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Advances in Peripheral Revascularization

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Vascular Medicine".

Deadline for manuscript submissions: closed (25 January 2023) | Viewed by 23863

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Special Issue Editor

Prof. Dr. Christine Espinola-Klein

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Guest Editor

Department of Angiology, Center of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
Interests: peripheral arterial disease; venous thromboembolism; antithrombotic medication; atherosclerosis; secondary prevention

Special Issue Information

Dear colleagues,

Peripheral arterial disease (PAD) is one of the leading causes for major amputations. In particular, patients with critical limb ischemia are at increased risk for both major adverse limb events and major adverse cardiovascular events. Therefore, peripheral revascularisation is very important to improve the prognosis of PAD patients. There are two principal options: endovascular or surgical revascularisation. After successful revascularisation, secondary prevention including anti-thrombotic therapy and regular follow-up are needed to maintain vessel patency.

This issue will give an overview on the current treatment option for aorto-iliac, femoro-popliteal and below the knee revascularisation. In addition, it will summarise state of the art for post-procedure management, including medical therapy, on a combination of original research and review papers.

Topics will include

Impact of revascularisation on prognosis
Management of chronic critical limb ischemia
Management of acute limb ischemia
Aorto-iliac revascularisation: endovascular and surgical
Femoro-popliteal revascularisation: endovascular and surgical
Below the knee revascularisation: endovascular and surgical
Follow-up after peripheral revascularisation
Anti-thrombotic management after peripheral revascularisation

Prof. Dr. Christine Espinola-Klein
Guest Editor

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Keywords

peripheral arterial disease
endovascular revascularization
bypass-surgery
anti-thrombotic therapy after revascularization
aorto-iliac revascularization
femoro-popliteal revascularization
below the knee revascularization

Published Papers (14 papers)

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Research

18 pages, 3381 KiB

Open AccessArticle

Patients with Acute Limb Ischemia Might Benefit from Endovascular Therapy—A 17-Year Retrospective Single-Center Series of 985 Patients

by Kerstin Stoklasa, Sabine Sieber, Shamsun Naher, Bianca Bohmann, Andreas Kuehnl, Thomas Stadlbauer, Heiko Wendorff, Gabor Biro, Michael A. Kallmayer, Christoph Knappich, Albert Busch and Hans-Henning Eckstein

J. Clin. Med. 2023, 12(17), 5462; https://doi.org/10.3390/jcm12175462 - 23 Aug 2023

Viewed by 794

Abstract

Acute lower limb ischemia (ALI) is a common vascular emergency, requiring urgent revascularization by open or endovascular means. The aim of this retrospective study was to evaluate patient demographics, treatment and periprocedural variables affecting the outcome in ALI patients in a consecutive cohort in a tertiary referral center. Primary outcome events (POE) were 30-day (safety) and 180-day (efficacy) combined mortality and major amputation rates, respectively. Secondary outcomes were perioperative medical and surgical leg-related complications and the 5-year combined mortality and major amputation rate. Statistical analysis used descriptive and uni- and multivariable Cox regression analysis. In 985 patients (71 ± 9 years, 56% men) from 2004 to 2020, the 30-day and 180-day combined mortality and major amputation rates were 15% and 27%. Upon multivariable analysis, older age (30 d: aHR 1.17; 180 d: 1.27) and advanced Rutherford ischemia stage significantly worsened the safety and efficacy POE (30 d: TASC IIa aHR 3.29, TASC IIb aHR 3.93, TASC III aHR 7.79; 180 d: TASC IIa aHR 1.97, TASC IIb aHR 2.43, TASC III aHR 4.2), while endovascular treatment was associated with significant improved POE after 30 days (aHR 0.35) and 180 days (aHR 0.39), respectively. Looking at five consecutive patient quintiles, a significant increase in endovascular procedures especially in the last quintile could be observed (17.5% to 39.5%, p < 0.001). Simultaneously, the re-occlusion rate as well as the number of patients with any previous revascularization increased. In conclusion, despite a slightly increasing early re-occlusion rate, endovascular treatment might, if possible, be favorable in ALI treatment. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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14 pages, 2639 KiB

