Larry J. Diaz-Sandoval

Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis.

Background and Purpose— We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods— We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results— Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. Conclusions— This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.

Tibio‐pedal arterial minimally invasive retrograde revascularization in patients with advanced peripheral vascular disease: The TAMI technique, original case series

A tibial‐pedal access method is needed for patients with advanced peripheral artery disease (PAD) unable to tolerate common femoral artery (CFA) access and intervention due to body habitus or comorbidities. This is the first case series reporting an alternative technique to revascularize such patients. Using ultrasound (US) and the tibio‐pedal arterial minimally invasive retrograde revascularization (TAMI) technique, operators accessed, and revascularized the lower extremity completely via tibial‐pedal arterial access.

Percutaneous Transluminal Angioplasty in Patients With Infrapopliteal Arterial Disease: Systematic Review and Meta-Analysis

Background—Contemporary outcomes of percutaneous transluminal angioplasty for the treatment of infrapopliteal atherosclerotic lesions are not well characterized. Hence, a systematic review and meta-analysis was performed to determine the safety and effectiveness of this approach in patients with advanced below-the-knee arterial disease. Methods and Results—MEDLINE and EMBASE databases were searched for contemporary studies (2005–2015) on the effects of percutaneous transluminal angioplasty for the treatment of infrapopliteal lesions. A random effects meta-analysis model was used to analyze procedural (technical success, flow-limiting dissection, provisional stent placement) and long-term (primary patency, repeat revascularization, major amputation, all-cause mortality) outcomes. Ultimately, 52 studies encompassing 6769 patients with 9399 below-the-knee lesions were included in the analysis. Technical success was 91.1% (95% confidence interval [CI], 88.8–93.0), and the incidence of flow-limiting dissections and bailout stenting was 5.6% (95% CI, 3.2–9.8) and 9.1% (95% CI, 6.3–12.9), respectively. Outcomes at 1 year were primary patency, 63.1% (95% CI, 57.3–68.6); repeat revascularization, 18.2% (95% CI, 14.5–22.6); major amputation, 14.9% (95% CI, 12.3–18.0); and all-cause mortality, 15.1% (95% CI, 12.8–17.7). Significant heterogeneity and publication bias were observed for most percutaneous transluminal angioplasty outcomes. Conclusions—Contemporary studies of the use of percutaneous transluminal angioplasty as primary treatment for patients with infrapopliteal arterial disease reveal suboptimal procedural and 1-year clinical outcomes.

Feasibility and 1‐Year outcomes of subintimal revascularization with supera® stenting of long femoropopliteal occlusions in critical limb ischemia

Stent‐based revascularization of long femoro‐popliteal (FP) lesions has been mainly studied in claudicants and compromised by restenosis and stent fractures. The Supera® stents biomimetic design allows enhanced fracture resistance. Data for Supera® stenting to treat long chronic total occlusions (CTOs) in patients with critical limb ischemia (CLI), are scarce.

Automated Carbon Dioxide Angiography for the Evaluation and Endovascular Treatment of Diabetic Patients With Critical Limb Ischemia

Purpose: To test the safety, efficacy, and diagnostic accuracy of automated carbon dioxide (CO2) angiography (ACDA) for the evaluation of diabetic patients with critical limb ischemia (CLI) and baseline renal insufficiency and compare ACDA with iodinated contrast medium (ICM) during endovascular treatment. Methods: From November 2014 to January 2015, 36 consecutive diabetic patients (mean age 74.8±5.8 years; 27 men) with stage ≥3 chronic kidney disease (CKD ≥3) and CLI underwent lower limb angiography with both CO2 and ICM followed by balloon angioplasty in a prospective single-center study. The primary outcome measure was the safety and efficacy of ACDA as the exclusive agent to guide angioplasty in this cohort. The secondary outcomes were the safety and diagnostic accuracy of ACDA injection as compared with ICM digital subtraction angiography (DSA) for invasive evaluation of these patients. Results: ACDA safely and effectively guided angioplasty in all patients without complications. Transcutaneous oxygen pressure improved from 11.8±6.3 to 58.4±7.6 mm Hg (p<0.001). There were no complications related to ACDA during diagnostic imaging and no significant changes in the estimated glomerular filtration rate from baseline to 24 hours (44.7±13.3 vs 47.0±0.8 mL/min/1.73 m2; nonsignificant). The diagnostic accuracy of CO2 was 89.8% (sensitivity 92.3%; specificity 75%; positive predictive value 95.5%; negative predictive value 63.1%). There was no statistically significant difference in the qualitative diagnostic accuracy between the media (p=0.197). Conclusion: ACDA is an accurate, safe, and effective technique that can be utilized to guide endovascular interventions in diabetics with CLI and baseline CKD ≥3. Larger multicenter randomized studies are needed to validate these results.

