Infrainguinal Interventions Research Articles

OR9-3 | Endovascular Outcomes of Patients with Heart Failure Undergoing Non-Stent Infrainguinal Interventions from the XLPAD Registry

OR9-3 | Endovascular Outcomes of Patients with Heart Failure Undergoing Non-Stent Infrainguinal Interventions from the XLPAD Registry

Characteristics, Antithrombotic Patterns, and Prognostic Outcomes in Claudication and Critical Limb-Threatening Ischemia Undergoing Endovascular Therapy

Purpose: The underlying difference between intermittent claudication (IC) and critical limb-threatening ischemia (CLTI) still remains unclear. This prospective multicenter observational study aimed to clarify differences in clinical features and prognostic outcomes between IC and CLTI, and prognostic factors in patients undergoing endovascular therapy (EVT). Materials and Methods: A total of 692 patients with 808 limbs were enrolled from 20 institutions in Japan. The primary measurements were the 3-year rates of major adverse cardiovascular event (MACE) and reintervention. Results: Among patients, 79.0% had IC and 21.0% had CLTI. Patients with CLTI were more frequently women and more likely to have impaired functional status, undernutrition, comorbidities, hypercoagulation, hyperinflammation, distal artery disease, short single antiplatelet and long anticoagulation therapies, and late cilostazol than patients with IC. Aortoiliac and femoropopliteal diseases were dominant in patients with IC and infrapopliteal disease was dominant in patients with CLTI. Patients with CLTI underwent less frequently aortoiliac intervention and more frequently infrapopliteal intervention than patients with IC. Longitudinal change of ankle-brachial index (ABI) exhibited different patterns between IC and CLTI (pinteraction=0.002), but ABI improved after EVT both in IC and in CLTI (p<0.001), which was sustained over time. Dorsal and plantar skin perfusion pressure in CLTI showed a similar improvement pattern (pinteraction=0.181). Distribution of Rutherford category improved both in IC and in CLTI (each p<0.001). Three-year MACE rates were 20.4% and 42.3% and 3-year reintervention rates were 22.1% and 46.8% for patients with IC and CLTI, respectively (log-rank p<0.001). Elevated D-dimer (p=0.001), age (p=0.043), impaired functional status (p=0.018), and end-stage renal disease (p=0.019) were independently associated with MACE. After considering competing risks of death and major amputation for reintervention, elevated erythrocyte sedimentation rate (p=0.003) and infrainguinal intervention (p=0.002) were independently associated with reintervention. Patients with CLTI merely showed borderline significance for MACE (adjusted hazard ratio 1.700, 95% confidence interval 0.950–3.042, p=0.074) and reintervention (adjusted hazard ratio 1.976, 95% confidence interval 0.999–3.909, p=0.05). Conclusions: The CLTI is characterized not only by more systemic comorbidities and distal disease but also by more inflammatory coagulation disorder compared with IC. Also, CLTI has approximately twice MACE and reintervention rates than IC, and the underlying inflammatory coagulation disorder per se is associated with these outcomes. Clinical Impact The underlying difference between intermittent claudication (IC) and critical limb-threatening ischemia (CLTI) still remains unclear. This prospective multicenter observational study, JPASSION study found that CLTI was characterized not only by more systemic comorbidities and distal disease but also by more inflammatory coagulation disorder compared to IC. Also, CLTI had approximately twice major adverse cardiovascular event (MACE) and reintervention rates than IC. Intriguingly, the underlying inflammatory coagulation disorder per se was independently associated with MACE and reintervention. Further studies to clarify the role of anticoagulation and anti-inflammatory therapies will contribute to the development of post-interventional therapeutics in the context of peripheral artery disease.

Modified Two Wire Technique Using Fogarty Catheter in Antegrade Femoral Access.

Antegrade femoral access is a routinely used technique for infra-inguinal interventions. However, it can be challenging in cases of high femoral bifurcations, obliterative disease process and obese patients. A simple method of antegrade access using a Fogarty catheter and guide wires, under flouroscopic control is presented , which has lead to easy access in obliterative disease of SFA with minimal complications. We have done fourteen successful punctures using this technique over the past 6 months. In obese patients or patients with a pannus another assistant was used to pull the pannus back while doing the procedure. However, in two cases, while withdrawing the sheath into the CFA, there was inadvertent slippage of sheath outside the lumen of CFA. Immediate haemostasis was ensured by pulling the inflated Fogarty catheter backwards followed by manual compression before reintroducing the sheath inside the lumen. In both these cases, the patients were obese with a pannus and our puncture angle was more vertical which most probably led to this complication. However, post intervention results were satisfactory with no evidence of any pseudoaneurysm formation. This simple method allows to achieve antegrade SFA access in a safe and secure manner.

