Femoropopliteal Level Research Articles

Omniflow prosthesis for treatment prosthetic graft infection of the aorto-iliac and femoropopliteal level on the infrarenal aortic segment and lower extremity.

To report outcomes after the use of the Omniflow II biosynthetic graft (LeMaitre Vascular, Il, USA) for vascular reconstruction in patients with prosthetic infection at the aorto-iliac and femoropopliteal level. Within a six-year period, all consecutive patients with aorto-iliac and femoro-popliteal graft infection treated by resection of the infected graft material, extensive local debridement and reconstruction using Omniflow II biosynthetic graft were retrospectively analzyed. Patient characteristics, intraoperative details, postoperative outcomes, and infection details were assessed. Overall 18 patients were operated in the study period. The anatomical localization of the index surgery was the abdominal aorta n=3 (17%), iliac arteries n=5 (27%) and lower extremities (thigh) n=10 (56%). Previous surgery included 8 (44%) reconstructions with alloplastic and 10 (55.6%) reconstructions with bovine xenopericardium. An obturator rerouting for the aorto-iliac level was used in 8 patients (44 %), a femoro-femoral cross-over routing was used in 7 patients (39%) and a femoro-popliteal routing was used in 3 patients (17%). Overall, 3 patients (17%) expired in-hospital. Five (28%) patients required secondary wound closure. Operative revision due to bleeding was performed in three patients. During follow-up (mean 41.4 ± 25.7 months), one patient received a stent angioplasty to maintain graft patency. We observed one reinfection (6%), treated by explanation of the prosthesis and no further revascularization was performed. Secondary graft patency was 100% and one reintervention at the level of the foramen obturatum was needed. The concept of using the Omniflow II biosynthetic graft for vascular reconstruction in patients with prosthetic infection at the aorto-iliac and femoro-popliteal level shows very promising mid-term results. Graft patency is high and reinfection rate is low.

Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy

BackgroundAcute limb ischemia (ALI) carries a 15% to 20% risk of combined death or amputation at 30 days and 50% to 60% at 1 year. Percutaneous mechanical thrombectomy (PT) is an emerging minimally invasive alternative to open thrombectomy (OT). However, ALI thrombectomy cases are omitted from most quality databases, limiting comparisons of limb and survival outcomes between PT and OT. Therefore, our aim was to compare in-hospital outcomes between PT and OT using the National Inpatient Sample. MethodsWe analyzed survey-weighted National Inpatient Sample data (2015-2020) to include emergent admissions of aged adults (50+ years) with a primary diagnosis of lower extremity ALI undergoing index procedures within 2 days of hospitalization. We excluded hospitalizations with concurrent trauma or dissection diagnoses and index procedures using catheter-directed thrombolysis. Our primary outcome was composite in-hospital major amputation or death. Secondary outcomes included in-hospital major amputation, death, in-hospital reintervention (including angioplasty/stent, thrombolysis, PT, OT, or bypass), and extended length of stay (eLOS; defined as LOS >75th percentile). Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were generated by multivariable logistic regression, adjusting for demographics, frailty (Risk Analysis Index), secondary diagnoses including atrial fibrillation and peripheral artery disease, hospital characteristics, and index procedure data including the anatomic thrombectomy level and fasciotomy. A priori subgroup analyses were performed using interaction terms. ResultsWe included 23,795 survey-weighted ALI hospitalizations (mean age: 72.2 years, 50.4% female, 79.2% White, and 22.3% frail), with 7335 (30.8%) undergoing PT. Hospitalization characteristics for PT vs OT differed by atrial fibrillation (28.7% vs 36.5%, P < .0001), frequency of intervention at the femoropopliteal level (86.2% vs 88.8%, P = .009), and fasciotomy (4.8% vs 6.9%, P = .006). In total, 2530 (10.6%) underwent major amputation or died. Unadjusted (10.1% vs 10.9%, P = .43) and adjusted (aOR = 0.96 [95% CI, 0.77-1.20], P = .74) risk did not differ between the groups. PT was associated with increased odds of reintervention (aOR = 2.10 [95% CI, 1.72-2.56], P < .0001) when compared with OT, but this was not seen in the tibial subgroup (aOR = 1.31 [95% CI, 0.86-2.01], P = .21, Pinteraction < .0001). Further, 79.1% of PT hospitalizations undergoing reintervention were salvaged with endovascular therapy. Lastly, PT was associated with significantly decreased odds of eLOS (aOR = 0.80 [95% CI, 0.69-0.94], P = .005). ConclusionsPT was associated with comparable in-hospital limb salvage and mortality rates compared with OT. Despite an increased risk of reintervention, most PT reinterventions avoided open surgery, and PT was associated with a decreased risk of eLOS. Thus, PT may be an appropriate alternative to OT in appropriately selected patients.

