Superficial Femoral Artery Stenosis Research Articles

Prognostic Factors for Restenosis of Superficial Femoral Artery after Endovascular Treatment.

High incidence of superficial femoral artery (SFA) restenosis after percutaneous transluminal angioplasty (PTA) poses a persistent challenge in peripheral arterial disease (PAD) treatment. We studied how the patients' and lesions' characteristics, thrombin generation, overall haemostatic potential (OHP), and single nucleotide polymorphisms (SNPs) of the NR4A2 and PECAM1 genes affected the likelihood of restenosis. In total, 206 consecutive PAD patients with limiting intermittent claudication due to SFA stenosis who were treated with balloon angioplasty with bailout stenting when necessary were included. Patients' clinical status and patency of the treated arterial segment on ultrasound examination were assessed 1, 6, and 12 months after the procedure. Restenosis occurred in 45% of patients, with less than 20% of all patients experiencing symptoms. In the multivariate analysis, predictors of restenosis proved to be poor infrapopliteal runoff, higher lesion complexity, absence of treated arterial hypertension, delayed lag phase in thrombin generation, and higher contribution of plasma extracellular vesicles to thrombin concentration. Poor infrapopliteal runoff increased the risk of restenosis in the first 6 months, but not later. The negative effect of poor infrapopliteal runoff on SFA patency opens questions about the potential benefits of simultaneous revascularisation of below-knee arteries along with SFA revascularisation.

The relationship between plasma atherogenic index and long-term outcomes after endovascular intervention in superficial femoral artery lesions.

Peripheral arterial disease (PAD) results from the systemic atherosclerotic process. In this study, we aimed to determine the relationship between plasma atherogenic index (AIP), a ratio of molar concentrations of triglycerides to HDL-cholesterol, and long-term outcomes after endovascular therapy (EVT) in patients with superficial femoral artery (SFA) stenosis. We retrospectively evaluated 673 patients who underwent EVT for PAD in our tertiary center between January 2015 and December 2020. In the receiver operating characteristic (ROC) curve analysis, the AIP value with the optimum cutoff value was determined as 0.576 to detect the presence of major adverse limb events (MALEs). Patients were divided into two groups according to low AIP (<0.576 as group 1) and high AIP (>0.576 as group 2). Among the major endpoints, long-term restenosis rates were significantly higher in patients in the high-AIP group than in the low-AIP group (p<.001). The lower extremity amputation rate was not statistically significant between the two groups. All-cause mortality rate (54 (31.6) versus 117 (68.4), p<.001) was significantly higher in patients in the high-AIP group than in the low-AIP group. In addition, the MALE rate (94 (29.2) versus 218 (62.1), p<.001) was significantly higher in patients in the high-AIP group than in those in the low-AIP group. In conclusion, we found that AIP is a significant independent predictor of long-term MALE in patients who underwent EVT for SFA.

Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses

Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (Pd/Pa) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting Pd/Pa was not influenced by the degree of stenosis (p= .074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p= .019). An FFR of <0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75- 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 - 0.89), eABPI (0.72;0.57 - 0.83), and PSVR (0.65; 0.51 - 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p< .001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13±0.09; p= .009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 - 1.00). This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation.

Tomographic 3D ultrasound for grading stenosis of superficial femoral artery.

Treatment decision of lower extremity peripheral arterial disease (PAD) is governed by the severity of stenosis. Tomographic 3D ultrasound (t3DUS) is a reliable imaging technique for measuring vessel stenosis. In this study we attempted to provide a precise measurement of superficial femoral artery (SFA) stenosis using t3DUS in patients with PAD. t3DUS was used to measure maximum stenosis percentage in SFA from 50 patients with lower extremity PAD. The maximum stenosed segment in SFA was defined using Duplex 2DUS aliasing was noted. The peak systolic velocity (PSV) was measured at the maximum stenotic site and proximal to aliasing for calculating the velocity ratio. The association between blood flow velocity ratio and the degree of stenosis measured using Duplex 2DUS and t3DUS, respectively, was assessed using Spearman rank correlation. There was a strong positive correlation between velocity ratio and degree of stenosis in SFA measured using t3DUS (correlation value (r) = 0.99, p < 0.001). The correlation between Stenosis percentage and velocity ratio in SFA are as followed: <50:<2; 50-54:2-2.4; 55-59:2.5-2.9; 60-64:3-3.4; 65-69:3.5-3.9; 70-74:4-4.4; 75-79:4.5-4.9; >80:>5.

