Repeat Angioplasty Research Articles

Intravascular lithotripsy-assisted percutaneous deep vein arterialization for no-option chronic limb-threatening patients and heavily calcified tibial occlusive disease.

To report the first chronic limb-threatening ischemia (CLTI) patients who underwent an intravascular lithotripsy (IVL)-assisted percutaneous deep vein arterialization (pDVA). An 81-year-old patient presented with CLTI and a heavily calcified lesion of the popliteal artery and tibioperoneal trunk (TPT), with a distal tibial and foot arch occlusion. The patient underwent IVL and drug-coated balloon angioplasty for the distal popliteal artery and of the TPT to improve the inflow prior to pDVA. The wound situation remained stable without secondary procedure until the patient`s deaths due to complications of urosepsis 3months later. A 64-year-old patient with rest pain of the left limb with a single-vessel tibial run-off (peroneal artery) and occluded pedal arch was treated with 3.5mm IVL followed by a successful pDVA as mentioned above. IVL performed in the proximal posterior tibial artery to optimize the inflow to the circuit and change the compliance of the crossing point from the arterial to the vein system. The patient underwent repeat angioplasty of the plantar vein arch 5months after the index procedure and thereafter remained asymptomatic during 2years of follow-up. The combined use of IVL and pDVA could improve the patency of the reconstruction with clinical benefits in no-option CTLI patients.

Treatment of In-stent Restenosis of the Internal Carotid Artery Using Drug-eluting Balloons.

In-stent restenosis (ISR) following internal carotid artery (ICA) stenting is relatively common with an estimated incidence of 5%. Treatment options include repeat angioplasty with conventional or drug-eluting balloons (DEB), repeat stent angioplasty and surgical intervention. Application of DEB in ISR of the coronary and peripheral arteries is an established method; however, data on DEB treatment of ICA ISR are sparse. In this work, results from aretrospective cohort of 45patients harboring 46ICA ISR lesions treated with DEB angioplasty are presented. Clinical, procedural and imaging data from DEB angioplasty treatment of 46high-grade ICA ISR lesions in 45patients, performed between 2013 and 2021 were collected. Asingle type of DEB (Elutax, Aachen Resonance, Aachen, Germany) was used in all procedures. Imaging follow-up was performed by regular Doppler ultrasound (DUS), verified by computed tomography angiography (CTA) in cases suspicious for arecurrent ISR. Technical success was 100%. Intraprocedural and postprocedural complications were not encountered. Clinical follow-up was obtained in all patients. Recurrent stroke in the affected territory was not encountered. Arecurrent ISR following DEB treatment was confirmed by DUS and CTA in 4/46(8.7%) of the lesions and were retreated with DEB. Athird recurrent ISR occurred in asingle case (2%) and following asecond DEB retreatment there were no signs of afourth recurrence after 36months follow-up. The use of DEB angioplasty is asafe and effective treatment of ICA ISR lesions, yielding significantly better results compared to other modalities. Randomized multicenter studies are warranted.

Two Years Follow-Up Outcome of Synergy™ Coronary Stent: Comparison between Case Control Study-Oriented Definition/Criterion and Real-World Results

Objectives: To clarify the 2 years outcome of Bioabsorbable Polymer Everolimus-Eluting Stent (BP-EES) using several criteria/definitions. Previous reports have showed worse outcomes in Real-World (RW) setting than case-Controlled Clinical trials (CC). Methods and Materials: We studied consecutive patients who received BP-EES implantation from October 2017 through January 2018. We adopted the parameters used in previous BP-EES associated CC (SYNERGY, EVOLVE), compared the CC inclusion criteria (on-label) with others (offlabel) at 2 years follow-up. Results: There were 678 BP-EESs inserted in 437 patients (283 male, mean age 72.3±11.2 years). Data from 4 patients lacked, and therefore the follow-up rate was 99.1%. There were 381 patients (87.2%) satisfying the CC criteria. Male gender, ejection fraction <40%, smoker, multiple stenting, total stent length, target vessel failure and all death was higher in the off-label group (P<0.05). Regarding revascularization- related parameters (all target lesion/non-target lesion revascularization), there was no difference between the 2 groups (TLR 6.1% vs 3.6%, non-TL TVR 5.6% vs 10.9%; CC vs off-label, p=ns, respectively). On the other hand, comparison of TLR using the CC definition (ischemia-oriented TLR) and real-world definition (any TLR) showed approximately 2-3 times higher frequency in the real-world basis (1.6% vs 5.8% per patient basis and 2.1%vs 5.8% per stent basis). Conclusions: Different definitions for repeat angioplasty among the reports may be a key cause of the discrepancy in revascularization frequency in dug-eluting stent studies, and it is the different inclusion criteria among studies that are associated with patient vulnerability.

