Steven G. Katz

Primary stenting of the superficial femoral and popliteal artery

OBJECTIVES Over the last decade, the number of endovascular procedures performed on the superficial femoral (SFA) and popliteal arteries (PA) has significantly increased. There is no consensus on the optimal form of intervention used in this arterial segment. While some have advocated balloon angioplasty alone, others have championed either selective or primary stenting of these lesions. It is the purpose of this study to determine the efficacy and durability of primary stenting of the superficial femoral and popliteal artery. METHODS All patients undergoing peripheral angioplasty by a single vascular surgeon were prospectively enrolled in an Institutional Review Board-approved, primary-stenting protocol. During a 44-month period, all patients undergoing percutaneous transluminal angioplasty of the SFA or PA also received primary arterial stenting with bare, self-expanding nitinol stents. Patient demographics and risk factors were identified. TransAtlantic InterSociety Consensus (TASC) classifications were determined for all lesions. Loss of primary patency was said to have occurred when an occlusion or a 50% or greater stenosis in any treated arterial segment was diagnosed by arterial duplex or angiography. Only time to loss of primary patency was recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log rank method. RESULTS Between January 16, 2004 and August 13, 2007, 201 angioplasties with primary stenting were performed on 161 patients. One hundred twenty-three stents were placed for claudication, and 78 for critical limb ischemia. Forty-six segments treated were TASC A, 82 were TASC B, 38 were TASC C, and 35 were TASC D. Patient follow-up ranged from three to 1329 days (mean: 426 days). Primary patency rates for TASC A and B lesions were 79%, 67%, and 57% at 12, 24, and 36 months. For TASC C and D lesions, primary patency rates were 52.7%, 36%, and 19% at the same time intervals. Primary patency rates for TASC A and B lesions were significantly higher than for C and D lesions (P < .001). The limb salvage rate was 88.5% in patients with critical limb ischemia. Distal runoff did not influence patency (P = .827). CONCLUSIONS Primary stenting of the SFA and PA provides durable results in patients with TASC A and B lesions and may be an effective treatment strategy. This approach is significantly less effective when used in treating those with TASC C and D disease. Based on the results in this series, the use of primary stenting does not extend the anatomic limits of the current treatment recommendations for catheter-based intervention in patients with infrainguinal occlusive disease.

Clinical Outcomes and Implications of Failed Infrainguinal Endovascular Stents

OBJECTIVE While the influence of initial TransAtlantic InterSociety Consensus (TASC) II classification has been clearly shown to influence the primary patency of infrainguinal stenting procedures, its effect on outcomes once stent failure has occurred is less well documented. It is the objective of this paper to determine whether clinical outcomes and implications of anatomic stent failure vary according to initial TASC II classification. METHODS Results were analyzed by TASC II classification. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. A Cox proportional hazards regression model was used to perform the multivariate analysis. RESULTS During a 5-year period, 239 angioplasties and stents were performed in 192 patients. Primary patency was lost in 69 stented arteries. Failure was due to one or more hemodynamically significant stenoses in 43 patients, and occlusion in 26 patients. After primary stenting, limbs initially classified as TASC C and D were more likely to fail with occlusion (P < .0001), require open operation (P = .032), or lose run-off vessels (P = .0034) than those classified as TASC A or B. In two patients initially classified as TASC C, stent failure changed the level of open operation to a more distal site. Percutaneous reintervention was performed on 35 limbs. Successful reintervention improved the patency of TASC A and B lesions to 92%, 85%, and 64% and TASC C and D lesions to 78%, 72%, and 50% at 12, 24, and 36 months, respectively. Initial TASC classification was highly predictive of first anatomic failure (P < .0001), but it did not predict the durability of subsequent catheter based reintervention (P = .32). Ten patients with stent failure required operation, and five underwent amputation; all had failed with occlusion. Overall limb salvage was 89% and peri-procedural mortality was 0.4%. CONCLUSIONS Following primary stenting of the superficial femoral artery (SFA) and popliteal artery, lesions classified as TASC C or D are more likely to fail with occlusion, lose run-off vessels, and alter the site of subsequent open operation than their TASC A and B counterparts. Although these complications are infrequent, they may negatively impact later attempts at revascularization, and this must be considered when deciding upon the proper treatment strategy for patients with infrainguinal occlusive disease.

