Sympathetic autoregulation in peripheral vascular disease

BACKGROUND: Lower limb venous pressure increases on dependency, stimulating a local sympathetic axon reflex which triggers precapillary and arteriolar vasoconstriction. The resulting decrease in arterial calf inflow, known as the venoarteriolar response (VAR), is impaired in critical leg ischaemia. The aim of the study was to evaluate the VAR in symptomatic non-critical leg ischaemia and after restoration of leg perfusion following successful revascularization. METHODS: The study included 30 normal subjects, 30 patients with stable intermittent claudication and 30 patients with severe ischaemia who had undergone successful infrainguinal revascularization. In all patients the foot skin blood flow (flux) in the horizontal (HBF) and sitting (SBF) positions was measured using laser Doppler fluxmetry. The VAR was calculated as (HBF - SBF)/HBF x 100 per cent. The pressure that elicited the reflex (pVAR) was evaluated in the horizontal position. RESULTS: The median VAR was significantly lower in patients with stable claudication than in normal subjects or patients following successful revascularization (29.1 versus 59.5 and 63.9 per cent respectively; P < 0.0001). Similar results were obtained for the pVAR (22 versus 45 and 40 mmHg respectively; P < 0.001). There was no difference, however, in either the VAR or pVAR between normal individuals and patients following a successful bypass. CONCLUSION: Patients with claudication had a significant impairment of orthostatic sympathetic autoregulation. After successful revascularization, and in spite of the extensive disease in the receiving circulation, this autoregulation returned to normal. Presented previously to the Vascular Surgical Society in London, November 1997 and published in abstract form as Br J Surg 1998; 85: 557     

Long-term effects of combined iliac dilatation and distal arterial surgery

PURPOSE: When standard aortofemoral surgical procedure is combined with lower extremity vascular surgery, problems related with the hospital stay, morbidity, mortality and the cost of treatment will exist. The number of reports relating to combined iliac artery PTA and distal bypass surgery is limited. After the development of stenting procedures, the results of arterial system plasty have much more improved. This report reviews our preliminary experience with iliac artery angioplasty with distal bypass procedures. PATIENTS AND METHODS: A total of 41 patients have undergone combined iliac artery dilatation and distal arterial revascularization. Angioplastic procedures were performed in the angiography suite and distal surgery was carried out at the same day or the day after. Of all patients, 29 underwent percutaneous transluminal angioplasty (PTA) and 12 underwent combined PTA and stent placement. Ipsilateral femoropopliteal bypass was performed as a distal revascularization procedure in all patients. RESULTS: Mean systolic iliac artery pressure gradients improved from 34.7+/-8.6 mmHg to 3.9+/-3.2 mmHg after angioplastic procedures (P < 0.0001). Six patients needed reangioplasty because of restenosis in the follow-up period. Thrombectomy was performed on 1 patient in the early postoperative period and re-do femoropopliteal bypass was performed on two patients in the 2nd and 23rd months. Three minor wound infections were successfully treated with antibiotics and local care. Mean follow-up was 21.4 months (range 1-48 months).By life-table analyses, the overall 4-year cumulative primary patency of combined procedures was 78.1%. CONCLUSION: The results show that the combined procedure is a suitable method for the treatment of patients with multiple stenotic lesions at the iliac and distal arterial levels. We believe that the combined use of PTA and distal vascular surgery by an experienced surgical team will give beneficial results and a highly satisfactory outcome in this group of patients.     