Endovascular treatment of multilevel brachiocephalic artery lesions in asymptomatic patients: a case series

Objective: To evaluate the outcomes of complete endovascular carotid revascularization in asymptomatic patients with tandem lesions of common carotid arteries (CCA) and internal carotid arteries (ICA) and to demonstrate the endovascular technique.Methods: Endovascular treatment of two-level brachiocephalic artery lesions was performed in 23 patients at the Almazov National Medical Research Centre from 2017 to 2022. The mean age of the patients was 71.3 years. The lesions were localized in the left CCA and ICA in 11 patients, in the right CCA and ICA in 7 patients, and in the brachiocephalic trunk and right ICA in 5 patients. All patients were asymptomatic on the affected side. Results: Completed with successful stent implantation, all the procedures were effective, with no complications at the access site (hematoma, dissection, bleeding) and no perioperative mortality or residual stenoses. Postoperative neurological disorders developed in two patients including ipsilateral neurological symptoms (NIHSS score 4, Rankin score 1) in one of them and moderate aphasia and dysarthria NIHSS score 2, Rankin score 1) in the other. Brain MSCT showed signs of ischemic stroke that did not require any additional surgical treatment in the second patient. Following the rehabilitation, the neurological symptoms regressed. The mean hospital stay was 4 days. Two years after the intervention two patients required reintervention, i.e. repeat angioplasty of the ICA stent, due to in-stent restenosis.Conclusion: The outcomes in a series of patients with tandem brachiocephalic artery lesions indicate the efficacy of complete endovascular intervention with good short-term results. Received 23 June 2022. Revised 31 July 2022. Accepted 23 August 2022 Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interests: Authors declare no conflict of interest. Contribution of the authorsLiterature review: A.V. Soboleva, V.A. SolovievDrafting the article: A.G. Vanyurkin, Yu.K. BelovaCritical revision of the article: M.A. ChernyavskiySurgical treatment: M.A. Chernyavskiy, A.G. Vanyurkin, N.V. SusaninFinal approval of the version to be published: A.G. Vanyurkin, A.V. Soboleva, N.V. Susanin, Yu.K. Belova, V.A. Soloviev, M.A. Chernyavskiy

Abstract 14757: Affected Patients and Clinical Outcomes After Transcatheter Relief of Superior Vena Cava Stenosis

Background: Obstruction of the superior vena cava (SVC) is thought to be mostly iatrogenic. Transcatheter interventions relieve stenosis with good long-term results, but there is a paucity of published data. We aim to describe patient characteristics and outcomes after transcatheter SVC intervention. Methods: Single-center, retrospective study of patients who underwent transcatheter SVC intervention from December 2006 to January 2020. Patient characteristics included age, gender, height, weight, and BSA. Clinical parameters included congenital heart disease (CHD), orthotopic heart transplant (OHT), upper extremity central venous line (CVL), extracorporeal membranous oxygenation (ECMO), mortality, and symptoms. Procedural data included pre- and post-intervention SVC pressure gradient, dimensions, and complications. Results: A total of 42 patients (median age 1.5 years, IQR [0.31-15], 64.2% male) underwent 81 procedures with 1 major complication, and 20 patients (47.6%) had re-interventions. 12 patients (31.5%) had symptoms. Affected patient groups were as follows: history of CVL (92.9%), CHD (76.2%), post-OHT (42.9%), and post-ECMO (30.9%). Those who underwent initial balloon angioplasty were significantly younger (mean ± SD: 3.9 ± 6.8 vs. 13.1 ± 11.3 years, p<0.01) and smaller (15.9 ± 20.4 vs. 39.9 ± 31.2 kg, p<0.01) than those with initial stent. A lower pressure gradient and larger post-intervention dimension was achieved after stenting (p<0.01). Re-intervention rates were similar; 50% after balloon and 43.8% after stent, but nearly half of the angioplasty cohort resolved after repeat angioplasty alone, while most stents (85.7%) required serial re-dilation. Affected patient groups were not associated with re-intervention, and there were no significant differences in patient or procedural characteristics between those who did and did not require re-intervention. Conclusions: We describe at-risk groups who warrant surveillance of SVC stenosis in the setting of a low-symptom rate. Strongly consider balloon angioplasty as initial therapy, which may avoid the need for stent and subsequent re-dilations associated with growth. Re-intervention is likely after balloon angioplasty and stenting, but both are safe and effective.

