Failed Percutaneous Transluminal Angioplasty Research Articles

Intravascular Lithotripsy for Peripheral Artery Calcification: Mid-term Outcomes From the Randomized Disrupt PAD III Trial

BackgroundEndovascular treatment of calcified peripheral artery lesions may be associated with suboptimal vessel expansion, increased complication risk, and reduced long-term patency. The primary endpoint from the Disrupt PAD III randomized controlled trial (RCT) demonstrated superior procedural success in patients treated with intravascular lithotripsy (IVL) vs percutaneous transluminal angioplasty (PTA). The present study evaluates primary patency after 1 and 2 years in this randomized population.MethodsThe Disrupt PAD III RCT enrolled 306 patients with moderately-to-severely calcified femoropopliteal arteries treated with IVL (n = 153) or PTA (n = 153) prior to DCB treatment or stenting. The powered secondary effectiveness endpoint was primary patency at 1 year, defined as freedom from clinically driven target lesion revascularization plus freedom from restenosis determined by duplex ultrasound. Acute PTA failure requiring stent placement during the index procedure was prespecified as a loss of primary patency.ResultsPrimary patency at 1 year was significantly greater in the IVL arm (80.5% vs 68.0%, P = .017). The requirement for provisional stenting was significantly lower in the IVL group (4.6% vs 18.3%, P < .0001). Freedom from clinically driven target lesion revascularization (IVL: 95.7% vs PTA: 98.3%, P = .94) and restenosis rates (IVL: 90.0% vs PTA: 88.8%, P = .48) were similar between the 2 groups at 1 year. At 2 years, primary patency remained significantly greater in the IVL arm (70.3% vs 51.3%, P = .003).ConclusionsThe Disrupt PAD III RCT secondary endpoint of superior 1-year primary patency was achieved, confirming the consistent safety and effectiveness of IVL followed by DCB treatment to facilitate a durable approach for patients with heavily calcified femoropopliteal arteries largely without stent requirement.

Long-term outcomes of angioplasty for pediatric renovascular hypertension: A single-center experience.

We used single-center data to evaluate the long-term outcome of percutaneous transluminal angioplasty (PTA) for pediatric renovascular hypertension (RVH) and to analyze the factors that influence effectiveness. We retrospectively evaluated 33 pediatric RVH patients (18 boys; mean age: 9.1 ± 4 years, range: 2-16) who underwent PTA from January 2007 to December 2019. 15 patients had Takayasu arteritis (TA) and 18 were non-TA. The median follow-up from the initial PTA was 69months (range: 12-157; IQR: 25.5-89). The technical success rate of 52 PTA procedures was 90.4% in 33 children. Renal artery stents were implanted in two patients, external guidewires were used in two patients, and a drug-coated balloon was used in only one patient. The overall effective rate of PTA was 63.6%, including cured 39.4% and improved 24.2%, at the end of follow-up. Overall clinical outcomes were not statistically different between the TA and non-TA groups (p = 0.316), nor were cure rates (p = 0.072). 15 patients received reintervention due to restenosis after the first successful PTA; the interval was 2-56 months (median: 12 months). Four patients received reintervention due to a failed PTA. A total of four patients received open surgery. Binary logistics regression analysis showed that stenosis length and residual stenosis rate were strongly correlated with effective PTA (p = 0.045, p = 0.044). As a primary treatment for pediatric RVH, PTA can achieve satisfactory results, which are influenced by lesion length and residual stenosis rate.

