Lifestyle-limiting Claudication Research Articles

Directional Atherectomy With Antirestenotic Therapy vs Drug-Coated Balloon Angioplasty Alone for Common Femoral Artery Atherosclerotic Disease

Purpose: To report an experience using directional atherectomy (DA) with antirestenotic therapy (DAART) in the form of drug-coated balloon (DCB) angioplasty vs DCB angioplasty alone in common femoral artery (CFA) occlusive lesions. Methods: A retrospective review was conducted of 47 consecutive patients (mean age 71 years; 26 men) treated between October 2011 and July 2016 using either DCB angioplasty alone (n=26) or DAART (n=21) for CFA lesions. The majority of patients had lifestyle-limiting claudication (14 DCB and 15 DAART). Mean lesion length (39±14 mm DCB and 34±16 mm DAART) and vessel calcification (17/26 DCB and 11/21 DAART) were comparable between the groups. There were 4 chronic total occlusions, all in the DAART group. The main outcome measure was primary patency. Key secondary outcomes were technical success, secondary patency, and freedom from clinically-driven target lesion revascularization (TLR). Results: Technical success rates were 89% following DCB angioplasty and 95% for DAART (p=0.41). The 88% 12-month primary patency and 89% freedom from TLR for DAART were higher than the 68% and 75% estimates following DCB angioplasty alone, but neither difference was statistically significant. However, the secondary patency estimate at 12 months was significantly higher in the DAART group (100% vs 81% for DCB, p=0.03). Bailout stenting (1 DCB vs 1 DAART), vessel perforation (1 DCB vs 0 DAART), access site complications (4 DCB vs 3 DAART), and distal embolization (0 DCB vs 1 DAART) were comparable, whereas DCB angioplasty had more non-flow-limiting dissections (8 vs 1 for DAART, p=0.02). Conclusion: Preparation of the atherosclerotic CFA with directional atherectomy was not associated with statistically significantly higher primary patency or freedom from TLR compared to DCB angioplasty alone at 12 months. Nonetheless, both modalities had promising outcomes in a primarily surgically treated vascular territory.

Femoro-Supragenicular Popliteal Bypass with a Bridging Stent Graft in a Diffusely Diseased Distal Target Popliteal Artery: Alternative to Below-Knee Popliteal Polytetrafluoroethylene Bypass.

BackgroundLesions in distal target arteries hinder surgical bypass procedures in patients with peripheral arterial occlusive disease.MethodsBetween April 2012 and October 2015, 16 patients (18 limbs) with lifestyle-limiting claudication (n=12) or chronic critical limb ischemia (n=6) underwent femoral–above-knee (AK) polytetrafluoroethylene (PTFE) bypass grafts with a bridging stent graft placement between the distal target popliteal artery and the PTFE graft. Ring-supported PTFE grafts were used in all patients with no available vein for graft material. Follow-up evaluations assessed clinical symptoms, the ankle-brachial index, ultrasonographic imaging and/or computed tomography angiography, the primary patency rate, and complications.ResultsAll procedures were successful. The mean follow-up was 12.6 months (range, 11 to 14 months), and there were no major complications. The median baseline ankle-brachial index of 0.4 (range, 0.2 to 0.55) significantly increased to 0.8 (range, 0.5 to 1.0) at 12 months (p<0.01). The primary patency rate at 12 months was 83.3%. The presenting symptoms resolved within 2 weeks.ConclusionIn AK bypasses with a diffusely diseased distal target popliteal artery or when below-knee (BK) bypass surgery is impossible, this procedure could be clinically effective and safe when used as an alternative to femoral-BK bypass surgery.

Directional Atherectomy With Antirestenotic Therapy vs Drug-Coated Balloon Angioplasty Alone for Isolated Popliteal Artery Lesions