Open AccessArticle

Long-Term Results of Femorodistal Sequential Composite-Bypass Combining Heparin-Bonded PTFE-Prosthesis and Autologous Vein Using the Deutsch Bridge Technique in Critical Limb-Threatening Ischemia

by Achim Neufang, Valerian Zhghenti, Carolina Vargas-Gomez, Thomas Umscheid, Peter von Flotow, Rainer Schmiedel and Savvas Savvidis

J. Clin. Med. 2023, 12(8), 2895; https://doi.org/10.3390/jcm12082895 - 16 Apr 2023

Viewed by 1089

Abstract

Background: Autologous vein bypass provides excellent long-term results in critical limb-threatening ischemia (CLTI), but a substantial portion of patients have insufficient vein length. In limbs with two distal outflow vessels and limited vein length, a vascular prosthesis may be combined with autologous vein for a sequential composite bridge bypass (SCBB). Results regarding graft function, limb salvage and reinterventions are presented. Methods: Between January 2010 and December 2019, 47 consecutive SCBB operations with a heparin-bonded PTFE-prosthesis and autologous vein were performed. Grafts were followed with a duplex scan with prospective documentation in a computerized vascular database. Retrospective analysis of graft patency, limb salvage and patient survival was performed. Results: Mean follow-up was 34 months (range 1–127 months). 30-day mortality was 10.6% and 5-year patient survival 32%. Postoperative bypass occlusion occurred in 6.4% and late occlusions or graft stenoses in 30%. Two prostheses developed late infection and seven legs were amputated. Primary, primary assisted, secondary patency and limb salvage rate were 54%, 63%, 66% and 85% after 5 years, respectively. Conclusions: SCBB patency and limb salvage were good despite a high early postoperative mortality. Combination of a heparin-bonded PTFE-prosthesis and autologous vein appears to be a valuable tool in CLTI in case of insufficient vein. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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11 pages, 2338 KiB

Open AccessArticle

Ankle Doppler for Cuffless Ankle Brachial Index Estimation and Peripheral Artery Disease Diagnosis Independent of Diabetes

by Alexander D. Rodway, Darren Cheal, Charlotte Allan, Felipe Pazos-Casal, Lydia Hanna, Benjamin C. T. Field, Ajay Pankhania, Philip J. Aston, Simon S. Skene, Gary D. Maytham and Christian Heiss

J. Clin. Med. 2023, 12(1), 97; https://doi.org/10.3390/jcm12010097 - 22 Dec 2022

Cited by 4 | Viewed by 1743

Abstract

Ankle brachial pressure index (ABPI) is the first-line test to diagnose peripheral artery disease (PAD). Its adoption in clinical practice is poor and its validity, particularly in diabetes, is limited. We hypothesised that ABPI can be accurately and precisely estimated based on cuffless Doppler waveforms. Retrospective analysis of standard ABPI and handheld Doppler waveform characteristics (n = 200). Prospective analysis of angle-corrected Doppler acceleration index (AccI, n = 148) and standard ABPI with testing of performance to diagnose PAD as assessed with imaging reference standards in consecutive patients. The highest AccI from handheld Doppler at ankle arteries was significantly logarithmically associated with the highest standard ABPI (E[y] = 0.32 ln [1.71 ∗ x + 1], p < 0.001, R² = 0.68, n = 100 limbs). Estimated ABPI (eABPI) based on AccI closely resembled ABPI (r = 0.81, p < 0.001, average deviation −0.01 ± 0.13 [SD], n = 100 limbs). AccI from angle-corrected Doppler in patients without overt media sclerosis (ABPI ≤ 1.1) improved ABPI prediction (E[y] = 0.297 ∗ ln[0.039 ∗ x + 1], R² = 0.92, p = 0.006, average deviation 0.00 ± 0.08, n = 100). In a population (n = 148 limbs) including diabetes (56%), chronic limb-threatening ischaemia (51%) and media sclerosis (32%), receiver operating characteristics analysis of (angle-corrected) eABPI performed significantly better than standard ABPI to diagnose PAD defined by ultrasound (ROC AUC = 0.99 ± 0.01, p < 0.001; sensitivity: 97%, specificity: 96%) at the ≤0.9 cut-off. This was confirmed with CT angiography (ROC AUC = 0.98, p < 0.001, sensitivity: 97%, specificity: 100%) and was independent of the presence of diabetes (p = 0.608). ABPI can be estimated based on ankle Doppler AccI without compression, and eABPI performs better than standard ABPI to diagnose PAD independent of diabetes. eABPI has the potential to be included as a standard component of lower extremity ultrasound. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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12 pages, 4082 KiB