Simultaneous SFA Angioplasty/Stent Plus Popliteal Distal Bypass for Limb Salvage

Introduction: Treatment of severe critical limb ischemia (CLI) due to Superficial Femoral Artery (SFA) and below-the-knee (BTK) vessels' involvement could be compromised by the lack of a Great Saphenous Vein (GSV) suitable in its entire length. The purpose of this study is to assess the efficacy of a hybrid endovascular and open lower limbs arterial reconstruction in these patients with multilevel, advanced CLI. We combined two different techniques, each one largely validated for different level of intervention (endovascular for SFA, surgical for BTK), and we aimed to assess the efficacy of such an hybrid arterial reconstruction in patients with multilevel CLI in the lack of suitable autologous vein. Methods: From 2005 to 2019, we performed hybrid endovascular and surgical treatment for limb salvage in SFA-BTK CLI. This consisted of percutaneous transluminal angioplasty (PTA) with or without stenting of the SFA, along with distal origin vein graft bypass. Inclusion criteria were: Rutherford category 5 or 6, lack of a suitable GSV, patency of the popliteal artery, steno-obstructive lesions of the SFA, lesions of the three crural vessels > 5 cm in length each. The follow-up was performed with duplex scan surveillance of both the bypass graft and PTA sites. Results: The hybrid treatment was performed in 34 patients. 56% of the SFA steno-obstructive lesions were treated with simple PTA, except for the application of a bare metal stent in one patient (3%), while in all the SFA occlusions PTA was completed with covered stents (41%). Thirty-four popliteal-to-distal vein bypass grafts have been performed. There were no perioperative PTA or bypass graft failures. Clinical improvement was achieved in 26 (76%) patients. Overall, primary, assisted primary and secondary patency, limb salvage, and survival rates were 65%, 70%, 68%, and 75% at 5 years, respectively (Graph 1 and Graph 2). Conclusion: A hybrid strategy in multilevel SFA-BTK CLI is a well established approach. Additional studies are warranted to validate these results.Graph 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose

Simultaneous Superficial Femoral Artery Angioplasty/Stent Plus Popliteal Distal Bypass for Limb Salvage

Treatment of severe critical limb ischemia (CLI) due to superficial femoral artery (SFA) and below-the-knee (BTK) vessels' involvement could be compromised by the lack of a great saphenous vein (GSV) suitable in its entire length. The purpose of this study is to assess the efficacy of a hybrid endovascular and open lower limbs arterial reconstruction in these patients with multilevel, advanced CLI. From 2005 to 2019, we performed hybrid endovascular and surgical treatment for limb salvage in SFA-BTK CLI. This consisted of percutaneous transluminal angioplasty (PTA) with or without stenting of the SFA, along with distal origin vein graft bypass. Inclusion criteria were Rutherford category 5 or 6, lack of a suitable GSV, patency of the popliteal artery, steno-obstructive lesions of the SFA, lesions of the 3 crural vessels >5cm in length each. The follow-up was performed with duplex scan surveillance of both the bypass graft and PTA sites. The hybrid treatment could be performed in 34 patients. Fifty-six percent of the SFA steno-obstructive lesions were treated with simple PTA, except for the application of a bare metal stent in one patient (3%), while in all the SFA occlusions PTA was completed with covered stents (41%). Thirty-four popliteal-to-distal vein bypass grafts bypass grafts have been performed. There were no perioperative PTA or bypass graft failures. Clinical improvement was achieved in 26 (76%) patients. Overall, primary and secondary patency, limb salvage, and survival rates were 65%, 68%, 75%, and 75% at 5years, respectively. A hybrid strategy in multilevel SFA-BTK CLI is a well-established approach. Additional studies are warranted to validate these results.

Directional atherectomy with antirestenotic therapy for the treatment of no-stenting zones.

Endovascular treatment for peripheral artery occlusive disease carries unresolved problem of restenosis. Treatment modalities in areas of high mechanical stress like popliteal artery and common femoral artery remains challenging. New-generation devices improved the results of stent therapy in this anatomical territory, but could impact on future surgical options if they are needed. Vessel preparation prior to drug (paclitaxel)-coated balloons (DCB) angioplasty leads to better paclitaxel penetration into the arterial wall and improved drug uptake. The "leave nothing behind" strategies, DCB angioplasty and combined directional atherectomy (DA) and antirestenotic therapy (DAART), can theoretically overcome the problems caused by the mobility of the knee joint. However, calcified and longer lesions remain a challenging subset that is less responsive to DCBs, resulting in higher provisional stent rates. For the treatment of long and calcified femoropopliteal lesions, vessel preparation with DA before DCB angioplasty seems to be safe in mid-term follow-up and might have benefits in more challenging lesion subsets that are at higher risk for acute and chronic technical treatment failure of percutaneous transluminal angioplasty, including DCB angioplasty, such as severely calcified lesions. Treatment with DA+DCB resulted in both increased technical success and fewer flow-limiting dissections compared with treatment with DCB alone. In concept of "leave nothing behind" therapies for isolated popliteal artery lesions, DAART was associated with a higher primary patency rate than DCB angioplasty alone.