Purpose: To report a single-center study comparing drug-coated balloon (DCB) angioplasty vs directional atherectomy with antirestenotic therapy (DAART) for isolated lesions of the popliteal artery. Methods: Seventy-two patients were treated with either DCB angioplasty alone (n=31) or with DAART (n=41) for isolated popliteal artery stenotic disease between October 2009 and December 2015. The majority of patients presented with lifestyle-limiting claudication (74% vs 86%, respectively). Vessel calcification (29% vs 29%, respectively), mean lesion length (47 vs 42 mm, respectively), and number of runoff vessels were comparable between the groups. The primary outcome measure was primary patency; secondary outcomes were technical success (<30% residual stenosis or bailout stenting), secondary patency, and freedom from clinically driven target lesion revascularization (TLR). Results: The technical success rate following DCB was 84% vs 93% (p=0.24) after DAART. The 12-month primary patency rate was significantly higher in the DAART group (65% vs 82%; hazard ratio 2.64, 95% confidence interval 1.09 to 6.37, p=0.021), while freedom from TLR did not differ between the 2 treatment strategies (82% vs 94%, p=0.072). Secondary patency at 12 months was identical for both groups (96% vs 96%). Although not statistically significant, bailout stenting was more common after DCB angioplasty (16% vs 5% for DAART, p=0.13) and aneurysmal degeneration of the popliteal artery was seen more often after DAART (7% vs 0% for DCB alone, p=0.25). Popliteal artery injury was observed in 2 patients treated using DAART (5% vs 0% for DCB alone, p=0.5), whereas distal embolization rates were comparable between the groups (3% for DCB alone vs 5% for DAART, p=0.99). Conclusion: In this study, the use of DAART was associated with a higher primary patency rate compared with DCB angioplasty for isolated popliteal lesions. Nonetheless, both treatment options were associated with excellent 12-month secondary patency. Aneurysmal degeneration of the popliteal artery and increased bailout stenting could compromise the outcomes of DAART and DCB, respectively.

Two-year results from a randomized clinical trial of revascularization in patients with intermittent claudication.

Intermittent claudication is associated with significant impairment of health-related quality of life. The use of revascularization techniques to improve health-related quality of life remains controversial. Patients with intermittent claudication due to iliac or femoropopliteal peripheral artery disease were enrolled in the IRONIC trial. They were randomized to either best medical therapy (BMT), including a structured, non-supervised exercise programme, or revascularization with either endovascular or open techniques in addition to BMT. The primary outcome was health-related quality of life at 2 years assessed using the Short Form 36 (SF-36(®) ) questionnaire. Secondary outcomes included VascuQoL questionnaire results, treadmill walking distances and achievement of patient-specified treatment goals. Both randomized groups had improved health-related quality of life and treadmill walking distance at 2-year follow-up. Overall SF-36(®) physical component summary score, three SF-36(®) physical domain scores, overall VascuQoL score, and three of five VascuQoL domain scores showed significantly greater improvement in the group that also received invasive treatment. Intermittent claudication distance on a graded treadmill improved more in the revascularization + BMT group (117 versus 55 m; P = 0·003) whereas maximum walking distance and 6-min walk test distance were similar. Some 44 per cent of patients in the revascularization + BMT group reported they had fully achieved their treatment goal versus 10 per cent in the BMT group. A revascularization strategy with unsupervised exercise improved health-related quality of life and intermittent claudication distance more than standard BMT and an unsupervised exercise programme in patients with lifestyle-limiting claudication. NCT01219842 (http://www.clinicaltrials.gov).

Medical Therapy in Peripheral Artery Disease and Critical Limb Ischemia.

Peripheral artery disease (PAD) comprises atherosclerosis of the aorta and lower extremities. Many patients with PAD are asymptomatic, while others present with intermittent claudication (IC) or critical limb ischemia (CLI). Defined as rest pain or tissue loss that persists for >2weeks, CLI represents the most severe clinical manifestation of PAD and is associated with an increased risk of limb loss and death. Patients with PAD, including those with CLI, are underdiagnosed and undertreated. In addition to smoking cessation, medical therapy with an antiplatelet agent and statin is recommended for all patients with PAD. Regular exercise has been shown to improve walking distance and quality of life in patients with symptomatic PAD and should be incorporated into each patient's treatment plan. In patients who have CLI and in those with persistent lifestyle-limiting claudication despite optimal medical therapy and an exercise program, revascularization is indicated for limb salvage and symptom relief, respectively. Consensus guidelines currently support an endovascular first approach to revascularization in the majority of cases. Surgical procedures provide an alternative to endovascular therapy in select cases.