Open AccessArticle

Percutaneous Transluminal Renal Angioplasty for Fibromuscular Dysplasia and Prognostic Risk Factors: A Retrospective Chinese Cohort Study

by Yi-Ting Lu, Ze-Ming Zhou, Di Zhang, Lin Sun, Xin-Chang Liu, Yan-Kun Yang, Xiong-Jing Jiang and Xian-Liang Zhou

J. Clin. Med. 2023, 12(1), 23; https://doi.org/10.3390/jcm12010023 - 20 Dec 2022

Cited by 1 | Viewed by 1548

Abstract

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disease involving small-to-medium-sized arteries. The characteristics of Chinese patients with FMD remain unclear. We retrospectively analyzed the data of patients with renal FMD who underwent percutaneous transluminal renal angioplasty (PTRA) for the first time at Fuwai Hospital between 2010 and 2021. The variables were selected through least absolute shrinkage and selection operator regression (LASSO), and logistic regression models were constructed to identify independent risk factors. A total of 116 patients (52 males, median age at diagnosis, 25.0 years) were enrolled. Elevated blood pressure was the leading complaint. After a median follow-up period of 18.0 months (interquartile range: 6.0–48.0 months), hypertension recurred in 34 patients and restenosis in nine patients, among whom four patients underwent secondary intervention and one patient underwent surgical revascularization. Bilateral renal artery involvement (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.11–6.15; p = 0.028) and age at hypertension onset (OR: 0.93, 95% CI: 0.88–0.99; p = 0.018) were independent prognostic factors for adverse outcomes. The results indicate that patients with bilateral renal artery involvement and younger age at hypertension onset are more likely to have poorer clinical outcomes after PTRA, and should be more closely monitored. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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14 pages, 889 KiB

Open AccessArticle

Secondary Prevention in Lower Extremity Artery Disease Patients: Lipid-Lowering Therapy and Long-Term Guideline Adherence

by Linda Mueller, Christiane Engelbertz, Holger Reinecke, Eva Freisinger, Nasser M. Malyar, Matthias Meyborg, Tobias J. Brix, Julian Varghese and Katrin Gebauer

J. Clin. Med. 2022, 11(22), 6838; https://doi.org/10.3390/jcm11226838 - 19 Nov 2022

Cited by 2 | Viewed by 1637

Abstract

Lower extremity artery disease (LEAD) affects millions of elderly patients and is associated with elevated cardiovascular morbidity and mortality. Risk factor modification, including the therapy of dyslipidaemia, is mandatory to reduce cardiovascular event rates and to improve survival rates. However, only a minority achieve the recommended low-density lipoprotein cholesterol (LDL-C) target level < 55 mg/dL, according to the current ESC/EAS guidelines on the treatment of dyslipidaemia. This study elucidated the implementation of the lipid-lowering guideline recommendations of 400 LEAD patients with LDL-C > 100 mg/dL and their adherence to treatment adjustment during follow-up. Despite a sustained statin prescription in 93% of the patients, including 77% with high-intensity statins at follow-up, only 18% achieved the target level. Ezetimibe appeared in 21% and LDL-C goals were reached significantly more often with combination therapy. Recurrent revascularization appeared more often (28%) than coronary artery or cerebrovascular disease progression (14%) and 7% died. Despite the frequent use of high-intensity statins and expandable rates of ezetimibe, the progression of cardiovascular events remained inevitable. Only 18% of the patients had received recommendations on lifestyle modification, including dietary adaptations, which is key for a holistic approach to risk factor control. Thus, efforts for both pharmacological and behavioral strategies are needed to improve clinical outcomes and survival rates. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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13 pages, 1364 KiB

Open AccessArticle

Temporal Trends in Patients with Peripheral Artery Disease Influenced by COVID-19 Pandemic

by Karsten Keller, Volker H. Schmitt, Lukas Martin Alois Hobohm, Christoph Brochhausen, Thomas Münzel and Christine Espinola-Klein