Use of stents with medication coating for the treatment of occlusive-stenotic lesions of the superficial femoral artery

Objective ‒ to analyze the results of endovascular revascularization of the femoropopliteal segment with drug-eluting stents. Materials and methods. Endovascular intervention was performed in 23 patients with stenotic lesions of the superficial femoral artery (SFA). Paclitaxel-eluting stents were used. There were 10 men (43.5 %), 13 women (56.5 %). The mean age of the patients was (66.0 ± 3.5) years. There were 16 (69.6 %) patients with diabetes mellitus type 2 and diabetic angiopathy, and 7 (23.4 %) patients had obliterating atherosclerosis of the arteries of the lower limbs. Critical ischemia of the lower extremities was diagnosed in 18 (56.5 %) cases, intermittent claudication ‒ in 5 (21.7 %). Isolated lesions of the femoral-popliteal segment were noted in 3 (13.4 %) patients, lesions of the iliac and femoral-popliteal segments ‒ in 4 (17.4 %), lesions of the femoral-popliteal and ankle segments ‒ in 16 (69.6 %). Results. Twenty (86.6 %) scheduled procedures for stenting of the SFA were technically successful. Among postoperative complications, 3 (13.04 %) patients had puncture site hematomas that did not require surgical evacuation. In 6 (26.1 %) patients, signs of reperfusion syndrome were observed, which were treated with conservative treatment. During follow-up period (3 months), there were no cases of reocclusion or clinically significant restenosis at the stented level. In 1 (5.0 %) case, a hemodynamically significant stenosis of the SFA was observed outside the implanted stent. The patient successfully underwent angioplasty of SFA stenosis. There were no «major» amputations during follow-up period. «Small» ankle amputations were performed in 7 (35.0 %) patients with diabetic gangrene, where endovascular revascularization of the femoro-popliteal and ankle segments was the stage of surgical treatment. Conclusions. Implantation of drug-eluting stents is an effective method of endovascular revascularization in patients with SFA lesions. To compare the results of implantation of drug-eluting stents with other methods of revascularization of the lesions of the femoro-popliteal segment, it is necessary to accumulate more data and increase the duration of the follow-up period.

MO230: De Novo Double Glomerulopathy (Membranous Nephropathy, Mn and Collapsing Focal Segmental Glomerulosclerosis, CFSGS) Associated to Positive Myeloperoxidase-O (MPO) Antibody Following Pfizer-Biontech MRNA Vaccination Covid 19

