Femoropopliteal Occlusive Disease Research Articles

Repeat Angioplasty and Stenting for Femoropopliteal Occlusive Disease: Factors Affecting Outcomes of the Second-Time Endovascular Intervention

Introduction: Repeat percutaneous interventions for femoropopliteal occlusive disease are common, but the outcomes are poorly understood. We sought to determine the results of second-time femoropopliteal percutaneous transluminal angioplasty/stenting (SPTAS) and identify factors associated with outcome. Methods: A retrospective review of patients undergoing multiple percutaneous lower extremity procedures at a single institution from 2002 and 2007 identified 73 SPTAS in 73 limbs. Patient comorbidities, anatomic, and procedural characteristics were analyzed with respect to outcomes with descriptive statistics, life-table analysis, and Cox proportional hazards modeling. Patency rates were determined from the time of SPTAS. Results: Patients included 39 men (64%) and 22 women (36%) at a mean age of 70 ± 10 years. Indications included claudication in 56 limbs (77%) and critical limb ischemia in 17 (23%). Median time from the initial endoluminal intervention to SPTAS was 322 days. Twenty limbs (27%) had TransAtlantic Inter-Society Consensus II (TASCII) category D lesions; the rest were treated for TASCII A, B, and C disease. Technical success was achieved in 72 patients (99%) and initial clinical improvement in 64 (89%). During a mean follow-up of 15.3 months, 2-year primary patency, assisted primary patency, secondary patency, limb salvage, and survival were, respectively, 66% ± 8%, 86% ± 4%, 86% ± 4%, 97%, and 89%. Cox proportional hazard modeling showed that SPTAS ≤180 days of the initial endovascular intervention was the only significant predictor of failure of SPTAS primary patency (hazard ratio, 3.5; 95% confidence interval, 1.1-11). TASCII D classification was associated with failure of assisted primary and secondary patency. Conclusions: Second-time femoropopliteal angioplasty/stenting has excellent initial success but limited midterm primary patency. The need for early SPTAS is highly associated with failure of primary patency and the need for additional interventions. With vigilance, good midterm assisted primary and secondary patency in those with limited extent of disease as well as excellent limb salvage can be achieved.

Operative management of multilevel iliofemoral occlusive disease

The current trend is to treat both inflow and outflow occlusive disease using endovascular procedures either simultaneously or in a staged procedure. The long-term benefits of a combined one-stage approach are not available. The main objectives are to investigate the risks and long-term benefits of a combined one-stage approach using endovascular techniques for iliac occlusive disease and bypass for femoropopliteal occlusive disease. Fifty-three patients with limb ischemia underwent combined ilial stenting and distal bypass. Complications included minor wound problems in nine patients, atrial fibrillations in one patient, acute graft occlusion in one patient, toe amputation in two patients and one death. During a follow-up period of up to 96 months, eight patients required repeat distal bypass, five patients underwent revascularization on contralateral sides and four patients had repeat endovascular procedures. These results suggest that there are few risks with a combined endovascular procedure for iliac occlusion and bypass for femoropopliteal occlusive disease. Long-term complications with the combined approach included repeat distal bypass, revascularization on contralateral sides and repeat endovascular procedure.

Atherosclerotic Peripheral Vascular Disease Symposium II

Peripheral vascular diseases are important components of cardiovascular medicine. The high prevalence of these disorders in the clinical setting mandates effective communication among healthcare providers. The public health significance of these conditions requires clear and consistent terminology for community audiences. Therefore, the goal of this writing group was to suggest definitions, usage, and nomenclature of specific terms commonly used to describe vascular diseases by cardiovascular specialists and primary care communities. The need for clarity is driven by 2 major challenges: (1) the need for use of common keywords for literature searches; and (2) the need for healthcare professionals to use common, reasoned terminology when communicating with each other and with the public. The major structural components of the vascular system are the veins, lymphatic vessels, and arteries. These serve as the basis of the nomenclature system for vascular diseases (Figure). Figure. Major classification of vascular diseases. *Includes inflammatory, artery dysplasias, congenital, traumatic, and infections. In this report, the writing group focuses only on nomenclature that applies to non–coronary artery diseases. Venous and lymphatic diseases were outside the scope of this conference. Diseases of arteries are classified further into atherosclerotic occlusive disorders, nonatherosclerotic occlusive disorders, and aneurysms. …

