Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes
- Fri, 9/5/08 - 3:36pm
- 0 Comments
- 6773 reads
Introduction
The number of percutaneous revascularization procedures performed for symptomatic peripheral arterial disease (PAD) has significantly increased over the past several years.1 Traditionally, the use of percutaneous techniques were limited to certain anatomic subsets, such as stenosis or focal occlusions, with surgical treatment preferred for more extensive disease.2 More recently, endovascular specialists are facing the challenges of treating commonly- encountered peripheral chronic total occlusions (CTOs). Furthermore, unlike the coronary circulation, these occlusions are often long and associated with other features of complexity. The two primary issues concerning these lesions are the ability to safely achieve initial angiographic success and the longterm durability of therapy. This article will focus on the current status of treating lower extremity peripheral CTOs and expected clinical outcomes.
Distribution of Occlusive Disease
The distribution of PAD, including CTOs, varies with multiple factors, such as age and the presence of cardiovascular risk factors. Aortoiliac disease is associated with young age, females, and current smokers.3,4 Femoropopliteal involvement in occlusive PAD is extremely common and, in one series, was present in 80% of symptomatic patients undergoing angiography.3 The predilection of disease in this segment may be due to its conduit-like nature, with no or few major branches, and torsion or stretching resulting from limb movement. These characteristics may cause relatively more damage of the vaso vasorum and endothelium than other limb segments, leading to accelerated atherosclerosis.5 Additionally, the flow characteristics following the development of a stenosis may promote long occlusions. Infrapopliteal disease is associated with diabetes mellitus, and diffuse and occlusive disease is common. Despite the complex nature of infrapopliteal disease, endovascular techniques have acceptable limb salvage rates.6–8 This approach, therefore, may be increasingly used for CTOs in patients with limited surgical options, due to comorbidities or lack of bypass conduits or target vessels. Overall, CTOs are more the norm than the exception in PAD. The decision to attempt percutaneous revascularization of CTOs depends on many factors, such as severity of symptoms, and lesion characteristics, including location, calcification and length, and operator experience and institutional availability of the specialized devices discussed.
Diagnostic Considerations Prior to Intervention
The treatment of CTOs involves a fundamental understanding of the management of PAD in general. The level of occlusive disease can often be determined based on history and physical examination, including an ankle brachial index. Segmental limb pressures and duplex ultrasound are also routinely used as initial diagnostic modalities to determine the level and extent of PAD. Imaging studies, either CT or MR angiography, should be considered in patients that are candidates for revascularization. Although angiography remains the gold standard for diagnosis and allows for both anatomic and hemodynamic assessment of PAD, noninvasive imaging prior toangiography is useful in many respects. For patients with renal insufficiency, the risks of noninvasive imaging must be weighed against the potential information gained. Contrast nephropathy from CT angiography, similar to invasive angiography, can be minimized with appropriate prophylactic measures, such as intravenous hydration, sodium bicarbonate infusion, and N-acetylcycteine.
References
1. National Center for Health Statistics, National Hospital Discharge Survey, http://www.cdc.gov/nchs/about/major/hdasd/nhds.htm.
2. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg 2000;31:S1–S296.
3. Smith FB, Lee AJ, Fowkes FG, et al. Variation in cardiovascular risk factors by angiographic site of lower limb atherosclerosis. Eur J Vasc Endovasc Surg 1996;11:340–346.
4. Barretto S, Ballman KV, Rooke TW, Kullo IJ. Early-onset peripheral arterial occlusive disease: Clinical features and determinants of disease severity and location. Vasc Med 2003;8:95–100.
5. Scotland RS, Vallance PJ, Ahluwalia A. Endogenous factors involved in regulation of tone of arterial vasa vasorum: Implications for conduit vessel physiology. Cardiovasc Res 2000;46:403–411.
6. Bull PG, Mendel H, Hold M, et al. Distal popliteal and tibioperoneal transluminal angioplasty: Long-term follow-up. J Vasc Interven Radiol 1992;3:45–53.
