Angioplasty of the pelvic and femoral arteries in PAOD: Results and review of the literature

doi:10.1016/j.ejrad.2010.04.016

European Journal of Radiology

Volume 75, Issue 1, July 2010, Pages 48-56

https://doi.org/10.1016/j.ejrad.2010.04.016 Get rights and content

Abstract

Purpose

Evaluation of percutaneous recanalization of obstructed iliac as well as superficial femoral arteries (SFAs) in patients with peripheral arterial obstructive disease (PAOD).

Material and methods

The data of 195 consecutive patients with 285 obstructions of the common and or external iliac artery as well as the data of 452 consecutive patients with 602 long occlusions (length > 5 cm) of the SFA were retrospectively analyzed. The lesions were either treated with percutaneous transluminal angioplasty (PTA) or Excimer laser assisted percutaneous transluminal angioplasty (LPTA). Overall 316 stents were implanted (Nitinol stents: 136; stainless steel stents: 180) in the iliac artery and 669 stents were implanted (Nitinol stents: 311; Easy Wallstents: 358) in the SFA. The follow-up period was 36–65 months (mean 46.98 ± 7.11 months) postinterventionally using clinical examination, ABI calculation, and color-coded duplex sonography. Patency rates were calculated on the basis of the Kaplan–Meier analysis.

Results

The overall primary technical success rate was 97.89% for the iliac arteries and 92.35% for the SFA. Minor complications (hematoma, distal emboli and vessel dissection) were documented in 11.79% for the iliac arteries and 7.97% for the SFA. The primary patency rate was 90.3% for the iliac and 52.8% for the SFA after 4 years. The secondary patency rate was 96.84% for the iliac and 77.8% for the SFA after 4 years.

Conclusion

Percutaneous recanalization of iliac and superficial femoral artery obstructions is a safe and effective technique for the treatment of patients with PAOD. By consequent clinical monitoring high secondary patency rates can be achieved. The use of a stents seems to result in higher patency rate especially in the SFA when compared to the literature in long-term follow-up.

Introduction

The annual incidence of symptomatic peripheral arterial obstructive disease (PAOD) is 26/10,000 in men and 12/10,000 in women according to the results of the Framingham study; this means that PAOD is at least as frequent as angina in the U.S. population [1].

The most common clinical manifestation of PAOD is intermittent claudication involving the pelvis, upper thigh and lower limb. Patients presenting with critical limb ischemia usually have multisegmental disease with involvement of the infra-inguinal arteries.

Anatomically, approximately 30% of the arterial lesions are located in the iliac arteries, 70% in the femoro-popliteal and tibial tract. Isolated lesions below the knee are present in only 15% of the cases. Approximately 30% of the symptomatic PAD patients have diffuse arterial disease, and the majority of CLI patients, most of whom are diabetic, have distal arterial disease with occlusions in the tibial arteries [2].

Considerable advances have been made over the last decade in percutaneous technology for the treatment of atherosclerotic diseases in the iliac, femoro-popliteal, and distal tibioperoneal arteries [3], [4].

The techniques that have been developed include percutaneous balloon angioplasty and stenting, atherectomy and laser therapy [3], [5], [6].

The primary goal of any treatment of patients with PAOD will be either relief of significant lifestyle-limiting symptoms or limb salvage. Surgery has long been considered the gold standard treatment when symptoms could not be controlled by risk factor modification, exercise therapy or medication. With the introduction of new interventional techniques and devices acute treatment success and durability of endovascular technology has improved during the last decade. As a result, endovascular intervention has become a first line therapy to treat PAOD in many cases and even complex arterial diseases [2].

According to the recently updated TransAtlantic Consensus Document on treatment of PAOD (TASC II), the choice between endovascular therapy and surgery depends on the lesion type in terms of complexity and length [7].

This paper presents the follow-up data of patients with PAOD treated with percutaneous transluminal recanalization either in the iliac or femoral artery and reviews the literature to date.