Direct revascularization for the treatment of forearm and hand ischemia

During an 8-year period, 65 patients underwent operation for ischemia of the arm and hand. Fifty-four patients presented with an acutely ischemic extremity. Twenty-two had cardiac origin emboli, 9 had arterial-arterial emboli, 8 had traumatic occlusion of the brachial artery, and 15 patients developed arterial insufficiency after iatrogenic intervention. Twenty-one of 22 patients with cardiac emboli were successfully treated with embolectomy alone. The majority of patients with arterial-arterial emboli and traumatic or iatrogenic injuries required arterial reconstruction in addition to clot retrieval. After operation, 53 of 54 patients were asymptomatic. Eleven patients underwent operation for chronic ischemia. Seven patients had axillo-brachial saphenous vein grafts, two had carotid-subclavian bypass grafts, and two patients underwent aorto-innominate bypass. All grafts remained patent during follow-up that ranged from 6 months to 8 years. We conclude that operative therapy is very effective in preventing limb loss and functional impairment in patients with acute or chronic upper extremity ischemia.

Axillofemoral bypass for aortoiliac occlusive disease

BACKGROUND Although aortoiliac disease remains a common cause of lower extremity ischemia, the efficacy of axillofemoral bypass in this setting remains controversial. This report summarizes our institutional experience with axillofemoral bypass. METHODS A retrospective review of consecutive axillofemoral bypass grafts was performed at a single institution between 1984 and 1997. Only patients presenting with chronic aortoiliac occlusive disease were included. Patient demographics, risk factors, indications for surgery and outcomes were recorded. Survival curves for primary patency were plotted using the Kaplan-Meier method according to the standards set by the Society of Vascular Surgery-International Society for Cardiovascular Surgery. Comparisons between groups were made using the log rank method. Statistical significance was assumed at P values <0.05. RESULTS Sixty patients underwent axillofemoral bypass grafting of which 53 were bifemoral and 8 unifemoral. Forty-seven procedures were performed for limb salvage. Primary patency rates at 1, 3, and 5 years were 86%, 72%, and 63%, respectively. Thirty-day mortality rate was 4.9%. Sixty percent of graft occlusions occurred in the femorofemoral limb with continued patency of the axillofemoral limb. Risk factors, type of procedure and superficial femoral artery patency had no statistically significant effect on long-term patency. CONCLUSIONS In the setting of diffuse, chronic aortoiliac occlusive disease, long-term patency rates of axillofemoral grafts approach those of aortobifemoral bypass and exceed those quoted for percutaneous transluminal angioplasty, with results that are highly reproducible. Axillofemoral bypass is an excellent option in those patients at prohibitive risk for direct aortic reconstruction or those with limited life expectancy.

Endovascular Management of Central Thoracic Veno-Occlusive Diseases in Hemodialysis Patients: A Single Institutional Experience in 69 Consecutive Patients

PURPOSE To assess the functional status and long-term outcomes of endovascular management for the treatment of central veno-occlusive disease in patients undergoing hemodialysis. MATERIALS AND METHODS Retrospective chart evaluation of 600 patients with threatened upper extremity dialysis access showed central veno-occlusive disease in 69 patients (11%; 30 women and 39 men; mean age, 63.9 years; age range, 26-92 years). A total of 92 venous segments were involved with disease. Initial endovascular procedures consisted of transvenous angioplasty (n = 88) and stent placement (n = 6); there were 134 repeat interventions (14 stents). The mean follow-up was 14.5 months (range, 1-44 months). Angiographic data were reviewed prospectively by two independent observers for the extent of veno-occlusive disease. Technical failures were defined as residual stenosis of at least 30% or lesions that were unable to be dilated or crossed. Statistical analysis, including interobserver agreement and Kaplan-Meier analysis, was performed. RESULTS Technical success rates for initial and follow-up interventional procedures were 90% (81 of 92 segments) and 96% (129 of 134 interventions), respectively. Two complications required treatment with interventional procedures. There was excellent interobserver agreement (kappa = 0.84; 95% confidence interval: 0.67, 0.93) for grading the degree of venous stenoses. Primary patency rates of hemodialysis access at 1, 6, and 12 months were 81%, 46%, and 22%, respectively, which significantly (P = .001) improved to assisted patency rates of 91%, 77%, and 63% at 1, 6, and 12 months, respectively. CONCLUSIONS Endovascular management including a combination of angioplasty and selective stent placement can be effectively used to treat central veno-occlusive disease and preserve functional access in patients with threatened upper extremity dialysis access.