Pediatric renovascular hypertension: Treatment outcome according to underlying disease.

Renovascular hypertension (RVH) accounts for 5-10% of pediatric hypertension, and can be associated with underlying disease involving other organs. The purpose of this study was to evaluate the clinical characteristics and assess the treatment outcomes of Korean pediatric patients with RVH. The medical records of 25 Korean pediatric patients with RVH were retrospectively reviewed. Twenty-four patients had underlying disease, and the most common cause was moyamoya disease (MMD; n = 10; 40%). Of 10 patients with MMD, seven had RVH prior to MMD. All patients required antihypertensive medication as the initial treatment and 22 patients subsequently underwent percutaneous transluminal angioplasty (PTA). The majority of patients with MMD had ostial lesions on angiography. Eight patients had favorable outcomes after the first PTA. One patient received nephrectomy, and two patients received bypass surgery because of restenosis after PTA and technical failure of PTA, respectively. During follow up, blood pressure was well-controlled in nine patients, but only four patients were able to discontinue medication. Eight patients had target-organ damage of the brain, heart, and retina at the time of initial diagnosis, and five patients developed chronic kidney disease during follow up. The most common cause of RVH in Korean children is MMD, and RVH caused by MMD with an ostial lesion is associated with poor PTA outcomes. Angioplasty alone does not appear to control blood pressure effectively in MMD patients, and combined treatment is necessary to prevent target organ damage.

Stenting as a bail-out option after failed percutaneous transluminal angioplasty in infrainguinal vein bypass grafts.

To study the safety and efficacy of bare and covered stents in infrainguinal vein grafts after failure of PTA for treating graft stenoses. An analysis of a prospective database of all patients who underwent stenting of infrainguinal vein bypass grafts at this institution between 1 January 2008 and 31 December 2012 was carried out. The main outcome considered was primary patency, which was reported at 1, 6 and 12 months. A total of 18 patients with a mean age of 73 years (range: 56 to 86) were included. The indications for stent placement were significant recoil (7, 39%), graft rupture (6, 33%), residual vein cusps (3, 17%) and aneurysmal degeneration (2, 11%). There was a high overall technical success rate of 94% (17/18) and arrest of haemorrhage was achieved in all cases of graft rupture. The primary patency at 1, 6 and 12 months was 89%, 71% and 59%, respectively. The use of bare and covered stents in infrainguinal vein grafts appears safe and effective. They are an excellent bail-out option for the treatment of graft rupture and give acceptable short-term results.

Elastic Recoil after Balloon Angioplasty in Hemodialysis Accesses: Does It Actually Occur and Is It Clinically Relevant?

Purpose To qualify and quantify elastic recoil and determine its effect on access patency. Materials and Methods Research ethics board approval was obtained and all patients signed an informed consent form. This was a prospective, nonrandomized study of mature accesses that underwent balloon percutaneous transluminal angioplasty (PTA) between January 2009 and December 2012. After PTA, completion fistulography was performed at 0-, 5-, 10-, and 15-minute intervals. From Digital Imaging and Communications in Medicine images, percentage of lesion stenosis before and after PTA was measured at each time point. A total of 76 patients (44 men, 32 women; mean age, 59.6 years) were enrolled and underwent 154 PTAs in 56 grafts and 98 fistulas. Venous elastic recoil was defined as recurrent luminal narrowing greater than 50% within 15 minutes after full effacement of the stenosis by the angioplasty balloon. Data collected included sex, age, access type and location, lesion location, length, and time to next intervention. Access patency was estimated by using Kaplan-Meier survival method, association of variables with the risk of loss of patency was assessed by using a Cox proportional hazards model, and a multiple variable model was examined by considering all variables. Results Technical success of PTA with less than 30% residual stenosis was 78%. By 15 minutes, 15.6% (24 of 154) of treated lesions recurrently narrowed by more than 50%, with a majority observed at 5 minutes (15 of 24). Technical failure of PTA was predictive of elastic recoil (P < .001), as was cephalic arch stenosis in fistulas (P = .047) and autogenous fistulas (P = .04). Elastic recoil, when it did occur, did not influence patency. Six-month primary patency was 34.8% in grafts and 47.1% in fistulas. Conclusion Venous elastic recoil after PTA of stenoses in hemodialysis access circuits is common, but its occurrence does not influence access primary patency after PTA. (©) RSNA, 2015.

