Surgical transluminal iliac angioplasty with selective stenting: long-term results assessed by means of duplex scanning. (1/1972)

PURPOSE: The safety of iliac angioplasty and selective stenting performed in the operating room by vascular surgeons was evaluated, and the short- and long-term results were assessed by means of serial duplex scanning. METHODS: Between 1989 and 1996, 281 iliac stenotic or occlusive lesions in 235 consecutive patients with chronic limb ischemia were treated by means of percutaneous transluminal angioplasty (PTA) alone (n = 214) or PTA with stent (n = 67, 23.8%). There were 260 primary lesions and 21 restenosis after a first PTA, which were analyzed separately. Stents were implanted in selected cases, either primarily in totally occluded arteries or after suboptimum results of PTA (ie, residual stenosis or a dissection). Data were collected prospectively and analyzed retrospectively. Results were reported in an intention-to-treat basis. Clinical results and patency were evaluated by means of symptom assessment, ankle brachial pressure index, and duplex scanning at discharge and 1, 3, 6, and every 12 months after angioplasty. To identify factors that may affect outcome, 12 clinical and radiological variables, including the four categories of lesions defined by the Standards of Practice Committee of the Society of Cardiovascular and Interventional Radiology, were analyzed separately. The statistical significances of life-table analysis of patency were determined by means of the log-rank test. RESULTS: There were no postoperative deaths or amputations. Local, general, and vascular complications occurred in 2.1%, 1.3% and 4.7% of cases, respectively (total, 8.1%). The mean follow-up period was 29.6 months. The cumulative patency rates +/- SE of the 260 PTAs (including 55 PTAs plus stents) were 92.9% +/- 1.5% at 1 month, 86. 5% +/- 1.7% at 1 year, 81.2% +/- 2.3% at 2 years, 78.8% +/- 2.9% at 3 years, and 75.4% +/- 3.5% at 5 and 6 years. The two-year patency rate of 21 redo PTAs (including 11 PTAs plus stents) was 79.1% +/- 18.2%. Of 12 predictable variables studied in the first PTA group, only the category of the lesion was predictive of long-term patency. The two-year patency rate was 84% +/- 3% for 199 category 1 lesions and 69.7% +/- 6.5% for 61 category 2, 3, and 4 lesions together (P =. 02). There was no difference of patency in the stented and nonstented group. CONCLUSION: Iliac PTA alone or with the use of a stent (in cases of occlusion and/or suboptimal results of PTA) offers an excellent long-term patency rate. Categorization of lesions remains useful in predicting long-term outcome. PTA can be performed safely by vascular surgeons in the operating room and should be considered to be the primary treatment for localized iliac occlusive disease.  (+info)

Plaque area increase and vascular remodeling contribute to lumen area change after percutaneous transluminal angioplasty of the femoropopliteal artery: an intravascular ultrasound study. (2/1972)

OBJECTIVE: The aim of the study was to assess the change in lumen area (LA), plaque area (PLA), and vessel area (VA) after percutaneous transluminal angioplasty (PTA) of the femoropopliteal artery. METHODS: This was a prospective study. Twenty patients were studied with intravascular ultrasound (IVUS) immediately after PTA and at follow-up examination. Multiple corresponding IVUS cross-sections were analyzed at the segments that were dilated by PTA (ie, treated sites; n = 168), including the most stenotic site (n = 20) and the nondilated segments (ie, reference sites; n = 77). RESULTS: At follow-up examination, both the PLA increase (13%) and the VA decrease (9%) resulted in a significant LA decrease (43%) at the most stenotic sites (P =.001). At the treated sites, the LA decrease (15%) was smaller and was caused by the PLA increase (15%). At the reference sites, the PLA increase (15%) and the VA increase (6%) resulted in a slight LA decrease (3%). An analysis of the IVUS cross-sections that were grouped according to LA change (difference >/=10%) revealed a similar PLA increase in all the groups: the type of vascular remodeling (VA decrease, no change, or increase) determined the LA change. At the treated sites, the LA change and the VA change correlated closely (r = 0.77, P <.001). At the treated sites, significantly more PLA increase was seen in the IVUS cross-sections that showed hard lesion or media rupture (P <.05). No relationship was found between the presence of dissection and the quantitative changes. CONCLUSION: At the most stenotic sites, lumen narrowing was caused by plaque increase and vessel shrinkage. Both the treated sites and the reference sites showed a significant PLA increase: the type of vascular remodeling determined the LA change at follow-up examination. The extent of the PLA increase was significantly larger in the IVUS cross-sections that showed hard lesion or media rupture.  (+info)

Intraoperative transoesophageal echocardiography as an adjuvant to fluoroscopy during endovascular thoracic aortic repair. (3/1972)