Transluminal angioplasty performed by the surgeon in lower limb arterial occlusive disease: one hundred fifty cases

From February 1985 through November 1988, we performed 159 transluminal angioplasty in 135 patients with arterial occlusive disease of the lower limb. The indications were claudication, 114 cases (72%) and limb salvage, 45 cases (28%). Lesions consisted of one or more critical stenoses in 142 cases (61 iliac, 69 femoropopliteal, and 12 following surgical revascularization) and single segmental occlusion in 17 cases (one iliac and 16 femoropopliteal). Angioplasty failed because the guidewire could not be inserted in nine (5.7%) cases. Angioplasty was performed intraoperatively in 44 (29%) cases and as an isolated procedure in 106 cases (71%). When performed as an isolated procedure, the percutaneous approach was preferred in 34 of the iliac lesions (73%), 28 of the femoropopliteal lesions (50%), and four of the postsurgical lesions (50%). Early postoperative mortality was 3.3% (five patients). Eight early occlusions (5.3%) were observed, two after iliac and six after femoropopliteal angioplasty. Secondary clinical surveillance and hemodynamic and venous digital angiographic follow-up detected 35 instances of stenosis (25%), 18 of which were equal to or greater than 60%. Nine occlusions occurred (6.5%), six after iliac angioplasty and three after femoropopliteal angioplasty. At 24 months, primary cumulative patency of all transluminal angioplasties was 84% and secondary patency was 89%. Transluminal angioplasty performed by the surgeon in the operating room provides good results whether performed as an isolated procedure or as a complement to surgery. The study of secondary deteriorations confirms the value of morphologic surveillance by arteriograms. Arteriography appears to be of paramount importance in the evaluation of results and the codification of indications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Radiotherapy-induced supra-aortic trunk disease: early and long-term results of surgical and endovascular reconstruction

PURPOSE: Few articles have dealt specifically with management of radiotherapy-induced supra-aortic trunk disease. We investigated the results of surgical and endovascular treatment of these lesions, and present our findings in a large series of patients. METHODS: The study was conducted at 11 centers. Over 10 years 64 patients with radiotherapy-induced supra-aortic trunk disease underwent surgical or endovascular treatment. Data were collected retrospectively in a consecutive cohort of patients, and were analyzed with the Kaplan-Meier method. RESULTS: Mean patient age was 64.4 years. The indications for radiotherapy included breast cancer (30%), head and neck malignancies (50%), and lymphomas (19%). The mean interval between irradiation and arterial revascularization was 15.2 years. Thirteen of the 64 patients (20%) had asymptomatic disease, and 51 patients (80%) had symptomatic disease. Ninety-two stenotic or occlusive lesions were observed, which involved the common carotid artery (n = 62), the subclavian artery (n = 26), or the innominate artery (n = 4). Twenty-three patients (36%) had multiple supra-aortic trunk lesions, but only 8 patients underwent reconstruction of multiple supra-aortic trunks. Five patients (8%) underwent sternotomy for revascularization from the ascending aorta. Forty-seven patients required revascularization of a common carotid artery; procedures included bypass grafting (n = 30), angioplasty with stent placement (n = 13), carotid-carotid transposition (n = 2), and endarterectomy (n = 2). Fifteen patients underwent restoration of a subclavian artery. One patient died on postoperative day 5, of stroke after early occlusion of an intercarotid crossover bypass graft. Mean follow-up was 37 months (range, 2-120 months). Ten late deaths occurred during follow-up. The probability of survival at 4 years was 78.1% +/- 8.6%. During follow-up, 6 patients had stroke, 4 bypass occlusions occurred and 3 stenoses occurred in the revascularized arteries. At 4 years the probability of freedom from stroke was 85% +/- 8.8%. At 4 years the primary patency rate was 79.3% +/- 8.5% and the secondary patency rate was 87.9% +/- 7.2%. CONCLUSIONS: In light of the context, the results of arterial revascularization to treat radiation-induced arterial lesions of the supra-aortic trunk are satisfactory.     

Foot skin blood flow following infrainguinal revascularization for critical lower limb ischemia.