Friday, June 17, 202210:00 AM - 12 PMPO01: Intravascular Brachytherapy of the Coronary Arteries for In Stent In Stent Restenosis: Sicker Patients, but Just as Safe

<h3>Purpose</h3> More than 20 years ago prophylactic intravascular brachytherapy burst into the radiation oncology lexicon, only to be replaced within a few years by the introduction of drug eluting stents. However, restenosis still occurs in 5- 15% of high risk patients with two or more layers of drug eluting stents. We examined our experience in patients with in stent in stent restenosis who have no options for durable revascularization and therefore are forced to lead a shortened and sedentary life, comparing this to our historic control group. <h3>Materials and Methods</h3> A retrospective cohort of 134 patients treated with angioplasty followed by intracoronary brachytherapy was compared to a current high risk group of 122 patients with in stent in stent restenosis. All patients had a minimum 6 month follow up post brachytherapy. None of the original cohort had stenting performed at the time of brachytherapy, while all patients in the restenosis cohort had placement of at least 2 layers of intracoronary stents prior to repeat angioplasty and IVBT. <h3>Results</h3> In the original cohort, there were no intraprocedural deaths, while the high risk cohort had a single intraprocedural death due to intracoronary thrombosis. No high risk patient developed any significant cardiovascular event otherwise at 6 months post-procedure. <h3>Conclusions</h3> Intravascular brachytherapy for in stent in stent restenosis is equally safe compared to the historic post angioplasty IBVT safety profile, despite the fragile nature and relatively high risk disease status of these patients with limited options.

Coil Embolization Of Persistent Type 1 Endoleak

Type I endoleak is a well-known complication of endovascular repair which could be due to the patient or technical factors during the procedure. Every type I or type III endoleak should be repaired prior to completion of the endovascular repair procedure. In the case of type I endoleak aneurysm, the sac is still pressurized and will grow over time. Every attempt should be made to resolve endoleak prior to the completion of the procedure. Available strategies to treat type I endoleak include: (1) Repeat angioplasty of the seal zone; (2) Addition of an aortic cuff; (3) Use of balloon-expandable bare-metal stents to increase the radial force; (4) Use of endoanchors to obtain better graft/aorta apposition; (5) Extension of the graft with snorkel or fenestrated endograft to extend the seal zone beyond the visceral branches; and (6) Explantation and open repair.

Improvement of Cerebrovascular Reserve by Percutaneous Transluminal Angioplasty for Symptomatic Middle Cerebral Artery Stenosis.

The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF). Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01). PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events.

Balloon angioplasty of bidirectional Glenn anastomosis.