J. Clin. Med. 2022, 11(21), 6433; https://doi.org/10.3390/jcm11216433 - 30 Oct 2022

Cited by 4 | Viewed by 1329

Abstract

Background: The COVID-19 pandemic influences the health care management of acute and chronic diseases. Data concerning the influence of the pandemic on hospitalizations of patients with peripheral artery disease (PAD) are sparse. Methods: We analysed all patients hospitalized due to PAD between 1 January 2019 and 31 December 2020 in Germany. Hospitalizations of PAD patients during the pre-pandemic year 2019 were compared to the pandemic year 2020. Results: Overall, 361,029 hospitalizations of PAD patients in the years 2019 and 2020 (55.4% aged ≥70 years; 36.6% females) were included in this study. In the pre-pandemic year of 2019, a total of 25,501 (13.2%) more hospitalizations due to PAD were detected compared to the COVID-19 pandemic year of 2020 (2019: 192,765 [53.4%] vs. 2020: 168,264 [46.6%], p = 0.065). Overall, in 610 (0.4%) of the hospitalization cases, a COVID-19 infection was diagnosed. Regarding interventional/surgical treatments, total numbers of peripheral endovascular intervention of the lower extremity decreased by 9.9% (83,845 vs. 75,519, p < 0.001), surgical peripheral artery revascularization of the lower extremity by 11.4% (32,447 vs. 28,754, p = 0.041) and amputations by 4.0% (20,612 vs. 19,784, p < 0.001) in 2020 compared to 2019. The case fatality rate (2.6% vs. 2.4%, p < 0.001), as well as MACCE rate (3.4% vs. 3.2%, p < 0.001), were slightly higher during the pandemic year 2020 compared to the pre-pandemic year 2019. Conclusions: The COVID-19 pandemic influenced the number of hospitalizations of PAD patients with a 13.2% reduction in hospital admissions and decreased total numbers of revascularization and amputation treatments. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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12 pages, 246 KiB

Open AccessArticle

Clinical Characteristics and Current Practice of Endovascular Revascularization in Aorto-Iliac, Femoropopliteal and Infra-Popliteal Lower Extremity Artery Disease—Insights from the RECCORD Registry

by Jacqueline Stella, Jürgen Stausberg, Michael Lichtenberg, Ulrich Hoffmann and Nasser M. Malyar

J. Clin. Med. 2022, 11(20), 6074; https://doi.org/10.3390/jcm11206074 - 14 Oct 2022

Cited by 3 | Viewed by 1318

Abstract

Background: Endovascular revascularization (EVR) is a pillar of therapeutic management in patients with symptomatic lower extremity artery disease (LEAD). Due to lack of scientific evidence, the approach of EVR type and the devices used at the different anatomic vascular segments of the lower limbs vary substantially between operators and centers. We analyzed data from the RECcording COurses of vasculaR Diseases (RECCORD) registry to assess the current real-world EVR treatment patterns in relation to anatomic vascular segments in symptomatic LEAD patients in Germany. Patients and Methods: RECCORD is an ongoing, prospective, multicenter, all-comers and entirely web-based registry platform. Baseline demographic and periprocedural data of patients undergoing EVR for symptomatic LEAD were assessed and performed EVRs were grouped according to the intervened anatomic vascular segment. We analyzed four EVR groups comprising either the aorto-iliac, femoropopliteal, or infrapopliteal segments (all these EVRs with or without a further intervention in another anatomic segment) or the infrapopliteal segment alone. Results: A total of 2210 EVR segments (in 1639 patients) were analyzed. Of those 616 (27.9%) were aorto-iliacal, 1346 (60.9%) femoropopliteal, 248 (11.2%) infrapopliteal and 104 (4.7%) only infrapopliteal segments. Aorto-iliac EVR was associated with younger age, smoking, claudication and simple lesions, while the distal infrapopliteal EVRs were related to advanced age, diabetes, multiple comorbidities, limb threatening ischemia and complex lesions. The use of different EVR devices at the aorto-iliac, femoropopliteal, infrapopliteal and only infrapopliteal segments were: only ballon-angioplasty: 8.3%, 12.9%, 58.1% and 63.5%; stenting: 82.3%, 45.3%, 16.9% and 12.5%; drug-coated balloon: 11.2%, 55.0%, 19.4% and 19.2%. Conclusion: The RECCORD registry data demonstrate that in LEAD clinical and lesion characteristics are related to anatomic vascular segments. Despite the clear relationship between vascular segments and the current use of device types, prospective, segment-specific clinical studies are warranted to establish a consistent, evidence-based path for EVR in LEAD. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

