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Tsukagoshi J, Shimoda T, Yokoyama Y, Secemsky EA, Shirasu T, Nakama T, Jujo K, Wiley J, Takagi H, Aikawa T, Kuno T. The mid-term effect of intravascular ultrasound on endovascular interventions for lower extremity peripheral arterial disease: A systematic review and meta-analysis. J Vasc Surg 2024; 79:963-972.e11. [PMID: 37678642 DOI: 10.1016/j.jvs.2023.08.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Intravascular ultrasound (IVUS) is an important adjunctive tool for patients with lower extremity peripheral arterial disease (PAD) undergoing endovascular therapy (EVT). The evidence regarding the advantages of IVUS use is evolving, and recent studies have reported conflicting results. We aimed to perform a meta-analysis to evaluate the efficacy of IVUS during angiography-guided EVT for patients with PAD. METHODS MEDLINE and EMBASE were searched through April 2023 to identify studies that investigated the outcomes of IVUS with angiography-guided EVT vs angiography-alone-guided EVT. The primary outcome was restenosis/occlusion rate; secondary outcomes were target lesion revascularization, major amputation, and mortality. RESULTS One randomized controlled trial and 14 observational studies, largely of moderate quality, were included, yielding a total of 708,808 patients with 709,189 lesions that were treated with IVUS-guided EVT (n = 101,405) vs angiography-alone (n = 607,784). Compared with angiography alone, IVUS-guided EVT was associated with a non-significant trend towards decreased restenosis/occlusion (relative risk [RR], 0.74; 95% confidence interval [CI], 0.54-1.00; I2 = 60%). Although the risk of target lesion revascularization and mortality were comparable (RR, 0.85; 95% CI, 0.65-1.10; I2 = 70%; RR, 1.01; 95% CI, 0.79-1.28; I2 = 43%, respectively), the use of IVUS was also associated with significantly lower risk of major amputation (RR, 0.74; 95% CI, 0.67-0.82; I2 = 47%). Subgroup analysis focusing on femoropopliteal disease demonstrated significantly higher patency (RR, 0.72; 95% CI, 0.52-0.98; I2 = 73%). However, superiority with major amputation was not observed. CONCLUSIONS IVUS-guided EVT for PAD may possibly be associated with a lower major amputation rate compared with angiography alone-guided EVT, although the difference in patency remained an insignificant trend in favor of IVUS-guided EVT. Adjunctive use of IVUS during EVT may be beneficial, and further prospective studies are warranted to delineate this relationship and the applicability of this technology in routine practice.
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Affiliation(s)
- Junji Tsukagoshi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Yujiro Yokoyama
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Nakama
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
| | - Kentaro Jujo
- Department of Cardiology, Saitama Medical University, Iruma, Japan
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Tadao Aikawa
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Department of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Secemsky EA, Aronow HD, Kwolek CJ, Meissner M, Muck PE, Parikh SA, Winokur RS, George JC, Salazar G, Murphy EH, Costantino MM, Zhou W, Li J, Lookstein R, Desai KR. Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS. J Vasc Interv Radiol 2024; 35:335-348. [PMID: 38206255 DOI: 10.1016/j.jvir.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 01/12/2024] Open
Abstract
Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Herbert D Aronow
- Department of Medicine, Michigan State University, East Lansing, Michigan; Heart & Vascular Services, Henry Ford Health, Detroit, Michigan
| | - Christopher J Kwolek
- Harvard Medical School, Boston, Massachusetts; Newton-Wellesley Hospital, Wellesley, Massachusetts
| | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Patrick E Muck
- Department of Vascular Surgery, Good Samaritan Hospital, Cincinnati, Ohio
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ronald S Winokur
- Weill Cornell Vein Treatment Center and Division of Interventional Radiology, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Jon C George
- Division of Interventional Cardiology and Endovascular Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Gloria Salazar
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin H Murphy
- Venous and Lymphatic Center, Division of Vascular Surgery, Sanger Heart and Vascular, Atrium Health, Charlotte, North Carolina
| | | | - Wei Zhou
- Division of Vascular Surgery, University of Arizona and Banner University Medical Center, Tucson, Arizona
| | - Jun Li
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | | | - Kush R Desai