We aim to assess the safety and efficacy of the transcatheter balloon dilation of superior cavopulmonary anastomosis (SCPA). SCPA stenosis can lead to impaired pulmonary blood flow, hypoxemia and development of veno-venous collaterals with right-to-left shunt. Balloon dilation of SCPA has been rarely reported and follow-up information is lacking. We performed a retrospective review of patients who underwent cardiac catheterisation and angioplasty of SCPA and reviewed patient's demographics, diagnosis, SCPA surgery and post-operative course, catheterisation haemodynamics, procedural technique, angiography, and the findings of follow-up catheterisation. Between 2008 and 2017, seven patients showed significant narrowing of SCPA and underwent balloon angioplasty, all of whom had undergone bidirectional Glenn (BDG). Indications for cardiac catheterisation included persistent pleural effusion, hypoxemia, and echocardiographic evidence of BDG stenosis or routine pre-Fontan assessment. Five patients had bilateral SCPA. The procedure was successful in all cases with increase in the stenosis diameter from a median of 3.3 mm (range 1.2-4.7 mm) to a median of 4.7 mm (range 2.6-7.8 mm). All patients had at least one follow-up cardiac catheterisation. Only one patient required repeat angioplasty at the 2.3-month follow-up with no further recurrence. Sustained results and interval growth were noted in all other cases during up to 29 months of follow-up. No adverse events were encountered. Based on our small series, balloon angioplasty of BDG stenosis is feasible and safe and appears to provide sustained improvement with interval growth and only the rare recurrence of stenosis.

The Meaning of Life Related to Heart Disease and Its Relationship to Quality of Life After Repeat Coronary Artery Angioplasty.

Following angioplasty for coronary artery disease, patients may search for a new meaning of life. The purpose of this study was to determine patients' meaning of life related to heart disease and its relationship to quality of life after repeat coronary artery angioplasty. The current descriptive-correlation study recruited 144 patients with coronary artery disease admitted to hospitals in Karaj, Iran. Data were collected using a demographics questionnaire, the Meaning in Heart Disease (MHD) instrument, and the Iranian version of the Short Form Health Survey (SF-12), and were analyzed with descriptive statistics and the Pearson correlation. There was a significant relationship between the meaning of life related to heart disease (creating illusions, changing goals, reattribution, and meaning congruence) and quality of life scores (p <.05). The majority of the patients undergoing repeat angioplasty used the creation of illusions to support a positive attitude toward their heart disease. Nursing interventions based on the individual patient's meaning of life can promote health and life quality.

Percutaneous Venoplasty for Central Venous Stenosis: Effect on Patient's Symptoms and Patency of Arteriovenous Accesses.

To determine symptomatic relief and patency rate of arteriovenous (AV) fistulae and grafts after venoplasty in patients with central venous stenosis (CVS) on hemodialysis. Case series. The Aga Khan University Hospital, Karachi, from January 2012 to December 2017. The data of patients who had one session of successful venoplasty for CVS were reviewed. The outcomes measured were symptomatic recovery and improvement in the patency of AV accesses. Symptomatic recovery was termed 'complete', when there was complete symptomatic relief after venoplasty; and 'partial' when the procedure was technically successful, but symptoms were not resolved. Primary patency of AV access was the duration from first intervention till further intervention. Cumulative patency was the total duration of time fistula remains patent with multiple interventions. Events, considered end points to functional access status, were placement of new access site, ligation of access site, dialysis catheter placement or the patient death. Thirty-five patients had technically successful venoplasty with mean age of 56.86 ±14.6 years. Twenty-one (60%) were female patients. All patients tolerated the procedure well. Twenty-one (60%) patients had complete relief of symptoms. Fourteen patients (40%) had partial relief of symptoms. Twenty-one patients required repeat angioplasties. The mean follow-up was 18.6 ±9.02 months. Primary patency was 40%, 24%, 24% at 6, 12 and 24 months. Cumulative patency was 69%, 66% and 59% at 6, 12 and 24 months. Percutaneous venoplasty provided symptomatic relief to the patients and improved the short-term patency of AV accesses.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis

Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO2 digital subtraction angiography (CO2-DSA) and balloon angioplasty to manage failing renal transplants. Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities. Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75mL of CO2 was used, supplemented with 17.4mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence. CO2-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

Outcomes After Percutaneous Angioplasty of Arteriovenous Fistulas and Grafts in African American Patients