Lower extremity deep vein thrombosis: an ultrasound revisit regarding its diagnostic value

Aim: To determine the diagnostic value of ultrasound in lower extremity deep vein thrombosis (LEDVT). Methods: Data of 20 patients diagnosed with LEDVT and underwent endovascular treatment at Hue University of Medicine and Pharmacy hospital from 01/2021 - 08/2022 were analyzed. Ultrasound findings were documented and correlated with venography. All patients were initialized with anticoagulation upon the diagnosis of LEDVT. Endovascular treatment included diagnostic venography, inferior vena cava filter insertion, intraclot thrombolysis, manual thromboaspiration with or without venoplasty and stenting. Results: The mean age was 58.63 ± 16.9 (range, 17 - 85 age). The major risk factors were trauma, surgery, and a history of DVT. LEDVT was found prominently in the left leg and at the femoropopliteal level. Ultrasound had a sensitivity of 93.6%, a specificity of 97.6%, a positive predictive value of 98.6%, a negative predictive value of 89.1% and accuracy of 95% in the diagnosis of LEDVT. The sensitivity and specificity of ultrasound in differentiating between chronic and acute thrombus were 96.5% and 92%. Ultrasound had low sensitivity in evaluating collaterals and venous outflow obstruction (May-Thurner syndrome). Conclusion: Ultrasound has a high diagnostic value and remains the first line imaging modality in the investigation of LEDVT. Key words: deep vein thrombosis; ultrasound; venography; thromboaspiration; May-Thurner syndrome

Aortic-tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.

Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot.A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation.The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot. A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation. The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Appendix

Sensitivity and Specificity of Ultrasonographic Compared with CT Angiography in Detecting Femoropopliteal and Infrapopliteal Arterial Lesions in Lower Extremity Arterial Disease in Dr. Mohammad Hoesin General Hospital Palembang

Background: Peripheral artery disease (PAD) is a chronic occlusive arterial disease of the extremities caused by atherosclerosis.1 It is estimated that 20-30% of the population worldwide suffered PAD.2 PAD is associated with a 1-year mortality and limb loss rate of 20%.7 Critical limb ischemia (CLI) is a late stage clinical presentation of PAD. Imaging of the entire artery is possible using CT angiography. However, CT angiography has its drawbacks because the contrast used can be nephrotoxic, the risk of allergies, expensive, and not all health services have it. Ultrasonographic’s (USG) sensitivity, specificity and accuracy were 96.55%, 61.53%, and 78.84% for detecting lower limb distal artery lesions.11 Ultrasonographic does not require the use of contrast, radiation, low cost and almost all health services have them.12 However, the Ultrasonographic examination has its limitations depending on the operator's capabilities. It is therefore necessary to conduct research that have never been previously studied in South Sumatra.&#x0D; Methods: This study is a diagnostic test study that examines the sensitivity and specificity of ultrasound in detecting LEAD artery lesions. The samples were 29 patients.&#x0D; Results: At the femoropopliteal level, the results obtained were 91% sensitivity and 86% specificity. At the infrapopliteal level, the results obtained were 95% sensitivity and 87% specificity.&#x0D; Conclusion: Ultrasonographic has high sensitivity and specificity in detecting LEAD’s lesions

Unenhanced 3D Turbo Spin-Echo MR Angiography of Lower Limbs in Peripheral Arterial Disease: A Comparative Study With Gadolinium-Enhanced MR Angiography

