SFA Occlusion Research Articles

Real-time ultrasound-guided hemostasis using suture-mediated closure device.

Suture-mediated hemostasis device takes a long time to train and have limitations in finding appropriate compression point depending on the tactile sense of the hands. If the appropriate compression point is determined using ultrasound and the instrument is used under ultrasound guidance, it is expected to reduce the technical failure and additional manual compression. This retrospective study included 104 patients in whom the ProGlide vascular closure device (Abbott Vascular, Redwood City, CA, USA) was deployed to close common femoral artery access between January 2022 and June 2022. Ultrasound-guided hemostasis was performed in 54 patients and 50 conventional hemostasis was performed. We analyzed the medical records (procedure, patient body mass index, coagulation function, visual imaging, ultrasound imaging, time to achieve hemostasis) and post-treatment medical records (progress records, nursing records) to investigate the technical success rate and complications (hematoma, pseudoaneurysm formation, SFA occlusion, access site infection) of the procedure. Technical success rate was 52/54 (Ultrasound guided group) and 47/50 (conventional group), respectively (p > 0.05). Mean hemostasis time was 271 s (US guided group) and 317 s (conventional group), respectively (p > 0.05). Additional manual compression was applied in 7/54 (US guided group) and 15/50 (conventional group) (p < 0.05). In both groups, complications such as hematoma formation, access site infection and SFA occlusion did not occur. Using ultrasound guidance when using the suture mediated closing device reduces the frequency of additional manual compression without increased risk of complication.

Modeling of Competitive Flow in Aortofemoral Bypass

Competitive flow places surgical bypasses at risk for thrombosis in certain vascular beds, such as coronary bypass. However, the anatomic configurations that may lead to flow stagnation in aortofemoral bypass remain poorly characterized. We aimed to model competitive flow and determine parameters placing bypass patency at risk. We created an aortofemoral bypass flow dynamics computer model using MATLAB software (MathWorks). Our standard model (Fig 1) included a native iliac artery of 8 mm diameter with patent superficial femoral artery (SFA, 6 mm) and profunda femoris artery (4 mm) outflow and bypass conduit (8 mm) positioned over the profunda femoris artery. Models included native iliac stenosis ranging from 0% to 100% across four time points throughout the arterial impulse cycle. Sensitivity analyses were performed for SFA and profunda femoris arterial occlusion as well as varying arterial and graft diameters. We created a total of 40 models. Fig 2 shows our base model with increasing severity of stenosis. As the severity of native iliac stenosis increases, the arterial impulse in the graft arrives more briskly. With little or no native iliac stenosis, the arterial impulse in the graft limb is delayed, but stagnation of flow does not occur as shown by the aqua coloration moving through the graft limb across time points. Sensitivity analyses demonstrated similar findings. No model demonstrated stagnation of flow portending high risk of bypass graft or native arterial thrombosis. Computer modeling did not demonstrate flow stagnation in aortofemoral bypass across a range of anatomic configurations. Our models suggest that competitive flow of a native iliac artery may not put the bypass graft at risk of flow stagnation and thrombosis.Fig 2Flow dynamics of aortofemoral bypass overlying the profunda femoris artery with increasing stenosis of the native iliac inflow artery across four time points of arterial impulse.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Retrograde Versus Antegrade Approach for the Endovascular Treatment of Symptomatic Femoropopliteal Disease: Results of the 2-Year Follow Up.