Peripheral arterial disease affects kinematics during walking

Claudication is the most common manifestation of peripheral arterial disease (PAD) producing significant ambulatory compromise. The purpose of this study was to use advanced biomechanical analysis to characterize the kinematic ambulatory pattern of claudicating patients. We hypothesized that compared with control subjects, claudicating patients have altered kinematic gait patterns that can be fully characterized utilizing advanced biomechanical analysis. The study examined fourteen PAD patients (age: 58 +/- 3.4 years; weight: 80.99 +/- 15.64 kg) with clinically diagnosed femoro-popliteal occlusive disease (Ankle Brachial Index (ABI): 0.56 +/- 0.03, range 0.45 to 0.65) and five healthy controls (age: 53 +/- 3.4 years; weight: 87.38 +/- 12.75 kg; ABI >or= 1). Kinematic parameters (hip, knee, and ankle joint angles in the sagittal plane) were evaluated during gait in patients before and after the onset of claudication pain and compared with healthy controls. Joint angles were calculated during stance time. Dependent variables were assessed (maximum and minimum flexion and extension angles and ranges of motion) and mean ensemble curves were generated. Time to occurrence of the discrete variables was also identified. Significantly greater ankle plantar flexion in early stance and ankle range of motion during stance was observed in PAD patients (P < .05). Time to maximum ankle plantar flexion was shorter and time to maximum ankle dorsiflexion was longer in PAD patients (P < .05). These differences were noted when comparing PAD patients prior to and after the onset of claudication with healthy controls. The analysis of the kinematic parameters of the knee and the hip joints revealed no significant differences between PAD patients and controls. PAD patients with claudication demonstrate significant gait alterations in the ankle joint that are present prior to the onset of claudication pain. In contrast, the joint motion of the hip and knee did not differ in PAD patients when compared with controls. Further research is needed to verify our findings and assess the impact of more proximal disease in PAD patients as well as the effect of revascularization on joint kinematics.

Outcomes of endovascular interventions for TASC II B and C femoropopliteal lesions

To evaluate outcomes of endovascular interventions on femoropopliteal occlusive disease and determine predictors of restenosis of Trans Atlantic Inter-Societal Consensus (TASC) II B and C lesions. All patients undergoing endovascular interventions for femoropopliteal occlusive disease between May 2003 and July 2007 were reviewed. Patient demographics, pre- and post-procedure ankle-brachial indices (ABI), and anatomic factors (including categorization by TASC II classification, lesion length, and runoff vessel status) were analyzed. Outcomes evaluated included freedom from restenoses, freedom from re-intervention, overall patency, and assisted-patency. A total of 237 total limbs were treated during the period reviewed. The study group included 108 TASC B and 32 TASC C limbs in 125 patients (mean age 73.1 +/- 10.4 years, male sex: 59%). Seventy-one percent of patients were Rutherford classification 2/3 while the remaining 29% were Rutherford classification 4/5. Mean follow-up period was 12.7 months (range, 1-52 m). Forty-one (41) limbs experienced restenosis or occlusion at a mean time of 8 months (range, 1-24 m). Freedom from restenosis/occlusion was 58.9% at 12 months and 47.9% at 24 months. Predictors of restenosis included a preoperative ABI <0.5 (hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.36-6.86, P = .007) and hypercholesterolemia (HR 2.42, 95% CI 1.11-5.25, P = .025). Lesion length as a continuous variable (per centimeter) also correlated with a higher risk of restenosis (HR 1.06, 95% CI 1.00-1.12, P = .057). The overall assisted-primary and secondary-patency rates were 87% and 94% respectively at 3 years with no significant differences between TASC B and TASC C limbs. Endovascular interventions for TASC II B and C lesions are associated with restenosis/occlusion rates that are at least as good as those of open femoropopliteal bypass surgery from historical, previously published series. Furthermore, overall assisted-patency rates are excellent, although low preoperative ABIs continue to be associated with worse outcomes.