Role of Stent Grafts and Helical-Woven Bare-Metal Stents in the Superficial Femoral and Popliteal Arteries

Peripheral vascular disease (PVD) is a devastating medical problem that may lead to significant life alterations for patients, from simply limiting their daily activities to potential loss of limbs and eventual demise. Superficial femoral and popliteal arteries are significantly common locations for PVD sequelae to present itself, and owing to their length and mobile nature, treatment of these segments are quite challenging. Indications for PVD treatment include lifestyle-limiting claudication that is not responding to medical management, ischemic rest pain, nonhealing ulcers, and lower extremity gangrene. There is a wide variety of treatment options that include medical management, interventional, and surgical techniques. Interventional techniques include plain old balloon angioplasty, cryoplasty, drug-coated balloon angioplasty, self-expanding bare-nitinol stents, self-expanding covered stents, self-expanding drug-eluding stents, and a number of atherectomy devices (ie, laser, rotational, orbital, and excisional). The scope of this article is to review indications, patient selection, and deployment techniques of Viabahn and Supera self-expanding stents.

Efficacy and Safety of Transbrachial Access for Iliac Endovascular Interventions

Purpose: To evaluate the use of a brachial artery access for endovascular treatment of iliac artery disease. Methods: A retrospective review was conducted of 201 patients (mean age 73 years; 147 men) treated via a brachial artery access for iliac artery stenosis. The majority (n=141, 70%) presented with lifestyle-limiting claudication (Rutherford category 3), whereas the incidence of critical limb ischemia (Rutherford categories 4–6) was 30% (n=70). Diagnostic angiography revealed a TransAtlantic Inter-Society Consensus II (TASC) C/D lesion in 114 (57%) patients. The primary outcome was technical success achieved exclusively with a brachial artery access. Secondary outcomes were secondary technical success (adjunctive transfemoral access), access site complications, and stroke/transient ischemic attack (TIA). Results: In 17 (8%) patients, lesion crossing was unsuccessful, while an adjunctive transfemoral approach was necessary to restore iliac vessel patency in 23 (11%) cases. Thus, the primary and secondary technical success rates were 81% and 92%, respectively. Local hematomas (9, 4%) dominated the access site complications, followed by pseudoaneurysms (8, 4%), late brachial artery bleeding (4, 2%), brachial artery occlusion (2, 1%), and puncture site infection (2, 1%). No transient or permanent median nerve dysfunction was observed. The stroke/TIA rate was 2% (n=4). A single patient died due to acute coronary syndrome (0.5% mortality). TASC II class (p=0.58), sex (p=0.66), and target vessel (p>0.3 for all locations) had no effect on technical success. Female gender unfavorably influenced the incidence of access site complications (hazard ratio 6.7, 95% confidence interval 2.7 to 15, p<0.001), but sheath size did not (p=0.22). Conclusion: Brachial artery access enables endovascular treatment of iliac artery disease in the majority of patients, although an adjunctive transfemoral access may be required. However, the high incidences of access site complications and cerebral events remain a significant limitation of the transbrachial approach.

RR9. Characterization of Tibial Velocities by Duplex Ultrasound in Severe Peripheral Arterial Disease and Healthy Controls