The purpose of this study was to assess the feasibility and diagnostic performance of an unenhanced MR angiography sequence (Syngo Native Space, Siemens Healthcare) to detect and quantify lower-limb peripheral arterial disease (PAD), with gadolinium-enhanced MR angiography (CE-MRA) as the reference standard. Fifty-one patients known to have lower-limb arteriopathy were included in this prospective study. For every patient, we performed Native sequence and CE-MRA on a 1.5-T system. We evaluated examination duration, image quality, and location, number, and severity of lesions. Examination duration was longer for Native sequence (mean, 39.6 min, vs 10 min for CE-MRA). Image quality was significantly better for CE-MRA, with 92% of images listed as good to excellent for CE-MRA, compared to 53% for Native. Sensitivity, specificity, negative predictive value (NPV), and accuracy of Native were respectively 75%, 95%, 89%, and 88% for all mixed levels; 52%, 97%, 88%, and 87% for aortoiliac level; 87%, 99%, 95%, and 92% for femoropopliteal level; and 82%, 87%, 87%, and 85% for subpopliteal level. If we considered only patients with Leriche and Fontaine stage II arteriopathy, Native results were slightly better, with respective specificities and NPVs of 96% and 91% for all mixed levels; 98% and 90% for aortoiliac level; 98% and 93% for femoropopliteal level; and 91% and 90% for subpopliteal level. Unenhanced MR angiography, cheaper than CE-MRA, showed in our study a good NPV, which suggests its utility as first-line test to screen for PAD, especially in patients at risk of nephrogenic systemic fibrosis.

The changes of plasma thrombin-antithrombin complex in the patients with peripheral arterial disease undergoing surgical revascularization

In patients with severe lower limb ischemia the coagulation and fibrinolytic systems have been found to be activated preoperatively. The aim of the study was to evaluate the changes of TAT level as a selected coagulation factor, before, during and after surgical revascularization and the analysis of the impact of coexisting diseases on the coagulation during the procedure. 50 patients with PAOD, in Fontaine stages IIb to IV (29 men and 21 women; median age 65.8 years, ASA II/III) undergoing elective surgical revascularization were studied. Two groups of patients were compared: 20 undergoing reconstruction on aorto-femoral and 30 on femoropopliteal level. Blood samples were collected 5 times: 24 hours before the operation; intraoperatively after artery exposure; after heparin administration and clamping; after reperfusion and -24 hours postoperatively. Elevated values of TAT (10.5 g/l ±7.1) were found before the operation. The elevated value of TAT increased intraoperatively (25.1 g/l ±44.58; p<0.001) (norm 1-4.1 g/l) and maintaining higher levels after the surgery. The significant correlations between plasma level of TAT and ischemia degree were found. Also the correlation between intraoperative increase of TAT and the duration of surgery was noticed. No significant differences between two analysed groups were observed. The results indicate the activation of coagulation and prothrombotic state in the patients with advanced arteriosclerosis. During the surgical revascularisation permanent increase of activation of blood coagulation was observed. This activation depends on duration of the procedure and maintains increased one-day after the operation. Our findings may explain the unexpected occurrence of early thrombotic complications after technically successful vascular reconstructions.

Cryoplasty for the Treatment of Femoropopliteal Arterial Disease: Will Freezing Solve the Problem of Cold Feet?