Remedial operations for failed endovascular therapy of 32 renal artery stenoses in 24 children.

Percutaneous transluminal angioplasty (PTA) for the treatment of pediatric renovascular hypertension (RVH) in contemporary practice is accompanied with ill-defined complications. This study examines the mode of pediatric renal PTA failures and the results of their surgical management. Twenty-four children underwent remedial operations at the University of Michigan from 1996 to 2014 for failures of renal PTA. Their clinical courses were retrospectively reviewed and results analyzed. Renal PTA of 32 arteries, including 13 with stenting, was performed for severe RVH in 12 boys and 12 girls, having a mean age of 9.3years. Developmental ostial stenoses affected 22 children. PTA failures included: 27 restenoses and five thromboses. Remedial operations included: 13 renal artery-aortic reimplantations, one segmental renal artery-main renal artery reimplantation, ten aortorenal bypasses, one arterioplasty, one iliorenal bypass, and six nephrectomies for unreconstructable arteries; the latter all in children younger than 10years. Follow-up averaged 2.1years. Postoperatively, hypertension was cured, improved, or unchanged in 25, 54, and 21%, respectively. There was no perioperative renal failure or mortality. Renal PTA for the treatment of pediatric RVH due to ostial disease may be complicated by failures requiring complex remedial operations or nephrectomy, the latter usually affecting younger children.

Why vascular access trials on flow surveillance failed.

Since the introduction of access flow surveillance technology for routine patient screening in 1995, more than 30 clinical trials have been presented in peer reviewed journals. Despite overall positive outcomes, some trials, including randomized control trials (RCTs), failed to produce positive outcomes for access surveillance. The purpose of this study is to analyze published data related to the main component of access surveillance--adequate increase of access flow after percutaneous transluminal angioplasty (PTA). A total of nine studies for arteriovenous grafts (AVGs) that include 350 accesses and nine studies for arteriovenous fistula (AVF) that included 503 accesses were considered for analysis from 14 publications. Practically, all reference data find high sensitivity (>90%) of access flow measurement to predict 50% stenosis. Mean access flow increase after PTA in AVGs was 319 ml/min (from 238 to 524 ml/min). Mean access flow increase in AVFs was 331 ml/min (from 195 to 402 ml/min). Relative flow increase in AVFs was 1.6 times greater than in AVGs. The authors of failed RCT for AVGs either did not select patients for PTA based on KDOQI guidelines and did not provide/analyze PTA flow results data, or reveal data that obviously show failure of PTA to adequately improve access flow. Access flow surveillance successfully identifies patients with hemodynamically significant stenosis. PTA performed on AVFs produce better hemodynamic results than in AVGs. Inadequate flow increases during PTA and not following KDOQI guidelines are major contributing factors for failed AVG randomized tails. Radiologists should use objective means for flow evaluation during PTA.