OBJECTIVES: To define the utility of intraoperative transeophageal echocardiography (TEE) during endovascular thoracic aortic repair. DESIGN: Retrospective study. MATERIALS: Five patients underwent six transluminal endovascular stent-graft procedures for repair of thoracic aortic disease. METHODS: After induction of anaesthesia, a multiplane or biplane TEE probe was placed to obtain views of the diseased aorta. Both transverse and longitudinal planes of the aortic arch and descending thoracic aortic segments were imaged. The aortic pathology was confirmed by TEE and the proximal and distal extents of the intrathoracic lesion were defined. Doppler and colour-flow imaging was used to identify flow patterns through the aorta before and after stent-graft deployment. RESULTS: Visualisation and confirmation of the aortic pathology by ultrasonography was accomplished in all patients. TEE was able to confirm proper placement of the endograft relative to the aortic lesion after deployment and was able to confirm exclusion of blood flow into the aneurysm sacs. CONCLUSIONS: TEE may facilitate repair by confirming aortic pathology, identifying endograft placement, assessment of the adequacy of aneurysm sack isolation, as well as dynamic intraoperative cardiac assessment.  (+info)

Effect and outcome of balloon angioplasty and stenting of the iliac arteries evaluated by intravascular ultrasound. (4/1972)

OBJECTIVES: To document the mechanism of percutaneous transluminal angioplasty (PTA) and stenting of the iliac arteries, and to relate the effect to patency. MATERIALS AND METHODS: Thirty-seven stenotic iliac arteries were examined by intravascular ultrasound (IVUS) and arteriography before and after PTA, and after stent deployment (n = 16). The patients were followed prospectively by duplex scanning at 3, 6, 12, 18 and 24 months after the intervention. RESULTS: The effect of PTA was established by both compression and stretching with the major contribution arising from stretching. There were differences in the effect of PTA dependent on plaque morphology: in homogeneous eccentric lesions, stretching contributed significantly more than compression to the luminal gain, while stretching and compression contributed equally in concentric or heterogeneous plaques. Stenting of the arteries had no effect on the free luminal area as measured by IVUS. The primary 1-year patency rate was 72%. The patency was related to the free luminal area and diameter and the heterogenicity of the plaque as evaluated by IVUS. The arteriographic measurements did not have any predictive value. CONCLUSION: IVUS was able to document the effect of PTA and stenting in the iliac arteries, and predict the outcome. The luminal gain and reduction in degree of stenosis seemed to be accomplished primarily by stretching of the arteries and to a lesser extent by plaque compression. Stenting did not change the IVUS measurements. Patency was related to the size of the free lumen and the heterogenicity of the plaque.  (+info)

Antegrade visceral revascularisation via a thoracoabdominal approach for chronic mesenteric ischaemia. (5/1972)

OBJECTIVES: It has been suggested that patients with chronic visceral ischaemia are elderly and emaciated hence they may not tolerate antegrade visceral revascularisation via a thoracoabdominal approach. There are no studies to support this assumption. The purpose of this study is to assess the efficacy of this approach for the treatment of chronic visceral ischaemia. METHODS: Between 1988 and 1996, 10 patients underwent antegrade visceral revascularisation for chronic visceral ischaemia via a thoracoabdominal approach and were followed-up for a mean of 40 months. Eight patients were treated with aorto superior mesenteric artery bypass and implantation of the coeliac axis in the graft and two patients with aorto superior mesenteric bypass alone. Graft patency was monitored with duplex scanning. RESULTS: There were no postoperative deaths in this series. Two patients developed postoperative pulmonary infections and required intubation for a short period of time. All patients were discharged after a mean of 17 days (range 7-38). Follow up with duplex scanning revealed that all grafts were patent. One patient developed a high grade anastomotic stenosis which was followed by recurrence of the symptoms. This was dilated on three occasions by balloon angioplasty within a period of 17 months. On the last occasion a stent was placed and since the patient remains asymptomatic. CONCLUSIONS: Antegrade visceral revascularisation via a thoracoabdominal approach is a durable and effective method of relieving symptoms of chronic visceral ischaemia. The low morbidity in this series justifies larger studies in order to establish the true incidence of complications.  (+info)

Outcome of the first 100 femoropopliteal angioplasties performed in the operating theatre. (6/1972)

OBJECTIVES: To examine the factors influencing outcome and restenosis in an initial series of 100 infrainguinal angioplasties. DESIGN: Prospective study of angioplasties of the superficial femoral and popliteal arteries performed over a 42-month period. MATERIALS AND METHODS: One hundred consecutive angioplasties in 96 patients performed in the operating theatre between January 1993 and June 1996 were followed prospectively with clinical, ABI, and duplex assessment. Forty-four procedures were for disabling claudication and 56 for critical ischaemia. Stents were deployed in 30 limbs. RESULTS: Angioplasty was successful in 84 of 100 limbs. Cumulative patency of the entire group at 3, 6, 12 and 18 months was 78%, 60%, 53%, and 49% respectively, while excluding initial failures, gave patencies of 95%, 69%, 63%, and 58%, respectively. Claudicants with a 1-year patency of 64% did significantly better than patients with critical ischaemia (44% p < 0.05). Angioplasties performed during the initial 21 months had a 1-year patency of 42%, while those performed in the final 21 months had a 74% patency (p = N.S.). The patency for stented arteries was 66% vs. 49% for angioplasty alone (p = N.S.). The 2-year limb salvage rate was 91% in patents with critical ischaemia. Forty-six per cent of restenoses were asymptomatic. CONCLUSIONS: The results suggest that while angioplasty is useful in treating infrainguinal arterial disease, there is a learning curve, resulting in a high restenosis rate for occlusive and multilevel disease, while concomitant placement of stents may be beneficial.  (+info)

