Percutaneous Peripheral Interventions Research Articles

Safety and Efficacy of Combined Coronary and Peripheral Percutaneous Revascularization: A Proof-of-Concept Study.

Background. Lower extremity peripheral artery disease (LEPAD) frequently coexists with coronary artery disease (CAD) in patients with multisite vascular disease (MVD). While percutaneous revascularization is well-established for both LEPAD and CAD, limited evidence exists for patients eligible for both procedures. Specifically, the feasibility of concomitant LEPAD and CAD percutaneous revascularization remains unknown. Objectives. To compare the efficacy and safety of concomitant coronary and lower extremity elective percutaneous revascularization. Methods. Between 2012 and 2021, we included 135 patients in an observational, retrospective single-center registry. The population was stratified into two groups: 45 patients (concomitant group) underwent simultaneous coronary and peripheral percutaneous interventions, and 90 patients (deferred group) underwent two separate procedures within one year. The primary efficacy endpoint was major adverse cardiovascular events (MACE) at one year, while the primary safety endpoint was in-hospital contrast-induced nephropathy (CIN). Results. Study groups were well-balanced in baseline characteristics. In terms of coronary features, the concomitant revascularization group more often underwent single-vessel percutaneous coronary intervention (PCI), while the deferred group had multivessel PCI with diffuse coronary disease. No differences were detected in the number of LEPAD lesions between groups. For the primary efficacy endpoint, the incidence of MACE at one year was 37.8% in the concomitant group vs. 34.4% in the deferred group (HR 1.20, 95% CI 0.64-2.10; p = 0.61). No significant differences were found in CIN occurrence between the concomitant and deferred groups (11.1% vs. 8.9%; OR 1.30; 95% CI 0.36-4.21; p = 0.68). Conclusions. Multisite vascular disease patients eligible for CAD and LEPAD percutaneous revascularization exhibited a high cardiovascular risk profile with diffuse multivessel coronary and lower extremity disease. Our study suggests the efficacy and safety of concomitant coronary and lower extremity percutaneous revascularization based on one-year MACE incidence and in-hospital CIN. However, dedicated studies are warranted to confirm the short- and long-term outcomes of the concomitant revascularization strategy.

Chinese expert consensus on transradial access in percutaneous peripheral interventions

Transradial access (TRA) is a safe and comfortable approach and the preferred access for percutaneous coronary intervention. However, TRA is not widely used for peripheral interventions. Currently, there is a lack of data on patient selection, appropriate medical devices, complication prevention, and TRA adoption. Therefore, the Chinese Society of Interventional Oncology of the China Anti-Cancer Association organized nationwide experts to establish a Working Group of China Expert Consensus on TRA in percutaneous peripheral interventions in 2022, and jointly formulated this consensus to better promote the application of TRA in peripheral interventions to guide clinicians on patient selection, technical recommendations, and physician training. This consensus mainly focuses on the current situation, advantages and limitations of TRA in peripheral interventions, anatomical characteristics of the radial artery, patient selection, technical aspects, prevention and management of complications, radiation dose, and learning curve. A consensus was reached through a literature evaluation and by referring to the opinions of the expert group.

Drug-Eluting, Balloon-Expandable, Bioresorbable Vascular Scaffolds Reduce Neointimal Thickness and Stenosis in an Animal Model of Percutaneous Peripheral Intervention

Drug-Eluting, Balloon-Expandable, Bioresorbable Vascular Scaffolds Reduce Neointimal Thickness and Stenosis in an Animal Model of Percutaneous Peripheral Intervention

Drug-eluting, balloon-expandable, bioresorbable vascular scaffolds reduce neointimal thickness and stenosis in an animal model of percutaneous peripheral intervention