The Evidence for Stenting in Femoropopliteal Occlusive Disease

The Evidence for Stenting in Femoropopliteal Occlusive Disease

Periodontitis May Increase the Risk of Peripheral Arterial Disease

The aim of this case control study was to evaluate whether periodontitis was associated with peripheral arterial disease (PAD). Twenty-five patients diagnosed with aorto-iliac and/or femoro-popliteal occlusive disease and thirty-two generally healthy control subjects were enrolled in this study. Polymerase chain reaction (PCR) was used to identify Porphyromonas gingivalis, Treponema denticola, Actinobacillus actinomycetemcomitans, Prevotella intermedia, Cytomegalovirus (CMV), Chlamydia pneumoniae, and Helicobacter pylori in tissue specimens taken from the anastomotic site of distal bypasses. Periodontal status was evaluated; serum IgG titres against the four listed bacteria were measured. Periodontopathic bacteria were detected in 13/25 (52%) atherosclerotic specimens. CMV or C. pneumoniae was detected in 1/25 (4%) specimens; H. pylori was not detected from any of these specimens. Fontaine grade III or IV patients showed higher detection frequency of P. gingivalis than Fontaine grade II patients (57.1% vs 22.2%, P=0.09). After adjusting for age, gender, diabetes and smoking, periodontitis increased 5-fold the risk of having PAD (OR 5.45). There were preliminary indications that periodontitis was associated with increased serum IL-6 and TNF-alpha concentrations. This study suggests that periodontitis may be associated with an increased risk of PAD. This association could result from the increased concentration of serum inflammatory cytokines in those with periodontitis.

Peripheral arterial disease affects ground reaction forces during walking

Claudication is the most common manifestation of peripheral arterial disease (PAD), producing significant ambulatory compromise. The gait of claudicating patients has been evaluated using primarily temporal and spatial parameters. With the present study, we used advanced biomechanical measures to further delineate the ambulatory impairment of claudicating patients. We hypothesized that the claudicating legs of PAD patients have an altered kinetic gait pattern compared with normal legs from control subjects. Ambulation kinetics (ground reaction forces) were evaluated in claudicating patients and compared with age-matched healthy controls. Forces were analyzed in the vertical, anterior-posterior, and medial-lateral directions. Time from heel touch-down to toe-off (stance time) and time spent in double-limb support were also evaluated. The study recruited 14 PAD patients (age, 58 +/- 3.4 years; weight, 80.99 +/- 15.64 kg) with femoropopliteal occlusive disease (ankle-brachial index [ABI], 0.56 +/- 0.03) and five controls (age, 53 +/- 3.4 years; weight, 87.38 +/- 12.75 kg; ABI, >or=1.00). Vertical force curve evaluation demonstrated significant flattening in claudicating patients resulting in a lower and less fluctuant center of mass when ambulating. In the anterior-posterior direction, claudicating patients demonstrated significantly decreased propulsion forces. In the medial-lateral direction, they had significantly increased forces consistent with wider steps and an inability to swing their legs straight through. Claudicating patients demonstrated a greater stance time and time in double limb support compared with healthy controls. Most importantly, gait abnormalities were present before the onset of claudication, with gait worsening after the onset of claudication. Claudicating patients demonstrate significant gait impairments that are present even before they experience any limb discomfort. These alterations may make them feel more stable and secure while attempting to minimize use of the affected limb. Advanced biomechanical analysis, using ambulation kinetics, permits objective and quantitative evaluation of the gaits of claudicating patients. Such evaluation may point to new rehabilitation strategies and provide objective measurement of functional outcomes after medical and surgical therapy.

