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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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Kovaleski A. Trends in outcomes associated with the use of Auryon atherectomy system in a real-world setting. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:27-31. [PMID: 37393189 DOI: 10.1016/j.carrev.2023.06.020] [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] [Received: 12/08/2022] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND While endovascular approaches are considered first line treatment for stenosis or occlusion of the lower limb arteries, major dissections and embolic events remain procedural risks. Newer technologies are needed which limit these complications while achieving desired clinical outcomes. METHODS The Auryon atherectomy system (AngioDynamics) consists of a 355-nm wavelength solid-state Nd:YAG short pulse laser combined with dedicated optical catheters. This single-center, retrospective chart review assessed the safety and efficacy of this device in patients with PAD treated at our center between March and December 2020. RESULTS A total of 55 patients were included. Mean age was 73.7 ± 9.3 years with 63.6 % of patients being males. Lesions were above the knee only for 16.4 % of patients, below the knee only for 3.6 %, and both above and below the knee for 80.0 % of patients. One patient had in-stent restenosis. Chronic total occlusions and critical limb ischemia were present for 43.6 % of patients respectively. Procedural success, defined as <30 % residual stenosis without any complications, was achieved in 85.5 % of patients. Stenosis/re-occlusion occurred in 25.5 % of patients at a mean of 168.9 ± 73.4 days with resultant target lesion revascularization (TLR) at 218.3 ± 92.4 days. Four patients underwent minor amputations. No patients experienced procedure-related complications. One patient died unrelated to the procedure. CONCLUSION The Auryon laser system was shown to be safe and effective in this real-world patient population with no procedural adverse events or deaths and improvements in patient outcomes.
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Affiliation(s)
- Aaron Kovaleski
- Endovascular Consultants of Colorado, Lone Tree, CO 80124, United States of America.
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Tay S, Abdulnabi S, Saffaf O, Harroun N, Yang C, Semenkovich CF, Zayed MA. Comprehensive Assessment of Current Management Strategies for Patients With Diabetes and Chronic Limb-Threatening Ischemia. Clin Diabetes 2021; 39:358-388. [PMID: 34866779 PMCID: PMC8603325 DOI: 10.2337/cd21-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease. It is estimated that 60% of all nontraumatic lower-extremity amputations performed annually in the United States are in patients with diabetes and CLTI. The consequences of this condition are extraordinary, with substantial patient morbidity and mortality and high socioeconomic costs. Strategies that optimize the success of arterial revascularization in this unique patient population can have a substantial public health impact and improve patient outcomes. This article provides an up-to-date comprehensive assessment of management strategies for patients afflicted by both diabetes and CLTI.
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Affiliation(s)
- Shirli Tay
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sami Abdulnabi
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Omar Saffaf
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Nikolai Harroun
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Chao Yang
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Clay F. Semenkovich
- Department of Internal Medicine, Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - Mohamed A. Zayed
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
- Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO
- Department of Biomedical Engineering, Washington University McKelvey School of Engineering, St. Louis, MO
- Veterans Affairs St. Louis Health Care System, St. Louis, MO