IN patients with symptomatic femoropopliteal arterial disease, percutaneous transluminal angioplasty (PTA) has been established as the first-line treatment for the majority of atherosclerotic lesions. A significant drawback of the procedure is the high rate of recurrent stenosis, which usually develops during the first 12 months after treatment (1). Initial failure of PTA caused by elastic recoil or hemodynamically relevant dissection can be managed by the implantation of stents, but clinical and experimental studies have shown that angioplasty triggers multiple cellular and molecular mechanisms that lead to a cascade of events that eventually results in increased vascular smooth muscle cell proliferation, synthesis of extracellular matrix, and consecutive formation of neointimal hyperplasia with luminal narrowing. Although stents may dramatically improve the appearance immediately after angioplasty, they have yet failed to show superior long-term efficacy, as intimal hyperplasia is even more pronounced after stent implantation than after PTA alone (2,3). In this respect, the search for new techniques and devices dedicated to endovascular management of peripheral artery disease is a contemporary issue and has to be continued. Each year, a vast number of experimental and clinical studies are performed to test refinements of current balloon/stent systems or to explore new and more innovative techniques for transluminal treatment of femoropopliteal obstructions. However, most of the new devices and strategies fail to show significant improvements in long-term outcome when finally introduced into clinical practice. Recanalization techniques like atherectomy (rotational and directional), excimer laser–assisted angioplasty, or subintimal angioplasty mainly address the appearance of the vessel immediately after angioplasty. Transluminal removal of the atherosclerotic plaque and/or creation of a subintimal channel results in a wider lumen (or neolumen) with a relatively smooth surface, while the profound vessel wall trauma of balloon angioplasty is avoided (4–7). However, the efficacy of these techniques in terms of reduction of neointimal hyperplasia has not been determined for treatment of femoropopliteal arterial disease. The same is true for cutting balloon angioplasty, which represents a modification of conventional balloon dilation. The cutting blades of the balloon make controlled longitudinal incisions into the plaque and reduce the force needed to dilate the vessel. This is thought to result in lower rates of dissection and to trigger a more benign course of arterial healing as a result of the limited stretch injury. Although cutting balloon angioplasty has been positively evaluated in the coronary circulation, there are few reports about its use for peripheral vessels (8). During the past two decades, nearly all available stent designs— mostly variations of balloon-expandable devices and thermal or self-expanding cobalt or nickel titanium alloy (ie, nitinol) systems—have been used at the femoropopliteal level for salvage of PTA or even off-label primary treatment. However, in randomized studies, stents have generally failed to prove a significant benefit when evaluated versus PTA alone (9). The fact that the stent design can have significant impact on neointimal thickness independently of the extent of stretch injury has been demonstrated by Garasic et al (10), thereby finding that the optimal structure for these devices might be a key requirement for restenosis prevention. Recent investigations have highlighted the various forces that affect a stent when implanted into the femoropopliteal artery. In this territory, a combination of stresses like longitudinal extension, torsion, flexion at the popliteal level, and muscle compression in the adductor channel are encountered that may significantly influence long-term success (11). Newer generations of nitinol self-expanding coil and mesh stents, which seem to provide the necessary flexibility in multiple dimensions, appear to have a positive impact on femoropopliteal patency, but this notion has not been confirmed in a randomized setting (12–14). Fabric-covered From the Department of Radiology, University Clinics Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 9, 24105 Kiel, Germany. Address correspondence to T.J.; E-mail: jahnke@medscape.com

Noninvasive Localization of Infrainguinal Arterial Occlusive Disease in Diabetics

A retrospective review of 101 diabetics without aortoiliac disease was carried out to analyze the ability of various noninvasive tests to predict the level of significant (>50% stenosis) infrainguinal arterial disease. Patients were studied with anklebrachial indices (ABI), toebrachial indices (TBI), segmental pulse volume recordings (PVR), segmental pressures (SEGP), segmental Doppler waveforms (DWF), and arteriography. Results were classified as normal, disease at the femoropopliteal level, infrapopliteal level, or both levels (multilevel), or noninterpretable. Our findings for the entire study showed that, as a single test, DWF appears to have the best angiographic correlation, although the summed diagnosis of combined DWF and PVR data is superior in distinguishing multilevel disease from isolated tibial disease. SEGP are of very limited use in diabetics, even in multimodality testing, and we no longer include that test in our routine evaluation of diabetics.

Occlusive and aneurysmal peripheral arterial disease: assessment of a stent-graft system.

To assess the use of a recently developed stent-graft system for treatment of occlusive lesions and aneurysms in the iliac and femoropopliteal arteries. The stent-graft consisted of a nitinol stent framework covered by a thin-walled polyester fabric. The device was used in 105 patients with symptomatic peripheral vascular disease. Implant locations were iliac artery (n = 38), femoral artery (n = 62), and popliteal artery (n = 5). Initial technical success was achieved in all patients except one with occlusive disease and one with aneurysmal disease. Residual stenosis after stent-graft implantation was 0.5% +/- 3. Mean ankle-brachial index increased from 0.53 to 0.98. Complications were hematoma (n = 3), pseudoaneurysm (n = 2), puncture site thrombosis (n = 1), early graft thrombosis (n = 8), graft misplacement (n = 1), distal embolization (n = 2), delayed thrombosis (n = 14), pain and fever (n = 27). At the iliac level, primary patency was 97% and secondary patency was 100%. At the femoral level, primary patency was 59% and secondary patency was 81%. Endoluminal bypass with a percutaneously delivered stent-graft is feasible. Technical results are good, and the number of complications is few at the iliac level. At the femoropopliteal level, patency is not as good and the number of complications is higher.

