The Influence of the Ipsilateral Superficial Femoral Artery on Iliac Angioplasty

Our objective was to evaluate the impact of the ipsilateral superficial femoral artery (SFA) on percutaneous transluminal angioplasty (PTA) of the iliac arteries. From 1993 to 2005, 183 iliac lesions (179 stenoses, 4 occlusions; 37 common, 35 external, and 111 both iliac arteries) in 127 patients with disabling claudication [94 (52%)], rest pain [43 (23%)], and ulcer/gangrene [46 (25%)] were treated by PTA. TransAtlantic Inter-Society Consensus (TASC) iliac lesion types were A in 48 limbs (26%), B in 92 (50%), C in 38 (21%), and D in 5 (3%). Stents were placed selectively for primary angioplasty failure [residual stenosis (>30%) or pressure gradient (>5 mm Hg)]. Seventy-seven limbs (42%) had patent SFAs (66 intact/<50% stenosis and 11 previously bypassed, pSFA group), 28 (15%) had stenotic SFAs (50-99%, sSFA group), 51 (28%) had occluded SFAs (oSFA group), and 27 (15%) had concomitant SFA angioplasty (aSFA group). The Society for Vascular Surgery and the International Society for Cardiovascular Surgery reporting standards were followed to define outcomes. There were no perioperative deaths. Total complication rate was 1.1% (2/183, groin hematomas). The mean follow-up was 20 months (range 1-115). One hundred twenty-five limbs (68%) had PTA alone for iliac lesions, and 58 (32%) had iliac stenting (a total of 91 stents). TASC iliac lesion types and the status of the ipsilateral profunda femoris artery were not significantly different among the four groups. Seventeen limbs (9%) had subsequent infrainguinal bypass: three in the pSFA, seven in the oSFA, four in the sSFA, and three in the aSFA groups (p = 0.19). The primary patency rate was significantly decreased in the sSFA group (29% at 3 years, Kaplan-Meier log-rank, p < 0.0001) compared with the other three groups; however, there were no significant differences among the pSFA, oSFA, and aSFA groups (67%, 67%, and 86% at 3 years, respectively; p = 0.92). The continued clinical improvement rates were significantly decreased in the sSFA group (36% at 3 years, p = 0.0043) compared with the other three groups; however, there was no significant difference between the pSFA, oSFA, and aSFA groups (81%, 84%, and 75% at 3 years, respectively; p = 0.088). The assisted primary and secondary patency and limb salvage rates were not significantly different among the four groups (p > 0.40). Stratified analysis in patients with TASC type B/type C, critical limb ischemia, or claudicants revealed similar results. The primary patency and continued clinical improvement were significantly decreased in patients with stenotic SFAs, suggesting that concomitant SFA angioplasty might improve iliac patency after iliac PTA for patients with stenotic SFAs. The presence of an occluded SFA did not adversely affect the outcomes of iliac PTA. During iliac PTA, a stenotic SFA should be considered for revascularization via endovascular means but an occluded SFA can be observed.     

Percutaneous angioplasty and stenting of the superficial femoral artery

OBJECTIVES: The objectives of this study were to examine factors predictive of success or failure after percutaneous angioplasty (PTA) and stenting (S) of the superficial femoral artery (SFA) and to compare the results of PTA/S with a contemporary group of patients treated with femoropopliteal bypass. METHODS: A database of patients undergoing PTA and/or S of the SFA between 1986 and 2004 was maintained. Intention-to-treat analysis was performed. Patients underwent duplex scanning follow-up at 1, 3, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics and preprocedure and postprocedure runoff. Results were standardized to current TransAtlantic Inter-Society Consensus (TASC) and Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazard analyses were performed to assess factors associated with patient survival and treatment efficacy. RESULTS: Three hundred eighty total limbs underwent PTA/S in 329 patients (67% male, 33% female; average age, 65 years). Mean follow-up was 1.8 years from the date of initial intervention. Indications for intervention were claudication in 66%, rest pain in 16%, and tissue loss in 18%. Runoff at the tibial level was 2.1 +/- 0.8 patent vessels. Mean SVS ischemia grade was 3.1 (range, 1 to 5). TASC lesion grades were A (48%), B (18%), C (22%), and D (12%). Angioplasty alone was used in 63% of cases. Primary treatment failure (inability to cross lesion) was seen in 7% of patients. There was one periprocedural death. Primary patency rates were 86% at 3 months, 80% at 6 months, 75% at 12 months, 66% at 24 months, 60% at 36 months, 58% at 48 months, and 52% at 60 months. Assisted primary patency rates were slightly higher ( P = not significant). By Cox proportional hazards analysis, patency of PTA/S was associated with higher preoperative ankle/brachial index ( P = .016) and the performance of angioplasty only ( P = .011). Failed or occluded PTA/S was associated with TASC C ( P < .0001) and TASC D lesions ( P < .0001). Patient death was associated with the presence of congestive heart failure ( P = .003). Subgroup analysis revealed that primary patency rates are highly dependent on lesion type (A > B > C > D, P < .0001). PTA/S patency for TASC A and B lesions compared favorably to prosthetic and venous femoropopliteal bypass. Surgical bypass was superior to PTA/S for TASC C and D lesions. CONCLUSIONS: PTA and stenting of the SFA can be performed safely with excellent procedural success rates. Improved patency of these interventions was seen with increased ankle/brachial index and the performance of angioplasty only. Worse patency was seen with TASC C and TASC D lesions. Patency rates were strongly dependent on lesion type, and the results of angioplasty and stenting compared favorably with surgical bypass for TASC A and B lesions.     

