TransAtlantic Inter-Society Consensus Type Research Articles

Endovascular Treatment of TASC C and D Femoropopliteal Arterial Disease With Heparin-Bonded Covered Stents: The Impact of Distal Run-Off Vessels.

In the last 2 decades, several studies in the literature evaluated the possible role of covered stents in the treatment of TransAtlantic Inter-Society Consensus (TASC) C and D femoropopliteal lesions but, despite the encouraging results, the employment of these devices was never included in clinical guidelines. The aim of this study is to evaluate the role of the technical aspects in patients with TASC C or D lesions that were treated with the GORE VIABAHN endoprosthesis and to elaborate a computerized method to objectively estimate the post-stent run-off and predict stent-graft failure. In this monocentric retrospective study, we collected the patients who were treated in our department from December 2014 to May 2021. Inclusion criteria comprised: (1) patients who underwent endovascular treatment of a TASC C or D femoropopliteal lesions using one or more heparin-bonded covered stent(s) and (2) clinical follow-up >2 years. Exclusion criteria were clinical follow-up <2 years or missing. An in-house computerized analysis to estimate the post-stent run-off, CEVERO (Computerized Estimation of VEssel Run-Off), was elaborated. Sixty-six patients were enrolled in the study. Eleven patients had a TASC type C lesion, and 55 patients presented a type D lesion. The median follow-up time was 2.6 years. Twenty-nine patients (43.9%) experienced a major adverse limb event. Primary patency after 6, 12 and 24 months was 74.2%, 60.6%, and 57.6%; primary-assisted patency was 78.8%, 65.2%, and 59.1%. The presence of <2 run-off vessels (p<0.001) was correlated with stent-graft failure. The CEVERO analysis demonstrated an accuracy of 90.0% in predicting stent-graft failure. The treatment of TASC C and D femoropopliteal lesions remains technically challenging. Our study supported the hypothesis that run-off is the most critical factor in determining the outcome of the procedure and that concomitant angioplasty of the tibial vessels might improve the patency of the covered stent. The CEVERO analysis could permit a real-time, objective estimation of the distal run-off using conventional angiographic images, and it might be employed as a tool in the intraprocedural decision-making process, but its clinical applicability should be evaluated on external validation cohorts. The endovascular treatment of TASC C and D femoropopliteal lesions is technically challenging and run-off seems to be the most critical factor in determining the outcome. Concurrent angioplasty of the tibial vessels can create adequate run-off to avoid stent failure. The CEVERO analysis is a computerized estimation of run-off that might be a useful tool in the decision-making process.

Impact of sarcopenia in aortoiliac occlusive disease in Mediterranean population.

Background This study aims to validate the psoas muscle area and psoas muscle density as morphometric predictors in cardiovascular and cerebrovascular endpoints in patients with extensive aortoiliac peripheral arterial disease. Methods A total of 57 patients (55 males, 2 females; mean age 60±8.2 years; range, 35 to 83 years) with Trans-Atlantic Inter-Society Consensus type D lesions who underwent revascularization at two Portuguese tertiary hospitals between January 2013 and July 2019 were retrospectively analyzed. The patients with a recent (<6 months) computed tomography scan prior to the revascularization procedure were included in the study. Both centers offered to their patients open and endovascular repair of aortoiliac peripheral arterial disease. Major adverse cardiovascular and cerebrovascular events and major adverse limb events were evaluated. Results The median follow-up was 20 months. The mean survival rate was 93±3.4% at 30 days and 62.7±8.6% at 48 months. The discriminative thresholds found in this population were 2,175.8 mm2 for total psoas area and 51.75 Hounsfield unit for psoas muscle density. There was a statistically significant difference in the one-year survival rate (p=0.003 and p=0.291, respectively) and major adverse cardiovascular and cerebrovascular events (p=0.005 and p=0.206, respectively) for total psoas area compared to psoas muscle density. Conclusion Total psoas area shows a prognostic value for survival and major adverse cardiovascular and cerebrovascular events in this patient population.

