Objectives Experience with open surgical bypass suggests similar overall outcomes in women compared with men, but significantly increased risk of wound complications. Percutaneous treatment of lower ...extremity occlusive disease is therefore an attractive alternative in women, although it is not clear whether there is a difference in outcomes between women and men treated with this technique. We sought to determine the results and predictors of failure in women treated by percutaneous intervention. Methods Percutaneous infrainguinal revascularization was performed on 309 women between 2001 and 2006. Procedures, complications, demographics, comorbidities, and follow-up data were entered into a prospective database for review. Patency was assessed primarily by duplex ultrasonography. Outcomes were expressed by Kaplan-Meier curves and compared by log-rank analysis. Results A total of 447 percutaneous interventions performed in 309 women were analyzed and compared with 553 interventions in men. Mean age in women was 73.2 years; comorbidities included hypertension (HTN) (86%), diabetes melitus (DM) (58%), chronic renal insufficiency (CRI) (15%), hemodialysis (7%), hypercholesterolemia (52%), coronary artery disease (CAD) (42%), and tobacco use (47%). Indications in women included claudication (38.0%), rest pain (18.8%), and tissue loss (43.2%). Overall primary & secondary patency and limb-salvage rates for women were 38% ± 4%, 66% ± 3%, and 80% ± 4% at 24 months. In this patient sample, women were significantly more likely than men to present with limb-threatening ischemia (61.6% vs 47.3%, P < 0.001) and have lesions of TASC C and D severity (71.4% vs 61.7%, P < .005). However, there were no significant differences in primary and secondary patency rates or limb-salvage rates between genders. Furthermore, while women with limb-threat, diabetes, and advanced TASC severity lesions were at increased risk of failure overall, there were no differences between women and men with these characteristics. Conclusions Percutaneous infrainguinal revascularization is a very effective modality in women with lower extremity occlusive disease. Although women in this sample were more likely to present with limb-threat than men, patency and limb-salvage rates were equivalent between genders, even in high-risk subsets such as diabetics or those with lesions of increased TASC severity.
Endovascular revascularization (ER) via percutaneous transluminal angioplasty (PTA) and stenting are viable options for revascularization in below-the-knee (BTK) peripheral arterial disease. ...Two-dimensional angiography has been the standard of practice for estimating vessel size and selecting treatment devices during ER. However, in other vascular territories, intravascular ultrasound (IVUS) offers better visualization of the lumen dimensions.
To compare angiographic and intravascular ultrasound reference vessel (lumen) measurements in below-the-knee peripheral artery interventions.
Twenty consecutive patients were enrolled in the BTK Calibration study from 2 sites in the United States and Australia. Patients with at least one diseased segment in a native infra-popliteal artery (below-the-knee) and a clinical indication for endovascular therapy (EVT) were included with no limitations with regard to vessel diameter or lesion length. Digital subtraction angiography and IVUS imaging were collected pre- and post-PTA and images were sent to an independent core lab for standardized quantitative analysis of the normal-looking reference vessel dimensions when available. The results were presented as least square means with 95% confidence intervals and a p-value of <0.05 was considered significant.
The overall (N = 19) mean reference vessel diameter for QVA was 2.98 ± 1.24 mm vs. 3.47 ± 0.72 mm for IVUS (mean difference was −0.50 mm, (95% CI: −0.80, −0.20; p = 0.14). As expected, in the proximal segments (N = 12), the mean reference vessel diameters were larger: for QVA, it was 3.17 ± 1.34 mm vs. 3.55 ± 0.76 mm in IVUS, (mean difference was −0.38 mm, (95% CI: -0.79, 0.03; p = 0.40); while in the distal segments (N = 7), mean reference vessel diameters were smaller: for QVA, it was 2.64 ± 1.06 mm vs. 3.33 ± 0.67 mm in IVUS, (mean difference was −0.69 mm, (95% CI: -1.04, 0.34; p = 0.17). We observed a greater degree of acute gain in cases where the treatment balloon size correlated with the IVUS measured reference size.
Angiography underestimates infrapopliteal reference vessel lumen size even when quantitatively assessed. Adjunctive IVUS imaging use in guiding BTK procedures could help ensure adequate sizing and possibly impact immediate post-procedure indices.