Factor Xa Inhibitor in Peripheral Revascularization: A Vascular Quality Initiative Analysis

Adding rivaroxaban to standard antiplatelet therapy has been shown to reduce mortality from cardiovascular causes, myocardial infarction (MI), stroke, and lower acute limb ischemia (ALI). To determine the generalizability of these results and assess the effects of adding a factor Xa inhibitor (FXI) to antiplatelet therapy in peripheral revascularization, an analysis was conducted with a large, multinational database. A retrospective cohort study of all patients undergoing infrainguinal interventions within the Vascular Quality Initiative from 2015 to 2020 was conducted. Patients prescribed single antiplatelet therapy (SAPT: aspirin or clopidogrel) or dual antiplatelet therapy (DAPT: aspirin and clopidogrel) combined with a FXI at discharge were compared with those on SAPT and DAPT alone. Outcomes were all-cause mortality, MI, major amputations, artery reintervention, target lesion revascularization, and ALI. A χ2 test of association was used for group comparisons. Propensity score matching, based on preoperative demographics, was used to generate uniform cohorts for analysis of the SAPT with FXI and DAPT groups. Overall all-cause mortality rates were significantly lower with the addition of a FXI to the SAPT or DAPT regimen compared with SAPT or DAPT alone; however, 30-day, 6-month, and 1-year analysis did not produce a similar pattern (Table I). FXI did not influence the rates of major amputations nor postoperative MI, but correlated with increased artery reintervention, target lesion revascularization, and ALI. There were 7288 patients from the DAPT and SAPT with FXI cohorts (14,576 total) who were identified via propensity score matching for further analysis of the most clinically applicable groups (Table II). Overall all-cause mortality was lower in SAPT with FXI compared with DAPT (11.67 vs 14.13; P < .0001), but there was no difference in 30-day, 6-month, and 1-year all-cause mortality. Rates of postoperative MI did not differ between the two groups. Compared with DAPT, SAPT with FXI correlated with lower rates of major amputation (2.11 vs 2.24; P < .0001), but was associated with increased artery reintervention, target lesion revascularization (intervention: 2.55 vs 1.45; P < .0001; surgery: 0.55 vs 0.38; P < .0001), and ALI (0.1 vs 0.07; P < .0001). Addition of a FXI correlated with decreased overall all-cause mortality and rates of major amputation but also with increased rates of target vessel or lesion reintervention and ALI in a large, multinational database. Further analysis is needed to investigate the real-world application of FXI in peripheral revascularization.Table IGroup comparisons of outcomesSAPTDAPTSAPT with FXIDAPT with FXIP value(n = 30,075)(n = 62,492)(n = 9074)(n = 2731)All-cause mortality Overall5097 (16.95)8984 (14.38)1060 (11.69)300 (10.98)<.0001 30 days342 (1.14)491 (0.79)98 (1.08)23 (0.84) 6 months1821 (6.06)2880 (4.61)509 (5.61)135 (4.95) 1 year2773 (9.22)4682 (7.49)757 (8.34)204 (7.48)Postoperative MI None18,876 (99.72)41,301 (99.58)8629 (99.53)2533 (99.37) Troponin only32 (0.17)81 (0.20)24 (0.28)9 (0.35) EKG or clinical21 (0.11)92 (0.22)17 (0.20)7 (0.27) Major amputation1202 (6.95)1879 (4.95)191 (5.59)59 (4.92)Artery reintervention None10,264 (84.26)23,254 (86.75)1786 (82.19)617 (79.31)<.0001 Interventional962 (8.18)2547 (9.50)289 (13.30)114 (15.65) Surgical521 (4.43)964 (3.60)90 (4.14)42 (5.40) Both15 (0.13)40 (0.15)8 (0.37)5 (0.64)Target lesion revascularization Intervention426 (2.46)1249 (3.29)220 (6.44)84 (7.00)<.0001 Surgery123 (0.71)300 (0.79)48 (1.41)28 (2.33)<.0001 Acute limb ischemia18 (0.10)45 (0.12)9 (0.26)4 (0.33)<.0001DAPT, Dual antiplatelet therapy; EKG, electrocardiogram; FXI, factor Xa inhibitor; MI, myocardial infarction; SAPT, single antiplatelet therapy.Values are number (%). Open table in a new tab Table IIPropensity-scored analysis of dual antiplatelet therapy (DAPT) vs single antiplatelet therapy (SAPT) with factor Xa inhibitor (FXI)DAPTSAPT with FXIP value(n = 7288)(n = 7288)All-cause mortality Overall1030 (14.13)850 (11.67)<.0001 30 days59 (0.81)79 (1.08).087 6 months380 (5.21)406 (5.57).3394 1 year605 (8.30)614 (8.43).7858Postoperative MI None5084 (99.59)6931 (99.55).0681 Troponin only6 (0.12)19 (0.27) EKG or clinical15 (0.29)12 (0.17) Major amputation163 (2.24)154 (2.11)<.0001Artery reintervention None2480 (34.03)1435 (19.69)<.0001 Interventional215 (2.95)240 (3.29) Surgical91 (1.25)77 (1.06) Both5 (0.07)8 (0.11) Unknown4497 (61.70)5528 (75.85)Target lesion revascularization Intervention106 (1.45)186 (2.55)<.0001 Surgery28 (0.38)40 (0.55)<.0001 Acute limb ischemia5 (0.07)7 (0.1)<.0001EKG, Electrocardiogram; MI, myocardial infarction.Values are number (%). Open table in a new tab