Section snippets

Iliac artery recanalizations

The data of 195 consecutive patients with 285 obstructions of the common and or external iliac artery were retrospectively analyzed. These patients were identified by routine registry and routine scheduled follow-up regimens. The lesions were either treated with percutaneous transluminal angioplasty (PTA) or Excimer laser assisted percutaneous transluminal angioplasty (LPTA). Overall 316 stents were implanted (Nitinol stents: 136; stainless steel stents: 180). A total of 134 men (mean age 60.9 ±

Iliac arteries

195 patients, 134 men (mean age 60.9 ± 12.5 years) and 61 women (mean age 58.8 ± 10.8 years) with intermittent claudication or chronic limb ischemia classified as Fontaine stages IIb, III or IV, were treated with PTA and stent implantation. The clinical characteristics of the patients are summarized in Table 1.

Overall 285 lesions in the pelvic arteries were detected which could be subdivided into 234 stenosis (50–74%: n = 46; 75–99%: n = 188 (Fig. 1); based on biplane angiographies and measurements in

Iliac arteries

Today the percutaneous recanalization of iliac artery obstructions is considered as method of choice in the wide majority of iliac artery lesions. Still issue for discussion remains on employed techniques for recanalization (retrograde, antegrade, primary stenting and debulking first), the outcome in female versus male patients, as well as the stent material employed (self-expanding, balloon expanding and covered stents). Besides disease progression long-term outcome also depends on outflow

Conclusion

In summary, the data on percutaneous iliac artery recanalization underline that stent-supported reconstruction of even complex lesions, classified as TASC C and D can be treated successfully with endovascular intervention (Table 3). However, further investigations should be focused on the 5- and 10 year patency rates in comparison with the surgical results. Still unresolved seems to be the discussion on primary was selective stent implantation.

Concerning the treatment of SFA lesions PTA remains

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Cited by (34)

