Angioplasty using a Nd:YAG laser with a sapphire probe

Laser angioplasty with Sapphire Contact Probes coupled to a Nd:YAG laser followed by balloon angioplasty was performed in 30 patients with 26 femoropopliteal and 4 iliac artery occlusions. Mean length of the occlusions was 4.5 +/- 1.6 cm with a mean duration of occlusion of 7.06 +/- 6.18 months. Initial angiographic success was obtained in 25/30 (83%) procedures, including 3/4 successes in the iliac artery (75%) and 22/26 successes in the femoropopliteal artery (84%). Reason for failure was perforation in 2 patients, and subintimal passage of the probe in 2, and heavy calcification of the lesion in 1 patient. Early rethrombosis in 3 patients reduced the primary success rate to 73%. Peripheral emboli necessitating surgical intervention occurred in 2 patients. Of the 22 recanalized arteries 21 remained patent with a mean follow-up of 8.4 +/- 3.3 months. It remains to be determined whether the angiographic and clinical short and long term success rate of "laser assisted balloon angioplasty" will be greater than after thrombolysis or conventional balloon angioplasty.     

Laser-assisted balloon angioplasty in complete femoropopliteal occlusions: Preliminary results

Laser-assisted balloon angioplasty (LA) using a Nd-YAG laser with a sapphire tip probe was performed in 40 selected patients with complete chronic femoropopliteal occlusions (SFA n=30, PA n=10), in whom the lesion was resistent to conventional guidewire/catheter traversal. Overall technical success rate was 77.5% (31/40). Technical failure occurred in nine cases due to calcifications (n=2), imminent perforation (n=5), or complete perforation (n=4). In I case a Simpson atherectomy was done following LA. In addition, 3 cases of peripheral embolizations were managed successfully by selective fibrinolysis and thrombus aspiration. Follow-up studies up to 14 months demonstrated a clinical improvement in 87% (27/31). Early reocclusion rate was 4/31; after 2–14 months, reocclusion rate was 7/31. Our results demonstrate that LA may be recommended for chronic occlusions resistent to conventional guidewire or catheter traversal in spite of a relatively high rate of technical failure and complications, and recurrence.     

The use of soft and flexible guidewires in the treatment of chronic total coronary occlusions by activated guidewire angioplasty.

Activated guidewire angioplasty (AGA) is a new technique which has been designed to assist in angioplasty of total occlusions. The purpose of this study was to determine the safety and efficacy of using flexible relatively soft guidewires (floppy wires) in conjunction with this technique and also to determine the predictors of lesion crossing and final success by this technique in patients with chronic total coronary occlusions. 73 patients with 73 chronic total coronary occlusions in whom coronary angioplasty using conventional techniques had failed were treated with AGA using floppy guidewires. The success of crossing these lesions was 65.7% (48/73) resulting in a final angioplasty success of 56.1% (41/73). Angioplasty success was reduced compared with crossing success in seven arteries in which complications occurred during balloon angioplasty. Multiple stepwise logistic regression analysis identified the location of the occlusion (right coronary artery, p = 0.005) as independent predictor of crossing success of this technique and the male gender (p = 0.03), the duration of occlusion (p = 0.05), the lesion length (p = 0.01) and the location of the occlusion (right coronary artery, p = 0.02) as independent predictors of final procedural success of the method.     

Comparison of pulsed laser-assisted angioplasty and balloon angioplasty in femoropopliteal artery occlusions.

The authors performed a prospective, comparative study of 96 patients (age, 41-87 years) with femoropopliteal artery occlusions. Laser-assisted angioplasty was performed in 64 patients with 9- and 7-F over-the-wire multifiber catheters. Supplemental balloon dilation was performed after laser angioplasty. Thirty-two patients underwent excimer laser angioplasty (ELA), and 32 underwent pulsed dye laser angioplasty (DLA). The remaining 32 patients underwent conventional balloon angioplasty (BA). The length of occlusions was 3-10 cm (mean, 6.3 cm). Lesion characteristics in the three patient groups were similar. Technical success rates were 84% for ELA, 78% for pulsed DLA, and 81% for conventional BA. The 1-year clinical success rate was 69% (22 of 32 patients) in the ELA group, 63% (20 of 32 patients) in the pulsed DLA group, and 66% (21 of 32 patients) in the BA group (differences were not significant). Laser-assisted angioplasty with multifiber catheters in femoropopliteal artery occlusions did not help improve the technical success rate and 1-year clinical success rate when compared with those of conventional BA.     