ObjectiveRecanalization with balloon angioplasty and/or self-expanding stents (SES) has become the endovascular treatment of choice for symptomatic femoropopliteal occlusive disease. These strategies generate suboptimal clinical results, however, because they fail to expand the artery fully and ineffectively prevent recoil, neointimal hyperplasia, and restenosis. Balloon-expandable stents, given their greater radial force and rigid structure, represent a more effective treatment strategy, but only short lengths can be implanted safely in arteries that deform and bend with skeletal motion. The purpose of this preclinical experiment was to test the hypothesis that simultaneous implantation of a series of short, resorbable, balloon-expandable, paclitaxel-eluting scaffolds would prevent neointimal hyperplasia and stenosis compared with SES in an animal model of percutaneous femoropopliteal intervention. MethodsWe extruded 6 × 60 mm Efemoral Vascular Scaffold Systems (EVSS) from copolymers of poly-L-lactic acid, coated with paclitaxel 3 μg/mm2, crimped onto a single delivery balloon, and implanted percutaneously into the iliofemoral arteries of eight Yucatan mini-swine. We implanted 7- to 8-mm × 60 mm SES into the contralateral experimental arteries. The animals were serially imaged with contrast angiography and optical coherence tomography after 30, 90, 180, 365, and 730 days. The primary end point of this study was neointimal morphometry over time. Secondary end points included acute deformation and angiographic and optical coherence tomography-derived measurements of chronic vascular response. ResultsOver the 2-year study period, one SES was found to be completely occluded at 90 days; all EVSS were widely patent at all time points. Arteries treated with SES exhibited profound neointimal hyperplasia with in-stent stenosis. In contrast, arteries treated with EVSS exhibited only modest vascular responses and minimal stenosis. After 2 years, the mean neointimal thickness (0.45 ± 0.12 vs 1.31 ± 0.91 mm; P < .05) and area (8.41 ± 3.35 vs 21.86 ± 7.37 mm2; P < .05) were significantly decreased after EVSS implantation. By 2 years, all scaffolds in all EVSS-treated arteries had resorbed fully. ConclusionsIn this preclinical animal model of peripheral endovascular intervention, the EVSS decreased neointimal hyperplasia and stenosis significantly compared with SES, then dissolved completely between the first and second years after implantation.

Monitoring antiplatelet therapy: where are we now?

Single antiplatelet therapy represents the cornerstone of thrombosis prevention in atherosclerotic cardiovascular disease. Dual antiplatelet therapy (DAPT), consisting of aspirin plus a P2Y 12 inhibitor, is the standard of care for patients with acute coronary syndrome or undergoing both coronary and peripheral percutaneous interventions. Recent data suggest the efficacy of DAPT also after minor stroke. In this setting, a large body of evidence has documented that genetic and acquired patients' characteristics may affect the magnitude of platelet inhibition induced by antiplatelet agents. The implementation of tools allowing the identification and prediction of platelet inhibition has recently been shown to improve outcomes, leading to an optimal balance between antithrombotic efficacy and bleeding risk. We are therefore clearly moving towards tailored antiplatelet therapy. The aim of this paper is to summarize the available evidence on the evaluation of platelet inhibition in patients with coronary, peripheral, or cerebrovascular atherosclerosis. We will here focus on antiplatelet therapy based on both aspirin and P2Y 12 inhibitors. In addition, we provide practical insights into the clinical settings in which it appears reasonable to implement antiplatelet therapy monitoring.

Abstract 14681: Quantitative Whole Blood Platelet Aggregation Predicts Occurrence of Subacute Thrombosis in Patients After Percutaneous Coronary or Peripheral Intervention