Bilateral Infrapopliteal Artery Aneurysms

The authors report the case of a 37-year-old man with bilateral posterior tibial artery aneurysms and concomitant collagen vascular disease. The patient initially presented with pain and swelling of the calves. The diagnosis was made by duplex scan and confirmed with arteriography. Diagnostic studies later verified the presence of a lupus-like syndrome. To date, 10 patients with aneurysms of the infrapopliteal arteries have been reported in the literature; four of these have had associated systemic diseases. These reports are reviewed; their clinical manifestations are discussed, and a treatment plan for these uncommon lesions is presented.

Selective use of the intensive care unit after nonaortic arterial surgery

PURPOSE The purpose of this study was to determine whether the institution of a clinical protocol combining 6 hours of recovery room observation and guidelines for intensive care unit (ICU) admission would allow selected patients to be safely transferred directly to a surgical floor after nonaortic arterial reconstruction. METHODS After a clinical pathway was formed, 134 consecutive patients undergoing 154 nonaortic arterial operations were prospectively enrolled in this study. Patients requiring ICU care and the responsible factors were identified. Comparisons of risk factors and demographics were made between those patients who did and did not require ICU care. RESULTS Twelve (7.8%) patients spent a total of 27 days in the ICU (range 1 to 11 days). As per our guidelines four patients were transferred to the ICU for invasive monitoring, and four were sent to the ICU because of refractory hemodynamic instability or arrhythmia in the postanesthetic recovery room. An additional four patients were transferred to the ICU after having been on the surgical floor for 24 to 72 hours because of the following perioperative complications: prolonged chest pain (one), pneumonia (one), heart failure (one), and graft occlusion requiring a urokinase infusion. Patients admitted to the ICU were more likely to have heart disease (p = 0.02) and to have had an operation other than carotid endarterectomy (p = 0.04) than those who were not. The 30-day mortality rate was 1.4%. CONCLUSIONS The implementation of a clinical protocol similar to the one used in this study will allow many patients undergoing nonaortic vascular surgery to avoid the use of the ICU. This approach will conserve hospital and financial resources without adversely affecting patient morbidity and mortality rates.

Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation

BACKGROUND Arterial steal syndrome after angioaccess surgery can lead to potentially devastating complications. Past treatments either ensured loss of the newly created access through ligation or attempted salvage by increasing resistance within the fistula. None of these proved to be entirely satisfactory. In 1994, we began to employ distal revascularization with interval ligation (DRIL) as our primary method of relieving hand ischemia after dialysis access creation. Described here is our experience with this procedure. METHODS After institutional review board approval, the charts of patients undergoing the DRIL procedure for relief of hand ischemia after dialysis access surgery were reviewed. Patient demographics, risk factors, types of fistulas, and indications for operation were recorded. The clinical results of DRIL surgery, as well as fistula and bypass graft patency, were noted. RESULTS Between May 1994 and August 2011, 81 DRIL procedures were performed on 77 patients ranging from 37 to 94 (mean, 65) years of age. Forty-four were female and 33 were male, with diabetes present in 83.3%. DRIL procedures were performed for ischemic symptoms after 37 autogenous brachiocephalic, 30 prosthetic bridge, and 14 autogenous brachiobasilic fistulas. Thirty-eight DRIL procedures were performed for ischemic rest pain (46.9%), 21 for digital ulceration (25.9%), 16 for neurological deficits (19.7%), and six for digital gangrene (7.4%). Complete symptom resolution was seen in 31 patients with ischemic rest pain (81.6%), 19 patients with digital ulcerations (90.5%), nine patients with neurological deficits (56.3%), and five patients with digital gangrene (83.3%). Fistula and brachial-brachial bypass survival 60 months after the DRIL procedure was 56% and 96.9%, respectively. The overall complication rate was 17.2%, and no patients died within 30 days of operation. CONCLUSIONS The DRIL procedure is a very effective treatment for symptomatic steal syndrome and is associated with low morbidity and mortality. It is extremely effective in the treatment of ischemic hand pain and tissue loss, but less so for neurological sequelae. It can allow for prolonged fistula utilization.