Results of Excimer Laser Ablation Combined with Drug-Coated Balloon for Atherosclerotic Obliterans of Lower Extremity and Risk Factors for Loss of Primary Patency
2023, Annals of Vascular Surgery
Citation Excerpt :
In the present study, we concluded the poor run-off was the independent predictor of loss of primary patency after ELA. The superficial femoral artery and popliteal artery are important targets in the treatment of ASO in the lower extremity;15-17 however, below the knee (BTK) arteries also play an important role in the preservation of perfusion in the distal limb. Especially, in the endovascular treatment of the femoropopliteal artery, BTK artery acts as an outflow runoff vessel, and it could affect the outcomes of femoropopliteal intervention itself.18,19
The results of excimer laser ablation (ELA) combining with drug-coated balloon (DCB) in the treatment for atherosclerotic obliterans (ASO) remains unclear.
Retrospectively enrolled patients who underwent ELA combined with DCB in 2 centers. The primary endpoint was primary patency, and secondary endpoints included technical success, procedure-related complications, major amputation, clinically driven target lesions reintervention (CD-TLR), measurements of ankle-brachial index (ABI), and quality of life (QoL).
102 patients were enrolled. The primary patency was 86.7% (95% confidence interval [CI]: 72.9%–89.0%) at 12 months and 82.6% (95% CI: 78.2%–92.1%) at 24 months. The freedom from reintervention was 87.8% (95% CI: 79.5%–92.9%) at 12 months and 86.6% (95% CI: 78.1%–92.0%) at 24 months. The ABI measurement and QoL were significantly improved at each follow-up point. Sixteen (15.7%) patients lost the primary patency. Patients losing the primary patency demonstrated higher Rutherford class (P = 0.004), worse runoff (P < 0.001), higher Peripheral Arterial Calcium Scoring System (PACSS) (P < 0.001), and smaller ratio of tube diameter to reference vessel diameter (TD/RVD) (P < 0.001) compared with patients without losing it. The run-off ≥7 (adjusted odds ratio [aOR]: 34.3; 95% CI: 2.9–398.3; P = 0.005) and TD/RVD <4.9 (aOR: 24.7; 95% CI: 1.7–359.5; P = 0.019) were independent risk factors for loss of primary patency.
ELA combined with DCB seemed an effective and safe treatment for ASO of lower extremity, and it could not only reduce the implantation of stent but significantly improve QoL. The run-off ≥7 and TD/RVD <4.9 were independent risk factors for loss of primary patency.
Use of multi-detector CT angiography in assessment of collateral circulations in chronic lower limb ischemia, clinical and anatomical application
2016, Egyptian Journal of Radiology and Nuclear Medicine
Citation Excerpt :
Patients in the present work presented with a mean age of 60.86 for females versus 56.96 years for males. The age distribution in the current study reflects a higher prevalence of peripheral arterial disease in the late fifties – early sixties, which is comparable to data provided by (7,8) where their mean age was 59 and 60 respectively. Females presented with an older mean age in the present work.
To evaluate role of multi-detector CT angiography in assessment of collateral circulations in chronic lower limb ischemia based on anatomical background as well as mapping the collateral circulations and identifying their frequencies and variations, and whether they are pre-existing or newly formed.
105 patients with manifestation of lower limb ischemia underwent CT angiography for disease evaluation and further treatment planning.
On the basis of CT angiographic findings, the study shows the distribution of the arterial lesions and the different patterns of the arterial collateralization in peripheral arterial disease. The diabetic patients had an infrapoplitial disease distribution tendency more than the non-diabetic ones with the superficial femoral artery most affected in both parties. Collateral circulations were present significantly more in non-diabetic subjects than in diabetic ones. The patterns included both systemic and visceral anastomotic pathways.
MDCT angiography is excellent noninvasive scanning technique for patients with chronic lower limb ischemia, with higher spatial resolution and faster acquisition times, allowing excellent assessment of the lower limb arterial lesions and collateral pathways.
Outcomes of the endovascular treatment of stenotic lesions versus chronic total occlusions in the iliac sector
2016, Annals of Vascular Surgery
Citation Excerpt :
In the past 10 years, several factors indicating a worse prognosis have been identified in patients undergoing EVT of an iliac artery lesion including poor distal runoff, female sex, treatment of the external iliac artery (EIA), and a longer treated lesion.3 However, the effects on the outcome of some of these factors such as female sex4,5 and lesion site6,7 have been questioned by some authors. Only a few studies have compared the outcomes of EVT of stenotic lesions and chronic total occlusions (CTOs) in the iliac sector,8 mainly because lesions are usually classified according to the TASC II classification,2 which often assigns these 2 lesion types to a single class.
This study compares outcomes of the endovascular treatment (EVT) of iliac artery occlusive disease according to whether the treated lesion is a stenosis or a chronic total occlusion (CTO).
Patients undergoing EVT from 2003 to 2013 for iliac artery occlusive disease were identified and the lesions treated stratified into stenotic (Group 1, n = 375) or CTO (Group 2, n = 87). Patients were followed clinically and hemodynamically (thigh–brachial index, TBI). Comorbidities, procedural factors, and outcomes were compared between the 2 groups using Kaplan–Meier, Breslow, and Cox models.
Four hundred sixty-two iliac endovascular procedures in 378 patients were included in a retrospective study. The 2 groups only differed in preprocedural TBI [0.77 (Group 1) vs. 0.67 (Group 2), P < 0.001], lesion length [39.7 mm (Group 1) vs. 49.9 mm (Group 2), P < 0.001], and the use of a covered stent [11.6% (Group 1) vs. 46.2% (Group 2), P < 0.001]. The technical success rate was higher in Group 1 (99.2% vs. 89.7%, P < 0.001). Five early occlusions were recorded in Group 1 and 3 in Group 2 (1.3% vs. 3.8%, P = 0.146). Median follow-up was 34 months (1–113). At 12 and 36 months, stenotic lesions showed better primary (P1) and secondary (P2) patency rates [P1 93.0% and 85.8% vs. 83.1% and 74.7%, hazard ratio (HR) 1.90 (1.15–3.14), P = 0.018; P2 97.8% and 96.8% vs. 93.0% and 87.4%, HR 2.86 (1.39–5.90), P = 0.007] and freedom from reintervention (FFR) rates [91.6% and 83.5% vs. 84.1% and 78.9%, HR 1.51 (0.90–2.53), P = 0.132]. In a multivariate analysis, CTO showed a worse P2 than stenotic lesions [HR 2.81 (1.17–6.76), P = 0.021], yet no differences emerged in P1 [HR 1.41 (0.76–2.63), P = 0.277] or FFR [HR 1.43 (0.79–2.57), P = 0.237]. A lower preprocedural TBI was correlated with a greater risk of EVT failure in terms of patency and FFR (P < 0.05). The use of a stent shorter than 40 mm emerged as a protective factor with an HR for P1 of 3.68 (1.53–8.87) (P = 0.004).