INTRODUCTION: The aim of this study was to assess the blood flow in the feet before and after lower limb revascularization using laser Doppler imaging (LDI). METHODS: Ten patients with critical lower limb ischemia were prospectively enrolled from June to October 2004. All patients underwent successful unilateral surgical interventions including above-knee bypass, distal bypass and endarterectomy. Skin blood flow (SBF) over the plantar surface of both forefeet and heels was measured by LDI 24h before and 10 days after revascularization, expressed in perfusion units (PU), and reported as mean+/-SD. RESULTS: Measurements in the forefoot and heel were similar. Before revascularization mean SBF was significantly lower in the ischemic foot (130+/-71 PU) compared to the contralateral foot (212+/-68 PU), p<0.05. After revascularization a significant increase of the SBF in the forefoot (from 135+/-67 to 202+/-86 PU, p=0.001) and hindfoot (from 148+/-58 to 203+/-83, p=0.001) was observed on the treatment side. However, a large decrease of the SBF was seen in forefoot and hindfoot on the untreated side (from 250+/-123 PU to 176+/-83 and from 208+/-116 to 133+/-40, p=0.001, respectively). CONCLUSION: This study confirms the benefits of revascularization in patients with nonhealing foot lesions due to critical limb ischemia. A significant increase of the SBF was observed on the treatment side. However, an unexpected decrease was observed on the untreated side.     

The Correlation of the Trans-Atlantic Inter-Society Consensus Classification to Outcomes of Pedal Amputations

In an attempt at limb salvage for patients with peripheral arterial disease, revascularization is often performed prior to pedal amputation. The purpose of this study was to evaluate the association between proximal arterial lesions, based on Trans-Atlantic Inter-Society Consensus aortoiliac, femoropopliteal, and infrapopliteal classifications, and healing pedal amputations post endovascular revascularization. Patients with revascularization up to 90 days prior to pedal amputation with a minimum of 12 months postoperative follow-up were included. Each level of proximal disease was subdivided into Trans-Atlantic Inter-Society Consensus classifications A through D, which range in severity from a single short stenosis or occlusion to more complex stenoses and chronic total occlusion. For comparison, we categorized A and/or B lesions into Group 1 and C and/or D lesions into Group 2. The frequency of proximal lesions was recorded as either isolated, bi-level, or multilevel disease. Chi-square and Fisher's exact tests were used to compare categorical variables. Of the 310 patients, there were a total of 68 aortoiliac, 256 femoropopliteal, and 172 infrapopliteal lesions; 140 patients had isolated lesions, 154 had bi-level disease, and 16 had multilevel disease. Although not statistically significant, patients in Group 1 (A and/or B lesions) had higher proportion of failed amputation compared to Group 2 (C and/or D lesions) in either aortoiliac (84.4% vs 15.6%, p = .17), femoropopliteal (61.2% vs 38.8%, p = .72), or infrapopliteal (57.3% vs 42.7%, p = .44). Bi-level disease showed a higher proportion of failure (50.6%) compared to isolated lesions (43.8%) and multilevel disease (5.6%), (p = .86). To our knowledge, this is the first study to evaluate the association between Trans-Atlantic Inter-Society Consensus arterial lesions and incisional healing of pedal amputations. Despite our belief, there was no correlation between patients with simple, isolated lesions compared to either complex arterial lesions or multilevel disease in healing pedal amputations.     

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.     

Plaque excision with the Silverhawk catheter: early results in patients with claudication or critical limb ischemia

