Endovascular Management of the Popliteal Artery: Comparison of Atherectomy and Angioplasty

Section of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA 02118, USA.
Vascular and Endovascular Surgery (Impact Factor: 0.77). 11/2009; 44(1):25-31. DOI: 10.1177/1538574409345028
Source: PubMed

ABSTRACT Symptomatic atherosclerotic disease of the popliteal artery presents challenges for endovascular therapy. We evaluated the technical success, complications, and midterm outcomes of atherectomy and angioplasty involving the popliteal segment.
We conducted a retrospective review of outcomes of popliteal artery intervention using atherectomy or angioplasty performed between 2003 and 2008.
A total of 56 patients (36% women, age 72.8 +/- 12.2 years, 77% critical limb ischemia) underwent popliteal atherectomy (n = 18) or angioplasty (n = 38). These patients had similar clinical characteristics, TransAtlantic Intersociety Consensus (TASC)/ TASC II classification, mean lesion length, and runoff scores. We observed a trend toward higher rates of technical success defined as <30% residual stenosis after atherectomy compared to angioplasty (94% vs 71%, P = .08). While angioplasty was associated with a higher frequency of arterial dissection (23% vs 0%, P = .003), atherectomy was associated with a higher rate of thromboembolic events (22% vs 0%, P = 0.01). Adjunctive stenting was used more frequently following angioplasty compared to atherectomy (45% vs 6%, P = .005). Thrombolysis was used to treat embolization in 4 patients in the atherectomy group. The improvement in the ankle-brachial index (ABI) was similar between the 2 treatment groups. Primary patency of the popliteal artery at 3, 6, and 12 months was 94%, 88%, and 75% in the atherectomy group and 89%, 82%, and 73% in the angioplasty group (P = not significant [NS]). There were no significant differences in limb salvage and freedom from reintervention at 1 year between the atherectomy and angioplasty groups.
Our experience with popliteal artery endovascular therapy indicates a distinct pattern of procedural complications with atherectomy compared to angioplasty but similar midterm patency, limb salvage, and freedom from intervention.