The relationship between tibial velocities and peripheral arterial disease (PAD) severity is not well understood. We sought to characterize tibial velocities in patients with critical limb ischemia (CLI) or lifestyle-limiting claudication (LLC) and in healthy control patients without PAD. Patients with an arterial duplex ultrasound (DUS) with PAD (CLI or LLC) evaluated over a 5-year period were retrospectively compared with controls, patients without PAD, and a normal ankle-brachial index (ABI; 0.9-1.2). Control duplex ultrasound images were collected sequentially over a 60-month period. LLC was defined as short-distance claudication, objective PAD, and symptoms warranting revascularization. CLI was defined as ischemic rest pain or nonhealing ulcer/gangrene. For each artery, measurements were obtained at the proximal, middle, and distal portion of the vessel and averaged for each artery. Mean peak systolic velocities (PSV in cm/s), ABIs, peak ankle velocity (PAV), defined as the maximum PSV of any portion of the posterior tibial (PT) or anterior tibial (AT) artery, and average ankle velocity (AAV, the mean of the AT and PT PSV) were compared using independent t-tests. Preoperative DUS was available in 90 patients with PAD (54 CLI, 36 LLC) and 71 healthy controls. Mean ABI in the PAD group was 0.66 compared with 1.08 in controls. Mean PSV in PAD was significantly lower than controls at the popliteal (63.6 vs 76.2, P = .020), peroneal (33.9 vs 53.8, P < .001), AT (43.2 vs 65.4, P < .001), and PT artery (42.9 vs 74.1, P < .001). PAV (56.5 vs 89.2, P < .001) and AAV (43.5 vs 69.7, P < .001) were also significantly lower in the PAD group than in controls, whereas velocities in the profunda femoris artery were significantly higher in PAD group (132.1 vs 96.2, P = .001). From this, 95% confidence interval reference ranges were established for severe PAD and healthy controls (Table). This is the first study to characterize lower extremity arterial PSVs, PAVs and AAVs in severe PAD and healthy, non-PAD patients. These early criteria establish reference ranges to guide clinical decision-making and vascular lab interpretation.TableConfidence intervals in critical limb ischemia (CLI) and lifestyle-limiting claudication (LLC) compared with healthy nonperipheral arterial disease (PAD) patientsCLI and LLC (cm/s)Healthy controls (cm/s)PArtery Common femoral116.9-146.8111.3-133.0NS Profunda femoris115.0-149.285.5-106.9.001 Superficial femoral103.3-137.296.4-113.5NS Popliteal55.5-71.869.1-83.2<.001 Anterior tibial36.6-49.759.4-71.3<.001 Peroneal28.3-39.648.3-59.4<.001 Posterior tibial34.2– 51.666.9-81.3<.001Alternate parameters PAV AT46.6-69.470.4-86.1<.001 PAV PT41.3-71.879.4-99.0<.001 PAV Peroneal36.5-50.658.7-72.1<.001 AAV37.1-49.963.7-75.7<.001AAV, average ankle velocity; AT, anterior tibial; NS, not significant (P > .05); PAV, peak ankle velocity; PI, posterior tibial. Open table in a new tab

PC70. Acute Limb Ischemia After Cardiothoracic Surgery Is Associated With High Rates of Amputation and Mortality

Objectives: Failure of a femoropopliteal bypass often necessitates redo lower extremity surgery and is associated with increased mortality and morbidity. An alternative strategy is to perform endovascular revascularization of the superficial femoral artery (SFA) and avoid catheter-directed lysis or open surgery. The purpose of this retrospective study was to examine the outcomes of native SFA chronic total occlusion (CTO) recanalization compared with bypass after failed femoropopliteal bypass. Methods: Patients presenting with a symptomatic failed femoropopliteal bypass who underwent attempted CTO recannulization of the native SFA or a redo femoropopliteal bypass from2000 to 2014were included. Patients undergoing catheter-directed thrombolysis were excluded. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performedusing aCoxproportional hazardmodel for time-dependentvariables. Results: A total of 104 patients (69% male, average age 65 years) underwent nativeCTO recannulization (n1⁄4 40) or redobypass (n1⁄4 64) after presentation with symptomatic occlusion of a previous femoropopliteal bypass graft (rest pain in 84% and life style-limiting claudication in 16%, 79% to the aboveknee popliteal), 81% of the lesions being TASC-II category D and 19% TASC-II category C. Tibial runoff was one tibial vessel in most patients (79%) and two-vessel runoff in the remainder. Lesions treated endovascularly underwent primary stenting with a median of three stents used. Sixty-nine percent of the bypasses were to the below-knee popliteal and remainder to the proximal tibials (68% of the patients has venous conduit). Overall, 30-day major adverse cardiac eventswere 5.6%andall-causemorbiditywas6.3%. 30-daymajor adverse limbevents was 17% and30-day amputation ratewas 8% (Table).Overall amputation-free survival was 43%6 9% and freedom frommajor adverse limb events was28%6 7%at3years (Table).Critical ischemia,TASC-II lesion (D), andonevessel tibial runoff were significant predictors of failure.