OBJECTIVE: This study was conducted to detail the early experience after infrainguinal atherectomy using the Silverhawk plaque excision catheter for the treatment of symptomatic peripheral vascular disease. METHODS: A prospective database was established in August 2004 in which data for operations, outcomes, and follow-up were recorded for patients undergoing percutaneous plaque excision for peripheral arterial occlusive disease. Society for Vascular Surgery (SVS) ischemia scores and femoropopliteal TransAtlantic Inter-Society Consensus (TASC) criteria were assigned. A follow-up protocol included duplex ultrasound surveillance at 1, 3, and 6 months and then yearly thereafter. Standard statistical analyses were performed. RESULTS: During a 17-month period, 66 limbs of 60 patients (37 men [61.7%]) underwent 70 plaque excisions (four repeat procedures). Indications included tissue loss based on SVS ischemia at grades 5 and 6 (25/70), rest pain at grade 4 (22/70), and claudication at grades 2 to 3 (23/70). The mean lesion length was 8.8 +/- 0.7 cm. The technical success rate was 87.1% (61/70). Adjunctive treatment was required in 17 procedures (24.3%), consisting of 14 balloon angioplasties and three stents. Femoropopliteal TASC criteria included 5 TASC A lesions, 14 TASC B lesions, 32 TASC C lesions, and 19 TASC D lesions. Although 17 plaque excisions included a tibial vessel, no patient underwent isolated tibial atherectomy. The mean increase in ankle-brachial index was 0.27 +/- 0.04 and in toe pressure, 20.3 +/- 6.9 mm Hg. Mean duplex ultrasound follow-up was 5.2 months (range, 1 to 17 months). One-year primary, primary assisted, and secondary patency was 61.7%, 64.1%, and 76.4%, respectively. Restenosis or occlusion developed in 12 patients (16.7%) and was detected at a mean of 2.8 +/- 0.7 months. Restenosis or occlusion was significantly more common (P < .05) in patients with TASC C and D lesions compared with patients with TASC A and B lesions. Six (8.3%) of 12 patients underwent reintervention on the basis of duplex ultrasound surveillance results. Four (33.3%) of 12 patients experienced reocclusion during the same hospitalization, and amputation and open revascularization were required in two patients each. CONCLUSIONS: Percutaneous plaque excision is a viable treatment option for lower extremity revascularization. Outcomes are related to ischemia and lesion severity. Patency and limb salvage rates are equivalent to other endovascular modalities.     

Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes

BACKGROUND: Percutaneous therapy for symptomatic visceral occlusive disease is rapidly gaining popularity in many centers. This study evaluates the anatomic and functional outcomes of open and endovascular therapy for chronic mesenteric ischemia at an academic medical center. STUDY DESIGN: We performed a retrospective review of patients who underwent endovascular or open mesenteric arterial revascularization for chronic mesenteric ischemia between January 1989 and September 2003. Indications for revascularization included postprandial abdominal pain (92%) or weight loss (54%). All had atherosclerotic visceral occlusive disease with a median of 2 vessels with more than 50% stenosis or occlusion on angiography. Sixty patients (44 women, mean age 66 years) underwent 67 interventions (43 vessels bypassed, 23 vessel endarterectomies, 22 vessel angioplasty and stents). The median numbers of vessels revascularized were two in the open group and one in the endovascular group. RESULTS: Thirty-day mortality and cumulative survival at 3 years were similar (open, 15% and 62% +/- 9%; endovascular, 21% and 63%+/-14%, respectively; p=NS). Cumulative patencies at 6 months were 83%+/-7% and 68%+/-14% in the open and endovascular groups, respectively (p=NS). Major morbidity, median postoperative length of stay, and cumulative freedom from recurrent symptoms at 6 months were significantly greater in the open group (open, 46%, 23 days, and 71%+/-7%, respectively; endovascular, 19%, 1 day, and 34%+/-10%, respectively; p < 0.01). CONCLUSIONS: Endovascular revascularization is attractive because it carries equivalent patency to open revascularization. Symptomatic benefit of endovascular revascularization is not achieved, probably as a result of incomplete revascularization. Despite incomplete revascularization, endovascular therapy has equivalent survival and lower morbidity compared with open revascularization. Complete endovascular revascularization needs further evaluation to determine if it is superior to open revascularization. In the interim, endovascular therapy should be reserved for the patient unable to undergo open revascularization.     

