Comparison of endovascular therapies for chronic limb-threatening ischemia and claudication

OBJECTIVE

Analysis of regional data from the Vascular Quality Initiative (VQI) suggested improved survival for patients undergoing stent placement compared with balloon angioplasty and atherectomy. Using national data from the VQI linked to Medicare claims data through the Vascular Implant Surveillance and Interventional Outcomes Network program, this study aimed to compare the rates of mortality, reintervention, and amputation after endovascular interventions (atherectomy, stenting, and balloon angioplasty) for two separate cohorts: patients with chronic limb-threatening ischemia (CLTI) and patients with claudication.

METHODS

This was a secondary data analysis of Society for Vascular Surgery National VQI data linked to Medicare claims, between October 2016 and December 2019. Patients aged ≥65 years with symptoms of claudication or CLTI and a diagnosis of occlusive disease were included. Urgent or emergent interventions or those with concurrent procedures (endarterectomy, bypass, or bilateral intervention) were excluded. Interventions were grouped into (1) balloon angioplasty only; (2) stent (with or without balloon angioplasty); or (3) atherectomy (alone, with or without stent, with or without balloon angioplasty). Propensity score-matched cohorts were constructed to conduct pairwise intervention comparisons of mortality, reintervention, and amputation rates. Multivariable logistic regression was used to derive propensity scores for each patient. Kaplan-Meier estimates and Cox proportional hazards ratios (HRs) (95% confidence interval [CI]) analyses were performed.

RESULTS

A total of 9785 (2665 claudication, 7120 CLTI) eligible patients were identified. After propensity score matching for the CLTI group, 2826, 3608, and 2796 pairs of cases were used to compare balloon angioplasty vs atherectomy, balloon angioplasty vs stent, and stent vs atherectomy, respectively. No statistically significant difference in mortality was observed among all interventions. However, atherectomy was associated with a significant increase in reintervention rate compared with balloon angioplasty (HR, 1.22; 95% CI, 1.06-1.39; P = .01) and compared with stenting (HR, 1.27; 95% CI, 1.10-1.46; P < .01) within the first year after the index procedure. Of note, both atherectomy (HR, 0.82; 95% CI, 0.68-0.98; P < .05) and stenting (HR, 0.76; 95% CI, 0.64-0.90; P < .01) showed lower rates of major amputation when compared with balloon angioplasty within 1 year after the index procedure. In the claudication group, there were no significant differences observed among interventions for peripheral arterial disease for mortality, reintervention, or amputation rates.

CONCLUSIONS

Further studies are needed to identify appropriate indications for atherectomy, because there may be a subset of patients with CLTI who benefit from this therapy with respect to amputation rates. Until then, caution should be exercised when using atherectomy because it is also associated with higher reintervention rates.

Systematic review and meta-analysis comparing the autogenous vein bypass versus a prosthetic graft for above-the-knee femoropopliteal bypass surgery in patients with intermittent claudication

OBJECTIVES

According to guidelines, the autogenous saphenous vein (ASV) is the preferred conduit for femoropopliteal bypass surgery in all patients with peripheral artery disease. However, in contrast to patients with critical limb ischemia (CLI), patients with intermittent claudication (IC) only, tend to have milder disease, and thus a prosthetic graft may be as good as a vein conduit. The objective of this study was to compare patency rates of the ASV and a prosthetic graft in femoropopliteal bypass surgery in patients with IC.

METHODS

A systematic literature search was performed in the PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing prosthetic graft versus ASV in patients with IC. Articles with a mixed IC and CLI study population were included if more than 50% of the study cohort was treated for IC. Primary analysis was performed on IC patients only. Secondary analysis was performed on the mixed group. The primary endpoint was short- and long-term patency and secondary endpoints were complications, limb salvage, and mortality.

RESULTS

In total, six studies with 524 patients were included. Only two studies reported solely on patients with IC. All these patients underwent above-the-knee bypasses and average patency rates at one and 5 years were 88% and 76% vs 81% and 68% in the ASV and the PTFE groups, respectively. One and five-year patency was not statistically different between the groups (OR 5.21; 95% CI 0.60-45.36 and OR 2.10; 95% CI 0.88-5.01). In a mixed population of patients with IC and CLI (84% IC patients), 1 year patency was comparable (OR 1.40; 95% CI 0.87-2.25). However, after a follow-up of over 3 years, this mixed group had significantly higher patency rates in favour of the ASV (OR 2.06; 95 % CI 1.30-3.26). Complication and amputation rates were comparable in both groups.

CONCLUSIONS

Limited data are available for patients receiving above-the-knee femoropopliteal bypass for intermittent claudication. The ASV remains the conduit of choice for femoropopliteal bypass surgery. However, the prosthetic conduit seems a feasible alternative for patients with intermittent claudication in whom the ASV is not present or unsuitable.

Outcomes of lower extremity revascularization in octogenarians and nonagenarians for intermittent claudication

OBJECTIVE

Revascularization for intermittent claudication (IC) due to infrainguinal peripheral arterial disease (PAD) is dependent on durability and expected benefit. We aimed to assess outcomes for IC interventions in octogenarians and nonagenarians (age ≥80 years) and those younger than 80 years (age <80 years).

METHODS

The Vascular Quality Initiative was queried (2010-2020) for peripheral vascular interventions (PVIs) and infrainguinal bypasses (IIBs) performed to treat IC. Baseline characteristics, procedural details, and outcomes were analyzed (comparing age ≥80 years and age <80 years).

RESULTS

There were 84,210 PVIs (12.1% age ≥80 years and 87.9% age <80 years) and 10,980 IIBs (7.4% age ≥80 years and 92.6% age <80 years) for IC. For PVI, patients aged ≥80 years more often underwent femoropopliteal (70.7% vs 58.1%) and infrapopliteal (19% vs 9.3%) interventions, and less often iliac interventions (32.1% vs 48%) (P < .001 for all). Patients aged ≥80 years had more perioperative hematomas (3.5% vs 2.4%) and 30-day mortality (0.9% vs 0.4%) (P < .001). At 1-year post-intervention, the age ≥80 years cohort had fewer independently ambulatory patients (80% vs 91.5%; P < .001). Kaplan-Meier analysis showed patients aged ≥80 years had lower reintervention/amputation-free survival (81.4% vs 86.8%), amputation-free survival (87.1% vs 94.1%), and survival (92.3% vs 96.8%) (P < .001) at 1-year after PVI. Risk adjusted analysis showed that age ≥80 years was associated with higher reintervention/amputation/death (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.1-1.35), amputation/death (HR, 1.85; 95% CI, 1.61-2.13), and mortality (HR, 1.92; 95% CI, 1.66-2.23) (P < .001 for all) for PVI. For IIB, patients aged ≥80 years more often had an infrapopliteal target (28.4% vs 19.4%) and had higher 30-day mortality (1.3% vs 0.5%), renal failure (4.1% vs 2.2%), and cardiac complications (5.4% vs 3.1%) (P < .001). At 1 year, the age ≥80 years group had fewer independently ambulatory patients (81.7% vs 88.8%; P = .02). Kaplan-Meier analysis showed that the age ≥80 years cohort had lower reintervention/amputation-free survival (75.7% vs 81.5%), amputation-free survival (86.9% vs 93.9%), and survival (90.4% vs 96.5%) (P < .001 for all). Risk-adjusted analysis showed age ≥80 years was associated with higher amputation/death (HR, 1.68; 95% CI, 1.1-2.54; P = .015) and mortality (HR, 1.85; 95% CI, 1.16-2.93; P = .009), but not reintervention/amputation/death (HR, 1.1; 95% CI, 0.85-1.44; P = .47) after IIB.

CONCLUSIONS

Octogenarians and nonagenarians have greater perioperative morbidity and long-term ambulatory impairment, limb loss, and mortality after PVI and IIB for claudication. Risks of intervention on elderly patients with claudication should be carefully weighed against the perceived benefits of revascularization. Medical and exercise therapy efforts should be maximized in this population.

A scoping review of female sex-related outcomes after endovascular intervention for lifestyle-limiting claudication and chronic limb-threatening ischemia

Peripheral arterial disease (PAD) is on the rise, with a growing prevalence in an aging population and increasing rates of diabetes. Chronic limb-threatening ischemia poses a significant risk of limb loss. PAD is common in females, particularly after menopause, with a 35% prevalence rate in females older than 65 years. Studies have suggested that females have inferior outcomes compared with men after endovascular revascularization for PAD. With the rising utilization of endovascular interventions for the treatment of PAD, we sought to perform a review of sex-based outcomes of peripheral endovascular interventions for the treatment of symptomatic PAD. A scoping literature review was conducted to evaluate outcomes in females patients undergoing endovascular peripheral interventions for PAD. Eligibility criteria included studies focusing on adult females with lifestyle-limiting claudication or chronic limb-threatening ischemia who underwent endovascular intervention. Various endovascular procedures were considered and outcomes of interest included mortality, amputations, reinterventions, bleeding complications, and major adverse cardiac events. A systematic search was conducted in PubMed, Embase, Web of Science, and Cochrane Library databases. Sixteen studies were included in the review. Females patients undergoing endovascular interventions were associated with bleeding complications, higher rates of reintervention, and a risk of nonfatal strokes. However, females sex was not linked to higher rates of amputation or conclusively higher mortality rates post intervention. The comprehensive scoping review reveals important sex-related disparities in outcomes after endovascular procedures for symptomatic PAD. Females patients have been reported to experience worse outcomes in terms of reinterventions and bleeding complications. These findings emphasize the need for future trials focusing specifically on females patients to develop sex-inclusive treatment recommendations for advanced PAD.