Invasively-treated incidence of lower extremity peripheral arterial disease and associated factors in Taiwan: 2000–2011 nationwide hospitalized data analysis

BackgroundLower extremity (LE) peripheral artery disease (PAD), which is associated with a reduced quality of life and increased mortality from atherosclerotic cardio-/cerebro-vascular occlusion, is a significant public health problem, especial for an aging society such as that of Taiwan.MethodsSpecific datasets of the 2000–2011 nationwide inpatient databases were analyzed. Two inclusion criteria, including one of the major diagnosis codes of PAD and one of three categorical invasive treatments of LE PAD, were used consecutively to select cases diagnosed as LE PAD and receiving invasive treatment. The epidemiology of invasively-treated PAD in Taiwan was estimated, and the influences of potential confounders on these invasively-treated methods were evaluated.ResultsIn general, the invasively-treated incidence of PAD in Taiwan doubled, from 3.73/10,000 (in 2000) to 7.48/10,000 (in 2011). On average, the total direct medical cost of one hospitalized and invasively-treated PAD case ranged from $US 4,600 to $US 5,900. The annual cases of bypass surgery for the PAD cases averaged 1,000 and the cases for limb amputation ranged from 4,100 to 5,100 annually. However, the number of percutaneous transluminal angioplasty (PTA) procedures remarkably increased by 15 times, from 600/year to 9,100/year, from 2000 to 2011. 51.3% of all the enrolled cases were treated with limb amputations, and female, young and middle-aged people (30–65 years of age), DM patients and those on a low income had a tendency to undergo amputation due to PAD. 37.6% of all the enrolled cases were treated with PTAs related to hypertension, cardiovascular disease, hyperlipidemia and catastrophic Illness. 2-year PTA failure rates of 22.13%, 11.91% and 10.61% were noted among the first (2000–2001), second (2004–2005) and the third (2008–2009) cohort groups, respectively.ConclusionsIn Taiwan, a gender difference and age and period effects on the invasively-treated incidence of LE PAD were observed. Female, young and middle-aged people (30–50 and 50–65 years of age), DM patients and those on a low income had a tendency to undergo amputation. The number of PTA procedures remarkably increased, but the 2-year failure rate of PTAs reduced from 2000 to 2011.

Sustained Safety and Effectiveness of Paclitaxel-Eluting Stents for Femoropopliteal Lesions: 2-Year Follow-Up From the Zilver PTX Randomized and Single-Arm Clinical Studies

A prospective, multinational randomized controlled trial (RCT) and a complementary single-arm study evaluated the 2-year safety and effectiveness of a paclitaxel-coated drug-eluting stent (DES) in patients with superficial femoral artery lesions. The RCT compared the DES with percutaneous transluminal angioplasty (PTA) and provisional bare-metal stent (BMS) placement. Local drug delivery for superficial femoral artery lesions has been investigated with the intent of limiting restenosis similarly to DES for the coronary arteries. One-year outcomes of DES in the superficial femoral artery are promising, but longer-term benefits have not been established. In the RCT, patients were randomly assigned to primary DES implantation (n= 236) or PTA (n= 238). Acute PTA failure occurred in 120 patients, who underwent secondary randomization to DES (n= 61) or BMS (n= 59) placement. The single-arm study enrolled 787 patients with DES treatment. Compared with the control group, the primary DES group demonstrated significantly superior 2-year event-free survival (86.6% vs. 77.9%, p= 0.02) and primary patency (74.8% vs. 26.5%, p< 0.01). In addition, the provisional DES group exhibited superior 2-year primary patency compared with the provisional BMS group (83.4% vs. 64.1%, p< 0.01) and achieved higher sustained clinical benefit (83.9% vs. 68.4%, p= 0.05). Two-year freedom from target lesion revascularization with primary DES placement was 80.5% in the single-arm study and 86.6% in the RCT. Two-year outcomes with the paclitaxel-eluting stent support its sustained safety and effectiveness in patients with femoropopliteal artery disease, including the long-term superiority of the DES to PTA and to provisional BMS placement. (Evaluation of the Zilver PTX Drug-Eluting Stent in the Above-the-Knee Femoropopliteal Artery; NCT00120406; Zilver(®) PTX™ Global Registry; NCT01094678).