Abstract BACKGROUND AND AIMS In the COVID 19 pandemic era, anti SARS-CoV-2 vaccination showed high efficacy at preventing the infection and its most severe complications. The aim of this report is to describe an unusual double glomerulopathy related to anti SARS-CoV-2 vaccination and the good results obtained with the immunosoppressive treatment. METHOD An 80-year-old caucasian woman developed a nephrotic syndrome, progressive renal insufficiency and microhematuria. The patient presented a medical history of thrombocytopenic purpura treated and resolved by steroids in 2013, hypothyroidism, hypertension, ischaemic heart disease treated with surgical bypass in 2019 and pacemaker in 2020 for atrial ventricular block. Due to pandemic COVID 19 status, she received two doses of the Pfizer BioNTech mRNA COVID-19 vaccine in March 2021. Two weeks after the second dose her weight increased of 23 kg. The family physician added furosemide to her therapy for generalized edema with no diuretic effect. In April, creatinine was 1.38 mg/dL (versus 0.8 mg/dL 1 year before); urinalysis showed proteinuria (300 mg/dL) and microscopic hematuria; serum total cholesterol level was 218 mg/dL and triglycerides 178 mg/dL; then it was suggested to increase the doses of furosemide. In May 2021, creatinine resulted 2 mg/dL, serum albumin 2 g/dL, and urinalysis confirmed proteinuria and microscopic hematuria; proteinuria was 10 g/day. Abdomen ultrasound showed normal liver, kidneys and spleen, not ascites. Lower limb eco-Doppler showed right superficial femoral artery stenosis of 60% and absence of venous thrombosis. The physical examination evidenced anasarca. The patients were admitted to the nephrology unit; hepatitis B surface antigen, hepatitis C antibody and human immunodeficiency virus antigen and antibody were negative. Both complement C3 and C4 levels resulted within the normal range. Cryoglobulins were absent. Urinary Bence Jones, antinuclear antibody (ANA), anti-extractable nuclear antigen (ENA), anti-double stranded DNA (nDNA) antibodies were negative. Antineutrophil cytoplasm antibodies (ANCA) were 1:2560 with Perinuclear pattern and anti-MPO positivity (716 UA/mL); anti-proteinase-3 antibodies (PR3) were negative. Anti-phosholipase A2 receptor antibody (PLA2R Ab) was positive with high titre. A kidney biopsy was performed showing a double nephropathy: a focal segmental glomerulosclerosis (FSGS) with some collapsing features, superimposed on membranous glomerulonephritis (Fig. 1). RESULTS We started the Ponticelli regimen (alternate months steroids and cyclophosphamide). After the first month of therapy, blood tests revealed creatinine 1.7 mg/dL, haemoglobin 11.7 g/dL; serum albumin 2.7 g/dL and urinalysis without microscopic haematuria. At the third month of therapy, the patient developed atrial fibrillation and started anticoagulation; blood tests were as follows: creatinine 1.1 mg/dL, serum albumin 3.0 g/dL, Ab anti-MPO 7 UA/mL and PLA2R Ab was absent. A left ocular, frontal and parietal herpes zoster induced a short discontinuation of therapy and responded well to Acyclovir; then we concluded the fourth month of therapy. At the fifth month, a SARS CoV 2 RT PCR unexpectedly resulted positive; the patient remained asymptomatic, but we stopped definitively the therapy. One month later, blood tests showed: creatinine 1 mg/dL, serum albumin 4 g/dL, proteinuria 0.7 g/die, MPO 2 UA/mL and PLA2R Ab absent. CONCLUSION To our knowledge, this is the first case of nephrotic sindrome secondary to a de novo MN and FSGS, associated with positive MPO antibody, following Pfizer–BioNTech mRNA vaccination COVID 19; the patient responded well to immunosoppression going in remission and regaining renal function.

Mixed-braided stent: An effective way to improve comprehensive mechanical properties of poly (L-lactic acid) self-expandable braided stent

For its unique flexibility, self-expandable braided stent has been wildly used in the treatment of peripheral vascular diseases, such as the superficial femoral artery stenosis. With the application of bioabsorbable polymer materials, stent braided by polymer filaments is explored, and expected to minimize the complications caused by long-term retention of commercial metallic stents in the human body. Poly (L-lactic acid) (PLLA) is the representative of degradable polymer materials, and has been broadly applied in stent for its good mechanical properties and biocompatibility. This study aimed to propose a new preparation method for PLLA self-expandable braided stent by mixed-braided technology, and evaluate its mechanical properties especially in radial supporting performance and flexibility. For this purpose, a series of stent samples were prepared by mixed braiding PLLA monofilament with different diameters. In addition, the pitch angle and monofilament diameter are also considered as two critical design parameters affecting stent mechanical performance. Then, the radial strength and flexibility of different samples were evaluated respectively. The results show that the mixed-braided stent keep the excellent flexibility of thin monofilament braided stent, meanwhile it possesses the good radial supporting performance of the thick monofilament braided stent. This paper provides an idea to improve the comprehensive mechanical properties of PLLA self-expandable braided stent.

Predictors of Peripheral Artery Disease Progression. Is there Any Role for Vascular Age?

Predictors of Peripheral Artery Disease Progression. Is there Any Role for Vascular Age?

Aneurysmal degeneration of fluoropolymer-coated paclitaxel-eluting stent in the superficial femoral artery: a rising concern

BackgroundAlthough several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia; Boston Scientific, Marlborough, MA, USA) placement, aneurysmal degeneration after drug-eluting stent (Eluvia) placement has raised clinical concerns. Here, we report a case with progressive aneurysm formation on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery atheromatous plaque.Case presentationA 79-year-old woman with right leg intermittent claudication at 100 m distance was referred to our hospital. Pre-procedural angiography showed long-segment severe stenosis from the middle-to-distal part of the right superficial femoral artery, and a 7 mm wide drug-eluting stent (Eluvia) was placed. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal superficial femoral artery in-stent restenosis. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed femoral artery enlargement with a maximum vessel diameter of 10.0 mm at the distal edge of the stent. Intermittent claudication on the right side recurred again 50 months after drug-eluting stent (Eluvia). Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Peri-stent contrast staining was found at the distal part of the drug-eluting stent (Eluvia) site. Intravascular ultrasound showed a further enlargement of maximum vessel diameter to 12.0 mm at the distal edge of the stent.ConclusionsWe report a case with progressive aneurysm degeneration on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery stenosis.