Open versus endovascular treatment of complex femoropopliteal occlusive disease

METHODS: From 2003 2006, open and endovascular (TASC C and D) cases of femoropopliteal revascularization were retrospectively reviewed. Clinical and demographic variables were collected. Hospital cost associated with the index procedure was obtained from an administrative database. Data was analyzed with multivariate techniques. RESULTS: 294 cases were identified (183 open, 111 endovascular: 92 TASC C, 19 TASC D). The mean follow-up was 553 / 20 days. Patency probability for open revascularization was greater than endovascular at 12 months. (73 / 3.5% versus 53 / 5%, P 0.05) Hospital stay was longer in the open group (6.6 / 0.5 days versus 2.7 / 0.4 days, P 0.001). Total hospital cost was higher in the open surgical group compared to the endovascular group ($13,890 / 1364 versus $8,783 / 713, P 0.001). However, there was no significant difference in the cost per day of patency between the two groups (Open $125 / 24/day versus Endovascular $339 / 153/day).

Endovascular treatment of long lesions of the superficial femoral artery: Results from a multicenter registry of a spiral, covered polytetrafluoroethylene stent

Information on outcome of patients with long superficial femoral artery (SFA) obstruction undergoing endovascular treatment is scarce. The present study reports results from a prospective multicenter registry designed to evaluate the safety, effectiveness, and patency of the aSpire self-expanding polytetrafluoroethylene covered stent (Vascular Architects Inc, San Jose, Calif) in patients with femoropopliteal occlusive disease. The aSpire Registry included 150 patients (166 limbs) enrolled in 16 centers during a 28-month period (2003 to 2005) for medium/long (>3 cm) occlusion (n = 115) or stenosis (n = 51) of the SFA (n = 51) or of the proximal popliteal (n = 115) arteries. Procedures were performed for intermittent claudication in 92, for rest pain in 33, and for limb savage in 41. The mean length of arterial segment covered was 107.35 +/- 73.7 mm. Indications for treatment included 44 type B1, 57 type B2, 47 type C1, and 18 type D lesions according to TransAtlantic Inter-Society Consensus classification. Clinical and ultrasound evaluation was performed at discharge and at 1, 6, 12 months, and yearly thereafter. Mean follow-up was 13 months (range, 1 to 36). Primary end points were immediate technical success (vessel recanalization with residual stenosis < or =30%) and stent patency. Initial technical success was obtained in 162 (97.6%) of 166 procedures. More than one stent was applied in 48 procedures, for a total of 214 stents. No periprocedural deaths occurred. Procedure-related complications occurred in 22 of 166 procedures, including 6 peripheral embolizations, 7 thromboses, 2 hemorrhages requiring revision, 1 vessel rupture, and 6 vessel dissections. Life-table estimates of primary patency at 12, 24, and 36 months were 64%, 59%, and 59%, respectively. Thirty-two reinterventions were performed during follow-up, resulting in secondary patency rates at 12, 24, and 36 months of 74.2%, 67%, and 67%, respectively. Amputation was required in six of 41 patients treated for limb salvage. At multivariate analysis, critical limb ischemia was the only significant predictor of late failure. Endovascular treatment of SFA occlusive lesions provides interesting results. Length of lesion and clinical symptoms influence negatively the patency. The aSpire covered stent showed good mid-term results, but a number of reinterventions were necessary to obtain an optimal secondary patency. Risk of patency failure was related to critical limb ischemia as an indication for the procedure. Technologic and pharmacologic improvement and longer follow-up are needed to define the indications for the aSpire stent.

Advances in Endovascular Treatment of Femoropopliteal Arterial Occlusive Disease

Over the past decade, accumulated experience and considerable advances in percutaneous endovascular techniques have enabled their use with increasing frequency for the management of peripheral arterial occlusive disease. However, despite the established role of endoluminal approaches in many other arterial territories, their application for the treatment of femoropopliteal occlusive disease is still debatable due to unique unfavorable anatomical, functional, and flow characteristics of this area. Conventional balloon angioplasty in the femoral and popliteal arteries is frequently associated with suboptimal results and high restenosis rates. To overcome these limitations, emerging approaches have been introduced or are currently under investigation. These include angioplasty modifications, newer concepts in stent design, adjunctive pharmacotherapy, debulking devices, and the application of gamma radiation and freezing in an attempt to reduce intimal hyperplastic response and consequently to expand the application of minimal invasive techniques in the hostile femoropopliteal environment. This review article will present the current status and future trends of endovascular therapy of femoropopliteal artery occlusive disease.

Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: A contemporary series

Percutaneous endovascular therapy is becoming a primary option for managing infrainguinal occlusive disease. This study examined the results of femoropopliteal percutaneous transluminal angioplasty (PTA) with intermediate (mean, 24 months) follow-up in a contemporary series of patients presenting with critical limb ischemia or claudication. Femoropopliteal PTA was performed on 238 consecutive limbs (208 patients) from January 2002 to July 2004. Study end points, including primary patency, assisted patency, and limb salvage (Society of Vascular Surgery reporting standards), were assessed by Kaplan-Meier life-table analysis, and factors predictive of hemodynamic or clinical failure, or both, were evaluated by univariate and multivariate methods. Clinical and demographic features included a mean age, 72 years; male (62%); critical limb ischemia (46%); diabetes mellitus (49%); and renal insufficiency (creatinine >or= 1.5 mg/dL) (29%). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A (11%), B (43%), C (41%), and D (5%). PTA was confined to the femoropopliteal segment in 77 patients (33%), and 161 (67%) underwent concurrent interventions in other anatomic locations. Femoropopliteal interventions included angioplasty only in 183 (78%), and the remaining 53 (22%) received at least one stent. Technical success was achieved in 97% of patients, with no deaths and a major morbidity rate of 3%. The 36-month actuarial primary patency was 54.3%, and assisted patency was 92.6% (37 peripheral reinterventions), resulting in a limb preservation rate of 95.4% in all patients regardless of clinical presentation. Interval conversion to bypass surgery occurred in 19 patients (8%). Comparison between critical limb ischemia and claudication revealed a primary patency of 40.8% vs 64.8%, assisted patency of 93.8% vs 92.6%, and limb salvage of 89.7% vs 100%, respectively. Negative predictors of primary patency determined by multivariate analysis included history of congestive heart failure (P = .02) and TASC C/D (P = .02). However, further evaluation of TASC C/D vs A/B revealed an assisted patency of 89.7% vs 94.3% (P = .37) and limb salvage of 94.3% vs 96.4% (P = .58). Femoropopliteal PTA can be performed with a low perioperative morbidity and mortality. Intermediate primary patency is directly related to TASC classification. Although secondary intervention is often necessary to maintain patency in TASC C/D lesions, these data suggest that it would be appropriate to use PTA as initial therapy for chronic femoropopliteal occlusive disease regardless of clinical classification at presentation or TASC category of lesion severity.

Transluminal Stenting for Femoropopliteal Occlusive Disease: Analysis of Restenosis by Serial Arteriography

Our objective was to evaluate restenosis after stenting of femoropopliteal occlusions and the impact of percutaneous transluminal angioplasty (PTA) on recurrent stenosis. We used a retrospective analysis of contrast angiograms obtained during follow-up of stented limbs. Subjects included 27 claudicants (34 limbs) who had complete superficial femoral artery occlusion treated with PTA and Wallstents at the Veterans Adminstration Medical Center. During follow-up, 31 PTAs, three thrombolytic treatments, and one additional stenting were performed. Outcome was measured by contrast angiography. Primary patency at 1 and 3 years was 38% and 8% after stenting, and secondary patency (PTA required at least once in 21/34 limbs) was 89% and 55%, respectively. PTA performed during follow-up reduced within-stent restenosis on average from 48.3 +/- 13.6% to 22.8 +/- 18.0%. Recurrent stenosis after PTA measured 14.9 +/- 10.9 months later was 46.8 +/- 16.7%, showing little permanent impact of PTA on stenosis. Severe within-stent stenosis develops commonly after initial stenting of complete femoropopliteal occlusions. Supplemental PTA performed during follow-up provides immediate improvement in lumen diameter, but severe restenosis is still likely to recur.

Aortofemoral bypass and the role of concomitant femorodistal reconstruction.