Introduction: The risk of subacute thrombosis (SAT) after percutaneous coronary intervention (PCI) or percutaneous peripheral intervention (PPI) is high if patients show high whole blood platelet aggregation. Hypothesis: For such high-risk patients, even though dual antiplatelet therapy is performed, whole platelet aggregation should be quantitated and if high, the indication for additional antiplatelet therapy determined. Methods: This is a retrospective analysis of 12095 stents from 12095 patients (9173 males; mean age 69±11 years; 9470 PCI, 2625 PPI). The whole blood platelet aggregatory threshold index (PATI; WBA-Neo; ISK, Osaka, Japan) was calculated. PATI was used to determine the minimum concentration of adenosine 5'-diphosphate causing a non-reversible aggregation of platelets and indicated platelet aggregation (range 0-8 μM). The higher the PATI, the lower the platelet aggregation. All patients received single or double antiplatelet drug therapy according to physician choice. Results: SAT occurred in 18 (0.19%) of 9470 patients after PCI and in 9 patients (0.34%) of 2625 patients after PPI. Of 9470 patients after PCI, total blood PATI was 4.40 in 18 patients with SAT and 7.00 in 9452 patients without SAT (P&lt;0.001). Of 2625 patients after PPI, the total blood PATI was 4.97 in nine patients with SAT and 6.39 in 2616 patients without SAT; the former was significantly lower than the latter (P&lt;0.001). We combined patients with PCI and PPI. PATI was divided into nine grades: 0-0.99, 1-1.99, 2-2.99. 3-3.99, 4-4.99. 5-5.99, 6-6.99, 7-7.99, and &gt;7.99. Of 12095 patients, if PATI was 0-0.99, the incidence of SAT was greatest at 1.89%. If PATI was &gt;7.99, the incidence of SAT was lowest at 0.09%. We divided 12095 patients into two groups: PATI of 0-4.99 (N=2229) and PATI of &gt;4.99(N=9866); the incidence of SAT was greater in the former (0.72%) than latter (0.11%; P&lt;0.001). No significant differences existed in the percentage of each coronary risk factor between patients with and without SAT after PCI, PPI, and PCI or PPI. Conclusions: In patients after PCI and/or PPI, despite single or double antiplatelet drug therapy, the whole blood platelet aggregation should be checked, and if PATI is 0-4.99 the indication for additional antiplatelet therapy should be considered.

Extravascular Access Artery Closure Following Percutaneous Peripheral Intervention

Percutaneous closure of the access artery following endovascular intervention has become commonplace. In patients with peripheral vascular disease, however, control of a femoral puncture site is problematic as the access artery is frequently plaque-laden and stenotic. Ischemic complications in the access extremity are more common in these cases, particularly when using devices requiring the deployment of prosthetic material within the compromised arterial lumen. The purpose of this retrospective clinical study was to assess the efficacy of totally extravascular/bioresorbable closure of femoral artery puncture sites following percutaneous peripheral intervention (PPI).

Experience with Optical Coherence Tomography Enhanced by a Novel Software (Ultreon™ 1.0 Software)-The First One Hundred Cases.

Introduction: Optical coherence tomography (OCT) intravascular imaging including the latest version Ultreon™ 1.0 Software (Abbott Vascular, Santa Clara, CA, USA), not only improve patients prognosis, but also facilitates improved percutaneous coronary intervention (PCI). Objectives: The aim of the study was to compare procedure related decision making, procedural indices, clinical outcomes according to the extent of stent expansion and assess risk factors of underexpansion in patients treated with PCI using OCT. Methods: The study comprised 100 patients, which were divided in groups according to the extent of stent expansion: <90 (29 patients) and ≥90% (71 patients). Comparison of OCT parameters, selected clinical and procedural characteristics was performed between groups. We assessed clinical outcomes during the follow-up: major adverse cardiovascular events and risk factors of stent underexpansion. Results: Patients from the stent underexpansion group were treated more often in the past with percutaneous peripheral interventions (p = 0.02), no other significant differences being noted in general characteristics, procedural characteristics or clinical outcomes comparing both groups. Significant predictors of stent underexpansion assessed by simple linear univariable analysis included: hypercholesterolemia, obstructive bronchial diseases and treatment with inhalators, family history of cardiovascular disease, PCI of other than the left main coronary artery, stent and drug-eluting stent implantation, PCI without drug-eluting balloon, paclitaxel antimitotic agent, greater maximal stent diameter and lower mean Euroscore II value. Univariable logistic regression analysis revealed a correlation between stent underexpansion and greater creatinine serum concentration before [OR: 0.97, 95%CI: 0.95–0.99, p = 0.01)] and after PCI [OR: 0.98, 95%CI: 0.96–0.99, p = 0.02)]. Conclusions: Based on the presented analysis, the degree of stent expansion is not related to the selected procedural, OCT imaging indices and clinical outcomes. Logistic regression analysis confirmed such a relationship for creatinine level.