Predictors for Nonhome Patient Discharge following Lower Extremity Arterial Interventions

PurposeTo identify the variables associated with patient discharge disposition to optimize postprocedural care and discharge planning following lower extremity arterial interventions for peripheral artery disease (PAD). Materials and MethodsThe 2014–2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using current procedural terminology codes for endovascular infrainguinal interventions for PAD. The main outcome variable of interest was nonhome discharge. Covariates included patient sociodemographic variables, age quartile (upper quartile, ≥77 years), comorbidities (diabetes, renal disease, bleeding disorder, congestive heart failure [CHF], and chronic obstructive pulmonary disease), presence of an open wound before a procedure, type of procedure, operative time, symptom severity, American Society of Anesthesiologists class, and baseline functional status. Univariate analysis and multivariate logistic regression were performed on Stata/SE 15.1. ResultsA total of 3,190 patients met the inclusion criteria, of whom 664 (20.8%) had nonhome discharge. Multivariate regression revealed that age (odds ratio [OR], 1.9 for the upper age quartile [>77 years]; 95% confidence interval [CI], 1.46–2.50), operative time (OR, 1.2 per increase in quartile; 95% CI, 1.09–1.30), preoperative wound (OR, 1.5; 95% CI, 1.24–1.90), renal failure (OR, 1.7; 95% CI, 1.30–2.14), CHF (OR, 2.2; 95% CI, 1.51–3.24), symptom severity (OR, 1.7; 95% CI, 1.46–1.98), and independent functional status (OR, 0.74; 95% CI, 0.59–0.92; P = .007) were associated with nonhome discharge. All P values were ≤.001 unless otherwise stated. ConclusionsProlonged procedural time, the presence of preprocedural wound and patient comorbidities, symptomatology, and baseline functional status may be used to identify patients who will require a nonhome discharge and early discharge planning.

The Use of Paclitaxel-Coated Devices In The Treatment Of Peripheral Arterial Disease Is Not Associated With Increased Mortality Or Amputations