EVT for iliac artery disease offers good outcomes in terms of long-term patency, although improved results were observed here for the treatment of stenotic lesions over CTO. Procedures performed in patients with a lower TBI and the use of a stent >40 mm were related to a worse stent patency.
Effect of perioperative complications after endovascular therapy in patients with peripheral artery disease due to femoropopliteal lesions
2015, Journal of Vascular Surgery
Despite wide use, high initial success, and acceptable durability of endovascular therapy (EVT) for femoropopliteal (FP) lesions, the frequency of 30-day perioperative complications (POCs) and their effect on clinical outcomes have not been systematically evaluated, which is the subject of this study.
We used a multicenter database of 2145 consecutive patients (70% male; overall mean age, 73 ± 9 years) who successfully underwent EVT for FP lesions to investigate independent predictors of POCs (logistic regression analysis) and effect of POCs on prognostic outcomes (Cox proportional regression).
POCs were observed in 209 patients (10%). In multivariate logistic regression analysis, body mass index <18.5 kg/m², critical limb ischemia, and TransAtlanic Inter-Society Consensus for the Management of Peripheral Arterial Disease class D lesions were independently associated with POCs (adjusted odds ratios [95% confidence intervals], 2.0 [1.3-2.9], 2.5 [1.9-3.3], and 1.6 [1.2-2.1], respectively). After risk stratification of POCs according to the number of these risk factors, the incidence of POCs was higher in the groups with higher scores. Follow-up for >30 days (mean, 2.3 ± 1.8 years) was available for 2079 of 2145 patients. A Cox hazard regression model adjusted for baseline clinical characteristics showed POCs were negatively and independently associated with future occurrence of major adverse limb events (defined as major amputation and major reintervention) or death (hazard ratio [95% confidence interval], 1.6 [1.2-2.1]; P < .05).
Body mass index <18.5 kg/m², critical limb ischemia, and TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease class D lesion were positively associated with POCs after EVT for FP lesions. The occurrence of POCs may adversely affect clinical outcomes in the chronic phase.
Shared and differential factors influencing restenosis following endovascular therapy between TASC (Trans-Atlantic Inter-Society Consensus) II Class A to C and D lesions in the femoropopliteal artery
2014, JACC: Cardiovascular Interventions
This study sought to investigate factors associated with restenosis after endovascular therapy comparing TASC (Trans-Atlantic Inter-Society Consensus) II classes A to C with class D femoropopliteal (FP) lesions.
It is unclear whether the determinants of restenosis for TASC II class D lesions are the same as those for TASC II classes A to C FP lesions.
We studied 2,400 limbs from 1,889 consecutive patients (73 ± 17 years of age; 31% women; 30% critical limb ischemia) who underwent successful endovascular therapy for de novo FP lesions. Predictors for restenosis in TASC II classes A to C and class D lesions were assessed using a Cox proportional hazards model.
The 5-year primary patency rate was 50% in TASC II classes A to C and 34% in TASC II class D lesions, respectively (p < 0.001). Overall, restenosis had a significant interaction with sex and renal failure (both p < 0.01). Female sex was a significant risk factor for restenosis in TASC II class D lesions (adjusted hazard ratio [HR]: 1.80, p < 0.001) but not TASC II classes A to C lesions (adjusted HR: 1.10, p = 0.352). Conversely, renal insufficiency was a significant risk factor for restenosis in TASC II classes A to C lesions (adjusted HR: 1.43, p < 0.001) but not TASC II class D lesions (adjusted HR: 0.79, p = 0.129). Diabetes mellitus, no stent use, chronic total occlusion, and poor below-the-knee runoff were shared risk factors for restenosis between TASC II classes A to C and class D lesions (all p < 0.05).
For de novo FP lesions, diabetes, no stent use, chronic total occlusion, and poor below-the-knee runoff were shared restenosis predictors for TASC II classes A to C and class D lesions, whereas renal failure was a predictor for TASC II classes A to C lesions and female sex for TASC II class D lesions.
Effects of successful percutaneous lower extremity revascularization on cardiovascular outcome in patients with peripheral arterial disease
2013, International Journal of Cardiology
Citation Excerpt :
While PTA of the lower limbs is widely recognized to be effective in improving functional status and quality of life in claudicants [8,10], no data are currently available regarding its impact on cardiovascular outcome in this high-risk population. Interestingly, PTA in LE-PAD entails an increase of ankle/brachial index (ABI) [11], the most consistent and powerful prognostic indicator in these patients [12]. Moreover, PTA in LE-PAD patients improves endothelial dysfunction [13], which plays a key role in the pathophysiology and natural history of the disease [14], and reduces the ischemia–reperfusion injury which promotes systemic inflammation [15].
Lower extremity peripheral arterial disease (LE-PAD) reduces walking capacity and is associated with an increased cardiovascular risk. Endovascular revascularization of LE-PAD improves walking performance and quality of life. In the present study, we determined whether successful lower limbs revascularization also impacts cardiovascular outcome in LE-PAD patients.
479 consecutive LE-PAD patients at stage II of Fontaine's classification, with ankle/brachial index ≤ 0.90 and one or more stenosis > 50% in at least one leg artery, were enrolled in the study. According to the Trans-Atlantic Inter Society Consensus II recommendations, 264 (55.1%) underwent percutaneous lower extremity angioplasty (PTA group), while 215 (44.9%) were managed with conservative therapy (MT group). The incidence of major cardiovascular events (including cardiovascular death, myocardial infarction, ischemic stroke, coronary and carotid revascularizations) was prospectively analyzed by Kaplan–Meier curves. Crude and adjusted HRs (95% CI) of developing a cardiovascular event were calculated by Cox analysis.
No baseline differences were observed among the groups, except for a lower maximum walking distance in the PTA group. During a median follow-up of 21 months (12.0–29.0), the incidence of cardiovascular events was markedly lower in PTA compared to MT patients (6.4% vs. 16.3%; p = 0.003), and patients in the MT group showed a 4.1-fold increased cardiovascular risk compared to patients in the PTA group, after adjustment for potential confounders (95% CI 1.22–13.57, p = 0.023).
This study shows that successful revascularization of LE-PAD patients affected by intermittent claudication, in addition to improving functional status, reduces the occurrence of future major cardiovascular events.