Primary iliac stenting versus transluminal angioplasty with selective stenting

BACKGROUND: The preferential use of primary iliac stenting vs selective stenting is controversial. This study compares the early and late clinical outcomes of primary vs selective iliac stenting at our institution. METHODS: A total of 110 consecutive patients with iliac stenosis (149 lesions) underwent primary stenting over a recent 5-year period (primary stent group). The early technical and clinical success and late clinical outcomes were compared with 41 patients (41 iliac lesions) who had percutaneous transluminal angioplasty (PTA) followed by selective stenting for suboptimal PTA (selective stent group). All patients were evaluated clinically and by duplex scanning with ankle-brachial indexes at 1, 6, and 12 months and every 12 months thereafter. RESULTS: The perioperative complication rate for the primary stent group was 2.7% (three minor hematomas) vs 24% for the selective stent group (P < .0001). The overall early clinical success rate was 97% for the primary stent group vs 83% for the selective stent group (P = .002), however, the rate was 100% for short stenosis (A and B lesions <5 cm TASC classification) in both groups; in contrast to 93% for the primary stent group vs 46% for the selective stent group for longer stenoses (TASC - C and D lesions, P = .0003). The overall late clinical success was comparable for both groups: 88% for the primary stent group vs 80% for the selective stent group, however, this rate was superior for the longer lesions in the primary stent group, 84% vs 46% (P = .007). The primary patency rates at 1, 2, 3, and 5 years were 98%, 94%, 87%, and 77% for the primary stent group vs 83%, 78%, 69%, and 69% for the selective stent group (P = .030). These rates were comparable in both groups for shorter lesions: 100%, 98%, 98%, and 87% for the primary stent group vs 100%, 93%, 85%, and 85% for the selective stent group (P = .637). However, they were superior for the primary stent group in longer lesions: 96%, 90%, and 72% vs 46%, 46%, and 28% for the selective stent group at 1, 2, and 3 years (P < .0001). CONCLUSIONS: The overall early clinical success rate was superior for the primary stent group. However, the initial (early) and late clinical success rates were comparable for short lesions (TASC - A and B lesions), but were inferior in selective stenting for longer lesions (TASC - C and D). Therefore, primary stenting should be offered to all TASC - C and D lesions.     

血管腔内成形术治疗髂动脉硬化闭塞症

目的 探讨血管腔内成形术治疗髂动脉硬化闭塞症的临床疗效.方法 回顾性分析2002年12月至2008年12月收治的61例(76条血管)髂动脉硬化闭塞症患者的临床资料,其中男46例,女15例.平均年龄(67±11)岁.主要临床症状包括严重的间歇性跛行(跛行距离<100 m)38例,静息痛13例,肢/趾端溃疡10例.TASC A型病变29例,B型16例,C型11例,D型5例.应用导丝导管或超声消融开通闭塞段,行腔内支架置入术后随访.结果 61例患者71条血管成功开通(共置入63枚支架),开通率93%(71/76).成功者临床症状改善率100%.踝肱指数(ABI)由术前0.33±0.17提高到术后0.72±0.20,差异有统计学意义(P<0.05).随访51例,随访率83%.随访时间6-60个月,平均(26±14)个月.1年通畅率90%(TASC A、B组92%;TASC C、D组84%).3年通畅率75%(TASC A、B组80%;TASC C、D组63%);5年通畅率72%.结论 髂动脉硬化闭塞的腔内成形术较传统的血管重建手术创伤小、并发症低,近、中期通畅率相当.     

Iliac artery stenting versus surgical reconstruction for TASC (TransAtlantic Inter-Society Consensus) type B and type C iliac lesions

OBJECTIVE: The TransAtlantic Inter-Society Consensus (TASC) document did not define the best treatment for moderately severe iliac artery lesions, ie, TASC type B and type C iliac lesions, because of insufficient solid evidence to make firm recommendations. The purpose of this study was to evaluate the influence of risk factors on outcome of iliac stenting and operative procedures used to treat TASC type B and type C lesions. METHODS: Over the 5 years from 1996 to 2001, 188 endovascular and direct aortoiliac surgical reconstruction procedures were performed in 87 women and 101 men with TASC type B and type C iliac lesions and chronic limb ischemia. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) were followed to define variables. Both univariate analysis (Kaplan-Meier method) and multivariate analysis (Cox proportional hazards model) were used to determine the association between variables, cumulative patency rate, limb salvage, and survival. RESULTS: Indications for revascularization were disabling claudication (73%), limb salvage (25%), and blue toe syndrome (2%). Patients in the surgery group (n = 52) had significantly higher primary patency rates compared with patients in the stent group (n = 136) at univariate analysis (Kaplan-Meier method, log-rank test; P =.015). Primary patency rates at 1, 3, and 5 years were 85%, 72%, and 64% after iliac stenting, and 89%, 86%, and 86% after surgical reconstruction, respectively. Univariate and multivariate Cox regression analysis enabled identification of poor runoff (ie, runoff score >5 for unilateral procedures or >2.5 for bilateral outflow procedures; relative risk, 2.5; 95% confidence interval [CI], 1.4-4.2; P =.001) as the only independent predictor of decreased primary patency in all patients. However, stratified analysis including only patients with poor runoff revealed that patients undergoing iliac stenting had significantly lower primary patency rates compared with those undergoing surgical reconstruction (Kaplan-Meier method, log-rank test; P =.05). External iliac artery disease and female gender were also identified as independent predictors of decreased primary stent patency. CONCLUSIONS: Poor infrainguinal runoff is the main risk factor for decreased primary patency after surgical reconstruction and iliac stenting to treat TASC type B and type C iliac lesions. However, primary patency is less affected by poor runoff in patients undergoing surgical procedures. The presence of poor runoff, external iliac artery disease, and female gender are independent predictors of poor outcome after iliac stenting, and therefore these risk factors should determine the need for surgical reconstruction.     