Midterm Outcomes After Endovascular Intervention for Occluded vs Stenosed External Iliac Arteries

Purpose: To evaluate the association between a chronic total occlusion (CTO) and long-term outcomes among patients undergoing endovascular intervention to the external iliac artery (EIA). Methods: A 2-center retrospective study was conducted of 331 patients (mean age 64.7±12.7 years; 221 men) who underwent endovascular intervention for 481 EIA atherosclerotic lesions between 2006 and 2016. A quarter of the lesions (115, 23.9%) were CTOs. The majority of patients (184, 60.9%) were treated for claudication; 172 (38%) lesions were TransAtlantic Inter-Society Consensus type C or D. Target lesion revascularization (TLR) and major adverse limb event (MALE) rates were compared between lesions with or without an EIA CTO. A Cox proportional hazard model was subsequently developed to determine baseline variables associated with long-term outcomes after successful endovascular intervention of stented EIAs; outcomes are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results: The mean lesion length was longer (84 vs 50 mm, p<0.001) among patients treated for CTOs. While overall the target lesion failure rates were very low (2.8%), vessel perforation (2.7% vs 0.3%, p=0.02) and distal embolization (2.7% vs 0.9%, p=0.02) were more common in the CTO group. Among 377 successfully crossed and stented lesions (93 CTOs), the overall 1-year primary patency was 78% and secondary patency was 92%. One-year and 5-year TLR rates were 8.2% and 15.4%, respectively. CTO intervention was associated with higher 5-year TLR rates in the unadjusted analysis (HR 1.72, 95% CI 1.00 to 2.56, p=0.050), but the association did not remain significant after multivariable adjustment. Conclusion: Intervention to EIA CTOs is associated with increased intraprocedural complexity but with similar midterm outcomes, including high patency and low rates of TLR to 5 years.

Abstract No. 414 Peripheral atherectomy in Trans-Atlantic Inter-society Consensus (TASC) type C and D femoropopiliteal lesions in chronic limb ischemia

To evaluate the efficacy of peripheral atherectomy device in TASC type C and D femoropopiliteal lesions. In a period of 14 months (December 2015 to January 2017), all patients with complaints of chronic limb ischemia were evaluated. A detailed clinical and laboratory evaluation, doppler scan with lower limb CT angiography was performed, to determine TASC lesion type for femoropopiliteal lesions. Patients falling in TASC C and D category were included in the study. Written informed consent was obtained. All the 11 patients were males and mean age was 56 years. 2 or more of risk factors (hypertension, diabetes, smoking and hyperlipidemia) were present in all patients. Clinically, all patients fell in Rutherford IV to VI category (category III-1, IV-2, V-1, VII-7). 2 patients had ABI beyond 1.2, suggestive of heavily calcified vessels. Femoral access was taken and occlusion was crossed using hydrophilic 0.035” guide-wire (Terumo) in 8 patients and using 0.014” wire (Nitrex, Medtronic) in 3 patients. The 0.035” wire was exchanged with 0.014” wire and Directional Atherectomy device (Turbohawk, Medtronic) was then used. A distal embolic protection device was not used. Post-atherectomy angiogram was taken, followed by DCB angioplasty (Medtronic). Co-existing tibial disease noted in 9 patients and co-existing iliac disease was treated. Technical success was considered if residual stenosis was less than 30%. Patients were evaluated on follow-up at 1, 3 and 6 months for symptomatic relief, limb salvage and for ABI. Postprocedure, increase in ABI was noted in the 9 patients with ABI between 0.2 to 0.8. In the 5 patients presenting with digital gangrene, level of amputation was confined to digits and thus preventing further progression of gangrene. Satisfactory wound healing was noted in all the 7 patients in Rutherford category VI. 1 patient with rest-pain had persistence of symptoms, despite persistently improved ABI and no residual stenosis on follow-up angiogram. Combination of atherectomy device with DCB, provides significant limb salvage results for TASC C and D femoropopilteal lesions.

Use of the Gore Tigris Vascular Stent in Advanced Femoropopliteal Peripheral Arterial Disease