Indications for a "Surgery-First" Approach for the Treatment of Lower Extremity Arterial Disease

BACKGROUND

In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization.

METHODS

A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models.

RESULTS

We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis.

CONCLUSIONS

Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm.

Long-Term Patient Outcomes After Femoropopliteal Peripheral Vascular Intervention in Patients With Intermittent Claudication

BACKGROUND

In patients with intermittent claudication (IC), short-term amputation rates from clinical trial data following lower extremity femoropopliteal (FP) peripheral vascular intervention (PVI) are <1% with unknown longer-term rates.

OBJECTIVES

The aim of this study was to identify revascularization and amputation rates following PVI in the FP segment and to assess 4-year amputation and revascularization rates after FP PVI for IC.

METHODS

From 2016 to 2020, 19,324 patients undergoing FP PVI for IC were included from the PINC AI Healthcare Database and evaluated by treatment level (superficial femoral artery [SFA], popliteal artery [POP], or both). The primary outcome was index limb amputation (ILA) assessed by Kaplan-Meier estimate. The secondary outcomes were index limb major amputation and repeat revascularization. HRs were estimated using Cox proportional hazard regression.

RESULTS

The 4-year index limb amputation rate following FP PVI was 4.3% (95% CI: 4.0-4.7), with a major amputation rate of 3.2% (95% CI: 2.9-3.5). After POP PVI, ILA was significantly higher than SFA alone (7.5% vs 3.4%) or both segment PVI (5.5%). In multivariate analysis, POP PVI was associated with higher ILA rates at 4 years compared with isolated SFA PVI (HR: 2.10; 95% CI: 1.52-2.91) and index limb major amputation (HR: 1.98; 95% CI: 1.32-2.95). Repeat FP revascularization rates were 15.2%; they were highest in patients undergoing both SFA and POP PVI (18.7%; P < 0.0001) compared with SFA (13.9%) and POP (17.1%) only.

CONCLUSIONS

IC patients undergoing FP PVI had 4-year rates of index limb repeat revascularization of 16.7% and ILA rates of 4.3%. Further risk factors for amputation requires further investigation.

Association between sex and long-term outcomes of endovascular treatment for peripheral artery disease

BACKGROUND

Endovascular peripheral vascular intervention (PVI) has become the primary revascularization technique used for peripheral artery disease (PAD). Yet, there is limited understanding of long-term outcomes of PVI among women versus men. In this study, our objective was to investigate sex differences in the long-term outcomes of patients undergoing PVI.

METHODS

We performed a cohort study of patients undergoing PVI for PAD from January 1, 2010 to September 30, 2015 using data in the Vascular Quality Initiative (VQI) registry. Patients were linked to fee-for-service Medicare claims to identify late outcomes including major amputation, reintervention, major adverse limb event (major amputation or reintervention [MALE]), and mortality. Sex differences in outcomes were evaluated using cumulative incidence curves, Gray's test, and mixed effects Cox proportional hazards regression accounting for patient and lesion characteristics using inverse probability weighted estimates.

RESULTS

In this cohort of 15,437 patients, 44% (n = 6731) were women. Women were less likely to present with claudication than men (45% vs. 49%, p < 0.001, absolute standardized difference, d = 0.08) or be able to ambulate independently (ambulatory: 70% vs. 76%, p < 0.001, d = 0.14). There were no major sex differences in lesion characteristics, except for an increased frequency of tibial artery treatment in men (23% vs. 18% in women, p < 0.001, d = 0.12). Among patients with claudication, women had a higher risk-adjusted rate of major amputation (hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.18-2.49), but a lower risk of mortality (HR = 0.86, 95% CI: 0.75-0.99). There were no sex differences in reintervention or MALE for patients with claudication. However, among patients with chronic limb-threatening ischemia, women had a lower risk-adjusted hazard of major amputation (HR = 0.79, 95% CI: 0.67-0.93), MALE (HR = 0.86, 95% CI: 0.78-0.96), and mortality (HR = 0.86, 95% CI: 0.79-0.94).

CONCLUSION

There is significant heterogeneity in PVI outcomes among men and women, especially after stratifying by symptom severity. A lower overall mortality in women with claudication was accompanied by a higher risk of major amputation. Men with chronic limb-threatening ischemia had a higher risk of major amputation, MALE, and mortality. Developing sex-specific approaches to PVI that prioritizes limb outcomes in women can improve the quality of vascular care for men and women.

Use of the 11-Item Modified Frailty Index to Determine Accurate Prognosis and Revascularization Strategy in Patients Undergoing Vascular Bypass Surgery for Intermittent Claudication

BACKGROUND

In cases of intermittent claudication (IC) where traditionally noninvasive management yields unsatisfactory results, revascularization strategy in IC patients is generally decided based on anatomical considerations and the availability of a saphenous vein graft. Life expectancy should also be considered. This study aimed to investigate the relationship between the 11-item modified frailty index (mFI-11) and the overall survival (OS) in patients with IC who underwent vascular bypass surgery to facilitate revascularization strategy selection.

METHODS

We reviewed the records of 144 consecutive patients (153 lower limbs) who underwent infrainguinal bypass for IC between 2011 and 2020. Patients were divided into 2 groups based on their mFI-11 score: high frailty (H), mFI score >0.3; and low frailty (L), mFI score ≤0.3. The OS was compared among the 2 groups. Rates of graft patency and freedom from major adverse limb event (ffMALE) were also determined and compared.

RESULTS

Five-year OS in the L and H groups was 92% and 55% (P < 0.001). Multivariate analysis showed that mFI, age, and end-stage renal disease were independent predictors of OS. Five-year rates of primary and secondary patency and ffMALE for vein grafts were 81%, 91%, and 94%, respectively; those for prosthetic grafts were 65%, 80%, and 84%, respectively; the differences were not significant.

CONCLUSIONS

The mFI-11 was a helpful tool in predicting OS for patients with IC who underwent vascular bypass surgery. Those with H should not undergo open revascularization; however, for IC patients who have either not responded to a regimen of exercise and medication, or have specifically requested a more aggressive approach, obtaining a good score in frailty assessment is useful in determining whether or not bypass surgery would be a viable option.

Inflammation and Loss of Skeletal Muscle Mass in Chronic Limb Threatening Ischemia

BACKGROUND

Lower extremity peripheral arterial disease (PAD) is an atherosclerotic disease of the lower extremities. Atherosclerosis, inflammation, and sarcopenia are independently associated and potentiate each other. Inflammation is deeply involved in the formation and progression of atherosclerosis and is also involved in the pathophysiology of sarcopenia. Sarcopenia is defined as low muscle mass, with low muscle strength. This study aims to determine the differences in skeletal muscle characteristics and in inflammatory parameters between patients with claudication and with chronic limb threatening ischemia (CLTI).

METHODS

An observational, prospective study in patients with PAD was conducted from January 2018 to December 2020. The clinical characteristics and the cardiovascular risk factors were prospectively registered. The inflammatory parameters determined were: positive acute phase proteins (C-reactive Protein- CRP- and fibrinogen) and negative acute phase proteins albumin, total cholesterol and high-density lipoprotein (HDL). The skeletal muscle area and density were quantified with a computed topography (CT) scan. The strength was determined with a Jamar® hydraulic hand dynamometer.

RESULTS

A total of 116 patients (mean age: 67.65 ± 9.53 years-old) 64% with claudication and 46% with CLTI were enrolled in the study. No differences were registered between patients with claudication and CLTI on age, cardiovascular risk factors (hypertension, dyslipidemia, diabetes mellitus, and smoking habits) and medication. There was a higher prevalence of men in the claudication group (88.89% vs. 71.70%, P = 0.019). Analyzing the inflammatory parameters, we noted that patients with CLTI had increased serum levels of positive acute phase proteins: CRP (37.53 ± 46.61 mg/L vs. 9.18 ± 26.12 mg/L, P = 0.000), and fibrinogen (466.18 ± 208.07 mg/dL vs. 317.37 ± 79.42 mg/dL, P = 0.000). CLTI patients had decreased negative acute phase proteins: albumin (3.53 ± 0.85 g/dL vs. 3.91 ± 0.72 g/dL, P = 0.001), total cholesterol (145.41 ± 38.59 mg/dL vs. 161.84 ± 34.94 mg/dL, P = 0.013) and HDL (38.70 ± 12.19 mg/dL vs. 51.31 ± 15.85 mg/dL, P = 0.000). We noted that patients with CLTI had lower skeletal muscle area and mass (14,349.77 ± 3,036.60 mm² vs. 15,690.56 ± 3,183.97 mm²P = 0.013; 10.11 ± 17.03HU vs. 18.02 ± 13.63HU P = 0.013). After adjusting for the variable sex, the association between skeletal muscle density and CLTI persisted (r (97) = -0.232, P = 0.021). The groups did not differ in strength (patients with claudication: 25.39 ± 8.23 Kgf vs. CLTI: 25.17 ± 11.95 Kgf P = 0.910).