PurposeArteriovenous fistulas and grafts, necessary for hemodialysis, may develop stenoses due to neointimal hyperplasia, which often require percutaneous transluminal angioplasty. Patient and lesion characteristics were evaluated prior to angioplasty and were correlated with 1- and 6-month outcomes. Materials and MethodsThis was an observational study of African American hemodialysis patients who presented for angioplasty of a dysfunctional fistula or graft. Clinical outcomes were ascertained from dialysis facilities 1 month and 6 months after angioplasty. One-month clinical success was defined as dialyzer blood flows of 450 mL/min without complications or interval shunt thrombosis, interventions, or loss of access, which was rarely achieved at 6 months. Logistic regression models were used to evaluate associations of clinical variables with outcomes. ResultsThere were 150 stenoses treated during 99 procedures performed on 82 patients. The clinical success rate at one month was 67% with no complications as a result of the percutaneous transluminal angioplasty. Success at 1 month was positively associated with use of aspirin (P = .005) and with referral for high venous pressures (P = .004). Six-month data were available for 81 procedures, with 45.7% requiring repeat angioplasty and 12.3% suffering major complications (thrombectomy, revision surgery, or access abandonment). Major complications were seen predominantly in patients who were not receiving aspirin. ConclusionsAspirin use and high venous pressure were associated with 1-month clinical success and fewer major complications at 6 months. Future work should investigate biologic mechanisms of action of aspirin and long-term effects of use to maintain vascular access.

Abstract WP118: Incidence and Management of Re-stenosis in Patients Stented for Intracranial Atherosclerotic Disease: A Consecutive Series of 226 Patients

Introduction: Angioplasty and stenting for intracranial atherosclerotic disease can re-establish adequate luminal diameter in highly stenotic arteries and improve cerebral blood flow. As in other vascular territories, intracranial stented arteries may develop delayed re-stenosis due to progression of atherosclerotic disease or endothelial hyperplasia. The primary strategies for management of re-stenosis have included aggressive medical therapy, angioplasty only, and repeat angioplasty and stenting. Materials and Methods: A total of 226 patients underwent intracranial angioplasty and stenting for symptomatic ICAD from 2000-2017. Patients were treated with balloon expandable coronary stents until 2002, when self-expanding intracranial nitinol stents became available. The series included: 21 balloon expandable coronary stents, 33 Neuroform stents, 37 Enterprise stents, and 135 Wingspan stents. Of this group, 210 patients had delayed follow up intracranial vascular imaging at 6 months, 1 year, and longer. In follow up, 24 of the 210 patients (11.4 %) developed significant re-stenosis, defined as 70% or greater. Eleven of the patients were symptomatic and 13 had no symptoms. A total of 17 patients underwent endovascular treatment of their re-stenosis, and 7 had medical management only. Results: The mean time interval for re-stenosis was 8.7 months. Of the 17 patients treated with endovascular therapy for re-stenosis, 4 patients had angioplasty only and 13 patients had angioplasty and stenting. There was one peri-procedural stroke in this group (5.9%) and no other strokes in the follow up period (mean 2.4 years, range 6 months - 7 years). Of the 7 patients who were managed medically, 1 patient had a stroke (14.3%) in the follow up period at 10 months (mean follow up 2.1 years, range 3 months - 5 years). Discussion: The preliminary data from this study suggests that patients with severe re-stenosis may be at significant risk of stroke, even if the re-stenosis is currently asymptomatic. As with other vascular territories, re-stenosis can be managed with multiple modalities, but repeat angioplasty and stenting in this series appears to be a low risk and viable option for these patients compared with medical therapy alone.

Combined Endovascular Treatment with Distal Radial Artery Coil Embolization and Angioplasty in Steal Syndrome Associated with Forearm Dialysis Fistula.

The present study was performed to define the results of the endovascular treatment with angioplasty and distal radial artery embolization in ischemic steal syndrome associated with forearm arteriovenous accesses. The cases referred to our interventional radiology unit with symptoms and physical examination findings suggestive of ischemic steal syndrome were retrospectively evaluated first by Doppler ultrasonography, and then by angiography. Cases with proximal artery stenosis were applied angioplasty, and those with steal syndrome underwent coil embolization to distal radial artery. Of 589 patients who underwent endovascular intervention for dialysis arteriovenous fistulae (AVF)-associated problems, 6 (1.01%) (5 female, 1 males; mean age 62 (range 41-78) with forearm fistula underwent combined endovascular treatment for steal syndrome. In addition to steal phenomenon, there were stenosis and/or occlusion in proximal radial and/or ulnar artery in 6 patients concurrently. Embolization of distal radial artery and angioplasty to proximal arterial stenoses were performed in all patients. Ischemic symptoms were eliminated in all patients and the AVF were in use at the time of study. In one patient, ischemic symptoms recurring 6months later were alleviated by repeat angioplasty of ulnar artery. In palmar arch steal syndrome affecting forearm fistulae, combined distal radial embolization and angioplasty is also an effective treatment method in the presence of proximal radial and ulnar arterial stenoses and occlusions.