12 pages, 1965 KiB

Open AccessArticle

Antithrombotic Treatment Patterns of Patients with Symptomatic Peripheral Arterial Occlusive Disease in Germany: Evidence from Health Insurance Claims Data

by Frederik Peters, Jenny Kuchenbecker, Laura Acar, Ursula Marschall, Helmut L’Hoest, Fabien Lareyre, Konstantinos Spanos and Christian-Alexander Behrendt

J. Clin. Med. 2022, 11(18), 5455; https://doi.org/10.3390/jcm11185455 - 16 Sep 2022

Cited by 5 | Viewed by 2532

Abstract

Objectives: Patients with peripheral arterial occlusive disease (PAOD) are at risk of worsening limb symptoms, major adverse cardiovascular events and exhibit an impaired life expectancy. There is a lack of evidence on the extent of pharmacological secondary prevention in PAOD patients. This study assesses treatment patterns of antithrombotic agents in symptomatic PAOD patients. Methods: This is a retrospective cohort study using data from the second largest insurance fund in Germany, BARMER. We included symptomatic PAOD patients undergoing in-hospital treatment with an index admission between 1 January 2010 and 31 December 2017. Outcomes were proportions of single antiplatelets (SAPT), dual antiplatelets (DAPT), vitamin-K antagonists (VKA), or direct oral anticoagulants (DOAC) in the 12 months prior and 6 months after the index hospitalization. Non-parametric cumulative incidence for competing risks was estimated to account for censoring and death after discharge from hospital stay. Patient flows were visualised by alluvial diagrams. All analyses were stratified by intermittent claudication (IC) and chronic limb-threatening ischaemia (CLTI). The protocol was registered to ClinicalTrials.gov (NCT03909022). Results: A total of 80,426 unique patient encounters were identified. Mean age was 72.7 (46.3% female). Amongst all patients, 25.6% were on SAPT, 4.1% on DAPT, 9.1% on VKA, 3.9% on DOAC, 3.9% on both antiplatelets and oral anticoagulation, and 53.3% without any antithrombotic therapy during the 12 months before index stay. The estimated cumulative incidence was 37.9% SAPT, 14.8% DAPT, 7.5% VKA, 4.3% DOAC, 7.4% both, and 28.1% without any antithrombotic therapy during the 6 months after index stay. The considerable increases in antiplatelet therapy were mainly driven by the group of patients without antithrombotics before index stay. As compared with IC, patients who suffered from CLTI received less often antiplatelets but more often anticoagulants both before and after index stay. Conclusions: Utilisation rates of antithrombotic therapy increased considerably after in-hospital treatment for PAOD. Yet, remarkably high rates of symptomatic patients without any blood-thinning therapy constitute a major concern with respect to adequate secondary prevention of PAOD patients. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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11 pages, 268 KiB

Open AccessArticle

The Impact of Chronic Kidney Disease on Mid-Term Outcomes after Revascularisation of Peripheral Arterial Occlusive Disease: Results from a Prospective Cohort Study

by Artur Kotov, Deven A. Blasche, Frederik Peters, Philip Pospiech, Ulrich Rother, Konstantinos Stavroulakis, Jürgen Remig, Christian Schmidt-Lauber, Thomas Zeller, Hartmut Görtz, Jörg Teßarek and Christian-Alexander Behrendt

