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Abstract No. 135: Ultrasound guided endovascular management of femoropopliteal artery lesions in patients with renal insufficiency
S56 䡲 Monday
Scientific Session 䡲 JVIR
Conclusion: This study demonstrates reproducibility in perfusion measurements when varying user-definable inputs. This is useful for perfusion analysis in patients with critical limb ischemia who often have multivessel disease and could potentially have occlusion of the posterior or anterior tibial arteries or significant tissue loss.
1:54 PM
Abstract No. 133
Efficacy of express ld vascular stent in iliac artery lesions: initial and 3 year result
MONDAY: Scientific Sessions
S. Ichihashi, H. Wataru, I. Hirofumi, S. Shoji, K. Kichikawa; Radiology, Nara Medical University, Kashihara, Nara, Japan Purpose: To evaluate initial result and 3 year cumulative primary patency rate of balloon expandable Express-LD vascular stent. Materials and Methods: Primary stent placement for de novo iliac lesion using Express LD was performed for 56 patients, 72 limbs. Median follow up term is 14 months (1-44 months). According to the TASC-II classification, the number of patients was 25 in type A (45%), 23 in type B (41%), 2 in type C (3%), and 6 in type D (11%). The number of patients with intermittent claudication was 50 (89%) and with critical limb ischemia was 6 (11%). Of the 72 limbs, Express LD was deployed for ostial lesions of the common iliac artery in 63 limbs (88%), for additional dilation of the self-expanding nitinol stent with a stent-instent maneuver in 9 limbs (12%), which didn’t expand completely due to compression by hard plaque or subintimal recanalization. 64% of the treated lesions have heavy calcification. Initial technical success of iliac stenting and cumulative primary patency rate was evaluated. Results: Successful revascularization with primary stenting was achieved in all cases (100%). Mean ABI value improved from 0.61 to 0.93. Mean pressure gradient also improved from 55 to 5 mmHg. In the 9 limbs of insufficient expansion of self-expanding stents, additional deployment of Express LD with a stent in stent maneuver improved pressure gradient from 29 to 11mmHg. Complication occurred in 5 limbs. Dissections at the stent distal edge occurred in 3 limbs and additional self-expanding stents were placed. Distal embolism occurred in 2 limbs, but patients complained no symptom and no additional procedures were needed. One death occurred on the next day of the intervention due to reperfusion syndrome. Improvement of the symptom was achieved in 48 patients (90.5%). Cumulative primary patency rate of the stent was 98% at 1 year, 81% at 3year, and cumulative secondary patency rate was 100% at 1 and 3 years. Conclusion: Iliac stenting using Express LD vascular stent provide acceptable initial and midterm result for the heavy calcified lesion or supporting dilation of the self-expanding stent which expand insufficiently. It’s to be noted dissection may occur at stent edge.
2:02 PM
Abstract No. 134
Radiofrequency wire recanalization of chronic total artery occlusions G. Annamalai, J. Comin, R. Pugash, E. David; Vascular and Interventional Radiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Purpose: To assess the feasibility of radiofrequency (RF) wire recanalization of chronic total iliac artery occlusions, as a substitute or adjunct for conventional arterial recanalization techniques. To our knowledge, there have been no reports of arterial application outside the coronary circulation. Materials and Methods: Five patients were referred for recanalization of chronic total left common iliac artery occlusions. In each case, retrograde access was obtained to both common femoral arteries, and aortography was performed from the right side to define the location and extent of the left sided occlusion. Initial antegrade and retrograde attempts were made to recanalize the occlusions, using conventional catheter and guidewire techniques. When these techniques were unsuccessful, a PowerWire (Baylis Medical, Montreal, Canada) was used to impart radiofrequency energy to either the distal or proximal end of the occlusion, and retrograde or antegrade radiofrequency recanalization was continued through the occlusion in a similar fashion. Given the perceived high risk of luminal perforation with the application of RF energy, the PowerWire was steered with the assistance of an angled catheter, using vascular calcification and parallax as a fluoroscopic roadmap. Once intraluminal reentry was established, patients were anticoagulated with heparin. In the case of the antegrade recanalizations, through-and-through retrograde access from the left was achieved with a goose-neck snare. Subsequently, the previously occluded segments were stented and the patients were commenced on aspirin and clopidogrel. Results: All patients’ occlusions were successfully recanalized using the PowerWire, without immediate or delayed complication. Conclusion: Radiofrequency is an effective and safe means of recanalizing chronic total artery occlusions when traditional recanalization techniques have failed. It is an appealing alternative to other devices utilized in chronic total occlusions, due to its simplicity and speed.