PurposeTo prospectively evaluate the safety and efficacy of using the Tigris vascular stent (Gore, Flagstaff, Arizona) alone or in combination with the Viabahn stent (Gore) for revascularizing femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) type B–D lesions with varying degrees of calcification. Materials and MethodsPatients with Rutherford stage ≥ 3 and TASC type ≥ B were included in the study. From January 2015 to April 2017, 31 segments in 31 patients (21 men, ovarall mean age 73.3 ± 9.2 years) were treated. The breakdown by TASC type and Rutherford stage were TASC B (n = 12), C (n = 6), and D (n = 13), and Rutherford 3 (n = 28) and 4 (n = 3). The lesions were located in the common femoral artery (n = 1), superficial femoral artery (SFA; n = 20), distal SFA to P1 (n = 3), popliteal P1 (n = 1), popliteal P1–3 (n = 3), popliteal P2–3 (n = 2), and 1 femoropopliteal bypass. There were 18 occlusions (58.1%) and 13 stenoses (41.9%). The mean diseased segment length was 15.5 ± 9.9 cm with 80.6% of moderate/severe calcification. The follow-up consisted of color Doppler ultrasound and clinical assessment at 1, 3, 6, 9, 12, and 15 months. ResultsTechnical success was 100%. There were no periprocedural or postprocedural complications. The mean stented lesion length was 17.2 ± 10.5 cm with a mean follow-up of 13.1 ± 6.9 months. Primary patency rates at 6, 9, 12, and 15 months were, respectively, 100% (24/31 patients), 90.5% (21/31 patients), 88.9% (20/31 patients), and 80% (15/31 patients). The median postprocedural Rutherford stage was 1. Three occlusions occurred at 7, 9, and 14 months, leading to a target lesion revascularization of 9.7% and a secondary patency of 100% at 15 months. Logistic analysis results demonstrated that lesion length (P = .003) was associated with reocclusion. Amputation-free survival at 15 months was 100%. Intrastent restenosis was observed in four cases (12.9%) but none were associated with worsening of symptoms. No stent fractures were observed. ConclusionsThe Tigris stent used alone or in combination with a Viabahn stent for femoropopliteal TASC B–D lesions demonstrated acceptable 12-month primary patency with a low reintervention rate.

Efficacy of iliac inflow repair in patients with concomitant iliac and superficial femoral artery occlusive disease

In multilevel arterial disease, whether complete revascularization or staged runoff repair should be performed remains controversial. The aim of this study was to evaluate the efficacy of iliac inflow repair and to identify clinical conditions that are associated with the need for runoff repair in concomitant iliac and superficial femoral artery (SFA) occlusive disease. Patients undergoing inflow repair for complicated flow-limiting iliac lesions with diffuse SFA disease between 2007 and 2013 were retrospectively reviewed. Patients with poor response to inflow repair underwent infrainguinal revascularization (IIR). The 29 ischemic limbs examined in this study represent 26 different patients (22 males; mean age, 77±8years). Indications for inflow repair were Rutherford Classifications III (31%), IV (31%), V (31%), and VI (7%). Severity of the complicated SFA disease was either TASC (TransAtlantic Inter-Society Consensus) type C (14%) or type D (86%). Overall, freedom from IIR was 90% after 30days and 83% after 1year. Patients having claudication, rest pain, and shallow ischemic ulcers experienced the relief of symptoms, whereas patients with deep gangrene that needed minor amputation required IIR more frequently (p<0.01). Anatomical risk factors for poor response to inflow repair were poor quality of the deep femoral artery (p<0.01) and the flow-limiting popliteal artery (p=0.02), and poor below-knee runoff (≤ 1 vessel, p<0.01). Iliac inflow repair can reverse the symptoms in patients with multilevel arterial occlusive disease that are not associated with gangrenous toes.

One-year outcomes of the U.S. and Japanese regulatory trial of the Misago stent for treatment of superficial femoral artery disease (OSPREY study)

The purpose of this study was to assess the safety and efficacy of the Misago stent (Terumo Corp, Tokyo, Japan) in occlusive and stenotic superficial femoral artery (SFA) disease. The safety and efficacy of the Misago SFA stent were evaluated prospectively in this initial collaboration trial between Japan and the United States. Because this trial enrolled patients mainly from Japan and the United States and because there is a question as to whether a race difference exists in SFA stent performance, the race difference on outcome was also analyzed. In addition, results were compared with a prior SFA stent trial. The Misago stent was implanted in 261 subjects with TransAtlantic Inter-Society Consensus (TASC) type A and type B SFA lesions (201 subjects in the United States, 50 in Japan, 9 in Taiwan, 1 in South Korea). The mean age of the patients was 69.3 ± 10.0 years, and the mean lesion length was 83.8 ± 41.3 mm. The overall 12-month primary patency rate and clinically driven target lesion revascularization were 82.9% and 13.0%, respectively. Regional differences within the Occlusive/Stenotic Peripheral Artery Revascularization Study (OSPREY) and outcomes between U.S. and Asian patients were similar, including primary patency (82.9% vs 83.0%; P = .889), clinically driven target lesion revascularization (13.4% vs 11.7%; P = .829), stent fracture rate (1.3% vs 0.0%; P = 1.000), and stent thrombosis rate (0.5% vs 0.0%; P = 1.000). OSPREY 12-month data showed satisfactory outcome of the Misago stent for the treatment of TASC type A and type B SFA lesions and appears to be comparable to recent stent trials. In addition, the lack of difference in outcome among races supports the value of international trials.