Recent advances in atherectomy and devices for treatment of infra-inguinal arterial occlusive disease

The prevalence of peripheral arterial disease (PAD) continues to rise in an ever ageing society and consumes a significant part of health resources. Percutaneous revascularization has revolutionized the treatment of lower extremity peripheral vascular disease over the past 10 years. Additionally, novel devices have allowed improved endovascular treatment of femoropopliteal as well as infrapopliteal disease. Although percutaneous transluminal angioplasty (PTA) can be an effective modality for focal lesions in the iliac arteries, the results for complex infra-inguinal arterial disease have been disappointing. One class of new technology has concentrated on debulking the plaque, while others focus to improve safety (distal embolic protection devices) or are directed to specific clinical challenges such as chronic total occlusions. However, the lack of uniform performance criteria and reporting standards for these and other devices has resulted in heterogeneous study end points, making comparative efficacy difficult. Here we review the current data for atherectomy and atheroablative technologies as well as other adjunctive devices in the treatment of lower extremity peripheral arterial disease.     

Changes in peripheral hemodynamics after percutaneous transluminal angioplasty

We measured ankle/arm pressure indexes and blood flow rates before and after performing percutaneous transluminal angioplasty in 36 extremities. Flow rates through the leg were determined with a magnetic resonance blood flow scanner. All patients had claudication; one had gangrene, another had an ulcer, and two complained of rest pain. The median age was 65 years, and 72% were men. There were 25 dilations of the iliac artery, 12 of the superficial femoral artery, and eight of the popliteal arteries; nine patients had two arterial segments dilated. Nineteen legs had ankle/arm pressure indexes before percutaneous transluminal angioplasty of less than 0.80 (range 0.51 to 0.75); their flow rates averaged 40 +/- 20 (SD) ml/min. After percutaneous transluminal angioplasty flow and pressure increased significantly in 14 of these 19 legs, and three had no hemodynamic improvement; in one leg only pressure and in another only flow increased significantly. The remaining 17 extremities had ankle/arm pressure indexes before percutaneous transluminal angioplasty ranging from 0.81 to 1.09; their flow rates averaged 53 +/- 27 (SD) ml/min. Abnormal flow rates were detected in 15 of these 17 extremities. With near-normal ankle/arm pressure indexes no significant increase in pressure was anticipated. Flow rates augmented to 75 +/- 28 (SD) ml/min after percutaneous transluminal angioplasty; a significant increase in flow was noted in 12 legs (71%). For patients with ankle/arm indexes before percutaneous transluminal angioplasty of less than 0.80, either pressure or flow measurements should corroborate the benefits of the operation, whereas if the ankle arm index is greater than 0.80, flow measurements are most likely to substantiate changes in peripheral hemodynamics.     

Use of colour duplex imaging to diagnose and guide angioplasty of lower limb arterial lesions.

BACKGROUND: The purpose of this study was to investigate whether colour duplex imaging alone could safely and effectively be used to diagnose lower limb arterial lesions and guide subsequent percutaneous transluminal angioplasty (PTA). METHODS: Patients with discrete lower limb arterial lesions, preferably stenoses, which could be visualized clearly by colour duplex imaging were selected for duplex-guided PTA. Duplex-guided PTA was performed in an operating theatre using conventional balloon catheters. RESULTS: Duplex imaging was used to diagnose and guide PTA of 55 arterial lesions in 50 legs of 45 patients. There were 53 stenoses and two occlusions. The median (range) ankle : brachial pressure index was 0. 86 (0.52-1.10) before dilatation and 1.00 (0.83-1.40) immediately after dilatation (P = 0.0001). There were no complications during or after any of the procedures and 46 of the 47 symptomatic legs were markedly improved at a median follow-up of 23 days. Radiographic imaging was not required for any of the procedures. CONCLUSION: It is possible to diagnose and angioplasty lower limb arterial lesions using colour duplex imaging alone.     