CONCLUSIONS

CLTI patients have decreased skeletal muscle mass and a systemic inflammation status. Recognizing the deleterious triad of atherosclerosis, inflammation and loss of skeletal mass patients with CLTI is an opportunity to improve medical therapy and to perform a timely intervention to stop this vicious cycle.

ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update

Arterial claudication is a common manifestation of peripheral artery disease. This document focuses on necessary imaging before revascularization for claudication. Appropriate use of ultrasound, invasive arteriography, MR angiography, and CT angiography are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Female Sex is Associated with More Reinterventions after Endovascular and Open Interventions for Intermittent Claudication

BACKGROUND

Intermittent claudication (IC) is a commonly treated vascular condition. Patient sex has been shown to influence outcomes of interventions for other vascular disorders; however, whether outcomes of interventions for IC vary by sex is unclear. We sought to assess the association of patient sex with outcomes after IC interventions.

METHODS

The Vascular Quality Initiative was queried from 2010-2020 for all peripheral endovascular interventions (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for any degree IC. Univariable and multivariable analyses compared peri-operative and long-term outcomes by patient sex.

RESULTS

There were 24,701 female and 40,051 male patients undergoing PVI, 2,789 female and 6,525 male patients undergoing IIB, and 1,695 female and 2,370 male patients undergoing SIB for IC. Guideline-recommended pre-operative medical therapy differed with female patients less often prescribed aspirin for PVI (73.4% vs. 77.3%), IIB (71.5% vs. 74.8%), and SIB (70.9% vs. 74.3%) or statins for PVI (71.8% vs. 76.7%) and IIB (73.1% vs. 76.0%) (all P < 0.05). Female compared with male patients had lower 1-year reintervention-free survival after PVI (84.4% ± 0.3% vs. 86.3% ± 0.2%, P < 0.001), IIB (79.0% ± 0.9% vs. 81.2% ± 0.6%, P = 0.04), and SIB (89.4% ± 0.9% vs. 92.6% ± 0.7%, P = 0.005), but similar amputation-free survival and survival across all procedures. Multivariable analysis confirmed that female sex was associated with increased 1-year reintervention for PVI (HR 1.16, 95% CI 1.09-1.24, P < 0.001), IIB, (HR 1.16, 95% CI 1.03-1.31, P = 0.02), and SIB (HR 1.60, 95% CI 1.20-2.13, P = 0.001).

CONCLUSIONS

Female patients undergoing interventions for IC were less often pre-operatively medically optimized than male patients, though the difference was small. Furthermore, female sex was associated with more reinterventions after interventions. Interventionists treating female patients should increase their efforts to maximize medical therapy. Future research should clarify reasons for poorer intervention durability in female patients.

Impact of supervised exercise on skeletal muscle blood flow and vascular function measured with MRI in patients with peripheral artery disease

Supervised exercise is a common therapeutic intervention for patients with peripheral artery disease (PAD), however, the mechanism underlying the improvement in claudication symptomatology is not completely understood. The hypothesis that exercise improves microvascular blood flow is herein tested via temporally resolved magnetic resonance imaging (MRI) measurement of blood flow and oxygenation dynamics during reactive hyperemia in the leg with the lower ankle-brachial index. One hundred and forty-eight subjects with PAD were prospectively assigned to standard medical care or 3 mo of supervised exercise therapy. Before and after the intervention period, subjects performed a graded treadmill walking test, and MRI data were collected with Perfusion, Intravascular Venous Oxygen saturation, and T2* (PIVOT), a method that simultaneously quantifies microvascular perfusion, as well as relative oxygenation changes in skeletal muscle and venous oxygen saturation in a large draining vein. The 3-mo exercise intervention was associated with an improvement in peak walking time (64% greater in those randomized to the exercise group at follow-up, P < 0.001). Significant differences were not observed in the MRI measures between the subjects randomized to exercise therapy versus standard medical care based on an intention-to-treat analysis. However, the peak postischemia perfusion averaged across the leg between baseline and follow-up visits increased by 10% (P = 0.021) in participants that were adherent to the exercise protocol (completed >80% of prescribed exercise visits). In this cohort of adherent exercisers, there was no difference in the time to peak perfusion or oxygenation metrics, suggesting that there was no improvement in microvascular function nor changes in tissue metabolism in response to the 3-mo exercise intervention.NEW & NOTEWORTHY Supervised exercise interventions can improve symptomatology in patients with peripheral artery disease, but the underlying mechanism remains unclear. Here, MRI was used to evaluate perfusion, relative tissue oxygenation, and venous oxygen saturation in response to cuff-induced ischemia. Reactive hyperemia responses were measured before and after 3 mo of randomized supervised exercise therapy or standard medical care. Those participants who were adherent to the exercise regimen had a significant improvement in peak perfusion.

Major adverse limb events among patients with premature peripheral artery disease compared with those at the common age undergoing revascularization in the Vascular Quality Initiative

OBJECTIVES

Premature peripheral artery disease (PAD), defined as ≤ 50 years of age, is associated with poor outcomes following lower extremity revascularization (LER). However, the specific characteristics and outcomes of this group of patients compared to those at the common age undergoing revascularization have not been examined. The aim of this study is to compare patients with early versus late onset premature PAD undergoing LER focusing on major adverse limb events (MALEs).

METHODS

All LER procedures (open and endovascular) in the Vascular Quality Initiative (VQI) were reviewed. A histogram of patient age at the time of initial LER (no prior LER) was used to define the common age, which included all patients within one standard deviation of the mean. Characteristics and outcomes of patients with premature PAD were compared to patients treated at the common age of presentation undergoing LER.

RESULTS

A histogram of all patients undergoing LER was used to define 60 to 80 years as the common age. Patients with premature PAD were more likely to be female, African American, and Hispanic compared to patients at the common age. Patients with premature PAD were also more likely to have insulin-dependent diabetes, be current smokers, on dialysis, and be treated for claudication. Patients with premature PAD were less likely to have Transatlantic Intersociety Consensus (TASC II) C or D disease and were less likely to be on antiplatelets and statins. These differences were more pronounced in patients with chronic limb-threatening ischemia (CLTI). Cox proportional hazards regression demonstrated that premature PAD was independently associated with major adverse limb events (MALEs) at one-year for patients with claudication (HR:1.7, 95% CI:1.4-2.0) and CLTI (HR:1.3, 95% CI:1.2-1.5) compared to patients 60 to 80 years of age.

CONCLUSION

Patients with premature PAD have significant differences in characteristics compared to patients treated at the common age. Vascular providers should emphasize medical therapy prior to LER given the lower rates of medical optimization and worse one-year MALEs in patients with premature PAD.

Short- and Long-Term Results of Operative Iliac Artery Release in Endurance Athletes

OBJECTIVE

Endurance athletes may develop intermittent claudication due to sport-related flow-limitations of the iliac artery (FLIA) caused by arterial kinking. This study investigated short- and long-term efficacy of an operative release for iliac artery kinking.

METHODS

Between 1996 and 2015, all patients diagnosed and operated with FLIA due to iliac artery kinking without significant arterial stenosis (<15%) or excessive arterial length (vessel length to straight ratio <1.25) were included. Short-term follow up consisted of cycling tests including ankle-brachial index with flexed hip (ABI_flexed) and echo-Doppler examinations (peak systolic velocity, PSV) before and 6-18 months after surgery. Additionally, short-term and long-term efficacy were evaluated using questionnaires.

RESULTS

A total of 142 endurance athletes (155 legs, 88.4% male, median age 26, (22-31; interquartile range)) were available for analysis. In the short-term, symptoms were reduced in 83.9% of the patients with an overall 80.3% satisfaction rate. Power during a maximal cycling test improved from 420 (384-465) to 440 (400-485) Watt (P<.05). Symptom free workload increased from 300 (235-352) to 400 (332-460) Watt (P<.001). Post-exercise ABI_flexed increased from 0.53 (0.39-0.62) to 0.57 (0.47-0.64) (P<.05) and PSV with flexed hip decreased from 1.98 (1.58-2.51) to 1.60 (1.20-2.15) m/s (P<.001). Postoperative imaging revealed (minor) kinking in 37%, mostly a-symptomatic. Long-term results were evaluated after a median 15.2 (10.9-19.5) years. The athletes cycled an additional 125.500 (72.00-227.500) kilometres. This is approximately equal to the 131.000 (98.250-220.000) cycled kilometres before the diagnosis of FLIA. On the long-term, a total of 63.9% reported persistent reduction of complaints with an overall 59.1% satisfaction rate. Eight patients needed a reintervention of which six were considered failures and two were considered as newly developed FLIA.