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Secemsky EA, Mosarla RC, Rosenfield K, Kohi M, Lichtenberg M, Meissner M, Varcoe R, Holden A, Jaff MR, Chalyan D, Clair D, Hawkins BM, Parikh SA. Appropriate Use of Intravascular Ultrasound During Arterial and Venous Lower Extremity Interventions. JACC Cardiovasc Interv 2022; 15:1558-1568. [PMID: 35926922 DOI: 10.1016/j.jcin.2022.04.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/11/2022] [Accepted: 04/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND There has been growing use of intravascular ultrasound (IVUS) during lower extremity arterial and venous revascularization. Observational data suggest that the use of IVUS can improve periprocedural and long-term outcomes, but largescale prospective data remain limited. Consensus opinion regarding the appropriate use of IVUS during peripheral intervention is needed. OBJECTIVES The purpose of this consensus document is to provide guidance on the appropriate use of IVUS in various phases of peripheral arterial and venous interventions. METHODS A 12-member writing committee was convened to derive consensus regarding the appropriate clinical scenarios for use of peripheral IVUS. The group iteratively created a 72-question survey representing 12 lower extremity arterial interventional scenarios. Separately, a 40-question survey representing 8 iliofemoral venous interventional scenarios was constructed. Clinical scenarios were categorized by interventional phases: preintervention, intraprocedure, and postintervention optimization. Thirty international vascular experts (15 for each survey) anonymously completed the survey instrument. Results were categorized by appropriateness using the median value and disseminated to the voting panel to reevaluate for any disagreement. RESULTS Consensus opinion concluded that IVUS use may be appropriate during the preintervention phase for evaluating the etiology of vessel occlusion and plaque morphology in the iliac and femoropopliteal arteries. IVUS was otherwise rated as appropriate during iliac and femoropopliteal revascularization in most other preintervention scenarios, as well as intraprocedural and postprocedural optimization phases. IVUS was rated appropriate in all interventional phases for the tibial arteries. For iliofemoral venous interventions, IVUS was rated as appropriate in all interventional phases. CONCLUSIONS Expert consensus can help define clinical procedural scenarios in which peripheral IVUS may have value during lower extremity arterial and venous intervention while additional prospective data are collected.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Ramya C Mosarla
- Division of Cardiology, Department of Medicine, New York University Medical Center, New York, New York, USA
| | | | - Maureen Kohi
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ramon Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
| | - Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Michael R Jaff
- Harvard Medical School, Boston, Massachusetts, USA; Boston Scientific, Marlborough, Massachusetts, USA
| | - David Chalyan
- Department of Radiological Sciences, University of California, Irvine, Irvine, California, USA; Royal Philips, Noord-Holland, Amsterdam, the Netherlands
| | - Daniel Clair
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Beau M Hawkins
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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Natesan S, Mosarla RC, Parikh SA, Rosenfield K, Suomi J, Chalyan D, Jaff M, Secemsky EA. Intravascular ultrasound in peripheral venous and arterial interventions: A contemporary systematic review and grading of the quality of evidence. Vasc Med 2022; 27:392-400. [PMID: 35546056 DOI: 10.1177/1358863x221092817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although angiography has been the primary imaging modality used in peripheral vascular intervention, this technique has major limitations due to the evaluation of three-dimensional vessels in two dimensions. Intravascular ultrasound (IVUS) is an important adjunctive tool that can address some of these limitations. This systematic review assesses the appropriateness of IVUS as an imaging modality for guiding peripheral intervention through evidence collection and clinical appraisal of studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a cohort of 48 studies (29 arterial; 19 venous) detailing IVUS use in peripheral vascular intervention were extracted. Qualitative assessment of the studies evaluated pre- and postprocedure efficacy of IVUS and revealed that IVUS-guided peripheral intervention in arterial and venous diagnosis and treatment was superior to other imaging techniques alone. Each study in the cohort was further assessed for reliability and validity using the Oxford Centre for Evidence Based Medicine (CEBM) level of evidence scale. The majority of both arterial (79.3%) and venous (73.7%) studies received a 2b rating, the second highest level of evidence rating. The evidence to date indicates that IVUS results in better clinical outcomes overall and should be more widely adopted as an adjunctive imaging modality during peripheral intervention. (PROSPERO Registration No.: CRD42021232353).