Distal Radial Artery Access for Superficial Femoral Artery Interventions

Purpose: To compare the acute success and complication rates of distal radial (DR) vs proximal radial (PR) artery access for superficial femoral artery (SFA) interventions. Materials and Methods: Between 2016 and 2019, 195 consecutive patients with symptomatic SFA stenosis were treated via DR (n=38) or PR (n=157) access using a sheathless guide. Secondary access was achieved through the pedal artery when necessary. The main outcomes were technical success, major adverse events (MAEs), and access site complications. Secondary outcomes were treatment success, fluoroscopy time, radiation dose, procedure time, and crossover rate to another puncture site. Results: Overall technical success was achieved in 188 patients (96.4%): 37 of 38 patients (97.3%) in the DR group and 151 of 157 patients (96.2%) in the PR group (p=0.9). Dual (transradial and transpedal) access was used in 14 patients (36.8%) in the DR group and 28 patients (18.9%) in the PR group (p<0.01). Chronic total occlusions were recanalized in 25 of 26 DR patients (96.1%) and in 79 of 81 PR patients (92.6%) (p=0.57). The crossover rate to femoral access was 0% in the DR group vs 3.2% in the PR group (p=0.59). Stents were implanted in the SFA in 15 DR patients (39.4%) and in 39 patients (24.8%) in the PR group (p=0.1). The contrast volume, fluoroscopy time, radiation dose, and procedure time were not statistically different between the DR and PR groups, nor were the rates of access site complications (2.6% and 7.0%, respectively). The cumulative incidences of MAE at 6 months in the DR and PR groups were 15.7% vs 14.6%, respectively (p=0.8). Conclusion: SFA interventions can be safely and effectively performed using PR or DR access with acceptable morbidity and a high technical success rate. DR access is associated with few access site complications.

Severe radial artery spasm causing entrapment of the Terumo radial to peripheral destination slender sheath: a case report.

BackgroundRadial access for lower-extremity peripheral vascular interventions (PVIs) has been limited due to inadequate equipment lengths. The Terumo R2P Destination Slender sheath is a relatively new sheath designed for these interventions. However, complications related to this sheath or access strategy for lower-extremity PVI have not been reported.Case summaryA 69-year-old woman presented with purple discolouration of her 1st and 5th toes of the left foot for approximately 1 month. Lower-extremity arterial duplex ultrasound showed mid left superficial femoral artery (SFA) greater than 90% stenosis. Peripheral angiogram was performed via the left radial artery and this confirmed the presence of severe left SFA stenosis. Intra-arterial vasodilators including verapamil and nitroglycerine were administered to prevent radial artery spasm. Next, we attempted to deliver the Terumo 6-Fr R2P Destination Slender 119 cm sheath for the interventional procedure. However, the sheath became stuck at the level of mid axillary artery due to severe radial artery spasm. Despite use of intra-arterial vasodilators, deep sedation with propofol, and gentle retraction, the sheath could not be removed and eventually broke requiring surgical removal.DiscussionThis case demonstrates severe radial artery spasm causing sheath entrapment that required emergency surgery for sheath removal. Unfortunately, the sheath could not be removed despite typical manoeuvres for severe spasm including intra-arterial vasodilators and deep sedation with propofol. Physicians performing PVIs via radial access need to be aware of this potentially serious complication.

Health-related quality of life after vascular surgery and endovascular treatment in subjects with critical limb ischemia.