Hemodynamic outcome of endovascular therapy for TransAtlantic InterSociety Consensus type B femoropopliteal arterial occlusive lesions

OBJECTIVE: Endovascular therapy for moderate femoropopliteal arterial occlusive disease remains controversial. This study reviewed our experience with endovascular therapy for TransAtlantic InterSociety Consensus (TASC) type B disease, which is defined as multiple stenoses less than 3 cm in diameter or a single stenosis or occlusion 3 to 5 cm in diameter. Stenosis-free patency was used as an objective end point to evaluate the hemodynamic outcome. METHODS: A retrospective review was performed of all patients who had undergone endovascular treatment of TASC type B lesions between 1997 and 2002 at two referral centers. Balloon angioplasty was performed in all patients. Stenting was used selectively as an adjunct in patients with suboptimal angioplasty results. The treated sites were examined with duplex ultrasound scanning at 6-month to 12-month intervals. Stenosis-free patency was defined as the absence of stenosis greater than 50% diameter in the treated arterial segment with standard duplex criteria. RESULTS: One hundred fifteen limbs in 98 patients were studied. The indication for treatment was claudication in 92 patients (80%) and ischemic rest pain or gangrene in the remaining patients (20%). Multiple lesions greater than 3 cm were treated in 89 limbs (77%), and a single lesion 3 to 5 cm long was treated in 26 limbs (23%). Balloon angioplasty alone was performed in 74 limbs (65%), and angioplasty and adjunctive stenting was performed in 41 limbs (35%). Endovascular therapy was technically successful in all but one patient (99%), and there was no perioperative mortality or limb loss. During follow-up recurrent stenosis was detected in 46 limbs (40%), and reocclusion occurred in 11 limbs (10%). Seven patients (6%) underwent surgical bypass after endovascular treatment failure. The aggregate 1-year stenosis-free patency rate at life table analysis was 55.1%. The 1-year stenosis-free patency for angioplasty alone was 58%, compared with 51% (NS) for angioplasty and adjunctive stenting. Univariate regression analysis failed to demonstrate a difference in stenosis-free patency for demographic variables, medical comorbidities, and anatomic characteristics (multiple vs single lesions; number of angioplasty procedures). CONCLUSIONS: Endovascular therapy for TASC type B femoropopliteal lesions is safe and technically feasible. However, the length of time that a treated arterial segment remains free of stenosis is limited, and is not improved with adjunctive stenting. Recurrent stenosis, not occlusion, was the most common study end point, and few patients subsequently required surgical bypass. Predictors of outcome after endovascular therapy for TASC type B lesions were not identified in this study.     

The treatment of disabling intermittent claudication in patients with superficial femoral artery occlusive disease--decision analysis

OBJECTIVE: To determine the preferred approach to superficial femoral artery (SFA) revascularization of Trans-Atlantic Inter-Societal Consensus (TASC) B and C lesions in claudicants requiring intervention based on a review of published data. DESIGN: Decision analysis, Markov state transition model. SUBJECTS: Hypothetical cohorts of claudicants with TASC B or TASC C superficial femoral artery lesions considered candidates for either angioplasty with selective stenting (PTA/S) or greater saphenous vein bypass (GSVB). MAIN OUTCOME MEASURE: Quality adjusted life years (QALYs). RESULTS: For a 65-year-old man with disabling claudication, percutaneous transluminal angioplasty and selective stenting (PTA/S) was preferred over GSVB for a TASC B SFA lesion. In an otherwise identical patient with a TASC C lesion, bypass was the preferred therapy. Treating PTA/S failures with subsequent bypass increased the utility of PTA/S but bypass remained the preferred initial therapy for TASC C lesions. Sensitivity analysis showed that PTA/S surpasses bypass efficacy for TASC C lesions if PTA/S primary patency is >32% at 5 years, patient age is >80 years, or GSVB operative mortality is >6%. CONCLUSION: PTA/S is the preferred initial therapy over GSVB for TASC B SFA lesions in patients with disabling intermittent claudication who require intervention. Given contemporary published outcomes for TASC C lesions, GSVB is the preferred therapy in operative candidates. In elderly patients or patients at high risk for bypass, PTA/S should be considered over GSVB. Improved technology that results in a 5-year primary patency of 32% would also justify PTA/S for TASC C SFA lesions.     