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    ABSTRACT: BackgroundRemoval of the atherosclerotic plaque by atherectomy rather than compression by balloon angioplasty has held the interest of vascular surgeons since the introduction of remote loop endarterectomy instruments in the 1950s.MethodsWe have reviewed our experience with a directional atherotome (SilverHawk; eV3, Plymouth, MN, USA) for patients who had advanced, TransAtlantic Inter-Society Consensus Stages III and IV (Rutherford categories 4, 5, and 6) occlusive disease. The patients were not candidates for bypass operations or had failed bypass and/or stenting. From August 2007 through April 2009, we used the SilverHawk device in 16 men, aged 48 through 81, median age 66 years (standard deviation = 8.75). Risk factors include diabetes (9) and history of smoking (12). The indications for the procedure were nonhealing wounds in six, tissue necrosis in four, and ischemic rest pain in six patients.ResultsEleven patients had atherectomy of occluded popliteal or tibial arteries. There were no intraoperative complications, specifically embolization or arterial wall perforation. One patient developed a common femoral pseudoaneurysm at the arteriotomy site. In each patient, completion arteriograms showed target lesion revascularization. Follow-up was from 8 to 54 months with a median of 26.5 months. Below-knee amputations on the site of the intervention were required in two patients at 1 month and 9 months. Transmetatarsal amputations were done in two patients following the vascular intervention, one of which was planned preoperatively. Both transmetatarsal amputation sites healed. In five of six patients, relief of rest pain was obtained, and healing of wounds occurred in the remaining six patients.ConclusionUnder the special circumstances of advanced limb ischemia, atherectomy may provide limb salvage in patients who no longer have the option of a bypass operation.
    Journal of Experimental and Clinical Medicine 12/2010; DOI:10.1016/j.jecm.2010.09.002
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    ABSTRACT: The purpose of this study was to assess the efficacy of interventional therapy for peripheral arterial occlusive disease and the difference between diabetic patients and non-diabetic patients. 139 consecutive patients between September 2006 and September 2010 who underwent percutaneous lower extremity revascularization for arterial lesions were divided into diabetes group (n = 62) and non-diabetes group (n = 77). Before intervention, rest ankle brachial indexes and three dimensional computed tomography angiography from abdominal aorta to tiptoe were performed. The interventional treatments included angioplasty with or without stenting. The clinical outcomes included rest ankle-brachial indexes, primary patency rates, secondary patency rates and limb-salvage rates for 6-month, 12-month, 24-month and 36-month after treatment. The primary and secondary patency rates of all interventions and the limb-salvage rates of the patients are illustrated by Kaplan-Meier curves and compared by log-rank analysis. The interventional operation success rates were 98.4% (61/62) in diabetes group and 100% (77/77) in non-diabetes group. The re-interventional operation success rates were 85.7% (18/21) in diabetes group and 76.9% (20/26) in non-diabetes group. The mean value of ankle brachial indexes was significantly increased after intervention (0.397 ± 0.125 versus 0.779 ± 0.137, t = -25.780, P < 0.001) in diabetes group and (0.406 ± 0.101 versus 0.786 ± 0.121, t = -37.221, P < 0.001) in non-diabetes group. Perioperative 30-day mortality was 0%. Major complications included groin hematoma in 7.2%, and pseudoaneurysm formation 2.2%. In diabetes group, 6, 12, 24, and 36-month primary patency rates were 88.7% ± 4.0%, 62.3% ± 6.6%, 55.3% ± 7.0%, and 46.5% ± 7.5%; secondary patency rates were 93.5% ± 3.1%, 82.3% ± 5.1%, 70.8% ± 6.5%, and 65.7% ± 7%; limb-salvage rates were 95.2% ± 2.7%, 87.7% ± 4.4%, 85.5% ± 4.8%, and 81.9% ± 5.8%. In non-diabetes group, 6, 12, 24, and 36-month primary patency rates were 90.9% ± 3.3%, 71.8% ± 5.4%, 71.8% ± 5.4%, and 60.9% ± 6.2%; secondary patency rates were 96.1% ± 2.2%, 91.6% ± 3.3%, 82.7% ± 4.8%, and 71.8% ± 6.2%; limb-salvage rates were 97.4% ± 1.8%, 94.4% ± 2.7%, 90.6% ± 3.7%, and 83.1% ± 5.4%. The differences between two groups were not significant (P > 0.05). With a low risk of morbidity and mortality, the percutaneous revascularization accepted by patients does not affect ultimate necessary surgical revascularization and consequently should be considered as the preferred therapy for chronic lower extremity ischemia. The efficacy and prognosis of interventional therapy in diabetic patients is similar that in non-diabetic patients.
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    ABSTRACT: BACKGROUND: Stenting has been shown to improve patency after femoral artery revascularization in comparison to balloon angioplasty (PTA). Limited data are available evaluating endovascular treatment for obstructive lesions of the popliteal artery (PA). METHODS AND RESULTS: This prospective, randomized, multi-centre trial compares primary nitinol stent (NS) placement to PTA in patients with peripheral artery disease Rutherford-Becker class (RC) 2-5 who had a de-novo lesion in the PA. The primary study endpoint was 1-year primary patency defined as freedom from target lesion restenosis (luminal narrowing of ≥50%) detected with duplex ultrasound. Secondary endpoints included target lesion revascularization (TLR) rate and changes in RC. Provisional stent placement was considered as TLR and loss of primary patency.Two-hundred-forty-six patients were included in this trial. The mean target lesion length was 42.3mm. One-hundred-ninety-seven patients were available for the1-year follow-up. The 1-year primary patency rate was significantly higher in the NS group (67.4%) than in the PTA group (44.9%, P=0.002). TLR rates were 14.7% and 44.1% (P=0.0001). However, when provisional NS placement was not considered as TLR and loss in patency no significant differences prevailed between the study groups (67.4% vs. 65.7%, P=0.92 for primary patency). Approximately 73% of patients in the PTA group and 77% in the NS group showed an improvement of at least one RC (P=0.31). CONCLUSIONS: Primary NS of obstructive lesions of the popliteal artery achieves superior acute technical success and higher 1-year primary patency, only if provisional stenting is considered as TLR. Provisional stenting, as part of a PTA strategy has equivalent 1-year patency, and should be preferred over primary stenting. CLINICAL TRIAL REGISTRATION INFORMATION: Identifier: NCT00712309.
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