Long-term results of percutaneous transluminal angioplasty: a study of 4750 dilatations and local lyses

Circulating cell adhesion molecules and endothelial markers before and after transluminal angioplasty in peripheral arterial occlusive disease

In the present study, the levels of soluble adhesion molecules P- and E-selectin, intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1) and of other markers of endothelial activation or injury, such as thrombomodulin, von Willebrand factor (vWF), as well as homocysteine, were prospectively investigated in 71 patients (21 women, 50 men, age 68+/-13) with predominantly femoropopliteal peripheral arterial occlusive disease (PAOD, stage II-IV, Fontaine) before and after percutaneous transluminal angioplasty (PTA). Thirty patients (42.3%) developed restenosis within 6 months, defined as a > 50% reduction of the lumen diameter at the site of PTA. At entry in the study, 46% and 58% of all patients had higher than normal levels of soluble P-selectin and VCAM-1, respectively. Thrombomodulin (P < 0.01) measured at entry, was significantly higher in patients who developed late restenosis, with trends for higher values for P-selectin, VCAM-1 and vWF. The relative risks for developing restenosis were 2.41 (CI95%: 1.23-4.75) and 1.54 (CI95%: 0.98-2.72) for thrombomodulin and P-selectin, respectively. Soluble P-selectin and the severity of PAOD (Fontaine stage III/IV) were found to be statistically indicative factors for late restenosis in a logistic regression risk factor analysis with an overall predictive value of 72%. At 6 months, those who developed restenosis had also higher soluble P-selectin (P < 0.01), VCAM-1 (P < 0.05) and a trend for higher thrombomodulin. Homocysteine was elevated in 52% of the patients at entry but neither was it associated with higher restenosis rates nor did it correlate with the levels of thrombomodulin or the other adhesion molecules. These findings indicate that patients with PAOD have to a significant proportion, elevated levels of circulating soluble adhesion molecules and markers of endothelial activation occurring in concert with an ongoing atherosclerotic process.

Thrombolysis and angioplasty of chronic iliac artery occlusions

The role of percutaneous angioplasty in the management of chronic iliac artery occlusions is controversial. This article reviews 7 years of experience in treating patients with complete chronic iliac artery occlusions (n = 99) by using thrombolysis and angioplasty. Patients were not excluded due to age or length of the lesion, or severity of underlying peripheral vascular disease. Thrombolysis was conducted with infusion of urokinase at a rate of 60,000-80,000 IU/h for 24 hours. Angioplasty was then performed irrespective of the results of thrombolysis. Seventy-nine percent of patients responded to urokinase, with complete lysis achieved in 55%. Angioplasty was successful in all patients with complete thrombolysis and in 88% of those with partial thrombolysis. The overall success rate was 86%, and more than 80% of surviving patients were symptom free at 5 years. There were seven complications, and the 30-day mortality rate was 2%. Our present results confirm the efficacy of thrombolysis/angioplasty for chronic arterial occlusions.

Percutaneous transluminal angioplasty for lower-limb critical ischaemia

Percutaneous transluminal angioplasty (PTA) alone was used to treat 54 (23 per cent) of 232 lower limbs with critical ischaemia. Technical success was achieved in 49 cases (91 per cent) with an immediate symptomatic improvement in 47 (87 per cent). There was no death or limb loss attributable to PTA and three embolic complications were successfully treated by percutaneous aspiration. Symptomatic improvement and haemodynamic patency rates at 24 months were 77 and 78 per cent respectively; 27 of 34 limbs with ulceration or gangrene had healed with minor surgery by a median of 7.5 (range 3.0-18.0) months. Patient survival and limb salvage rates at the same time interval were 76 and 89 per cent respectively. These results demonstrate that, for a selected group of patients with lower-limb critical ischaemia, PTA can be a highly successful therapeutic option with a low associated morbidity.

Classical and endovascular surgery: indications and outcomes

For more than 40 years, endarterectomy and bypass grafting have been the primary means of surgically revascularizing peripheral vessels threatened by atherosclerotic disease. However, with today's endovascular technology, stenoses and occlusions in nearly every circulatory system can be approached intraluminally with a wide variety of techniques: thrombolysis, laser angioplasty, atherectomy, balloon dilation, and intravascular stents. Just as exciting is the newer technique of endoluminal grafting, which has extended percutaneous therapy to aneurysmal disease in the thoracic and abdominal aorta and distal arteries, as well as to long-segment occlusive disease. Today's vascular surgeon is in a unique position to combine his or her classical surgical training with these catheter-based interventions. Certainly, the potential advantages of percutaneous therapy as compared to surgical reconstruction are significant: no general anesthesia or lengthy incisions, shorter hospitalization, lower morbidity and mortality, earlier intervention in the course of the disease, and less complicated reapplication in the event of disease recurrence. Undoubtedly, endovascular techniques will become a major component of the vascular surgeon's armamentarium, and as we approach the year 2000, they will be the treatment of choice in nearly every vascular pathology and circulatory system.

Meta-analysis of failure-time data with adjustment for covariates

The objective of this study was to present and illustrate a technique for combining failure-time data from various sources, adjusting for differences in case-mix among studies. Based on the proportional-hazards model and the actuarial life-table approach, the method used assumes that the variation across studies is in part due to heterogeneity of the case-mix and adjusts for the case-mix before pooling results. As an example, the technique is applied to life-table data from six selected papers reporting patency of affected arteries following femoropopliteal angioplasty. Published 4- and 5-year patency results ranged from 25% to 58%, with a pooled five-year cumulative patency rate (without adjustment for case-mix) of 45% (+/- 2%). The populations in these studies, however, differed markedly in the prevalence of factors with prognostic value: type of lesion and distal runoff vessels. After adjustment for these differences in case-mix, the pooled five-year patency rates ranged from 60% (+/- 2%) for patients with stenotic lesions and good runoff to 24% (+/- 9%) for those with occlusion and poor runoff. The authors conclude that pooling studies without considering the effect of case-mix yields an average result with inappropriately narrow confidence intervals that does not reflect the variability across subgroups. The presented technique provides a method for combining failure-time data, adjusting for case-mix.

Angioplasty of the iliac and femoral arteries. Initial and long-term results in short stenotic lesions

This retrospective study presents the initial and long-term results of 212 iliac and femoral angioplasties in a selected group of 175 patients with one to three short stenotic lesions (less than 3 cm each). Patients who had iliac (n = 157) and femoral (n = 55) angioplasties were followed for 6-101 months. Claudication was the principal indication for intervention. Success or failure was defined by using a combination of clinical and objective vascular laboratory criteria. Long-term success was estimated by the Kaplan-Meier method. Differences between survival curves for factors such as site of angioplasty and status of run-off were analysed with the log-rank test. For all 212 angioplasties, the initial technical success rate was 93%. The immediate failure rate was 7% (15/212). The cumulative patency rate after 5 years of all technical successful angioplasties was 82% (SE 4%). Five-year patency rates were 84% (SE 4%) for iliac and 73% (SE 11%) for femoral angioplasty. Only one variable in this selected group of patients was associated with success: the site of the lesion.