Rutherford classification (RC) from baseline to 2 years (mean RC change: -1.3, -1.5, and -1.5, respectively). Compared with all-vessel intervention, both anterior and posterior groups had lower rate of major adverse events (MAE) and target vessel revascularization (TVR) at 3 years (MAE: 12% and 15% in anterior and posterior groups, respectively compared with 51% in the all-vessel group; hazard ratios and 95% CIs 0.22 [0.06-0.74], p = .015; 0.24 [0.09-0.64], p = .004). Other outcomes were similar among the three groups. The anterior group showed more improvement in pain subdomain and total VascuQoL scores compared with posterior and all-vessel groups at 2 years (p = .016, p = .020 and p = .068, p = .009, respectively). CONCLUSIONS Both anterior or posterior revascularization have favorable outcomes and may be beneficial for improvement of symptoms in claudicants with isolated infrapopliteal PAD.
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Affiliation(s)
- Taufiq Salahuddin
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - George Adams
- North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, North Carolina, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, Colorado, USA
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Review of the Latest Percutaneous Devices in Critical Limb Ischemia. J Clin Med 2018; 7:jcm7040082. [PMID: 29661987 PMCID: PMC5920456 DOI: 10.3390/jcm7040082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 04/10/2018] [Accepted: 04/10/2018] [Indexed: 12/05/2022] Open
Abstract
Critical limb ischemia (CLI) is a terminal stage of peripheral arterial disease that, in the absence of intervention, may lead to lower extremity amputation or death. Endovascular interventions have become a first-line approach to the management of CLI and have advanced considerably within the past decade. This review summarizes the types of percutaneous devices and the techniques that are available for the management of CLI and the data supporting their use. These include devices that establish and maintain vessel patency, including percutaneous transluminal angioplasty, drug-coated balloons, bare metal stents, drug-eluting stents, bioresorbable vascular scaffolds, and atherectomy; devices that provide protection from embolization; and, cell-based therapies. Additionally, ongoing trials with important implications for the field are discussed.
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Mustapha J, Diaz-Sandoval LJ. Balloon Angioplasty in Tibioperoneal Interventions for Patients With Critical Limb Ischemia. Tech Vasc Interv Radiol 2014; 17:183-96. [DOI: 10.1053/j.tvir.2014.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gray BH, Diaz-Sandoval LJ, Dieter RS, Jaff MR, White CJ. SCAI expert consensus statement for infrapopliteal arterial intervention appropriate use. Catheter Cardiovasc Interv 2014; 84:539-45. [DOI: 10.1002/ccd.25395] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 01/01/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Bruce H. Gray
- University of South Carolina School of Medicine/Greenville; Greenville South Carolina
| | | | | | - Michael R. Jaff
- MGH Institute for Heart, Vascular and Stroke Care, Harvard University, Boston, Massachusetts
| | - Christopher J. White
- John Ochsner Heart & Vascular institute, Ochsner Medical Center; New Orleans Louisiana
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Davies MG, Anaya-Ayala JE. Endovascular techniques in limb salvage: cutting, cryo, brachy, and drug-eluting balloons. Methodist Debakey Cardiovasc J 2014; 9:69-72. [PMID: 23805337 DOI: 10.14797/mdcj-9-2-69] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The complex pathophysiology response to injury of the lower-extremity arteries has prompted the development of several unique balloon technologies to overcome initial technical failures and short-term intimal hyperplasia. Cryoplasty alters the cellular and mechanical properties of the vessel wall during angioplasty. Cutting balloons incise the wall, preventing elastic recoil and allowing expansion of the lumen at a lower pressure, thus limiting barotrauma. Drug-eluting balloons actively transfer inhibitory compounds to the wall during the initial therapy, while brachytherapy balloons allow for localized delivery of radiation to inhibit the proliferative response seen after angioplasty. These platforms provide unique means to enhance immediate and short-term results and also reduce stent usage in the lower extremity.