Occluded peripheral arteries: clinical utility of argon laser recanalization

Optically diverged direct argon laser light energy was used prior to conventional balloon angioplasty to recanalize 30 occluded peripheral arteries in 26 patients. Three of five (60%) iliac and 22 of 25 (88%) femoropopliteal lesions ranging in length from 1 to 47 cm (mean, 17.3 cm) were successfully treated, for an overall technical success rate of 83%. In the femoropopliteal system, 13 of 14 (93%) procedures in lesions less than 20 cm and nine of 11 (82%) procedures in lesions greater than 20 cm were treated successfully. No statistically significant differences in success rate based on lesion site, lesion length, degree of lesion calcification, or severity of peripheral vascular disease were found. Major complications were a laser perforation resulting in treatment failure in one case (3%) and a successfully treated distal embolus in another (3%). No reocclusions occurred in the immediate postoperative period. While long-term follow-up will be required to assess continued patency, this system can potentially increase the number of patients amenable to conventional balloon angioplasty and is currently advocated as an alternative to amputation in patients in whom surgical bypass grafting is contraindicated or unfeasible.     

Short (1-10 cm) superficial femoral artery occlusions: results of treatment with excimer laser angioplasty

Purpose: To evaluate the safety and long-term results after laser angioplasty of short occlusions of the superficial femoral artery (SFA). Methods: In a prospective trial in 312 patients with short occlusions of the SFA excimer laser angioplasty for recanalization was applied. The average occlusion length of the SFA was 7.5 cm (range 1–10 cm). The recanalization attempt was done using either a cross-over technique from the contralateral femoral artery (278 patients), antegrade technique (16 patients) or transpopliteal technique (18 patients). Results: Percutaneous transluminal laser angioplasty (PTLA) produced successful recanalization of the SFA in 286 of 312 patients (91.7%). In 26 patients (8.3%) recanalization was not possible. The reason for the unsuccessful PTLAs was obstructing calcified materialn = 8) which was resistant to laser application. In nine cases obstructing calcifications resulted in positioning of the laser catheter in subintimal tissue or perforation of the SFA. In another four patients there was an aberrant anatomy of the SFA which resulted in a direct vessel injury after advancing the laser catheter. In five patients subintimal recanalization failed. After a follow-up period of 36 months there was a primary, primary assisted and secondary patency rate of 49.2%, 76.5% and 86.3%. Conclusion:Excimer laser angioplasty of short occlusions of the SFA is a feasible procedure with a low failure rate. Long-term results are promising but additional interventions are required in most patients to achieve a patency rate of 86.3% after 3 years. Further studies are needed to compare the clinical outcome of PTLA and PTA in short occlusions of the SFA.     

Percutaneous laser thermal angioplasty: initial results and 1-year follow-up in 129 femoropopliteal lesions

Percutaneous peripheral laser thermal angioplasty with a laser-heated metallic-capped fiber was used as an adjunct to conventional balloon angioplasty. Initial angiographic and clinical success was achieved in 99 of 129 (77%) femoropopliteal stenoses and occlusions (21 of 22 [95%] stenoses, 17 of 17 [100%] short [1-3-cm] occlusions, 26 of 37 [70%] medium-length [4-7-cm] occlusions, and 35 of 53 [66%] long [greater than 7 cm] occlusions). There was a 4% frequency of vessel perforation without clinical sequelae and no necessity for emergency bypass surgery. The 1-year cumulative clinical patency was 77% for the 99 lesions with an initial clinical success. In the 21 stenoses and 17 short occlusions, the cumulative clinical patency rates were 95% and 93%, respectively. In the longer occlusions (4-7 cm and greater than 7 cm), the clinical patency rates were 76% and 58%, respectively. The initial angiographic and clinical success, as well as the 1-year cumulative clinical patency, for stenoses and short occlusions after laser-assisted balloon angioplasty may be greater than after conventional balloon angioplasty alone.     