J. Clin. Med. 2022, 11(16), 4750; https://doi.org/10.3390/jcm11164750 - 14 Aug 2022

Cited by 6 | Viewed by 1970

Abstract

Objective: The current study aimed to determine the relationship between chronic kidney disease (CKD) and major 12-month outcomes for patients with in-hospital treatment for symptomatic peripheral arterial occlusive disease (PAOD). Methods: An analysis of the prospective longitudinal multicentric cohort study with 12-month follow-up was conducted including patients who underwent endovascular or open surgery for symptomatic PAOD at 35 German vascular centres (initial study protocol: NCT03098290). Severity of CKD was grouped into four stages combining information about the estimated glomerular filtration rate (eGFR) at baseline and dialysis dependency. Outcomes included overall mortality as well as the two composite endpoints of amputation or death, and of major cardiovascular events (MACE). 12-month incidences and adjusted hazard ratios were estimated using the Kaplan–Meier function and Cox proportional hazard models. Results: A total of 4354 patients (32% female, 69 years mean age, 68% intermittent claudication, 69% percutaneous endovascular revascularisation) were included and followed for 244 days in median. Thereof, 22% had any CKD and 5% had end stage kidney disease (ESKD) at baseline. The 12-month overall mortality rate was 3.6% (95% CI 2.3–4.9) with 96 events in the entire cohort: 147 were amputated or died (5.3%, 95% CI 5.2–5.3), and 277 had a MACE (9.5%, 95% CI 9.4–9.5). When compared with patients without kidney disease, ESKD was significantly associated with overall mortality (HR 1.9; 95% CI 1.1–3.5), amputation or death (HR 2.4; 95% CI 1.4–4.1), and MACE (HR 2.0; 95% CI 1.3–3.2). Conclusions: In the current study on mid-term outcomes after invasive revascularisation for symptomatic PAOD, one out of five patients suffered from any CKD while those few with ESKD had twice the odds of death, of amputation or death, and of major adverse cardiovascular events after twelve months. These results emphasise that concomitant CKD and its impact on outcomes should be considered by severity while mild and moderate grades should not lead to ineffectual treatment strategies. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

9 pages, 228 KiB

Open AccessArticle

Preoperative Factors Associated with Target Lesion Revascularization following Endovascular Therapy of the Superficial Femoral Artery

by Mathias Kaspar, Alexander Bott, Aljoscha Rastan, Joern Fredrik Dopheide, Heinz Drexel and Marc Schindewolf

J. Clin. Med. 2022, 11(15), 4606; https://doi.org/10.3390/jcm11154606 - 8 Aug 2022

Viewed by 1239

Abstract

Objectives: In patients with symptomatic peripheral arterial occlusive disease (PAOD), endovascular revascularization of the superficial femoral artery (SFA) is the most frequent intervention. A major drawback of endovascular procedures is clinically driven target lesion revascularization (CD-TLR), which may cause recurrence of symptoms, re-hospitalizations, and re-interventions. Outcome studies comparing endovascular modalities are heterogeneous and focus more on intraoperative rather than preoperative aspects. Studies have not examined potential risk factors in patients’ phenotype before an intervention to prevent CD-TLR. Design: Monocentric, retrospective cohort study of 781 patients with symptomatic PAOD referred to an endovascular intervention of the SFA between 2000 and 2018. Methods: The study aim was to identify risk factors and phenotypes leading to symptomatic PAOD in patients with de novo lesions of the SFA and ≥1 CD-TLR within 12 months post-index procedure. Two groups were differentiated: patients without CD-TLR and with ≥1 CD-TLR. Patient phenotype was compared for cardiovascular (CV) risk factors, age, gender, and renal function. Results: 662 patients (84.8%) (age 73.5 ± 11.2 years; 243 women (36.7%)) with no CD-TLR were compared to 119 patients (15.2%) with ≥1 CD-TLR (age 70.9 ± 12.4 years; 55 women (46.2%)). Women, as well as subjects with dyslipidemia, had each a 1.8-time higher odds ratio of receiving multiple interventions within one year than men or subjects without dyslipidemia. Older subjects (per decade) had a lower odds ratio (0.7) for multiple interventions. Subjects with an eGFR (estimated glomerular filtration rate) <30 mL/min had 3.8 times higher and subjects with eGFR ≥30 and <60 mL/min had a 2.4 higher odds ratio of receiving multiple interventions than subjects with eGFR values ≥90 mL/min. Conclusion: Our data indicate that younger women, patients with dyslipidemia, or those with renal insufficiency are at risk for recurrent midterm CD-TLR after endovascular therapy of the SFA. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

