Femoral Artery Percutaneous Transluminal Angioplasty Research Articles

Outcome after Hybrid Outflow Interventions for Chronic Limb-threatening Ischemia.

Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia. This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V-VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days-183 months). Limb salvage was at 30 days-92%, at 1 year-91%, and at 5 and 10 years-86%. Survival and amputation-free survival were at 30 days-93% and 86%, at 1 year-80% and 76%, at 5 years-51% and 48%, and at 10 years-21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days-97%, at 1 year-88%, at 5 years-72%, and at 10 years-66%. Hybrid outflow revascularization is an important tool in the vascular surgeon's armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.

Endovascular treatment of femoro-popliteal artery stenosis/obstruction using a repositionable self-expanding nitinol stent: a preliminary study

Introduction. The aim of this study was to report our preliminary results regarding the use of the repositionable self-expanding nitinol stent in a cohort of patients with femoro-popliteal artery occlusion/stenosis. Material and methods. The study groups consisted a total of 8 patients (10 extremities) between 47 and 70 years of age who presented with typical symptoms of intermittent claudication and/or critical limb ischaemia (Fontaine stage II–IV) and underwent primary elective superficial femoral artery percutaneous transluminal angioplasty and/or stenting using a Jaguar repositionable self-expanding nitinol stent in the dates of 2013–2015. Information for patency at 6th month after the stenting procedure was obtained. Results. The mean operation time was 38.56 ± 26.40 minutes. No patients had procedure-related stent fracture, distal thromboembolism, haematoma, femoral pseudoaneurysm or stent occlusion. At 6-month follow-up, at least one categorical improvement was observed in 7 patients (87.5% of intent-to-treat population). Conclusions. The Jaguar self-expanding nitinol stent has several technical advantages, and its use was associated with a low risk of complications. Further study is warranted to establish its superiority in providing good long-term patency.

Initial Experience with Percutaneous Angioplasty of the Common Femoral Artery in De Novo Stenotic Lesions

The aim of this study was to report an initial experience with percutaneous transluminal angioplasty (PTA) in de novo stenotic lesions of the common femoral artery (CFA). A retrospective analysis for 34 consecutive patients was conducted. The follow-up consisted of clinical evaluation and color duplex ultrasound scan (CDU) 1, 6, and 12 months after the procedure. The symptoms were claudication in 16 patients (47%), critical limb ischemia in 17 (50%), and preservation of an infrainguinal bypass in 1 (3%). PTA was performed in CFA alone in 45.7%, associated to iliac and/or profunda/superficial femoral artery PTA in 54.3%. Stenting was performed in 23 patients (65.7%). All procedures were successful. Two patients required surgery for a local complication. Median hospital stay was 2 days. Mean follow-up was 11 months (range 1-56). Primary and secondary sustained clinical improvement rates were 77% and 85%, and primary, CDU-controlled patency rate was 88%. Four reinterventions were required for symptomatic CFA restenosis. At the end of follow-up, no major amputation had been performed, all patients with claudication remained improved with no restenosis, and the secondary sustained improvement rate was 85%. PTA for primary CFA lesions is feasible and safe, with acceptable short-term results in claudicants. In patients with tissue loss, frequent reinterventions raise questions about PTA benefit. This approach needs to be compared with open surgery in a randomized trial.

Vascular complications in steroid treated patients undergoing transfemoral aortic valve implantation.

To assess the rate of Vascular complications in steroid treated patients undergoing transfemoral aortic valve implantation (TAVI). Steroid therapy has been associated with increased post-surgical bleeding. Vascular complications are a major concern in patients undergoing TAVI. However, the effect of corticosteroids on vascular complications has not been assessed in these patients. We conducted a retrospective analysis of 220 consecutive patients undergoing transfemoral TAVI at our institute between 2009 and 2013. Patients who were on steroids at the time of the procedure (n = 25) were compared with those who were not (n = 195). Baseline characteristics between groups were similar except for greater incidence of chronic renal failure (52 vs. 25%, P = 0.05) and lower left ventricular ejection fraction (50.3 vs. 55.8%, P = 0.037) in the steroid group. The rate of procedural success and nonvascular complication were similar in both groups with the exception of more temporary AV block in the steroid group (24 vs. 8%, P = 0.016). Patients treated with steroids had significantly more minor vascular complication (44 vs. 23%, P = 0.024), and significantly more femoral artery stenosis (16 vs. 5%, P = 0.036), occlusion (8 vs. 1%, P = 0.014), need for femoral artery percutaneous transluminal angioplasty (PTA) (32 vs. 12%, P = 0.009), and femoral artery PTA or stenting (32% vs. 15%, P = 0.031). On multivariate analysis steroid treatment was the only predictor of minor vascular complications (RR=2.65, 95% CI 1.04-6.8, P = 0.042). Concurrent corticosteroid treatment is associated with a higher rate of minor vascular complication following transfemoral TAVI. Operators should be aware of this risk when assessing patients for the procedure.

