Trans-Atlantic Inter-Society Consensus II Research Articles

Early and midterm results of covered balloon-expandable stents (VBX-Gore) for endovascular treatment of chronic aorto-iliac occlusion.

Endovascular treatment is nowadays accepted as first-line treatment for most patients with aorto-iliac obstructive disease (AIOD), including those with Trans-Atlantic Inter-Society Consensus II (TASC-II) lesion types C and D. Aim of the study was to evaluate the role of Viabahn VBX (W. L. Gore and Associates, Flagstaff, AZ, USA), in patients with chronic occlusive aorto-iliac disease (ChO). A retrospective review of patients undergone elective endovascular repair with VBX (W. L. Gore and Associates) for ChO at five referral vascular institutions in Italy from 2018 to 2022 was conducted. Primary endpoints were technical success and the incidence of any early and midterm procedure-related reintervention. Secondary endpoints were clinical success, primary and secondary patency. Among 89 included patients, technical success was obtained in 87 patients (97.8%). Postoperative complication requiring early surgical reintervention was necessary in 5 (6%), all but one for arterial bleeding. Clinical improvement of at least 3 classes was observed in 49 (55%). After a mean follow-up of 24.1 months ±14.1, primary patency and freedom from any procedure-related reintervention at 12, 24 and 36 months was 83.0% and 94.8%, 80.0% and 91.5%, 77.9% and 89.3%, respectively. Secondary patency was 100%. TASC-II D lesion (OR=3.67, 95% CI: 1.1289-11.9823, P=0.03) and Grade III iliac calcification (OR=3.41, 95% CI: 1.0944-10.6428, P=0.03) were identified as independent predictors for procedure-related reintervention. Use of VBX (W. L. Gore and Associates) in ChO was safe and effective with low rate of stenosis/occlusion in the early and mid-term follow-up. TASC-II D and Grade III calcifications resulted as independent predictors for procedure-related reintervention.

Outcomes of covered vs bare metal stents for the treatment of aortoiliac occlusive disease

ObjectiveWe retrospectively compared the clinical outcomes of self-expanding covered stents (CSs) and bare metal stents (BMSs) in the treatment of aortoiliac occlusive disease (AIOD) at a single center between 2016 and 2022. MethodsAll patients with AIOD receiving endovascular therapy at a single center from January 2016 to October 2022 were continuously analyzed, including patients with lesions of all classes according to the Trans-Atlantic Inter-Society Consensus II (TASC-II). Relevant clinical and baseline data were collected, and propensity score matching was performed to compare CSs and BMSs in terms of baseline characteristics, surgical factors, 30-day outcomes, 5-year primary patency, and limb salvage. The follow-up results were analyzed by Kaplan-Meier curves. Cox proportional hazard models were used to identify predictors of primary patency. ResultsA total of 209 patients with AIOD were enrolled in the study, including 135 patients (64.6%) in the CS group and 74 patients (35.4%) in the BMS group. Surgical success rates (100% vs 100%; P = 1.00), early (<30-day) mortality rates (0% vs 0%; P = 1.00), cumulative surgical complication rate (12.0% vs 8.0%; P = .891), 5-year primary patency rate (83.4% vs 86.9%; P = .330), secondary patency rate (96% vs 100%; P = .570), and limb salvage rate (100% vs 100%; P = 1.00) did not exhibit significant differences between the two groups. Patients in the CS group had a lower preoperative ankle-brachial index (0.48 ± 0.26 vs 0.52 ± 0.19; P = .032), more cases of complex AIOD (especially TASC D) (47.4% vs 9.5%; P < .001), more chronic total occlusive lesions (77.0% vs 31.1%; P < .001), and more severe calcification (20.7% vs 14.9%; P < .036). After propensity score matching, 50 patients (25 with CS and 25 with BMS) were selected. The results showed that only severe calcification (32.0% vs 8.0%; P = .034) and ankle-brachial index increase (0.45 ± 0.15 vs 0.41 ± 0.22; P = .038) were significantly different between the groups. In terms of surgical factors, patients in the CS group had more use of bilateral femoral or combined brachial artery percutaneous access (60.0% vs 12.0%; P < .001), more number of stents used (2.3 ± 1.2 vs 1.3 ± 0.7; P < .001), longer mean stent length (9.3 ± 3.3 vs 5.8 ± 2.6 cm; P < .001), and more catheter-directed thrombolysis treatment (32.0% vs 4.0%; P = .009). Multivariate Cox survival analysis showed that severe calcification (hazard ratio, 1.32; 95% confidence interval, 1.04-1.85; P = .048) was the only independent predictor of the primary patency rate. ConclusionsAll patients with AIOD who underwent endovascular therapy were included and achieved good outcomes with both CSs and BMSs. The influence of confounding factors in the two groups was minimized by propensity score matching, and the 5-year patency rates were generally similar in the unmatched and matched cohorts. Postoperative hemodynamic improvement was more obvious in patients in the CS group. For more complex lesions, CS is recommended to be preferred. Especially for severe calcification lesions, which is the only independent predictor of primary patency, CS showed obvious advantages. Further studies with more samples are needed to investigate the role of stent types in AIOD treatment.