Initial clinical experience with a new low-profile thoracic endograft

The Zenith Alpha thoracic endograft (William Cook Europe, ApS, Bjaeverskov, Denmark) is a new low-profile thoracic endograft that has recently become commercially available in Europe. The reduced profile offers potential benefits and extended applicability, especially in patients with small or diseased iliofemoral vessels. The aim of this study was to evaluate the safety and efficacy of thoracic endovascular aortic repair performed with the new Zenith Alpha thoracic endograft. From November 2013 to the present, Zenith Alpha thoracic stent grafts have been employed to treat 42 patients (31 men; median age, 71 years; range, 54-83 years) suffering from descending thoracic aortic disease: 34 degenerative aneurysms, 4 aortic ulcers, 2 false aneurysms following prior thoracic open repair, and 2 traumatic blunt injuries. The mean proximal neck length was 25 mm (range, 17-40 mm), with a mean access vessel diameter of 6.7 mm (range, 6-11 mm). In 11 cases, aortoiliac occlusive disease (TransAtlantic Inter-Society Consensus type B and C lesions) was present. The proximal landing was in zone 1 in 2 cases, in zone 2 in 25 cases, in zone 3 in 11 cases, and in zone 4 in 4 cases. Fifty-one endografts (45 proximal components and 6 distal components) were deployed in 42 patients. The endografts were deployed safely and effectively from one surgical femoral access site in all cases. In patients with associated aortoiliac disease, no adjunctive procedures for device insertion, except for predilation with balloon angioplasty in two cases, were required. No major complications related to the devices were observed in any of the patients during the postoperative course, and there was no perioperative mortality, paraparesis, or paraplegia. At 30 days, morbid events included one case of major stroke, two cases of transient acute renal failure, and one case of postimplantation syndrome. No access-related complications were recorded. Computed tomography performed within 6 months was obtained in 39 patients and confirmed 100% clinical success without device-related complications. No type I endoleaks or bird's beak effects were documented. Our early experience shows that deployment of the new Zenith Alpha endograft from a surgical femoral access is safe and effective in treating thoracic aortic aneurysms, aortic ulcers, and traumatic blunt injuries, even in patients with small or diseased access vessels. Endograft conformance to the aorta and exclusion of the aneurysm were satisfactory. Long-term durability remains to be evaluated.

Stenting of femoropopliteal lesions using interwoven nitinol stents

The Supera stent (Abbott Laboratories, Abbott Park, Ill) has a unique biomimetic design allowing axial and longitudinal flexibility and fracture resistance. The aim of this retrospective study was to assess the midterm patency of Supera stents used to treat patients with superficial femoral and popliteal arterial disease by a single practice. From April 2010 to December 2011, 53 patients and 59 limbs with symptomatic femoropopliteal lesions underwent angioplasty and stenting with the Supera stent. Five patients had no follow-up and were excluded. Demographics of the patients, radiographic images, morphologic features of the lesions, procedural reports, reinterventions, and follow-up clinical visit notes were reviewed. Primary patency was defined as clinical resolution of symptoms with no secondary interventions. Primary and secondary patency rates at 12, 24, and 36 months were estimated by Kaplan-Meier analysis. A total of 48 patients (42 men, six women; 54 limbs; mean age, 64.3 years [range, 51-87]) received Supera stents and had at least one follow-up visit as part of their treatment for femoropopliteal disease. Primary indications for intervention included claudication, rest pain, and tissue loss, at rates of 54% (29 of 54), 26% (14 of 54), and 20% (11 of 54), respectively; 22% of lesions were TransAtlantic Inter-Society Consensus type A or B and 78% were type C or D. Mean lesion length was 24.0 cm (range, 3-51). Mean follow-up was 27.5 months (range, 1-45). The ankle-brachial index increased from 0.58 ± 0.20 preoperatively to 0.77 ± 0.18 postoperatively (P = .00004). Primary, primary assisted, and secondary patency rates at latest follow-up were 79.6%, 88.9%, and 92.3%, respectively. Cumulative primary patency rates by Kaplan-Meier analysis at 12, 24, and 36 months were 85.6%, 83.1%, and 76.7%, respectively. Secondary patency rates by Kaplan-Meier estimates at 12, 24, and 36 months were 93.8%, 93.8%, and 89.3%, respectively. No stent fractures were found at the time of any reinterventions. Long lesions >30 cm (n = 18) showed equivalent patency to lesions of 1 to 15 cm (n = 18) and lesions 15 to 30 cm in length (n = 18). Our midterm results show that Supera stents are durable in treating femoropopliteal lesions, with notably high patency rates in patients with long lesion lengths.

Effects of Simultaneous Iliac Artery Angioplasty on Graft and Patient Survival After Living-Donor Kidney Transplantation

Renal transplant candidates with extended indications, such as older age and advanced atherosclerosis, are currently accepted onto the waiting list. We retrospectively evaluated the clinical outcomes of simultaneous kidney transplantation and angioplasty compared with transplantation alone. We included 748 patients who underwent living-donor kidney transplant because of end-stage renal disease during a 5-year period, consisting of 27 kidney transplants with simultaneous angioplasty and 721 without additional vascular procedures. As candidates for simultaneous angioplasty and transplant, we considered patients with TransAtlantic Inter-Society Consensus type A and B aorto-iliac disease. We compared transplant outcomes in patients who did or did not receive simultaneous angioplasty. Although simultaneous iliac artery angioplasty was significantly related to recipient age, diabetes mellitus, hypertension, and coronary artery disease, it was not associated with graft (uncensored, P=0.937; death censored, P=0.981) or patient (P=0.804) survival during the follow-up period. In addition, simultaneous angioplasty was not associated with a higher risk of delayed graft function (P=0.099) or a longer hospital stay (P=0.790). There was no significant difference in mortality due to a cardiovascular event between the two groups (P=0.199). Simultaneous iliac artery angioplasty and kidney transplantation in carefully selected patients can be performed safely with equivalent graft and patient survival to transplantation alone.

Endovascular Stents: A Review of Their Use in Peripheral Arterial Disease

Technological advances in the past decade have shifted revascularization strategies from traditional open surgical approaches toward lower-morbidity percutaneous endovascular treatments for patients with lower extremity peripheral arterial disease (PAD). The continuing advances in stent design, more than any other advances, have fueled the growth of catheter-based procedures by improving the safety, durability, and predictability of percutaneous revascularization. Although the 2007 TransAtlantic Inter-Society Consensus (TASC) guidelines recommend endovascular therapy for type A and B aortoiliac and femoropopliteal lesions, recent developments in stent technology and increased experience of interventionists have suggested that a strategy of endovascular therapy first is appropriate in experienced hands for TASC type D lesions. The role of endovascular interventions is also expanding in the treatment of limb-threatening ischemia.

The efficacy analysis of endovascular intervention therapy for transatlantic inter society consensus type C and type D femoropopliteal arteriosclerosis lesion

To evaluate the efficacy of the endovascular intervention for transatlantic inter society consensus (TASC) type C and type D femoropopliteal artery disease. We conducted a retrospective analysis on 95 cases (98 lower limbs) with TASC type C and type D femoropopliteal artery arteriosclerosis lesion treated by percutaneous transluminal angioplasty and/or primary stent implantation from January 2007 to April 2009. We used ankle brachial index (ABI), Fontaine stages, limb salvage percentage and primary patency to evaluate the efficacy of the endovascular intervention therapy. The technical success rate of the 98 limbs was 94.9%, the perioperation mortality was 4.2% and the total amputation rate was 5.1%. 81 cases (84 limbs) were followed-up for a mean time of (13 ± 7) months, whose average ABI in dorsalis pedis artery and posterior tibial artery were 0.58 ± 0.22 and 0.60 ± 0.21 and increased 0.14 ± 0.25 and 0.13 ± 0.22 respectively than the ABI before intervention therapy. The statistical analysis showed a significant difference in ABI. The limbs of critical limb ischemia (CLI) were of 16.4% in the follow-up period and of 73.5% before the intervention therapy. The statistical results showed a significant difference in the percentage of CLI. Percutaneous endovascular intervention is an effective and minimally invasive method, and has a curative clinical efficacy to treat TASC type C and type D femoropopliteal artery disease.

The Influence of the Ipsilateral Superficial Femoral Artery on Iliac Angioplasty

Our objective was to evaluate the impact of the ipsilateral superficial femoral artery (SFA) on percutaneous transluminal angioplasty (PTA) of the iliac arteries. From 1993 to 2005, 183 iliac lesions (179 stenoses, 4 occlusions; 37 common, 35 external, and 111 both iliac arteries) in 127 patients with disabling claudication [94 (52%)], rest pain [43 (23%)], and ulcer/gangrene [46 (25%)] were treated by PTA. TransAtlantic Inter-Society Consensus (TASC) iliac lesion types were A in 48 limbs (26%), B in 92 (50%), C in 38 (21%), and D in 5 (3%). Stents were placed selectively for primary angioplasty failure [residual stenosis (>30%) or pressure gradient (>5 mm Hg)]. Seventy-seven limbs (42%) had patent SFAs (66 intact/<50% stenosis and 11 previously bypassed, pSFA group), 28 (15%) had stenotic SFAs (50-99%, sSFA group), 51 (28%) had occluded SFAs (oSFA group), and 27 (15%) had concomitant SFA angioplasty (aSFA group). The Society for Vascular Surgery and the International Society for Cardiovascular Surgery reporting standards were followed to define outcomes. There were no perioperative deaths. Total complication rate was 1.1% (2/183, groin hematomas). The mean follow-up was 20 months (range 1-115). One hundred twenty-five limbs (68%) had PTA alone for iliac lesions, and 58 (32%) had iliac stenting (a total of 91 stents). TASC iliac lesion types and the status of the ipsilateral profunda femoris artery were not significantly different among the four groups. Seventeen limbs (9%) had subsequent infrainguinal bypass: three in the pSFA, seven in the oSFA, four in the sSFA, and three in the aSFA groups (p = 0.19). The primary patency rate was significantly decreased in the sSFA group (29% at 3 years, Kaplan-Meier log-rank, p < 0.0001) compared with the other three groups; however, there were no significant differences among the pSFA, oSFA, and aSFA groups (67%, 67%, and 86% at 3 years, respectively; p = 0.92). The continued clinical improvement rates were significantly decreased in the sSFA group (36% at 3 years, p = 0.0043) compared with the other three groups; however, there was no significant difference between the pSFA, oSFA, and aSFA groups (81%, 84%, and 75% at 3 years, respectively; p = 0.088). The assisted primary and secondary patency and limb salvage rates were not significantly different among the four groups (p > 0.40). Stratified analysis in patients with TASC type B/type C, critical limb ischemia, or claudicants revealed similar results. The primary patency and continued clinical improvement were significantly decreased in patients with stenotic SFAs, suggesting that concomitant SFA angioplasty might improve iliac patency after iliac PTA for patients with stenotic SFAs. The presence of an occluded SFA did not adversely affect the outcomes of iliac PTA. During iliac PTA, a stenotic SFA should be considered for revascularization via endovascular means but an occluded SFA can be observed.

Advances in the Management of Iliac Artery Occlusive Disease: A Short Review

There have been considerable advances in the management of patients with aortoiliac occlusive disease. While endovascular procedure is the treatment of choice for Trans-Atlantic Inter-Society Consensus (TASC) type A and is more often used in TASC type B iliac lesions, recent studies report encouraging results in patients with intermittent claudication suffering from TASC type C and D iliac disease. Modern surgical techniques have been proposed for the treatment of high-risk subjects with critical limb ischemia due to advanced aortoiliac disease. Combined or hybrid interventions involving endovascular and open procedures performed either successively or intraoperatively are becoming more popular as vascular surgeons acquire endovascular skills. However, the long-term results of these therapies especially in the presence of multilevel occlusive lesions still remain uncertain.

Hemodynamic outcome of endovascular therapy for TransAtlantic InterSociety Consensus type B femoropopliteal arterial occlusive lesions.