Cost and budgetary impact of the vascular systems of closure versus manual compression for peripheral endovascular procedures

To evaluate the annual costs and the budgetary impact of the use of a vascular closure device (VCD) compared to manual compression to obtain hemostasis after ambulatory percutaneous peripheral endovascular interventions.

Systemic immune inflammation index: is it a new marker for contrast-induced nephropathy?

Introduction: Worldwide, &amp;gt;200 million patients are affected by peripheral arterial disease (PAD) and endovascular interventional treatments are increasingly being applied. Contrast-induced nephropathy (CIN) is the third most common cause of renal failure in hospitals. However, factors such as renal vasoconstriction, decrease in renal blood flow, endothelial dysfunction, and oxidative stress have been suggested in the etiology of CIN. Studies are showing that inflammatory markers increase in CIN. Systemic immune inflammation index (SII), a newly defined parameter, is calculated by multiplying the platelet and lymphocyte counts and dividing by the neutrophil count. Studies are showing that this parameter influences prognosis in various cancer types. Considering that inflammation may play a role in CIN, we planned this study to investigate the role of SII in patients undergoing percutaneous peripheral vascular interventions. Material and Method: 300 patients who underwent percutaneous peripheral vascular interventions between August 2018-December 2021 due to peripheral arterial disease were included in the study. The data of the patients were scanned retrospectively from the patient files. The neutrophil-lymphocyte ratio (NLR) was calculated by dividing the neutrophil count by the lymphocyte count. SII was found by multiplying NLR with platelet count Results: Contrast-induced nephropathy developed in 41 (12.3%) patients. CIN(+) patients also, had higher CRP levels (5.1±0.7vs 2.4±0.4,P&amp;lt;0.05), NLR (4.07±1.07vs 2.65±0.84, P&amp;lt;.005), SII score (1778±627.57vs 867.14±491.88, P&amp;lt;.005.) the contrast media used was also higher in CIN(+) patients (176.19±48.44 vs 128.72±48.44;P&amp;lt;0.05) Multivariate logistic regression analysis demonstrated that a high SII score was an independent predictor of development of CIN (odds ratio [OR]: 1.002, 95% confidence interval [CI]: 1.001-1.002, P&amp;lt;.0005) together with high NLR (OR: 3.56, 95% CI: 1.905-6.675, P&amp;lt;.005) and CRP (OR: 1.002, 95% CI: 1.001-1.002, P&amp;lt;.005 Receiver operating characteristic curve analysis demonstrated that the best cutoff value of 1224 for SII to predict the development of CIN with 85% sensitivity and 72% specificity (area under ROC curve 0.904 [95% CI: 0.866-0.942], P&amp;lt;.005). Conclusion: Imbalance in inflammatory cells, the increase in neutrophils, and the decrease in lymphocytes play a role in developing kidney damage. Impaired immune functions due to lymphocytopenia contribute to the development of acute kidney injury. Oxidative stress exacerbates the inflammatory state by increasing inflammatory cell infiltration. AS a result, SII may be a powerful predictor of inflammation and can be used to determine the risk before interventional procedures.

Extravascular Access Artery Closure After Percutaneous Peripheral Intervention

Percutaneous closure of the access artery has become commonplace after endovascular intervention. In patients with peripheral vascular occlusive disease, however, control of the puncture site is more problematic as the access artery is frequently plaque-laden and stenotic. Ischemic complications in the access extremity are more common in these cases, particularly when using devices that depend on the deployment of prosthetic material within the compromised arterial lumen. The purpose of this retrospective clinical study was to assess the efficacy of totally extravascular/bioresorbable closure of the femoral artery puncture sites after percutaneous peripheral intervention (PPI).