2:10 PM
Abstract No. 135
Ultrasound guided endovascular management of femoropopliteal artery lesions in patients with renal insufficiency M.I. Bhalla, N. Bhalla; Radiology, Siddhi Vinayak Imaging Centre, Ahmedabad, India Purpose: To evaluate the early results of Ultrasound (US) guided angioplasty and stenting of femoropopliteal arteries in patients with compromised renal function. Materials and Methods: 22 patients (6 women, 16 men) with pre existing renal insufficiency were treated with US guided angioplasty/stenting for lower extremity vascular complain. Limb claudication (80%) and critical ischaemia (20 %) were the two most common presenting complains. Duplex US was performed and level and length of lesion identified in SFA and/or popliteal arteries. Besides preprocedure map, Ankle/Brachial index (ABI) was performed. Patients with only discrete lesions which could be visualized clearly by colour duplex imaging were selected. Procedure was performed under local anaesthesia and light sedation. Ipsilateral common femoral artery (CFA) was cannulated under US guidance. Heparin was administered intraarterially. Guide wire was passed across the diseased segment under US guidance. Diseased segment was balloon dilated,starting from most distal lesion. Stent was placed in 12 patients, when the diameter of diseased lumen reduced ⬎30%. Post procedure duplex scan and
JVIR 䡲 Scientific Session
Monday 䡲 S57
ABI were performed. Follow ups were scheduled at 1 month, 3 months and 12 months. Results: Technical success was achieved in 19 patients (86.4%). No intraoperative and postioperative complications (pseudoaneursym / haematoma at puncture site or early restenosis) were noted. No further intervention was required in the treated patients in next one year. In 3 patients (13.6%), guide wire could not be negotiated through the lesion. Conclusion: US guided angioplasty/ stenting appears to be safe and effective alternative technique for treatment of femorpopliteal occlusions and stenosis in patients with renal failure. Besides the two main advantages of avoiding radiation exposure (to patient and staff) and avoiding the nephrotoxic effect of contrast, US had adavantage in immediately confirming the treatment by imaging parameters, puncturing arteries under direct visualization and selection of balloon.
2:18 PM
Abstract No. 136
F. Fanelli, A. Cannavale, M. Corona, P. Lucatelli, M. Allegritti, R. Passariello; Radiological Sciences, Vascular and Interventional Radiology Unit “Sapienza” University of Rome, Rome, Italy Purpose: Drug-eluting balloons have shown promising results in recent trials improving the patency rate in steno-obstructive disease of the femoro-popliteal region. We evaluate mid-term patency of peripheral angioplasty with paclitaxel-coated balloons (DEB) in comparison with conventional balloon (PTA) evaluating the results of a single-center randomized study. Materials and Methods: Fifty consecutive patients (mean age 66⫹/⫺4 years), with stenosis or occlusion of the femoro-popliteal artery were enrolled and randomly assigned to percutaneous treatment with DEB (25 pts, 57 lesions; IN.PACT Amphirion, Medtronic) and with uncoated balloons (25 pts, 65 lesions; control group). Patients characteristics were similar in both groups: 28% smokers, 45% diabetes and 59% hypercholesterolemia. According to the TASC-II classification, 38% were class B, 34% were C and 10% D. The primary end-point was late lumen loss at 6 months. Secondary end-points were target lesion revascularization (TLR), amputation and thrombosis at 6 months. During the follow-up patients underwent clinical and ultrasound-color-doppler (USCD) examination 1 day after the procedure and at 6 months. Results: Twenty-two percent of the lesions were total occlusions, while 36% were stenosis. The mean lesion length was 5.5⫹/⫺3.5cm: 22% (N⫽21) longer than 15cm, 51%(N⫽63) between 7 and 15cm. There were no adverse events correlated to the paclitaxel-coated balloons. At 6 months, USCD showed neointimal thickness of 1.6⫹/⫺1.7 mm in the control group, compared with 0.5⫹/⫺1.4 mm (P⫽0.001) in the group treated with DEB.Target lesion revascularization rate at 6 months was 9 of 25 (36%) in the control group, and 2 of 25 (8%) in the DEB group (P⫽0.001 vs. control group). Thrombosis rate was 12% (PTA) vs 7% (DEB) p⬍0.01. Amputation rate was 8% (PTA) vs 3% (DEB) p⬍0.01. Ankle brachial index (ABI) improved in the DEB group from 0.65⫾0.26 to 0.87⫾0.22 and in the control group from 0.61⫾0.12 to 0.7⫾0.13 (p⬍0.05 PTA vs DEB).