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Affiliation(s)
- Sahana Natesan
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ramya C Mosarla
- Division of Cardiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sahil A Parikh
- Department of Medicine, Center for Interventional Vascular Therapy and Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | | | - Joanna Suomi
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Independent Medical Writer
| | - David Chalyan
- Department of Radiological Sciences, University of California-Irvine, Irvine, CA, USA
| | - Michael Jaff
- Boston Scientific Corporation, Marlborough, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Aru RG, Tyagi SC. Endovascular Treatment of Femoropopliteal Arterial Occlusive Disease: Current Techniques and Limitations. Semin Vasc Surg 2022; 35:180-189. [DOI: 10.1053/j.semvascsurg.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 11/11/2022]
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Abstract
BACKGROUND Symptomatic peripheral arterial disease (PAD) has several treatment options, including angioplasty, stenting, exercise therapy, and bypass surgery. Atherectomy is an alternative procedure, in which atheroma is cut or ground away within the artery. This is the first update of a Cochrane Review published in 2014. OBJECTIVES To evaluate the effectiveness of atherectomy for peripheral arterial disease compared to other established treatments. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine (AMED) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 August 2019. SELECTION CRITERIA We included all randomised controlled trials that compared atherectomy with other established treatments. All participants had symptomatic PAD with either claudication or critical limb ischaemia and evidence of lower limb arterial disease. DATA COLLECTION AND ANALYSIS Two review authors screened studies for inclusion, extracted data, assessed risk of bias and used GRADE criteria to assess the certainty of the evidence. We resolved any disagreements through discussion. Outcomes of interest were: primary patency (at six and 12 months), all-cause mortality, fatal and non-fatal cardiovascular events, initial technical failure rates, target vessel revascularisation rates (TVR; at six and 12 months); and complications. MAIN RESULTS We included seven studies, with a total of 527 participants and 581 treated lesions. We found two comparisons: atherectomy versus balloon angioplasty (BA) and atherectomy versus BA with primary stenting. No studies compared atherectomy with bypass surgery. Overall, the evidence from this review was of very low certainty, due to a high risk of bias, imprecision and inconsistency. Six studies (372 participants, 427 treated lesions) compared atherectomy versus BA. We found no clear difference between atherectomy and BA for the primary outcomes: six-month primary patency rates (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.94 to 1.20; 3 studies, 186 participants; very low-certainty evidence); 12-month primary patency rates (RR 1.20, 95% CI 0.78 to 1.84; 2 studies, 149 participants; very low-certainty evidence) or mortality rates (RR 0.50, 95% CI 0.10 to 2.66, 3 studies, 210 participants, very low-certainty evidence). One study reported cardiac failure and acute coronary syndrome as causes of death at 24 months but it was unclear which arm the participants belonged to, and one study reported no cardiovascular events. There was no clear difference when examining: initial technical failure rates (RR 0.48, 95% CI 0.22 to 1.08; 6 studies, 425 treated vessels; very low-certainty evidence), six-month TVR (RR 0.51, 95% CI 0.06 to 4.42; 2 studies, 136 treated vessels; very low-certainty evidence) or 12-month TVR (RR 0.59, 95% CI 0.25 to 1.42; 3 studies, 176 treated vessels; very low-certainty evidence). All six studies reported complication rates (RR 0.69, 95% CI 0.28 to 1.68; 6 studies, 387 participants; very low-certainty evidence) and embolisation events (RR 2.51, 95% CI 0.64 to 9.80; 6 studies, 387 participants; very low-certainty evidence). Atherectomy may be less likely to cause dissection (RR 0.28, 95% CI 0.14 to 0.54; 4 studies, 290 participants; very low-certainty evidence) and may be associated with a reduction in bailout stenting (RR 0.26, 95% CI 0.09 to 0.74; 4 studies, 315 treated vessels; very low-certainty evidence). Four studies reported