CONCLUSION

An operative iliac artery release for sport-related functional kinking in the absence of stenosis of excessive vessel length is short-term and long-term effective in most athletes.

Outcomes of Axillofemoral Bypass for Intermittent Claudication

OBJECTIVE

While endovascular therapy is often first-line treatment for medically refractory intermittent claudication (IC) caused by aorto-femoral disease, suprainguinal bypass is commonly performed. Although this is often aorto-femoral bypass (AoFB), axillo-femoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC.

METHODS

The Vascular Quality Initiative (2009-2019) was queried for suprainguinal bypass performed for IC. Univariable and multivariable analyses were used to compare perioperative and one-year outcomes between AxFB and a comparison cohort of AoFB.

RESULTS

We identified 3,261 suprainguinal bypasses performed for IC: 436 AxFB and 2,825 AoFB. Overall, mean age was 61.4 ± 9.1 years, 58.8% of patients were male sex, and 59.7% currently smoked. Patients undergoing AxFB, compared with AoFB, were more often older, male, never-smokers, and ambulated with assistance (all P<.001). They more often had hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, previous outflow peripheral endovascular interventions, and previous inflow or outflow bypass. AxFB, compared with AoFB, were more often uni-femoral (all P<.05). Patients undergoing AxFB, compared with AoFB, had shorter postoperative length of stay (median 4 vs. 6 days) and fewer perioperative pulmonary (3% vs. 7.9%) and renal complications (5.5% vs. 9.9%), but more perioperative ipsilateral major amputations (.9% vs. 0.04%) (all P<.05). There were no significant differences in perioperative myocardial infarction (2.8% vs. 2.7%), stroke (.7% vs. 1.1%), and death (1.8% vs. 1.7%) rates, respectively. At one year, Kaplan-Meier analysis demonstrated that the AxFB, compared with AoFB cohort, exhibited higher rates of death (7.3% vs. 3.6%, P=.002); graft occlusion or death (14.3% vs. 7.2%, P=.001); ipsilateral major amputation or death (12.5% vs. 5.6%, P<.001); and reintervention, amputation, or death (19% vs. 8.6%, P<.001). On multivariable analysis, AxFB was independently associated with increased risk of one-year reintervention, amputation, or death (HR 1.6, 95% CI 1.03-2.4, P=.04).

CONCLUSIONS

This retrospective analysis suggests that long-term complications were more frequent in patients who underwent AxFB as compared to AoFB, although patients treated with AxFB were at higher risk with more comorbidities. Since AxFB is associated with significant perioperative morbidity, mortality, and long-term complications, serious consideration should be given prior to its use for IC.

Efficacy and one-year outcomes of Luminor® paclitaxel-coated drug-eluting balloon in the treatment of popliteal artery atherosclerosis lesions

PURPOSE

Reporting outcomes with a new generation paclitaxel eluting balloon (Luminor®; iVascular, Vascular, S.L.U., Barcelona, Spain) in the popliteal district. Endovascular treatment of popliteal artery atherosclerotic disease is still debated without definitive evidences.

METHODS

From January to June 2019, patients' data presenting popliteal artery atherosclerotic diseases and treated with the Luminor® (iVascular) drug eluting balloon (DEB) were prospectively collected. Critical limb ischemia (CLI) or severe claudication associated with popliteal artery stenosis >50% were the inclusion criteria. Measured outcomes were technical success, early and late results; including mortality, morbidity, symptoms recurrence, amputation, ankle-brachial index (ABI), survival, primary patency, secondary patency, freedom from restenosis. Median follow-up was 22.43 ± 4 (mean:21.58; IQR:20-24) months.

RESULTS

Of the 33 included patients, 28 (85%) were diagnosed with CLI, with a mean preoperative run-off score of 5.39 (r:0-10; SD:3) and a chronic popliteal occlusion in 21 (64%). Technical success was achieved in all cases. Perioperative mortality was observed in 1 (3%) patient and perioperative complications in 2 (6%). During the follow-up were reported 2 symptoms recurrence; a significant ABI increase (0.57; IQR:0.41-0.47 vs. 0.69; IQR:0.50-0.67; P < 0.01); 1 (3%) major and 2 (6%) minor amputations. Estimated 24 months survival, primary patency, secondary patency, and freedom from restenosis were 97%, 96.9%, 100%, and 93.8% respectively.

CONCLUSIONS

In this prospective study, the use of the Luminor® (iVascular) was safe and effective in addressing atherosclerotic popliteal artery lesions. Larger studies with longer term-outcomes are required to assess the durability of this device in the popliteal artery.

Femoral-popliteal peripheral artery disease: From symptom presentation to management and treatment controversies

Peripheral artery disease (PAD) is a common condition with increasing prevalence domestically and worldwide. Patients with PAD have a poor prognosis, as PAD is associated with high rates of myocardial infarction, ischemic stroke, and cardiovascular disease death. The primary symptom of PAD, claudication, significantly reduces quality of life and functional status and is associated with depression. In addition to several advances in medications for PAD over the last decade, endovascular device therapy has seen a significant breakthrough in the form of paclitaxel-coated devices (PCDs), which significantly reduce rates of restenosis relative to non-PCDs, a finding which has been demonstrated in numerous randomized clinical trials. After their introduction to the market in 2012 (paclitaxel-eluting stents) and 2014 (paclitaxel-coated balloons) their use surged as they replaced non-PCDs and were designated the first-line endovascular therapy by society guidelines. This trend was abruptly reversed, however, after a meta-analysis of summary-level data was published in December of 2018 that reported an elevated mortality associated with PCDs compared with non-PCDs 2-5 years after treatment. This meta-analysis has been criticized for considerable methodological flaws. The Food and Drug Administration conducted a review and concluded that insufficient data existed to make a definitive statement regarding the safety of PCDs. They called for restriction of the use of PCDs to the highest-risk patient populations. At the same time, the FDA deemed pursuing new RCTs to better evaluate PCDs unfeasible due to the high numbers of patients and long follow-up time that would be required. In this setting, real-world data emerged as a powerful source of information for the evaluation of PCDs. Real-world data offers advantages over randomized-controlled trials including expeditious access to and analysis of data and the availability of large numbers of patients. Several retrospective observational studies demonstrate no difference in long-term all-cause mortality in patients treated with PCDs relative to those treated with non-PCDs. This paclitaxel controversy has illustrated the critical role that real-world data is assuming in long-term safety monitoring of medical devices.

Epithelioid Hemangioendothelioma of the Lower Limb, Discovered by a Claudication

Epithelioid hemangioendothelioma (EHE) is a rare case of a tumor with different clinical behaviors and a difficult anatomopathological diagnosis. The diagnosis of EHE is usually confirmed by postoperative histopathologic examination. Actually, it is a challenge to put a correct diagnosis and to propose aggressive treatment. We report a case of an EHE of the left lower limb discovered in a 53-year-old claudicant woman. Surgical resection, arterial, and venous bypass were performed. The histology demonstrated EHE with a low mitotic index, emerging for the femoral vein.

Paclitaxel exposure: Long-term safety and effectiveness of a drug-coated balloon for claudication in pooled randomized trials

BACKGROUND

Paclitaxel drug-coated balloons (DCB) prevent recurrent claudication after angioplasty, yet data from randomized trials with incomplete follow-up have raised uncertainty regarding long-term mortality.

OBJECTIVES

To evaluate the effect of paclitaxel exposure on the long-term safety and efficacy of angioplasty of femoropopliteal artery lesions in the combined IN.PACT randomized trials.

METHODS

The IN.PACT randomized trials (SFA, N = 331 and Japan, N = 100) each compared the DCB with standard percutaneous transluminal angioplasty (PTA) for claudication, and consented patients for 5 and 3 years, respectively. To address long-term safety, sites were requested to obtain vital status follow-up. In the pooled, updated data set, we examined the association between randomized treatment and mortality by cumulative incidence and hazard ratio (HR), and freedom from clinically driven target lesion revascularization (CD-TLR). Multivariable Cox regression with adjustment for baseline characteristics was used to evaluate the dose effect. Causes of death were adjudicated by a blinded clinical events committee that included oncologists with paclitaxel expertise.

RESULTS

The rate of long-term vital status ascertainment increased from 81% to 97% for DCB and from 85% to 97% for PTA in the IN.PACT SFA trial. The cumulative incidence of mortality was 14.7% DCB versus 12.0% PTA at 5 years, HR 1.39, log-rank p = .286. Paclitaxel dose (mg) was not an independent predictor of mortality (HR 1.02, p = .381), but was an independent predictor of reduced risk of CD-TLR (HR 0.79; p < .001). Causes of death did not differ by treatment arm.

CONCLUSIONS

In pooled randomized trial data with updated vital status ascertainment, paclitaxel was associated with improved efficacy but was not associated with increased mortality.

Three-Year Sustained Clinical Efficacy of Drug-Coated Balloon Angioplasty in a Real-World Femoropopliteal Cohort

Purpose: To report the 36-month outcomes from the prospective, multicenter, single-arm IN.PACT Global Study (ClinicalTrials.gov identifier NCT01609296) evaluating the performance of the IN.PACT Admiral drug-coated balloon (DCB) in real-world patients with femoropopliteal occlusive disease. Materials and Methods: The IN.PACT Global Study was conducted at 64 international sites and enrolled 1535 patients with complex lesions, which included bilateral disease, multiple lesions, de novo in-stent restenosis, long lesions, and chronic total occlusions. The predefined full clinical cohort included 1406 patients (mean age 68.6 years; 67.8% men) with claudication or rest pain treated with the study DCB. Mean lesion length was 12.09±9.54 cm; 18.0% had in-stent restenosis, 35.5% were totally occluded, and 68.7% were calcified. Freedom from clinically-driven target lesion revascularization (CD-TLR) was evaluated through 36 months. The safety composite endpoint was freedom from device- and procedure-related death through 30 days and freedom from major target limb amputation and clinically-driven target vessel revascularization within 36 months. All safety and revascularization events were reviewed by an independent clinical events committee. Results: The Kaplan-Meier estimate of freedom from CD-TLR through 36 months was 76.9%. The composite safety endpoint was achieved in 75.6% of patients. The 36-month all-cause mortality rate was 11.6%, and the major target limb amputation rate was 1.0%. The Kaplan-Meier estimate of freedom from CD-TLR through 36 months was significantly lower in patients with chronic limb-threatening ischemia (CLTI) compared with claudicants (67.6% vs 78.0%; p=0.003). Lesions affecting both the superficial femoral artery (SFA) and popliteal artery had lower Kaplan-Meier freedom from CD-TLR through 36 months (69.2%) than either isolated SFA (79.7%) or popliteal artery lesions (76.5%; log- rank p<0.001). Predictors of CD-TLR through 36 months included increased lesion length, reference vessel diameter ≤4.5 mm, in-stent restenosis, bilateral disease, CLTI, and hyperlipidemia. Conclusion: DCB angioplasty with the IN.PACT Admiral DCB for femoropopliteal disease in a diverse and complex real-world population is associated with sustained clinical efficacy and low rates of reinterventions at 3 years after the initial procedure.

Tibial bypass in patients with intermittent claudication is associated with poor outcomes

OBJECTIVE

Given that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC.

METHODS

The Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries.

RESULTS

Of 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival.

CONCLUSIONS

In patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.

Aortoiliac Endarterectomy: A Useful Tool in Modern Vascular Practice

Aortoiliac endarterectomy was the standard treatment for aortoiliac occlusive disease before the availability of prosthetic graft material for aortobifemoral bypass, although the number of patients appropriate for this repair continues to diminish in the endovascular era. Patients with focal aortoiliac disease are often treated with bilateral "kissing" iliac stents through an endovascular approach. However, in patients with eccentric plaque morphology or smaller caliber vessels, the risk of distal embolization and vessel rupture is not insignificant. On the other hand, if the disease is localized to the distal aortic bifurcation, an open aortobifemoral bypass may be excessive and incur additional morbidity. Our case report reviews a 60-year-old woman who presented with lifestyle-limiting claudication from an isolated aortoiliac atherosclerotic plaque who we proceeded with an open aortoiliac endarterectomy.

Comparison of ante-versus retrograde access for the endovascular treatment of long and calcified, de novo femoropopliteal occlusive lesions

To compare antegrade versus retrograde recanalization, in terms of procedural time, radiation and contrast agent exposure, number and total length of implanted stents and procedural complications, in long and calcified, de novo femoropopliteal occlusions. We performed retrospective matching of prospectively acquired data by lesion length, occlusion length and lesion calcification by the peripheral arterial calcium scoring system (PACSS) score in patients who were referred for endovascular treatment due to symptomatic peripheral artery disease (PAD). Forty-two consecutive patients with antegrade and 23 patients with retrograde after failed antegrade recanalization were identified (mean lesion length = 32.1 ± 6.9 cm; mean occlusion length = 24.6 ± 7.7 cm; PACSS score = 3.25 ± 0.91). 23% of the patients had intermittent claudication, whereas 77% exhibited critical limb ischemia (CLI). Patients who underwent retrograde versus antegrade recanalization required a significantly lower number of stents (0.9 ± 1.0 versus 1.8 ± 1.4, p = 0.01) and a lower total stent length (6.8 ± 8.5 cm versus 11.7 ± 9.9 cm, p < 0.05) in the interest of more extensive coverage of the lesions using drug coated balloons (DCB) (28.5 ± 12.0 cm versus 18.2 ± 16.0 cm, p = 0.01). No re-entry device was required with the retrograde versus 9 of 42 (21%) with the antegrade recanalization group (p = 0.02). The rate of complications due to retrograde puncture was low (one patient with hematoma and one with distal pseudoaneurysm, both managed conservatively). In long and calcified femoropopliteal occlusions, the retrograde approach is associated with a lower number of re-entry devices and stents and with more extensive lesion coverage with DCB, in the interest of costs and possibly long-term patency.German Clinical Trials Register: DRKS00015277.

Exercise therapy in routine management of peripheral arterial disease and intermittent claudication: a scoping review

BACKGROUND

Little is known about the extent to which routine care management of peripheral arterial disease (PAD) and intermittent claudication (IC) align with best practice recommendations on exercise therapy. We conducted a scoping review to examine the published literature on the availability and workings of exercise therapy in the routine management of patients with PAD and IC, and the attitude and practice of health professionals and patients.

METHODS

A systematic search was conducted in February 2018. The Cumulative Index of Nursing and Allied Health Literature, Ovid MEDLINE, Allied and Complementary Medicine Database, ScienceDirect, Web of Science and the Directory of Open Access Repositories were searched. Hand searching of reference lists of identified studies was also performed. Inclusion criteria were based on study aim, and included studies that reported on the perceptions, practices, and workings of routine exercise programs for patients with IC, their availability, access, and perceived barriers.

RESULTS

Eight studies met the eligibility criteria and were included in the review. Studies conducted within Europe were included. Findings indicated that vascular surgeons in parts of Europe generally recognize supervised exercise therapy as a best practice treatment for IC, but do not often refer their patients for supervised exercise therapy due to the unavailability of, or lack of access to supervised exercise therapy programs. Available supervised exercise therapy programs do not implement best practice recommendations, and in the majority, patients only undergo one session per week. Some challenges were cited as the cause of the suboptimal program implementation. These included issues related to patients' engagement and adherence as well as resource constraints.

CONCLUSION

There is a dearth of published research on exercise therapy in the routine management of PAD and IC. Available data from a few countries within Europe indicated that supervised exercise is underutilized despite health professionals recognizing the benefits. Research is needed to understand how to improve the availability, access, uptake, and adherence to the best exercise recommendations in the routine management of people with PAD and IC.

Endovascular Treatment of Iliac Artery Stenosis Caused by Takayasu Arteritis: A 10-Year Experience

Purpose: To evaluate the safety and efficacy of endovascular treatment for iliac artery stenosis caused by Takayasu arteritis (TA). Methods: Twenty-three consecutive TA patients (mean age 28.6±9.5 years; 17 women) with 30 iliac artery stenoses underwent percutaneous transluminal angioplasty (PTA) and selective stent implantation between January 2007 and December 2016. All had claudication (Rutherford category 2 or 3). The changes in the Rutherford category, ankle-brachial index (ABI), 6-minute walking capacity, and adverse events were assessed. Results: The success rate of endovascular therapy for iliac artery lesions was 93.3% (28/30). Guidewires could not cross either lesion in a patient with bilateral stenoses. Twenty-four lesions were treated by PTA alone and the other 4 lesions with provisional stents. One patient had a puncture site hematoma. Over an average of 4.8±3.3 years, 18 patients remained asymptomatic or had mild intermittent claudication. The other 4 patients developed moderate to severe intermittent claudication due to progression of a previously existing iliac lesion (n=1) or restenosis (n=3); all 4 underwent PTA. At the last follow-up, improvements were seen in the ABI (0.95±0.12 vs 0.51±0.22, p<0.001), 6-minute walking capacity (409.5±46.1 vs 272.6±32.3 m, p<0.001), and the Rutherford category of 22 patients. One patient died of a hemorrhagic stroke at 27 months due to uncontrolled hypertension. Conclusion: Endovascular therapy was safe and effective in treating TA patients with iliac artery stenosis, with good clinical outcomes in the long term.

When Less Invasive Causes Major Sequelae: A Dramatic Evolution of an Infected Common Femoral Artery Patch

Endarterectomy of the common and profunda femoris is currently performed for treatment of atherosclerotic lesions involving femoral bifurcation. Misperception of surgical risk in terms of morbidity and mortality has induced the trend to extend the indication for treatment to patients with mild symptoms at presentation, at the cost of unnecessary increased complication rate and mortality risk, which persists even after patient discharge. We report the case of a giant infected femoral pseudoaneurysm occurring in a 74-year-old patient, previously treated with femoral artery endarterectomy with prosthetic patch closure because of mild claudication. Surgically managed with en block resection and autologous vein reconstruction, his postoperatory course was further complicated by fatal sepsis. Complications for femoral artery endarterectomy, including infectious and fatal events, need a close follow-up of these patients to promptly diagnose and treat any event which may occur, preventing its evolution to more challenging and potentially life-threatening clinical scenario.