Managing Budd-Chiari syndrome: a retrospective review of percutaneous hepatic vein angioplasty and surgical shunting. (7/1972)

BACKGROUND: The role of percutaneous hepatic vein angioplasty in the management of Budd-Chiari syndrome has not been well defined. Over a 10 year period at our unit, we have often used this technique in cases of short length hepatic vein stenosis or occlusion, reserving surgical mesocaval shunting for cases of diffuse hepatic vein occlusion or failed angioplasty. AIMS: To review the outcome of angioplasty and surgical shunting to define their respective roles. PATIENTS: All patients treated by angioplasty or surgical shunting for non-malignant hepatic vein obstruction over a ten year period from 1987 to 1996. METHODS: A case note review of pretreatment features and clinical outcome. RESULTS: Angioplasty was attempted in 21 patients with patent hepatic vein branches and was successful in 18; in three patients treatment was unsuccessful and these patients had surgical shunts. Fifteen patients were treated by surgical shunting only. Mortality according to definitive treatment was 3/18 following angioplasty and 8/18 following surgery; in most cases this reflected high risk status prior to treatment. Venous or shunt reocclusion rates were similar for both groups and were associated with subtherapeutic warfarin in half of these cases. Most surviving patients in both groups are asymptomatic although one surgical patient has chronic hepatic encephalopathy. CONCLUSION: With appropriate case selection, many patients with Budd-Chiari syndrome caused by short length hepatic vein stenosis or occlusion may be managed successfully by angioplasty alone. Medium term outcome is good following this procedure provided that anticoagulation is maintained. Further follow up is required to assess for definitive benefits but we suggest that this should be included as a valid initial approach in the algorithm for management of Budd-Chiari syndrome.  (+info)

Follow-up results of transvenous occlusion of patent ductus arteriosus with the buttoned device. (8/1972)

OBJECTIVES: The purpose of this presentation is to document results of buttoned device (BD) occlusion of patent ductus arteriosus (PDA) in a large number of patients with particular emphasis on long-term follow-up in an attempt to provide evidence for feasibility, safety and effectiveness of this method of PDA closure. BACKGROUND: Immediate and short-term results of BD occlusion of PDA have been documented in a limited number of children. METHODS: During a six-year period ending August 1996, transcatheter BD closure of PDA was attempted in 284 patients, ages 0.3 to 92 years (median 7) under a protocol approved by the local institutional review boards and FDA with an investigational device exemption in U.S. cases. RESULTS: The PDAs measured 1 to 15 mm (median 4) at the narrowest diameter; 20 were larger than 8 mm and 10 larger than 10 mm. They were occluded with devices measuring from 15 to 35 mm delivered via 7F (N = 140) or 8F (N = 144) sheaths. Successful implantation of the device was accomplished in 278 (98%) of 284 patients. The Qp:Qs decreased from 1.8+/-0.6 (mean+/-SD) to 1.09+/-0.19 (p < 0.001). Effective occlusion defined as no (N = 167 [60%]) or trivial (N = 79 [28%]) residual shunt was achieved in 246 (88%) patients. All types of PDAs, irrespective of the shape (conical, tubular or short), size (small or large) or length (short or long) of the PDA and previously implanted Rashkind devices, could be occluded. Follow-up data, 1 to 60 months (median 24) after device implantation, were available in 234 (84%) patients. Seven (3%) patients required reintervention to treat residual shunt with (N = 2) or without (N = 5) hemolysis. Actuarial reintervention-free rates were 95% at 1 and 5 years. There was gradual reduction of actuarial residual shunts and were 40%, 28%, 21%, 14%, 11%, 10%, 6% and 0% respectively at 1 day, 1, 6, 12, 24, 36, 48 and 60 months after device implantation. Incorporation of folding plug over the button loop in 10 additional patients produced immediate and complete occlusion of PDA. CONCLUSIONS: This large multiinstitutional experience confirms the feasibility, safety and effectiveness of buttoned device closure of PDAs. All types of PDAs irrespective of the shape, length and diameter can be effectively occluded. Incorporation of folding plug over the button loop produces complete PDA occlusion at the time of device implantation.  (+info)

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