支架成形术治疗髂动脉慢性闭塞症的中长期疗效分析

目的:评价支架成形术治疗髂动脉慢性闭塞症的中长期疗效。方法 :回顾性分析我科自2004年1月至2009年12月经支架成形术治疗的髂动脉慢性闭塞病人的技术成功率、支架通畅率及介入并发症。结果:髂动脉慢性闭塞症病人167例(194条患肢)纳入研究,男103例(126条患肢),女64例(68条患肢);平均年龄(71.3±12.4)岁。TASC B型47例(54条患肢),TASC C型88例(102条患肢),TASC D型32例(38条患肢)。TASC B型、C型、D型技术成功率分别为98.1%(53/54)、97.1%(99/102)、94.7%(36/38),各组比较无统计学差异;髂动脉支架成形术后1年一期通畅率、一期辅助通畅率和二期通畅率分别为94.6%、98.8%和98.8%,2年分别为90.0%、94.5%和96.2%,5年分别为78.8%、89.4%和93.5%,TASC各型之间无统计学差异。肱动脉穿刺部位血肿多于股动脉(P=0.047)。结论:支架成形术治疗髂动脉慢性闭塞安全、有效,技术成功率、支架通畅率和并发症发生率与TASCⅡ分型无相关性。     

Percutaneous placement of stents in chronic iliac and aortic occlusive disease.

OBJECTIVES: to evaluate the long-term results of stenting in iliac and aortic occlusive disease and identify factors predicting clinical outcome. Design: retrospective study. MATERIALS AND METHODS: 82 patients (87 limbs) with stenoses (n =63) and occlusions (n =24) in the aortoiliac segment were treated with stents. 81 lesions involved the iliac arteries, 3 the infrarenal aorta and 3 the aortic bifurcation. Primary stenting was performed in 57 limbs (complex stenotic lesions and occlusions). Stents were placed following failed PTA in 30 limbs. Median follow-up was 13.2 months (1-66 months). RESULTS: technical success was 99% and clinical success 89%. Cumulative primary and secondary patency of stented iliac atherosclerotic lesions at 1 and 3 years was 75 and 61%, and 83 and 75% respectively. The factors predicting outcome of primary patency identified in Cox multivariate analysis were ankle-brachial index (ABI) prior stenting (p =0.03) and length of the lesion (p =0. 007). Major non-fatal complications occurred in 7.4% of the patients and there were no deaths attributed to the treatment. The 30-day mortality was 3.7%. CONCLUSION: stenting of complex aortoiliac stenoses and chronic occlusions is a safe and effective treatment modality. Long lesions and lower pre-procedure ABIs were found to negatively influence outcome.     

The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience

OBJECTIVE: To determine the efficacy, safety, and long-term results, including continued clinical improvement and limb salvage, of percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). METHODS: From August 1993 to March 2004, 138 limbs in 111 patients with CLI (rest pain in 62 [45%] and ulcer/gangrene in 76 [55%]) were treated by PTA. In iliac lesions, stents were placed selectively for primary PTA failure: residual stenosis (>30%) or pressure gradient (>5 mm Hg). Stent placement was limited in infrainguinal lesions. The most distal affected arteries treated with angioplasty were the iliac artery in 45 limbs (33%; iliac group), the femoropopliteal artery in 41 limbs (30%; FP group), and tibial arteries in 52 limbs (37%; BK group). All analysis was performed according to an intent-to-treat basis. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed to evaluate initial success, and late follow-up status was evaluated with the Kaplan-Meier method. Patency was evaluated by using ultrasound scanning and ankle-brachial pressure index measurement. RESULTS: There was one (0.9%) perioperative death. Twenty stents were placed selectively in 14 iliac arteries. Mean follow-up was 14.7 months (range, 1-75 months). Overall, initial technical and clinical success rates were 96.4% and 92.8%, respectively. The cumulative primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates +/- SE at 5 years were 31.4% +/- 10.4%, 75.5% +/- 5.7%, 79.6% +/- 5.5%, 36.1% +/- 10.0%, and 89.1% +/- 4.0%, respectively. In each subgroup, the primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates at 3 years were 51.6%, 94.7%, 97.8%, 65.1%, and 95.0%, respectively, in the iliac group; 49.4%, 72.2%, 76.4%, 57.4%, and 92.7%, respectively, in the FP group; and 23.5%, 41.8%, 46.1%, 51.1%, and 77.3%, respectively, in the BK group. Of the 12 predictable variables, hypertension, multiple segment lesions, more distal lesions, and TransAtlantic Inter-Society Consensus classification type D were significant independent risk factors for the outcomes ( P < .05; univariate log-rank test and Cox regression multivariate analysis). CONCLUSIONS: PTA is a feasible, safe, and effective procedure for the treatment of CLI. The high limb salvage rate is attributed to the high assisted primary and secondary patency rates despite the low primary patency rate. Angioplasty can be the primary choice for the treatment of CLI due to iliac and infrainguinal arterial occlusive disease.     

Long-term outcomes following 282 consecutive cases of infrapopliteal PTA and association of risk factors with primary patency and limb salvage

We aimed to determine the long-term results after infrapopliteal PTA (primary patency, limb salvage, survival) and examine for association with risk factors (e.g. diabetes, infection, etc). We studied 268 patients with 282 critically ischemic limbs treated with PTA of at least one crural artery during a six-year period. Data included TASC II morphological classification of lesions and risk factors. Technical success rate was 97.2%, and overall mortality 0.7%. Patients with milder TASC lesions preserved primary patency longer than patients with more severe lesions. Similar results were obtained for limb salvage and survival. Fontaine stage, TASC class and postoperative infection of operated limb increased the risk for loss of primary patency and major amputation. Concomitant carotid stenosis was associated with loss of primary patency. Diabetes mellitus, preoperative ulcer or gangrene were associated with need of major amputation. PTA was a safe and effective treatment for CLI due to lesions of infrapopliteal vessels.     