Major adverse limb events and major adverse cardiac events after contemporary lower extremity bypass and infrainguinal endovascular intervention in patients with claudication

OBJECTIVE

Major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) at 30 days provide standardized metrics for comparison and have been adopted by the Society for Vascular Surgery's objective performance goals for critical limb ischemia. However, MALEs and MACEs have not been widely adopted within the claudication population, and the comparative outcomes after lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) remain unclear. The purpose of this study was to compare MALEs and MACEs after LEB and IEI in a contemporary national cohort and to determine predictors of MALEs and MACEs after revascularization for claudication.

METHODS

A national data set of LEB and IEI performed for claudication was obtained using National Surgical Quality Improvement Program vascular targeted Participant Use Data Files from 2011 to 2014. Patients were stratified by LEB vs IEI and compared by appropriate univariate analysis. The primary outcomes were MALE (defined as untreated loss of patency, reintervention on the index arterial segment, or amputation of the index limb) and MACE (defined as stroke, myocardial infarction, or death). Multivariable logistic regression was used to identify predictors of MALEs and MACEs.

RESULTS

A total of 3925 infrainguinal revascularization procedures (2155 LEB and 1770 IEI) were performed for claudication. There was no difference in 30-day MALEs between LEB and IEI (4.0% vs 3.2%; P = .17). On multivariable logistic regression, predictors of 30-day MALEs included tibial revascularization (odds ratio [OR], 2.2; P < .0001) and prior LEB on the same arterial segment (OR, 1.8; P = .004). LEB had significantly higher 30-day MACEs (2.0% vs 1.0%; P = .01) but similar mortality (0.5% vs 0.4%; P = .6). Predictors of MACEs included LEB vs IEI (OR, 2.1; P = .01), chronic obstructive pulmonary disease (OR, 2.2; P = .01), dialysis dependence (OR, 4.4; P = .003), and diabetes (OR, 1.9; P = .02).

CONCLUSIONS

In this large national cohort, LEB and IEI for claudication are associated with similar 30-day MALEs. Tibial revascularization and revascularization after prior failed bypass predict MALEs in claudicants and should therefore be undertaken with caution. LEB was associated with more 30-day MACEs but comparable 30-day mortality compared with IEI. Patients with end-stage renal disease, chronic obstructive pulmonary disease, and diabetes are at high risk for MACEs. The risk of 30-day MACEs after LEB should be weighed against the longer term outcomes of LEB vs IEI and conservative management, particularly in these higher risk patients. This analysis helps define contemporary 30-day outcomes after infrainguinal revascularization performed for claudication and serves as a baseline with which the short-term outcomes of future treatments can be compared.

Endovascular Treatment of Claudication due to Isolated Internal Iliac Artery Occlusive Disease

Aortoiliac occlusive disease is a common cause of lower extremity claudication. Patients are typically found to have diminished femoral pulses and abnormal noninvasive vascular studies of the lower extremities. Isolated lesions of the internal iliac arteries are much less commonly treated but can cause similar claudication symptoms in the buttocks, hips, or thighs. Occlusive disease in the internal iliac artery is more challenging to diagnose because the lower extremity pulses and vascular studies can be normal. This may falsely steer the diagnosis away from a vascular etiology. We present a case of disabling buttock claudication in a patient with normal pulses and isolated ipsilateral internal iliac artery stenosis. This was treated successfully with drug-eluting balloon angioplasty. We review the literature for similar cases of isolated internal iliac artery occlusive disease and summarize the disease characteristics and treatment modalities.

Achilles tendon elasticity decreases with intermittent claudication in patients by Acoustic Radiation Force Impulse Imaging (ARFI)

OBJECTIVE

To investigate the value of Acoustic Radiation Force Impulse elastography and its application in Achilles tendon elasticity of intermittent claudication due to lower extremity arterial ischaemia.

METHODS

This prospective case-control study was conducted at the Department of Radiology, Faculty of Medicine, Baskent University, Istanbul, Turkey, from October 2015 to January 2016, and comprised bilateral Achilles tendons of patients with intermittent claudication and healthy individuals. Shear-Wave Velocity (SWV) of each tendon was measured using Acoustic Radiation Force Impulse elastography. Arterial Doppler ultrasonography at tibialis posterior artery was performed to establish the diagnosis of occlusive arterial disease, and the degree of obstruction was recorded. SPSS 16 was used for data analysis.

RESULTS

Of the 84 subjects, 42(50%) were patients and 42(50%) were controls. The number of bilateral Achilles tendons was 168, i.e. 84(50%) of patients and 84(50%) of controls. SWV of the Achilles tendon were different between the two groups (p<0.05). The mean SWV was 5.24±0.45 m/s in the relaxed state in the patients and 2.83±0.56 m/s in the controls. No monophasic flow pattern was observed in 23(54.8%) posterior tibial artery and SWV was 4.94±0.40 m/s in the relaxed state Achilles tendon in patients. Monophasic flow pattern was observed in 61(72.6%) posterior tibial artery and SWV was 5.35±0.42 m/s in the relaxed state Achilles tendon in patients. SWV values were higher in monophasic flow patterns in the posterior tibial artery than in those without monophasic flow patterns in patients group (p<0.01).

CONCLUSIONS

The elasticity of healthy tendon decreased with intermittent claudication in patients.

Endovascular treatment of iliac and common femoral arteries disease by the transradial access: A prospective, feasibility study

AIM

To report feasibility and safety of endovascular interventions on iliac and common femoral arteries, using the transradial access (TRA).

METHODS

100 consecutive patients (19 women; mean age 71, range 37-90years) with critical limb ischemia (30%) or claudication, and TASC A-D lesions in iliac or common femoral arteries, were prospectively enrolled, from January 2013 to June 2015, to be treated via the TRA. Exclusion criteria included no palpable radial arteries (RA) and the presence of a fistula for hemodialysis. Patients were evaluated for procedural technical success, in-hospital complications, and 30days clinical success (defined as improvement of at least one grade in the Rutherford classification of symptoms).

RESULTS

A total of 131 iliac and common femoral arteries lesions were treated (58 in common iliac arteries, 38 in external iliac arteries and 35 in common femoral arteries). Ninety-two stents were deployed in 58 patients. Procedural technical success was achieved in 91% of the lesions; with 95% technical success rate in common iliac arteries, 87% in external iliac arteries and 89% in common femoral arteries; with 72% technical success rate in occlusions and 98% in stenosis. No in-hospital complications were observed. At 30days, 93 patients (93%) had an improvement of at least one category in the Rutherford classification of symptoms (clinical success rate 93%); 12 patients (12%) had an asymptomatic occlusion of the RA.

CONCLUSIONS

TRA can be used to treat iliac and common femoral arteries lesions with a high grade of technical success and a low rate of complications.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts

BACKGROUND

The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair.

METHODS

From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7 years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 21) or bilateral common iliac artery aneurysms (n = 20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year.

RESULTS

A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30 days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention.

CONCLUSIONS

IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.

Intermittent claudication and severe renal artery stenosis are independently associated in hypertensive patients referred for renal arteriography

OBJECTIVE:

The purpose of this study was to evaluate the association between the presence of clinical symptoms of peripheral artery disease and severe renal artery stenosis in patients referred for renal angiography.

METHOD:

We included 82 patients with clinical suspicion of renovascular hypertension and performed an imaging investigation (renal Doppler ultrasound and/or renal scintigraphy) for possible renal artery stenosis. All patients underwent renal arteriography and were examined for peripheral artery disease based on the presence of intermittent claudication and ankle-brachial index test results. Severe renal artery stenosis was defined as a lesion causing 70% obstruction.

RESULTS:

Severe renal artery stenosis was present in 32 of 82 (39%) patients. Patients with severe renal artery stenosis were older (63±12 vs 56±12 years, p=0.006), had more intermittent claudication (55 vs 45%, p=0.027), and had a greater prevalence of an ankle-brachial index <0.9 (44% vs 20%, p=0.021) than patients without severe renal artery stenosis. Multivariate logistic regression analysis showed that the presence of intermittent claudication was independently associated with renal artery stenosis ≥70% (OR: 3.33; 95% CI 1.03-10.82, p=0.04), unlike the ankle-brachial index, which showed no association (OR: 1.44; 95% CI 0.37-5.66, p=0.60).

CONCLUSION:

Intermittent claudication is independently associated with severe renal artery stenosis (≥70%) in patients clinically suspected of having renovascular hypertension.