Percutaneous Peripheral Atherectomy Using the Rotablator: A Single-Center Experience

Purpose: In order to assess the role of percutaneous peripheral rotational ablation using Rotablator™, 150 symptomatic patients (94 males, 56 females; mean age 73 ± 1 years, range 42 to 90) having 212 complex peripheral vascular lesions were treated. Methods: Fifty percent of lesions were below the knee; 65% of patients had severe claudication, 11% moderate (24% were in stage III or IV Fontaine classification). The femoral lesions were significantly longer than those at other sites (5.7 ± 0.4 versus 2.9 ± 0.3 cm, p &lt; 0.001). The mean length was 4.0 ± 0.2 cm (range 1 to 20). All the lesions were considered complex; 93% of the lesions were calcified, and 63% were located at a bifurcation. Complementary balloon dilation (percutaneous transluminal angioplasty [PTA]) was significantly (p &lt; 0.001) more frequent in femoropopliteal lesions (70 PTAs in 86 femoral arteries, 10 PTAs in 19 popliteal arteries) than in distal leg lesions (14 in 106 arteries). Results: After Rotablator therapy alone, the percent stenosis decreased from 81.0% ± 0.8% to 18.0% ± 1.1%. The residual stenosis was greater at the femoral (44%) than at the distal level (19%) (p &lt; 0.01). Adjunctive PTA (47 lesions) lowered residual stenosis to 10% at the femoral level and 3% at the distal level. Thirty-seven in traprocedural complications occurred (spasm, thrombosis, dissection, perforation, distal emboli, no reflow); seven procedures subsequently failed for an overall technical success of 97%. The mean follow-up period was 14.4 ± 1.0 months (range 1 to 51). Among 125 patients having a follow-up period &gt; 4 months, 114 patients representing 163 lesions underwent angiography. One hundred twenty-three lesions (76%) were patent, and 40 lesions (24%) showed restenosis (&gt; 50% luminal narrowing) of 82.0% ± 2.1. The restenosis rate was higher in femoral (36%) than in distal (21%) or popliteal arteries (7%). Restenosis was more frequent for all lesions &gt; 7 cm (p &lt; 0.001) and for both above- and below-knee locations: 55% versus 19% for &lt; 7 cm at the femoropopliteal level (p &lt; 0.03), and 80% versus 18% at the distal level (p &lt; 0.01). Conclusions: In our experience, percutaneous peripheral rotational ablation has taken a pre-eminent position in the treatment of distal leg arteries, especially in complex lesions. Our results have led us to broaden its indications to complex vascular lesions ≤ 6 cm. In particular, the use of this technique for treatment of runoff vessels should improve the long-term patency of proximal PTA and bypass grafts. This device has become in dispensable in our laboratory, where Rotablator therapy comprises 15% of all PTA procedures.

Iliac and Femoropopliteal Lesions: Evaluation of Balloon Angioplasty and Classical Surgery

