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Featured Speaker: 19th Annual Dotter Lecture
New England ]ournal of Medicine 2002; 346(23): 1773-1780. 9:05 a.m. Featured Speaker: 19th Annual Dotter Lecture Robert L. Vogelzang, MD Northwestern Memorial Hospital Chicago, II
Infrainguinal Arterial Interventions
Saturday, March 29, 2003 10:00 a.m.-11:30 a.m. Moderator: Richard R. Saxon, MD 10:00 a.m. Femoropopliteal Angioplasty: Long-term Outcomes Gordon K. McLean, lvlD The Western Pennsylvania Hospital Pittsburgh, PA Objectives 1. Based on long-term studies, what are the overall l, 3 and 5-year patencies of femoropopliteal angioplasty?
2. List four patient risk factors that may impact the 10ngterm pateney of femoropopliteal PTA. 3. What subsets of patients with peripheral vaseular disease are most suitable for femoropopliteal PTA? Over the past 25 years, percutaneous transluminal angioplasty (PTA) has been used with varying degrees of success in virtually every part of the circulatory system. In some instances, these have been "niche applications" which have been of limited clinical value; however, in other eases, PTA has beeome standard first line therapy. In the 1980's, angioplasty was frequently compared to the surgical alternatives that were considered "standard" therapy. Although such eomparisons may still be valid and do appeal' in the surgicalliteratllre, to an increasing degree, PTA itself has become the standard and is used as a baekground against which to eompare more exotic and innovative therapies. The complex and ongoing evolution of vascular therapy has inspired eonsiderable debate over the merits of the different techniques involved. Unfortunately, many of t11e issues raised in this debate have been impossible to resolve because of considerable inconsistencies in reporting standards. Despite the fact that the femoral and popliteal arteries were among the first vessels treated by PTA, the nllmber of studies that allow meaningful comparisons with alternative forms of therapy are limited. Luckily, over the past deeade, a number of investigators have analyzed the factors that influence long-term outcome. Based on such studies, the appropriate role of PTA in the treatment of
femoropopliteal occlusive disease can be determined with a reasonable degree of aecuracy. With this as baekground, an evaluation of more adventurous therapies (e.g., brachytherapy, drug-eluting stents) can be made. In an era characterized by the rapid development and introduction of staltling new materials and technojogies, evaluating the long-term effieaey of any treatment becomes problematic. It's almost a tautology that the numbers we cite for current patency rates do not, in faet, reflect the teehniqlles we're using on patients today. In some cases (e.g., laser angioplasty), this disconnect has been so profound that what proved to be in the long run an almost completely ineffective teehnique, was carried along by its own enthusiasm for a number of years. Luckily, femoropopliteal PTA by virtue of its being mlddle-aged, is somewhat immune to the vagaries of technological fashion. Instruments and imaglng systems not withstanding, a femoral Ol' popliteal PTA done in 2003 is not vely different than one done in 1993 and, in fact, not fundamentally different from those done in 1983. This of course assumes that exotic second-Iine technologies such as braehytherapy and stenting are not brought into play. This also assumes t11at the evolution in drug therapy adjunctive to PTA has had only a modest effect on long-term outcome. This last point is a somewhat tenuous assumption since the broad applieation of anti-platelet agents to a broad variety of angioplasty objectives has been a new and faidy aggresslve ehange in therapy of most peripheral intelventionalists. Long a mainstay of the cardiac eatheterization lab, the GPIIBIIIA inhibitors have become commonplace in peripheral vascular laboratories as well. Even a brief review of major papers that have repOlted long-term follow-up of patients who have undergone femoropopliteal angioplasty reveals some slriking similarities. Reports dating from 1984 through 2001 report much the same outeome despite the above Iloted evolution in techniques and pharmacology. Primary patencies at 1 year, 3 years, and 5 years are about 60%, 50%, and 45%-50% respectiveJy. Clearly, this is an oversimplification and numbers have varied in individual series as well as with individual risk factors, but overall, this is a faidy accurate representation of what can be expected from femoropopliteal PTA. For most referring physicians (e.g., PCP's) and for most patients, this is enough information. In layman's language, as a result of a simple, fairly inexpensive outpatient procedure, there is a fifty-fifty chance that the results of suceessful therapy will endure for 5 years. Obviously, the data can be dissected out to yield far more detail and predictably, the scientific literature has risen to the challenge. Long-term outcome has been con'e1ated with an array presenting signs and symptoms, co-morbid conditions, demographic variabIes, imaging findings and anatomic factors. Purportedly, the value of sueh subanalyses is to define groups of patients who are more or less Iikely to benefit from the therapy. In a logical world, this would result in the exclusion of cer-
P91
Infrainguinal Arterial Interventions
Saturday, March 29, 2003 10:00 a.m.-11:30 a.m. Moderator: Richard R. Saxon, MD 10:00 a.m. Femoropopliteal Angioplasty: Long-term Outcomes Gordon K. McLean, lvlD The Western Pennsylvania Hospital Pittsburgh, PA Objectives 1. Based on long-term studies, what are the overall l, 3 and 5-year patencies of femoropopliteal angioplasty?