9 pages, 851 KiB

Open AccessArticle

Physician-Modified TEVAR versus Hybrid Repair of the Proximal Descending Thoracic Aorta

by Miroslav Dimitrov Yordanov, Alexander Oberhuber and Abdulhakim Ibrahim

J. Clin. Med. 2022, 11(12), 3455; https://doi.org/10.3390/jcm11123455 - 16 Jun 2022

Viewed by 1672

Abstract

There are different surgical options for the treatment of proximal lesions of the descending thoracic aorta. The aim of this study was to compare the outcome of physician-modified TEVAR (pmTEVAR) vs. hybrid repair of the thoracic aorta in terms of TEVAR with carotid-subclavian bypass (hdTEVAR). This was a single-centre, retrospective comparative study of all patients who underwent pmTEVAR and hybrid repair of the proximal descending aorta from January 2018 to June 2021. Primary outcomes were technical success, 30-day mortality, perioperative stroke, 30-day reinterventions and supraaortic access related complications. Secondary outcomes were patient survival, late complications, late reinterventions, and bypass/bridging stent patency. A total of 181 patients underwent TEVAR within the period of 42 months. In our study, only patients with proximal landing in zone 2 (n = 39) were included. A total of 5 of 15 pmTEVAR and 8 of 24 hybrid repair operations (33% vs. 33%, respectively) were performed due to aneurysms. Among the rest of the patients, 10 of 15 pmTEVAR and 16 of 24 hybrid operations (67% vs. 67%) were performed due to aortic dissection. Technical success was achieved in 100% of the patients. No significant difference in terms of postoperative complications could be detected in the early and midterm follow up period. The 30-day mortality was 12.5% in the hybrid repair group (n = 3) vs. 6.66% (n = 1) in the pmTEVAR group (p = 0.498). These patients underwent the operation in an emergency setting. No patient died after an elective operation. The causes of early mortality were major stroke (n = 2), haemorrhagic shock (n = 1) in the hybrid group and progredient spinal cord ischemia with tetraplegia and acute respiratory insufficiency (n = 1) in the pmTEVAR group. In conclusion, both therapies are robust techniques, with comparable patency rate and perioperative complications. pmTEVAR appears to be advantageous in terms of operation time and tendency to lower mortality rates. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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10 pages, 1009 KiB

Open AccessArticle

Evaluation of Stent Angioplasty in the Treatment of Arteriosclerotic Lesions of the Common Femoral Artery

by Tanja Böhme, Thomas Zeller, Mohamed Abboud, Ulrich Beschorner and Elias Noory

J. Clin. Med. 2022, 11(10), 2694; https://doi.org/10.3390/jcm11102694 - 10 May 2022

Cited by 2 | Viewed by 1749

Abstract

In many vascular segments, endovascular therapy is the treatment of choice for arteriosclerotic lesions. For the treatment of common femoral artery (CFA) lesions, surgical reconstruction is still considered the gold standard. The purpose of this study is to evaluate the safety and efficacy of stent angioplasty for the treatment of common femoral artery (CFA) lesions in a real-world population during a two-year follow up. This retrospective, single-center study includes 250 patients requiring treatment with stent angioplasty of CFA lesions. The primary end point was the target lesion revascularization (TLR) rate. Secondary end points were the overall procedural complication rate, the rate of ipsilateral CFA punctures during follow-up, changes in the Rutherford–Becker class (RBC) and ankle–brachial index (ABI), primary patency rates, amputation rate, time to and the type of TLR. A total of 236 interventions (94.4%) were successfully defined as a residual stenosis < 30%. Periinterventionally, there were 23 complications (9.1%), 3 of which had to be treated surgically. Median follow up was 21 months (average 19.2 ± 7.8). In total, 41 patients (16.4%) needed a TLR. The primary patency rate was 90.8%, 81.2% and 72% at 6, 12 and 24 months, respectively. ABI and RBC were significantly better at all time points compared to baseline. During follow up, seven amputations (three minor and four major) had to be performed. More than half of the patients (56.0%) were punctured at the stented CFA during the follow up. Multivariate logistic regression analysis showed continued nicotine use and coronary heart disease as predictors for TLR. Stent angioplasty for the treatment of CFA lesions is safe and effective. Further studies are needed to compare this endovascular option with surgical therapy. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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16 pages, 1888 KiB

Open AccessArticle

The Predictive Role of NLR and PLR in Outcome and Patency of Lower Limb Revascularization in Patients with Femoropopliteal Disease

by Eliza Russu, Adrian Vasile Mureșan, Emil Marian Arbănași, Réka Kaller, Ioan Hosu, Septimiu Voidăzan, Eliza Mihaela Arbănași and Cătălin Mircea Coșarcă