Iliac artery stenting in patients with poor distal runoff: Influence of concomitant infrainguinal arterial reconstruction

OBJECTIVE: Inadequate infrainguinal runoff is considered an important risk factor for iliac stent failure. However, the influence of concomitant infrainguinal arterial reconstruction (CIAR) on iliac stent patency is unknown. This study evaluated the influence of CIAR on outcome of iliac angioplasty and stenting (IAS) in patients with poor distal runoff. METHODS: Over 5 years (1996 to 2001), 68 IAS procedures (78 stents) were performed in 62 patients with poor distal runoff (angiographic runoff score >or=5). The SVS/AAVS reporting standards were followed to define outcome variables and risk factors. Data were analyzed with both univariate analysis (Kaplan-Meier method [K-M]) and regression analysis (Cox proportional hazards model). RESULTS: Indications for iliac artery stenting were disabling claudication (59%) and limb salvage (41%). Of the 68 procedures, IAS with CIAR was performed in 31 patients (46%), and IAS alone was performed in 37 patients (54%). Patients undergoing IAS with CIAR were older (P =.03) and had more extensive and multifocal iliac artery occlusive disease, with more TASC (TransAtlantic Inter-Society Consensus) type C lesions (P =.03), compared with patients undergoing IAS alone. No other significant differences in risk factors were noted. Runoff scores between patients undergoing IAS with CIAR and those undergoing IAS alone were not significantly different (median runoff scores, 6 [range, 5-8] and 7 [range, 5-9], respectively; P =.77). Primary stent patency rate at 1, 3, and 5 years was 87%, 54%, and 42%, respectively, for patients undergoing IAS with CIAR, and was 76%, 66%, and 55%, respectively, for patients undergoing IAS. Univariate analysis revealed that primary stent patency rate was not significantly different between the 2 groups (K-M, log-rank test, P =.81). Primary graft patency rate for CIAR was 81%, 52%, and 46% at 1, 3, and 5 years, respectively. Performing CIAR did not affect primary iliac stent patency (relative risk, 1.1; 95% confidence interval, 0.49-2.47; P =.81). Overall, there was a trend toward improved limb salvage in patients undergoing IAS with CIAR, compared with those undergoing IAS alone (K-M, log rank test, P =.07). CONCLUSION: In patients undergoing IAS with poor distal runoff, CIAR does not improve iliac artery stent patency. Infrainguinal bypass procedures should therefore be reserved for patients who do not demonstrate clinical improvement and possibly for those with limb-threatening ischemia.     

Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: a contemporary series

BACKGROUND: Percutaneous endovascular therapy is becoming a primary option for managing infrainguinal occlusive disease. This study examined the results of femoropopliteal percutaneous transluminal angioplasty (PTA) with intermediate (mean, 24 months) follow-up in a contemporary series of patients presenting with critical limb ischemia or claudication. METHODS: Femoropopliteal PTA was performed on 238 consecutive limbs (208 patients) from January 2002 to July 2004. Study end points, including primary patency, assisted patency, and limb salvage (Society of Vascular Surgery reporting standards), were assessed by Kaplan-Meier life-table analysis, and factors predictive of hemodynamic or clinical failure, or both, were evaluated by univariate and multivariate methods. RESULTS: Clinical and demographic features included a mean age, 72 years; male (62%); critical limb ischemia (46%); diabetes mellitus (49%); and renal insufficiency (creatinine >or= 1.5 mg/dL) (29%). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A (11%), B (43%), C (41%), and D (5%). PTA was confined to the femoropopliteal segment in 77 patients (33%), and 161 (67%) underwent concurrent interventions in other anatomic locations. Femoropopliteal interventions included angioplasty only in 183 (78%), and the remaining 53 (22%) received at least one stent. Technical success was achieved in 97% of patients, with no deaths and a major morbidity rate of 3%. The 36-month actuarial primary patency was 54.3%, and assisted patency was 92.6% (37 peripheral reinterventions), resulting in a limb preservation rate of 95.4% in all patients regardless of clinical presentation. Interval conversion to bypass surgery occurred in 19 patients (8%). Comparison between critical limb ischemia and claudication revealed a primary patency of 40.8% vs 64.8%, assisted patency of 93.8% vs 92.6%, and limb salvage of 89.7% vs 100%, respectively. Negative predictors of primary patency determined by multivariate analysis included history of congestive heart failure (P = .02) and TASC C/D (P = .02). However, further evaluation of TASC C/D vs A/B revealed an assisted patency of 89.7% vs 94.3% (P = .37) and limb salvage of 94.3% vs 96.4% (P = .58). CONCLUSIONS: Femoropopliteal PTA can be performed with a low perioperative morbidity and mortality. Intermediate primary patency is directly related to TASC classification. Although secondary intervention is often necessary to maintain patency in TASC C/D lesions, these data suggest that it would be appropriate to use PTA as initial therapy for chronic femoropopliteal occlusive disease regardless of clinical classification at presentation or TASC category of lesion severity.     

