Laser recanalization of peripheral arteries

The aim of this study was to assess safety and efficacy of excimer laser (XeCl, 308 nm) recanalization of diseased peripheral arteries not amenable to conventional balloon dilatation. In 21 patients (ages 44–77) with multiple vascular lesions, laser recanalization of 43 calcified occlusions (2–5 per patient) of 0.5–17.5 cm in length; iliac (21 iliac lesions in 9 patients: group I, 31 femoropopliteal lesions in 12 patients: group II) was attempted. Laser irradiation (60–80 mJ io:/mm² and 120 ns per pulse, 20 Hz) was applied via concentric and excentric multifiber 4.5–9.0 Fr catheters. In group I, perforation of the aortic wall occurred in one, long-term patency, and normal pain-free walking distances were achieved in all nine patients. In group II, perforation/dissection occurred in four, successful recanalization resulted in peripheral embolization in three, and late reocclusion occurred in two patients. However, clinical improvement (Fontaine class 0–II) could be verified in 7 (60%) of the 12 patients in a follow-up of 9–34 months. Excimer laser recanalization is an alternative to surgical revascularization in patients with peripheral artery occlusions not amenable to conventional percutaneous angioplasty procedures.Presented at the 35th World Congress, International College of Angiology, Copenhagen, Denmark, July 1993     

经皮介入治疗下肢动脉阻塞136例分析

目的评估下肢动脉严重狭窄患者经皮球囊成形术或选择性支架置入术的近中期临床疗效和安全性。方法连续136例下肢严重间歇性跛行或慢性缺血的患者,病因均为动脉粥样硬化,其中髂动脉阻塞81例,股浅动脉阻塞43例,胭动脉阻塞12例,所有病变首先均进行经皮球囊成形术,如果有夹层或残余狭窄〉30％,则置入支架。随访1年,在6个月和12个月时评估再狭窄和临床疗效。结果共进行36例经皮球囊成形术和99例选择性支架置入术。术前病变狭窄程度70％～100％（88．6％±7．5％）,狭窄长度1．5～18．0cm[（6．2±2．9）cm],治疗节段2．0～19.0cm[（7．3±3．2）cm],术后残余狭窄0％～30．0％（8．7％±5．1％）。手术相关的并发症2例。6个月随访发现,再狭窄率在髂动脉、股胭动脉和所有病变分别为7．3％、19．4％和12．3％,球囊成形术组和支架置入术组再狭窄率分别为17．8％比10．2％（P〉0．05）;12个月随访发现,再狭窄率在髂动脉、股胭动脉和所有病变分别为12．5％、29．9％和19．6％,球囊成形术组和支架置入术组再狭窄率分别为28．9％比16．1％（P〉0．05）。但6min最大步行距离和踝肱收缩压比球囊成形术组均显著小于支架置入术组（P〈0．001）。12个月随访期间发生急性心肌梗死3例和小卒中2例,无死亡病例。结论经皮介入治疗下肢动脉阻塞安全有效。中期疗效显示,选择性支架置入术组的再狭窄率与球囊成形术组相当,但6min最大步行距离和踝肱收缩压比优于球囊成形组。     

Wall shear stress in the stented superficial femoral artery in peripheral arterial disease

Objective

Local changes in wall shear stress (WSS) contribute to vascular wall thickening and subsequent stenosis. Restenosis after stenting is a major concern, especially in the superficial femoral artery (SFA) of patients with peripheral arterial disease (PAD). Local alterations in WSS after stenting might contribute to restenosis/reocclusion. To test the hypothesis that WSS is impaired along the stented SFA segment, we studied the profile of WSS along the femoro-popliteal axis after stent placement in a cross-sectional design.

Methods

Eighty-seven patients with PAD (89 limbs) were included one day after stenting of the SFA. Flow velocities (peak and mean) and vessel diameter were measured by duplex ultrasound in five predefined segments along the femoro-popliteal axis, at rest and after exercise (30 toe raises); WSS (peak and mean) was calculated from flow velocities, vessel diameter and whole blood viscosity.

Results

WSS progressively declined along the stented segment at rest (peak WSS, p < 0.0001; mean WSS, p < 0.05); after exercise, WSS increased in all segments (all p < 0.001), but, again, progressively declined along the stent (peak WSS, p < 0.0001; mean WSS, p < 0.05). The internal vessel diameter remained unchanged after exercise in the stented and in the non-stented parts of the femoro-popliteal axis (all p > 0.05).