•Two-dimensional angiography-the main imaging tool used in below-the-knee endovascular interventions underestimated luminal size compared to intravascular-ultrasound based on quantitatively assessed angiography (QVA) and IVUS reference vessel-lumen-measurements.•There was a mean difference of −0.45(−0.70,-0.21) between Core Lab assessed QVA and IVUS mean reference measurements.•The post-procedure acute gain was found to be more favorable when treatment balloon sizes were closer to IVUS reference vessel lumen measurements.•Interventionalists and surgeons treating infra-popliteal artery lesions without the use of IVUS-guided vessel-sizing should be mindful of the vessel lumen size drop-off on angiography.
A significant percent of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) have concomitant common iliac artery aneurysms. While most of these patients will tolerate sacrifice ...of the hypogastric artery during repair, a subset will develop sequelae of hypogastric occlusion. EVAR was performed in two patients using a bifurcation-sparing unibody endograft (Powerlink, Endologix, Irvine, CA, USA). To avoid simultaneous bilateral hypogastric occlusion, one side was treated with coil embolization while the other was treated with a hypogastric graft (Viabahn, W L Gore and Associates, Flagstaff, AZ, USA). Access to the preserved hypogastric artery was obtained from a sheath inserted from the contralateral femoral artery and brought over the aortic bifurcation with the assistance of a 'rail-wire' traversing from the contralateral to ipsilateral femoral sheaths. The hypogastric limb was deployed simultaneously with the ipsilateral external iliac limb extension, creating a double-barrel flow lumen preserving both hypogastric and external iliac flow. At a mean follow-up of 5.1 months, both hypogastric limbs are patent and no endoleaks were observed. In conclusion, until commercially-produced branched hypogastric endografts are widely available, techniques such as those described above can allow for hypogastric preservation during aortoiliac aneurysm repair without the need for device modification or brachial access for hypogastric limb delivery.
Iliocaval venous lesions produce a spectrum of symptoms ranging from mild swelling to venous ulcerations. In this study we examine the management and outcomes of these patients at our center.
In this ...study we performed a retrospective analysis of patients with symptomatic iliocaval venous stenoses, occlusions, or venous compression syndromes, who were treated with endovascular intervention during the period 2006-2010.
Of the 36 patients evaluated, mean age was 43.0 years; prior deep venous thrombosis (DVT), pulmonary embolism (PE), and hypercoaguable states were present in 55.5%, 25.0%, and 44.4%, respectively. Patients were stratified by the presence (group I, n = 22) or absence (group II, n = 14) of underlying May-Thurner (MT) syndrome. In group I, 11 patients had nonocclusive MT-related stenoses and 11 had acute DVT with underlying MT, causing pain/swelling (100%), venous claudication (66.7%), or CEAP class 3 (95%) or 6 (5%). Female preponderance was 2.1:1. Eighteen patients had successful intervention (angioplasty/stent with or without lysis), with clinical improvement in 94.4% and a decrease in CEAP score in 83.3%. All group II patients had chronic iliocaval occlusions causing: pain (100%); swelling (88.9%); venous claudication (44.4%); or CEAP class 3 (58%), 4 (25%), or 6 (8%). Recanalization was attempted in all patients and was successful in 71.4%. Successful recanalization was associated with clinical improvement in 88.9% and a decrease in CEAP score in 44.4%. Complications included 2 early reocclusions, 2 hematomas, and no cases of PE or death. Primary and secondary 1-year patency was 86% and 100% overall (mean follow-up 9.6 months). Primary 1-year patency for groups I and II was 87.5% and 83.3%, respectively.
Percutaneous intervention for chronic iliocaval venous lesions is associated with excellent 1-year patency rates and a significant reduction in symptoms and decrease in CEAP score.