SCAI appropriate use criteria for peripheral arterial interventions: An update

Andrew J. Klein, MD, FSCAI1 | Michael R. Jaff, DO, FSCAI2 | Bruce H. Gray, DO, FSCAI3 | Herbert D. Aronow, MD, MPH, FSCAI4 | Robert M. Bersin, MD, MPH, FSCAI5 | Larry J. Diaz-Sandoval, MD, FSCAI6 | Robert S. Dieter, MD, RVT, FSCAI7 | Douglas E. Drachman, MD, FSCAI8 | Dmitriy N. Feldman, MD, FSCAI9 | Osvaldo S. Gigliotti, MD, FSCAI10 | Kamal Gupta, MD, FSCAI11 | Sahil A. Parikh, MD, FSCAI12 | Duane S. Pinto, MD, MPH, FSCAI13 | Mehdi H. Shishehbor, DO, MPH, PhD, FSCAI14 | Christopher J. White, MD, MSCAI15

Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification:

Purpose: To present the chronic total occlusion (CTO) crossing approach based on plaque cap morphology (CTOP) classification system and assess its ability to predict successful lesion crossing. Methods: A retrospective analysis was conducted of imaging and procedure data from 114 consecutive symptomatic patients (mean age 69±11 years; 84 men) with claudication (Rutherford category 3) or critical limb ischemia (Rutherford category 4–6) who underwent endovascular interventions for 142 CTOs. CTO cap morphology was determined from a review of angiography and duplex ultrasonography and classified into 4 types (I, II, III, or IV) based on the concave or convex shape of the proximal and distal caps. Results: Statistically significant differences among groups were found in patients with rest pain, lesion length, and severe calcification. CTOP type II CTOs were most common and type III lesions the least common. Type I CTOs were most likely to be crossed antegrade and had a lower incidence of severe calcification. Type IV lesions were more likely to be crossed retrograde from a tibiopedal approach. CTOP type IV was least likely to be crossed in an antegrade fashion. Access conversion, or need for an alternate access, was commonly seen in types II, III, and IV lesions. Distinctive predictors of access conversion were CTO types II and III, lesion length, and severe calcification. Conclusion: CTOP type I lesions were easiest to cross in antegrade fashion and type IV the most difficult. Lesion length >10 cm, severe calcification, and CTO types II, III, and IV benefited from the addition of retrograde tibiopedal access.

Innovations in the Endovascular Management of Critical Limb Ischemia: Retrograde Tibiopedal Access and Advanced Percutaneous Techniques

Purpose of ReviewRetrograde tibiopedal access and interventions have contributed to advance of endovascular techniques to treat critical limb ischemia (CLI) patients. This review encompasses the spectrum from advanced diagnostic imaging and technical therapeutic approaches for infrapopliteal occlusions, to a discussion of current standards and future directions.Recent FindingsContemporary studies of infrapopliteal angioplasty show suboptimal short-term and 1-year clinical outcomes. Comparative data is needed to shift the focus from PTA to disruptive treatment modalities that can further improve outcomes. Retrograde pedal access has emerged as an important tool to facilitate successfully percutaneous revascularization and limb salvage in patients with CLI.SummaryTo efficiently approach the complexity of CLI, new thought processes are needed to change the reigning paradigms. Retrograde tibial-pedal access has shown improvement in the rate of successful revascularizations and is an important tool in the amputation-prevention armamentarium. Additional technologies may further improve success rates. Drug-eluting stents have shown better outcomes than PTA in patients with focal infrapopliteal lesions. Registry data have demonstrated the advantage of several atherectomy devices in the tibial arteries. More recently, bioresorbable vascular scaffolds have been used successfully, and further studies with drug-coated balloons are underway. Interventional operators are now even working in the inframalleolar space to reconstitute the plantar arch. Well-conducted studies are needed to generate high-quality evidence in the field of critical limb ischemia management.

Precise Retrograde Supera Stenting of the Ostium (PRESTO) of the Superficial Femoral Artery for Complex Femoropopliteal Occlusions: The PRESTO Technique:

Purpose: To describe a novel technique designed to safely and precisely deploy the Supera stent accurately at the ostium of the proximal superficial femoral artery (SFA) without compromising the profunda and common femoral arteries. Technique: After antegrade crossing of the chronic total occlusion (CTO) at the SFA ostium and accurate predilation of the entire SFA lesion, a retrograde arterial access is obtained. The Supera stent is navigated in retrograde fashion to position the first crown to be released just at the SFA ostium. Antegrade dilation is performed across the retrograde access site to obtain adequate hemostasis. The technique has been applied successfully in 21 patients (mean age 78.1±8.2 years; 13 men) with critical limb ischemia using retrograde Supera stenting from the proximal anterior tibial artery (n=6), the posterior tibial artery (n=2), retrograde stent puncture in the mid to distal SFA (n=2), the native distal SFA/proximal popliteal segment (n=6), and the distal anterior tibial artery (n=5). No complications were observed. Conclusion: Distal retrograde Supera stent passage and reverse deployment allow precise and safe Supera stenting at the SFA ostium.

The Long-Term Care of Patients with Critical Limb Ischemia (CLI)

Critical limb ischemia (CLI) is the end stage of peripheral artery disease (PAD). It encompasses <5 % of all cases of PAD, but its prognosis is poor. The 1-year mortality and major amputation rates range from 20 to 50 %. The treatment of the patient with CLI is complex. Its foundation is based on the development of three pillars, each of which represents diverse aspects and goals of therapy: medical, interventional, and surveillance. Medical management has a role in the treatment of risk factors for secondary prevention of cardiovascular disease, with a less established role in the treatment of symptoms and complications of severe limb hypoperfusion. Pharmacological agents may also have a role as adjuncts or alternatives in patients who are unsuitable for revascularization or those who have suboptimal results. Interventional therapies (surgical and endovascular) are the mainstay form of treatment in CLI and are directed to achieve revascularization, symptom control, wound healing, and limb salvage. Last but not least, the surveillance pillar of treatment is the one that is currently least well represented and represents the Achilles heel of contemporary CLI care, as most patients do not have a rigorous follow-up. It is intended to provide close follow-up and monitoring after revascularization and healing. At the first sign of decline or evidence of stalled progress, the patient should once again be promptly referred to the CLI team and the continuum of care reinitiated. Future directions include the development of biological therapies based on the use of growth factors, gene therapy, and stem cells, which are currently being investigated.