Trends in mortality,readmissions, and complications after endovascular and open infrainguinal revascularization

BackgroundAlthough short-term outcomes of endovascular and open infrainguinal revascularization in patients with peripheral arterial disease have been previously reported, 30-day readmission and resource utilization after these procedures remain unknown.MethodsWe used the 2010–2014 Nationwide Readmissions Database and the International Classification of Diseases, Ninth Edition, to identify patients with peripheral arterial disease undergoing either in-hospital endovascular or open infrainguinal revascularization.ResultsOf an estimated 574,201 hospitalized patients treated for peripheral arterial disease, 308,056 and 266,145 underwent lower limb endovascular and open infrainguinal revascularization, respectively. Compared with patients who underwent open revascularization, endovascular patients were more commonly female (44.8% vs 36.7%, P < .001) and older (69.5 vs 67.2 years, P < .001). Moreover, they had higher rates of 30-day readmission (15.6% vs 13.5%, P < .001), in-hospital complications (22.3% vs 20.9%, P < .001), and in-hospital index mortality (2.1% vs 1.8%, P < .001). In contrast, risk-adjusted multivariable analysis found open revascularization to be independently associated with increased odds of 30-day readmission (odds ratio, 1.13; 95% confidence interval 1.10–1.16), index complications (odds ratio, 1.23; 95% confidence interval 1.20–1.27), and mortality (odds ratio, 1.26; 95% confidence interval 1.16–1.36) compared with those who underwent endovascular revascularization. Trend analysis revealed an overall decrease in the utilization of both endovascular and open revascularization procedures in the inpatient setting.ConclusionDespite lower rates of adverse events compared to endovascular, open infrainguinal revascularization is independently associated with increased risk of short-term readmission, complications, and mortality. These findings should be considered in the selection of appropriate surgical therapy for lower extremity arterial occlusive disease.     

Reinterventions for recurrent ischemic heart disease following a successful first re-do myocardial revascularization: predictors, indications and results.

Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% (n = 144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P<0.001) and in patients with unstable angina (55.6% versus 33.3%, NS) or a Left Ventricular Ejection Fraction (LVEF) <30% (34.8% versus 20%, P<0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3+/-0.3 versus 1+/-0.6, P<0.001), proximal occlusive disease (P<0.001) and for graft disease of a longer duration (7.18+/-1.7 years versus 3+/-0.6 years, P<0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis >70%, long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG (n = 48: early 21, late 27), repeat graft angioplasty (n = 34: early 8, late 26) or transplant (n = 1). Recurrent symptoms following a second re-do CABG required a graft angioplasty (n = 6: early 2, late 4), a subsequent re-do CABG (n = 32) or a transplant (n = 4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively (P<0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.     

Percutaneous transluminal angioplasty of infrarenal arteries in intermittent claudication

Percutaneous transluminal angioplasty was performed on 55 iliac and 31 femoropopliteal arteries in 71 patients with intermittent claudication (23 women, 48 men). The two-year patency rate was 80% after iliac and 41% after femoropopliteal angioplasty. In 17 femoropopliteal cases with lesions greater than or equal to 5 cm the 2-year patency rate was only 32%, but the corresponding figure for shorter lesions was 53%. Complicating haematoma appeared in 10% of the cases and the arterial state deteriorated in one patient. There was no distal embolization. Percutaneous transluminal angioplasty in intermittent claudication is indicated for all cases of occlusion or stenosis of the iliac artery and for occlusion or stenosis shorter than 5 cm of the superficial femoral or the popliteal artery.     

Endovascular treatment of femoropopliteal arterial occlusive disease: Current techniques and limitations