INTRODUCTION AND OBJECTIVES Strategies for the most effective treatment for peripheral arterial disease (PAD) remain controversial among clinicians. Several trials have shown improved primary patency of infrainguinal interventions with the utilization of paclitaxel-coated balloons or stents (DCBS) compared to conventional balloons or stents. However, a 2018 meta-analysis suggested an increased mortality risk for patients receiving DCBS, resulting in an international pause in the use of DCBS. A 2021 meta-analysis by the same group suggested an increased risk of major amputation following DCBS use in peripheral arterial revascularization procedures. Here we report our long-term institutional outcomes comparing uncoated devices to DCBS. METHODS We performed a retrospective review of all patients who underwent peripheral arterial angioplasty, stenting, atherectomy, or a combination between 2011 and 2020 within our regional healthcare system. Univariate and survival analyses were performed using standard statistical methods to assess the primary endpoints of overall survival, 5-year survival, and amputation-free survival. RESULTS A total of 2717 patients were identified, of whom 1965 were treated with conventional uncoated devices and 752 were treated with DCBS. Univariate analysis demonstrated longer survival time for patients receiving conventional angioplasty (20.9 months vs. 9.8 months, p<0.0001). However, log-rank test found no significant difference in overall survival probability (p=0.9375), 5-year survival probability (p=0.9876), and amputation-free survival (p=0.3310). Proportional hazards model found that patients using beta blockers or aspirin, or with dyslipidemia, prior coronary artery bypass graft (CABG), or hypercoagulability were at increased risk of mortality following treatment with paclitaxel or conventional devices. CONCLUSIONS DCBS are not associated with increased mortality or worse amputation-free survival in this real-world cohort of patients treated for PAD. Additionally, our data indicates that mortality is linked to pre-existing patient factors rather than type of device utilized. Strategies for the most effective treatment for peripheral arterial disease (PAD) remain controversial among clinicians. Several trials have shown improved primary patency of infrainguinal interventions with the utilization of paclitaxel-coated balloons or stents (DCBS) compared to conventional balloons or stents. However, a 2018 meta-analysis suggested an increased mortality risk for patients receiving DCBS, resulting in an international pause in the use of DCBS. A 2021 meta-analysis by the same group suggested an increased risk of major amputation following DCBS use in peripheral arterial revascularization procedures. Here we report our long-term institutional outcomes comparing uncoated devices to DCBS. We performed a retrospective review of all patients who underwent peripheral arterial angioplasty, stenting, atherectomy, or a combination between 2011 and 2020 within our regional healthcare system. Univariate and survival analyses were performed using standard statistical methods to assess the primary endpoints of overall survival, 5-year survival, and amputation-free survival. A total of 2717 patients were identified, of whom 1965 were treated with conventional uncoated devices and 752 were treated with DCBS. Univariate analysis demonstrated longer survival time for patients receiving conventional angioplasty (20.9 months vs. 9.8 months, p<0.0001). However, log-rank test found no significant difference in overall survival probability (p=0.9375), 5-year survival probability (p=0.9876), and amputation-free survival (p=0.3310). Proportional hazards model found that patients using beta blockers or aspirin, or with dyslipidemia, prior coronary artery bypass graft (CABG), or hypercoagulability were at increased risk of mortality following treatment with paclitaxel or conventional devices. DCBS are not associated with increased mortality or worse amputation-free survival in this real-world cohort of patients treated for PAD. Additionally, our data indicates that mortality is linked to pre-existing patient factors rather than type of device utilized.

Iliac Artery Calcification Burden is Associated With Adverse Cardiovascular Outcomes and Mortality After Infrainguinal Revascularization for Chronic Limb-threatening Ischemia

Coronary artery calcification has been shown to increase cardiovascular risk beyond that predicted by traditional Framingham risk factors. The purpose of this study was to determine whether the burden of iliac artery calcification is associated with adverse cardiovascular events and mortality following infrainguinal interventions for chronic limb-threatening ischemia (CLTI).

Abstract No. 490 Predictors for non-home patient discharge following lower extremity arterial interventions

To identify variables associated with patient discharge disposition in order to triage patients who may benefit from additional discharge planning resources and optimize post-procedure care after lower extremity arterial interventions for peripheral artery disease (PAD) The 2014 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using CPT codes for endovascular infrainguinal interventions for PAD. Patients were included if they were inpatients originally admitted from home. The main outcome variable of interest was non-home discharge (e.g., discharge to a skilled nursing or rehabilitation facility). Covariates included patient sociodemographic variables, age quartile (upper quartile ≥ 77 years), comorbidities (diabetes, renal disease, bleeding disorders, CHF, COPD), preprocedural wound, type of procedure, operative time, symptom severity, ASA class, and baseline functional status. Univariate analysis was performed using Fischer’s exact test or chi-squared test where appropriate. Multivariate logistic regression was performed on Stata SE 15.1. A total of 3190 patients met inclusion criteria, of which 664 (20.8%) had non-home discharge. Multivariate regression revealed that age (odds ratio [OR] 1.9 for the upper age quartile [ > 77 years], 95% confidence interval [CI] 1.46–2.50)), operative time (OR 1.2 per increase in quartile, 95% CI 1.09–1.30), preoperative wound (OR 1.5, 95% CI 1.24–1.90), renal failure (OR 1.7, 95% CI 1.30–2.14), congestive heart failure (OR 2.2, 95% CI 1.51–3.24), symptom severity (OR 1.7, 95% CI 1.46–1.98), and independent functional status (OR 0.74, 95% CI 0.59–0.92, P-value 0.007) were associated with non-home discharge. All P values were ≤ 0.001 unless otherwise stated. Patients who are age > 77 or have CHF, renal failure, preoperative wounds, severe symptoms, or prolonged operative time are more likely to require non-home discharge and may benefit from early discharge planning.

