Superficial Femoral Popliteal Artery Research Articles

IVUS Improves Outcomes With SUPERA Stents for the Treatment of Superficial Femoral-Popliteal Artery Disease.

Nitinol interwoven bare metal stents represent an advancement in stent technology; however, nominal deployment remains an area of focus. Intravascular ultrasound (IVUS) has been shown to improve outcomes in both the coronary and peripheral vasculature by providing the operator with greater vessel detail; however, the use of adjunctive IVUS with nitinol bare metal stents has not been widely studied. This studies aims to determine the effect of IVUS when used adjunctively with nitinol interwoven bare metal stents in the management of femoropopliteal lesions. Retrospective study. This study included a cohort of 200 consecutive patients with peripheral artery disease. All patients were treated with ≥1 Supera bare metal stent, and 91 received adjunctive IVUS imaging prior to stent deployment. Deployment conditions of nominal, compressed, and elongated were measured, and the primary clinical outcomes included target lesion reintervention, amputation, and mortality. This study also showed that 8.3 number needed to treat (NNT) patients must be treated with IVUS to avoid an additional revascularization event. The patients who received IVUS had a significantly greater number of nominally deployed stents (p<0.001). Patients who had IVUS imaging also had significantly lower reintervention rates compared with those who did not receive IVUS imaging (p=0.047). The IVUS and angiography decreases clinically-driven target lesion reintervention and increases nominal deployment compared with angiography alone in femoropopliteal lesions treated with interwoven bare metal nitinol stents. Endovascular surgones may conisder the adjuctive use of IVUS when using the Supera stent for the treatment of infra inguinal superficial femoral artery lesions. The adjunct use of IVUS may lead to improved sizing, vessel prep, deployment, and ultiamtely reduction in CD-TLR.

Research progress of drug-coated balloons for the treatment of infrapopliteal artery disease

Great progress has been made in devices and techniques for the endovascular treatment of peripheral artery diseases. The plain old balloon angioplasty, stent implantation and the emerging drug-coated balloon angioplasty have provided new means of treatment. In recent years, drug-coated balloons have been proved valuable by many clinical trials for the treatment of superficial femoral and proximal popliteal artery lesions. However, there are still insufficient evidence and much controversy about the role of drug-coated balloons in treating infrapopliteal lesions. This article will briefly review the current research status and progress of drug-coated balloons for the treatment of infrapopliteal lesions. Key words: Arteriosclerosis obliterans; Lower extremity; Pharmaceutical preparations; Peripheral artery disease; Drug-coated balloon; Infrapopliteal lesions

RS01. Mortality After Paclitaxel-Coated Balloon Angioplasty and Stenting of Superficial Femoral and Popliteal Artery

A recent meta-analysis of 4663 patients reported higher 2- and 5-year mortality in patients with femoral-popliteal artery occlusive disease treated with paclitaxel-coated balloons and stents compared with plain balloon angioplasty and bare metal stenting. Our aim was to compare mortality after similar treatments using a multicenter vascular registry. Patients (n = 6992) without prior peripheral vascular intervention undergoing endovascular treatment of superficial femoral-popliteal artery occlusive disease in the Vascular Quality Initiative (VQI) were studied from September 2016 to September 2017. All-cause mortality was compared between patients treated with nondrug-coated devices (n = 3905) versus paclitaxel-coated balloons and/or eluting stents (paclitaxel group; n = 3087). Mortality rates with hazard ratios (HR) and 95% confidence intervals (CI) were compared between unadjusted and propensity matched cohorts and illustrated by Kaplan-Meier analysis. Subgroup analysis was performed for intermittent claudication and critical limb ischemia (CLI). Mortality was higher in the nondrug group (13.4%) compared with the paclitaxel group (10.8%) in the unmatched cohorts (HR, 0.80; 95% CI, 0.69-0.93; P < .01). After 1:1 propensity matching the paclitaxel (n = 2440) and nondrug-coated device (n = 2440) groups were similar except for differences at the extremes of age and symptom status (CLI 54% vs 59% respectively; P < .01). Mortality was similar for the nondrug group (13.2%) and paclitaxel group (11.5%) after propensity matching (HR, 0.87; 95% CI, 0.73-1.04; P = .12) at a mean follow-up of 509 days (17 months; range, 0-813 days [0-27 months]). Subgroup analysis of patients with claudication showed no mortality difference in the matched cohorts; nondrug coated device (5.1%; n = 41/804) and paclitaxel (3.8%; n = 32/842; HR, 0.74; 95% CI, 0.46-1.17; P = .20). Subgroup analysis of patients with CLI showed no mortality difference in the matched cohorts; nondrug-coated device (18.9%; n = 191/1012) and paclitaxel (18.5%; n = 200/1081) groups (HR, 0.99; 95% CI, 0.81-1.20; P = .90). By Kaplan-Meier analysis mortality was similar in the paclitaxel versus nondrug device group (Fig). At a mean follow-up of 17 months, mortality is similar for patients with claudication and CLI after treatment of femoral-popliteal occlusive disease with paclitaxel coated and nondrug coated devices. Additional VQI analysis is planned for 2019 to assess for mortality differences at later time points. This work highlights the potential use of the VQI for surveillance of the safety of new peripheral arterial devices.