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Angioplasty of the pelvic and femoral arteries in PAOD: Results and review of the literature

Abstract

Purpose

Material and methods

Results

Conclusion

Introduction

Section snippets

Iliac artery recanalizations

Iliac arteries

Iliac arteries

Conclusion

Tech Vasc Interv Radiol

J Vasc Surg

Am J Med

J Vasc Surg

J Vasc Interv Radiol

J Vasc Interv Radiol

J Am Coll Cardiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Surg

J Vasc Surg

J Vasc Surg

Ann Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Interv Radiol

J Vasc Surg

J Vasc Surg

Intermittent claudication: incidence in the Framingham study

Circulation

Current state of endovascular treatment of femoro-popliteal artery disease

Vasc Med

An update on endovascular therapy of the lower extremities

J Endovasc Ther

Percutaneous vascular interventions in the superficial femoral artery. A review

Minerva Cardioangiol

Endovascular treatment of femoropopliteal obstructive disease

Minerva Cardioangiol

The TransAtlantic Inter-Society Consensus (TASC II) document on management of peripheral arterial disease

Eur J Vasc Endovasc Surg

Percutaneous interventional reconstruction of the iliac arteries: primary and long-term success rate in selected TASC C and D lesions

Eur Radiol

Percutaneous laser assisted recanalization of long chronic iliac artery occlusions: primary and mid-term results

Eur Radiol

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Am J Card