In an aging population with a rising incidence of peripheral artery disease, endovascular therapy is a favorable alternative to open surgical bypass. As a minimally invasive approach, endovascular therapy incurs less physiologic stress and periprocedural complications. Balloon angioplasty and stenting have been the predominant tools in peripheral endovascular therapy. The mechanisms of endovascular therapy have evolved beyond pneumatic dilation and forcing plaque against vessel wall with angioplasty and stenting. Technology has broadened to adjunctive local treatments with pharmaceutical agents coating balloons or eluting from stents, atherectomy to remove intimal and medial plaque, and more recently, intravascular lithotripsy to fracture and modify plaque. These technologies have performed well in curated clinical trials and in the real world for short-segment disease. Despite the excellent outcomes of treatment for short-segment occlusive disease, post-procedural patency of endovascular treatment for long-segment, highly calcified lesions remains challenging in the femoropopliteal region. The development of drug-coated balloons and stents brings the hope of improved patency. However, the results are incrementally better at best and are not superior to surgical bypass. In addition, there is controversy regarding the long-term mortality risk. With numerous devices and techniques as well as differing magnitudes of peripheral artery disease, it will be difficult to practically have a study to answer all questions regarding endovascular treatment of the femoropopliteal artery. This review examines current endovascular techniques for de novo and recurrent femoropopliteal arterial occlusive disease, as well as the applicability of intravascular ultrasound and optimal stenting strategies for long-segment disease.     

Cilostazol reduces restenosis after endovascular therapy in patients with femoropopliteal lesions

BACKGROUND: Despite the recent development of endovascular therapy (EVT), a high incidence of restenosis remains as an unsolved issue in patients presenting with femoropopliteal lesions. We investigated whether cilostazol reduces restenosis after successful EVT for de novo femoropopliteal lesions. METHODS: This study was designed as a prospective, randomized, open-label, blinded end point study in a single institution. Between March 2004 and June 2005, we randomized 127 patients who were successfully treated with EVT for de novo femoropopliteal lesions to receive cilostazol (200 mg/d, n = 63) or ticlopidine (200 mg/d, n = 64) in addition to aspirin (100 mg/d). Antiplatelet medications were started at least 1 week before EVT and were continued until the end of follow-up. Patency was defined by duplex ultrasound imaging with peak systolic velocity ratio >2.4. RESULTS: There were no significant differences in the patients and lesion characteristics. Sixteen patients dropped out of the study protocol, six of whom were withdrawn due to adverse drug effects (cilostazol, n = 5; ticlopidine, n = 1; P = .09). Ten patients died (cilostazol, n = 4; ticlopidine, n = 6; P = .53) during the follow-up period. Patency rates at 12, 24, and 36 months were 87%, 82%, and 73% in the cilostazol group and 65%, 60%, and 51% in ticlopidine group by intention-to-treat analysis (P = .013) and were 87%, 82%, and 73% in the cilostazol group and 64%, 57%, and 48% in the ticlopidine group (P = .0088) by as-treated analysis. Freedom from target lesion revascularization and all adverse events (restenosis, amputation, and death) was significantly higher in cilostazol group than in ticlopidine group (P = .036, P = .031). No acute, subacute, or chronic thrombotic occlusion was encountered, and bleeding complication rates were similar between the two groups. CONCLUSIONS: Cilostazol significantly reduces restenosis after EVT in femoropopliteal lesions.     

Angioplasty does not affect subsequent operative renal artery revascularization

BACKGROUND: Although increased application of percutaneous renal artery angioplasty and stenting has facilitated nonoperative renal revascularization, patient outcomes after failed angioplasty are not established. METHODS: Renal artery revascularization was performed in 31 patients (38 arteries) from 1993 to 1999. Twenty patients underwent primary surgical repair, and 11 patients underwent secondary reconstruction after angioplasty (n = 7) or angioplasty and stenting (n = 4). Before operation, all patients had severe hypertension (blood pressure 166+/-5.2/92 +/- 2.7 mm Hg) that required an average of 3.0 +/- 0.2 medications for control. In addition, 12 patients (primary 45% vs secondary 27%; P = NS) had evidence of renal insufficiency (creatinine > or =1.7 mg/dL). RESULTS: There was no difference between primary and secondary procedures in the length of hospital stay (12+/- 1.4 vs. 12+/-3.2 days; P = NS), major morbidity (10% vs. 18%; P = NS) or perioperative mortality (overall mortality 2 of 31; primary 5% vs secondary 9%; P = NS). The majority of patients demonstrated improvement or cure of hypertension (primary 94% vs secondary 90%; P = NS) and stable or decreased creatinine (primary 74% vs secondary 82%; P = not significant). Overall survival (mean follow-up 22+/-3.5 months) was 89%+/-5.7%. CONCLUSIONS: Although this surgical series does not address the true outcomes of renal artery angioplasty, the results suggest that renal artery angioplasty does not prejudice subsequent surgical outcomes in patients who are carefully followed after angioplasty.     