2:26 PM
Abstract No. 137
Angiosome directed angioplasty for limb salvage in critical limb ischemia C. Soon1, K. Tay1,2, M. Taneja2, T. Teo2, R. Lo2, M.C. Burgmans2, F.G. Irani2, T. Yeow2, A. Gogna2, S. Pasupathy3, S. Chng3, B. Chua3, S. Tan3, M. Pwint1, B. Tan1; 1Duke-NUS, Singapore, Singapore; 2Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore; 3Vascular Surgery Unit, Singapore General Hospital, Singapore, Singapore Purpose: To evaluate the clinical benefit in lower limb preservation after angioplasty guided by an angiosome model of perfusion in patients with lower limb ulcer or gangrene. Materials and Methods: Retrospective review of 546 angioplasty procedures performed in 381 critically ischemic legs (131 legs with ulcers, 250 legs with gangrene) in 350 patients (183 males and 167 females) with mean age of 69.2 years (range 37-90 years) between January 2009 and December 2010 was performed. Diabetes Mellitus was noted in 92% and End Stage Renal Failure was present in 27% of patients. The legs were categorized into direct or indirect angioplasty groups depending on whether straight line flow to the site of lesion based on the angiosome concept was achieved on completion angiography. Major amputation is defined as any amputation above the ankle and limb salvage is defined as freedom from major amputation. Limb salvage rate was compared between the direct and the indirect groups by Kaplan-Meier analysis. Results: The angioplasty procedures were successfully performed in all patients. Repeat angioplasty sessions were required in 56 legs (14.7%). There were 197 legs in the direct angioplasty and 184 legs in the indirect angioplasty groups. The overall limb salvage rate was 76.9% (293/381). Limb salvage rates for the direct and indirect angioplasty groups were 85.8% (169/197) and 67.4% (124/184) respectively (p⬍0.001). Bail out stent rate was 7.9%. There were 2 major distal embolisations requiring aspiration thrombectomy and thrombolysis. Thirty day mortality was 2.6%. Conclusion: In our experience, angiosome directed angioplasty had superior limb salvage rate in patients with critical limb ischemia.
2:34 PM
Abstract No. 138
Orbital atherectomy for infrainguinal arterial occlusive disease in an office-based endovascular lab W. Swee, W.H. Julien; South Florida Vascular Associates, Coconut Creek, FL Purpose: To assess the acute safety and efficacy of orbital atherectomy in a freestanding office-based setting. Materials and Methods: Prospective single center study of 100 consecutive infrainguinal arterial cases treated with CSI Diamondback orbital atherectomy over a 9-month period. All procedures were performed by a single experienced operator in an office-based endovascular suite. Demographics, clinical presenta-
MONDAY: Scientific Sessions
Paclitaxel-coated balloon angioplasty for lower extremity revascularization: better way to fight restenosis?
Conclusion: Use of DEB in femoro-popliteal disease is associated with significant reduction in late lumen loss and target-lesion revascularization compared with conventional angioplasty.