External iliac and common iliac artery angioplasty and stenting in men and women

OBJECTIVE: The effect of anatomic location of stent placement on the outcome of iliac artery angioplasty and stenting is not defined. Analyses of patency rates of external iliac artery (EIA) and common iliac artery (CIA) stents have provided conflicting results and have not considered men and women independently. The purpose of this study was to estimate the influence of the anatomic location of stenting on the outcome of iliac angioplasty and stent placement in both men and women. METHODS: From 1995 to 1999, 247 iliac angioplasty and stent placement procedures (303 stents) were performed in 67 women and 122 men, and all were included in a retrospective cohort study. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Both univariate (Kaplan-Meier [KM]) and multivariate analyses (Cox proportional hazards model) were used to determine the association among the variables, cumulative patency, limb salvage, and survival. RESULTS: Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (33%), and blue toe syndrome (2%). Primary stenting was performed in 103 procedures (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Patients with EIA stents, as compared with those who had CIA stents, had more extensive lesions (TransAtlantic Inter-Society Consensus type C lesions), poorer runoff, smaller vessel size, and less frequency of hyperlipidemia (P <.05). Primary patency rates at 1, 3, and 5 years were 76%, 56%, and 56%, respectively, for patients with EIA stents and 92%, 85%, and 76%, respectively, for those with CIA stents. Although overall primary patency rates were significantly decreased in patients with EIA lesions (KM, log-rank test, P =.001), stratified analyses revealed that women with EIA stents had the poorest outcome, with 61%, 47%, and 23% primary patency rates at 1, 3, and 5 years, respectively, (KM, log-rank test, P <.001). Cox regression analysis identified EIA stenting (relative risk, 4.3; 95% CI, 2.3-7.9; P <.001) as an independent predictor of decreased primary patency in women but not in men. CONCLUSIONS: Women undergoing EIA angioplasty with stent placement have significantly reduced primary patency rates. Despite initial technical success, these patients are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. Conversely, men undergoing EIA stenting have a more favorable outcome than women.     

Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs

OBJECTIVE: Recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI). However, little data are available regarding infrapopliteal angioplasty outcomes based on TransAtlantic InterSociety Consensus (TASC) classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification. METHODS: From February 2004 to March 2007, 176 consecutive limbs (163 patients) underwent infrapopliteal angioplasty for CLI. Stents were placed for lesions refractory to PTA or flow-limiting dissections. Patients were stratified by TASC classification and suitability for bypass grafting. Primary outcome was freedom from restenosis, reintervention, or amputation. Primary patency, freedom from secondary restenosis, limb salvage, reintervention by repeat angioplasty or bypass, and survival were determined. RESULTS: Median age was 73 years (range, 39-94 years). Technical success was 93%. Average follow-up was 10 months (range, 1-41 months). At 1 and 2 years, freedom from restenosis, reintervention, or amputation was 39% and 35%, conventional primary patency was 53% and 51%, and freedom from secondary restenosis and reintervention were 63% and 61%, respectively. Limb salvage was 84% at 1, 2, and 3 years. Within 2 years, 15% underwent bypass and 18% underwent repeat infrapopliteal PTA. Postoperative complications occurred in 9% and intraprocedural complications in 10%. The 30-day mortality was 5% (9 of 181). Overall survival was 81%, 65%, and 54% at 1, 2, and 3 years. TASC D classification predicted diminished technical success (75% D vs 100% A, B, and C; P < .001), primary restenosis, reintervention, or amputation (hazard ratio [HR], 3.4; 95% confidence interval [CI], 2.1-5.5, P < .001), primary patency (HR, 2.2; 95% CI, 1.3-3.9, P < .004), secondary restenosis (HR, 3.2; 95% CI, 1.6-6.4, P = .001), and limb salvage (HR, 2.6; 95% CI, 1.1-6.3, P < .05). Unsuitability for surgical bypass also predicted restenosis, reintervention, or amputation, secondary restenosis, need for repeated angioplasty, and inferior primary patency and limb salvage rates. CONCLUSION: Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.     

Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients

OBJECTIVE: The preferential use of endovascular techniques to treat complex aortoiliac disease has increased in recent years. The purpose of this study was to review the outcomes and durability of recanalization, percutaneous transluminal angioplasty, and stenting for iliac occlusions based on the patient's TransAtlantic Inter-Society Consensus (TASC) stratification. METHODS: Between 1998 and 2004, more than 628 patients with a clinical diagnosis of aortoiliac atherosclerotic disease underwent arteriography. The endovascular treatment of 89 consecutive patients (mean age, 66 years; 58% male) with symptomatic iliac occlusions (TASC-B, -C, and -D) was the basis for this study. Original angiographic imaging was evaluated for lesion grade and runoff. Electronic and hard copy medical records were reviewed for demographic data, clinical variables, and noninvasive vascular laboratory testing. Kaplan-Meier estimators were used to determine patency rates according to Society for Vascular Surgery criteria. Univariate and multivariate analyses were performed. P values of <.05 were considered significant. RESULTS: Recanalization and percutaneous transluminal angioplasty/stenting (total, 178 stents) of occluded iliac arteries was technically successful in 84 (91%) of 92 procedures. Patients in the TASC-C and -D groups often required multiple access sites (50%) and femoral artery endarterectomy/patch angioplasty for diffuse disease (24%). The mean ankle-brachial index increased from 0.45 to 0.83. Distal embolization led to major amputation and eventual death in one patient. Two other deaths occurred in the perioperative period secondary to cardiorespiratory causes. Three-year primary patency, secondary patency, and limb salvage rates were 76%, 90%, and 97%, respectively, and progression of infrainguinal disease led to late limb loss in two patients. Diabetes as a risk factor was significantly associated with decreased primary patency (57% vs 83%; P = .049). Critical ischemia at presentation was associated with decreased patency rates as well (P = .002), but TASC classification did not significantly alter patency rates. CONCLUSIONS: Complex long-segment and bilateral iliac occlusions can be safely treated via endovascular means with high rates of symptom resolution. Initial technical success, low morbidity, and mid-term durability are comparable to results with open reconstruction. A liberal posture to open femoral artery reconstruction extends the ability to treat diffuse TASC-C and -D lesions via endovascular means.     

