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.     

下肢动脉支架与单纯球囊扩张成形治疗股浅动脉病变的对比性研究

目的观察并比较单纯经皮血管腔内成形(PTA)与自膨式镍钛记忆合金支架植入治疗下肢缺血的疗效。方法对2005年1月～2006年6月支架治疗61例患者的临床资料进行回顾性研究,包括22例(36.1%)PTA(PTA组)和39例(63.9%)球囊扩张后的支架植入(支架组)。49例(80.3%)患者为糖尿病下肢动脉硬化,12例(19.7%)为非糖尿病下肢动脉硬化。3例(4.9%)为严重间歇性跛行,20例(32.8%)有静息痛,25例(41.0%)伴有足部溃疡,13例(21.3%)有足部坏疽。结果 PTA组和支架组的总有效率分别为95.5%和94.9%,两组近期疗效无明显差异(P0.05);平均随访15.5个月,PTA组和支架组的总有效率分别为68.2%和89.7%,支架的疗效明显优于单纯PTA(P0.05)。PTA组和支架组的截肢率分别为13.6%和2.6%,两组在保肢方面无明显差异(P0.05)。结论对于治疗股浅动脉病变所导致的下肢缺血的疗效,在短期内单纯PTA与支架植入没有明显差异,而在术后1年的随访中股浅动脉支架的疗效明显优于PTA。两组救肢效果在术后1年左右也基本相同。     

Combined long-segment angioplasty and stenting of the superficial femoral artery and popliteal-distal bypass for limb salvage

The treatment of multisegment superficial femoral artery and tibial vessels atherosclerotic disease is traditionally a femoro-distal bypass using in situ or reversed autogenous vein. The improved result of balloon angioplasty and stenting of the superficial femoral artery (SFA) has extended its application to treat long segment SFA stenosis. A combined endovascular-open surgery approach of SFA endovascular stenting with a popliteal-distal bypass is an alternative less invasive procedure to achieve optimum distal revascularization for limb salvage.     

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.     

Primary utilization of stents in angioplasty of superficial femoral artery

Percutaneous transluminal angioplasty (PTA) of infrainguinal arteries has been frequently reported in the literature. Independent of the technical feasibility, the results, in short-and long-term follow-up differ among published series. The objective of this article was to assess the long-term results of angioplasty in small, (<3 cm) segmental lesions of the superficial femoral artery treated with primary stenting. Eighteen patients (12 men, 6 women) with lesions of the superficial femoral artery smaller than 3 cm were selected for endovascular treatment and follow-up. The median patient age was 65 years (range, 54 to 84). The indication for treatment was intermittent claudication in 7 patients and critical ischemia (ischemic pain associated with trophic lesions) in 11 patients (62%). Of these, 13 lesions were stenoses and 5 total occlusions. The run-off was good in 15 patients who had more than 2 distal arteries and 3 had only 1 patent artery. During follow-up, all patients were observed with physical examination, progressive exercise treadmill test; pulse volume was measured with Doppler and duplex scan after 1, 3, and 6 months, and then twice a year. There was only 1 primary failure; the initial success rate was 94%. During follow-up of 40 months (6 to 70 months), only 1 patient presented with thrombosis of the stent 6 months after the procedure. There was no symptomatic restenosis in our study. One patient suffered an acute myocardial infraction after 45 months and died. The primary patency after 1 and 3 years was 88%. No patient was lost to follow-up. Primary stenting of segmental lesions (less than 3 cm) of the superficial femoral artery produced satisfactory results immediately and during long-term follow-up.     

Retrograde stent-graft angioplasty of superficial femoral artery occlusion in a claudicant

Endovascular therapy has become an accepted mode of therapy for lifestyle-limiting claudication, especially if the disease is confined to the superficial femoral artery (SFA). The standard approach to these lesions is from the contralateral femoral artery and crossing over the aortic bifurcation. In patients who have an aortobifemoral bypass (AFB), this technique is usually not feasible secondary to the angles of the graft. The authors report on their approach to a 60-year-old man with lifestyle-limiting claudication and SFA disease, and an AFB in place. They performed a retrograde approach to the SFA via a small above-knee popliteal artery exposure. They used the recently approved (in the United States) heparin-bonded VIABAHN for the revascularization via this approach, which would have allowed them to proceed to an open bypass procedure if they were unsuccessful in the same setting.     