7. Dorros G, Jaff MR, Dorros AM, et al. Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: Five-year follow-up. Circulation 2001;104:2057–2062.
8. Soder HK, Manninen HI, Jaakkola P, et al. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia. J Vasc Interven Radiol 2000;11:1021–1031.
9. Perazella MA, Rodby RA. Nephrogenic systemic fibrosis: A devastating complication of gadolinium in patients with severe renal impairment. Vascular Disease Management 2007;4:45–47.
10. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease) — summary of recommendations. J Vasc Interven Radiol 2006;17:1383–1397.
11. Cutress ML, Blanshard K, Shaw M, et al. Retrograde subintimal angioplasty via a popliteal artery approach. Eur J Vasc Endovasc Surg 2002;23:275–276.
12. Saha S, Gibson M, Magee TR, et al. Early results of retrograde transpopliteal angioplasty of iliofemoral lesions. Cardiovasc Interven Radiol 2001;24:378–382.
13. Spinosa DJ, Leung DA, Harthun NL, et al. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. J Vasc Interven Radiol 2003;14:1449–1454.
14. Spinosa DJ, Harthun NL, Bissonette EA, et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interven Radiol 2005;16:37–44.
15. Yilmaz S, Sindel T, Luleci E. Bilateral transpopliteal approach for treatment of complex SFA and iliac occlusions. Eur Radiol 2002;12:911–914.
16. Nadal LL, Cynamon J, Lipsitz EC, Bolia A. Subintimal angioplasty for chronic arterial occlusions. Tech Vasc Interven Radiol 2004;7:16–22.
17. Bosch JL, Hunink MG. Meta-analysis of the results of percutaneous transluminal angioplasty and stent placement for aortoiliac occlusive disease. Radiology 1997;204:87–96.
18. Casserly IP, Sachar R, Bajzer C, Yadav JS. Utility of IVUS-guided transaccess catheter in the treatment of long chronic total occlusion of the superficial femoral artery. Catheter Cardiovasc Interven 2004;62:237–243.
19. Saketkhoo RR, Razavi MK, Padidar A, et al. Percutaneous bypass: Subintimal recanalization of peripheral occlusive disease with IVUS guided luminal re-entry. Tech Vasc Interven Radiol 2004;7:23–27.
20. Hausegger KA, Georgieva B, Portugaller H, et al. The outback catheter: A new device for true lumen re-entry after dissection during recanalization of arterial occlusions. Cardiovasc Interven Radiol 2004;27:26–30.
21. Riddick J, Cates C, Niazi K, Cates C. True lumen re-entry catheter availability improves procedural success in endovascular intervention of peripheral total occlusions. J Am Coll Cardiol 2007;49:29B.
22. Jacobs DL, Motaganahalli RL, Cox DE, et al. True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: Initial report. J Vasc Surg 2006;43:1291–1296.
23. Mossop P, Cincotta M, Whitbourn R. First case reports of controlled blunt microdissection for percutaneous transluminal angioplasty ofchronic total occlusions in peripheral arteries. Catheter Cardiovasc Interven 2003;59:255–258.
24. Kirvaitis RJ, Heuser RR, Das TS, et al. Usefulness of optical coherent reflectometry with guided radiofrequency energy to treat chronic total occlusions in peripheral arteries (the GRIP trial). Am J Cardiol 2004;94:1081–1084.
25. Kirvaitis R, Parr L, Kelly L, et al. Recanalization of chronic total peripheral arterial occlusions using optical coherent reflectometry with guided radiofrequency energy: A single center experience. Catheter Cardiovasc Interven 2007;69:532–540.
26. Topaz O, Minisi AJ, Bernardo NL, et al. Alterations of platelet aggregation kinetics with ultraviolet laser emission: The “stunned platelet” phenomenon. Thromb Haemostasis 2001;86:1087–1093.