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Affiliation(s)
- Mark G Davies
- Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, Texas, USA
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Shin SH, Baril DT, Chaer RA, Makaroun MS, Marone LK. Cryoplasty offers no advantage over standard balloon angioplasty for the treatment of in-stent stenosis. Vascular 2013; 21:349–54. [DOI: 10.1177/1708538112473968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In-stent restenosis is the primary failure mode of endovascular treatment of occlusive disease in the femeropopliteal segment. Cryoplasty has been proposed to reduce intimal hyperplasia through induction of apoptosis. We sought to evaluate the efficacy of cryoplasty for treatment of in-stent restenosis compared to conventional balloon angioplasty (CBA). After IRB approval, a retrospective record review was performed of reinterventions for in-stent restenosis by a single vascular surgery group at a university hospital. Reinterventions involving cryoplasty and CBA were evaluated at 1, 3, 6 and 12 months after intervention with duplex imaging to identify significant recurrent stenosis utilizing established velocity criteria. Data collected included basic demographic information and comorbidities as well as time to restenosis. Statistical analysis was performed using Kaplan–Meier survival curves with the log rank test, Wilcoxon rank test, and Cox proportional hazards models. From December 2004 to November 2007, 76 reinterventions were performed using CBA (n = 39) or cryoplasty (n = 37) for in-stent restenosis without placement of additional stents. Periprocedural technical success (>30% residual stenosis) was 100% for both groups, with no complications. The two cohorts were statistically similar in mean age, gender, comorbidities, tobacco use and use of statins, aspirin and Plavix. However, the mean lesion length was significantly longer in the cryoplasty cohort (CBA: 140.9 mm, Cyro: 191.7 mm; P = 0.032). The mean time to recurrent stenosis or need for additional secondary intervention was significantly shorter for the cyroplasty cohort than for the CBA, 4.09 and 10.79 months, respectively ( P = .0001). Recurrent stenosis-free survival was significantly lower in the cyroplasty cohort at 3 months (CBA: 96.9%, Cyro: 88.9%) and 6 months (CBA: 84.0%, Cyro: 43.8%; P = .0089). Cyroplasty as a modality for treatment of in-stent stenosis in the femoropopliteal segment offers no benefit over CBA.
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Rollins KE, Jackson D, Coughlin PA. Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia. Br J Surg 2013; 100:1002-8. [PMID: 23649310 DOI: 10.1002/bjs.9127] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Critical leg ischaemia (CLI) has been associated with high mortality rates. There is a lack of contemporary data on both short- and long-term mortality rates in patients diagnosed with CLI. METHODS This was a systematic literature search for studies prospectively reporting mortality in patients diagnosed with CLI. Meta-analysis and meta-regression models were developed to determine overall mortality rates and specific patient-related factors that were associated with death. RESULTS A total of 50 studies were included in the analysis The estimated probability of all-cause mortality in patients with CLI was 3·7 per cent at 30 days, 17·5 per cent at 1 year, 35·1 per cent at 3 years and 46·2 per cent at 5 years. Men had a statistically significant survival benefit at 30 days and 3 years. The presence of ischaemic heart disease, tissue loss and older age resulted in a higher probability of death at 3 years. CONCLUSION Early mortality rates in patients diagnosed with CLI have improved slightly compared with previous historical data, but long-term mortality rates are still high.
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Affiliation(s)
- K E Rollins
- Department of Vascular Surgery, Addenbrooke's Hospital, Cambridge, UK
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Rand T, Uberoi R. Current Status of Interventional Radiology Treatment of Infrapopliteal Arterial Disease. Cardiovasc Intervent Radiol 2012; 36:588-98. [DOI: 10.1007/s00270-012-0524-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 11/05/2012] [Indexed: 10/27/2022]
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Venkatachalam S, Shishehbor MH, Gray BH. Basic Data Related to Endovascular Management of Peripheral Arterial Disease in Critical Limb Ischemia. Ann Vasc Surg 2012; 26:1039-51. [DOI: 10.1016/j.avsg.2012.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
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Post-Dilation of Superficial Femoral Artery Stents With Cryoplasty. J Am Coll Cardiol 2012; 60:1360-3. [DOI: 10.1016/j.jacc.2012.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 11/19/2022]
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11
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New Treatments for Infrapopliteal Disease: Devices, Techniques, and Outcomes So Far. Cardiovasc Intervent Radiol 2012; 35:715-24. [DOI: 10.1007/s00270-012-0412-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 04/20/2012] [Indexed: 11/25/2022]
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12
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Shammas NW, Coiner D, Shammas G, Christensen L, Jerin M. Percutaneous lower extremity arterial interventions using primary balloon angioplasty versus cryoplasty: a randomized pilot trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2012; 13:172-6. [DOI: 10.1016/j.carrev.2011.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Revised: 11/24/2011] [Accepted: 12/08/2011] [Indexed: 10/28/2022]