2. List four patient risk factors that may impact the 10ngterm pateney of femoropopliteal PTA. 3. What subsets of patients with peripheral vaseular disease are most suitable for femoropopliteal PTA? Over the past 25 years, percutaneous transluminal angioplasty (PTA) has been used with varying degrees of success in virtually every part of the circulatory system. In some instances, these have been "niche applications" which have been of limited clinical value; however, in other eases, PTA has beeome standard first line therapy. In the 1980's, angioplasty was frequently compared to the surgical alternatives that were considered "standard" therapy. Although such eomparisons may still be valid and do appeal' in the surgicalliteratllre, to an increasing degree, PTA itself has become the standard and is used as a baekground against which to eompare more exotic and innovative therapies. The complex and ongoing evolution of vascular therapy has inspired eonsiderable debate over the merits of the different techniques involved. Unfortunately, many of t11e issues raised in this debate have been impossible to resolve because of considerable inconsistencies in reporting standards. Despite the fact that the femoral and popliteal arteries were among the first vessels treated by PTA, the nllmber of studies that allow meaningful comparisons with alternative forms of therapy are limited. Luckily, over the past deeade, a number of investigators have analyzed the factors that influence long-term outcome. Based on such studies, the appropriate role of PTA in the treatment of
femoropopliteal occlusive disease can be determined with a reasonable degree of aecuracy. With this as baekground, an evaluation of more adventurous therapies (e.g., brachytherapy, drug-eluting stents) can be made. In an era characterized by the rapid development and introduction of staltling new materials and technojogies, evaluating the long-term effieaey of any treatment becomes problematic. It's almost a tautology that the numbers we cite for current patency rates do not, in faet, reflect the teehniqlles we're using on patients today. In some cases (e.g., laser angioplasty), this disconnect has been so profound that what proved to be in the long run an almost completely ineffective teehnique, was carried along by its own enthusiasm for a number of years. Luckily, femoropopliteal PTA by virtue of its being mlddle-aged, is somewhat immune to the vagaries of technological fashion. Instruments and imaglng systems not withstanding, a femoral Ol' popliteal PTA done in 2003 is not vely different than one done in 1993 and, in fact, not fundamentally different from those done in 1983. This of course assumes that exotic second-Iine technologies such as braehytherapy and stenting are not brought into play. This also assumes t11at the evolution in drug therapy adjunctive to PTA has had only a modest effect on long-term outcome. This last point is a somewhat tenuous assumption since the broad applieation of anti-platelet agents to a broad variety of angioplasty objectives has been a new and faidy aggresslve ehange in therapy of most peripheral intelventionalists. Long a mainstay of the cardiac eatheterization lab, the GPIIBIIIA inhibitors have become commonplace in peripheral vascular laboratories as well. Even a brief review of major papers that have repOlted long-term follow-up of patients who have undergone femoropopliteal angioplasty reveals some slriking similarities. Reports dating from 1984 through 2001 report much the same outeome despite the above Iloted evolution in techniques and pharmacology. Primary patencies at 1 year, 3 years, and 5 years are about 60%, 50%, and 45%-50% respectiveJy. Clearly, this is an oversimplification and numbers have varied in individual series as well as with individual risk factors, but overall, this is a faidy accurate representation of what can be expected from femoropopliteal PTA. For most referring physicians (e.g., PCP's) and for most patients, this is enough information. In layman's language, as a result of a simple, fairly inexpensive outpatient procedure, there is a fifty-fifty chance that the results of suceessful therapy will endure for 5 years. Obviously, the data can be dissected out to yield far more detail and predictably, the scientific literature has risen to the challenge. Long-term outcome has been con'e1ated with an array presenting signs and symptoms, co-morbid conditions, demographic variabIes, imaging findings and anatomic factors. Purportedly, the value of sueh subanalyses is to define groups of patients who are more or less Iikely to benefit from the therapy. In a logical world, this would result in the exclusion of cer-
P91