Propensity-Matched Comparison of Endovascular versus Open Reconstruction for TASC-II C/D AortoIliac Occlusive Disease. A Ten-Year Single-Center Experience with Self-Expanding Covered Stents

To compare endovascular therapy (EVT) using kissing self-expanding covered stents, with open repair (OR) with aortobifemoral bypass (ABF), for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus II (TASC-II) C/D aortoiliac occlusive disease (AIOD). A single-center retrospective analysis of patients treated by EVT or ABF for TASC-II C/D AIOD (2009-2018) was carried out. The perioperative risk was quantified by the Society for Vascular Surgery (SVS) and American Society of Anesthesiologists (ASA) scores. Outcomes of interest were early (30 days) mortality and complication rates, length of hospitalization, and midterm patency that were compared between EVT and OR after propensity score matching. Follow-up results were analyzed with Kaplan-Meier curves. Cox proportional hazards were used to identify predictors of patency. Sixty-three EVT and 55 OR patients were treated; the EVT group had higher perioperative risk (ASA score, P=0.012. SVS score, P=0.012) and less advanced disease (TASC D lesions, 52.3% vs. 72.7%; P=0.036. Iliac occlusion, 46.8% vs. 87.2%; P=0.024). After propensity score matching, 148 limbs were selected (74 EVT and 74 OR), resulting in well-balanced groups regarding risk (ASA score, P=0.514. SVS score, P=0.373) and anatomical complexity (TASC D lesions, 60.4% vs. 63.0%; P=0.516. Iliac occlusion, 47.3% vs. 59.5%; P=0.187). Mortality was 0%. The EVT group showed significantly shorter hospital (4.5±7.6days vs. 9.9±6.8days; P<0.001) and intensive care unit stay (0±0.1days vs. 1.7±1.5days; P=0.046) and less surgical complications (4% vs. 14.8%; P=0.046). Five-year primary patency was similar between EVT and OR (84.1% vs. 88.3%; P=0.454); multivariate analysis showed that Rutherford category was the only predictor of primary patency (HR 4.1, P=0.023). The endovascular kissing self-expanding covered stent technique for TASC-II C/D AIOD presented a primary patency equal to ABF at 5years, with the advantage of less surgical complications and shorter hospitalization. Therefore, it may be considered as a valid option for complex atherosclerotic lesions involving the aortic bifurcation.

The triglyceride-glucose index predicts peripheral artery disease complexity

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

Assessment of the relation between C-reactive protein to albumin ratio and the severity and complexity of peripheral arterial disease.