Background & Objective:Revascularization of the target vessel and restoration of distal flow is critical not only to reduce mortality and morbidity but also improve health-related quality of life (HRQoL) in patients with critical limb ischemia. However, data concerning the impact of surgical bypass and percutaneous transluminal angioplasty (PTA) on HRQoL is limited. This study aimed to compare the impact of surgical bypass and PTA on HRQoL in subjects undergoing superficial femoral artery (SFA) or popliteal artery revascularization.Methods:Seventy-one subjects who underwent successful revascularization of the SFA or popliteal artery either with surgical revascularization or PTA were enrolled in this study. Three months after revascularization, all subjects underwent ankle-brachial index (ABI) measurement, 6-minute walking test and completed the Nottingham Health Profile (NHP) questionnaire. The NHP score differences (measured at the post-procedural 3rd month) between subjects undergoing surgical or endovascular (PTA) revascularization subjects was the primary outcome measure of the study.Results:Both groups experienced significant improvements in ABI and 6-minute walking distance at post-procedure three months. NHP total scores of Part I and Part II at post-procedural six months were similar in the two groups. However, social isolation [77.98 (0 - 85) vs. 22.53 (0 - 100), p=0.002] and physical abilities [78.7 (30.31 - 87.7) vs. 54.47 (0 - 100), P=0.014] domain scores of the surgical revascularization group were significantly higher than that of the endovascular treatment group.Conclusion:This study shows that total scores obtained from the NHP questionnaire applied three months after revascularization of SFA stenosis are similar in subjects undergoing surgical revascularization or PTA. However, the social isolation and physical abilities domains of the NHP are significantly higher in subjects receiving surgical revascularization compared to those receiving PTA.

Pressure- and Velocity-Based Physiological Assessment of Stenotic Lesions at Hyperemia in Superficial Femoral Artery Disease: Importance of Hyperemic Stenosis Resistance.

Background: In superficial femoral artery (SFA) stenosis, stenosis resistance may increase, but the relationship between stenosis resistance and stenotic severity remains to be seen. This study aimed to investigate the physiological response, through a hyperemic condition, and the pathophysiological significance of Doppler flow and stenosis resistance in SFA.Methods: Twenty-four limbs with focal stenosis of the SFA were analyzed. We assessed the fractional flow reserve (FFR), hyperemic stenosis resistance (h-SR), and vascular flow reserve (VFR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT).Results: FFR, h-SR, and VFR changed significantly after EVT. h-SR was more strongly correlated with % area stenosis, measured by intravascular ultrasound than FFR (FFR: r=−0.716, h-SR: r=0.741, p<0.0001, respectively). However, VFR was not associated with % area stenosis. A receiver operating characteristic curve showed cut-offs h-SR >0.36 mmHg·sec/cm, and FFR <0.88 predicted >75% area stenosis with area under curves of 0.883 and 0.828, respectively.Conclusion: h-SR can indicate stenotic severity in an SFA focal lesion more prominently than FFR and may be a new physiological index to determine indication for EVT. VFR was not feasible for assessment in SFA focal stenosis.

Effects of mean platelet volume and platelet counts on peripheral biodegradable stent restenosis

Aim: Thrombocytes play a key role in atherosclerosis and acute vascular events. The purpose of this study is to investigate the association between mean platelet volume (MPV), platelet counts as well as other hematological parameters and biodegradable stent re-stenosis.Methods: 53 patients who underwent percutaneous biodegradable peripheral stent placement procedure were included in this retrospective cohort study. Blood samples were collected a day before the operation. Patients were followed for a mean of 6 months and Doppler ultrasonography (DUSG) was performed for control examination. According to the DUSG results, patients were divided into two groups: Group 1 included patients with ≥50% in-stent re-stenosis and Group 2, with &lt;50% in-stent re-stenosis. Results: The mean age of the patients was 58.1 (6.7) years. 6 (11.3%) patients were female and 47 (88.7%) patients were male. Eight (15%) had iliac artery and 45 (84.9%) had superficial femoral artery stenosis. Doppler US reports showed that 11 (20.8%) patients had ≥50% in-stent re-stenosis (Group 1). Re-stenosis rates were higher at younger ages (P=0.020). There was no statistically difference between the groups in terms of gender (P=0.636), MPV (P=0.210), PLT counts (P=0.129) or any other hematologic parameters.Conclusion: Several studies have shown that some blood parameters, especially MPV, are effective on coronary and peripheral stent stenosis. In our study, we found that none of the hematologic or common blood parameters can predict biodegradable stents re-stenosis.

Successful Percutaneous Transluminal Angioplasty to Right Superficial Femoral Artery Stenosis via True Lumen to True Lumen with Outback Re-Entry Device.