Drug-eluting balloon angioplasty versus bare-metal stent in treating chronic total occlusion of femoropopliteal arterial segment: a review of 1-year outcome of 90 patients with TASC C and D lesions

Background Bare-metal stent (BMS) scaffolding of superficial femoral artery occlusive lesions has been associated with high rates of late clinical failure. Maintaining the patency of recanalized arterial segments was the main issue behind the concept of leaving nothing behind to be evolved and percutaneous balloon angioplasty becomes the preferred option for endovascular therapy. Drug-eluting balloons (DEBs) have shown to be an effective alternative to BMS for patients with de novo complex superficial femoral occlusive disease. Aims The aim was to compare the outcome of DEB versus BMS in treating complex chronic total occlusion of superficial femoral and proximal popliteal artery in patients with disabling claudication and critical limb ischemia regarding technical success, primary patency, clinically driven target lesion revascularization (cd-TLR), and limb salvage rate. Materials and methods The current study is a multicenter, prospective, randomized study. Ninety patients (110 limbs) complaining of disabling and critical limb ischemia due to complex femoropopliteal occlusive lesions were randomly allocated into two groups according to the intervention method performed. Group A included 48 patients (57 limbs) who were submitted for treatment with paclitaxel DEBs and group B included 42 patients (53 limbs) submitted for treatment with BMS. The follow-up period was for 1, 6, and 12 months. Statistical analysis was performed by using the IBM SPSS Statistics version 22 for Windows Program Package (SPSS Inc., Chicago, IL, USA). Results BMSs seem to have lower patency and higher cd-TLR rates compared with patients who received paclitaxel drug-coated balloons but was not statistically significant. The primary patency rates were 100, 96, and 86.2% at 1, 6, and 12 months’ respectively’ in the DEB group versus 100, 89.8, and 77.6% at 1, 6, and 12 months, respectively, in the BMS group. Clinically driven TLR rates were 2 and 7.8% at 6 and 12 months, respectively, in the DEB group versus 6.1 and 14.2% at 6 and 12 months, respectively, in the BMS group. Conclusion Percutaneous therapy for Trans atlantic inter-societies consensus (TASC) C and D femoropopliteal lesion using DEB or BMS is safe and effective with a high patency rate of 1 year. Paclitaxel drug-eluting balloons seem to have a promising role in the prevention of restenosis and recurrence of peripheral arterial occlusive disease. However, stents are still playing important bailout role in the treatment of residual stenosis and dissection. Further follow-up is essential to obtain and document long-term outcome of different percutaneous therapy for complex and long superficial femoral artery (SFA) lesions.

Dual Incision Remote Endarterectomy Is a Novel Treatment Option for Long-Segment Superficial Femoral-Popliteal Artery Occlusive Disease