Peripheral arterial disease is associated with increased cardiovascular mortality and morbidity. C-reactive protein and albumin are biomarkers of inflammation and malnutrition that play key roles in the pathophysiological pathways involved in the progression of atherosclerosis and peripheral arterial disease. In this study, we aimed to assess the relationship between C-reactive protein to albumin ratio and the suprapopliteal peripheral arterial disease severity and complexity as assessed by TransAtlantic Inter-Society Consensus-II (TASC-II) classification. Our study enrolled 224 consecutive patients referred for peripheral angiography with the clinical features of possible peripheral arterial disease at a tertiary care center between January 2016 and September 2019. Level of disease and lesion characteristics were defined with reference to angiographic findings according to the TASC-II classification. C-reactive protein/albumin ratio levels were significantly higher in TASC-II class C and D than in TASC-II class B patients with a median level of 1.8 to 2.1 vs 1.4, respectively (p = 0.018). In multivariate regression analysis, C-reactive protein to albumin ratio remained an independent predictor of severe peripheral arterial disease. The predictive performance of C-reactive protein to albumin ratio, C-reactive protein, and albumin were compared by Receiver Operating Characteristic curve analysis. C-reactive protein to albumin ratio surpassed C-reactive protein and albumin in predicting peripheral arterial disease severity and complexity. A level of C-reactive protein to albumin ratio > 0.14 predicted a higher grade of suprapopliteal TASC-II class with sensitivity and specificity of 68.2% and 56.0%, respectively. C-reactive protein to albumin ratio was strongly associated with peripheral arterial disease severity and complexity, as assessed by TASC-II classification. Also, C-reactive protein to albumin ratio was found to be a more accurate marker than C-reactive protein and albumin alone in predicting more severe and complex lesions in patients with peripheral arterial disease.

Outcomes of Total Aortoiliac Revascularization for TASC-II C&D Lesion with Kissing Self-Expanding Covered Stents

The endovascular approach has been widely used for aortoiliac occlusive disease (AIOD), especially for aortic bifurcation and iliac artery Trans-Atlantic Inter-Society Consensus II (TASC-II) A and B lesions. However, the outcomes of self-expanding covered stents (SECSs) for extensive aortoiliac lesion remain unclear. This study aimed to assess the short-term patency of kissing covered stents for the revascularization of aortoiliac TASC-II C and D diseases. Thirty-three patients with TASC-II C and D lesions of AIOD were treated with kissing covered stents. All patients were reviewed under a standard institutional review board protocol. Demographic variables, lesion location and characteristics, stenting configuration, and patency were analyzed. Thirty-one male and 2 female patients with a mean age of 65.1±10.7years underwent aortoiliac bifurcation reconstruction with kissing SECSs. Eight patients had TASC-II C lesions, and 25 patients had TASC-II D lesions. Among them, 8 patients had total infrarenal aortoiliac occlusion, of which 5 had juxtarenal aortoiliac lesions. The mean lesion length was 11.6±2.1cm. Mean diameters of aorta and common iliac artery were 18.3±2.1 and 10.7±1.5mm, respectively. Among them, the abutting stent configuration was used in 11 patients with short or focal ostial lesions, whereas the crossing stent configuration was used in 22 patients with longer lesions extending into the distal aorta. The mean follow-up was 24.5±7.8months, the follow-up rate was 93.9% (31 of 33), and 29 patients had follow-up longer than 12months. Primary patency rate at 12months was 96.5%, and secondary patency rate was 100%. The use of kissing SECSs for the revascularization of extensive AIOD is safe and effective. The short-term primary patency rates of endovascular treatment of TASC-II C and D lesions were favorable.

Is it possible to predict the complexity of peripheral artery disease with atherogenic index?

Lower extremity peripheral artery disease develops mainly due to atherosclerosis and occurs as a result of the systemic atherosclerotic process. Increased triglyceride (TG) and decreased high density lipoprotein cholesterol (HDL-C) values increase atherosclerosis risk. With regard to this information, TG/HDL-C ratio is used as the atherogenic index. The aim of the present study was to evaluate the role of TG/HDL-C ratio to predict the complexity of disease in patients with peripheral artery disease. Patients who were diagnosed with peripheral artery disease and admitted to our clinic between August 2013 and August 2019 were included in this study retrospectively. Patients were divided into two groups based on angiographic evaluations with TransAtlantic Inter-Society Consensus-II classification. Those with TASC A-B lesions were included in Group 1 and those with TASC C-D lesions constituted Group 2. The mean ages of Group 1 (n = 314) and Group 2 (n = 98) patients were 56.1 ± 9.3 and 58.4.1 ± 8.1 years, respectively. The frequency of male gender and coronary artery disease was significantly higher in Group 2 (p = 0.043, p = 0.001, respectively). In Group 2, triglyceride and TG/HDL-C ratios were significantly high, while HDL-C was significantly low (p = 0.022, p < 0.001, p = 0.010, respectively). The multivariate logistic regression analysis performed to evaluate the parameters in predicting the angiographic complexity of peripheral artery disease showed that coronary artery disease (OR: 1.009 CI 95%: 1.003-1.021 p = 0.016) and TG/HDL-C ratio (OR: 5.385 CI 95%: 2.553-9.357 p = 0.001) were independent predictors for complexity. ROC analysis revealed that the cut-off value of TG/HDL-C was 2.9 (AUC = 0.670, p < 0.001) with 75.5% sensitivity and 56.7% specificity. It is possible to predict the angiographic complexity of peripheral artery disease with TG/HDL-C ratio, also known as atherogenic index, which is easily obtained by routine biochemical parameters.