Outback LTD re-entry device (LuMend, Redwood City, Calif; acquired by Cordis Corp, Miami Lakes, Fla)1 is a lumen catheter designed to facilitate placement and positioning of guidewires and catheters during peripheral vascular intervention.2,3 The primary difficulty in the treatment of chronic occlusions of peripheral arterial disease is the inability to re-enter the true lumen after subintimal crossing of the occlusion.4-6 Thus Outback LTD re-entry device plays an important role in treating difficult lesions by re-directing wire from subintimal space to true lumen of distal vessel. Here we report a case with critical right superficial femoral artery stenosis in which an acute angle of the artery makes successful wiring difficult. We use Outback LTD re-entry device to assist with successful wiring to the critical stenotic lesion directly via true lumen to true lumen.

The Computational Fluid Dynamic Simulations for Gangrene Disease in Diabetic Foot

The diabetic foot is considered one of the long term diabetes complications caused by a defect in blood vessel and nerve system. This requires dealing with diabetic foot with professional medical care, so as to prevent its development in advanced stages which could end to gangrene and amputation of the foot. This study has been initiated through follow-up of twelve patients with diabetes and the presence various occlusions in lower limb artery. One patient from them was chosen for investigation, this patient has stenosis in popliteal artery and presence multiple stenosis in superficial femoral artery. This study based on analysis present case of patient and prediction for progress stenosis in superficial femoral artery till arrive semi total occlusion of the artery and interpret the occurrence of gangrene in the lower limb. The geometrical values of the artery and stenosis were acquired measured directly from the patient by using angiography device. The disease of gangrene and artery stenosis in diabetic foot has been investigated by using a simulation program (ANSYS Fluent CFD). The results of study by using four models with (75%, 90%) stenosis from original artery diameter in the healthy patient case are presented and compared with present and healthy case (without stenosis). It has been appeared, with presence of multi stenosis in superficial femoral artery for diabetic foot, and by assuming the blood to be a Newtonian fluid, a significant increase in the blood velocity and wall shear stress in the area of stenosis compared with non stenosis region. The blood flow rate was decreased constrained as the degree of stenosis increased and vice versa. Peak blood velocity is about (0.88) m/sec for healthy artery, it reaches (2) m/sec for a 42.4% stenosis (current case).The maximum velocity values were (10.36, 49.31) m/sec for 75%, 90% stenosis respectively. The maximum wall shear stress at the stenosis region varies from (1094) pa in the 75% stenosis to (15916) pa in the 90% stenosis against a values of (6.36, 380.5) pa in the healthy artery, current case respectively.

Ultra-Long Inflation in Superficial Femoral Artery Stenosis and Occluded Lesions Using Guide Liner (“Ultra SOUL”): A Case Report

Following an era of the use of several drug-coated balloons in angioplasty, "leave nothing behind" and stentless strategies have been gaining attention. In stentless strategies, it is necessary to avoid major dissections and limit flow. Balloon dilation is an important step in vessel preparation. In this study, we report a novel predilation technique. We performed prolonged balloon inflation for >10min after normal ballooning in a procedure to treat an occluded lesion in the superficial femoral artery (SFA). We used a guide extension catheter to avoid foot ischemia and obtained better angiographic results than those using short duration balloon inflation. We named this technique "Ultra-Long Inflation in SFA Stenosis and Occluded Lesions Using Guide Liner" or "Ultra SOUL." The Ultra SOUL technique may be considered a useful option in balloon dilation.

Pathophysiological Significance of Velocity-Based Microvascular Resistance at Maximal Hyperemia in Peripheral Artery Disease.

Aim: Maximal hyperemic response, leading to examination of microvascular resistance in lower-limb lesions is not well understood. This study aimed to investigate the infrainguinal arterial physiological response through a hyperemic condition and the pathophysiological significance of microvascular resistance in peripheral artery disease.Methods: Sixteen limbs with focal stenosis of the superficial femoral artery (SFA) and 16 control limbs were analyzed. We assessed the fractional flow reserve (FFR), vascular flow reserve (VFR), and hyperemic microvascular resistance (h-MR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT). Skin perfusion pressure (SPP) on both the dorsal and the plantar sides of the foot was measured at baseline before and after the endovascular procedures.Results: FFR (p < 0.05) and VFR (p < 0.05), but not h-MR, improved after EVT. There was no association between h-MR and FFR or VFR before EVT. h-MR was negatively correlated with the dorsal SPP before EVT (r = −0.589, p < 0.05). h-MR in patients with high h-MR before EVT significantly decreased after EVT (p < 0.05). Patients with high, but not those with low, h-MR before EVT exhibited a significant increase in dorsal and plantar SPP after EVT (p < 0.05, each).Conclusion: EVT for SFA stenosis improved FFR and VFR comprehensively, with no apparent change in h-MR. However, high h-MR before EVT may play a predictive role for limb perfusion improvement associated with h-MR reduction after EVT.