Scientific Session 䡲 JVIR
Conclusion: This study demonstrates reproducibility in perfusion measurements when varying user-definable inputs. This is useful for perfusion analysis in patients with critical limb ischemia who often have multivessel disease and could potentially have occlusion of the posterior or anterior tibial arteries or significant tissue loss.
1:54 PM
Abstract No. 133
Efficacy of express ld vascular stent in iliac artery lesions: initial and 3 year result
MONDAY: Scientific Sessions
S. Ichihashi, H. Wataru, I. Hirofumi, S. Shoji, K. Kichikawa; Radiology, Nara Medical University, Kashihara, Nara, Japan Purpose: To evaluate initial result and 3 year cumulative primary patency rate of balloon expandable Express-LD vascular stent. Materials and Methods: Primary stent placement for de novo iliac lesion using Express LD was performed for 56 patients, 72 limbs. Median follow up term is 14 months (1-44 months). According to the TASC-II classification, the number of patients was 25 in type A (45%), 23 in type B (41%), 2 in type C (3%), and 6 in type D (11%). The number of patients with intermittent claudication was 50 (89%) and with critical limb ischemia was 6 (11%). Of the 72 limbs, Express LD was deployed for ostial lesions of the common iliac artery in 63 limbs (88%), for additional dilation of the self-expanding nitinol stent with a stent-instent maneuver in 9 limbs (12%), which didn’t expand completely due to compression by hard plaque or subintimal recanalization. 64% of the treated lesions have heavy calcification. Initial technical success of iliac stenting and cumulative primary patency rate was evaluated. Results: Successful revascularization with primary stenting was achieved in all cases (100%). Mean ABI value improved from 0.61 to 0.93. Mean pressure gradient also improved from 55 to 5 mmHg. In the 9 limbs of insufficient expansion of self-expanding stents, additional deployment of Express LD with a stent in stent maneuver improved pressure gradient from 29 to 11mmHg. Complication occurred in 5 limbs. Dissections at the stent distal edge occurred in 3 limbs and additional self-expanding stents were placed. Distal embolism occurred in 2 limbs, but patients complained no symptom and no additional procedures were needed. One death occurred on the next day of the intervention due to reperfusion syndrome. Improvement of the symptom was achieved in 48 patients (90.5%). Cumulative primary patency rate of the stent was 98% at 1 year, 81% at 3year, and cumulative secondary patency rate was 100% at 1 and 3 years. Conclusion: Iliac stenting using Express LD vascular stent provide acceptable initial and midterm result for the heavy calcified lesion or supporting dilation of the self-expanding stent which expand insufficiently. It’s to be noted dissection may occur at stent edge.
2:02 PM
Abstract No. 134
Radiofrequency wire recanalization of chronic total artery occlusions G. Annamalai, J. Comin, R. Pugash, E. David; Vascular and Interventional Radiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Purpose: To assess the feasibility of radiofrequency (RF) wire recanalization of chronic total iliac artery occlusions, as a substitute or adjunct for conventional arterial recanalization techniques. To our knowledge, there have been no reports of arterial application outside the coronary circulation. Materials and Methods: Five patients were referred for recanalization of chronic total left common iliac artery occlusions. In each case, retrograde access was obtained to both common femoral arteries, and aortography was performed from the right side to define the location and extent of the left sided occlusion. Initial antegrade and retrograde attempts were made to recanalize the occlusions, using conventional catheter and guidewire techniques. When these techniques were unsuccessful, a PowerWire (Baylis Medical, Montreal, Canada) was used to impart radiofrequency energy to either the distal or proximal end of the occlusion, and retrograde or antegrade radiofrequency recanalization was continued through the occlusion in a similar fashion. Given the perceived high risk of luminal perforation with the application of RF energy, the PowerWire was steered with the assistance of an angled catheter, using vascular calcification and parallax as a fluoroscopic roadmap. Once intraluminal reentry was established, patients were anticoagulated with heparin. In the case of the antegrade recanalizations, through-and-through retrograde access from the left was achieved with a goose-neck snare. Subsequently, the previously occluded segments were stented and the patients were commenced on aspirin and clopidogrel. Results: All patients’ occlusions were successfully recanalized using the PowerWire, without immediate or delayed complication. Conclusion: Radiofrequency is an effective and safe means of recanalizing chronic total artery occlusions when traditional recanalization techniques have failed. It is an appealing alternative to other devices utilized in chronic total occlusions, due to its simplicity and speed.