8:08 AM Abstract No. 13 - Single-center experience with drug-eluting stents in the treatment of critical limb ischemia: midterm follow-up

Purpose The endovascular treatment of infrapopliteal arterial disease in the setting of critical limb ischemia (CLI) is increasing in use. When percutaneous transluminal angioplasty (PTA) results in suboptimal angiographic results, flow limiting dissection or re-coil is thought to limit acute and long-term clinical success. This single-center experience examines the angiographic and clinical results when Drug-Eluting Stents (DES) were placed in a large cohort of patients with CLI after immediate infrapopliteal PTA failure. Materials and Methods A retrospective review of a prospectively collected single-center endovascular database was performed. 107 Rutherford grade 4, 5, and 6 patients were treated between October 2005 and October 2012 with PTA because lack of an acceptable autologous vein for bypass-grafting or severe medical comorbidities precluded them from surgical bypass. The study cohort had suboptimal angiographic results immediately after PTA that was subsequently treated with DES. Patients were then placed on clopidogrel and aspirin indefinitely. Angiographic, clinical, and the results of noninvasive vascular examinations were collected and reviewed. Results In total, 171 stents (106 sirolimus, 62 everolimus, 3 paclitaxel) were placed in 107 patients to treat a total of 143 angiographic lesions. Simultaneous femoral-popliteal intervention was performed in 71% of the patients while 41% of the treated lesions were total occlusions. Lesion length ranged from 13 mm-147 mm (mean 52 mm). Initial technical success was 100%, with all 143 lesions being treated successfully with less than 10% stenosis after stent implantation. Mean follow-up was 25 months (1-75 months) with 6, 12, and 24-month primary patency rates of 92%, 84%, and 70% respectively. Freedom from major amputation was 89% (95/107) with all 12 major amputations occurring in the Rutherford grade 6 group (12/25). Overall mortality rate was 21% (22/107) with one death occurring within 30 days. Conclusion The use of drug-eluting stents following suboptimal PTA for the treatment of infrapopliteal arterial disease in this cohort of patients with CLI produced high primary patency and limb salvage rates supporting the efficacy of this treatment strategy.

Endovascular Treatment of Popliteal Artery Segments P1 and P2 in Patients With Critical Limb Ischemia: Initial Experience Using a Helical Nitinol Stent With Increased Radial Force

To evaluate efficacy, safety, and midterm patency of a helical, self-expanding nitinol stent after failed percutaneous transluminal angioplasty (PTA) of popliteal artery segments P1 and P2 in patients with chronic critical limb ischemia (CLI) or lifestyle-limiting claudication. Between February 2009 and March 2011, 40 patients (23 men; mean age 77±10 years) classified as Rutherford category 3 (n = 10) or 4/5 (n = 30) underwent PTA of the proximal and mid popliteal artery followed by implantation of a SUPERA stent for elastic recoil, residual stenosis, or flow-limiting dissection. All patients had an elevated operative risk. Before and after the procedure and during the 12-month follow-up, a clinical investigation, ankle-brachial-index (ABI) measurement, and color-coded duplex sonography and/or digital subtraction angiography were performed. Primary endpoints were limb salvage and anatomical patency at 12 months. Stent implantation was successful in all patients. The major complication rate was 7.5% (an access-site pseudoaneurysm, 2 retroperitoneal hematomas, and 1 death from retroperitoneal bleeding). Mean follow-up was 15.9 months (range 0.5-27.9). The mean baseline ABI of 0.37 significantly increased to 0.91 at 12 months (p<0.01). Three (7.5%) patients underwent bypass surgery owing to lack of clinical improvement (<0.10 improvement in ABI). Primary and secondary patency rates at 12 months in the 34 patients eligible for follow-up were 68.4% and 79.8%, respectively. The major amputation rate was 5% at 1 year. Five (12.5%) in-stent stenoses and 1 of 2 (5.0%) in-stent occlusions were successfully recanalized (the second occlusion was asymptomatic). Implantation of this helical stent into segments of the popliteal artery at the knee joint in CLI patients is a safe and clinically effective bailout method with acceptable intermediate patency.

