Faculty Bibliography

OBJECTIVE: We describe a novel approach for the endovascular treatment of femoral artery occlusion as a result of Angio-Seal closure device deployment. BACKGROUND: Angio-Seal is the most commonly used vascular closure device following percutaneous coronary and peripheral catheterizations worldwide. A rare complication of Angio-Seal deployment is an occlusion of the femoral artery leading to limb ischemia requiring revascularization. Given its unique ability to cut both atherosclerotic plaque and the Angio-Seal anchor with a collagen plug at operator-directed planes, TurboHawk/HawkOne atherectomy device can be a fast and effective approach to treat Angio-Seal-associated femoral artery occlusions. METHODS: We studied 13 consecutive patients who developed Angio-Seal-associated femoral artery occlusions that occurred from 3 hours to several weeks after catheterization. These patients were successfully treated with TurboHawk/HawkOne directional atherectomy followed by balloon angioplasty with no complications. During a mean follow-up period of 20.4 +/- 17.3 months, 12 patients remained claudication free with no evidence of obstructive arterial disease of the treated segment on imaging studies. One patient developed restenosis that was treated with repeat atherectomy and balloon angioplasty following which he was asymptomatic at follow-up. CONCLUSION: The use of directional atherectomy followed by balloon angioplasty is a quick, safe, and effective endovascular approach to treating Angio-Seal-associated femoral artery occlusions. It is associated with an excellent success rate, no complications, and good midterm outcomes.

Background: Unlike for coronary artery disease, the association between neutrophil-lymphocyte ratio (NLR) and peripheral artery disease (PAD) has not been well established. The aim of this study was to determine the association between neutrophil-lymphocyte ratio and the severity of lower extremity peripheral artery disease. Methods: A retrospective chart review analysis identified 928 patients referred for peripheral angiography at a tertiary care center between December 2012 and June 2015. NLR was assessed from routine pre-procedural hemograms with automated differentials and available in 733 (79%) patients. Outcomes of interest included extent of disease on peripheral angiography and target vessel revascularization. Median follow-up was 10.4 months. Odds ratio (OR) [95% confidence intervals] was assessed using a logistic regression model. Results: There was a significant association between elevated NLR and the presence of severe multi-level PAD versus isolated suprapopliteal or isolated infrapopliteal disease (OR 1.42 [1.18-1.70], p=<0.001). This association between NLR and severe multi-level PAD remained significant even after adjustment for age (OR 1.31 [1.09-1.58], p=0.004); age, sex, race, and body mass index (OR 1.27 [1.05-1.5], p=0.015); and age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, and creatinine (OR 1.25 [1.03-1.53], p=0.024). In patients who underwent endovascular intervention (n=523), there was no significant difference in the rate of target vessel revascularization on follow-up across tertiles of NLR (1st tertile 14.8%, 2nd tertile 14.1%, 3rd tertile 20.1%; p= 0.32). Conclusion: In a contemporary cohort of patients undergoing peripheral angiography with possible endovascular intervention, elevated NLR was independently associated with severe multi-level PAD

BACKGROUND: In-stent restenosis (ISR) in the superficial femoral artery (SFA) continues to be the Achilles heel of endovascular treatment of obstructive peripheral arterial disease. Stent fracture (SF) has been identified as one of the possible causes of ISR, but data on the role of SF in the development of ISR remains to be controversial. METHODS: 97 consecutive patients (105 limbs) with angiographically confirmed obstructive ISR in the SFA who had previously undergone endovascular revascularization with nitinol stents were studied. Patients with covered stents (Viabahn) were excluded. Stents were evaluated by fluoroscopy in at least 2 orthogonal views. Stent fracture rates, severity, and angiographic relationship to ISR were studied. Logistic regression analysis was performed. RESULTS: Mean time from the stent implantation to presentation with ISR was 15.5+/-15.3 months. Out of 105 limbs with ISR, SF was present in 31 (30%) limbs, of which only 3 (10%) limbs had SF associated with ISR. Stent fracture occurred more frequently in males, smokers, and in the distal SFA. There were no significant differences in mean stented length or procedural and demographic characteristics between groups with and without SF. CONCLUSIONS: Stent fractures in the SFA play a modest role in the development of ISR. In our study, the association between ISR and SF was observed in only 10% of limbs with SF. This represents only 2.9% of the 105 limbs included in our study. Therefore, a vast majority of patients with ISR did not have SF. The strongest predictors of SF were male sex, smoking, and larger stent diameter.