To compare the antegrade and retrograde approaches, in terms of access site complications and long-term patency in subjects undergoing EVT for symptomatic SFA or popliteal artery stenosis or occlusions. All consecutive patients who underwent retrograde recanalization for partial stenosis or chronic total occlusion of the SFA or PA at 2 centers were enrolled in this retrospective analysis. Subjects were divided into 2 groups, according to the approach selected for EVT as antegrade approach group or retrograde approach group. The rate of primary patency, which was defined as the lack of restenosis at the target lesion, was the primary outcome measure, during the follow-up evaluations. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were secondary outcome measures. A significant improvement occurred in ABI, following the intervention in both the antegrade approach group [0.7 (0.3 - 1.1) versus 0.85 (0.4 - 1.3), P < 0.001] and retrograde approach group [0.5 (0.3 - 1.1) versus 0.8 (0.3 - 1.3), P < .001]. The primary patency rate at the 1st, 6th, 12th and 24th months of the intervention in the antegrade approach group were 94.85%, 83.82%, 74.26%, and 66.91%, respectively. The primary patency rate at the 1st, 6th, 12th, and 24th months of the intervention in the retrograde approach group were 93.33%, 86.67%, 84.44%, and 71.11%, respectively. The groups were similar with respect to the primary patency rates. The rate of complications, including hematoma, bleeding, and distal embolization was similar in the 2 groups. Antegrade approach and retrograde approach provide a similar safety profile in the EVT of SFA and popliteal artery stenosis and occlusion. The primary patency rates at the 1st, 6th, 12th, and 24th months of follow up also were similar in the 2 groups. However, the significant difference in the lesion characteristics of the subjects undergoing retrograde or antegrade approach complicates the ability to reach a clear conclusion, regarding the superiority of one technique over the other.

The Influence of Diabetes Mellitus on the Outcome of Superficial Femoral Artery Recanalization is Debatable.

A retrospective analysis was carried out on 110 patients who had undergone endovascular treatment of the SFA from 2010 to 2017 comparing outcomes in diabetic (DM) vs non-diabetic patients (nDM). 56 (50.9%) of the patients were diabetic and 54 were non-diabetic (49.1%). 52.7% (62.7% DM vs 35.2% nDM, p = 0.0003) were patients with critical limb ischemia. SFA occlusion was present in 65.5% (60.7% DM vs 70.4% nDM, p = 0.29) of all patients. All had undergone PTA of the SFA and 40.9% had received adjunctive stenting (44.6% DM vs 37.0% nDM, p = 0.41). A multilevel treatment was executed in 39.1% (51.8% DM vs 25.9% nDM) of the cases whereas an infra-popliteal procedure was associated in 27.3% (37.5% DM vs 16.7% nDM). In both groups the presence of diabetes was significantly associated (p = 0.005 e p = 0.014, respectively). Reintervention rate was 22.7%; 13 in the diabetic group (23.2%) and 12 in the non-diabetic group (22.2%). Of those who had had reintervention (p = 0.77); 9 patients (8.2%) had undergone an open surgical operation, 6 of whom had diabetes (p = 0.32). 5 patients (4.5%) had had major amputation, 4 of whom were diabetic (p = 0.20). Curves assessing freedom from target lesion restenosis were substantially overlapping between the two groups. No statistical associations between diabetes and reintervention or amputation rates were found. Indication to treat the SFA were not influenced by the presence of diabetes but further investigation is required to verify our hypothesis.

Supervised Exercise Therapy or Endovascular Revascularization for Patients with Intermittent Claudication due to an Iliac Artery Obstruction? The Super Study