Adventitial Cystic Disease Communicating with the Knee Joint: A Case Report with Histopathological Study of the Connection

Adventitial cystic disease is a rare nonatheromatous cause of popliteal artery disease. Here, we present a case of a 51-year-old male patient who presented with right calf claudication caused by adventitial cystic disease. Preoperative magnetic resonance imaging and intraoperative findings revealed the presence of a connection between the cyst and adjacent knee joint. In addition, histopathological examination revealed that the tissue structure of the connection was similar to that of adventitial cysts. The tissue composed of 2 types of cells, namely macrophages and fibroblast-like cells, and lesional cells expressed D2-40. These findings supported the ganglion theory as the underlying physiopathology of this disease and were helpful in deciding the management of this case.

Lack of Association Between Limb Hemodynamics and Response to Infrapopliteal Endovascular Therapy in Patients With Critical Limb Ischemia

BACKGROUND

Non-invasive limb hemodynamics may aid in diagnosis of critical limb ischemia (CLI), although the relationship with disease severity and response to endovascular therapy is unclear.

METHODS AND RESULTS

This prospective, single-center study enrolled 100 CLI patients (Rutherford class 4-6) who underwent infrapopliteal endovascular revascularization (175 lesions) in the Peripheral RegIstry of Endovascular Clinical OutcoMEs (PRIME) registry. Hemodynamic measures included ankle-brachial index (ABI), toe-brachial index (TBI), and toe pressure (TP). Procedure success following revascularization was defined as stenosis ≤30%. Hemodynamic success was defined as an increase >0.15 in ABI or TBI relative to baseline. Freedom from amputation was defined as no major or minor amputation during follow-up. Clinical success was defined as a decrease of at least one Rutherford class during follow-up. Treatment success was defined as procedure success, freedom from amputation, and clinical improvement. Median baseline hemodynamic values were 0.90 for ABI, 0.39 for TBI, and 54 mm Hg for TP. Twenty-nine patients (29%) did not meet the common hemodynamic diagnostic criterion for eligibility in CLI trials (ABI ≤0.5, TBI ≤0.5, or TP <50 mm Hg). Main outcomes included 96% procedure success, 95% freedom from amputation, 64% clinical success, and 62% treatment success. There was no relationship between baseline (or with the pretreatment to posttreatment change) limb hemodynamic values and the response to infrapopliteal endovascular therapy.

CONCLUSION

Non-invasive hemodynamic studies may have limited clinical usefulness in patients with CLI. The usefulness of these parameters to confirm eligibility and to assess response to therapy in interventional CLI clinical trials should be re-evaluated.

Natural History of Iatrogenic Pediatric Femoral Artery Injury

BACKGROUND

Iatrogenic femoral artery trauma complicates the course of critically ill neonates and children. Complications from persistent arterial occlusion may include claudication and limb length discrepancies. Data supporting risk factors for such and need for revascularization are lacking.

METHODS

Review of a prospectively maintained database at a tertiary institution of iatrogenic pediatric femoral artery injuries incurred between 2013 and 2014 was performed. Additional injuries were identified by review of pediatric arterial duplex performed between 2008 and 2013. Demographics, risk factors, and outcomes were queried. Data analysis utilized Fischer's exact t-test and logistic regression.

RESULTS

Seventy-six patients were identified of which 68 presented with acute limb ischemia (ALI) and 8 with chronic iliofemoral arterial occlusion resulting in claudication (n = 6) or limb length discrepancy (n = 2). Mean weight at injury was 6.3 kg; mean age at injury was 49 weeks (50% aged <3 months). Mean follow-up was 14 months (out to 11 years). Six patients required surgery for ALI, and 6 required delayed operation for limb length discrepancy (n = 4) or for persistent external iliac artery (EIA) occlusion. Mean age at delayed revascularization was 6 years (range: 2-13 years). Vasopressor use, mechanism/location of injury, and concomitant venous thrombosis were not significantly correlated with need for operation; trends suggested that cardiac catheterization and EIA thrombosis may correlate with chronic disease. Increased age at injury was associated with need for operation.

CONCLUSIONS

Although a majority of children with ALI may be successfully treated medically, 9% will require operation for ALI and 16% ultimately required revascularization during follow-up. Persistent iliofemoral arterial thrombosis is a likely risk factor for limb length discrepancy with growth; identifying risk factors for this and improved methods for surveillance requires ongoing investigation.

Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization

OBJECTIVE

Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment.

METHODS

Patients undergoing nonemergent infrainguinal bypass between 2011 and 2014 were identified in the National Surgical Quality Improvement Program Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared with those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass with prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes.

RESULTS

A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs 7.4%; odds ratio [OR], 1.4 [95% confidence interval (CI), 1.1-1.7]) and claudication (5.2% vs 2.5%; OR, 2.1 [95% CI, 1.3-3.5]). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: OR, 1.4 [95% CI, 1.1-1.8]; claudication: OR, 2.1 [95% CI, 1.3-3.5]), bleeding (CLTI: OR, 1.4 [95% CI, 1.2-1.6]; claudication: OR, 1.7 [95% CI, 1.3-2.4]), and unplanned reoperation (CLTI: OR, 1.2 [95% CI, 1.0-1.4]; claudication: OR, 1.6 [95% CI, 1.1-2.1]), whereas major amputation was increased in CLTI patients only (OR, 1.3 [95% CI, 1.01-1.8]). Postoperative mortality was not significantly different in patients undergoing secondary compared with primary bypass (CLTI: 1.7% vs 2.2% [P = .22]; claudication: 0.4% vs 0.6% [P = .76]). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs 4.9%; OR, 1.5 [95% CI, 1.0-2.2]) but fewer wound infections (7.3% vs 12%; OR, 0.6 [95% CI, 0.4-0.8]) compared with patients with prior endovascular intervention.

CONCLUSIONS

Prior revascularization, in both patients with CLTI and patients with claudication, is associated with worse perioperative outcomes compared with primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of the selection of patients for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.

High dose-rate brachytherapy for the treatment of lower extremity in-stent restenosis

OBJECTIVE

Historically, edge stenosis and late thrombosis limited the effectiveness of adjunctive endovascular brachytherapy (EVBT) for in-stent restenosis (ISR) after percutaneous transluminal angioplasty (PTA) and stenting. We evaluated an updated protocol of PTA and EVBT for ISR among patients with lower extremity occlusive disease.

METHODS

This is a retrospective, single-center review of patients treated with PTA and EVBT for ISR in the iliac and femoropopliteal segments between 2004 and 2012. A dose of 20 Gy was given at a depth of 0.5 mm beyond the radius of the largest PTA balloon using iridium 192, with at least 2-cm-long margins of radiation coverage proximal and distal to the injured area. Stents were assessed for patency by duplex ultrasound imaging at 1, 3, 6, 9, 12, and 18 months and then yearly. The primary end point was freedom from ≥50% restenosis in the treated segment at 6 months, 1 year, and 2 years. Patency data were estimated using the Kaplan-Meier method. Secondary end points were early and late thrombotic occlusion.

RESULTS

Among 42 consecutive cases in 35 patients of EVBT for ISR in common or external iliac (9 [20.8%]) and superficial femoral or popliteal (33 [76.7%]) arteries, or both, 21 patients (50%) had claudication, asymptomatic hemodynamically significant stenoses were identified on duplex ultrasound imaging in 16 (38.1%), and 4 (9.8%) had critical limb ischemia. Mean treated length was 23.5 ± 12.3 cm over a mean duration of 16.1 ± 9.6 minutes. There was one technical failure (2.3%). Median post-EVBT follow-up time was 682 days (range, 1-2262 days). There were two (4.9%) and five (11.9%) cases of early and late thrombotic occlusions, respectively. There was one death, believed to be secondary to acute coronary syndrome. Primary, assisted primary, and secondary patency in the entire cohort was 75.2%, 89.1%, and 89.1%, respectively, at 1 year and 63.7%, 80.6%, and 85.6%, respectively, at 2 years.

CONCLUSIONS

This contemporary protocol of PTA and adjunctive EVBT for lower extremity ISR, which is updated from those used in prior trials and includes a surveillance strategy that identifies at-risk stents for reintervention before occlusion, may be a promising treatment for lower extremity ISR at institutions where a close collaboration between vascular surgeons and radiation oncologists is feasible.

Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative

OBJECTIVE

Prior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice.

METHODS

The VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ² analysis was used to assess for differences across regions where appropriate.

RESULTS

A total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001).

CONCLUSIONS

Significant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.

Surveillance Versus Nonsurveillance for Femoro-Popliteal Bypass Grafts

This is a study of 97 patients who underwent 106 femoropopliteal bypass grafts (9 bilateral bypasses) for short-distance claudication and critical ischemia. Patients were divided into 2 groups. The first group (n=64) was followed up by use of duplex scans. The second group (n=42) was followed up in clinic without duplex surveillance. Twenty-three patients from the surveillance group developed stenoses of the grafts. Of these, 14 underwent successful angioplasty. A total of 43 grafts became blocked. Graft occlusion was significantly more common in the nonsurveillance group (n=29) as compared to the surveillance group (n=14) after both 1 and 3 years of observation (p=0.001). Patients with critical ischemia showed a higher rate of graft occlusion than the claudicants (p=0.0075). Sixteen patients in the nonsurveillance group underwent above/below-knee amputation compared to 1 in the surveillance group. There was no significant difference in the mortality rate in the 2 groups. Graft surveillance helped to improve patency of grafts by identifying the correctable lesions.