Objectives Percutaneous revascularization has become increasingly utilized for the treatment of lower extremity ischemia. Patients with limb-threat have been shown to be at increased risk of failure, ...although the reasons for this remain unclear. This study analyzed factors associated with percutaneous treatment failure, focusing specifically on lesion characteristics and treatment complexity. Methods We retrospectively reviewed percutaneous infra-inguinal interventions performed for peripheral occlusive disease between 2002 and 2005 using a prospectively maintained database. Lesion characteristics were assessed by angiography, and lesions were graded according to the TransAtlantic InterSociety Consensus (TASC) criteria. Patency was expressed by Kaplan-Meier method and compared by log-rank analysis. Multivariate Cox-regression analysis was used to assess significant factors on univariate analysis. Mean follow-up was 11.8 months. Results A total of 324 interventions for claudication (55.8%), rest pain (18.4%), or tissue loss (25.8%) were analyzed, including 284 primary interventions and 40 re-interventions in 258 patients (mean age 72.1 ± 10 years, 51.0% male). TASC lesion grades included: A (4.9%), B (29.3%), C (37.7%), and D (28.1%). Isolated single-level interventions (femoral, popliteal, or tibial) were performed in 38.9%, while two-level interventions were performed in 46.2% and three-level interventions in 14.9%. Overall primary patency (± SD) at 6, 12, and 18 months was 87 ± 2%, 66 ± 2% and 59 ± 4%, respectively. Secondary patency at 6, 12, and 18 months was 89 ± 2%, 76 ± 3%, and 69 ± 5%. One-year limb salvage rate (limb-threat patients) was 85 ± 3%. Limb-threatening ischemia as the indication for intervention was most highly associated with failure of both primary and secondary patency and was associated with four indicators of lesion severity and treatment complexity, including increasing TASC grade, multilevel intervention, tibial intervention, and reduced tibial outflow. One-year primary patency was inversely correlated with TASC severity (TASC A-C: 67 ± 6%, D: 61 ± 4%; P < .05), multilevel intervention (76 ± 5% and 49 ± 9% for single vs multilevel, P = .002), distal interventions (74 ± 5% and 57 ± 7% for femoral vs tibial, P < .05), and decreased tibial runoff (83 ± 6% and 52 ± 6% for three- vs < three-vessels, P < .02). No differences in secondary patency or limb-salvage rates existed for these lesion- and treatment-related variables. Multilevel intervention and tibial intervention remained significant independently associated with primary patency on multivariate analysis. Conclusions Patients with limb-threatening ischemia are at increased risk of initial failure compared with claudicants, likely as a result of the increased prevalence of advanced lesion severity and treatment complexity, which are associated with decreased primary patency. However, this finding did not extend to secondary patency or limb-salvage in the overall patient population. Although additional studies with longer follow-up are needed, these findings argue that percutaneous intervention may still be considered as a primary treatment modality with the understanding that these patients may have higher re-intervention rates and may ultimately require salvage open surgical bypass for persistent failures of percutaneous therapy.
Carotid stent and/or angioplasty (CAS) via the transfemoral route with distal protection carries twice the risk of stroke and/or death when compared with carotid endarterectomy (CEA) in multiple ...randomized trials. Potential causes for this include disadvantaged aortic arch anatomy and the need to traverse the lesion to place a distal protection device. This report describes the technique and our experience with direct CAS using flow reversal for embolic protection.
University of California at Los Angeles (UCLA) division of Vascular and Endovascular surgery was a participant in the multi-institutional Roadster Trial of high-risk patients. We are reporting on our experience with 8 patients who met high-risk criteria. Using a small supraclavicular cutdown, the Michi sheath from Silk Road Medical was inserted into the common carotid artery. This provides a working channel for internal CAS as well as a side port to reverse and divert blood flow to the femoral vein, for embolic protection. All patients qualified as medically high risk because of a combination of factors including advanced age, smoking history, hypertension, diabetes, coronary artery disease, or hostile neck anatomy.
All 8 patients had 3 or more risk factors including age >75 years (6 of 8), smoking (6 of 8), hypertension (7 of 8), overt coronary artery disease (4 of 8), diabetes (2 of 8), and chronic obstructive pulmonary disease (1 of 8). All stenoses were in the 80-99% category, and all were asymptomatic. All patients tolerated temporary clamping with flow reversal with no electroencephalogram changes. There were no deaths, strokes, transient ischemic attacks, or myocardial infarctions. All patients were discharged on the first postoperative day. Follow-up ranged from 7 to 21 months. One patient developed in-stent restenosis (asymptomatic).
Direct CAS with flow reversal appears to be a safe, less invasive alternative to CEA.
Patients with iliofemoral deep venous thrombosis are at risk for development of post-thrombotic syndrome. Iliac vein stenting has been shown to significantly improve clinical outcomes in patients ...with venous outflow obstruction, although many studies include a heterogeneous population with several different venous pathologic processes. Our objective was to evaluate the results of iliocaval and infrainguinal venous intervention for venous outflow obstruction due to post-thrombotic chronic venous occlusive disease.