2:10 PM
Abstract No. 135
Ultrasound guided endovascular management of femoropopliteal artery lesions in patients with renal insufficiency M.I. Bhalla, N. Bhalla; Radiology, Siddhi Vinayak Imaging Centre, Ahmedabad, India Purpose: To evaluate the early results of Ultrasound (US) guided angioplasty and stenting of femoropopliteal arteries in patients with compromised renal function. Materials and Methods: 22 patients (6 women, 16 men) with pre existing renal insufficiency were treated with US guided angioplasty/stenting for lower extremity vascular complain. Limb claudication (80%) and critical ischaemia (20 %) were the two most common presenting complains. Duplex US was performed and level and length of lesion identified in SFA and/or popliteal arteries. Besides preprocedure map, Ankle/Brachial index (ABI) was performed. Patients with only discrete lesions which could be visualized clearly by colour duplex imaging were selected. Procedure was performed under local anaesthesia and light sedation. Ipsilateral common femoral artery (CFA) was cannulated under US guidance. Heparin was administered intraarterially. Guide wire was passed across the diseased segment under US guidance. Diseased segment was balloon dilated,starting from most distal lesion. Stent was placed in 12 patients, when the diameter of diseased lumen reduced ⬎30%. Post procedure duplex scan and
JVIR 䡲 Scientific Session
Monday 䡲 S57
ABI were performed. Follow ups were scheduled at 1 month, 3 months and 12 months. Results: Technical success was achieved in 19 patients (86.4%). No intraoperative and postioperative complications (pseudoaneursym / haematoma at puncture site or early restenosis) were noted. No further intervention was required in the treated patients in next one year. In 3 patients (13.6%), guide wire could not be negotiated through the lesion. Conclusion: US guided angioplasty/ stenting appears to be safe and effective alternative technique for treatment of femorpopliteal occlusions and stenosis in patients with renal failure. Besides the two main advantages of avoiding radiation exposure (to patient and staff) and avoiding the nephrotoxic effect of contrast, US had adavantage in immediately confirming the treatment by imaging parameters, puncturing arteries under direct visualization and selection of balloon.
2:18 PM
Abstract No. 136
F. Fanelli, A. Cannavale, M. Corona, P. Lucatelli, M. Allegritti, R. Passariello; Radiological Sciences, Vascular and Interventional Radiology Unit “Sapienza” University of Rome, Rome, Italy Purpose: Drug-eluting balloons have shown promising results in recent trials improving the patency rate in steno-obstructive disease of the femoro-popliteal region. We evaluate mid-term patency of peripheral angioplasty with paclitaxel-coated balloons (DEB) in comparison with conventional balloon (PTA) evaluating the results of a single-center randomized study. Materials and Methods: Fifty consecutive patients (mean age 66⫹/⫺4 years), with stenosis or occlusion of the femoro-popliteal artery were enrolled and randomly assigned to percutaneous treatment with DEB (25 pts, 57 lesions; IN.PACT Amphirion, Medtronic) and with uncoated balloons (25 pts, 65 lesions; control group). Patients characteristics were similar in both groups: 28% smokers, 45% diabetes and 59% hypercholesterolemia. According to the TASC-II classification, 38% were class B, 34% were C and 10% D. The primary end-point was late lumen loss at 6 months. Secondary end-points were target lesion revascularization (TLR), amputation and thrombosis at 6 months. During the follow-up patients underwent clinical and ultrasound-color-doppler (USCD) examination 1 day after the procedure and at 6 months. Results: Twenty-two percent of the lesions were total occlusions, while 36% were stenosis. The mean lesion length was 5.5⫹/⫺3.5cm: 22% (N⫽21) longer than 15cm, 51%(N⫽63) between 7 and 15cm. There were no adverse events correlated to the paclitaxel-coated balloons. At 6 months, USCD showed neointimal thickness of 1.6⫹/⫺1.7 mm in the control group, compared with 0.5⫹/⫺1.4 mm (P⫽0.001) in the group treated with DEB.Target lesion revascularization rate at 6 months was 9 of 25 (36%) in the control group, and 2 of 25 (8%) in the DEB group (P⫽0.001 vs. control group). Thrombosis rate was 12% (PTA) vs 7% (DEB) p⬍0.01. Amputation rate was 8% (PTA) vs 3% (DEB) p⬍0.01. Ankle brachial index (ABI) improved in the DEB group from 0.65⫾0.26 to 0.87⫾0.22 and in the control group from 0.61⫾0.12 to 0.7⫾0.13 (p⬍0.05 PTA vs DEB).
