[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
Journal of Vascular Surgery 11/2007; 46(4):709-16. DOI:10.1016/j.jvs.2007.05.059 · 3.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year, eighty percent are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter randomized controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis, and compare these data to a critical analysis of the recent results of CAS.
Reviews on Recent Clinical Trials 10/2006; 1(3):293-301. DOI:10.1177/153857440604000301
[Show abstract][Hide abstract] ABSTRACT: Introduction. Conventional postoperative surveillance after endovascular repair of abdominal aortic aneurysms (AAA) relies on computed tomography to identify endoleaks. This study sought to evaluate the potential use of magnetic resonance imaging (MRI) to determine the success of endovascular AAA exclusion by correlating MRI signal intensity with intraaneurysmal thrombus histology and luminosity in a canine model of endovascular AAA repair. Methods. Infrarenal AAA were created in 12 mongrel dogs: 6 with persistently patent retrograde (type II) endoleaks and 6 with no endoleak. T1, T2, and cine-MRA gadolinium-enhanced images were obtained using a fast spoiled gradient recalled protocol in a 3.0 Tesla MR system at 2 days, and 1, 2, and 4 weeks after aneurysms were excluded from antegrade perfusion by a stent graft. T1- and T2-weighted signal intensities of the intraaneurysmal thrombus were analyzed and quantified as signal:noise ratio. Animals were euthanized at a mean of 71 days after aneurysm exclusion for those with multiple side branch endoleaks and at 28 days for control animals with no endoleak. Quantitative analysis of fibrin and intact RBC content as well as total luminosity were analyzed using computerized image analysis. Results were correlated with distance from the endoleak channel for aneurysms with patent endoleaks and correlated with time following exclusion in aneurysms without endoleak. Results. Cine-MRA confirmed endoleak patency and demonstrated pulsatile perfusion of the intraaneurysmal endoleak channel. T1- and T2-weighted MR signal intensity evolved progressively over time in completely excluded aneurysms. Signal intensity varied as a function of distance from patent endoleaks. Intra-aneurysmal thrombus appearance and signal intensity correlated to histologic findings (Tables). The percentage of RBC decreased from 69.5 to 2.7%, while the percentage of fibrin increased from 5.7 to 93.3% with progressively increasing distance from endoleak (Graph). Computerized image analysis revealed increase in luminosity of the visual spectrum evidenced by luminosity of 127 ± 15.59 for areas within 5 mm of the endoleak versus 155 ± 5.7 further than 10 mm from the endoleak, indicating a more homogenous deposition with minimal remodeling and minimal cellularity. The correlation between histologic and MR findings evolved with time in a manner similar to distance from the endoleak channel with increasing luminosity, increasing fibrin content (10 → 87%) and RBC fragments and decreasing intact RBC (61 → 7%). Conclusions. MRI signal intensity corresponds to the histological evolution of thrombus over time in fully excluded aneurysms. A similar pattern of MRI and histological appearance of thrombus organization occurs with increasing distance from persistently patent retrograde endoleaks. Further studies are necessary to determine the utility of MRI assessment of intraaneurysmal thrombus as a technique for postoperative surveillance. TABLE I—ABSTRACT P62No Endoleak (n = 6). Chronologic MR and Histologic Characteristics of Intraaneurysmal Thrombus Over Time.TimeHistologyT1 signal:noise ratioT2 signal:noise ratioLuminosity2 DaysIntact RBC∗1.28:10.96:1N/A1 WeekRBC∗ lysis4.14:124.3:11272 WeeksMet-Hgb∗10.4:116.7:11434 WeeksFerritin & fibrin6.6:14.8:1155∗RBC: red blood cells; Met-Hgb: met-hemoglobin.TABLE II—ABSTRACT P62Retrograde (type II) endoleak (n = 6). Anatomic MR and Histologic Analysis of Intraaneurysmal Thrombus as a Function of Distance from Endoleak Channel.Distance to endoleak channelHistologyT1 signal:noise ratioT2 signal:noise ratioLuminosityWithin channelIntact RBC∗1.15:11.01:1N/ARBC∗ lysis4.26:125.8:11305–10 mmMet-Hgb∗9.3:114.0:1141> 10 mmFerritin & fibrin7.3:14.4:1157∗RBC: red blood cells; Met-Hgb: met-hemoglobin.
Journal of Surgical Research 10/2004; 121(2):325-326. DOI:10.1016/j.jss.2004.07.191 · 1.94 Impact Factor