Conclusion

In PAD patients with SFA stenting WSS is impaired along the femoro-popliteal axis. The consequences of this finding in terms of local effects on the vessel wall that might favor restenosis/reocclusion needs further investigation.     

High-risk plaque in the superficial femoral artery of people with peripheral artery disease: Prevalence and associated clinical characteristics

Objective

We used magnetic resonance imaging (MRI) to study the prevalence and associated clinical characteristics of high-risk plaque (defined as presence of lipid-rich necrotic core [LRNC] and intraplaque hemorrhage) in the superficial femoral arteries (SFA) among people with peripheral artery disease (PAD).

Background

The prevalence and clinical characteristics associated with high-risk plaque in the SFA are unknown.

Methods

Three-hundred-three participants with PAD underwent MRI of the proximal SFA using a 1.5 T S platform. Twelve contiguous 2.5 mm cross-sectional images were obtained.

Results

LRNC was present in 68 (22.4%) participants. Only one had intra-plaque hemorrhage. After adjusting for age and sex, smoking prevalence was higher among adults with LRNC than among those without LRNC (35.9% vs. 21.4%, p = 0.02). Among participants with vs. without LRNC there were no differences in mean percent lumen area (31% vs. 33%, p = 0.42), normalized mean wall area (0.71 vs. 0.70, p = 0.67) or maximum wall area (0.96 vs. 0.92, p = 0.54) in the SFA. Among participants with LRNC, cross-sectional images containing LRNC had a smaller percent lumen area (33% ± 1% vs. 39% ± 1%, p < 0.001), greater normalized mean wall thickness (0.25 ± 0.01 vs. 0.22 ± 0.01, p < 0.001), and greater normalized maximum wall thickness (0.41 ± 0.01 vs. 0.31 ± 0.01, p < 0.001), compared to cross-sectional images without LRNC.

Conclusions

Fewer than 25% of adults with PAD had high-risk plaque in the proximal SFA using MRI. Smoking was the only clinical characteristic associated with presence of LRNC. Further study is needed to determine the prognostic significance of LRNC in the SFA.

Clinical trial registration—URL

http://www.clinicaltrials.gov. Unique identifier: NCT00520312.     

Determinants of failure in superficial femoral artery angioplasty.

Although results of iliac artery balloon angioplasty have been shown to be good, there are much less data regarding initial success and durability of superficial femoral artery (SFA) dilation. The authors retrospectively reviewed the results of 22 patients treated for 27 SFA lesions between 1981 and 1986. Mean age was 64.5 years (fifty-five to seventy-six). Results were analyzed with respect to initial, early (< twelve months), and late (> twelve months) angiographic and clinical success. Indications were claudication (22), nonhealing ulcer (3), and rest pain (2). Mean follow-up was 30.9 months; 100% at one year and 92% at two years. Initial failure occurred in 9 (33%) lesions. There were 2 early and 2 late failures for a cumulative patency rate of 90.3% and 78% at one and two years, respectively. Predictors of clinical failure were: (1) initial--age, SFA occlusion, and angioplasty rating; (2) early--age, SFA occlusion, degree of atherosclerosis, and angioplasty rating; (3) late--angioplasty rating. There were 3 complications (11%). The authors conclude that: (1) 33% of attempted SFA angioplasties were initially unsuccessful and that the cumulative patency rate was 78% at two years. (2) Age is predictive of initial and early failure; SFA occlusion, of initial and early failure; degree of atherosclerosis, of early failure; and angioplasty appearance, of initial, early, and late failures. (3) Complications did not result in limb loss or require surgery.     

Stenting of the superficial femoral artery after suboptimal balloon angioplasty: one-year results.

AIM: The aim of this study was to analyze the intermediate results of selective stenting of superficial femoral artery (SFA) lesions after a suboptimal balloon angioplasty result. METHODS: We analyzed 70 consecutive patients with claudication or critical limb ischemia due to peripheral arterial occlusive disease who underwent stent implantation of the SFA after unsuccessful balloon-angioplasty. All patients were followed-up immediately after the procedure and 3, 6 and 12 months thereafter. Restenosis was defined as an increase of peak systolic velocity-index >2 as determined by duplex sonography. RESULTS: Primary patency rates at 3, 6 and 12 months were 83.4%, 66.2% and 59%, respectively. Successful reinterventions were performed for 17 reobstructions, resulting in a secondary patency rate at 3, 6 and 12 months of 91%, 89.3%, and 83.8%, respectively. At 12 months 68.6% of the patients were asymptomatic, 21.6% complained of mild (Fontaine class II a), 5.9% of severe (Fontaine class II b) claudication and 2.9% were in critical limb ischemia. CONCLUSIONS: Our data indicate that selective stenting of the SFA after suboptimal balloon angioplasty results in intermediate patency rates similar to that reported for primarily successful PTA, thereby supporting the widely accepted policy of selective stenting as a rescue procedure after unsuccessful balloon angioplasty.     