Endovascular Training Using a Simulation Based Curriculum is Less Expensive than Training in the Hybrid Angiosuite

This study aimed to determine the cost-effectiveness of a PROficiency based StePwise Endovascular Curricular Training (PROSPECT) program, including e-learning and hands on virtual reality simulation. A prospective, single blinded, randomised controlled trial (RCT) was carried out to evaluate the impact of a PROSPECT training program on real life operative performance. Under supervision, all subjects performed two endovascular interventions on patients with symptomatic iliac and/or superficial femoral artery stenosis. Primary outcomes were technical performance (Global Rating Scale, Examiner Checklist), operative metrics, and patient outcomes, adjusted for case difficulty and the trainee's experience. Additionally, an analysis of costs and savings related to implementation of this endovascular training program was performed. Thirty-two general surgery trainees were randomised into three groups: group 1 (n=11) received e-learning and simulation training (PROSPECT program); group 2 (n=10) only had access to e-learning; group 3 (n=11) did not receive supplementary education besides clinical training. Developmental cost, implementation cost, training time cost, and the operational cost of PROSPECT were determined. Time spent studying and practicing was converted to indirect saving of operating time. The costs of logistics, faculty time supervising simulation sessions, and 30 day complication rates were registered. Sensitivity analysis was performed to assess the robustness of the results. Fifty-eight peripheral endovascular interventions, performed by 29 surgical trainees (three dropouts) were included in this RCT from October 2014 to February 2016. Annual costs from the perspective of the hospital were €6589 for curriculum design, €31,484 for implementation, and €1143 in operational costs. Per trainee, simulation based training until proficiency cost €3806. In comparison, if endovascular proficiency levels were obtained with conventional training only, this may have cost €5001 per trainee. Simulation based training in endovascular procedures may be cost saving, because training occurs outside the angiosuite. It is possible that cost savings are underestimated as, in contrast to the literature, prevented costs related to complications could not be defined.

Mitochondrial complex I defect resulting from exercise-induced lower limb ischemia in patients with peripheral arterial disease.

This study aims to compare the structural and mitochondrial alterations between muscle segments affected by exercise-induced ischemia and segments of the same muscle without ischemia, in the same subject. In a prospective analysis, 34 patients presenting either peripheral arterial disease or chronic coronary syndrome without any evidence of peripheral arterial disease were eligible for inclusion based on findings indicating a need for either a femoro-popliteal bypass or a saphenous harvesting for coronary bypass. Before surgery, we assessed the level of exercise-induced ischemia in proximal and distal sections of the thigh by the measurement of transcutaneous oxygen pressure during an exercise treadmill test. Distal and proximal biopsies of the sartorius muscle were procured during vascular surgical procedures to assess mitochondrial function and morphometric parameters of the sartorius myofibers. Comparisons were made between the distal and proximal biopsies, with respect to these parameters. Thirteen of the study patients that initially presented with peripheral arterial disease had evidence of an isolated distal thigh exercise-induced ischemia, associated with a 35% decrease in the mitochondrial complex I enzymatic activity in the distal muscle biopsy. This defect was also associated with a decreased expression of the manganese superoxide dismutase enzyme and with alterations of the shapes of the myofibers. No functional or structural alterations were observed in the patients with coronary syndrome. We validated a specific model ischemia in peripheral arterial disease characterized by muscular alterations. This "Distal-Proximal-Sartorius Model" would be promising to explore the physiopathological consequences specific to chronic ischemia. NEW & NOTEWORTHY We compared proximal versus distal biopsies of the sartorius muscle in patients with superficial femoral artery stenosis or occlusion and proof of, distal only, regional blood flow impairment with exercise oximetry. We identified a decrease in the mitochondrial complex I enzymatic activity and antioxidant system impairment at the distal level only. We validate a model to explore the physiopathological consequences of chronic muscle ischemia.