Endovascular 30-day Outcomes for Critical Limb Ischemia Are Improving in Recent Years Relative to Surgical Bypass Grafting

Data from 2011 to 2014 have shown lower extremity bypass (LEB) to outperform infrainguinal endovascular intervention (IEI) regarding major adverse limb events (MALEs) but noted no significant difference in major adverse cardiac events (MACE) in propensity matched cohorts. This study aimed to determine if more recent (2015-2018) endovascular outcomes data have improved compared to surgical bypass. The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients undergoing endovascular intervention for critical limb ischemia from 2015 to 2018. The cohort was categorized as being a LEB or IEI. Primary 30-day outcomes included MACE, MALEs, and major amputation. Univariate analyses were performed using the χ2 test and the Wilcoxon rank-sum test. Multivariate analysis was performed using inverse probability weights. A total of 13,200 patients were identified who underwent an infrainguinal intervention for CLI from 2015 to 2018: 7489 (56.7%) underwent LEB and 5711 (43.3%) underwent IEI. In this cohort, 37.6% were considered high anatomic risk, and 30.5% were considered high clinical risk. Median age was 68 years (interquartile range, 60-76 years). The IEI cohort versus the LEB cohort experienced a myocardial infarction/stroke rate of 2.3% versus 4.0% (P < .001), had a mortality rate of 2.5% versus 2.1% (P = .16), and a composite MACE of 4.3% versus 5.5% (P = .001). The reintervention rate for IEI versus LEB was 4.6% versus 5.5% (P = .01), loss of patency (no reintervention) rate was 1.7% versus 1.9% (P = .6), and major amputation rate was 5.0% versus 4.2% (P = .04), resulting in a composite MALE of 10.0% versus 9.6% (P = .46). When only high anatomic risk patients (IEI vs LEB) were considered (n = 4967), MACE was noted in 3.8% versus 5.2% (P = .02), MALE was noted in 12.2% versus 11.1% (P = .25) and amputation rates were 5.2% versus 4.9% (P = .53). When only high clinical risk patients were considered (n = 4019), MACE was experienced in 7.3% versus 9.9% (P = .003), MALE by 10.9% versus 10.3% (P = .54) and amputation by 5.6% versus 5.1% (P = .53). After inverse probability weighting, comparing the IEI to the reference LEB, MALE (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 0.94-1.20), MACE (AOR, 0.64; 95% CI, 0.54-0.76), and major amputation (AOR, 1.1; 95% CI, 0.95-1.3). Endovascular outcomes no longer demonstrate inferiority in MALE or major amputation. Endovascular intervention has a significantly reduced incidence of MACE. These results demonstrate an improvement in endovascular MACE, MALE and amputation rates in recent years relative to surgical bypass.

Dealing with complex external iliac artery disease

Interventional therapy has emerged as the preferred way to treat the majority of patients with iliac occlusive disease. As Henretta and colleagues1 have identified, however, the results of treating this problem with stenting of extensive external iliac disease are not as successful as treatment of common iliac disease, and the technique they have described may be a way to improve outcomes. Whereas the cause of this inferior patency may relate to the diameter of the external iliac artery or to an inability to achieve adequate expansion of stents, it is clear that increasingly surgeons are combining iliac intervention in this location with some form of outflow enhancement, whether it be common femoral endarterectomy alone or in conjunction with an infrainguinal intervention or bypass grafting.

Safety and feasibility of transradial infrainguinal peripheral arterial disease interventions

ObjectiveTransradial access (TRA) has traditionally been favored for coronary interventions. Tools with up to 200 cm length now allow operators to treat infrainguinal peripheral arterial disease (PAD) using TRA. This study aims to assess the safety and feasibility of TRA infrainguinal interventions. MethodsPatients with infrainguinal PAD who underwent intervention via TRA from July 2013 through June 2019 were retrospectively reviewed. Exclusion criteria included Barbeau D waveform, a radial artery diameter of greater than 2 mm, radial artery occlusion, Raynaud syndrome, or peripheral vasculitis. Procedural success (adequate inline flow to the foot), TRA alone failure (crossover or use of an additional access site), clinical success (defined as improvement in ankle brachial index, clinical symptoms, or wound healing) and adverse events were recorded from procedure notes and follow-up visits. ResultsThirty-six procedures were attempted using TRA in 32 patients (mean age, 65.8 years; range, 29-86; 22 male, 14 female) with mean height of 65.8 inches (range, 59.0-72.0 inches) and a body mass index of 28.7 (range, 19.1-43.9). Preprocedure Rutherford classification (II/III/IV/V/VI) was 8/15/2/7/4, respectively. The left radial artery was used for 35 of 36 procedures (97.2%). Treated vessels included the common femoral (n = 4), superficial femoral (n = 25), deep femoral (n = 1), popliteal (n = 10), tibioperoneal trunk (n = 2), tibial (n = 4), and plantar (n = 1) arteries. Interventions included angioplasty (n = 32, 100%), atherectomy (n = 8, 25%), and stenting (n = 13, 41%). Procedural success was 100%, the TRA alone failure rate was 11.1%, and clinical success was 89.3%. The median follow-up was 286.5 days (range, 0-919 days). Adverse events included radial artery pseudoaneurysm (n = 1), access site hematoma/bleeding (n = 3), radial artery occlusion (n = 1), groin hematoma (n = 1), popliteal artery dissection treated with stenting (n = 2), and a small superficial femoral artery perforation (n = 1) treated with prolonged balloon tamponade. No patients experienced signs of cerebrovascular events or distal embolism. ConclusionsTRA is a useful option for treating patients with PAD; however, several limitations still exist.