Does Metformin Have an Effect on Stent Patency Rates.

Metformin is the most commonly used drug for type 2 diabetes. Research has shown that metformin also has a protective effect on endothelium by decreasing endothelial vascular reactivity. We hypothesize that metformin will decrease restenosis/reintervention rates in patients receiving lower extremity non-drug-eluting stents (nDESs) in the superficial femoral artery(SFA) and/or popliteal artery. Retrospective study was performed on 187 patients from October 2012 to December 2015 who received an nDES in the SFA and/or popliteal artery. Patients were divided into 3 groups (Table 1) and compared against for duplex based restenosis (>60%) rates, limb loss rates, and reintervention rates. Each patient's Trans-Atlantic-Inter-Society-Consensus II (TASC-II) class was collected. Postoperative duplex was performed 1 week after the procedure, then every 3 months for the first year, then, every 6 months to check for patency. IBM-SPSS-22 was used for all analyses. Average age of the patients was 64.65 ± 73.4 years. 101 patients had 101 procedures performed on the left lower extremity; 86 patients had 86 procedures performed on the right lower extremity; 123 patients were male and 64 were female. Average length of follow-up was 13.1±9.7 months. Most common indication for intervention was claudication, followed by critical limb threatening ischemia. Restenosis and reintervention by groups can be seen in Table 1. No patients experienced limb loss. There were no statistically significant differences between any of the 3 groups and their limb loss, restenosis, or reintervention rates. Despite having multiple proven effects in improving certain clinical outcomes and a proven protective effect on endothelium by decreasing endothelial vascular reactivity, metformin does not appear to reduce restenosis or reintervention rates in patients receiving lower extremity nDESs in the SFA and/or popliteal artery.

Endovascular and Hybrid Revascularization for Complicated Aorto-Iliac Occlusive Disease: Short-Term Results in Single Institute Experience.

Treatment for extensive aortoiliac occlusive disease (AIOD) includes endovascular interventions, hybrid procedures and surgical reconstruction. This study evaluated the short-term outcomes of endovascular and hybrid procedures in patients with Trans-Atlantic Inter-Society Consensus II (TASC-II) D AIOD lesions. From January 2013 to June 2015, 41 patients with TASC-II D AIOD lesions who underwent revascularization at our institute were retrospectively included. Nineteen underwent endovascular procedures and 22 underwent hybrid procedures with a postoperative surveillance program for at least 1 year. Patient demographics and short-term outcomes were analyzed. The procedural success rate in all patients was 100%. The accumulative postoperative complication rate was 20.2%, and the major complication was acute kidney injury (14.6%). The time of freedom from target lesion revascularization was 18.9 months. The primary patency rates in the endovascular group were 89.5% and 84.2% at 1 and 2 years, respectively, compared to 95.5% at 1 and 2 years in the hybrid group; however, the difference was not significant (p = 0.234). The secondary patency rates were 94.7% and 93% at 1 and 2 years, respectively, in the endovascular group, and 95.5% and 94% at 1 and 2 years, respectively, in the hybrid group; however, the differences was not significant (p = 0.916). Our study revealed that endovascular and hybrid procedures are favorable treatment choices for patients with TASC-II D AIOD lesions. In patients with multilevel steno-occlusive lesions, hybrid procedures improved distal runoff flow and reduced the complexity of endovascular procedures.

Neutrophil-to-lymphocyte ratio may be a marker of peripheral artery disease complexity.