OBJECTIVE: The Tissue Removal Assessment with Ultrasound of the SFA and Popliteal (TRUTH) study assessed the performance of the orbital atherectomy system (OAS) to treat femoropopliteal arteries, including determining its effect on plaque removal. METHODS: Patients with symptomatic femoropopliteal peripheral arterial disease were treated with the OAS followed by adjunctive balloon angioplasty (BA). Intravascular ultrasound (IVUS) images were collected pre- and post-OAS and post-OAS BA. Patients were followed through 12 months post-procedure. RESULTS: Twenty-nine lesions were treated with OAS-BA in 25 patients. The mean maximum balloon inflation pressure was 5.2 +/- 1.2 atm. Virtual histology IVUS (VH-IVUS) analysis revealed at the maximum calcium ablation site that calcium reduction was responsible for 86% of the lumen area increase. The minimum lumen area increased from 4.0 mm2 to 9.1 mm2 (<.0001), and the percentage of area stenosis decreased from 76.9% to 43.0% (<.0001) after OAS-BA. At 12 months, the target lesion revascularization rate was 8.2%, and ankle-brachial index and Rutherford classification improved significantly from baseline through follow-up. CONCLUSION: The VH-IVUS analysis reveals that OAS modifies the calcified component of the plaque burden. It is hypothesized that calcium modification by OAS changes the lesion compliance, allowing for low pressure adjunctive BA. The clinical outcomes were favorable through 12-month follow-up.

Acute mesenteric ischemia is associated with a high mortality rate and requires emergent evaluation and surgical management. However, patients with chronic mesenteric ischemia can undergo either surgical or endovascular revascularization. Review of recent medical literature suggests lower rates of mortality and complications after endovascular revascularization, but higher rates of primary patency after surgical revascularization. The decision regarding method of revascularization in patients with chronic mesenteric ischemia should be based on the patient's vascular anatomy, comorbidities, and life expectancy.

Objective: We describe a novel approach for the endovascular treatment of femoral artery occlusion as a result of Angioseal closure device deployment. Background: Angioseal is the most commonly used vascular closure device following percutaneous coronary and peripheral catheterizations worldwide. A rare complication of Angioseal deployment is occlusion of the femoral artery leading to limb ischemia and requiring revascularization. Given its unique ability to cut both plaque and the Angioseal device at operator-directed planes, TurboHawk can be a fast and effective approach to treat Angioseal-associated femoral artery occlusions. Case Series: We report 4 cases of Angioseal-associated femoral artery occlusions that occurred between 3 hours and 12 days after catheterization. These patients were successfully treated with TurboHawk directional atherectomy followed by balloon angioplasty with no complications. During a mean follow-up period of 12.1 months +/- 8.6 months, patients remained claudication free with no evidence of obstructive arterial disease of the treated limb on imaging studies. Conclusion: The use of directional atherectomy followed by balloon angioplasty is a quick, safe, and effective endovascular approach to treating Angioseal-associated femoral artery occlusions. It is associated with a high success rate, no complications, and good midterm outcomes

There is no universally accepted method to treat in-stent restenosis (ISR) in the superficial femoral artery (SFA). It is hypothesized that using the Viabahn expandable polytetrafluoroethylene- covered stent to treat ISR may prevent tissue infiltration and intimal hyperplasia that leads to restenosis. METHODS: We studied 22 patients (27 limbs) referred for treatment of severe ISR of the SFA. All patients were treated with the Viabahn stent implanted in the restenotic segments. We also analyzed several demographic, procedural, and laboratory parameters that could potentially be predictors of Viabahn restenosis. RESULTS: Among patients treated, 63% had severe claudication and 37% had critical limb ischemia. Mean treated lesion length was 214.8 +/- 87.2 mm, mean run-off score was 3.9 +/- 2.8. Mean follow-up period was 21.8 +/- 10.3 months. Ten patients (37%) developed Viabahn restenosis. The mean lesion length was 180.0 +/- 107.9 mm in the restenosis group and 219.4 +/- 78.9 mm in the no-restenosis group (P=.27). There was no significant difference between the two groups in the rest of demographic, procedural, and laboratory parameters. In 90%, restenosis occurred within the first 12 months and the remaining 10% occurred within 14 months. The mean time to restenosis was 6.2 +/- 4.3 months. We observed no Viabahn ISR occurring after 14 month of follow-up. CONCLUSION: The Viabahn stent can be used to treat ISR in the SFA, with favorable results of 63% primary patency at up to 3 years of follow-up. Analysis of multiple factors showed no association with restenosis occurrence. If the Viabahn remained patent for 14 months, the likelihood of restenosis was low.

As the number of endovascular peripheral arterial interventions is increasing nationwide, so is the rate of observed in-stent restenosis, specifically in the superficial femoral artery. A paucity of literature is available regarding the pathophysiology, risk factors, and therapies associated with in-stent restenosis of the superficial femoral artery. This article summarizes the accumulated knowledge on these topics and sheds some light on the prospects for future therapies.