Spliced Arm Vein Grafts Are a Durable Conduit for Lower Extremity Bypass

Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution. A retrospective chart review was conducted of all PAD patients undergoing lower extremity bypass or tibial angioplasty for lifestyle-limiting claudication or critical limb ischemia at a single institution over a 7-year period. Statistical analysis was conducted by Kaplan-Meier survival analysis and Cox proportional hazards model. Statistical significance was set at P=0.05. From 2005 to 2012, there were 120 patients who underwent infrageniculate revascularization with conduit other than GSV. Over half of the patients (66 patients, 71.2% male, mean age 62 years) underwent bypass operations using arm vein conduit, and 88% of those bypasses were to tibial vessels. Patency was 100% at 1 year and 85% at 2 years. There was no impact on patency or amputation rate based on the source of vein or the number of splices. Forty-three patients underwent tibial angioplasty and patency was 70% at 1 year and 50% at 2 years. When GSV is not available, spliced arm vein grafts provide durable lower extremity revascularization with favorable patency and limb preservation rates. Spliced arm vein grafts should be considered over prosthetic grafts and angioplasty alone in patients with distal occlusive disease.

Improved Quality of Life After 1 Year With an Invasive Versus a Noninvasive Treatment Strategy in Claudicants: One-Year Results on the Invasive Revascularization or Not in Intermittent Claudication (IRONIC) Trial

An invasive treatment strategy improves health-related quality of life and intermittent claudication distance after 1 year in patients with stable lifestyle-limiting claudication receiving current medical management.

Improved Quality of Life After 1 Year With an Invasive Versus a Noninvasive Treatment Strategy in Claudicants: One-Year Results of the Invasive Revascularization or Not in Intermittent Claudication (IRONIC) Trial

An invasive treatment strategy improves intermittent claudication (IC) distance and health-related quality of life at 1 year in patients with stable lifestyle-limiting claudication undergoing current medical management.

Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis).

The purpose of this study was to evaluate the safety and efficacy of excimer laser atherectomy (ELA) with adjunctive percutaneous transluminal angioplasty (PTA) versus PTA alone for treating patients with chronic peripheral artery disease with femoropopliteal bare nitinol in-stent restenosis (ISR). Femoropopliteal stenting has shown superiority to PTA for lifestyle-limiting claudication and critical limb ischemia, although treating post-stenting artery reobstruction, or ISR, remains challenging. The multicenter, prospective, randomized, controlled EXCITE ISR (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis) trial was conducted across 40 U.S. centers. Patients with Rutherford Class 1 to 4 and lesions of target lesion length ≥4 cm, vessel diameter 5 to 7 mm were enrolled and randomly divided into ELA + PTA and PTA groups by a 2:1 ratio. The primary efficacy endpoint was target lesion revascularization (TLR) at 6-month follow up. The primary safety endpoint was major adverse event (death, amputation, or TLR) at 30 days post-procedure. Study enrollment was stopped at 250 patients due to early efficacy demonstrated at a prospectively-specified interim analysis. A total of 169 ELA + PTA subjects (62.7% male; mean age 68.5 ± 9.8 years) and 81 PTA patients (61.7% male; mean age 67.8 ± 10.3 years) were enrolled. Mean lesion length was 19.6 ± 12.0 cm versus 19.3 ± 11.9 cm, and 30.5% versus 36.8% of patients exhibited total occlusion. ELA + PTA subjects demonstrated superior procedural success (93.5% vs. 82.7%; p = 0.01) with significantly fewer procedural complications. ELA + PTA and PTA subject 6-month freedom from TLR was 73.5% versus 51.8% (p < 0.005), and 30-day major adverse event rates were 5.8% versus 20.5% (p < 0.001), respectively. ELA + PTA was associated with a 52% reduction in TLR (hazard ratio: 0.48; 95% confidence interval: 0.31 to 0.74). The EXCITE ISR trial is the first large, prospective, randomized study to demonstrate superiority of ELA + PTA versus PTA alone for treating femoropopliteal ISR. (Randomized Study of Laser and Balloon Angioplasty Versus Balloon Angioplasty to Treat Peripheral In-stent Restenosis [EXCITE ISR]; NCT01330628).