Factors that influence the outcome of aortoiliac and femoropopliteal percutaneous transluminal angioplasty.

In the past, patients with peripheral arterial occlusive disease were managed by conservative treatment or by vascular reconstructive surgery. Now, percutaneous transluminal angioplasty and other endovascular methods provide an important alternative for managing selected patients with peripheral arterial occlusive disease. Overall, the 5-year success rate after iliac angioplasty is 53.4%, but the success rate is higher if percutaneous transluminal angioplasty is performed on the common iliac artery or on a stenosed artery. In contrast, percutaneous transluminal angioplasty of the femoral and popliteal arteries has a relatively poor long-term success rate except for the treatment of patients with stenoses with good run-off. When the run-off is poor or an arterial occlusion is present, the role of femoropopliteal angioplasty is limited, and the procedure should be considered only for high-risk patients who do not have autogenous tissue for reconstructive surgery.     

Non-randomized, prospective, multi-centre evaluation of the ABSOLUTE .035 peripheral self-expanding stent system for occluded or stenotic superficial femoral or proximal popliteal arteries (ASSESS Trial): acute and 30-day results

AIM: The aim of the paper was to investigate the performance of the ABSOLUTE .035 Peripheral Self-Expanding Stent System in preventing restenosis of superficial femoral or proximal popliteal arteries. Due to a lack of large controlled trials proving its long-term durability femoropopliteal artery stenting is still a matter of debate. In this paper we report the study design, the acute and short-term results of a prospective European registry on the treatment of TASC B and C femoropopliteal lesions with the use of the ABSOLUTE stent. METHODS: This prospective, non-randomized, multi-centre study enrolled 122 patients with symptomatic peripheral occlusive disease at 14 sites in Europe. Patients were included with obstructed femoropopliteal arteries. Key inclusion criteria were de novo lesions > or = 4.0 mm and < or = 7.0 mm in diameter, and > or = 40 mm and < or = 200 mm in length. Single target vessel treatment had to be performed with a maximum of three stents. RESULTS: Mean target lesion length was 108 +/- 44 mm (range 22.2 to 200 mm) and mean reference vessel diameter 4.6 +/- 0.8 mm by quantitative angiography; 71% of the lesions analyzable by quantitative angiography (QA) had total occlusions. A total of 227 stents were implanted, 224 of which were deployed successfully (98.7%). Mean percentage of diameter stenosis was reduced from 90.9 +/- 15.5 % (range 41.3 to 100) to 19.0 +/- 8.4% (range 2.3 to 41.5). Device and procedural success were 83.6% each whereas technical success reached 100%. Sixteen lesions had a > or = 30% residual stenosis post-procedure, 6 of them (37.5%) rated as being calcified. Eleven patients experienced major complications (9.1%) and 6 patients experienced minor complications (5%) within 30 days. Duplex ultrasound based 1-month restenosis rate was 9.3%. Target lesion revascularization (TLR) and target vessel revascularization (TVR) rates were 0.8% and 1.7%, respectively and amputation rate was 0.8%. Mean ankle-brachial index (ABI) at rest and after exercise increased significantly from baseline to 30 days follow-up by 0.63 +/- 0.20 to 0.94 +/- 0.17 and from 0.44 +/- 0.23 to 0.85 +/- 0.21, respectively (P<0.001 each). CONCLUSION: The treatment of TASC B and C femoro-popliteal lesions with use of the ABSOLUTE stent is safe and feasible. Short-term follow-up documents persistent improvement of hemodynamics. The 6- and 12-month data have to be awaited for further conclusions: