Retrospective Case Control Matched Comparison of the Antegrade Versus Retrograde Strategy After Antegrade Recanalisation Failure in Complex de novo Femoropopliteal Occlusive Lesions

Intravascular ultrasound evaluation of BYCROSS™ Atherectomy

Background: BYCROSS™ atherectomy allows minimally invasive plaque removal in patients with peripheral arterial disease (PAD). Previously published reports with this device provided promising results. However, data on atherectomy combined with intravascular ultrasound (IVUS) are limited. The aim of this study was to assess luminal gain in patients treated with the BYCROSS™ device in femoropopliteal lesions using IVUS. Patients and methods: Consecutive patients with symptomatic PAD due to symptomatic femoropopliteal lesions or occlusions underwent BYCROSS™ atherectomy-assisted endovascular revascularization. Safety in terms of perforation and embolization were evaluated, while area of stenosis (%) and minimal luminal area were measured by IVUS at baseline, after atherectomy and after adjunctive therapy. Results: 21 patients (68.2±8.8 years, 16 male and 11 with chronic limb-threatening ischemia) were included. Mean lesion length was 139.8±68.8 mm and 15 (71.4%) of the lesions were chronic total occlusions (CTO). Most lesions (52.4%) exhibited moderate-to-severe calcification. Median minimal lumen diameter (MLA) was 0.0 mm² (IQR=0.0-2.55 mm²) before treatment, increased to 8.0 mm² (IQR=6.6-11.2 mm²) after atherectomy (p<0.0001 vs. baseline) and further increased to 17.6 mm² (IQR=11.6-22.3 mmm²) after further treatment with angioplasty and if required stenting (p=0.0001 vs. after atherectomy). No perforations were noted, while peripheral embolization was noted in 3 (14.3%) cases, which all could be treated by catheter aspiration. Conclusion: The BYCROSSTM atherectomy system can provide effective lumen gain in femoropopliteal lesions without barotrauma, which can be quantitatively assessed using IVUS. Further studies are now warranted to investigate the impact of luminal gain on long-term patency and limb-related outcomes.

Investigation of the Feasibility and Safety of a Highly Intensive Penetration Technique for Recanalization in Severe Calcified Femoropopliteal Occlusive Lesions: A Retrospective Observational Study

Background and Aims

When dealing with severely calcified lesions in endovascular therapy (EVT) for lower extremity artery disease (LEAD), navigating through severely calcified chronic total occlusion (CTO) using hard-tip guidewires can be challenging. To address this issue, we employed a novel highly intensive penetration (HIP) technique. This technique involves modifying the tail of a 0.035-inch guidewire to enhance its penetration capability, thus enabling effective navigation through the calcified lesion and facilitating the EVT procedure. This study aimed to assess the feasibility and safety of the HIP technique.

Methods

This single-center, retrospective study enrolled 27 consecutive patients (29 limbs) who underwent the HIP technique for the recanalization of calcified femoropopliteal CTO lesions that were resistant to penetration by high-tip load (≧ 40 g) guidewires between January 2015 and April 2023. Statistical analyses were performed using JMP 13 software.

Results

The mean patient age was 75.9 ± 10.1 years. The proportion of men, patients with hypertension, patients with diabetes mellitus, and patients on hemodialysis was 78%, 59%, 41%, and 44%, respectively. The crossover approach was selected for 55% of the patients. The reference vessel diameter was 5.3 ± 0.6 mm, and the lesion length was 19.7 ± 12.0 cm. The target lesions were predominantly located in the superficial femoral artery (76%). In-stent occlusion was treated in 14% of patients. The HIP technique was successfully performed in 79% of patients, and the complication rate of vascular perforation was 7%.

Conclusion

The HIP technique demonstrates remarkable effectiveness in navigating through highly calcified lesions, offering a reliable method for successful recanalization in challenging cases.

Lesion Localization and Limb Outcomes in Elderly Patients with and Without Type 2 Diabetes Mellitus Who Undergo Atherectomy-Assisted Endovascular Revascularization due to Symptomatic Peripheral Artery Disease

Background/Objectives: Type 2 diabetes mellitus (T2DM) represents a major risk factor for peripheral artery disease (PAD). We aimed to evaluate the impact of T2DM on lesion localization and complexity, clinical presentation by Rutherford categories, and limb outcomes in elderly patients with symptomatic PAD undergoing endovascular revascularization. Methods: Five hundred consecutive patients with symptomatic infra-inguinal PAD who underwent rotational atherectomy-assisted endovascular revascularization were included. PAD clinical presentation and lesion localization were recorded. The primary endpoints were clinically driven target lesion revascularization (CD-TLR) and major amputation rates during follow-up. Results: Overall, 245/500 (49.0%) patients had T2DM, whereas 179 (35.8%) presented with lifestyle limiting claudication and 321 (64.2%) with critical limb-threatening ischemia (CLTI). Median age was 78.0 (IQR = 70.0-84.0) years, and 201 (40.2%) patients were female. The presence of T2DM was significantly more frequent in patients with CLTI vs. those with claudication (58.6 vs. 31.8%; p < 0.001). Furthermore, the percentage of patients with below-the-knee (BTK) lesions was significantly higher in patients with vs. without T2DM (40.7 vs. 27.5%, p = 0.0002). During median follow-up of 21.9 (IQR = 12.8-28.8) months, CD-TLR rates were similar in patients with vs. without T2DM (HR = 1.2, 95%CI = 0.8-2.0, p = 0.39). However, patients with T2DM had a ~5.5-fold increased risk for major above-the-ankle amputation (HR = 5.5, 95%CI = 1.6-19.0, p = 0.007). After adjustment for age, gender, lesion complexity, and calcification, T2DM remained predictive for major amputation (p = 0.04). Conclusions: T2DM is more frequently associated with CLTI, BTK-PAD, and amputations despite successful endovascular revascularization. More stringent surveillance of patients with PAD and T2DM is warranted to prevent atherosclerosis-related complications.