Percutaneous popliteal approach for angioplasty of superficial femoral artery occlusions

Angioplasty using the percutaneous popliteal approach was utilized in 50 patients (PTS) to recanalize 59 occluded superficial femoral arteries which had been unsuccessfully canalized by using the antegrade approach because of either a flush origin occlusion or inability to maintain the guide wire in the true lumen. All PTS had claudication; 8 had rest pain; 3 had non-healing ulcers. The laser Probe was used in 17 cases and the Rotablator in 3 cases. Occlusion length varied between 1 and 40 cm: 7 lesions were less than 10 cm (group 1); 9 were between 10 and 20 cm (group 2); and 43 were greater than 20 cm (group 3). An angiographic success was obtained in 48/59 lesions (81%): 14/16 (87%) in groups 1 and 2 and 34/43 (79%) in group 3. Three PTS needed complementary common femoral endarterectomy and one required percutaneous aspiration of a thromboembolus. Complications included: arterial perforation and/or dissection (without clinical sequelae) in 11 and a popliteal hematoma in 1 PT. One patient with a severely ischemic leg underwent successful emergency vascular surgery, while another limb salvage patient required below-knee amputation. There was no worsening of limb ischemia from any popliteal approach attempt. At discharge, 39 patients (78%) whose outcome would have been unsuccessful with the traditional antegrade approach were clinically improved after utilizing the popliteal approach to achieve a successful angioplasty procedure.     

Impact of calcification on clinical outcomes after drug-coated balloon angioplasty for superficial femoral artery disease: Assessment using the peripheral artery calcification scoring system

There remains significant controversy in the risk stratification and management of patients with anomalous right coronary artery originating from the opposite sinus (R-ACAOS). We present the case of a patient with an inferior ST-elevation myocardial infarction, found to have R-ACAOS and severe atherosclerotic right coronary artery disease, treated with fractional flow reserve and intravascular ultrasound-guided percutaneous coronary intervention.     

冠心病合并外周动脉病变的治疗--附21例临床分析

目的　探讨冠心病患者合并外周血管病变的综合治疗方法。方法　对 2 1例合并外周血管病变的冠心病患者 ,采用经皮穿刺外周血管成形术治疗后进行心肌血运重建术或以便于内科药物治疗冠心病。结果　 2 1例外周血管成形术均获得成功 ,无严重并发症发生 ,使冠心病的进一步治疗获得良好的效果。结论　经皮穿刺外周血管成形术和支架植入术疗效好 ,成功率高 ,对冠心病的进一步治疗和预后有重要的意义     

Complement component C5a predicts restenosis after superficial femoral artery balloon angioplasty.

PURPOSE: To investigate whether balloon angioplasty of the superficial femoral artery (SFA) increases serum levels of C5a and whether C5a predicts risk of restenosis. METHODS: C5a antigen was measured at baseline and 8 hours after intervention in 131 consecutive patients (76 women; median age 72 years) with intermittent claudication who underwent successful primary SFA balloon angioplasty. Patients were followed for a median 10 months [interquartile range (IQR) 6 to 14] for the occurrence of >50% restenosis by duplex ultrasound. RESULTS: Median C5a levels increased significantly from 39.7 ng/mL (IQR 27.8 to 55.0) at baseline to 53.8 ng/mL (IQR 35.6 to 85.1, p<0.001) 8 hours post intervention. During the follow-up period, 70 (53%) patients developed restenosis. Increasing levels of C5a (quartiles) at baseline were significantly associated with an increased risk for restenosis (p=0.0092). Adjusted hazard ratios (95% confidence intervals) for restenosis with increasing quartiles of baseline serum C5a levels were 1.24 (0.60 to 2.58), 1.93 (0.95 to 3.93), and 2.08 (1.02 to 4.21), respectively, compared to the lowest quartile. This effect was independent of nonspecific inflammation as reflected by plasma levels of C-reactive protein. CONCLUSION: Inflammatory mechanisms play a major role in the development of restenosis after angioplasty. The complement component C5a exerts strong chemotactic and proinflammatory effects. Enhanced complement activation prior to PTA, as measured by higher levels of C5a, was significantly associated with restenosis after SFA balloon angioplasty. Pathways of complement inhibition thus may be worth investigating with respect to improving patency rates.     