Surgical transluminal iliac angioplasty with selective stenting: long-term results assessed by means of duplex scanning

PURPOSE: The safety of iliac angioplasty and selective stenting performed in the operating room by vascular surgeons was evaluated, and the short- and long-term results were assessed by means of serial duplex scanning. METHODS: Between 1989 and 1996, 281 iliac stenotic or occlusive lesions in 235 consecutive patients with chronic limb ischemia were treated by means of percutaneous transluminal angioplasty (PTA) alone (n = 214) or PTA with stent (n = 67, 23.8%). There were 260 primary lesions and 21 restenosis after a first PTA, which were analyzed separately. Stents were implanted in selected cases, either primarily in totally occluded arteries or after suboptimum results of PTA (ie, residual stenosis or a dissection). Data were collected prospectively and analyzed retrospectively. Results were reported in an intention-to-treat basis. Clinical results and patency were evaluated by means of symptom assessment, ankle brachial pressure index, and duplex scanning at discharge and 1, 3, 6, and every 12 months after angioplasty. To identify factors that may affect outcome, 12 clinical and radiological variables, including the four categories of lesions defined by the Standards of Practice Committee of the Society of Cardiovascular and Interventional Radiology, were analyzed separately. The statistical significances of life-table analysis of patency were determined by means of the log-rank test. RESULTS: There were no postoperative deaths or amputations. Local, general, and vascular complications occurred in 2.1%, 1.3% and 4.7% of cases, respectively (total, 8.1%). The mean follow-up period was 29.6 months. The cumulative patency rates +/- SE of the 260 PTAs (including 55 PTAs plus stents) were 92.9% +/- 1.5% at 1 month, 86. 5% +/- 1.7% at 1 year, 81.2% +/- 2.3% at 2 years, 78.8% +/- 2.9% at 3 years, and 75.4% +/- 3.5% at 5 and 6 years. The two-year patency rate of 21 redo PTAs (including 11 PTAs plus stents) was 79.1% +/- 18.2%. Of 12 predictable variables studied in the first PTA group, only the category of the lesion was predictive of long-term patency. The two-year patency rate was 84% +/- 3% for 199 category 1 lesions and 69.7% +/- 6.5% for 61 category 2, 3, and 4 lesions together (P =. 02). There was no difference of patency in the stented and nonstented group. CONCLUSION: Iliac PTA alone or with the use of a stent (in cases of occlusion and/or suboptimal results of PTA) offers an excellent long-term patency rate. Categorization of lesions remains useful in predicting long-term outcome. PTA can be performed safely by vascular surgeons in the operating room and should be considered to be the primary treatment for localized iliac occlusive disease.     

Outcomes of combined superficial femoral endovascular revascularization and popliteal to distal bypass for patients with tissue loss

Over the last 5 years there has been a significant shift toward lower limb revascularization using endoluminal techniques. However, in many instances endoluminal techniques alone are unable to salvage limbs that exhibit tissue loss. Many of these patients do not have adequate conduit for a long leg bypass, while tibial angioplasty does not appear to restore adequate perfusion to heal many significant foot lesions, making combined procedures attractive. However, previously available data evaluating combined endoluminal and bypass procedures have been too anatomically heterogeneous to be easily applied to patients with infrainguinal disease and tissue loss. From January 2002 to December 2005, intraoperative superficial femoral artery (SFA) percutaneous transluminal angioplasty (PTA) with selective stenting combined with simultaneous popliteal to distal vein bypass was evaluated in 22 limbs of 22 patients with isolated infrainguinal disease and tissue loss. There were 12 men and 10 women, average age 69. All the patients were diabetic, all had tissue loss, and three had end-stage renal disease (ESRD). Four patients underwent common femoral endarterectomy at the time of the SFA PTA; all had the PTA performed first, with antegrade punctures and flow maintained. Fourteen patients had PTA without stenting, eight had self-expanding stents placed for residual stenosis or dissection. There were no failures, with three TASC A, 13 TASC B, and six TASC C lesions addressed. The origin of the bypass was the above-knee popliteal in eight patients and the below-knee popliteal in 14 patients. The target vessel was the dorsalis pedis in six patients, the posterior tibial at the malleolus in three, the proximal posterior tibial in five, the peroneal in five, and the anterior tibial in three. The conduit was greater saphenous vein in 16 cases, femoral vein in three cases, and arm vein in three cases. Follow-up ranged from 3 months to 4 years. The primary patency rate was 21/22 (95%), and the secondary patency rate was 22/22 (100%). There was one amputation for ongoing gangrene in an ESRD patient with a patent bypass, resulting in an early limb salvage rate of 95%. For patients with inadequate conduit and tissue loss secondary to multilevel infrainguinal disease, simultaneous angioplasty with selective stenting of the SFA followed by distal vein bypass is a viable long-term solution that allows for limb salvage. Simultaneous performance is not associated with increased morbidity and decreases overall hospital use.     