Early experience and midterm follow-up results with a new,rotational thrombectomy catheter

Purpose: To assess the efficacy and safety of the Rotarex rotational thrombectomy catheter in treating occlusions of the femoropopliteal arteries. Methods: The Rotarex catheter (Straub Medical, Switzerland) is a rotational thrombectomy device which is supposed to be able to remove fresh and partially organized clot material from an acutely or subacutely occluded vessel. Nineteen limbs of 18 patients (10 women, 8 men; mean age 72.9 ± 7.3 years) with acute or subacute (23 ± 16 days) occlusions of the middle or distal third of the superficial femoral artery or the popliteal artery were treated. The occlusions were 3–20 cm long. Results: Thrombectomy was technically successful in 15 of 19 vessels (79%). The primary procedural success including additional procedures such as angioplasty and/or stent-graft placement in 17 limbs was 94%. The mean ankle-brachial index improved from 0.36 ± 0.26 (before thrombectomy) to 0.81 ± 0.21 (2 days after the procedure) (p = 0.012). Clinical symptoms shifted to at least one Fontaine stage lower in 13 limbs. As complications we observed two perforations (arteries showing heavily calcified plaques), one arteriovenous fistula and three distal embolizations. One perforation, the fistula and one intimal tear after percutaneous transluminal angioplasty were treated with covered stents; the three distal embolizations were treated successfully with aspiration or Rotarex thrombectomy. In the other perforation the intervention was terminated. None of the complications needed surgical treatment. The complication rate was 31.5%. Follow-up studies showed three early (4–11 days) and six late (1–6 months) reocclusions. The cumulative primary patency rate was 68 ± 12% at 3 months, and 39 ± 13% at 6, 12 and 19 months; the secondary patency rate was 68 ± 12% at 3 months and 53 ± 13% at 6, 12 and 20 months. Conclusion: The Rotarex thrombectomy catheter is effective and quick in treating acute and subacute occlusions of the superficial femoral and popliteal arteries. It should not be used in arteries with heavily calcified plaques because of the risk of perforation. Limited long-term patency is mainly due to the complexity of the underlying lesion. Our results suggest that the Rotarex mechanical thrombectomy catheter is effective and might serve as an alternative treatment modality to intra-arterial lysis.     

Crossover approach with a J-shaped sheath for angioplasty of Iliofemoral artery stenoses and occlusions

Thirty patients with atherosclerotic stenoses or occlusions of iliofemoral arteries were treated from the contralateral approach using a newly designed J-shaped sheath. Seven patients with stenoses and one with an occlusion were successfully dilated with balloon angioplasty. Twenty-two patients with occlusions were treated with urokinase infusion, 16 of whom received coaxial infusion with the J-shaped sheath and catheter. Complete thrombolysis was achieved in 18 patients. The treatment success rate was 100% in the stenotic group and 83% in the occlusion group. Initially, Jshaped sheaths were useful for treatment of iliofemoral artery lesions from the contralateral femoral artery     

Recanalization of Acute and Subacute Femoropopliteal Artery Occlusions with the Rotarex Catheter: One Year Follow-up, Single Center Experience