Retrograde Transpopliteal Access Is Safe and Effective—It Should Be Added to the Vascular Surgeon's Portfolio

The aim of the study was to review the outcomes of superficial femoral artery (SFA) interventions using a retrograde transpopliteal access approach after failed antegrade recanalization. A database of patients undergoing endovascular treatment of the SFA between 2008 and 2011 was retrospectively queried, and those cases with transpopliteal artery retrograde access were analyzed. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. A total of 16 patients (75% men; mean age 61 ± 9 years) underwent retrograde popliteal access after failed antegrade attempts. Patients had multiple cardiovascular comorbidities with a mean modified cardiac index score of 3.1 ± 1.8. The reason for intervention was lifestyle-limiting claudication in 67% of cases and critical ischemia in the remainder. Most of the lesions were Trans-Atlantic Inter-Society Consensus II C and D. Retrograde ultrasound-guided puncture of the popliteal artery was successful in all cases and there were no local site complications. Intervention was successful in 94% of cases. One uncomplicated perforation (7%) was encountered during attempted recanalization of the SFA in the thigh. There was no perioperative morbidity or 30-day mortality. The 30-day major adverse cardiovascular events rate was 6% but both 30-day major adverse limb events and the 30-day major amputation rate were 0%. There was a 40% increase in actual ankle-brachial index (ABI); 93% of patients achieved an ABI rise >0.15. On longer term follow-up, 2 patients developed restenosis and 1 an asymptomatic occlusion. Both restenosis patients required re-angioplasty. Two patients required expected toe amputations as a result of their presenting symptoms. The primary patency was 66 ± 9%, assisted patency 81 ± 9%, and secondary patency 87 ± 8% at 2 years. Limb salvage was 100%. Clinical efficacy was 63 ± 9% at 2 years. Ultrasound-guided retrograde transpopliteal access is a safe and successful technique, which extends the ability to perform endovascular interventions after failed antegrade approaches.

Safety and Effectiveness of Endovascular Therapy for Claudication in Octogenarians

Advanced age (≥ 80 years) has been associated with adverse outcomes after lower extremity bypass for critical limb ischemia (CLI), but endovascular therapy (ET) is reported to have comparable safety across age groups. Here, we assess the safety and effectiveness of advanced age on outcomes after ET for lifestyle-limiting intermittent claudication (IC). A retrospective review of a prospectively maintained institutional database (2007-2012) identified all patients undergoing ET for IC. Demographics, procedural details, and outcomes were assessed via univariate analysis and multivariate Cox regression. Effectiveness was assessed across a panel of outcome metrics including the following: overall survival, freedom from major adverse limb event (MALE), and freedom from reintervention, amputation, or restenosis (RAS). Freedom from MALE + perioperative death (MALE + POD) was the primary safety end point. Two hundred thirty-six patients underwent primary ET for 284 affected limbs. Of these, 46 interventions (16%) were performed in patients ≥ 80 years old. The average age of octogenarians treated was 84.4 years compared with 67.4 years among those aged <80 (P < 0.001). Compared with younger claudicants, octogenarians were less likely to have hypercholesterolemia (43.5% vs. 63.9%, P = 0.01) and more likely to deny a history of smoking (41.3% vs. 14.7%, P < 0.001). Octogenarians were also more likely to undergo interventions involving the popliteal artery (50% vs. 31.9%, P = 0.03). There were no other significant differences in demographics, comorbidities, TransAtlantic Inter-Society Consensus II classification, or treated arterial segment. Thirty-day freedom from MALE + POD was 100% in octogenarians and 99.6% in patients <80 years, with no difference between age groups. There were no differences in freedom from MALE, freedom from RAS, or overall survival at 1- and 3-year follow-up. Although age >80 years has been identified as an independent risk factor for poor outcomes in the surgical treatment of CLI, our results suggest that ET for selected octogenarians with lifestyle-limiting claudication is as safe and effective as ET in younger patients. Advanced age alone should not prohibit consideration of ET for patients with IC.

Clinical Features and Endovascular Management of Iliac Artery Fibromuscular Dysplasia

PurposeTo identify the spectrum of clinical presentation of iliac artery fibromuscular dysplasia (FMD) and to evaluate the outcomes of endovascular management of iliac artery FMD for claudication. Materials and MethodsAll patients in a single institution with a diagnosis of FMD between January 1980 and December 2010 were identified. Iliac artery FMD was present in 14 patients. Associated risk factors included hypertension (79%), hyperlipidemia (64%), smoking history (36%), coronary artery disease (21%), diabetes (0%), and obesity (36%). ResultsIn eight (57%) patients, iliac artery FMD was incidentally found on imaging. Lifestyle-limiting claudication involving one or both extremities was present in six (43%) patients. All six patients were reported to have mild peripheral arterial disease based on ankle-brachial index measurements (0.7–0.9). These six patients underwent 10 endovascular procedures for claudication, including angioplasty (n = 8) and self-expanding stent placement (n = 2). Mean symptom-free survival was 56.3 months. ConclusionsIliac artery FMD that is amenable to endovascular treatment may be found incidentally or may manifest with disabling claudication.