Objective:The aim of this study was to evaluate the relationship between peripheral artery disease (PAD) severity and complexity, as evaluated by TransAtlantic Inter-Society Consensus-II (TASC-II) classification, and neutrophil-to-lymphocyte (N/L) ratio.Methods:A total of 407 patients underwent peripheral angiography due to signs and symptoms of PAD; of these, 64 patients were excluded and the remaining 343 patients were enrolled in this cross-sectional study. Patients with previous peripheral revascularizations, acute coronary syndrome, vasculitis, non-atherosclerotic stenosis, and malignancy were excluded. Patients were divided into 4 groups according to TASC-II classification, and clinical and laboratory data were compared. The chi-square test, Student’s t-test, Mann–Whitney U test, analysis of variance, Kruskal–Wallis test, Spearman’s correlation analysis, multiple logistic regression analysis, and receiver operating characteristic (ROC) curve analysis were used for statistical analysis.Results:Lymphocyte count was weakly correlated (r=–0.169, p=0.002) whereas neutrophil count and N/L ratio were moderately correlated with the TASC score (r=0.432, p<0.001 and r=0.470, p<0.001, respectively). Low-density lipoprotein cholesterol [odds ratio (OR)=1.010, 95% confidence interval (CI) 95%=1.003–1.017, p=0.004], high-density lipoprotein cholesterol (OR=0.940, 95% CI=0.894–0.987, p=0.013), and N/L ratio (OR=1.914, 95% CI=1.515–2.418, p<0.001) were the independent factors for predicting a higher TASC class in multiple logistic regression analysis. The cut-off value of the N/L ratio for predicting TASC C&D class was >3.05 (sensitivity=75.0%, specificity=62.9%, area under the curve=0.678, 95% CI=0.688–0.784, p<0.001) in ROC curve analysis.Conclusion:The N/L ratio, a marker of inflammation, may be an important predictor of PAD complexity. Therefore, a simple blood count test may provide an important clue about the severity of PAD and risk stratification in patients presenting with intermittent claudication. Additional studies are required to confirm our findings.

Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis?

Background:Open surgery is the preferred approach for the treatment of type D lesions according to the Trans-Atlantic Inter-Society Consensus (TASC) II guideline, but endovascular solutions also appear to be a valid option in selected patients. The study aimed to identify the risk factors of restenosis after open and endovascular reconstruction of symptomatic TASC II D aortoiliac occlusive lesions (AIOLs).Methods:Fifty-six patients (82 limbs) who underwent open repair and endovascular treatment (ET) for symptomatic TASC ΙΙ D AIOLs between March 2005 and December 2012 were retrospectively reviewed. Baseline characteristics, preoperative and postoperative imaging, and operation procedure reports were reviewed and analyzed. Restenosis after revascularization was assessed by duplex ultrasound or computed tomography angiogram. Kaplan-Meier survival analysis, Log-rank test, and multivariate Cox regression were used to evaluate the relevance between risk factors and patency.Results:The mean duration of follow-up was 42.8 ± 23.5 months (ranging from 3 to 90 months). Primary patency rates at 1-, 3-, 5-, and 7-year were 93.6%, 89.3%, 87.0%, and 70.3%, respectively. Restenosis after revascularization occurred in 11 limbs. Kaplan-Meier survival analysis and the Log-rank test revealed that diabetes, Rutherford classification ≥5th and concurrent femoropopliteal TASC II type C/D lesions were significantly related to the duration of primary patency. According to the result of Cox regression, diabetes and femoropopliteal TASC ΙΙ type C/D lesions were identified as the risk factors for restenosis after revascularization.Conclusion:This study demonstrated that diabetes and femoropopliteal TASC ΙΙ type C/D lesions are risk factors associated with restenosis after open and ET of TASC II D AIOLs.

15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease.

The purpose of this study was to evaluate 15-year patency and life expectancy after endovascular treatment (EVT) with primary stenting guided by intravascular ultrasound (IVUS) for iliac artery lesions. Fifteen-year patency, factors causing restenosis, and survival after IVUS-guided EVT are unclear based on the TransAtlantic Inter-Society Consensus II (TASC-II) classification in peripheral arterial disease (PAD). EVT was performed for 507 lesions in 455 patients with PAD. The 15-year endpoints were primary, primary-assisted, and secondary patency; overall survival; freedom from major adverse cardiovascular events (MACE); and freedom from major adverse cardiovascular and limb events (MACLE). The 5-, 10-, and 15-year primary and secondary patencies were 89%, 83%, and 75%, respectively, and 92%, 91%, and 91%, respectively. There were no significant differences among TASC-II categories. IVUS-guided stenting for the iliac artery had favorable 15-year patency in all TASC categories. Life expectancy after EVT was poor, but stenting is feasible for patients with PAD.