Purpose: To assess the efficacy and safety of a new rotational catheter for percutaneous removal of fresh and organized thrombi in the femoropopliteal artery. Methods: Forty-one limbs in 38 patients (age 56–90 years, mean 75.6 years) with acute, subacute or chronic femoropopliteal occlusions of 1–180 days’ duration (mean 31.6 days) were treated with the Rotarex device. The Fontaine stage was mainly IIB (Rutherford 2–3, 22 patients) or III (Rutherford 4, 14 patients). The length of occlusion varied from 2 to 35 cm (mean 13.1 cm). After recanalization percutaneous transluminal angioplasty (PTA) was performed if there was a residual stenosis of >25%. Patients were followed up with color Doppler ultrasound at 48 hr and clinically with Doppler pressures and oscillometry at 3, 6, and 12 months. Results: After an average of two passages with the Rotarex catheter all but two limbs required PTA for residual stenosis >25%. Five patients needed additional stenting. Major complications were one groin hematoma requiring blood transfusion and one arteriovenous fistula spontaneously thrombosing after unsuccessful primary prolonged balloon dilation. Distal embolizations occurred in 10 patients; 6 clinically relevant emboli were aspirated. All occlusions were technically successfully recanalised there were 2 early reocclusions after 1 day and two at 2 weeks. Brachial–ankle indices improved from an average of 0.41 before to 0.93 after recanalization. Primary and secondary patency rates were 62% / 84% after 6 months and 39% / 68% after 1 year. The amputation-free survival at 12 months was 100%. Conclusion: The Rotarex mechanical thrombectomy device is an efficient, quick, easy to handle, and safe tool for the treatment of acute, subacute or even chronic peripheral arterial thromboembolic occlusions. It can be used for short or long occlusions with equal success, provided the obstruction is not heavily calcified and has been safely passed with a guidewire first.     

Percutaneous transluminal angioplasty for total occlusion of middle cerebral arteries

Although it is controversial whether total occlusions of intracranial arteries can safely be opened by angioplasty, we treated six patients with total occlusions of the middle cerebral artery by percutaneous transluminal cerebral angioplasty (PTCBA) in the chronic stage after a stroke, on average 10 weeks. We successfully opened four total occlusions less than 3 months old, while two total occlusions more than 3 months old could not be opened. No complications occurred. Even in the chronic stage, PTCBA for total occlusion of intracranial arteries can be done safely. Received: 8 September 1995 Accepted: 26 February 1996     

Stent placement for treatment of mesenteric artery stenoses or occlusions.

PURPOSE: To evaluate stent placement in the treatment of mesenteric ischemia. PATIENTS AND METHODS: Twelve patients (eight women, four men; mean age, 63 years) with chronic mesenteric ischemia underwent stent placement for stenoses or occlusions during a 5.5-year period. Nine patients with 10 stenoses (three celiac arteries, seven superior mesenteric arteries) and three patients with three chronic occlusions (two superior mesenteric arteries, one aortosuperior mesenteric artery bypass graft) were treated. RESULTS: Initial technical success was achieved in 11 of the 12 patients (92%), including all three patients with chronic occlusions. There were no technical complications. There was one postprocedural death (<30 days) due to bowel ischemia and infarction, despite a technically successful procedure. Clinical follow-up was available in all 12 patients, with a mean follow-up of 15.7 months (range, 0-38.5 months). Primary and primary-assisted patency up to 18 months was 74% (standard error [SE], 13%) and 83% (SE, 11%), respectively. Secondary patency was 83% (SE, 11%) at 3 years. All three patients (100%) with chronic occlusions had relief of clinical signs and symptoms at a mean follow-up of 22 months (range, 13-38.5 months). CONCLUSIONS: Stent placement is safe and clinically effective as an adjunctive therapy to angioplasty or as a primary method of treatment for chronic mesenteric ischemia in patients with focal visceral artery stenoses or occlusions.     

Vibrational angioplasty in recanalization of chronic femoropopliteal arterial occlusions: Single center experience

Purpose

This prospective study aims to present the overall success rate, safety and long-term outcome of vibrational angioplasty technique, in the treatment of chronic total femoropopliteal occlusions in our institute.

Methods

Between October 2000 and December 2008, patients with chronic total femoropoliteal arterial occlusions, treated with vibrational angioplasty during the same session after a failed attempt with conventional recanalization technique, were included. Patient's follow up included serial ankle-brachial index measurements and arterial duplex ultrasound examinations at 1, 3, 6, 12, 24, 36 and 48 months.