Objectives: Remote endarterectomy (RE) is a minimally invasive procedure conceived as an alternative to an above-the-knee bypass for patients with symptomatic limb ischemia. Successful RE outcome is frequently hampered by adherent plaque within and beyond the adductor canal and the insertion of a stent. We present a case series of modified RE enhanced by the addition of a distal leg incision to accomplish a longer segment plaque excision without the need for a distal stent. Methods: A retrospective record review identified RE procedures performed from May 2010 through March 2012. Adjunctive patch angioplasty was used to close the arteriotomies. Demographics, lesion characteristics, procedural details, andoutcomedatawere collected. Study endpointsweredeath, occlusion, reoperation, or last office follow-up visit. Results: REwas performed in 11 patients (5men;mean age, 68 years, 3 diabetics, 11 tobacco users). Indication for operation was claudication in 6, rest pain in 3, and gangrene in 2.REwas technically successful in all patients.Distal arterial exposure was above knee in 7 (64%), below knee in 2 (18%), and combined above-knee and below-knee exposures in 2 patients (18%). Two patients underwent concomitant balloon angioplasty in either the popliteal or anterior tibial vessels. Mean postoperative ankle-brachial index increase was .43 (P 1⁄4 .001). Operative complication of above-knee popliteal artery perforation occurred in one patient but was successfully repaired with covered stent deployment. Average procedure duration was 162 6 69 minutes (standard deviation) and average hospital stay was 4 days. All patients reported symptom resolution; both patients with tissue ulceration healed. During the 12-month follow-up period, a femoropopliteal reocclusion developed in four patients, resulting in one patient who underwent a successful femoral-popliteal bypass operation. Limb salvage rate was 100%. Conclusions: When endovascular therapies are exhausted, and should autologous saphenous vein be unavailable, the dual incision RE technique of long segment femoropopliteal occlusive lesions accomplishes effective revascularization. Symptom relief or limb salvage was achieved in all patients; the need for a subsequent bypass was rare and not adversely affected by having undergone the dual incision RE.

Routine stent implantation vs. percutaneous transluminal angioplasty in femoropopliteal artery disease: a meta-analysis of randomized controlled trials

We performed a meta-analysis of randomized controlled trials comparing routine stenting (ST) with percutaneous transluminal angioplasty (PTA) for symptomatic superficial femoral-popliteal artery (SFPA) disease. Ten trials were pooled randomizing patients to ST (n = 724 limbs) or PTA with provisional stenting (n = 718 limbs) with a follow-up period of 9-24 months. The mean lesion length was similar in the two groups (45.8 mm in the ST group and 43.3 mm in the PTA group). We calculated the summary risk ratios (RRs) for immediate technical failure, restenosis, and target vessel revascularization (TVR) using random-effects models. The immediate technical failure was higher in the PTA group than in the ST group [17.1 vs. 5.9%, respectively, RR = 0.28, 95% confidence interval (CI) = 0.15-0.54, P < 0.001], with 10.3% of the PTA patients undergoing stenting because of suboptimal result. There was a trend for lower restenosis in the ST group (37.6% in ST vs. 45.3% in PTA, RR = 0.85, 95% CI = 0.69-1.06, P = 0.146), but no difference in the need for TVR (20% in ST vs. 20.2% in PTA, RR = 0.98, 95% CI = 0.78-1.23, P = 0.89). In an analysis restricted to nitinol stents, there was a trend towards reduction in TVR (RR = 0.79, 95% CI = 0.59-1.06, P = 0.12). Despite the higher immediate success, routine stenting was not associated with a significant reduction in the rate of restenosis or TVR. Our data do not support use of routine stenting as the primary endovascular treatment for short SFPA lesions.

Salvage of Critical Limb Ischemia with the “Trellis Reserve” of Subintimal Superficial Femoral-Popliteal Artery Occlusion: A New Modality in Managing Critical Limb Ischemia

Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The ;;Trellis'' percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the ;;Trellis'' allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The ;;Trellis'' system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.

Percutaneous transluminal angioplasty against arteriosclerosis obliterans in dialysis patients

The incidence of peripheral arteriosclerosis is on the increase in chronic hemodialysis patients. Recently, the intervention (IV) treatment is conducted to deal with this problem. IV was performed in 4 dialysis patients against the complication of arteriosclerosis obliterans (ASO) but the result was unsuccessful in 3 of them. These 3 failure cases were investigated to find the problems associated with percutaneous transluminal angioplasty (PTA). Cases 1, 2 and 3 had intermittent claudication while case 4 had gangrenous toes as the major complaint. The symptoms in these cases were attributable to 90-100% stenosis and occlusion of superficial femoral artery, bilateral iliac arteries, bilateral superficial femoral-popliteal artery, branch of right iliac artery and left iliac artery region, respectively. IV was successful in case 1 but failed in cases 2 and 4 because the catheter itself did not go through due to the severe stenosis of vessel or the procedure of forcefully dilating the vessel caused dispersion of minute thrombi. In case 3, acute myocardial infarction occurred at 10 h after successful IV, resulting in sudden death. In view of the extent of invasion, IV is a treatment method selected against ASO in dialysis patients. However, the method has a high risk of causing thrombus formation, vessel rupture and organ failure. In this regard, it is advisable to evaluate the systemic condition and conduct IV if the extent of stenosis is mild.