Endovascular Revascularization for Carotid Artery Occlusion in Patients with Takayasu Arteritis

Type I Takayasu arteritis is a progressive inflammatory disease involving the aortic arch and its main branches. If untreated, patients may develop a variety of serious conditions ranging from hemiplegia to death. Whilst there is a relatively strong evidence base for the outcome of surgical techniques, few reports have focused on revascularization using an endovascular technique in patients with Takayasu arteritis. From May 2007 to March 2013, 11 consecutive patients with Takayasu arteritis presenting with severe cerebral ischemia symptoms caused by occlusive lesion in carotid artery underwent elective revascularization, 10 on the left carotid artery and 1 on the right. All patients received immunosuppressive treatment pre-and post-operation. Contraindications to open surgery included: ESR >40 mm/h; ipsilateral cerebral infarction of <2 weeks duration and sufficient poor health whereby the patient cannot tolerate general anesthesia. Quality of life was analyzed using the EQ-5D questionnaire before and after surgery. Patients were followed for a mean of 31.6±27.4 months. Seven cases of total occlusion and 2 cases of severe stenosis were recanalized successfully and experienced clinical remission. Recanalization failed in 2 patients, both of whom had occlusion of a long segment of the artery. Initial endovascularization comprised small diameter, low pressure dilatation only to allow time for the reopened arteries to respond. If clinically indicated, repeat angioplasty with a larger diameter balloon was performed 1-3 months later. Major complications occurred in 2 patients. Eight of the recanalized carotid arteries were patent at the end of follow-up and patients had satisfactory quality of life In patients with Takayasu arteritis, carotid artery recanalization via endovascular surgery combined with immunosuppressive therapy is effective and can be performed safely and repeatedly. The improvement in carotid artery blood flow supplying the central nervous system relieves symptoms of cerebral ischemia and is associated with an improved quality of life.

Balloon angioplasty for revision of failing lower extremity bypass grafts

The aim of this study was to evaluate the efficacy and safety of balloon angioplasty as the primary method of intervention in patients with color duplex ultrasound documented failing bypass grafts and to determine factors that may affect the patency of lower extremity bypass grafts revised by percutaneous transluminal angioplasty (PTA). All consecutive patients who underwent lower extremity bypass grafts from January 2009 to December 2013 were enrolled in a graft surveillance program. Patients identified as having failing grafts underwent arteriography to confirm the diagnosis with a view to concomitant treatment of the lesion using balloon angioplasty. Procedural success was defined as <30% residual stenosis. Treatment failure was defined as target lesion restenosis or graft occlusion. Descriptive and life-table analyses were performed. PTA was used to revise 96 failing grafts in 90 patients. Mean age was 65.8 years (range, 50-88 years), 64% were male, and 66% were symptomatic. Mean follow-up was 18.5 months (range, 3-24 months). Twenty-four grafts (25%) underwent repeat angioplasty for restenosis. Grafts with multiple lesions (P = .009) and grafts aged <6 months from the index operation (P = .004) were the only graft-related variables that showed a significant effect on the longevity of the endovascular revision. The PTA-revised grafts had primary, assisted primary, and secondary patency rates of 56.9%, 83.2%, and 90%, respectively, at 2 years. Primary balloon angioplasty of failing lower extremity bypass grafts, notwithstanding the higher restenosis rate and the need for reintervention, appears to be safe and is associated with acceptable early and medium-term patency rates. Grafts with multiple lesions and those revised ≤6 months of the index operation showed a significant association with the need for a second revision at the same site.