Introduction - The optimal treatment strategy for patients with intermittent claudication (IC) due to an iliac artery obstruction is as yet unclear. Should patients be referred for immediate Percutaneous Transluminal Angioplasty (PTA) or supervised exercise therapy (SET) and deferred PTA if SET fails? Methods - This multi-center randomized controlled trial included 240 patients from 18 hospitals in the Netherlands with IC due to a > 50% common or external iliac artery stenosis or occlusion, and a walking distance 100-300 meters on a treadmill (3.2 km/h, 10% incline). Patients were randomly allocated to PTA with or without stent, or SET, stratified for maximum walking distance (MWD) at baseline and concomitant SFA stenosis or occlusion. PTA was carried out according to local practice. SET comprised a 6 months program supervised by a dedicated physiotherapist twice a week during the first 12 weeks, once a week during the next 8 weeks and once every two weeks during the last 4 weeks. Primary endpoints were MWD on a treadmill (3.2 km/h, 10% incline) and disease specific quality of life (Qol) measured with the VascuQol questionnaire after 1 year follow-up. Analysis was performed according to the intention-to-treat principle. To take into account the repeated measurements structure of the data differences between MWD and VascuQol sumscore were assessed with a linear mixed model with a Toeplitz covariance structure. Results - Between November 2010 and May 2015, 114 patients were allocated to SET, 126 to PTA. Compliance to SET was poor; after 1 month 75/114 (66%) patients attended the program, declining to 68/114 (60%) and 57/114 (50%) after 3 and 6 months, respectively. Ten (8%) of the patients allocated to PTA did not receive the intervention, which was technically successful in 112/116 (97%) of the remaining patients. Five patients had a minor complication after PTA and 6 a major complication necessitating endovascular or surgical resolution. Some 90/114 (79%) patients allocated to SET completed one year follow-up, and 104/126 (83%) allocated to PTA. The mean MWD improved from 187 to 561 meters in the SET group and from 196 to 574 meters in the PTA group, (p=0.693) The VascuQol sumscore improved from 4.24 in the SET group to 5.58, and from 4.28 in the PTA group to 5.88, (p=0.048). Yet, in both groups the improvement in VascuQol sumscore was more than the minimally important clinical difference of 1.19 (derived from 100 participants of the SUPER study). Some 33/114 (29%) of patients allocated to SET had a PTA within one year, and 2/114 (2%) additional surgical revascularization (SR). Some 10/126 (8%) patients allocated to PTA had an additional PTA within one year and another 10/126 (8%) had SR. Conclusion - Both a strategy of immediate PTA, and SET with deferred PTA in case of SET failure improve MWD on a treadmill and disease specific Qol of patients with IC due to an iliac artery obstruction. It seems reasonable to start with SET in these patients and accept a 30% failure rate. The cost-effectiveness analysis of this RCT will further define clinical decision making.

A New Tool to Manage Side-Branch Occlusion After Covered-Stent Implantation for Vascular Complications: The Neocarina Reconstruction Technique

![Figure 1][1] Figure 1 The Neo-Carina Reconstruction-Technique (A) Femoral contrast angiography via the crossover sheath demonstrating SFA occlusion after Viabahn implantation. Schematic (B) and (C) angiographic representation of the Brockenbrough needle and Mullins sheath used to pass

Current treatment methods for long occlusions of the femoropopliteal segment in patients with intermittent claudication: Minireview

Backround. Intermittent claudication is a classic symptom of peripheral arterial disease. It is mainly treated conservatively but if this fails, a form of revascularization is indicated. The revascularization in chronic occlusion of femoropopliteal region is currently performed by two basic methods: the standard method of surgical bypass and the newer miniinvasive alternative represented by the endovascular method. The treatment of patients with solely claudication and long occlusion of femoropopliteal region remains controversial. The aim of this minireview was to determine whether surgical bypass is still the best method of choice in a time of endovascular techniques. A MEDLINE search for original and review articles using key terms, intermittent claudication and long femoropopliteal oclusion. No ideal treatment for long occlusions of the femoropopliteal segment has been established to date. It is clear that the role of endovascular techniques in the treatment of SFA occlusions is increasing. It remains that, lower risk patients with claudication should be examined to assess the quality of veins suitable for revascularization and bypass should be selected as the first method of choice.

TCT-600: The OCELOT Catheter for Long SFA Occlusions–The Six Months Follow Up

TCT-600: The OCELOT Catheter for Long SFA Occlusions–The Six Months Follow Up

Subintimal angioplasty: Our experience in the treatment of 506 infrainguinal arterial occlusions