Late presenting, contained rupture of the superficial femoral artery following atherectomy and stenting: Case report and literature review

Excisional atherectomy alone or followed by stenting is considered an appropriate treatment strategy for patients with lifestyle-limiting claudication due to obstructive infra-inguinal peripheral arterial disease (Ramaiah et al., J Endovasc Ther 2006;13:592-6021). We present a case of a 69-year-old man with eccentric severely calcified disease of the superficial femoral artery (SFA) treated with excisional atherectomy followed by stenting with an interwoven nitinol stent. The procedure was complicated by extravascular stent migration associated with a contained rupture presenting 30 days after the intervention. The complication was successfully treated with a stent graft. Although rare, pseudoaneurysms have been reported at the site of prior atherectomy; however, this case is the first description of a contained rupture post atherectomy associated with erosion of a nitinol stent into an extra-luminal position. The mechanism and management of this complication are discussed.

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Subintimal angioplasty with a true reentry device for treatment of chronic total occlusion of the arteries of the lower extremity

To report the efficacy and safety of the Outback(®) LTD(®) Re-Entry Catheter in reentering the distal true lumen during percutaneous intentional extraluminal revascularization (PIER). Reentry catheters are used to treat chronic, total arterial occlusions of the lower extremities when standard methods of recanalization have failed. Success and complication rates of these catheters in the real world are uncertain and variable. A retrospective review of our peripheral catheterization database from January 2004 to September 2009 was undertaken to identify consecutive cases of peripheral chronic total occlusions (CTOs) requiring the use of the Outback reentry catheter. Patient demographics, indication for the procedure, location and extent of occlusion, procedural success, and complications were studied. A total of 51 patients were identified. Of the 51, 28 (54.9%) patients presented with nonhealing ulcer and 22 (43.1%) had lifestyle-limiting claudication. One patient presented with acute limb ischemia. There were 6 (11.8%) patients with common iliac artery occlusion, 2 (3.9%) with external iliac artery occlusion, 1 (1.9%) with common femoral artery occlusion, 35 (68.6%) with superficial femoral artery occlusion, 6 (11.8%) with popliteal artery occlusion, and 1 (1.9%) with tibioperoneal artery occlusion. Median lesion length was 230 mm. Procedural success was achieved in 49 patients (96.1%). There was 1 (1.9%) periprocedural complication. Use of Outback(®) LTD(®) Re-Entry Catheter is a safe and valuable option for PIER/subintimal angioplasty and recanalization in patients with symptomatic lower-extremity CTOs. However, long-term patency remains unknown.

The Quality and Impact of Risk Factor Control in Patients With Stable Claudication Presenting for Peripheral Vascular Interventions

Peripheral arterial disease is a manifestation of systemic atherosclerosis and is predictive of future cardiovascular events. Clinical trial data have demonstrated that medical therapy can attenuate cardiovascular morbidity and mortality in patients with peripheral arterial disease. The utilization and impact of recommended medical therapy in a contemporary population of patients who undergo percutaneous interventions for lifestyle-limiting peripheral arterial disease is unknown. Using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention (BMC2 PVI) database, we identified 1357 peripheral vascular intervention encounters between January 2007 and December 2009 for the purpose of treating claudication. Before the intervention, 85% of these patients used aspirin, 76% used statin, 65% abstained from smoking, and 47% did all 3. There was no difference in cardiovascular events among those taking an aspirin and a statin on admission and those who were not. However, in both an unadjusted and a multivariable analysis, the odds of an adverse peripheral vascular outcome (repeat peripheral intervention, amputation, or limb salvage surgery) within 6 months decreased by more than half in patients receiving aspirin and statin therapy before peripheral vascular intervention as compared with those who received neither (odds ratio, 0.45; 95% CI, 0.29-0.71). The fundamental elements of medical therapy in patients with lifestyle-limiting claudication are often underutilized before referral for revascularization. Appropriate medical therapy before percutaneous revascularization is associated with fewer peripheral vascular events at 6 months.