Laser angioplasty for limb salvage: Observations on early results

During a 27-month period laser thermal angioplasty (LTA) was attempted in 15 patients who had totally occluded segments of their superficial femoral—popliteal arteries (SFA) with limb-threatening ischemia (rest pain or tissue necrosis). In five patients (33%) laser perforation of the SFA precluded successful angioplasty, and those five patients have been excluded from further analysis. In the remaining 10 patients the prelaser angiogram demonstrated an average SVS/ISCVS runoff score of 7.7 (best possible score, 1; worst possible score, 10). Seven patients (70%) had occlusions of all infrapopliteal arteries. All 10 patients were available for clinical follow-up, and follow-up angiograms were available for eight patients (80%). Clinical failure was defined as recurrence of the clinical signs or symptoms for which the LTA was performed. After 6 months of follow-up clinical failures occurred in nine patients (90%). Four patients had no clinical improvement. Five patients had transient clinical improvement after LTA, and all subsequently had early recurrence of symptoms. The average time from LTA to recurrence of symptoms was 1.7 months. Seven patients had subsequent bypasses or amputations an average of 2.2 months after laser angioplasty. The SFA patency rate by life-table analysis was 25% at 6 months. The single patient with clinical success (at 12 months) had no tibial vessel disease evident on his prelaser angiogram, and he underwent a concomitant inflow procedure at the time of his LTA. We believe that the disappointing results in this small series of patients can be attributed to tibial vessel disease that was not addressed by this technique. We anticipate that with improved technology, with smaller, steerable laser probes, we may be able to treat tibial vessel disease and achieve better results. We conclude that LTA, as it exists today, has a very limited role as the sole treatment of patients with limb-threatening ischemia, and this technique should be offered only to those patients who refuse surgery or have a prohibitively high risk for operative treatment.

Laser angioplasty for limb salvage: Observations on early results

During a 27-month period laser thermal angioplasty (LTA) was attempted in 15 patients who had totally occluded segments of their superficial femoral--popliteal arteries (SFA) with limb-threatening ischemia (rest pain or tissue necrosis). In five patients (33%) laser perforation of the SFA precluded successful angioplasty, and those five patients have been excluded from further analysis. In the remaining 10 patients the prelaser angiogram demonstrated an average SVS/ISCVS runoff score of 7.7 (best possible score, 1; worst possible score, 10). Seven patients (70%) had occlusions of all infrapopliteal arteries. All 10 patients were available for clinical follow-up, and follow-up angiograms were available for eight patients (80%). Clinical failure was defined as recurrence of the clinical signs or symptoms for which the LTA was performed. After 6 months of follow-up clinical failures occurred in nine patients (90%). Four patients had no clinical improvement. Five patients had transient clinical improvement after LTA, and all subsequently had early recurrence of symptoms. The average time from LTA to recurrence of symptoms was 1.7 months. Seven patients had subsequent bypasses or amputations an average of 2.2 months after laser angioplasty. The SFA patency rate by life-table analysis was 25% at 6 months. The single patient with clinical success (at 12 months) had no tibial vessel disease evident on his prelaser angiogram, and he underwent a concomitant inflow procedure at the time of his LTA. We believe that the disappointing results in this small series of patients can be attributed to tibial vessel disease that was not addressed by this technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal angioplasty for arterial disease of the lower extremities.

Percutaneous transluminal angioplasty has become an effective method of restoring blood flow and relieving symptoms of peripheral arterial disease in the lower limbs. It has the advantages of less pain, morbidity, and cost compared with surgery. Best results are in short stenotic lesions where the patency rate at 2 years in iliac, superficial femoral-popliteal arteries, and popliteal arteries is 85%-90%, 50%-75%, and 70%-80%, respectively. Complications of distal embolization, thrombosis, and perforation occur in 3%-5% of attempts and require immediate surgery. Some considerations for the selection of patients, approach, technique, and use of drugs to control arterial spasm and thrombosis are reviewed briefly.