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Basco MT, Schlösser FJV, Muhs BE, Indes JE, Blume PA, Key JJ, Aruny JE, Sumpio BE. Lower extremity limb salvage with cryoplasty: a single-center cohort study. Vascular 2012; 20:36-41. [DOI: 10.1258/vasc.2011.oa0309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endovascular techniques have been playing an increasing role in managing lower extremity chronic critical limb ischemia (CLI) in patients considered poor or non-candidates for surgical revascularization secondary to co-morbidities such as coronary artery disease, uncontrolled hypertension, diabetes mellitus or inadequate conduit. This study reviews our recent clinical experience in the treatment of peripheral artery disease solely using cryoplasty. A retrospective cohort study was performed. The cohort consisted of 88 patients who underwent lower extremity revascularization utilizing cryoplasty between December 2003 and August 2007. Indications for intervention included poor wound healing after forefoot amputation or persistent ulceration of the foot, disabling claudication and rest pain. Kaplan–Meier analysis was performed to assess salvage rates. One hundred twenty-six lesions were treated in 88 patients. Technical success rate was 97%. Limb salvage rates were 75 and 63% for patients with critical limbs ischemia after one and three years, respectively. A history of smoking was associated with a threefold increased risk of limb loss. In conclusion, endovascular management of lower extremity lesions with cryoplasty is an emerging and viable paradigm in the treatment of CLI in an attempt to preserve limbs and avoid major amputations.
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Affiliation(s)
- Maria T Basco
- Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
| | - Felix J V Schlösser
- Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
| | - Bart E Muhs
- Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
- Department of Radiology
| | - Jeffrey E Indes
- Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
| | | | - Jonathan J Key
- Department of Orthopaedics and Rehabilitation, Section of Podiatric Surgery, Yale School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | | | - Bauer E Sumpio
- Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
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Gasper WJ, Runge SJ, Owens CD. Management of Infrapopliteal Peripheral Arterial Occlusive Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:136-48. [DOI: 10.1007/s11936-012-0164-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Yan BP, Moran D, Hynes BG, Kiernan TJ, Yu CM. Advances in Endovascular Treatment of Critical Limb Ischemia. Circ J 2011; 75:756-65. [DOI: 10.1253/circj.cj-11-0103] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital & Institute of Vascular Medicine, The Chinese University of Hong Kong
| | - Darragh Moran
- Department of Cardiology, Cork University Hospital, University College Cork School of Medicine
| | - Brian G Hynes
- Section of Interventional Cardiology and Vascular Medicine, Massachusetts General Hospital
| | - Thomas J Kiernan
- Department of Cardiology, Cork University Hospital, University College Cork School of Medicine
| | - Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital & Institute of Vascular Medicine, The Chinese University of Hong Kong
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Huijbregts H, de Borst G, Veldhuis W, Verhagen H, Velema E, Pasterkamp G, Moll F, Blankestijn P, Hoefer I. Cryoplasty of the Venous Anastomosis for Prevention of Intimal Hyperplasia in a Validated Porcine Arteriovenous Graft Model. Eur J Vasc Endovasc Surg 2010; 39:620-6. [DOI: 10.1016/j.ejvs.2009.12.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Accepted: 12/25/2009] [Indexed: 11/26/2022]
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Simons JP, Goodney PP, Nolan BW, Cronenwett JL, Messina LM, Schanzer A. Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia. J Vasc Surg 2010; 51:1419-24. [PMID: 20456908 DOI: 10.1016/j.jvs.2010.01.083] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 01/26/2010] [Accepted: 01/26/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies of infrainguinal lower extremity bypass for critical limb ischemia (CLI) have traditionally emphasized outcomes of patency, limb salvage, and death. Because functional outcomes are equally important, our objectives were to describe the proportion of CLI patients who did not achieve symptomatic improvement 1 year after bypass, despite having patent grafts, and identify preoperative factors associated with this outcome. METHODS The prospectively collected Vascular Study Group of Northern New England database was used to identify all patients with elective infrainguinal lower extremity bypass for CLI (2003 to 2007) for whom long-term follow-up data were available. The primary composite study end point was clinical failure at 1 year after bypass, defined as amputation or persistent or worsened ischemic symptoms (rest pain or tissue loss), despite a patent graft. Variables identified on univariate screening (inclusion threshold, P < .20) were included in a multivariable logistic regression model to identify independent predictors. RESULTS Long-term follow-up data were available for 1012 patients who underwent infrainguinal bypasses for CLI, of which 788 (78%) remained patent at 1 year. Of these, 79 (10%) met criteria for the composite end point of clinical failure: 21 (2.7%) for major amputations and 58 (7.4%) for persistent rest pain or tissue loss. In multivariable analysis, significant predictors of clinical failure included dialysis dependence (odds ratio [OR], 3.74; 95% confidence interval [CI], 1.84-7.62; P < .001) and preoperative inability to ambulate independently (OR, 2.17; 95% CI, 1.26-3.73; P = .005). A history of coronary artery bypass graft or percutaneous coronary intervention was protective (OR, 0.52; 95% CI, 0.29-0.93; P = .03). CONCLUSIONS After infrainguinal lower extremity bypass for CLI, 10% of patients with a patent graft did not achieve clinical improvement at 1 year. Preoperative identification of this specific patient subgroup remains challenging. To improve surgical decision making and the overall care of CLI patients, further emphasis needs to be placed on functional outcomes in addition to traditional surgical end points.