Results

Twenty-seven patients (16 males and 11 females) and twenty-eight lesions were included in our study. Twenty-five lesions (89.3%) were successfully recanalized. Pain relief was noticed in twenty-one cases. From ten lesions with tissue loss (ulcer or gangrene) in successfully recanalized occlusions, six healed without major, or minor amputation. One non-healing amputation stump was healed after recanalization, without further complications. Four limbs underwent amputation (one minor and three major) despite successful recanalization, however all had an excellent healing of the amputation stump without further complications.The Kaplan–Meier test demonstrated 90%, 85% and 70% amputation-free survival rate at 12, 24 and 36 months, respectively. No major or minor complications were encountered.

Conclusions

Vibrational angioplasty is a safe, effective and durable endovascular technique for the treatment of chronic total occlusions in patients with limb ischemia that would be difficult to recanalize using conventional intraluminal techniques.     

Primary stenting in infrarenal aortic occlusive disease

Purpose: To evaluate the results of primary stenting in aortic occlusive disease. Methods: Thirty patients underwent primary stenting of focal concentric (n = 2) and complex aortic stenoses (n = 19), and aortic or aorto-iliac occlusions (n = 9). Sixteen patients underwent endovascular outflow procedures, three of whom also had distal open surgical reconstructions. Median follow-up was 16 months (range 1–60 months). Results: Guidewire crossing of two aorto-biiliac occlusions failed, resulting in a 93% (28/30) technical success. Major complications included one access hematoma, one myocardial infarction, one death (recurrent thromboembolism) in a patient with widespread malignancy, and one fatal hemorrhage during thrombolysis of distal emboli from a recanalized occluded iliac artery. One patient did not improve his symptoms, resulting in a 1-month clinical success of 83% (25/30). Following restenting the 26 stented survivors changed their clinical limb status to +3 (n = 17) and +2 (n = 9). During follow-up one symptomatic aortic restenosis occurred and was successfully restented. Conclusions: Primary stenting of complex aortic stenoses and short occlusions is an attractive alternative to conventional surgery. Larger studies with longer follow-up and stratification of lesion morphology are warranted to define its role relative to balloon angioplasty. Stenting of aorto-biiliac occlusions is feasible but its role relative to bypass grafting remains to be defined.     

Percutaneous treatment of complete chronic occlusions of the superficial femoral artery

PURPOSE: This study was done to evaluate the mid-and long-term patency rates of complete (from the origin to Hunter's duct) chronic occlusions of the superficial femoral artery (SFA) treated by angioplasty and/or stenting. MATERIALS AND METHODS: From February 2002 to March 2005, 21 patients with complete occlusion of the SFA and good distal runoff (two or three patent vessels) were treated with endovascular recanalisation. All patients had severe claudication or critical limb ischaemia. In all cases, recanalisation was performed with a contralateral approach by percutaneous transluminal angioplasty (PTA), with stenting only when PTA provided unsatisfactory results (due to elastic recoil and complications such as dissection). In the case of calcified occlusions and when the true lumen of the SFA could not be crossed, subintimal angioplasty was performed. Follow-up was done at 6 and 12 months and annually thereafter (range 6-55 months, mean 23 months) with clinical evaluation and colour-Doppler ultrasound. RESULTS: Immediate technical success was achieved in all cases (100%), with postprocedural angiography demonstrating complete recanalisation of the SFA. Two distal embolisations (9.5%) occurred, both treated successfully by local thrombolysis. Primary patency rates at 6, 12, 24, 32 and 44 months were 93.3%, 69.2%, 72.7%, 62.5% and 40%, respectively; secondary patency rates at 6, 12 and 24 months were 100%, 84.6% and 81.8%, respectively. CONCLUSIONS: Percutaneous treatment of complete chronic occlusions of the SFA showed good mid-and long-term primary patency rates, with few periprocedural complications. Reocclusions can be treated by a percutaneous technique, which ensures a good secondary patency rate.     