Mid-Term Outcomes of Endovascular Treatment for TASC-II D Femoropopliteal Occlusive Disease with Critical Limb Ischemia.

The purpose of the study was to assess the safety and midterm effectiveness of endovascular treatment in Trans-Atlantic Inter-Society Consensus II (TASC-II) D femoropopliteal occlusions in patients with critical limb ischemia (CLI). Patients with CLI who underwent endovascular treatment for TASC-D de novo femoropopliteal occlusive disease between September 2008 and December 2013 were selected. Data included anatomic features, pre- and postprocedure ankle-brachial index, duplex ultrasound, and periprocedural complications. Sustained clinical improvement, limb salvage rate, freedom from target lesion revascularization (TLR), and freedom from target extremity revascularization (TER) were assessed by Kaplan-Meier estimation and predictors of restenosis/occlusion with Cox analysis. Thirty-two patients underwent treatment of 35 TASC-D occlusions. Mean age was 76 ± 9. Mean lesion length was 23 ± 5 cm. Twenty-eight limbs (80 %) presented tissue loss. Seventeen limbs underwent treatment by stent, 13 by stent-graft, and 5 by angioplasty. Mean follow-up was 29 ± 20 months. Seven patients required major amputation and six patients died during follow-up. Eighteen endovascular and three surgical TLR procedures were performed due to restenosis or occlusion. Estimated freedom from TLR and TER rates at 2 years were 41 and 76%, whereas estimated primary and secondary patency rates were 41 and 79%, respectively. Endovascular treatment for TASC II D lesions is safe and offers satisfying outcomes. This patient subset would benefit from a minimally invasive approach. Follow-up is advisable due to a high rate of restenosis. Further follow-up is necessary to know the long-term efficacy of these procedures.

「血管内手術の現状と今後の展望」 末梢動脈閉塞，頸動脈に対する血管内手術

In the last decade, the therapeutic strategy for patients with peripheral arterial disease (PAD) has changed markedly after the introduction of endovascular treatment and surgical approaches. In particular, endovascular treatment of iliac occlusive disease is an established treatment modality, although the treatment of infrainguinal lesions remains controversial. The trans-Atlantic Inter-Society Consensus II (TASCII) document of 2007 recommended endovascular treatment in patients with TASCII types A and B lesions and surgical bypass in patients with TASCII types C and D lesions. Most patients with critical limb ischemia (CLI) are in poor general condition, and the goal of revascularization in CLI is not only limb salvage but preservation of life. Currently, bypass surgery is the optimal revascularization procedure for bypass-applicable CLI patients. Improvements in endovascular treatment and expansion of its indication may apply especially to CLI patients who are in poor general condition. Carotid disease is an important cause of stroke and may cause 10-20% of all ischemic strokes. The choice of revascularization strategy in tese cases should be based on the surgical risk profile of the patient and the institution′s expertise. Carotid artery stenting is particularly beneficial for patients at high surgical risk, e.g. surgically inaccessible lesions, radiation-induced carotid stenosis, prior ipsilateral radical neck dissection, and prior carotid endarterectomy. Results of medical treatment continue to improve, but there is still the need for more experience which will aid in establishing treatment strategies for severe carotid disease.