Standardisation of Technique and Volume of Iodinated Contrast Administration During Infrainguinal Angioplasty.

Acute Kidney injury is recognised to occur after administration of iodinated contrast during endovascular interventions for peripheral arterial disease. There are no standardised protocols for contrast delivery during infrainguinal angiography. The objective of this paper is to review published practice regarding the technique of conventional infrainguinal angiography and intervention, and describe a standard set of subtraction views, injection rates and contrast volumes for infrainguinal angioplasty. Database searches and review of papers containing (Angioplasty or Angiography) and ("lower limb" or peripheral or infrainguinal) and (method or technique or guidelines or protocol) was performed and defined procedures assessed. A small number of papers provided specific technical details relating to contrast volumes and angiography views. There was considerable variation from authors who have described the contrast volumes used for lower limb angiography. We describe our simple and consistent method. The precise pathophysiology of contrast related nephropathy is under scrutiny. There is interest in new technology to minimise contrast induced kidney injury. Few publications specify iodinated contrast doses, injection volumes or imaging views for infrainguinal arteriography. Standard infrainguinal angioplasty can be performed with conventional equipment using relatively small volumes of contrast by following a systematic technique.

Comparative Study between Contralateral and Ipsilateral Approaches in Endovascular Treatment of High Superficial Femoral Artery Lesions

Background: peripheral arterial disease (PAD) is defined as a slowly progressing, occlusive vascular disease of the extremities primarily due to atherosclerosis which can involve vasculitis and thrombosis. The incidence of PAD is increasing worldwide due to an overall increase in diabetes, obesity, and other cardiovascular disorders. Objective: the purpose of this study was to compare the outcomes, including the safety, of antegrade and retrograde puncture for SFA angioplasty access especially when lesion occurs in proximal part of SFA. The effect of these approaches upon procedure time and radiation dose was also assessed. Patients and Methods: a group of 40 consecutive patients (19 men, 21 women) were randomized for antegrade puncture or retrograde puncture of the common femoral artery. Following retrograde puncture the guidewire was turned’ and placed into the superficial femoral artery. The time for gaining access, screening time, radiation dose, and complications were recorded. Results: there was no significant difference in the time to achieve arterial access between the two groups but the retrograde puncture required a substantially longer screening time and resulted in a higher radiation dose than antegrade puncture. Conclusion: antegrade puncture is the standard means of obtaining access to the common femoral artery to carry out infrainguinal intervention. The antegrade approach has the advantage of permitting the use of shorter tools, and additional support for manipulating catheters and guidewires.

SU97EFFECT OF PHARMACOGENETICS-GUIDED ANTIDEPRESSANT TREATMENT ON SUICIDAL IDEATION

Infrainguinal revascularization for disabling claudication (DC) is frequently performed, but long-term results are still unknown. In this study, we compared clinical outcomes of infrainguinal endovascular (EV) and open interventions for DC after the failure of medical management.One hundred ninety-four patients with DC (Rutherford category 3) who had open (n = 53) or EV (n = 141) interventions were grouped as open–great saphenous vein (GSV) (n = 21), open-prosthetic (n = 32), EV-Trans-Atlantic Inter-Society Consensus II (TASC II) A and B (AB) (n = 48), and EV-TASC II C and D (CD) (n = 93). Patency, primary clinical success (PCS; sustained improvement in symptoms without reintervention), and secondary clinical success (SCS; sustained improvement in symptoms with reintervention) rates were compared.Mean follow-up was 57 ± 33 months. Five-year primary patency was 58% in open-GSV, 40% in open-prosthetic, 72% in EV-AB, and 38% in EV-CD (P < 0.001). Five-year secondary patency was 77% in open-GSV, 50% in open-prosthetic, 96% in EV-AB, and 61% in EV-CD (P < 0.001). Freedom from major adverse limb events was 73% in open-GSV, 77% in EV-AB, 70% in EV-CD, and 67% in open-prosthetic (P = 0.279). Five-year PCS was 46% in open-GSV, 40% in open-prosthetic, 57% in EV-AB, and 44% in EV-CD (P = 0.02). Five-year SCS was 78% in open-GSV, 78% in open-prosthetic, 85% in EV-AB, and 84% in EV-CD (P = 0.732). A total of 116 reinterventions were performed, 10 in 6 limbs (27%) in open-GSV, 18 in 12 limbs (36%) in open-prosthetic, 26 in 15 limbs (24%) in EV-AB, and 62 in 39 limbs (36%) in EV-CD. Reinterventions included 71 (61%) EV and 45 (39%) open procedures.Durability of infrainguinal interventions in claudicants depends mainly on anatomic complexity of disease. Good long-term clinical success can be achieved with both open and EV interventions, albeit with high reintervention rates, especially in patients with TASC II C and D disease. A considerable subset of EV patients will eventually require surgical revascularization to maintain clinical benefit. In this study, almost 20% of patients undergoing EV for TASC II C and D disease eventually required surgical bypass.