Cephalic arch stenosis: angioplasty to preserve a brachiocephalic fistula or new brachiobasilic fistula?: a cost-effectiveness study

Background: Our aim was to evaluate the cost-effectiveness of repeat angioplasty versus new brachiobasilic fistula (BBF) in patients with symptomatic cephalic arch stenosis (CAS). Methods: Patients presenting with symptomatic CAS (n = 22) underwent angioplasty. They were compared to patients undergoing BBF creation (n = 51). Primary outcomes were functional primary arteriovenous fistulae patency at 3, 6 and 12 months. Data were collected on number of interventions, alternative accesses and hospital days for access-related complications. Quality of life was assessed using Kidney Disease Quality of Life-36 scores. Decision tree, Monte Carlo simulation and sensitivity analysis permitted cost-utility analysis. Healthcare costs were derived from Department of Health figures and are presented as cost (£)/patient/year, cost/access preserved and cost/quality of life-adjusted year (QALY) for each of the treatment strategies. Results: Functional primary patency rates at 3, 6, 12 months were 87.5%, 81% and 43% for repeated angioplasty and 78%, 63% and 41% for BBF. The angioplasty cohort required 1.64 ± 0.23 angioplasties/patient and 0.64 ± 0.34 lines/patient. BBF required 0.36 ± 0.12 angioplasties/patient and 1.2 ± 0.2 lines/patient. Patients in the BBF cohort spent an additional 0.9 days/year in hospital due to access-related complications. Mean cost/patient/year in the angioplasty group was £5247.72/patient/year versus £3807.55/patient/year in the BBF cohort. Mean cost per access saved was £11,544.98 (angioplasty) versus £4979.10 (BBF). Average cost per QALY was £13,809.79 (angioplasty) versus £10,878.72 per QALY (BBF). Conclusions: CAS poses a difficult management problem with poor outcomes from conventional angioplasty. Optimal management will depend on patient factors, local outcomes and expertise, but consideration should be given to creation of a new BBF as a cost-effective means to manage this difficult problem.

E-062 Intracranial Stenting for Atherosclerotic Disease with Aggressive Anti-platelet Therapy Management: A Consecutive Series of 154 Patients

IntroductionContemporary studies of intracranial stenting have utilised standard or aggressive medical therapy involving dual anti-platelet therapy, but have not evaluated anti-platelet therapy resistance as a component of treatment failure.MethodsThe current...

Angioplasty of the superior gluteal artery in 34 patients with buttock claudication.

To evaluate the performance of balloon angioplasty in the treatment of superior gluteal artery (SGA) lesions and the factors influencing results. Between April 1997 and June 2012, 217 patients were treated for disabling buttock claudication. Of these, 34 (15%) consecutive patients (30 men; mean age 70±9 years) underwent angioplasty for 44 SGA origin lesions (5 bilateral): 24 stenoses and 20 occlusions. Standardized follow-up included clinical examination at 1 and 6 months and annually thereafter; angiography or computed tomography was obtained in cases of recurrent buttock claudication. Angioplasty was successful in 31 patients; 3 of the 20 SGA occlusions could not be recanalized. Twenty-four (59%) SGAs were treated without a stent (14 stenoses and 10 occlusions), while 10 stenoses and 7 occlusions were stented. There were no instances of SGA rupture, occlusion, or pseudoaneurysm. Two recanalizations were complicated with contrast extravasation in the buttock without consequence. Over a mean 49.8±39 months (range 1-132), 5 patients died of unrelated causes. Buttock claudication recurred in 13 (38%) patients (14 SGA lesions) at a mean 21.5±14 months (range 1-132); repeat angioplasty was successful in 8 patients. Estimates of primary and secondary freedom from symptom recurrence at 4 years were 60% and 68%, respectively. There was no difference in patency between SGAs treated for occlusion or stenosis or between those treated with or without a stent. In this series, angioplasty has proven to be a safe and efficacious way to treat SGA lesions with disabling claudication. Repeat balloon dilation was effective in treating SGA restenosis but failed in three quarters of the reocclusions. Progress in guidewire design and optimal use has improved success with SGA occlusions.