Predictors of Amputation-free Survival after Endovascular Intervention for Chronic Limb-Threatening Ischemia in the Modern era

Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1-year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention (PPI) constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival (AFS) in a contemporary cohort treated with endovascular recanalization and assess its predictors. Patients with CLTI undergoing endovascular revascularization at a single regional hospital between 2015-2019 were reviewed. Baseline demographic characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, technical details, and clinical outcomes were tabulated. The primary endpoint was AFS; a P-value < 0.05 was used for univariate screening and inclusion in a multivariable model. A total of 137 limbs in 111 patients were studied. Comorbidities were prevalent and included diabetes (65%), congestive heart failure (21%), and dialysis dependence (18%). The majority of revascularized limbs presented with advanced wounds (66% WIfI stages 3-4; 47% Rutherford category 6). Presenting WIfI stages were similar across races (P=0.26). Peripheral interventions most commonly targeted femoropopliteal disease (69%), although 26% were multilevel. Percutaneous atherectomy, stenting, and paclitaxel-coated or eluting devices were utilized in 68%, 28%, and 15% of cases, respectively. After a median follow-up of 16months (interquartile range IQR=4-29months), significant independent predictors of reduced AFS included nonWhite race (HR=2.96 [1.42-6.17]; P=0.004) and WIfI stage 4 wounds (HR=2.23 [1.10-4.52]; P=0.026). At one year following successful revascularization, only 59%±1% of patients were alive with their limb intact. Despite considerable and consistent advances in urban health care delivery and the techniques of PPI, CLTI remains a morbid and deadly disease. Even in the endovascular era, nearly half of all patients presenting with CLTI will lose their limb and/or life within the first year. Unfortunately, late-stage presentation continues to be commonplace. Although endovascular intervention can reliably restore patency to affected arteries, this appears insufficient to restore most patients to health.

Predictors of Amputation-free Survival After Endovascular Intervention for Chronic Limb-threatening Ischemia

Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1 year. Lethality increases to 45% if the patient requires a major amputation. Percutaneous peripheral intervention constitutes a less morbid treatment option for patients with CLTI. We assessed amputation-free survival (AFS) in a contemporary cohort treated with endovascular recanalization and assessed its predictors.

Predictors of Amputation-free Survival After Endovascular Intervention for Chronic Limb-threatening Ischemia

Chronic limb-threatening ischemia (CLTI) is associated with 25% limb loss and 25% mortality at 1 year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival in a contemporary cohort treated with endovascular recanalization and assess its predictors.

The impact of percutaneous peripheral interventions on endothelial function.

Background: Treatment of symptomatic peripheral artery disease (PAD) through endovascular interventions is the primary revascularization strategy. Interventions restore perfusion but may cause severe injury to the vascular endothelium, which regulates vascular tone. Endothelial dysfunction is involved in the progression of cardiovascular disease, with higher incidences of vascular events. We aimed to determine the impact of percutaneous interventions on change in endothelial function. Patients and methods: Endothelial function was determined using flow-mediated dilation (FMD) before, the day after lower limb intervention with paclitaxel-coated balloons or stent guided interventions and after a six-month follow-up in the target limb, control limb and the systemic circulation in 42 PAD patients aged 70.2±9 years and 66% men. Additionally, macro- and microvascular function were assessed. Results: In PAD patients aged 70.2±9 years and 66% men, we observed an immediate enhancement of macro-, microvascular and endothelial function after endovascular treatment (FMD of superficial femoral artery (SFA) 3.7±0.2% to 4.1±0.1%, n=42, p=0.02), a sustained long-term improvement after 6-months (FMD SFA 3.7±0.2% to 4.2±0.1%, n=42, p=0.01), and moreover an improved systemic endothelial function (FMD brachial artery 4.3±0.1% to 4.7±0.2, n=42, p=0.01) following peripheral interventions. Subgroup analysis however revealed that following paclitaxel-based percutaneous intervention, the paclitaxel dosage applied was inversely related to the chronic improvement in local endothelial function (r=-0.6, n=22, p=0.005) without evidence for systemic effects (r=-0.25, p=0.27). Conclusions: We demonstrate an improved local and systemic endothelial function after treatment of atherosclerotic peripheral disease with a distinguished response after endovascular intervention with higher dosage of applied paclitaxel restraining the benefits. Further studies have to determine the optimal interventional strategy with respect to different treatment modalities to maintain vessel functions.

