Bailout stenting in femoropopliteal arterial segment

Summary: Background: Disabling peripheral arterial disease (PAD) of femoropopliteal segment is usually treated with percutaneous balloon dilatation, and when this is not successful, stent is placed. Long-term patency of stent is often compromised due to in-stent restenosis (ISR). We aimed to identify factors associated with bailout stenting, and to recognise risk factors for ISR in procedures without paclitaxel application. Patients and methods: We analysed 592 consecutive successful femoropopliteal interventions performed in patients with either disabling intermittent claudication or chronic critical limb ischemia (CLI). In patients with stent implantation, clinical and ultrasound (US) examination were performed one year after the intervention to establish the presence of ISR, defined as >50% stenosis on US imaging. Results: Bailout stenting was required in 133 (22.5%) procedures. Patients with stent placement were younger (70±10 vs 72±11 years, p=0.007) and less often presented with CLI (29.3% vs 40.5%, p=0.019). They more often reported smoking (63.2% vs 49.2%, p=0.005), less often had diabetes mellitus (35.3% vs 47.5%, p=0.013) and arterial hypertension (82.0% vs 90.8%; p=0.004). Stenting was also dependent on lesion complexity (TASC II C>B>A; p<0.001). Subgroup analysis of 110 procedures with bare metal stent (BMS) placement performed in 107 patients revealed ISR in 46.4% of stents, in half of cases it was symptomatic. Neither clinical nor lesion characteristics proved to differ between the group of procedures with ISR and group of procedures without ISR. Conclusions: Factors associated with bailout stenting were age, diabetes mellitus, arterial hypertension, smoking, clinical picture of PAD and complexity of treated lesions. We did not find any risk factors influencing development of ISR in BMS.

Percutaneous Deep Foot Vein Arterialization IVUS-Guided in No-Option Critical Limb Ischemia Diabetic Patients

Purpose: To report our clinical experience with IVUS-guided percutaneous deep vein arterialization (pDVA) to treat chronic critical limb ischemia (cCLI) patients with no-endovascular or surgical options approach due to creation of an arteriovenous fistula (AVF). Materials and Methods: In a 2 years period, 14 no-option cCLI patients were treated with percutaneous deep vein arterialization (pDVA) by creating an AVF with a IVUS-guided system between posterior tibial artery and its satellite deep vein. Technical success was defined as successful AVF creation and venous perfusion of the wound site. Patients’ characteristics, procedure details, mortality and wound outcomes were assessed prospectively. Results: Successful pDVA was successfully performed in all patients (mean age 82 years) without any procedural complications. Clinical improvement was achieved in all patients with resolution of rest pain, tissue formation of granulation tissue or both; only 3 major amputations were performed within the study period with a limb salvage rate of 78%. Median wound healing time was 4.8 months. Conclusion: pDVA is a safe and feasible revascularization technique alternative in no-option cCLI patients.

Distal embolization during percutaneous revascularization of the lower extremity arteries

Summary: Background: Percutaneous endovascular therapy is nowadays the leading treatment option for patients with symptomatic peripheral arterial disease, but it can be complicated with distal embolization (DE). Patients and methods: We retrospectively analyzed 2054 endovascular revascularization interventions performed in patients with disabling claudication or chronic critical limb ischemia in the Catheterisation Laboratory of the Department of Vascular Diseases, University Medical Centre Ljubljana between January 2014 and December 2018. Lesions were treated by balloon angioplasty and/or stent implantation, without atherectomy. Results: The overall incidence of DE was 0.9%. DE was more frequent in females than males (1.6% vs 0.5%, p = 0.011), in the absence of antiplatelet treatment prior to intervention compared to previous antiplatelet treatment (2.1% vs 0.6%, p = 0.005) and in femoropopliteal stenting compared to angioplasty without stenting (2.2% vs 0.8%, p = 0.037). DE was successfully managed with percutaneous aspiration, in combination with angioplasty when necessary, in 84% of cases. In remaining 16% of patients, DE was managed with surgical thromboembolectomy. Conclusions: The incidence of DE during endovascular revascularization of chronic atherosclerotic lesions in lower limb arteries without use of atherectomy was low. DE was more frequent in women, in patients without prior antiplatelet treatment and in femoropopliteal stenting. The majority of DE was successfully managed percutaneously.

Successful limb salvage by endovascular treatment for critical limb ischemia subsequent to acute limb ischemia

Recently, there have been increasing opportunities to treat patients with peripheral arterial disease. Of those patients, both pathological conditions, such as acute limb ischemia (ALI) and chronic critical limb ischemia (CLI), are closely associated with high risks of major amputation, disability and death. We encountered a very rare case of CLI subsequent to ALI. An 83-year-old male showed the sudden onset of ALI, probably due to thromboembolism from an abdominal aortic aneurysm during an operation for gastric cancer. The patient was referred to another hospital for Fogarty thrombectomy. About 1 month after ALI onset, necrosis of the left first toe gradually progressed. On angiography of the left lower limb, we noted occlusions of both anterior and posterior tibial arteries. Then, we successfully conducted balloon angioplasty for the below-the-knee arteries. Thereby, favorable blood flow was achieved, which led to successful wound healing without amputations.