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Gupta R, Malgor RD, Siada S, Lai S, Al-Musawi M, Malgor EA, Jacobs DL. Critical Appraisal of the Contemporary Use of Atherectomy to Treat Femoral-Popliteal Atherosclerotic Disease. J Vasc Surg 2021; 75:697-708.e9. [PMID: 34303802 DOI: 10.1016/j.jvs.2021.07.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 07/06/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Atherectomy has become increasingly used as an endovascular treatment of lower extremity atherosclerotic disease in the United States. Concerns and controversies about its indication and outcomes exist. The goal of this systematic review and meta-analysis was to investigate the outcomes and complications related to atherectomy to treat femoropopliteal atherosclerotic disease. METHODS A systematic review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was performed. Four major scientific repositories, MEDLINE, EMBASE, The Cochrane Library, and Thompson Web of Sciences were queried from their inception to April 5, 2020. Data was reviewed and entered in a dedicated dataset by the investigators. Outcomes included patency rates, clinical and hemodynamic improvement, and morbidity and mortality associated with atherectomy interventions. RESULTS Twenty-four studies encompassing 1900 patients met inclusion criteria for this study. 74.3% of patients presented with Rutherford class (RC) 1-3 and 25.7% presented with RC class 4-6. 1445 patients underwent atherectomy, and 455 patients were treated without atherectomy. Atherectomy patients underwent directional atherectomy (DA, n = 851), rotational atherectomy (RA, n = 851), laser atherectomy (LA, n = 201), and orbital atherectomy (OA, n = 78). The majority of patients additionally received adjunct treatments which were variable across studies and included a combination of stenting, balloon angioplasty (BA), or drug coated balloon (DCB) angioplasty. Technical success was achieved in 92.3% of cases. Distal embolization, vessel perforation, and dissection occurred in 3.4%, 1.9%, and 4% of cases respectively. Initial patency was 95.4% and at 12-month median follow up primary patency was 72.6%. ABI improved from pre-operative mean of 0.6 to post-operative mean of 0.84. Incidence of major amputation and mortality over the follow up period was 2.2% and 3.4% respectively. CONCLUSIONS This review of the published data suggests that femoropopliteal atherectomy can be completed safely while modestly improving ABIs and maintaining one-year patency in nearly three out of four patients; however, this is based on heterogeneous studies that skew generalizable conclusions about atherectomy's efficacy. Atherectomy places a high cost burden on the healthcare system and is utilized in the United States at a higher rate than in other countries. Our review of the literature does not demonstrate clear atherectomy superiority to alternatives that would warrant pervasive and increasing use of this costly technology. Future work should focus on developing high quality randomized controlled trials to determine specific patient and lesion characteristics in which atherectomy can add value.
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Affiliation(s)
- Ryan Gupta
- General Surgery resident, Department of Surgery, University of Colorado, Anschutz medical center, Aurora, CO
| | - Rafael D Malgor
- Associate Professor, Division of Vascular and Endovascular Surgery, University of Colorado, Anschutz medical center, Aurora, CO.
| | - Sammy Siada
- Vascular Surgery Fellow, Division of Vascular and Endovascular Surgery, University of Colorado, Anschutz medical center, Aurora, CO
| | - Samuel Lai
- General Surgery resident, Department of Surgery, University of Colorado, Anschutz medical center, Aurora, CO
| | - Mohammed Al-Musawi
- Research Associate, Division of Vascular and Endovascular Surgery, University of Colorado, Anschutz medical center, Aurora, CO
| | - Emily A Malgor
- Assistant Professor, Division of Vascular and Endovascular Surgery, University of Colorado, Anschutz medical center, Aurora, CO
| | - Donald L Jacobs
- Chief, Division of Vascular and Endovascular Surgery, University of Colorado, Anschutz medical center, Aurora, CO
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Finn MT, Ingrassia JJ, Parikh SA. Plaque Modification in Endovascular Procedures in Patients with Infrainguinal Disease. Interv Cardiol Clin 2020; 9:125-137. [PMID: 32147115 DOI: 10.1016/j.iccl.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Plaque modification (PM) for atherosclerotic peripheral vascular lesions includes a variety of device types to alter the vessel structure with the aim of enhancing procedural success. PM device utilization has expanded significantly in the United States in recent years despite limited high-quality clinical trials. This article reviews societal guidelines for PM, evaluates currently available trial evidence, examines various pathologic subsets in which PM may be used, and discusses future areas for research.
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Affiliation(s)
- Matthew T Finn
- Department of Cardiology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 6th Floor, New York, NY 10032, USA
| | - Joseph J Ingrassia
- Department of Cardiology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 6th Floor, New York, NY 10032, USA
| | - Sahil A Parikh
- Department of Cardiology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 6th Floor, New York, NY 10032, USA.