The treatment of patients with chronic arterial occlusions involving the superficial femoral artery has changed significantly with the incorporation of subintimal angioplasty (SIA) into vascular surgery practice. To more clearly define technical feasibility, patency, and clinical outcomes of SIA, we reviewed our cumulative experience. A retrospective review of all patients who underwent SIA of arterial occlusions originating in the superficial femoral artery was performed. Patient history, demographics, procedural details, and follow-up information were collected and analyzed. Patency, limb salvage, sustained improvement in claudication, freedom from surgical bypass, and survival were determined by Kaplan-Meier analysis. From December, 2002, through July, 2006, 506 infrainguinal SIA procedures were performed in 472 patients with chronic arterial occlusion involving the superficial femoral artery. The mean age of patients treated was 69.4 +/- 11.9 years and the indication for intervention was critical limb ischemia in 63% of limbs (n = 317) and disabling claudication in 37% (n = 189). Forty-seven percent of limbs (n = 237) had isolated SFA occlusions, 40% (n = 205) had femoropopliteal occlusions, and 13% of limbs had occlusions beginning in the SFA and extending into the tibial arteries (n = 64). Technical success was achieved in 87% of procedures. Following successful SIA, the mean ankle-brachial index increased by 54%, from 0.50 +/- 0.16 to 0.77 +/- 0.23 (P < .0001). Median follow-up was 12.4 months (0-48 months) and 30-day mortality was 0.8%. Primary patency at 12 and 36 months was 45% (SE 3.0%) and 25% (SE 3.6%) respectively. Secondary patency was 76% (SE 2.6%) and 50% (SE 4.8%) at 12 and 36 months. Factors associated with reduced primary patency included femorotibial occlusions (HR 1.57, CI 1.05-2.36) and the presence of critical limb ischemia (HR 1.39, CI 1.02-1.89). Limb salvage in patients with critical limb ischemia was 75% (SE 5.9%) at 36 months. Freedom from surgical bypass in patients with either critical limb ischemia or disabling claudication was 77% (SE 4.1%) at 36 months. SIA is an effective percutaneous technique for the revascularization of patients with lower extremity chronic arterial occlusions involving the superficial femoral artery. The procedure is successfully performed in all segments of the lower extremity with minimal morbidity or mortality. Rates of limb salvage and improvement in claudication are similar to those achieved by open surgical bypass, while modest reductions in limb salvage and primary patency are experienced in limbs with femorotibial occlusions.

Abstract No. 250: Intervention of Long Segment SFA Occlusions – Is It Worthwhile?

Abstract No. 250: Intervention of Long Segment SFA Occlusions – Is It Worthwhile?

Successful complex bifurcation stenting of a native SFA after failed femoropopliteal bypass grafting

Endovascular treatments are becoming more beneficial in the treatment of complex peripheral arterial disease. We report a novel case of using a y-stenting technique at 2 bifurcation sites in the femoropopliteal region, to revascularize a long native SFA occlusion after failed femoropopliteal bypass grafting.

Percutaneous intentional extraluminal recanalization in patients with chronic critical limb ischemia.

To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI). Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival. Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%). PIER is a useful percutaneous technique for limb salvage in patients with CCLI.

Vascular 07

Aim: The course of peripheral arterial occlusive disease in patients with isolated SFA occlusion is benign. In light of the atheroprotective role of high shear-stress, we hypothesized that the haemodynamic and shear-stress alterations in distal arteries subsequent to SFA occlusion may confer atheroprotection; we determined the mean-shear-stress in the popliteal artery of stable claudicants with SFA occlusion in comparison with normal controls matched for age and sex. Methods: We measured popliteal artery diameter, mean velocity [MV] and flow [MQ] 2 cm distal to medial femoral condyle, on recumbency, using real-time gated Doppler/duplex in 50 limbs with SFA occlusion and 37 normal control limbs. Blood viscosity was calculated from plasma viscosity and haematocrit. Mean-shear-rate = 4MQ/π (Diameter/2)3; mean-shear-stress[dynes cm−2] = mean-shear-rate• viscosity. Data presented as median (interquartiles). Results: Arteriopaths' plasma viscosity [1.83(1.78–1.94)] mPa s−1 was similar to control [1.78(1.7–1.97)] mPa s−1. Conclusions: Popliteal artery mean-shear-stress in SFA occlusion is significantly higher than in normals, mainly due to higher MV and smaller diameter. Our data suggests that enhancement in haemodynamic shear forces distal to SFA occlusion may act atheroprotectively contributing to the benign vascular outcome in this pattern of disease.