J. Clin. Med. 2022, 11(9), 2620; https://doi.org/10.3390/jcm11092620 - 6 May 2022

Cited by 29 | Viewed by 2249

Abstract

Background: Peripheral arterial disease (PAD) changes the arterial structure and function, and is the most common manifestation of the atherosclerotic process, except for the coronary and cerebral arterial systems. Inflammation is well known to have a role in the progression of atherosclerosis and, by extension, in PAD. Among the recently studied markers in the literature, we list the neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR). This study aims to analyze the preoperative role of NLR and PLR in the medium-term outcome of patients surgically revascularized for femoropopliteal disease. Methods: A retrospective study included patients admitted to the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Târgu-Mureș, Romania, between January 2017 and December 2019, diagnosed with femoropopliteal disease and having presented an indication for surgical revascularization. The patients included in the study were classified according to the 12 months primary patency in two groups: “patency” and “nonpatency”. Results: Depending on the Rutherford classification (RC), there was a higher incidence of stages II and III in the patency group and a higher incidence of stage V in the nonpatency group. Depending on the optimal cut-off value according to ROC for the 12 months primary patency, obtained from Youden’s index (3.95 for NLR (82.6% sensitivity and 89.9% specificity), and 142.13 for PLR (79.1% sensitivity and 82.6% specificity)), in all high-NLR and high-PLR groups, there was a higher incidence of all adverse outcomes. Moreover, a multivariate analysis showed that a high baseline value for NLR and PLR was an independent predictor of all outcomes for all recruited patients. Furthermore, for all hospitalized patients, RC 5 was an independent predictor of poor prognosis. Conclusions: Our findings establish that a high value of preoperative NLR and PLR determined at hospital admission is strongly predictive of primary patency failure (12 months after revascularization). Additionally, elevated ratio values are an independent predictor for a higher amputation rate and death for all patients enrolled in the study, except for mortality in RC 2, and both amputation and mortality in RC 5. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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Open AccessArticle

Influence of Peripheral Transluminal Angioplasty Alongside Exercise Training on Oxidative Stress and Inflammation in Patients with Peripheral Arterial Disease

by Franziska Koppe-Schmeißer, Melanie Schwaderlapp, Julian Schmeißer, Jörn F. Dopheide, Thomas Münzel, Andreas Daiber and Christine Espinola-Klein

J. Clin. Med. 2021, 10(24), 5851; https://doi.org/10.3390/jcm10245851 - 13 Dec 2021

Cited by 5 | Viewed by 2001

Abstract

In patients with intermittent claudication, exercise training ameliorates inflammation by reducing oxidative stress. A total of 41 patients with intermittent claudication (Rutherford 3) were included in the study (with 21 patients treated by endovascular revascularization (ER), and 20 patients without ER). All patients were referred to home-based exercise training. Absolute and initial claudication distance (ACD, ICD) and ABI (ankle–brachial index) were measured. ROS (reactive oxygen species) formation was measured using the luminol analogue L-012. Follow-up was performed after 3 months. ROS production after NOX2 (NAPDH oxidase 2) stimulation showed a significant reduction in both groups at follow-up (PTA group: p = 0.002, control group: p = 0.019), with a higher relative reduction in ROS in the PTA group than in the control group (p = 0.014). ABI measurements showed a significant increase in the PTA (peripheral transluminal angioplasty) group (p = 0.001), but not in the control group (p = 0.127). Comparing both groups at follow-up, ABI was higher in the PTA group (p = 0.047). Both groups showed a significant increas ACD and ICD at follow-up (PTA group: ACD: p = 0.001, ICD: p < 0.0001; control group: ACD: p = 0.041, ICD: p = 0.002). There was no significant difference between both groups at follow-up (ACD: p = 0.421, ICD: p = 0.839). Endovascular therapy in combination with exercise training leads to a lower leukocyte activation state with a reduced NOX2-derived ROS production paralleled by an improved ABI, ACD and ICD. Our data support the strategy to combine exercise training with preceding endovascular therapy. Full article

(This article belongs to the Special Issue Advances in Peripheral Revascularization)

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