Comparison of Percutaneous Peripheral Intervention Performed in a Dedicated Hybrid Operating Theatre vs. Cardiac Catheterization Laboratory

Objective: Percutaneous Peripheral Intervention (PPI) has emerged as the treatment-of-choice for patients with symptomatic peripheral vascular occlusive disease. The procedure may be performed in a variety of clinical settings including a standard operating theatre, interventional radiology suite, hybrid operating theatre (hybrid room), or cardiac catheterization laboratory (cath lab). The purpose of this retrospective clinical study was to test the hypothesis that PPI could be performed safely by vascular surgery specialists in a cath lab at a reduced cost as compared to a hybrid theatre. Methods: Consecutive PPI procedures performed by three dedicated vascular surgeons were retrospectively analyzed. The choice of venue was primarily related to facility availability although patients with high medical risk were preferentially treated in the hybrid suite. Demographic characteristics, peri-procedural outcomes and cost were tabulated and compared. Results: A total of 146 PPI procedures performed either in the hybrid room (n=97) or the cath lab (n=49) was reviewed. Patient indications and comorbidities including coronary artery disease, hypertension, dialysis-dependence, critical limb ischemia, in-patient status, diagnostic vs. therapeutic procedure, operative time and anatomic level of intervention were similar for the two groups. Patients undergoing PPI in the hybrid room had a higher incidence of prior peripheral revascularization (46% vs. 29%; p=0.049), were more likely to require general anesthesia (18% vs. 0%, p<0.05), were more likely to require open femoral access (9.3% vs. 0%; p=0.03), were accessed with larger sheaths (61% vs. 35%; p<0.01) and were imaged with less contrast dye (73 ± 38 mL vs. 117 ± 57 mL; p<0.01). Major complications including retroperitoneal hematoma (0% vs. 2%; p=0.34), acute limb ischemia (1% vs. 0%; p=1) and/or acute kidney injury (1% vs. 0%; p=1) were rare in both groups. Patients treated in the cath lab were more likely to experience transient hypotension (10% vs. 22%; p=0.08) and/or transient postprocedure creatinine elevation (2.0 ± 2.1 vs. 3.0 ± 3.0; p=0.05). Surprisingly, both hospital charges and hospital costs were significantly less for patients treated in the hybrid room as compared to the cath lab (total charges $18714 ± 9633 vs. $26902 ± 19753; p<0.01, total direct and indirect costs $7174 ± 3847 vs. $9659 ± 7064; p=0.01). Medical supplies indirect cost and room services total direct and indirect costs were also higher in the cath lab (medical supplies indirect $336 ± 557 vs. $836 ± 1893; p=0.02; room services $3183 ± 2068 vs. $5169 ± 3314; p<0.01). Conclusions: PPI can be safely performed in either a hybrid surgical suite or cardiac catheterization laboratory although treatment in a hybrid suite utilizes less hospital resources.