Purpose: The purpose of this study was to compare the characteristics of patients treated for atherosclerotic disease of the lower extremities with balloon angioplasty (BA) or classical surgery (CS) and to assess the outcome of both techniques. Methods: The records of 1364 patients who were treated with BA or CS for chronic lower limb ischemia between 1986 and 1993 were analyzed. Demographic features of patients, immediate and long-term survival, patency, and amputation rates were compared in both groups according to the level of the revascularization (iliac or femoropopliteal). Results: Patients undergoing BA were slightly younger (62.3 years versus 65.9 years for CS group; p = NS) and demonstrated symptoms consistent with less severe atherosclerotic disease (81% claudication in the BA group versus 48% in the CS patients; p &lt; 0.001). At 30 days post-treatment in the BA and CS groups, respectively, there were 0.7% and 4% deaths (p &lt; 0.01); 13% and 6% primary failures (p = 0.013); 13% and 6% secondary failures (p = 0.01); 0.3% and 12% general complications (p = 0.001); and 3% and 8% nonvascular complications (p = 0.007). At the iliac level, in the angioplasty (n = 134 limbs) and surgery (n = 721 limbs) groups, respectively, the mean age was 57.6 and 63.7 years (p &lt; 0.01), and claudication was present in 91% and 72. Perioperative mortality was 0% and 1.9. The 4-year survival rates were 95% and 88%; patency was 70% and 79%; and the amputation rates were 0% and 5. At the femoropopliteal level, in the angioplasty (n = 138 limbs) and surgery (n = 656 limbs) groups, respectively, the mean age was 67.8 and 66.8 years (NS), and claudication was present in 69% and 28. Perioperative mortality was 0.9% and 5.5. The 4-year survival rates were 95% and 78%; and patency was 44% and 65. At 2 years, the amputation rates were 6% and 12. Conclusions: Patients treated by BA were younger, especially in the iliac group, and had less symptomatic lesions than patients treated with surgery. Surgery achieved a better long-term patency at the cost of a higher immediate complication rate and mortality. Whenever technically feasible, BA may be the better choice for initial therapy in appropriate patients suffering from chronic lower limb ischemia.

Percutaneous peripheral atherectomy using the rotablator: a single-center experience.

In order to assess the role of percutaneous peripheral rotational ablation using Rotablator, 150 symptomatic patients (94 males, 56 females; mean age 73 +/- 1 years, range 42 to 90) having 212 complex peripheral vascular lesions were treated. Fifty percent of lesions were below the knee; 65% of patients had severe claudication, 11% moderate (24% were in stage III or IV Fontaine classification). The femoral lesions were significantly longer than those at other sites (5.7 +/- 0.4 versus 2.9 +/- 0.3 cm, p < 0.001). The mean length was 4.0 +/- 0.2 cm (range 1 to 20). All the lesions were considered complex; 93% of the lesions were clacified, and 63% were located at a bifurcation. Complementary balloon dilation (percutaneous transluminal angioplasty [PTA]) was significantly (p < 0.001) more frequent in femoropopliteal lesions (70 PTAs in 86 femoral arteries, 10 PTAs in 19 popliteal arteries) than in distal leg lesions (14 in 106 arteries). After Rotablator therapy alone, the percent stenosis decreased from 81.0% +/- 0.8% to 18.0% +/- 1.1%. The residual stenosis was greater at the femoral (44%) than at the distal level (19%) (p < 0.01). Adjunctive PTA (47 lesions) lowered residual stenosis to 10% at the femoral level and 3% at the distal level. Thirty-seven intraprocedural complications occurred (spasm, thrombosis, dissection, perforation, distal emboli, no reflow); seven procedures subsequently failed for an overall technical success of 97%. The mean follow-up period was 14.4 +/- 1.0 months (range 1 to 51). Among 125 patients having a follow-up period > or = 4 months, 114 patients representing 163 lesions underwent angiography. One hundred twenty-three lesions (76%) were patent, and 40 lesions (24%) showed restenosis (> or = 50% luminal narrowing) of 82.0% +/- 21%. The restenosis rate was higher in femoral (36%) than in distal (21%) or popliteal arteries (7%). Restenosis was more frequent for all lesions > or = 7 cm (p < 0.001) and for both above- and below-knee locations: 55% versus 19% for < 7 cm at the femoropopliteal level (p < 0.03), and 80% versus 18% at the distal level (p < 0.01). In our experience, percutaneous peripheral rotational ablation has taken a pre-eminent position in the treatment of distal leg arteries, especially in complex lesions. Our results have led us to broaden its indications to complex vascular lesions < or = 6 cm. In particular, the use of this technique for treatment of runoff vessels should improve the long-term patency of proximal PTA and bypass grafts. This device has become indispensable in our laboratory, where Rotablator therapy comprises 15% of all PTA procedures.

Initial experience with the Cragg Endopro System 1 for intraluminal treatment of peripheral vascular disease.