Effect of Cholesterol Lowering and Cardiovascular Risk Factors on the Progression of Aortoiliac Arteriosclerosis: A Quantitative Cineangiography Study

The post-Coronary Artery Bypass Graft (Post-CABG) trial has shown that aggressive compared to moderate lowering of low-density lipoprotein cholesterol (LDL-C) delayed the progression of obstructive disease in aortocoronary saphenous vein grafts and in the left main coronary artery. Patients had been allocated to high- and low-dose lovastatin therapy for a 4-5 year period. The present study evaluated the effect of LDL-C lowering and the role of cardiovascular risk factors on the progression of arteriosclerosis in the distal abdominal aorta and common iliac arteries. From one of the participating centers of the post-CABG trial, 145 patients who had adequate imaging of the aortoiliac arteries at baseline and follow-up were included. Angiographic outcomes, presumed to reflect progression of arteriosclerosis and obtained from lumen diameter (LD) measurements using quantitative cineangiography, were as follows: significant decrease of the minimum lumen diameter (LD) and increase of the maximum LD, percent lumen stenosis, and percent lumen dilatation. These outcomes were not significantly less frequent in patients randomly allocated to aggressive compared to moderate LDL-C lowering. Of 9 cardiovascular risk factors, only 2 were significantly related to progression of aortoiliac arteriosclerosis. Current smoking predicted both percent lumen stenosis increase and, to a lesser degree, percent lumen dilatation increase (p=0.010 and p=0.055, respectively). Abnormally high body mass index (BMI ≥25 kg/m2) correlated with percent lumen dilatation increase (p=0.006). Aggressive compared to moderate LDL-C lowering did not prevent or delay the progression of aortoiliac arteriosclerosis. Smoking predicted both lumen narrowing and dilatation presumably caused by arteriosclerosis. Abnormally high BMI, reflecting overweight or obesity, was strongly associated with vessel dilatation.

Popliteal-to-Distal Bypass: Identifying Risk Factors Associated with Limb Loss and Graft Failure

Modern therapy, including endoluminal procedures and improved medical management, still yield less than desired results for tibial vessel occlusive disease. Despite the recent focus on these newer interventions, few modern series have evaluated the efficacy of popliteal-to-distal bypass procedures. The authors aimed to determine the efficacy of popliteal-distal bypass and to identify adverse prognostic factors for ultimate limb salvage. Eighty-seven patients (54 men; average age: 63 years) underwent 92 popliteal-distal bypasses. Duplex ultrasound was utilized to assess patency of all grafts. Data were analyzed by life-table analysis to determine patency rates at postoperative intervals. Median patient follow-up was 2.4 years. Major indications for bypass included chronic limb ischemia (86%) and disabling claudication (8%); 62% of the limbs were considered threatened, and 74% of the proximal anastomoses were above-knee. All procedures were technically successful. There were no perioperative (<30 days) deaths, and 86% of patients were alive at 5 years. Cumulative patency rates were 74% at 6 months, 70% at 2 years, and 63% at 5 years. Limb salvage rates closely paralleled patency rates. At 5 years, 62% of the affected limbs were intact; 72% of the limbs lost were associated with early (<180 days) bypass failures. Predictors of limb loss included early graft failure (84 days vs 1,288 days, p <0.0001), younger age (57 years vs 64 years, p = 0.039), history of previous ipsilateral vascular procedures (50% vs 21%, p = 0.03), heavy (>1 ppd) tobacco use (p = 0.001), and a thrombosed femoral-popliteal bypass at presentation (p = 0.002). When successful, popliteal-distal bypass is associated with excellent long-term patency and limb salvage rates. Early failures are often associated with limb loss. Heavy tobacco use, younger age, early graft failures, repeat revascularization, and presentation with a thrombosed femoral-popliteal graft are associated with limb loss.

Iatrogenic Limb Ischemia Caused by Angiography Closure Devices

Described are 2 cases of lower limb ischemia that resulted after deployment of 2 different arterial closure devices. One patient presented acutely with lower limb ischemia after an Angio-Seal (St Jude Medical, Minnetonka, Minn) device deployed at the conclusion of cerebral artery aneurysm embolization. The second patient, who underwent angioplasty for aortic recoarctation, presented with claudication 1 week after deployment of the Perclose (Perclose, Redwood City, Calif) device. The use of such devices can result in significant complications, and cardiologists, interventional radiologists, and vascular surgeons are advised to have a high index of suspicion for such complications and work in close conjunction to provide prompt and adequate treatment.

Comparison of Computed Tomography Angiography to Contrast Arteriography for Patients Undergoing Evaluation for Lower Extremity Revascularization

In an effort to explore alternatives to contrast arteriography, we compared computed tomography angiography to contrast arteriography for defining anatomic features of patients undergoing lower extremity revascularization. From November 2003 to March 2004, 36 inpatients with chronic lower extremity ischemia underwent contrast arteriography and computed tomography angiography before undergoing lower extremity revascularization procedures. A Siemens 16 slice multiplanar computed tomography device with bolus tracking was used for these exams. The reports of these tests and images were compared prospectively, and the differences in the aorto-iliac segment, femoral-popliteal, and infrapopliteal segments were noted. The vessels were classified as mild disease (<50%), moderate disease (50%-70%), severe (71%-99%), and occluded. The studies and treatment plans based on these data were compared. The mean age was 76 ± 12 years (SD). Indications for the procedures included gangrene (45%), ischemic ulcer (32%), rest pain (19%), and severe claudication (3%); 69% were diabetics. Accuracy of computed tomography angiography in the aorto-iliac, femoral-popliteal, and infrapopliteal segments was 100%, 81%, and 59%, respectively. Thirteen of 18 (72%) of these disagreements resulted in a different procedure than that suggested by computed tomography angiography. A review of the data obtained in this series indicated that computed tomography angiography appears to be unable to obtain adequate information in this highly selected population at our institution.

Cryoplasty for the Treatment of Femoropopliteal Arterial Disease: Extended Follow-up Results

Purpose:

To report the findings from a multicenter study of patients treated with cryoplasty who were then followed for an average of >2 years post-treatment.

Methods:

Extended clinical follow-up was obtained for 70 patients (45 men; mean age 70.5±8.8 years) who originally received cryoplasty therapy to treat symptoms of intermittent claudication as part of a multicenter investigational device exemption (IDE) study. For all subjects, cryoplasty was used to treat stenoses or occlusions ≤10 cm in the femoropopliteal arteries. The original IDE study protocol enrolled 102 patients with a primary endpoint of target lesion patency at 9 months post-treatment. This collection of additional longer term follow-up data was initiated 2.5 years after the onset of study enrollment.

Results:

Extended clinical follow-up ranged from 11 to 41 months (mean 31). The clinical patency rate (freedom from target lesion revascularization) calculated by the Kaplan-Meier method was 83.2% after the original follow-up period of 300 days. After >3 years (1253 days), the clinical patency rate was well maintained at 75.0%.

Conclusions:

Long-term data indicate that cryoplasty is a durable therapy, with relatively low long-term restenosis rates compared to other endovascular treatment approaches.

Early Post-Registry Experience With Drug-Eluting Stents in the Superficial Femoral Artery

OBJECTIVE

Restenosis remains the primary failure mode after stent placement in the superficial femoral artery (SFA). Drug-eluting technology aims to reduce intimal hyperplasia and subsequent stent failure, improving durability for endovascular management of SFA occlusive disease. We present our early experience with the Cook Zilver PTX stent.

METHODS

We retrospectively reviewed a prospectively collected database of patients undergoing placement of the Cook Zilver PTX stent for SFA or popliteal disease since its availability to our institution in October 2013. Patients treated with additional non-PTX stents were excluded. Patient demographics, comorbidities, concomitant procedures, TASC classification, procedural details, and follow-up were reviewed.

RESULTS

Thirty-one limbs in 30 patients were treated with Zilver PTX stents, 5 limbs were excluded for concomitant use of non-PTX stents, leaving 26 limbs in 26 patients for analysis. Indications for intervention were claudication in 17 (65.4%), rest pain in 1 (3.8%), and tissue loss in 8 (30.8%). A median of 2 PTX stents per limb was used to treat a mean length of 14.2 ± 11 cm with technical success of 100%. Concomitant inflow (N = 4) or atherectomy (N = 2) interventions were performed in 23%. Sixty-nine percent of lesions were TASC C (N = 7) or D (N = 11) and 42% were total occlusions. Over a mean 20-week follow-up, 2 occlusions were noted (mean 27 weeks), one was treated with surgical bypass and the other with endovascular salvage. Limb salvage in the series was 92.3% with 2 patients requiring major amputations for infected, non-healing wounds, despite patent stents.

CONCLUSION

On mean 20-week follow-up, we have seen 92.3% primary patency and 96.2% secondary patency. A larger number of patients and longer follow-up will be required to determine the true real-world efficacy of this drug-eluting device, but early experience is encouraging and warrants continued trial.