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Lee MS, Choi BG, Rha SW. Impact of diabetes mellitus on 5-year clinical outcomes following successful endovascular revascularization for peripheral artery disease. Vasc Med 2019; 25:33-40. [DOI: 10.1177/1358863x19879751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular therapy is a viable treatment option for symptomatic peripheral artery disease (PAD). Diabetes mellitus is a major risk factor for PAD. We evaluated the long-term impact of diabetes mellitus in patients with PAD who underwent endovascular therapy. In this prospective registry of 765 patients who underwent endovascular therapy for symptomatic PAD, 560 had diabetes and 205 did not have diabetes. Propensity score matching (PSM) analysis was performed to adjust for any potential confounders. The primary endpoints were 5-year major adverse cardiac and cerebrovascular events (MACE) and major adverse limb events (MALE). After PSM analysis, baseline clinical and limb characteristics were similar in patients with diabetes and in patients without diabetes. Patients with diabetes had a higher rate of major hematoma (> 4 cm) (9.9% vs 3.3%, p = 0.038). At 5-year clinical follow-up, patients with diabetes and patients without diabetes had similar rates of MACE (20.7% vs 20.7%, log rank p = 0.989) and MALE (19.8% vs 24.5%, log rank p = 0.312), as well as the individual endpoints. In subgroup analysis adjusted by PSM, female patients with diabetes had a higher risk of MALE (hazard ratio 0.31, 95% CI 0.13–0.69, p = 0.004). Although there was a higher rate of major hematoma, patients with diabetes who underwent endovascular therapy had similar 5-year cardiac and vascular outcomes compared with patients without diabetes. Bleeding avoidance strategies, including optimal antiplatelet and antithrombotic therapy, and meticulous vascular access techniques, are needed in patients with diabetes to reduce the risk of bleeding and its deleterious impact on morbidity and mortality.
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Affiliation(s)
- Michael S Lee
- Division of Cardiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Byoung Geol Choi
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
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Azar Y, DeRubertis B, Baril D, Woo K. Atherectomy-Associated Complications in the Southern California Vascular Outcomes Improvement Collaborative. Ann Vasc Surg 2017; 49:241-246. [PMID: 29197604 DOI: 10.1016/j.avsg.2017.11.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/24/2017] [Accepted: 11/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Atherectomy has become an increasingly utilized modality for the endovascular treatment of peripheral arterial occlusive disease. The objective of this study was to determine the incidence and risk factors for atherectomy-associated complications. METHODS A retrospective review was performed for all atherectomy procedures performed between January 2011 and December 2015 in the Southern California Vascular Outcomes Improvement Collaborative. Atherectomy was defined as laser, orbital, or excisional atherectomy. Complications were dissection, perforation, and distal embolization. RESULTS Seven hundred twenty-nine atherectomy procedures were performed at 7 institutions by 27 practitioners. The mean age was 73 years with 415 (57%) males. Four hundred nineteen (57%) were diabetic, 673 (92%) hypertensive, 457 (63%) smokers, and 244 (34%) had coronary artery disease. Dissection occurred in 51 (7%) procedures, embolization in 23 (3.1%), and perforation in 12 (1.6%). The mean number of lesions treated per artery was the same at 1.6 in patients with any complication and no complication (P = 0.77). The total occluded length was 7.4 cm for complications versus 7.2 cm for no complication (P = 0.73). The total treated length was 12.9 cm for complications versus 11.3 cm for no complication (P = 0.03). The incidence of complications for Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions were 13% compared to 10% for TASC A/B lesions (P = 0.05). The incidence of complications in superficial femoral/popliteal lesions was 12.9% vs. 10.4% in tibial lesions (P = 0.13). In multivariable analysis, treatment length was associated with a small increased risk of complication (odds ratio = 1.02, 95% confidence interval = 1.0-1.04). CONCLUSIONS Increased treatment length is associated with an increased risk of atherectomy-associated complications. Demographic factors and comorbidities were not predictors of complications.