A consecutive series of 200 patients having aortofemoral bypass grafts were studied in order to determine the effect of femoropopliteal occlusive disease on the results and the role of concomitant femorodistal bypass. Bifurcated aortic grafts were used in 177 patients and unilateral aortofemoral grafts in 23 giving 377 limbs for study. Of the 377 limbs, 184 (49 per cent) had minimal femoropopliteal disease (Group 1), 24 (6.4 per cent) had a femoropopliteal stenosis (Group 2) and 169 (44.6 per cent) had complete femoropopliteal occlusion (Group 3). In Group 3 aortofemoral bypass was carried out alone in 106 cases (Group 3a): in the other 63 cases femorodistal bypass was carried out at the same time as aortoiliac reconstruction (Group 3b). The cumulative patency at 5 years for all aortofemoral grafts together was 91 per cent. However, that for grafts in Group 3a was only 65 per cent compared with 98 per cent for Groups 1 and 3b and 94 per cent for Group 2. The cumulative patency rate for grafts in Group 3a was significantly lower than for all other groups (P less than 0.001). The operative mortality for those patients who had concomitant aortofemoral and femorodistal grafts (Group 3b) did not differ significantly from that of any of the other groups (P greater than 0.1). Of the cases in Group 3a, 21 (26 per cent) required femoropopliteal reconstruction at a later date. The results indicate that in the presence of combined aortoiliac and femoropopliteal occlusive disease concomitant reconstruction of both arterial segments yields significantly better results than aortoiliac bypass alone.

Muscle blood-flow following insertion of a by-pass vein-graft in femoropopliteal occlusive disease.

Abstract Muscle blood-flow has been measured by the local clearance of 133Xe in 32 patients (34 limbs) following arterial replacement with a by-pass vein-graft for atherosclerotic occlusive disease affecting the femoropopliteal segment. In 27 cases (29 limbs) in which the graft was functioning satisfactorily there was a marked improvement in muscle blood-flow with a return to within normal range in most instances. In 5 patients the graft occluded within 3 months of operation and in these cases there was no significant alteration in the muscle blood-flow following operation. The measurement of muscle blood-flow therefore provided objective corroborative evidence of the success or failure of the procedure. Seventeen of the group had muscle blood-flow measurements carried out at 3-monthly intervals for a year or more after operation. The postoperative flow tended to remain stable throughout this period, and did not show any tendency to return to the preoperative levels as has previously been reported for thrombo-endarterectomy. This lends further support for the view that in reconstructive surgery for femoropopliteal occlusive disease the long-term results are better with by-pass vein-grafts than with thrombo-endarterectomy.

Multi Centre Study to Assess the Feasibility of a New Covered Stent and Delivery System in Combination with Remote Superficial Femoral Artery Endarterectomy (RSFAE)

Objectives To evaluate the feasibility and efficacy of an innovative new covered stent and adjustable deployment system (aSpire™ Covered Stent, Vascular Architects Inc., San Jose, CA, USA) in combination with remote superficial femoral artery endarterectomy (RSFAE) for the treatment of long segment femoropopliteal occlusive disease. Design Prospective multi-centre trial. Materials and methods Sixty-two limbs in 61 patients (41 men; median age 69 years, range 40–88) with severe disabling claudication ( n=56) or critical limb ischaemia ( n=6) were treated in five European centres with aSpire stenting after RSFAE for long segment occlusions (mean length 25 cm). Follow-up was by duplex scanning at 1-, 6-, 12- and 18-months. Primary, primary-assisted and secondary patency rates were analysed. Results The median follow-up was 17 (range 2–34) months. A mean of 1.3 stents (range 1–3) were deployed with a median stent diameter of 7 mm (range 6–9). There were one early and 24 late failures. At 18-months the cumulative primary, primary-assisted and secondary patency rates were 60, 70 and 72%, respectively. There were no device related adverse events, such as kinking or fracturing and no stent migrations. Conclusions The aSpire stent and the delivery system are both safe and feasible in combination with RSFAE. The mid term follow-up appears favourable in view of the long segment occlusions treated. Further follow-up is required to compare the mid- and long-term outcomes with current stents and conventional femoropopliteal bypass.