Laser-assisted thermal angioplasty in human peripheral artery occlusions: mechanism of recanalization

Recanalization of completely occluded superficial femoral or popliteal arteries was attempted in 18 patients with use of an Argon laser-mediated thermal probe. The length of the occluded segments varied between 0.5 and 26.0 cm, but 67% of the occlusions were greater than 9 cm long. The initial success rate was 67%. Arterial perforation occurred in six patients but was not associated with major complications. To study the mechanism of the laser-mediated thermal probe, thermal recanalization was performed on 11 human arterial segments in vitro obtained after amputation, and mechanical recanalization was performed in vitro in 10 human peripheral arteries with use of a guide wire and catheter technique. An additional four arteries were studied with the laser probe as a non-heated mechanical device. Both the mechanical and thermal devices appear to follow a similar pathway through a complete obstruction. These studies suggest that the thermal probe burns through soft fibrous tissue but is mechanically deflected away from hard fibrocalcific plaque. The probe then advances along the plane between the intimal plaque and the media for a variable length before perforating through the adventitia. These observations suggest that the major mechanism of thermal probe recanalization may be a mechanical process. It appears that thermal probe devices do not inherently seek the true lumen of an occluded artery and that better guidance systems need to be developed.     

Arterial puncture closure using a clip device after transpopliteal retrograde approach for recanalization of the superficial femoral artery.

Purpose: To report the safety and efficacy of a clip device to close retrograde popliteal artery puncture sites used in recanalization of the superficial femoral artery (SFA). Methods: From January 2005 to March 2007, 28 patients (20 men; mean age 66+/-10 years) with stable chronic peripheral artery disease were treated for chronic total SFA occlusion. All patients received aspirin and clopidogrel and were heparinized during the procedure. After failed antegrade recanalization, the SFA was revascularized via a retrograde transpopliteal access. The StarClose Vascular System was used to seal the popliteal artery puncture site. Results: All (100%) interventions were finished successfully, and hemostasis was secured with the StarClose device in all cases. There was 1 (3.6%) major complication with the StarClose system: a transient popliteal artery occlusion induced by plaque shift during sheath removal, which was corrected with balloon angioplasty via the femoral access. Three (10.8%) small hematomas (<5 cm) occurred at the puncture site without causing significant patient discomfort. Conclusion: In this small experience, the StarClose Vascular Closure System appeared to be an effective and safe sealing device after percutaneous transpopliteal interventions. Plaque shifting leading to stenosis or occlusion at the puncture site can occur.     

经心外膜下侧支循环逆向介入治疗冠状动脉慢性完全闭塞病变

目的 探讨应用我国市场已有器械,经心外膜下侧支循环血管,对慢性完全闭塞(CTO)病变行逆向经皮冠状动脉介入治疗(PCI)的可行性.方法 5例CTO病变均在常规正向PCI失败后,行逆向PCI.将7 F强支撑逆向指引导管送至供体血管,超滑导丝通过心外膜下侧支循环血管到达CTO病变远端,在微导管支持下交换较硬的导丝,逆向通过CTO病变,逆向导丝继续进入6 F正向指引导管,并在正向指引导管内球囊扩张锚定.逆向扩张病变后,正向导丝通过病变,用常规PCI方法完成手术.其中应用捕获逆向导丝技术和反向CART技术各1例.结果 在逆向导丝通过侧支循环的路径中,经左前降支至右冠状动脉远端3例,经左回旋支至右冠状动脉1例,经钝缘支至左前降支1例.其中4例成功开通CTO病变,完成支架置入术.另外1例虽然导丝及微导管到达CTO病变远端,但无法逆向通过闭塞病变.所有患者介入术中均未发生并发症.结论 在我国没有专门逆向PCI工具的情况下,如果室间隔支不适合作为逆向通道,心外膜下侧支循环在符合一定条件时也可作为逆向通道,进行CTO病变的逆向PCI.     