Percutaneous excimer-laser and excimer-laser-assisted angioplasty of the lower extremities: results of initial clinical trial

Percutaneous peripheral excimer-laser angioplasty at 308 nm was used for treatment of 30 patients with peripheral vascular disease. Twenty-eight patients underwent laser-assisted balloon angioplasty, and two patients underwent laser angioplasty alone. Acute angiographic and clinical success was achieved in 24 of 31 (77%) femoropopliteal stenoses and occlusions. Seven of nine (78%) stenoses, six of seven (86%) short (0-5 cm) occlusions, seven of eight (88%) medium-length (6-10 cm) occlusions, three of four (75%) long (11-15 cm) occlusions, and one of three (33%) extreme (greater than 15 cm) occlusions were successfully treated. Inability to treat total occlusions was in each case related to a failure to maintain coaxial position and subintimal passage of the fiber. These cases demonstrate the feasibility of safely performing percutaneous peripheral excimer-laser or excimer-laser-assisted angioplasty. The overall frequency of restenosis after a mean follow-up period of 9.1 months was 29%. The data suggest that these procedures may be useful for the treatment of peripheral vascular disease in selected patients.     

Angioplasty for femoral artery occlusion: comparison with surgery

Forty-six patients with superficial femoral artery occlusions (range, 1-20 cm) had percutaneous transluminal angioplasty. The primary success rate was 76% with a late closure in six patients. Life table analysis showed a 1 year patency of 56.8%, maintained at 2 years among the group in whom the successful was 4 cm, while in those in whom the lesion was not crossed, it was 9 cm. Over the same period, 133 femoropopliteal bypass grafts were performed. The patients were comparable as to runoff, incidence of diabetes, and distal ischemia. The 1 year patency was 60.2% and the 2 year patency, 42.1%, largely because of the poor performance of grafts other than saphenous vein. Angioplasty seems to be the treatment of choice for short segment occlusions, and should be used in longer occlusions if saphenous vein is not going to be used.     

Percutaneous transluminal angioplasty: importance of anticoagulant and fibrinolytic drugs

At the Medical University of Pécs, Hungary, percutaneous transluminal angioplasty was performed on 252 lesions in 235 patients. Primary success rate was 75%. Long femoral artery occlusions were recanalized with a 66% patency rate in lesions 10-20 cm long and a 47% patency rate in lesions longer than 20 cm. These relatively high patency rates were attributed to the use of SP 54, a fibrinolytic agent. In a group of 52 patients treated with SP 54 there were only four reocclusions, two of these occurring 12 months after angioplasty when SP 54 was discontinued. It was concluded that long occlusions may be amenable to angioplasty provided that appropriate fibrinolytic therapy is instituted after the procedure.     

Follow-up of conventional angioplasty versus laser thermal angioplasty for total femoropopliteal artery occlusions: results of a randomized trial.

Sixty-eight patients with 68 femoropopliteal occlusions were entered into a randomized trial of conventional guide-wire and catheter percutaneous angioplasty versus laser thermal angioplasty. Thirty-four occlusions were randomized to conventional angioplasty and 34 to laser thermal angioplasty. After successful recanalization and balloon dilation, the patients were followed up for 1 year. Follow-up consisted of obtaining measurements of the ankle-arm indexes at 1, 3, 6, and 12 months. The increase in the mean resting ankle-arm index 1 year after conventional angioplasty (0.26) was greater than that after laser angioplasty (0.12). At 1-year follow-up, the cumulative success rate was 47% for patients treated with conventional angioplasty versus 39% for those treated with laser angioplasty. Statistical analysis showed no significant difference in clinical success between the two treatment groups.     

Management of the limitations in low-speed rotational transluminal angioplasty: Technical note

The low-speed rotational transluminal angioplasty catheter system (ROTACS) is a recently available device for recanalization of occlusions prior to balloon angioplasty. The presence of large collaterals originating just proximal to the occlusion with an acute angle, and insufficient space between the puncture site and the occlusion for placing an introducer sheath are reported to be limitations for ROTACS. To avoid the rotating catheter entering the collateral, we propose a technique to create a pilot inlet on the proximal aspect of the occlusion. This technique was applied successfully in 4 patients. A contralateral approach was used in 3 patients, in whom an ipsilateral access was not possible because of the insufficient space to place an introducer sheath.