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Affiliation(s)
- Yara Azar
- Division of Vascular Surgery, Department of Surgery, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Brian DeRubertis
- Division of Vascular Surgery, Department of Surgery, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Donald Baril
- Division of Vascular Surgery, Department of Surgery, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Dalal PK, Prasad A. Contemporary Outcomes of Endovascular Intervention for Critical Limb Ischemia. Interv Cardiol Clin 2017; 6:251-259. [PMID: 28257772 DOI: 10.1016/j.iccl.2016.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Critical limb ischemia (CLI) remains a significant cause of morbidity and mortality in patients with peripheral arterial disease. Optimal treatment strategies for CLI remain controversial. The only randomized trial comparing surgical with endovascular revascularization suggests no significant difference in limb salvage between open surgical bypass and angioplasty. Although novel endovascular strategies are now available, their efficacies remain largely untested in a randomized fashion. This review provides an overview of the data surrounding contemporary outcomes of endovascular therapy with an emphasis on current knowledge gaps.
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Affiliation(s)
- Pratik K Dalal
- Department of Cardiovascular Diseases, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7872, San Antonio, TX 78229, USA
| | - Anand Prasad
- Department of Cardiovascular Diseases, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7872, San Antonio, TX 78229, USA.
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Endovascular treatment of lower extremity peripheral arterial disease. Trends Cardiovasc Med 2016; 26:495-512. [DOI: 10.1016/j.tcm.2016.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/20/2016] [Accepted: 02/24/2016] [Indexed: 11/22/2022]
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Impact of lesion location on procedural and acute angiographic outcomes in patients with critical limb ischemia treated for peripheral artery disease with orbital atherectomy: A CONFIRM registries subanalysis. Catheter Cardiovasc Interv 2015; 87:440-5. [DOI: 10.1002/ccd.26349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/02/2015] [Accepted: 11/08/2015] [Indexed: 01/10/2023]
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Abstract
Advances in endovascular therapies during the past decade have broadened the options for treating peripheral vascular disease percutaneously. Endovascular treatment offers a lower risk alternative to open surgery in many patients with multiple comorbidities. Noninvasive physiological tests and arterial imaging precede an endovascular intervention and help localize the disease and plan the procedure. The timing and need for revascularization are broadly related to the 3 main clinical presentations of claudication, critical limb ischemia, and acute limb ischemia. Many patients with claudication can be treated by exercise and medical therapy. Endovascular procedures are considered when these fail to improve quality of life and function. In contrast, critical limb ischemia and acute limb ischemia threaten the limb and require more urgent revascularization. In general, endovascular treatments have greater long-term durability for aortoiliac disease than femoral popliteal disease. Infrapopliteal revascularization is generally reserved for critical and acute limb ischemia. Balloon angioplasty and stenting are the mainstays of endovascular therapy. New well-tested innovations include drug-eluting stents and drug-coated balloons. Adjunctive devices for crossing chronic total occlusions or debulking plaque with atherectomy are less rigorously studied and have niche roles. Patients receiving endovascular procedures need a structured surveillance plan for follow-up care. This includes intensive treatment of cardiovascular risk factors to prevent myocardial infarction and stroke, which are the main causes of death. Limb surveillance aims to identify restenosis and new disease beyond the intervened segments, both of which may jeopardize patency and lead to recurrent symptoms, functional impairment, or a threatened limb.
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Affiliation(s)
- Arun K Thukkani
- From BJCMG Cardiology, Missouri Baptist Hospital, Saint Louis (A.K.T.); and Cardiovascular Divisions, VA Boston Healthcare System and Brigham and Women's Hospital, MA
| | - Scott Kinlay
- From BJCMG Cardiology, Missouri Baptist Hospital, Saint Louis (A.K.T.); and Cardiovascular Divisions, VA Boston Healthcare System and Brigham and Women's Hospital, MA.
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