amputation rates, with only one amputation event recorded in a BA participant. We used subgroup analysis to compare the effect of plain balloons/stents and drug-eluting balloons/stents, but did not detect any differences between the subgroups. One study (155 participants, 155 treated lesions) compared atherectomy versus BA and primary stenting, so comparison was extremely limited and subject to imprecision. This study did not report primary patency. The study reported one death (RR 0.38, 95% CI 0.04 to 3.23; 155 participants; very low-certainty evidence) and three complication events (RR 7.04, 95% CI 0.80 to 62.23; 155 participants; very low-certainty evidence) in a very small data set, making conclusions unreliable. We found no clear difference between the treatment arms in cardiovascular events (RR 0.38, 95% CI 0.04 to 3.23; 155 participants; very low-certainty evidence). This study found no initial technical failure events, and TVR rates at six and 24 months showed little difference between treatment arms (RR 2.27, 95% CI 0.95 to 5.46; 155 participants; very low-certainty evidence and RR 2.05, 95% CI 0.96 to 4.37; 155 participants; very low-certainty evidence, respectively). AUTHORS' CONCLUSIONS This review update shows that the evidence is very uncertain about the effect of atherectomy on patency, mortality and cardiovascular event rates compared to plain balloon angioplasty, with or without stenting. We detected no clear differences in initial technical failure rates or TVR, but there may be reduced dissection and bailout stenting after atherectomy although this is uncertain. Included studies were small, heterogenous and at high risk of bias. Larger studies powered to detect clinically meaningful, patient-centred outcomes are required.
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Affiliation(s)
- Bethany G Wardle
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - Graeme K Ambler
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Robert J Hinchliffe
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Christopher P Twine
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
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Sheikh AB, Anantha-Narayanan M, Smolderen KG, Jelani QUA, Nagpal S, Schneider M, Llanos F, Ionescu C, Regan C, Attaran R, Altin SE, Mena-Hurtado C. Utility of Intravascular Ultrasound in Peripheral Vascular Interventions: Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2020; 54:413-422. [DOI: 10.1177/1538574420920998] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We sought to compare outcomes between intravascular ultrasound– (IVUS) versus angiography (AO)-guided peripheral vascular interventions (PVIs). Introduction: Intravascular ultrasound facilitates plaque visualization and angioplasty during PVIs for peripheral arterial disease. It is unclear whether IVUS may improve the durability of PVIs and lead to improved clinical outcomes. Methods: This is a study-level meta-analysis of observational studies. The primary end points of this study were rates of primary patency and reintervention. Secondary end points included rates of vascular complications, periprocedural adverse events, amputations, technical success, all-cause mortality, and myocardial infarction. Results: Eight observational studies were included in this analysis with 93 551 patients. Mean follow-up was 24.2 ± 15 months. Intravascular ultrasound–guided PVIs had similar patency rates when compared with AO-guided PVIs (relative risk [RR]: 1.30, 95% confidence interval [CI]: 0.99-1.71, P = .062). There was no difference in rates of reintervention in IVUS-guided PVIs when compared to non-IVUS-guided PVIs (RR: 0.41, 95% CI: 0.15-1.13, P = .085). There is a lower risk of periprocedural adverse events (RR: 0.81, 95% CI: 0.70-0.94, P = .006) and vascular complications (RR: 0.81, 95% CI: 0.68-0.96, P = .013) in the IVUS group. All-cause mortality (RR: 0.76, 95% CI: 0.56-1.04, P = .084), amputation rates (RR 0.83, 95% CI: 0.32-2.15, P = .705), myocardial infarctions (RR: 1.19, 95% CI: 0.58-2.41, P = .637), and technical success (RR: 1.01, 95% CI: 0.86-1.19, P = .886) were similar between the groups. Conclusions: Intravascular ultrasound–guided PVIs had similar primary patency and reintervention when compared with AO-guided PVIs with significantly lower rates of periprocedural adverse events and vascular complications in the IVUS-guided group.