To evaluate the safety and efficacy of a new covered stent, the Cragg Endopro System 1, for intraluminal treatment of peripheral vascular disease in the iliac and femoropopliteal arteries. Forty symptomatic patients with predominantly lengthy stenotic (24) or occlusive (13) lesions or aneurysms (3) in the iliac (19), femoral (19), or popliteal (2) arteries were treated percutaneously with balloon angioplasty followed by implantation of the self-expanding nitinol Cragg stent covered by a woven polyester fabric coated with low-molecular-weight heparin. The mean length of femoropopliteal lesions was 13.0 +/- 1.8 cm, as compared to 6.7 +/- 0.8 cm (p < 0.01) for iliac lesions. Mean percent stenosis was 89% +/- 2% with no significant difference between the arterial segments. With a total of 52 covered stents implanted, technical success was achieved in 98% (39/40 patients). One tortuous femoral artery aneurysm was not satisfactorily excluded to prevent leakage. Clinical success was seen in all patients with demonstrable improvements in the claudication stage and the ankle-brachial index from a mean 0.54 to 0.92. Three local complications (one hematoma, two false aneurysms) required surgical repair. One distal embolism, one acute thrombosis, and three subacute thromboses were encountered and successfully treated by thrombolysis and/or surgery. One patient with two iliac stents developed contralateral common iliac artery occlusion from a stent partially obstructing the aorta; placement of a covered stent in the blocked artery re-established normal flow. Over an 8-month follow-up with arteriographic re-examination, all iliac stents remained patent. At the femoropopliteal level, two stents were occluded at 4 months; one was successfully dilated, but the other required surgical bypass grafting. A third patient developed a stenotic lesion proximal to the stent; dilation restored adequate inflow to the stent. The Cragg Endopro System 1 appears to be effective as an "internal bypass" for iliac and femoropopliteal occlusive disease. More complications and restenosis were seen in femoropopliteal implantations; however, a change in postoperative medication may improve these results. Long-term results will determine if the Cragg Endopro System 1 can achieve a patency equal to conventional bypass grafting.

Initial Experience with the Cragg Endopro System 1 for Intraluminal Treatment of Peripheral Vascular Disease

Purpose: To evaluate the safety and efficacy of a new covered stent, the Cragg Endopro System 1, for intraluminal treatment of peripheral vascular disease in the iliac and femoropopliteal arteries. Methods: Forty symptomatic patients with predominantly lengthy stenotic (24) or occlusive (13) lesions or aneurysms (3) in the iliac (19), femoral (19), or popliteal (2) arteries were treated percutaneously with balloon angioplasty followed by implantation of the self-expanding nitinol Cragg stent covered by a woven polyester fabric coated with low-molecular-weight heparin. The mean length of femoropopliteal lesions was 13.0 ± 1.8 cm, as compared to 6.7 ± 0.8 cm (p &lt; 0.01) for iliac lesions. Mean percent stenosis was 89% ± 2% with no significant difference between the arterial segments. Results: With a total of 52 covered stents implanted, technical success was achieved in 98% (39/40 patients). One tortuous femoral artery aneurysm was not satisfactorily excluded to prevent leakage. Clinical success was seen in all patients with demonstrable improvements in the claudication stage and the ankle-brachial index from a mean 0.54 to 0.92. Three local complications (one hematoma, two false aneurysms) required surgical repair. One distal embolism, one acute thrombosis, and three subacute thromboses were encountered and successfully treated by thrombolysis and/or surgery. One patient with two iliac stents developed contralateral common iliac artery occlusion from a stent partially obstructing the aorta; placement of a covered stent in the blocked artery re-established normal flow. Over an 8-month follow-up with arteriographic re-examination, all iliac stents remained patent. At the femoropopliteal level, two stents were occluded at 4 months; one was successfully dilated, but the other required surgical bypass grafting. A third patient developed a stenotic lesion proximal to the stent; dilation restored adequate inflow to the stent. Conclusions: The Cragg Endopro System 1 appears to be effective as an “internal bypass” for iliac and femoropopliteal occlusive disease. More complications and restenosis were seen in femoropopliteal implantations; however, a change in postoperative medication may improve these results. Long-term results will determine if the Cragg Endopro System 1 can achieve a patency equal to conventional bypass grafting.