The triglyceride-glucose index predicts peripheral artery disease complexity

Background/aimHigh levels of triglyceride (TG) and fasting blood glucose (FBG) values increase atherosclerosis risk. This study evaluates the relationship between peripheral artery disease (PAD) severity and complexity, as assessed by TransAtlantic InterSociety Consensus-II (TASC-II) classification and the triglyceride-glucose (TyG) index.Materials and methodsA total of 71 consecutive patients with PAD (males 93%, mean age 63.3 ± 9.7), who underwent percutaneous peripheral intervention were included retrospectively. The patients were divided into two groups according to the angiographically detected lesions. Those with TASC A-B lesions were included in Group 1, and those with TASC C-D lesions were included in Group 2. TyG index was calculated as formula: ln[fasting TG (mg/dL) × fasting plasma glucose (mg/dL)/2].ResultsThere were 40 patients in Group 1 (90.3% men, with a mean age of 63.6 ± 9.3 years) and 31 patients in Group 2 (96.8% men, with a mean age of 62.0 ± 8.6 years). In the majority of patients in both groups, the target vessels are iliac arteries and femoral arteries. In Group 2, platelet count and TyG index were significantly high, according to Group 1. The TyG index was significantly correlated with TASC-II, Rutherford category, HbA1c, and HDL-C.ConclusionIn this present study, we showed that the TyG index was an independent predictor of peripheral artery disease complexity, according to TASC-II classification, for the first time in the literature.

“Failure-to-Cross” in Patients Undergoing Percutaneous Peripheral Intervention: The Nonreimbursed Procedure

Percutaneous peripheral intervention (PPI) is often the first mode of therapy for patients with symptomatic arterial occlusive disease. Technical success generally remains high although "failure-to-cross" still complicates 5-20% of cases. Extended efforts to cross long, occlusive lesions can utilize significant hospital and practitioner resources. The hospital is typically reimbursed for this effort as facility fees are charged by the hour and materials are charged per use. However, given the lack of a CPT® code for "failure-to-cross," practitioners are rarely appropriately compensated. The purpose of this study is to analyze the predictors, technical details, outcomes, and costs of "failure-to-cross" during PPI. All PPI procedures over a 2-year period at a single institution were retrospectively reviewed. Clinical characteristics, results, costs, and reimbursements obtained from hospital cost accounting were compared among successful therapeutic interventions, crossing failures, and diagnostic angiograms without attempted intervention. A total of 146 consecutive PPIs were identified; the rate of "failure-to-cross" was 11.6% (17 patients). The majority of patients with "failure-to-cross" were male (82%) with single-vessel runoff (53%). Compared to successful interventions, the incidences of chronic limb-threatening ischemia (82% vs. 70%, P=0.34) and infrapopliteal occlusive disease were similar (47% vs. 31%, P=0.20). "Failure-to-cross" procedures were just as long as successful procedures; there were no significant differences in fluoroscopy time (27±10 vs. 24±14min, P=0.52), in-room time (106±98 vs. 103±44min, P=0.84), or contrast dye volume utilization (73±37 vs. 96±54mL, P=0.12). As expected, "failure-to-cross" procedures incurred far higher hospital charges and costs compared to noninterventional diagnostic angiograms (charges $13,311±6,067 vs. $7,690±1,942, P<0.01; costs $5,289±2,099 vs. $2,826±1,198, P<0.01). Despite the additional time and effort spent attempting to cross difficult lesions, the operators were reimbursed at the same low rate as a purely diagnostic procedure (average fee charge $7,360; average reimbursement $992). After 1 year, the 17 patients in whom lesions could not be crossed were treated with advanced interventional procedures with success (n=2), surgical bypass grafting (n=5), extremity amputation (n=4), or no additional intervention in their salvaged limb (n=6). Patients whose lesions cannot be crossed during PPI fare worse than patients undergoing successful interventions. Hospital costs and charges appropriately reflect the high technical difficulty and resource utilization of extended attempts at endovascular therapy. For practitioners, crossing lesions during PPI is truly a "pay-for-performance" procedure in that only successful procedures are reasonably reimbursed.

Preprocedural Cross-Sectional Imaging Prior to Percutaneous Peripheral Arterial Disease Interventions.

Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.

Comparison of Percutaneous Peripheral Intervention Performed in a Dedicated Hybrid Operating Theater vs Cardiac Catheterization Laboratory

Journal of the American College of Surgeons 229(4):p e249, October 2019. | DOI: 10.1016/j.jamcollsurg.2019.08.1307