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Affiliation(s)
- Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass 01655, USA
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Schanzer A. Impact of Comorbidities on Decision-Making in Chronic Critical Limb Ischemia. Semin Vasc Surg 2009; 22:209-15. [DOI: 10.1053/j.semvascsurg.2009.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Biondi-Zoccai GGL, Sangiorgi G. Commentary: Below-the-Knee/Ankle Revascularization:Tools of the Trade. J Endovasc Ther 2009; 16:613-6. [PMID: 19842731 DOI: 10.1583/09-2793c1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
The 1- to 2-year primary patency rates associated with self-expanding nitinol stents for the treatment of symptomatic femoropopliteal disease are superior to those for percutaneous transluminal angioplasty (PTA) and the first-generation stainless steel balloon-expandable stents. The advantages of nitinol stents include improved radial strength and flexibility, the ability to recover from being crushed, reduced foreshortening, and (importantly) deployability without balloon dilation of the stent edge (which may decrease the incidence of the edge stenosis, or "candy-wrap" effect, often observed with balloon-expandable stents). The technical success rate associated with primary deployment of nitinol stents is very high, and acute to 6-month patency results are predictably excellent. Prior to the introduction of nitinol stents, the original guidelines (2000) of the multidisciplinary TransAtlantic Inter-Society Consensus (TASC I) recommended only an adjunctive role for femoropopliteal stents following suboptimal PTA. The abbreviated 2007 TASC II report essentially extended this recommendation to nitinol stents. Here, current trials of nitinol stenting in the femoropopliteal segment are discussed, with emphasis on the advantages of primary (and often direct) deployment in selected circumstances dependent on factors including lesion length, lesion location, indication for treatment (critical limb ischemia or claudication, in-stent restenosis, stent-graft restenosis), and the relative appropriateness of other modalities (e.g., covered stents). Technical considerations in primary nitinol stenting are briefly reviewed. Open questions regarding the factors involved in nitinol stent fracture and the possible association of fracture and restenosis are examined in the context of current clinical trials. A new generation of femoropopliteal nitinol stents combining superior durability and flexibility is expected soon. Development and implementation of uniform reporting and surveillance standards is important for optimizing current and future research.
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Affiliation(s)
- Mark W Mewissen
- Vascular Center, St. Luke's Medical Center, 2801 W. Kinnickinnic River Parkway, Suite 514, Milwaukee, WI 53215, USA.
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Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of critical limb ischemia. J Endovasc Ther 2009; 16:II31-62. [PMID: 19624074 DOI: 10.1583/08-2657.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.
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Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA.
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Lumsden AB, Das TS. Second Symposium on Endovascular Management of Infrainguinal Disease. J Endovasc Ther 2009; 16:II1-4. [PMID: 19624071 DOI: 10.1583/1545-1550-16.sp13.ii1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, Texas, USA
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Laird JR, Dawson DL. The Role for Cryoplasty in the Treatment of Infrainguinal Artery Disease:Case Studies. J Endovasc Ther 2009; 16:II116-28. [DOI: 10.1583/08-2653.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lyden SP, Smouse HB. TASC II and the Endovascular Management of Infrainguinal Disease. J Endovasc Ther 2009; 16:II5-18. [DOI: 10.1583/08-2659.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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