Does dextran 40 improve the early patency of autogenous infrainguinal bypass grafts

PURPOSE We determined whether the administration of dextran 40 would increase the early (30-day) patency of autogenous infrainguinal bypass grafts. METHODS During a 4-year period, 244 patients undergoing 273 autogenous infrainguinal bypass grafts were prospectively enrolled into and completed this study. Patients were randomized into two groups; one of the groups received a 72-hour infusion of dextran 40 after surgery, and the other did not. Comparisons were made between those patients who did and did not receive dextran 40 with respect to risks factors, demographics, and early graft patency. RESULTS One hundred twenty-six procedures were accompanied by the use of dextran; 147 were not. There was no significant difference between the two groups with respect to patient age, gender, perioperative risk factors, indication for surgery, or location of bypass graft (popliteal vs tibial). Among those patients receiving dextran, there were eight early occlusions (6.4%) and four deaths (3.2%); 89.7% of the patients were alive with patent grafts 30 days after surgery. In the group not receiving dextran, there were 10 early occlusions (6.8%) and 3 deaths (2%); 90.5% of the patients were alive with patent grafts 30 days after surgery. There was no significant difference between the two groups with respect to rate of early occlusion (p = 1.00), death (p = 0.71), or 30-day patency (p = 0.84). CONCLUSIONS The administration of dextran 40 does not increase the early patency of autogenous infrainguinal bypass grafts. Its routine use during these procedures cannot be recommended.

The number of patent tibial vessels does not influence primary patency after nitinol stenting of the femoral and popliteal arteries

OBJECTIVE Initial TransAtlantic Inter-Society consensus (TASC) II classification has been shown to influence the patency of stented femoral and popliteal arteries. Although several studies have shown the effect of the number of runoff vessels on the durability of infrainguinal angioplasty without stenting, the influence of tibial vessel runoff on the patency of primarily stented femoral and popliteal arteries has not been as well defined. The purpose of this study was to determine whether the number of patent tibial vessels affects primary patency after primary stenting of the femoral and popliteal arteries. METHODS The records of all patients undergoing angioplasty and primary nitinol stenting of the femoral and popliteal arteries, by or under the supervision of one vascular surgeon, were reviewed. Results were analyzed by both the number of patent tibial vessels documented on periprocedural angiography and by using a modified Society for Vascular Surgery runoff score. TASC II classification was also recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. Fisher exact and χ(2) tests were used to compare categoric factors. RESULTS During a 7-year period, 289 limbs in 236 patients underwent primary stenting of the femoral and popliteal arteries. Overall primary patency was 70.3% at 12 months, 52.4% at 24 months, and 39.1% at 36 months. Limbs classified as TASC A or B had significantly better patency rates than those classified as TASC C or D (P < .001). While the number of runoff vessels decreased with worsening of the TASC classification (P = .024), overall (P = .355), and within individual TASC classes (P ≥ .092 for each), there was no difference in the primary patency of stented segments with good runoff and those with compromised runoff. Limbs with poor runoff (one or no vessels) were no more likely to fail with occlusion than their counterparts with two or three patent tibial vessels (P = .383). The number of patent tibial vessels at the time of initial stenting did not impact ultimate limb salvage (P = .063). CONCLUSIONS The number of patent tibial vessels does not influence the primary patency of primarily stented femoral and popliteal arteries. TASC II classification appears to be significantly more predictive of initial failure after angioplasty and stenting of these vessels.