27. Boccalandro F, Muench A, Sdringola S, Rosales OR. Wireless laserassisted angioplasty of the superficial femoral artery in patients with critical limb ischemia who have failed conventional percutaneous revascularization. Catheter Cardiovasc Interven 2004;63:7–12.
28. Scheinert D, Laird JR, Jr., Schroder M, et al. Excimer laser-assisted recanalization of long, chronic superficial femoral artery occlusions. J Endovasc Ther 2001;8:156–166.
29. Laird JR, Zeller T, Gray BH, et al. Limb salvage following laser-assisted angioplasty for critical limb ischemia: Results of the LACI multicenter trial. J Endovasc Ther 2006;13:1–11.
30. Martin M, Schoop W, Zeitler E. Streptokinase in chronic arterial occlusive disease. JAMA 1970;211:1169–1173.
31. Poliwoda H, Alexander K, Buhl V, et al. Treatment of chronic arterial occlusions with streptokinase. N Engl J Med 1969;280:689–692.
32. Wholey MH, Maynar MA, Pulido-Duque JM, et al. Comparison of thrombolytic therapy of lower-extremity acute, subacute, and chronic arterial occlusions. Catheter Cardiovasc Diag 1998;44:159–169.
33. Motarjeme A, Gordon GI, Bodenhagen K. Thrombolysis and angioplasty of chronic iliac artery occlusions. JVIR 1995;6:668–728.
34. Motarjeme A, Gordon GI, Bodenhagen K. Limb salvage: Thrombolysoangioplasty as an alternative to amputation. Int Angiology 1993;12:281–290.
35. Grube E, Sutsch G, Lim VY, et al. High-frequency mechanical vibration to recanalize chronic total occlusions after failure to cross with conventional guidewires. J Invasive Cardiol 2006;18:85–91.
36. Conrad MF, Cambria RP, Stone DH, et al. Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: A contemporary series. J Vasc Surg 2006;44:762–769.
37. Jeans WD, Armstrong S, Cole SE, et al. Fate of patients undergoing transluminal angioplasty for lower-limb ischemia. Radiology 1990;177:559–564.
38. Capek P, McLean GK, Berkowitz HD. Femoropopliteal angioplasty. Factors influencing long-term success. Circulation 1991;83(suppl 2):I70–I80.
39. Scheinert D, Scheinert S, Sax J, et al. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol 2005;45:312–315.
40. Scheinert D, Schroder M, Ludwig J, et al. Stent-supported recanalization of chronic iliac artery occlusions. Am J Med 2001;110:708–715.
41. Duda SH, Pusich B, Richter G, et al. Sirolimus-eluting stents for the treatment of obstructive superficial femoral artery disease: Six-month results. Circulation 2002;106:1505–1509.
42. Duda SH, Bosiers M, Lammer J, et al. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: The SIROCCO II trial. JVIR 2005;16:331–338.
43. Duda SH, Bosiers M, Lammer J, et al. Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the superficial femoral artery: Long-term results from the SIROCCO trial. J Endovasc Ther 2006;13:701–710.
44. Duda SH, Bosiers M, Pusich B, et al. Endovascular treatment of peripheral artery disease with expanded PTFE-covered nitinol stents: Interim analysis from a prospective controlled study. Cardiovasc Interven Radiol 2002;25:413–418.
45. Ramaiah V, Gammon R, Kiesz S, et al. Midterm outcomes from the TALON Registry: Treating peripherals with SilverHawk: Outcomes collection. J Endovasc Ther 2006;13:592–602.
46. Laird J, Jaff MR, Biamino G, et al. Cryoplasty for the treatment of femoropopliteal arterial disease: Results of a prospective, multicenter registry. JVIR 2005;16:1067–1073.
47. Laird JR, Biamino G, McNamara T, et al. Cryoplasty for the treatment of femoropopliteal arterial disease: Extended follow-up results. J Endovasc Ther 2006;13:II52–9.
Post new comment