Early and mid-term results of surgical and endovascular intervention in total occlusion of superficial femoral artery: Which one is better?

Objectives: Lower extremity peripheral artery disease is a common and important type of systemic atherosclerosis. The purpose of this study is to compare safety and effectiveness of balloon angioplasty, primary stenting and femoropopliteal bypass to treat total superficial femoral artery (SFA) lesions. Methods: 181 consecutive limbs from 149 patients who underwent endovascularly or surgically infrainguinal interventions between June 2013 and June 2017 were included in this retrospective study. Seventy-four legs (40.2%) underwent femoropopliteal bypass surgery, 58 legs (31.5%) were treated with balloon angioplasty, and nitinol stents were used in 49 (23.9%) legs. Results: A total of 149 patients were treated; surgically 56 patients and endovascularly 45 + 40 patients. The mean follow-up time was 24 months (range 4–56 months). The patency rates were 86.7% in the angioplasty group, 82.5% in the stent group, and 94.6% in the bypass group at the end of 24 months (P = 0.159). The rate of reintervention was three patients in the bypass group, six patients in the angioplasty group, and seven patients in the stent group (P = 0.159). The mean reintervention time in bypass was 52.075 months, 43.467 months in balloon angioplasty, and 44.075 months in stent group. Conclusions: There was no significant difference between groups in terms of reintervention and patency rates.

Long-term Durability of Infrainguinal Endovascular and Open Revascularization for Disabling Claudication

Infrainguinal revascularization for disabling claudication (DC) is frequently performed, but long-term results are still unknown. In this study, we compared clinical outcomes of infrainguinal endovascular (EV) and open interventions for DC after the failure of medical management. One hundred ninety-four patients with DC (Rutherford category 3) who had open (n=53) or EV (n=141) interventions were grouped as open-great saphenous vein (GSV) (n=21), open-prosthetic (n=32), EV-Trans-Atlantic Inter-Society Consensus II (TASC II) A and B (AB) (n=48), and EV-TASC II C and D (CD) (n=93). Patency, primary clinical success (PCS; sustained improvement in symptoms without reintervention), and secondary clinical success (SCS; sustained improvement in symptoms with reintervention) rates were compared. Mean follow-up was 57±33months. Five-year primary patency was 58% in open-GSV, 40% in open-prosthetic, 72% in EV-AB, and 38% in EV-CD (P<0.001). Five-year secondary patency was 77% in open-GSV, 50% in open-prosthetic, 96% in EV-AB, and 61% in EV-CD (P<0.001). Freedom from major adverse limb events was 73% in open-GSV, 77% in EV-AB, 70% in EV-CD, and 67% in open-prosthetic (P=0.279). Five-year PCS was 46% in open-GSV, 40% in open-prosthetic, 57% in EV-AB, and 44% in EV-CD (P=0.02). Five-year SCS was 78% in open-GSV, 78% in open-prosthetic, 85% in EV-AB, and 84% in EV-CD (P=0.732). A total of 116 reinterventions were performed, 10 in 6 limbs (27%) in open-GSV, 18 in 12 limbs (36%) in open-prosthetic, 26 in 15 limbs (24%) in EV-AB, and 62 in 39 limbs (36%) in EV-CD. Reinterventions included 71 (61%) EV and 45 (39%) open procedures. Durability of infrainguinal interventions in claudicants depends mainly on anatomic complexity of disease. Good long-term clinical success can be achieved with both open and EV interventions, albeit with high reintervention rates, especially in patients with TASC II C and D disease. A considerable subset of EV patients will eventually require surgical revascularization to maintain clinical benefit. In this study, almost 20% of patients undergoing EV for TASC II C and D disease eventually required surgical bypass.