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Affiliation(s)
- Azfar Bilal Sheikh
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Mahesh Anantha-Narayanan
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Kim G. Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Sameer Nagpal
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Marabel Schneider
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Fiorella Llanos
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Costin Ionescu
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Christopher Regan
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Robert Attaran
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - S. Elissa Altin
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
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Abstract
BACKGROUND Symptomatic peripheral arterial disease may be treated by a number of options including exercise therapy, angioplasty, stenting and bypass surgery. Atherectomy is an alternative technique where atheroma is excised by a rotating cutting blade. OBJECTIVES The objective of this review was to analyse randomised controlled trials comparing atherectomy against any established treatment for peripheral arterial disease in order to evaluate the effectiveness of atherectomy. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2013) and CENTRAL (2013, Issue 10). Trials databases were searched for details of ongoing or unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing atherectomy and other established treatments were selected for inclusion. All participants had symptomatic peripheral arterial disease with either claudication or critical limb ischaemia and evidence of lower limb arterial disease. DATA COLLECTION AND ANALYSIS Two review authors (GA and CT) screened studies for inclusion, extracted data and assessed the quality of the trials. Any disagreements were resolved through discussion. MAIN RESULTS Four trials were included with a total of 220 participants (118 treated with atherectomy, 102 treated with balloon angioplasty) and 259 treated vessels (129 treated with atherectomy, 130 treated with balloon angioplasty). All studies compared atherectomy with angioplasty. No study was properly powered or assessors blinded to the procedures and there was a high risk of selection, attrition, detection and reporting biases.The estimated risk of success was similar between the treatment modalities although the confidence interval (CI) was compatible with small benefits of either treatment for the initial procedural success rate (Mantel-Haenszel risk ratio (RR) 0.92, 95% CI 0.44 to 1.91, P = 0.82), patency at six months (Mantel-Haenszel RR 0.92, 95% CI 0.51 to 1.66, P = 0.79) and patency at 12 months (Mantel-Haenszel RR 1.17, 95% CI 0.72 to 1.90, P = 0.53) following the procedure. The reduction in all-cause mortality with atherectomy was most likely due to an unexpectedly high mortality in the balloon angioplasty group in one of the two trials that reported mortality (Mantel-Haenszel RR 0.24, 95% CI 0.06 to 0.91, P = 0.04). Cardiovascular events were not reported in any study. There was a reduction in the rate of bailout stenting following atherectomy (Mantel-Haenszel RR 0.45, 95% CI 0.24 to 0.84, P = 0.01), and balloon inflation pressures were lower following atherectomy (mean difference -2.73 mmHg, 95% CI -3.48 to -1.98, P < 0.00001). Complications such as embolisation and vessel dissection were reported in two trials indicating more embolisations in the atherectomy group and more vessel dissections in the angioplasty group, but the data could not be pooled. From the limited data available, there was no clear evidence of different rates of adverse events between the atherectomy and balloon angioplasty groups for target vessel revascularisation and above-knee amputation. Quality of life and clinical and symptomatic outcomes such as walking distance or symptom relief were not reported in the studies. AUTHORS' CONCLUSIONS This review has identified poor quality evidence to support atherectomy as an alternative to balloon angioplasty in maintaining primary patency at any time interval. There was no evidence for superiority of atherectomy over angioplasty on any outcome, and distal embolisation was not reported in all trials of atherectomy. Properly powered trials are recommended.