Alternative Techniques for Treatment of Complex Below-the Knee Arterial Occlusions in Diabetic Patients With Critical Limb Ischemia

The purpose of this study was to describe alternative endovascular (EV) techniques and assess their feasibility and efficacy in minimizing failure rates in limb salvage for the treatment of complex below-the knee (BTK) occlusions that could not be crossed with a conventional antegrade access. Between December 2007 and November 2010, 1,035 patients (557 male) underwent EV treatment for critical limb ischemia in our institution. In 124 (12% [83 male], mean age 68.2±0.5years) patients, transfemoral antegrade revascularization attempt failed, and an alternative approach was used. Follow-up was performed at 1 and 6months. Results were compared with 56 patients treated between November 2002 and November 2007, in whom conventional technique was unsuccessful and unconventional techniques were not adopted. Technical success was achieved in 119 (96%) patients. The limb-salvage rates were 96.8% and 83% at 1- and 6-month follow-up, respectively. Sixteen (12.9%) and 33 (26.6%) patients underwent reintervention at 1- and 6-month follow-up, respectively. Transcutaneous oxygen tension increased at 1month (44.7±1.1 vs. 15.7±0.8mmHg; p<0.001) and remained stable at follow-up. Twenty (16.1%) patients required major amputation. Thirteen (10.4%) patients died during follow-up. In our previous experience, percutaneous transluminal angioplasty failure, amputation, and death rates were 10.9, 39.2, and 23.2%, respectively. Alternative techniques allowed a significant decrease of major amputation and death rates (p=0.0001 and p=0.02, respectively). The use of alternative techniques seems feasible in case of a failed antegrade BTK revascularization attempt and could minimize failure rates in the treatment of complex occlusions while providing satisfying clinical success rates at 6months.

Paclitaxel-Eluting Stents Show Superiority to Balloon Angioplasty and Bare Metal Stents in Femoropopliteal Disease

Sustained benefits of drug-eluting stents in femoropopliteal arteries have not been demonstrated. This prospective, multinational, randomized study was designed to compare the 12-month safety and effectiveness of a polymer-free, paclitaxel-coated nitinol drug-eluting stent (DES) with percutaneous transluminal angioplasty (PTA) and provisional bare metal stent (BMS) placement in patients with femoropopliteal peripheral artery disease. Patients were randomly assigned to primary DES implantation (n=236) or PTA (n=238). Demographics and lesion characteristics were similar between groups (eg, average lesion length, approximately 65±40 mm). One hundred twenty patients had acute PTA failure and underwent secondary random assignment to provisional DES (n=61) or BMS (n=59). Primary end points were the 12-month rates of event-free survival and patency in the primary DES and PTA groups. Compared with the PTA group, the primary DES group exhibited superior 12-month event-free survival (90.4% versus 82.6%; P=0.004) and primary patency (83.1% versus 32.8%; P<0.001), satisfying the primary hypotheses. In the secondary evaluations, (1) the primary DES group exhibited superior clinical benefit compared with the PTA group (88.3% versus 75.8%; P<0.001), (2) the provisional DES group exhibited superior primary patency (89.9% versus 73.0%; P=0.01) and superior clinical benefit (90.5% and 72.3%, P=0.009) compared with the provisional BMS group, and (3) the stent fracture rate (both DES and BMS) was 0.9% (4/457). Femoropopliteal peripheral artery disease treatment with the paclitaxel-eluting stent was associated with superior 12-month outcomes compared with PTA and provisional BMS placement.

Diagnosis and management of fibromuscular dysplasia: an expert consensus

Diagnosis and management of fibromuscular dysplasia: an expert consensus

Significant Prostacyclin/Thromboxane Level Imbalance after Lower Limb Arterial Angioplasty: A Possible Platelet Function Alteration

The authors investigated prostacyclin (PGI2) and thromboxane (TX) productions in peripheral venous blood after lower limb revascularization by percutaneous transluminal angioplasty (PTA) versus diagnostic angiography. The purpose of this study was to investigate PGI2/TX imbalance after PTA. This imbalance is of pathophysiologic importance and it is a potential sign of platelet function alteration. Twenty-five patients requiring PTA were compared with 20 patients undergoing angiography alone from April 2004-December 2005 from a single vascular unit. Patient age range was 42-90 years, and the majority of patients were men. Prostaglandin F2-alpha (PGF2-alpha) and thromboxane B2 (TXB2) were measured sequentially (preprocedure, at 1 hour, and 24 hours after procedure). Differences between postprocedure and preprocedure level were compared statistically between angiography and PTA. Baseline demographics were distributed equally between the two groups except presence of critical ischemia and ankle brachial pressure index, which were two significant confounders. TXB2 was significantly higher after PTA at 1 hour and 24 hours after PTA (P = .005 and P = .014 respectively), PGF2-alpha was significantly higher 24 hours after PTA only (P = .018) (Mann-Whitney U test). PGI2/TX balance homeostasis is of significant pathophysiologic importance. The authors found that PTA results in significant PGI2/TX imbalance and shifts more toward increased TX production. This finding is partly suggestive of significant platelet activation. This imbalance in PGI2/TX level may have implications for future failure of PTA. Future research in reducing this platelet activation is recommended.