Endovascular therapy for moderate femoropopliteal arterial occlusive disease remains controversial. This study reviewed our experience with endovascular therapy for TransAtlantic InterSociety Consensus (TASC) type B disease, which is defined as multiple stenoses less than 3 cm in diameter or a single stenosis or occlusion 3 to 5 cm in diameter. Stenosis-free patency was used as an objective end point to evaluate the hemodynamic outcome. A retrospective review was performed of all patients who had undergone endovascular treatment of TASC type B lesions between 1997 and 2002 at two referral centers. Balloon angioplasty was performed in all patients. Stenting was used selectively as an adjunct in patients with suboptimal angioplasty results. The treated sites were examined with duplex ultrasound scanning at 6-month to 12-month intervals. Stenosis-free patency was defined as the absence of stenosis greater than 50% diameter in the treated arterial segment with standard duplex criteria. One hundred fifteen limbs in 98 patients were studied. The indication for treatment was claudication in 92 patients (80%) and ischemic rest pain or gangrene in the remaining patients (20%). Multiple lesions greater than 3 cm were treated in 89 limbs (77%), and a single lesion 3 to 5 cm long was treated in 26 limbs (23%). Balloon angioplasty alone was performed in 74 limbs (65%), and angioplasty and adjunctive stenting was performed in 41 limbs (35%). Endovascular therapy was technically successful in all but one patient (99%), and there was no perioperative mortality or limb loss. During follow-up recurrent stenosis was detected in 46 limbs (40%), and reocclusion occurred in 11 limbs (10%). Seven patients (6%) underwent surgical bypass after endovascular treatment failure. The aggregate 1-year stenosis-free patency rate at life table analysis was 55.1%. The 1-year stenosis-free patency for angioplasty alone was 58%, compared with 51% (NS) for angioplasty and adjunctive stenting. Univariate regression analysis failed to demonstrate a difference in stenosis-free patency for demographic variables, medical comorbidities, and anatomic characteristics (multiple vs single lesions; number of angioplasty procedures). Endovascular therapy for TASC type B femoropopliteal lesions is safe and technically feasible. However, the length of time that a treated arterial segment remains free of stenosis is limited, and is not improved with adjunctive stenting. Recurrent stenosis, not occlusion, was the most common study end point, and few patients subsequently required surgical bypass. Predictors of outcome after endovascular therapy for TASC type B lesions were not identified in this study.

External iliac and common iliac artery angioplasty and stenting in men and women

Objective: The effect of anatomic location of stent placement on the outcome of iliac artery angioplasty and stenting is not defined. Analyses of patency rates of external iliac artery (EIA) and common iliac artery (CIA) stents have provided conflicting results and have not considered men and women independently. The purpose of this study was to estimate the influence of the anatomic location of stenting on the outcome of iliac angioplasty and stent placement in both men and women. Methods: From 1995 to 1999, 247 iliac angioplasty and stent placement procedures (303 stents) were performed in 67 women and 122 men, and all were included in a retrospective cohort study. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Both univariate (Kaplan-Meier [KM]) and multivariate analyses (Cox proportional hazards model) were used to determine the association among the variables, cumulative patency, limb salvage, and survival. Results: Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (33%), and blue toe syndrome (2%). Primary stenting was performed in 103 procedures (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Patients with EIA stents, as compared with those who had CIA stents, had more extensive lesions (TransAtlantic Inter-Society Consensus type C lesions), poorer runoff, smaller vessel size, and less frequency of hyperlipidemia (P <.05). Primary patency rates at 1, 3, and 5 years were 76%, 56%, and 56%, respectively, for patients with EIA stents and 92%, 85%, and 76%, respectively, for those with CIA stents. Although overall primary patency rates were significantly decreased in patients with EIA lesions (KM, log-rank test, P =.001), stratified analyses revealed that women with EIA stents had the poorest outcome, with 61%, 47%, and 23% primary patency rates at 1, 3, and 5 years, respectively, (KM, log-rank test, P <.001). Cox regression analysis identified EIA stenting (relative risk, 4.3; 95% CI, 2.3-7.9; P <.001) as an independent predictor of decreased primary patency in women but not in men. Conclusions: Women undergoing EIA angioplasty with stent placement have significantly reduced primary patency rates. Despite initial technical success, these patients are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. Conversely, men undergoing EIA stenting have a more favorable outcome than women. (J Vasc Surg 2001;34:440-6.)