Hemobahn Stent-Grafts for Treatment of Femoropopliteal Arterial Obstructions: Midterm Results of a Prospective Trial

To report a prospective study to evaluate safety, effectiveness, and midterm patency of self-expanding stent-grafts in patients with femoropopliteal occlusive disease. Sixty-three Hemobahn stent-grafts were used in 52 patients for treatment of medium- or long-segment (>3 cm) occlusions (82.7%) and stenoses (17.3%) of the femoropopliteal artery. The mean length of vessel segments covered was 10.9 cm +/- 5.13. Follow-up with documentation of clinical symptoms, assessment of Rutherford clinical stage of peripheral vascular disease, and color-coded duplex sonography was performed at discharge, at 1, 3, 6, 12, 18, and 24 months after implantation, and yearly thereafter. Mean follow-up duration was 23.8 months +/- 6.9 (range, 8-36 mo). Follow-up data at 12 and 24 months after treatment were available for 47 of 52 (90.4%) and 31 of 52 patients (59.6%), respectively. Device implantation was technically successful in all 52 patients, yielding an overall technical success rate of 100%. Procedure-related complications were observed in 12 of 52 patients (23.1%) and consisted of distal embolization (n = 4, 7.7%), minor groin hematoma (n = 7, 13.5%), and arteriovenous fistula (n = 1, 1.9%), but prolonged hospitalization and further medical, interventional, or surgical measures were not required. Stent-graft placement induced an initial improvement of the mean resting ankle-brachial index from 0.54 +/- 0.12 to 0.89 +/- 0.14 (P <.01). Primary patency rates at 12 and 24 months were 78.4% +/- 5.8 and 74.1% +/- 6.2, respectively. Primary assisted patency rates were 82.4% +/- 5.3 at 12 months and 80.3% +/- 5.6 at 24 months. Secondary patency rates at 12 and 24 months were 88.3% +/- 4.5 and 83.2% +/- 5.5, respectively. There was no significant difference (log-rank test, P >.3) between primary patency rates in patients grouped according to lengths of implanted grafts (ie, length of the treated lesions). Endovascular placement of Hemobahn stent-grafts for percutaneous treatment of medium- to long-segment high-grade stenoses and occlusions of the femoropopliteal artery is a safe procedure with excellent initial success rates and promising midterm results.

Infrainguinal Bypass Grafting Using Lyophilized Saphenous Vein Allografts for Limb Salvage

Critical ischemia in patients with extensive femoropopliteal occlusive disease often ends in amputation in the absence of a suitable autologous vein for reconstruction. Cryopreserved vascular allografts have been used as an alternative conduit with poor results. Antigenicity and rejection are assumed to account for graft failure. Lyophilized vessels have demonstrated patency and structural integrity in the vascular system in our previous experimental studies. We report four patients that underwent femorodistal bypass grafting with lyophilized saphenous veins who lacked usable autologous vein for arterial reconstruction. Early graft thrombosis occurred in three patients who required major amputations. Duplex scans for graft surveillance did not reveal previous significant abnormalities. These cases demonstrate that the clinical use of lyophilized venous allografts for infrainguinal arterial reconstructions failed to yield satisfactory patency and limb salvage. Lyophilized veins therefore are not useful alternative conduits in patients with critical ischemia and no suitable autologous vein grafts.

Femoropopliteal occlusive disease: diagnosis, indications for treatment, and results of interventional therapy.

The relative role of percutaneous therapy versus bypass surgery for femoropopliteal occlusive disease (FPD) represents an area of great controversy in the field of vascular medicine. This controversy is complicated by the very dynamic therapeutic options that continue to be introduced, particularly on the endovascular side. The purpose of this review is to provide an overview of the current diagnostic modalities available to characterize the level and degree of vascular insufficiency and summarize the currently available endovascular therapeutic options with their clinical role and outcomes. Finally, future therapeutic advances that will soon be evaluated in clinical trials will be discussed.

Comparative parallel group study of bypass surgery versus endovascular approach in aorto-iliac and femoro-popliteal occlusive disease in a tertiary referral centre. Does the introduction of peripheral angioplasty increase the workload and improve the 30-day outcome?

PTA managed higher risk patients with lower morbidity where bypass surgery used to be deferred. The cost and economic implications of introducing PTA must be viewed according to the changing face of vascular surgery. We recommend trials using Quality Adjusted Life Year measurement to determine short and long term outcome.