All patients treated at a single institution for symptomatic iliocaval venous occlusive lesions with and without infrainguinal extension between 2008 and 2015 were retrospectively analyzed. Nonthrombotic iliac vein lesions were excluded from analysis. All patients with symptomatic post-thrombotic occlusion of the iliac vein or inferior vena cava (IVC) and a Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) score of 3 or greater were included. Demographics of the patients, presence of IVC filters at presentation, presenting CEAP score, postintervention CEAP score, primary and secondary patency, wound healing and subjective clinical improvement outcomes, and procedural details were recorded in a database.
There were 105 patients with symptomatic iliocaval venous occlusive lesions identified, of which 31 patients (42 limbs) met inclusion criteria. Presenting symptoms included pain or swelling (100%); venous claudication (81%); and CEAP class 3 (76%), 4 or 5 (14%), or 6 (10%). All patients presented with either subacute (>30 days 35%) or chronic (>90 days 65%) iliocaval venous thrombosis. Procedural technical success with venous recanalization was achieved in 100% of cases and in 46% of IVC filter retrieval attempts. Overall clinical improvement was achieved in 84% of patients; complete clinical resolution was obtained in 42% and a decrease in CEAP score in 65%. At a mean follow-up of 14.7 months (range, 2-49 months), primary and secondary 1-year patency was 66% and 75% overall, and primary patency was equivalent between patients requiring isolated iliac venous stenting and those requiring infrainguinal stent extension (68% vs 65%, respectively; P = .74, not significant). Patients who presented with IVC filters had a higher rate of complete clinical resolution if the filter could be removed (100%) compared with those patients in whom the filter could not be removed (17%; P < .01).
Treatment of chronic venous occlusive disease with iliocaval and infrainguinal venous stenting is associated with acceptable 1-year patency rates, healing of venous ulcers, and a significant reduction in symptoms and CEAP score. Patients who underwent successful removal of indwelling IVC filters showed improved clinical outcomes compared with those in whom the IVC filter could not be removed.
Background Models of native abdominal aortic aneurysms (AAA) have been created in rodents using elastase and calcium chloride perfusion. These models, however, do not permit the evaluation of ...endovascular devices. This study describes the use of mechanical and enzymatic techniques to create native AAA in swine. Methods Surgically exposed abdominal aortas of ten male Yorkshire swine (25-35 kg) were dilated, then perfused for 20 min with a 50-mL solution of elastase (30 units) and collagenase (8000 units). Serial magnetic resonance imaging (MRI) at 1, 3, and 6 wk was used to evaluate postoperative aortic diameter. Animals were euthanized at 24 h, 48 h and 1, 2, and 6 wk for histological evaluation. Results MRI demonstrated an increase in mean aortic diameter by 73.3% ± 30.2% (33.3-116.7%), which gradually increased postoperatively. Partial endothelial loss, mural neutrophil infiltrate, and elastin disruption were evident (1, 3, and 7 days). Smooth muscle cell attrition occurred within the inner tunica media (7 days). Collagen deposition, limited SMC repopulation and luminal reendothelialization appeared at 3-6 wk. Elastin injury persisted. Conclusions The creation of an infrarenal aneurysm is possible within the native aorta of swine. After aneurysm creation, progressive increase in aortic diameter was detectable. Further evaluation will be necessary to more completely characterize the nature and extent of elastase-induced porcine aortic aneurysmal degeneration.
Our experience with bovine carotid artery graft (BCAG) for hemodialysis access (Artegraft, North Brunswick, New Jersey) is presented. A review of all patients who underwent placement of BCAG for ...hemodialysis access at our institution was performed. Between January 2012 and June 2013, 17 BCAGs were placed in 17 patients. Indications included skin compromise, recurrent expanded polytetrafluoroethylene (ePTFE) and catheter infections, immunosuppression, groin placement, and surgeon's choice. Actuarial primary, primary-assisted, and secondary patency rates at 18 months were 73.3%, 67%, and 89%, respectively. One immunosuppressed patient developed a vancomycin-resistant enterococcus graft infection and required removal 2 months following the initial procedure. We conclude that BCAG can be used as an alternative to ePTFE for angioaccess in patients with no available superficial vein in high-risk patients with low morbidity and good functional patency. Our 1-year patency rates were superior to ePTFE as reported in the contemporary peer-reviewed literature.
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