2:26 PM
Abstract No. 137
Angiosome directed angioplasty for limb salvage in critical limb ischemia C. Soon1, K. Tay1,2, M. Taneja2, T. Teo2, R. Lo2, M.C. Burgmans2, F.G. Irani2, T. Yeow2, A. Gogna2, S. Pasupathy3, S. Chng3, B. Chua3, S. Tan3, M. Pwint1, B. Tan1; 1Duke-NUS, Singapore, Singapore; 2Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore; 3Vascular Surgery Unit, Singapore General Hospital, Singapore, Singapore Purpose: To evaluate the clinical benefit in lower limb preservation after angioplasty guided by an angiosome model of perfusion in patients with lower limb ulcer or gangrene. Materials and Methods: Retrospective review of 546 angioplasty procedures performed in 381 critically ischemic legs (131 legs with ulcers, 250 legs with gangrene) in 350 patients (183 males and 167 females) with mean age of 69.2 years (range 37-90 years) between January 2009 and December 2010 was performed. Diabetes Mellitus was noted in 92% and End Stage Renal Failure was present in 27% of patients. The legs were categorized into direct or indirect angioplasty groups depending on whether straight line flow to the site of lesion based on the angiosome concept was achieved on completion angiography. Major amputation is defined as any amputation above the ankle and limb salvage is defined as freedom from major amputation. Limb salvage rate was compared between the direct and the indirect groups by Kaplan-Meier analysis. Results: The angioplasty procedures were successfully performed in all patients. Repeat angioplasty sessions were required in 56 legs (14.7%). There were 197 legs in the direct angioplasty and 184 legs in the indirect angioplasty groups. The overall limb salvage rate was 76.9% (293/381). Limb salvage rates for the direct and indirect angioplasty groups were 85.8% (169/197) and 67.4% (124/184) respectively (p⬍0.001). Bail out stent rate was 7.9%. There were 2 major distal embolisations requiring aspiration thrombectomy and thrombolysis. Thirty day mortality was 2.6%. Conclusion: In our experience, angiosome directed angioplasty had superior limb salvage rate in patients with critical limb ischemia.
2:34 PM
Abstract No. 138
Orbital atherectomy for infrainguinal arterial occlusive disease in an office-based endovascular lab W. Swee, W.H. Julien; South Florida Vascular Associates, Coconut Creek, FL Purpose: To assess the acute safety and efficacy of orbital atherectomy in a freestanding office-based setting. Materials and Methods: Prospective single center study of 100 consecutive infrainguinal arterial cases treated with CSI Diamondback orbital atherectomy over a 9-month period. All procedures were performed by a single experienced operator in an office-based endovascular suite. Demographics, clinical presenta-
MONDAY: Scientific Sessions
Paclitaxel-coated balloon angioplasty for lower extremity revascularization: better way to fight restenosis?
Conclusion: Use of DEB in femoro-popliteal disease is associated with significant reduction in late lumen loss and target-lesion revascularization compared with conventional angioplasty.