EMBOLIC PROTECTION USE DURING INFRAINGUINAL INTERVENTIONS: INSIGHTS FROM THE XLPAD MULTICENTER REGISTRY

Distal embolization during endovascular infrainguinal interventions is frequently encountered and requires additional therapy in 2-3% of cases. There are no uniform recommendations to the use of embolic protection devices (EPD) when treating the lower extremity arteries. It is unclear whether a

Mid-Term Outcomes of Stent Overlap in Long Total Occluded Lesions of Superficial Femoral Artery.

BackgroundSuperficial femoral artery chronic total occlusion (SCTO) is a common type of peripheral arterial disease (PAD). Endovascular therapy is a treatment approach that has a poor long-term success rate in this group. The aim of this study was to compare the mid-term results of two different uses of nitinol stents in long SCTO lesions (>100 mm): the use of one long stent or two shorter stents.Material/MethodsOf 154 patients who underwent percutaneous infrainguinal interventions from 2011 to 2014, a total of 170 CTO lesions were selected for this retrospective study analysis. The mean age of the study population was 63.4±10.4 years (range 29–89 years); 71.8% of the patients were male.ResultsPatients were divided into two groups according to the number of stents used. Patients treated with a single stent were placed into group A and patients treated with two stents were placed into group B. The stent fracture rate was significantly higher in group B compared to group A (29.2% vs. 42%). Type 1 and 2 fracture rates were higher in group A, but type 3 and 5 fracture rates were significantly higher in group B. The rate of stent restenosis was significantly higher in group B compared to group A (45.1% vs. 54.5%, p=0.05).ConclusionsMid-term patency rate was low in patients with long totally occluded superficial femoral artery (SFA) lesions. Using a long single stent had an acceptable mid-term patency rate compared to using a two stent strategy. Stent fracture seemed to be the main reason for in-stent restenosis in cases of multiple stenting. A long single stent strategy may be more appropriate and reasonable than a two stent strategy in the treatment of long SFA lesions.

3:27 PMAbstract No. 151 - Outcomes of infrainguinal interventions for critical limb ischemia and review of factors to predict limb salvage

3:27 PMAbstract No. 151 - Outcomes of infrainguinal interventions for critical limb ischemia and review of factors to predict limb salvage

Hybrid Common Femoral Artery Surgical Revascularization Associated to Endovascular Femoropopliteal Recanalization in High-Risk (ASA 3 - 4) Patients: A Seven-Year Period Institutional Experience

Objective: The present study was conceived to analyze the clinical benefit of hybrid interventions with surgical common femoral artery (CFA) reconstruction coupled to superficial femoral/popliteal endovascular recanalization for severe infrainguinal multilevel occlusive disease in high-risk ASA Class 3 - 4 patients. Material and Methods: From August 2008 until May 2015, a series of 143 hybrid infrainguinal interventions in 124 ASA Class 3 - 4 patients were performed in our department for Rutherford category 2 - 6 ischemic presentations. Patient demographics, specific risk factors, technical characteristics and patency results were retrospectively examined during a mean 36.8 months of follow-up. In a majority of 94 limbs (65%), the endovascular stage of interventions focused on long (>15 cm) femoropopliteal occlusions in parallel to regular CFA surgical revascularization. Two or three runoff tibial trunks were evinced in 84% cases, while one or none permeable vessel was found in 23 (16%) limbs. Results: Inasmuch surgical approach was successful in all cases, the endovascular stage was technically profitable in 134 (93%) cases. The ABI posto-peratively improved (>1.5) in 73% of cases, while clinical presentation gained at least one Rutherford category in 89% limbs. The mean hospital stay was 6.1 days (3 - 12 days) whereas the 30-day mortality rate in this homogeneous “high-risk” group of patients was 3.2%. Global risk factors alike age (>70 years/p = 0.0005), smoking ((p = 0.0170) and female gender (p = 0.0111), together with CTOs length (>15 cm/(p = 0.0470), severe calcifications (p = 0.0001), poor tibial runoff (p = 0.0001), TASC “C” and “D” lesions (p = 0.360 and (p = 0.0394), the stent number ((n = 3) and length (>6 cm) ((p = 0.0039 and (p = 0.0003) and the initial ABI scoring ((p = 0.0051) showed statistical negative influence on primary patency. Conclusion: Hybrid infrainguinal revascularization may afford useful results in selected ASA “high risk” patients, owning low invasiveness, reproducibility and acceptable patency in return to punctual postoperative surveillance.