Long-term results with the above-knee popliteal expanded polytetrafluoroethylene graft

Since approximately 30% to 40% of autogenous vein bypass grafts to the femoropopliteal level may occlude within 5 years of implantation, additional vein will be required for subsequent revisions. We undertook a study to determine whether the preferential use of an above-knee expanded polytetrafluoroethylene bypass graft to save vein is an appropriate option. We reviewed our experience with 114 above-knee expanded polytetrafluoroethylene bypass reconstructions. Life-table analysis of primary and secondary graft patency was carried out by the method of Peto and statistically analyzed for the influence of clinical indication, runoff as determined by both preoperative and intraoperative completion arteriography, smoking, and diabetes. The 5-year primary patency rate of 57% for patients with claudication was comparable to contemporary randomized or retrospective series with below-knee autogenous vein for that indication, and it was superior to the patency rate for limb salvage. The status of the runoff vessels was an important determinant of outcome. The 59 limbs with good arteriographic runoff (2 to 3 vessels) had a markedly higher 5-year patency rate (70%) than the poor arteriographic runoff (0 to 1 vessels) group (30%). Continued cigarette smoking and diabetes mellitus also appeared to affect adversely primary graft patency in our hands. Our data support the use of preferential above-knee expanded polytetrafluoroethylene grafts in patients with good angiographic runoff. This approach does not appear to prejudice the limb against secondary revisionary procedures or the use of a new autogenous graft, if required.

Intermittent Claudication With Pedal Pulses

Intermittent claudication occurred in 16 patients (22 legs) despite the presence of a pedal pulse at rest. Exercise, by walking or toe-stands, sufficient to induce claudication resulted in disappearance of the pedal pulse until the claudication subsided (one to three minutes) when the pulse was again palpable. Blood pressure at the ankle normally declines with exercise due to dilatation of the muscular vascular bed. Proximal occlusive disease results in a profound fall in distal blood pressure with concomitant loss of the pedal pulse. There was atherosclerotic occlusive disease at the aorto-iliac level in nine legs and at the femoro-popliteal level in nine legs. Traumatic or congenital arterial disease occurred in four legs. There were persistent pedal pulses after arterial reconstruction in 19 legs, and three have not been treated. Claudication in the presence of resting pedal pulses is usually associated with major artery disease that is amenable to reconstruction.

Limb salvage in diabetics with "hopeless" ischemia. Use of autogenous tissuereconstruction (ATR)

It is axiomatic in arterial reconstructive surgery that success is directly related to the size of the vessel and the adequacy of the "outflow tract" below the reconstructed segment. The results are always much more satisfactory in the large vessels of the aorto-iliac segment than in the smaller arteries at the femoropopliteal level.^1-4 While success in varying degrees is reported when a femoropopliteal arterial block is relatively discrete and the outflow tract is good, these circumstances usually attend relatively minor degrees of ischemia such as that which is manifested by claudication. When diffuse arteriosclerosis exists with femoropopliteal blocks at multiple levels, the results have been far less sanguine. Unfortunately, these patients who have pain while at rest, ischemic ulcers, and gangrene are the ones who need help most. The arterial lesions of diabetes tend to be very diffuse in the small and medium-sized vessels of the viscera and extremities.

Limb Salvage in Diabetics With "Hopeless" Ischemia

It is axiomatic in arterial reconstructive surgery that success is directly related to the size of the vessel and the adequacy of the "outflow tract" below the reconstructed segment. The results are always much more satisfactory in the large vessels of the aorto-iliac segment than in the smaller arteries at the femoropopliteal level. 1-4 While success in varying degrees is reported when a femoropopliteal arterial block is relatively discrete and the outflow tract is good, these circumstances usually attend relatively minor degrees of ischemia such as that which is manifested by claudication. When diffuse arteriosclerosis exists with femoropopliteal blocks at multiple levels, the results have been far less sanguine. Unfortunately, these patients who have pain while at rest, ischemic ulcers, and gangrene are the ones who need help most. The arterial lesions of diabetes tend to be very diffuse in the small and medium-sized vessels of the viscera and extremities.