Results of second-time angioplasty and stenting for femoropopliteal occlusive disease and factors affecting outcomes

Repeat percutaneous endoluminal interventions for femoropopliteal occlusive disease are common, but the outcomes are poorly understood. We sought to determine the results of second-time femoropopliteal percutaneous transluminal angioplasty/stenting (SPTAS) and identify factors associated with success or failure of a continued endoluminal revascularization strategy. A retrospective review of patients undergoing multiple percutaneous endoluminal lower extremity interventions at a single institution from 2002 and 2009 identified 70 SPTAS in 70 limbs. Patient comorbidities, anatomic severity of disease, and procedural characteristics were analyzed with respect to outcomes with descriptive statistics, Kaplan-Meier curves, and Cox proportional hazards modeling. Patency rates were determined from the time of SPTAS. Patients included 37 men (63%) and 22 women (27%) at a mean age of 70 ± 10 years. Indications for SPTAS included claudication in 54 limbs (77%) and critical limb ischemia (CLI) in 16 (23%). Median time from the initial endoluminal intervention to SPTAS was 330 days. Lesion TransAtlantic InterSociety Consensus II (TASCII) classification was A in 18 (25.7%), B in 18 (25.7%), C in 25 (35.7%), and D in 9 (12.9%). Technical success was achieved in 68 (97%) with low rates of intraprocedural (10%) and postprocedural (4%) complications as well as initial clinical improvement in 61 (87%) patients. Over a median follow-up of 22.9 months following SPTAS, 2-year primary patency, secondary patency, limb salvage (in patients with CLI), and survival were 33% ± 7%, 63% ± 7%, 87% ± 9%, and 88% ± 5%, respectively. Cox proportional hazard modeling showed that SPTAS within 180 days of the initial endovascular intervention was the only significant predictor of failure of primary patency (hazard ratio, 2.65; 95% confidence interval, 1.4-5.2) and secondary patency (hazard ratio, 3.1; 95% confidence interval, 1.4-7.1) of SPTAS. Second-time femoropopliteal angioplasty/stenting has excellent technical success but limited midterm primary and secondary patency. Early failure of the initial endovascular intervention strongly predicts poor outcome following SPTAS and in this cohort was more significant than comorbidities, anatomic factors, or procedural characteristics. These data suggest that after early endovascular failure, alternatives to a continued endoluminal strategy should be adopted.

Repeat Angioplasty and Stenting for Femoropopliteal Occlusive Disease: Factors Affecting Outcomes of the Second-Time Endovascular Intervention

Introduction: Repeat percutaneous interventions for femoropopliteal occlusive disease are common, but the outcomes are poorly understood. We sought to determine the results of second-time femoropopliteal percutaneous transluminal angioplasty/stenting (SPTAS) and identify factors associated with outcome. Methods: A retrospective review of patients undergoing multiple percutaneous lower extremity procedures at a single institution from 2002 and 2007 identified 73 SPTAS in 73 limbs. Patient comorbidities, anatomic, and procedural characteristics were analyzed with respect to outcomes with descriptive statistics, life-table analysis, and Cox proportional hazards modeling. Patency rates were determined from the time of SPTAS. Results: Patients included 39 men (64%) and 22 women (36%) at a mean age of 70 ± 10 years. Indications included claudication in 56 limbs (77%) and critical limb ischemia in 17 (23%). Median time from the initial endoluminal intervention to SPTAS was 322 days. Twenty limbs (27%) had TransAtlantic Inter-Society Consensus II (TASCII) category D lesions; the rest were treated for TASCII A, B, and C disease. Technical success was achieved in 72 patients (99%) and initial clinical improvement in 64 (89%). During a mean follow-up of 15.3 months, 2-year primary patency, assisted primary patency, secondary patency, limb salvage, and survival were, respectively, 66% ± 8%, 86% ± 4%, 86% ± 4%, 97%, and 89%. Cox proportional hazard modeling showed that SPTAS ≤180 days of the initial endovascular intervention was the only significant predictor of failure of SPTAS primary patency (hazard ratio, 3.5; 95% confidence interval, 1.1-11). TASCII D classification was associated with failure of assisted primary and secondary patency. Conclusions: Second-time femoropopliteal angioplasty/stenting has excellent initial success but limited midterm primary patency. The need for early SPTAS is highly associated with failure of primary patency and the need for additional interventions. With vigilance, good midterm assisted primary and secondary patency in those with limited extent of disease as well as excellent limb salvage can be achieved.