Laser angioplasty for superficial femoral and proximal popliteal artery occlusion.

A prospective study of percutaneous laser assisted thermal angioplasty for superficial femoral and proximal popliteal artery occlusions was performed on 93 consecutive patients with a mean length of occluded segment of 7.6 cm. Technical success was achieved in 78 patients (84%). Subsequent patency or occlusion has been confirmed by duplex ultrasound scanning or arteriography. The crude patency rate for successfully recanalised vessels was 48% during a mean follow-up period of 18 months. Subsequent femoropopliteal bypass or amputation was required in 20% of these patients. Factors predictive of reocclusion were a length of occluded segment greater than 8 cm (p = 0.05) and less than two patent vessels below the knee (p = 0.005).     

Peroneal artery approach for angioplasty of the superficial femoral artery: a case report

The authors report the implantation of a Palmaz stent in the superficial femoral artery using an approach not previously described, the peroneal artery. A 64-year-old man was admitted with extensive necrosis of the right foot. Physical examination showed a normal right femoral pulse but absence of popliteal and tibial pulses. Arteriography showed a superficial femoral artery with critical stenoses but a normal profunda artery. A classic below-knee amputation was performed. During the procedure, the muscular blood flow was considered insufficient, by clinical experience, to achieve limb healing at this level, and so the surgeon chose to perform an angioplasty of the superficial femoral artery lesion, utilizing an access through the leg arteries. After introducing the guidewire through the peroneal artery, the surgeon successfully dilated the lesion and implanted a Palmaz stent. Afterward, the popliteal pulse became palpable in physical examination and improved the skin and muscular aspect in this level. The surgery was finished with a closed stump. The surgery healed satisfactorily, without any complications, and the patient had a satisfactory follow-up, with ambulatory rehabilitation, and recovery of walking capacity with a leg prosthesis. The peroneal approach gave satisfactory results and should be considered in clinical situations like this.     

Delayed recanalization angioplasty after traumatic occlusion of the superficial femoral and popliteal artery

The management of patients presenting with limb-threatening ischemia after lower limb trauma poses particular demands on vascular surgeons. We describe two patients with lower limb arterial occlusions who presented with limb-threatening ischemia 8 years and 3 years after trauma to the lower limb. They were successfully managed by recanalization angioplasty, with a good early clinical outcome after 5 months and 3 months, respectively. Recanalization angioplasty is a useful adjunct in the management of ischemic limbs after trauma.     

Comparison of the results of percutaneous transluminal angioplasty and stenting with medical treatment for claudicants who have superficial femoral artery occlusive disease

The outcomes of medical management of peripheral vascular disease localized to the superficial femoral artery (SFA) were compared with those obtained by percutaneous transluminal angioplasty (PTA) with or without stenting in a review of selected studies. The natural history of localized SFA disease is favorable, with major amputation rates less than 10% and revascularization in only 18% of patients over a 10-year interval. Conservative treatment of claudicants shows increases (150%) in walking distance if the ankle brachial index (ABI) is over 0.6 and patients stop smoking. Analysis of 10 trials (882 patients) of PTA with or without stenting found that the overall primary patency rates at 12 months were 71.1% for PTA plus stenting and 58.3% for PTA alone. Technical success with PTA with or without stenting is over 90%, and early results at 6 months are superior to those with exercise. In three randomized controlled trials, however, the difference between PTA and medical treatment at 2 years, whether measured by walking distance or ABI, was not significant, nor was the quality of life. For long-term improvement in walking distance (> 1 year) in the claudicant, intervention is not superior to medical treatment and a monitored exercise program. Consideration should be given to including a nonintervention control group and 2-year outcomes in the evaluation of new SFA stents.     

球扩式支架扩张时致限制性股浅动脉破裂1例

<正>患者女,76岁,左下肢间歇性跛行2个月,静息痛4天,既往冠心病史20年,高血压病史5年。查体:左侧腘动脉、足背动脉搏动未触及,胫后动脉搏动减弱,左足趾发紫,触痛,左足皮温减低。超声:左股浅、足背动脉闭塞,左腘动脉不完全闭塞,胫前动脉狭窄,血流减低,胫后动脉血流减低。下肢CTA:左股