Three-year outcome of endovascular treatment of superficial femoral artery occlusion

HYPOTHESIS: Patency after primary percutaneous transluminal angioplasty (PTA) and stenting of superficial femoral artery (SFA) occlusions is better than historical experience with PTA alone. DESIGN: Consecutive case series of primary PTA with stenting, and follow-up with duplex imaging every 6 months (mean +/- SD follow-up, 32 +/- 15 months). SETTING: Veterans Affairs medical center. PATIENTS AND METHODS: Patients were 57 previously untreated men with 71 limbs having chronic atherosclerotic SFA occlusion with suprageniculate reconstitution and patent tibial runoff. Critical ischemia (Society for Vascular Surgery [SVS] category, 4-6) was present in 7 (10%), the remainder had intermittent claudication only (SVS, 1-3). INTERVENTIONS: Guidewire recanalization followed by PTA, Wallstent deployment, and adjunctive thrombolysis as necessary; 19 limbs (27%) required thrombolysis to manage periprocedural thrombosis. MAIN OUTCOME MEASURES: Cumulative patency, limb salvage, and complications. RESULTS: Length (mean +/- SD) of occlusion was 14.4 +/- 9.9 cm. Length of stented artery was 24.3 +/- 11.1 cm. Ankle brachial index increased from 0.59 +/- 0.14 to 0.86 +/- 0.16 (P<.001) after stenting. One- and 3-year patencies were as follows: primary, 54.6% +/- 6.3% and 29.9% +/- 6.6%; assisted primary, 72.3% +/- 5.6% and 59.0% +/- 6.8%; and secondary, 81.6% +/- 4.8% and 68.3% +/- 6.5%. Three-year secondary patency when periprocedural thrombolysis was required was 35.7% +/- 12.5% compared with 70.6% +/- 7.4% for limbs not requiring periprocedural thrombolysis (P=.02); the differences in occlusion length and severity of ischemia were not significant between these 2 groups. Limbs undergoing adjunctive PTA during angiography 6 to 12 months after initial stenting had 63.0% +/- 13.3% patency at 3 years compared with 100% patency in limbs not requiring PTA at 6 to 12 months angiography (P=.046). Periprocedural mortality and morbidity were 2.8% and 15.5%, respectively. Three of the 7 limbs with critical ischemia underwent amputation during follow-up compared with 2 (3%) of 64 limbs with functional ischemia (chi(2) test, P<.006). A mean of 1.8 endovascular interventions per limb were performed. CONCLUSIONS: Percutaneous transluminal angioplasty and stenting yielded higher patency rates than historical controls undergoing PTA alone. When periprocedural thrombolysis is required, subsequent patency appears to be significantly worse. Poor results after PTA and stenting of limbs with critical ischemia and the need for additional endovascular therapy limit the technique's utility.     

Contemporary outcomes after superficial femoral artery angioplasty and stenting: the influence of TASC classification and runoff score

OBJECTIVE: A recent randomized trial suggested nitinol self-expanding stents (SES) were associated with reduced restenosis rates compared with simple percutaneous transluminal angioplasty (PTA). We evaluated our results with superficial femoral artery (SFA) SES to determine whether TransAtlantic InterSociety Consensus (TASC) classification, indication for intervention, patient risk factors, or Society of Vascular Surgery (SVS) runoff score correlated with patency and clinical outcome, and to evaluate if bare nitinol stents or expanded polytetrafluoroethylene (ePTFE) covered stent placement adversely impacts the tibial artery runoff. METHODS: A total of 109 consecutive SFA stenting procedures (95 patients) at two university-affiliated hospitals from 2003 to 2006 were identified. Medical records, angiographic, and noninvasive studies were reviewed in detail. Patient demographics and risk factors were recorded. Procedural angiograms were classified according to TASC Criteria (I-2000 and II-2007 versions) and SVS runoff scores were determined in every patient; primary, primary-assisted, secondary patency, and limb salvage rates were calculated. Cox proportional hazard model was used to determine if indication, TASC classification, runoff score, and comorbidities affected outcome. RESULTS: Seventy-one patients (65%) underwent SES for claudication and 38 patients (35%) for critical limb ischemia (CLI). Average treatment length was 15.7 cm, average runoff score was 4.6. Overall 36-month primary, primary-assisted, and secondary rates were 52%, 64%, and 59%, respectively. Limb salvage was 75% in CLI patients. No limbs were lost following interventions in claudicants (mean follow-up 16 months). In 24 patients with stent occlusion, 15 underwent endovascular revision, only five (33%) ultimately remained patent (15.8 months after reintervention). In contrast, all nine reinterventions for in-stent stenosis remained patent (17.8 months). Of 24 patients who underwent 37 endovascular revisions for either occlusion or stenosis, eight (35%) had worsening of their runoff score (4.1 to 6.4). By Cox proportional hazards analysis, hypertension (hazard ratio [HR] 0.35), TASC D lesions (HR 5.5), and runoff score > 5 (HR 2.6) significantly affected primary patency. CONCLUSIONS: Self-expanding stents produce acceptable outcomes for treatment of SFA disease. Poorer patency rates are associated with TASC D lesions and poor initial runoff score; HTN was associated with improved patency rates. Stent occlusion and in-stent stenosis were not entirely benign; one-third of patients had deterioration of their tibial artery runoff. Future studies of SFA interventions need to stratify TASC classification and runoff score. Further evaluation of the long-term effects of SFA stenting on tibial runoff is needed.