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Affiliation(s)
- Graeme K Ambler
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK, CB2 0QQ
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Sacks D, Marinelli DL, Martin LG, Spies JB. Reporting Standards for Clinical Evaluation of New Peripheral Arterial Revascularization Devices. J Vasc Interv Radiol 2003; 14:S395-404. [PMID: 14514855 DOI: 10.1097/01.rvi.0000094613.61428.a9] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- David Sacks
- Department of Radiology, Reading Hospital and Medical Center, 6th and Spruce Streets, West Reading, PA 19603, USA
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10
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Vogt KC, Sillesen H, Schroeder TV. The use of intravascular ultrasound for intraoperative assessment during semiclosed thromboendarterectomy. ULTRASOUND IN MEDICINE & BIOLOGY 1998; 24:21-25. [PMID: 9483768 DOI: 10.1016/s0301-5629(97)00230-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
To evaluate the application of intravascular ultrasound (IVUS) for intraoperative assessment of semiclosed thromboendarterectomy (TEA), IVUS images of the iliofemoral segment in 20 patients were obtained. The configuration and size of residual atherosclerotic material were evaluated. Stenoses in the artery proximal to the endarterectomized area were measured and, along with any remaining material, related to patency. Patency was evaluated at clinical controls after 3, 6, 12 and 24 months with duplex scanning and ankle-brachial index. In 10 cases (50%), material left behind from the endarterectomy was detected in the artery by IVUS. The material was removed in five cases. The part of the iliac artery proximal to the endarterectomized segment was visualized in 14 cases and showed minor stenoses in 10 cases. After follow-up at a median of 8 months (range 1-24), occlusion had occurred in one of 20 patients and restenosis (> 50%) had developed in two (10%). At this point, patency cannot be related to IVUS findings. We conclude that IVUS is a feasible method for intraoperative assessment of semiclosed TEA. The rate of early failures due to residual material might be reduced by this new application of IVUS.
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Affiliation(s)
- K C Vogt
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.
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11
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Steenhuijsen JL, Vaartjes SR, Poortermans CJ, Havenith MG, Boom HB. Rupture of the arterial wall causes deflection in pressure time course during ex vivo balloon angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 42:92-101. [PMID: 9286552 DOI: 10.1002/(sici)1097-0304(199709)42:1<92::aid-ccd26>3.0.co;2-n] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A relation between restenosis and arterial lesions resulting from balloon angioplasty has been suggested in literature. Nevertheless, it is unclear to what extent angioplasty-induced arterial wall lesions contribute to the occurrence of restenosis. One problem is that arterial ruptures cannot be detected during balloon inflation. This study describes a method to detect ruptures in the arterial wall, based on deflections observable in the development of the balloon pressure. We performed ex vivo angioplasty with constant strain rate on 28 human femoral artery segments, showing deflections in 21 cases. In 20 cases wall rupture was confirmed histologically. From seven cases not showing deflections, four showed intact wall at microscopy. These figures result in a selectivity of the proposed method of 87 +/- 7% and a predictive value of the positive test of 95 +/- 5%. We conclude that this method can enhance detection of arterial rupture during ex vivo angioplasty and may become important clinically.
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Affiliation(s)
- J L Steenhuijsen
- Department of Electrical Engineering, University Twente, Enschede, The Netherlands
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12
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Sacks D, Marinelli DL, Martin LG, Spies JB. Reporting standards for clinical evaluation of new peripheral arterial revascularization devices. Technology Assessment Committee. J Vasc Interv Radiol 1997; 8:137-49. [PMID: 9025054 DOI: 10.1016/s1051-0443(97)70530-x] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- D Sacks
- Department of Radiology, Reading Hospital and Medical Center, PA 19603, USA
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