Ten-Year Patency and Factors Causing Restenosis After Endovascular Treatment of Iliac Artery Lesions

Long-term outcome and the factors associated with restenosis after endovascular treatment (EVT) for iliac artery lesions in peripheral arterial disease (PAD) were evaluated. EVT was performed for 487 lesions (TransAtlantic Inter-Society Consensus-II (TASC-II) Type-A: 275, B: 115, C: 37, and D: 60) in 436 PAD patients. The initial success rates for Type-B and Type-D lesions were lower than for Type-A lesions (P<0.05). The 3-, 5- and 10-year patency rates were 67%, 54% and 50%, respectively, with plain-old balloon angioplasty (POBA), and 88%, 82% and 75%, respectively, for stenting after suboptimal POBA, showing a significantly higher patency after treatment with a stent (P<0.001). With POBA, the long-term patency for Type-C/D lesions was lower than for Type-A/B lesions (P<0.05), but the patency after stenting did not differ significantly between Type-C/D and A/B. In the univariate analysis, the TASC-II classification, lesion length, pre- and post-procedural stenosis rates and stent use were found to be significant factors associated with restenosis (P<0.05). In the multivariate analysis, stent use (hazard ratio (HR) 0.345, confidence interval (CI) 0.193-0.616, P<0.001) and the post-procedural stenosis rate (HR 1.015, CI 1.001-1.030, P<0.05) were significantly associated with restenosis. Stent use and a low residual stenosis rate are significantly associated with patency, and favorable long-term patency can be obtained with stent placement for selected TASC-II Type-C/D lesions.

Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease

TransAtlantic Society Consensus (TASC)-II recommends bypass for TASC D and low-risk patients with TASC C lesions but does not specify graft types. Percutaneous balloon angioplasty/stenting (PTA/S) and above knee femoropopliteal bypass (AK-FPB) using polytetrafluoroethylene (PTFE) for these lesions were compared to determine if graft type should be part of the TASC-II recommendations for the treatment of TASC C lesions. Consecutive patients who underwent AK-FPB with PTFE, or PTA/S for TASC-II C (PTA/S-C) or D (PTA/S-D) SFA lesions between June 2001 and April 2007 were retrospectively analyzed. The primary end points were primary, assisted-primary, and secondary patency rates. In 127 patients (mean age, 68.7 +/- 10.0 years; median, 68; range, 49-97), 139 limbs were treated (46 AK-FPB, 49 PTA/S-C, 44 PTA/S-D). The mean occlusion and stented lengths were 9.9 +/- 3.8 and 24.3 +/- 6.6 cm (median, 10 and 20 cm) in PTA/S-C, and 26.6 +/- 5.5 and 30.0 +/- 5.2 cm (median, 26 and 29 cm) in PTA/S-D. Technical success was 84% in PTA/S-D and 100% in other groups. Mean follow-up was 26.4 +/- 18.0 months (median, 24). The 12- and 24-month primary patency was 83% +/- 6% and 80% +/- 7% for PTA/S-C; 54% +/- 8% and 28% +/- 12% for PTA/S-D; and 81% +/- 6% and 75% +/- 7% for AK-FPB (P < .001 PTA/S-D vs PTA/S-C and AK-FPB); assisted-primary patency was 95% +/- 3% and 95% +/- 3% for PTA/S-C, 62% +/- 8% and 49% +/- 10% for PTA/S-D, and 81% +/- 6% and 75% +/- 7% for AK-FPB (P < .001, PTA/S-C vs PTA/S-D; P = .003, PTA/S-C vs AK-FPB; and P = .03, PTA/S-D vs AK-FPB). Secondary patency was 98% +/- 3% and 98% +/- 3% for PTA/S-C; 72 % +/- 7% and 54% +/- 11% for PTA/S-D, and 81% +/- 6% and 78% +/- 7% for AK-FPB. Secondary patency was significantly better in PTA/S-C than AK-FPB (P = .003) and PTA/S-D groups (P < .001). The difference was marginally better in AK-FPB than in PTA/S-D (P = .064). PTA/S for TASC-II C lesions has a superior midterm patency than AK-FPB using PTFE, and AK-FPB with PTFE has better primary and assisted-primary patency than PTA/S-D. The TASC-II recommendations should be modified to recommend treatment of SFA TASC-II C lesions by PTA/S rather than PTFE bypass for all patients. PTA/S of TASC-II D lesions should only be considered in high-risk patients who cannot tolerate a bypass procedure using PTFE.