Patient age and patency rate after recanalization of occluded peripheral arteries

OBJECTIVES: Due to an increase in the percentage of older people in industrialized countries there is an increasing demand for medical care for the elderly. With advancing age, a series of structural, architectural and compositional modifications take place in the vasculature. Therefore, we analyzed the influence of patient age on the reocclusion rate of recanalized peripheral arteries. PATIENTS AND METHODS: 471 patients (mean age +/- SD: 62 +/- 12 years, range: 28-90 years) successfully treated by interventional recanalization were followed up (mean +/- SD: 18 +/- 17 months, range:6-48 months). Reocclusion of the recanalized arterial segment could be proven in 175 patients (37%), whereas octogenarians had the highest patency rate i.e. 68%. Univariate analysis, multivariate logistic regression analysis, and ROC analysis were performed. RESULTS: The univariate analysis showed a significant relation between reocclusion and PAOD stage, hyperlipoproteinemia, and total cholesterol level and erythrocyte sedimentation rate (ESR), respectively. Excluding age-related risk factors, the multivariate logistic regression analysis with backward selection reached a significant level for PAOD stage with p = 0.0012 and an odds ratio of 1.63, and for ESR with a p = 0.0013 and an odds ratio of only 1.02. Age did not reach a significant level with a p value of 0.13 and an odds ratio of 0.98. In the ROC analysis, prognostic relevance could be shown for the combination of PAOD stage and ESR adjusted for age and hyperlipidemia, and for PAOD stage and ESR value as a single prognostic factor, but not for patient age. CONCLUSION: Thus, despite proven and hypothetical differences in the vascular biology of older people compared to younger people, age is not related to middle term patency rates after interventional recanalization of peripheral arterial occlusions.     

Use of embolic capture angioplasty for the treatment of occluded superficial femoral artery segments

Treatment of peripheral chronic total occlusion (CTO) is one of the most challenging lesion subsets in peripheral revascularization. Advanced wire technology, novel re-entry catheters and imaging techniques help in crossing such lesions. Subintimal dissection using blunt microdissection devices along with true lumen reentry techniques have added to the success rates of treating peripheral CTOs. After crossing the occlusion, balloon angioplasty and the placement of self-expanding nitinol stents are usually performed. Peripheral embolization is a known complication of peripheral artery interventions, leading to significant lower-extremity ischemia and complications. Such interventions of peripheral CTOs have been shown to have higher rates of distal embolization. Though no dedicated distal embolic protection strategies are currently available for lower-extremity interventions, use of debris capture angioplasty balloon (Proteus?) may be a feasible alternative. We report 3 cases where this device has been used during recanalization of peripheral CTOs.     

Spontaneous recanalisation of the superficial femoral artery following angioplasty of the femoral artery in a patient with disseminated atherosclerosis--a case report

We present a case of a 51-year-old male with multivessel coronary artery disease and disseminated peripheral arterial disease (PAD) who underwent coronary angioplasty, followed by angioplasty with stent implantation of the left superficial iliac artery and right femoral artery. Thirty days later the patient was admitted for elective angioplasty of the previously closed superficial right femoral artery; however, angiography showed that the artery was patent with a residual stenosis which narrowed the vessel lumen by 10%. We believe that spontaneous recanalisation of this artery was caused by multiple factors, including cessation of smoking, physical training, pharmacological therapy and previous angioplasty of the right femoral artery.     

Routine stent implantation vs. percutaneous transluminal angioplasty in femoropopliteal artery disease: a meta-analysis of randomized controlled trials

Aims: We performed a meta-analysis of randomized controlled trialscomparing routine stenting (ST) with percutaneous transluminalangioplasty (PTA) for symptomatic superficial femoral-poplitealartery (SFPA) disease. Methods and results: Ten trials were pooled randomizing patients to ST (n = 724 limbs)or PTA with provisional stenting (n = 718 limbs) with a follow-upperiod of 9–24 months. The mean lesion length was similarin the two groups (45.8 mm in the ST group and 43.3 mm in thePTA group). We calculated the summary risk ratios (RRs) forimmediate technical failure, restenosis, and target vessel revascularization(TVR) using random-effects models. The immediate technical failurewas higher in the PTA group than in the ST group [17.1 vs. 5.9%,respectively, RR = 0.28, 95% confidence interval (CI) = 0.15–0.54,P < 0.001], with 10.3% of the PTA patients undergoing stentingbecause of suboptimal result. There was a trend for lower restenosisin the ST group (37.6% in ST vs. 45.3% in PTA, RR = 0.85, 95%CI = 0.69–1.06, P = 0.146), but no difference in the needfor TVR (20% in ST vs. 20.2% in PTA, RR = 0.98, 95% CI = 0.78–1.23,P = 0.89). In an analysis restricted to nitinol stents, therewas a trend towards reduction in TVR (RR = 0.79, 95% CI = 0.59–1.06,P = 0.12). Conclusion: Despite the higher immediate success, routine stenting was notassociated with a significant reduction in the rate of restenosisor TVR. Our data do not support use of routine stenting as theprimary endovascular treatment for short SFPA lesions.