Celiac artery compression syndrome managed by laparoscopy

Celiac artery compression syndrome (CACS) is an unusual condition caused by abnormally low insertion of the median fibrous arcuate ligament and muscular diaphragmatic fiber resulting in luminal narrowing of the celiac trunk. Surgical treatment is the release of the extrinsic compression by division of the median arcuate ligament overlying the celiac axis and skeletonization of the aorta and celiac trunk. The laparoscopic approach has been recently reported for single cases. Percutaneous transluminal angioplasty (PTA) and stenting of the CA alone, before or after the surgical relief of external compression to the celiac axis, has also been used. We report our 7-year experience with the laparoscopic management of CACS caused by the median arcuate ligament. Between July 2001 and May 2008, 16 patients (5 men; mean age, 52 years) were treated. Diagnosis was made by duplex ultrasound scan and angiogram (computed tomography [CT] or magnetic resonance). The mean body mass index of the patients was 21.2 kg/m(2). One patient underwent laparoscopic surgery after failure of PTA and stenting of the CA, and two patients after a stenting attempt failed. All procedural steps were laparoscopically completed, and the celiac trunk was skeletonized. The laparoscopic procedures lasted a mean of 90 minutes. Two cases were converted to open surgery for bleeding at the end of the operation when high energies were used. The postoperative course was uneventful. Mean postoperative hospital stay was 3 days. On follow-up, 14 patients remained asymptomatic, with postoperative CT angiogram showing no residual stenosis of the celiac trunk. One patient had restenosis and underwent aortoceliac artery bypass grafting after 3 months. Another patient had PTA and stenting 2 months after laparoscopic operation. All patients reported complete resolution of symptoms at a mean follow-up of 28.3 months. The laparoscopic approach to CACS appears to be feasible, safe, and successful, if performed by experienced laparoscopic surgeons. PTA and stenting resulted in a valid complementary procedure only when performed after the release of the extrinsic compression on the CA. Additional patients with longer follow-up are needed.

Percutaneous Transluminal Angioplasty of Lower Limb Arteries Causes a Systemic Inflammatory Response

Percutaneous transluminal angioplasty (PTA) of a lower limb arterial segment is a well-established treatment for suitable lesions for critical or noncritical lower limb ischemia. Our aim was to define the inflammatory response after PTA by measuring inflammatory markers. Twenty-five patients having PTA were compared with 20 patients having angiography alone. Interleukin-6 (IL-6), IL-8, IL-10, and tumor necrosis factor-alpha (TNF-alpha) were measured sequentially. The difference between postprocedure and preprocedure baseline levels were compared statistically between angiography alone and PTA. Patients were followed up to 1 year after the procedure, and the failure rate of PTA was noted. IL-6 and TNF-alpha were significantly higher in PTA patients at 1 hr after PTA (p < 0.05), and the IL-6 level only was significantly higher at 24 hr post-PTA (p < 0.05) compared to angiography alone (Mann-Whitney test). IL-8 and IL-10 levels did not differ significantly in the PTA group. At 1 year after the procedure, 45% of PTAs had failed. There was no statistically significant correlation between failed PTA and inflammatory response. PTA appears to cause a significant inflammatory response compared to angiography alone. This demonstrates a systemic manifestation of localized ischemia/reperfusion injury. Further investigation of the inflammatory response due to ischemia/reperfusion injury and its correlation with restenosis is recommended.