External Beam Irradiation and Restenosis Following Femoral Stenting: Long-Term Results of a Prospective Randomized Study

To assess the long-term outcome of external beam irradiation (EBI) for the prevention of restenosis due to neointimal hyperplasia, following percutaneous transluminal angioplasty (PTA) and stenting of the superficial femoral artery. Sixty consecutive patients with peripheral arterial disease, who were treated with "bail-out" stent implantation in the superficial femoral artery due to suboptimal PTA, were included in this study. Patients were randomly allocated into two groups, receiving either external beam irradiation (6 MV photons, total dose 24 Gy in a hypofractionated schedule) plus antiplatelet therapy (EBI group) or antiplatelet therapy alone (control group). No procedure-related complications occurred, and all patients of the EBI group received the full dose of 24 Gy. During the long-term follow-up, an overall statistically significant difference was demonstrated in favor of the EBI group patients, regarding both the in-stent (log-rank test, p = 0.0072) and the in-segment binary restenosis (log-rank test, p = 0.0103). The primary patency rates were also significantly better in the EBI group at specific time-points, such as in the first (74.2% vs 46.5%, p = 0.019), second (62.5% vs 33.8%, p = 0.020), and third (54.6% vs 29.0%, p = 0.039) year, respectively. Moreover, the overall clinically driven reintervention rate was significantly lower among patients of the irradiated group (log-rank test, p = 0.038). Our long-term follow-up analysis revealed that EBI following femoral artery PTA and stenting significantly reduces restenosis and reintervention rates, while improving primary patency.

Outcome After Endovascular Treatment of Deep Femoral Artery Stenosis:Results in a Consecutive Patient Series and Systematic Review of the Literature

To evaluate immediate and midterm clinical outcomes after percutaneous transluminal angioplasty (PTA) of deep femoral artery stenosis in patients with chronically occluded superficial femoral arteries (SFA) and to report the results of a systematic review of the literature in this field. A retrospective analysis was conducted of 55 consecutive patients (42 men; median age 72 years, interquartile range [IQR] 63-79) with severe intermittent claudication (n = 38) or critical limb ischemia (n = 17) who underwent balloon angioplasty of deep femoral artery stenosis. Patients were followed with ankle-brachial index (ABI) measurement, estimation of maximum walking capacity, clinical staging of peripheral artery disease (PAD), and duplex ultrasound imaging for restenosis. A systematic review of the literature using MEDLINE, EMBASE, and a hand search was done. Technical success (residual stenosis < 30%) was achieved in 85% (47/55), with 1 (2%) minor complication. The median ABI marginally increased from 0.48 at baseline to 0.53 post intervention without significant difference in the change of ABI between patients with supra- or infragenicular reconstitution of the femoropopliteal runoff. During a median 13-month (IQR 3-42) follow-up, no significant improvement in ABI or walking distance was maintained, and only 16 (29%) patients reported a sustained clinical improvement by 1 PAD stage. Cumulative patency and reintervention-free survival rates were, respectively, 71% and 61% at 1 year and 49% and 48% at 3 years. In the literature, only case series were found, but no randomized trial evaluating the efficacy of deep femoral artery PTA. PTA of the deep femoral artery can be performed with high technical success rates at a low interventional risk. However, in the majority of patients, this technique yields no sustained hemodynamic or clinical benefit. Due to a high rate of late failures, it should be reserved for limb salvage in patients without a surgical alternative.

Factors influencing ulcer healing in patients with combined arterial and venous insufficiency

Purpose: The purpose of this study was to determine the effectiveness of treatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better define criteria for interventional therapy. Study Design: We retrospectively reviewed the records of patients treated at four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, absent pedal pulse, and at least one in-line arterial stenosis > 50% by arteriography. Venous insufficiency was defined as characteristic clinical findings and duplex findings of either reflux or thrombus in the deep or superficial system. Clinical, demographic, and hemodynamic parameters were statistically analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage. Results: Fifty-nine patients with CAVI were treated for nonhealing ulcers that had been present from 1 to 39 months (mean, 6.4 months). All patients had edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty-two patients underwent arterial bypass grafting, three underwent an endarterectomy, one underwent superficial femoral artery percutaneous transluminal angioplasty, and three underwent primary below-knee amputation. For purposes of analysis, patients were divided into four groups according to the pattern of arterial and venous disease and the success of arterial reconstruction. Group 1 consisted of 22 patients with a patent arterial graft, superficial venous incompetence, and normal deep veins. Group 2 consisted of seven patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosis (DVT), and group 4 included eight patients with an occluded arterial graft. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine patients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) required below-knee amputation for nonhealed ulcers and uncontrolled infection. No patient with graft occlusion was healed, and 12 ulcers persisted despite successful arterial reconstruction. Twenty-one (78%) of 27 patients undergoing greater saphenous vein stripping were healed, but none of these patients had DVT. The mean interval from bypass graft to healing was 7.9 months. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas only two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significant in predicting healing ( P < .05). Conclusions: Ulcers may develop anywhere on the calf or foot in patients with CAVI, and healing requires correction of arterial insufficiency. Patients with prior DVT are unlikely to heal, even with a patent bypass graft. Ulcer healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prior DVT are unlikely to benefit from aggressive arterial or venous reconstruction. (J Vasc Surg 2001;33:1158-64.)

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

Objective: The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success.Methods: A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing.Results: Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound debridement in 50%. Infrainguinal bypass was performed for 81, patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed—all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P < .002), a palpable pedal pulse (85% healed vs 42%, P < .0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P < .02), and the number of patent tibial arteries after bypass to the ankle (P < .0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome.Conclusions: Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing.

The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success. A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing. Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound débridement in 50%. Infrainguinal bypass was performed for 81 patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed-all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P <.002), a palpable pedal pulse (85% healed vs 42%, P <.0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P <.02), and the number of patent tibial arteries after bypass to the ankle (P <.0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome. Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.