Open subintimal angioplasty of the superficial femoral and distal arteries.

To describe an open approach to subintimal angioplasty. Through a subinguinal incision and arteriotomy over the superficial femoral artery origin, the opening of a subintimal channel is created surgically. The subintimal plane is advanced distally with a guidewire, and this neolumen is expanded with sequential balloon dilations. The atherosclerotic core is dissected proximally in the common femoral artery and tacked down to ensure inflow. A patch graft closes the arteriotomy. Open subintimal angioplasty is a simple, minimally invasive alternative treatment for complete SFA occlusion. Long-term follow-up in a large group of patients will be necessary to determine the durability of the false arterial lumen.

Open Subintimal Angioplasty of the Superficial Femoral and Distal Arteries

PURPOSE To describe an open approach to subintimal angioplasty. TECHNIQUE Through a subinguinal incision and arteriotomy over the superficial femoral artery origin, the opening of a subintimal channel is created surgically. The subintimal plane is advanced distally with a guidewire, and this neolumen is expanded with sequential balloon dilations. The atherosclerotic core is dissected proximally in the common femoral artery and tacked down to ensure inflow. A patch graft closes the arteriotomy. CONCLUSIONS Open subintimal angioplasty is a simple, minimally invasive alternative treatment for complete SFA occlusion. Long-term follow-up in a large group of patients will be necessary to determine the durability of the false arterial lumen.

Aortoiliac stent deployment versus surgical reconstruction: Analysis of outcome and cost

Purpose:The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. Methods:From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with χ 2 analysis. Results:There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar ( p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups ($9383 versus $8626, respectively; p = 0.66, t-test). Conclusions:Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction. (J Vasc Surg 1998;28:94-103.)

796-3 Treatment of Superficial Femoral Artery Occlusion by Percutaneous Revascularization of Ipsilateral Iliac Artery Stenosis

The acute and long-term results of percutaneous revascularization of the lower extremities are typically superior for inflow (iliac) than distal (superficial femoral artery SFA, popliteal, or infrapopliteal disease). Accordingly, we investigated the utility of performing percutaneous revascularization for only inflow (iliac) lesions in pts with both inflow as well as distal disease. We treated 43 limbs in 36 pts (28 M, 8 F, age mean ± SD = 69 ± 8 yrs) with the combination of SFA occlusion and ipsilateral iliac artery lesions by percutaneous revascularization of the iliac artery lesion only. Ten lesions involved the common iliac artery, 18 involved both the common and the external iliac arteries, and 15 consisted of external iliac artery stenosis. All pts were symptomatically Rutherford class 3 and/or above. Mean ankle-brachial index (ABI) pre-procedure was 0.55 ± 0.19. Ipsilateral iliac artery stenosis, determined by quantitative angiography, was 80 ± 12%. All iliac lesions were treated with percutaneous transluminal angioplasty (PTA) ± stent placement. PostPTA, iliac artery stenosis decreased to 8 ± 8%. Of the 43 treated limbs, 40 (93%) were associated with improvement by at least one Rutherford class. One month post-procedure, mean ABI improved to 0.63 ± 0.19(p &lt; 0.009). Complications were limited to 1 instance of arterial dissection which was successfully treated with a stent. Six-month follow-up was available on 24/43 limbs; 19/24 (79%) continued to show improved symptoms measured by Rutherford class. ABI's were remeasured at six months in 22 pts, and 18/22 (82%) showed improved ABI compared to baseline. Percutaneous revascularization limited to iliac artery stenosis in patients with ipsilateral superficial femoral artery occlusion, by augmenting arterial inflow via a patent profunda, is frequently sufficient to produce clinical improvement of disabling symptoms.