A Review of Peripheral Vascular Intervention Technologies

Distal Vessel Occlusions in Acute Ischemic Stroke: Reframing Patient Selection and Reperfusion Strategies.

Midterm Outcomes of Endovascular‐First Revascularization for Multilevel Peripheral Arterial Disease With Chronic Limb‐Threatening Ischemia: A Retrospective Study From Vietnam

Background Peripheral arterial disease (PAD) with chronic limb‐threatening ischemia (CLTI) represents advanced systemic atherosclerosis and carries high risks of amputation and mortality. Multilevel arterial involvement is common and often requires revascularization of both inflow and outflow segments. However, midterm outcome data in Vietnam remain limited. Objectives This study is aimed at evaluating midterm clinical outcomes and identifying factors associated with wound healing, all‐cause mortality, and major limb amputation after an endovascular‐first revascularization strategy for multilevel PAD with CLTI. Methods This retrospective case series included 91 patients with multilevel PAD (≥ 2 anatomical levels according to TASC II) and CLTI (Rutherford 4–6) treated at a tertiary hospital in Vietnam from 2017 to 2019. Patients were followed for 24 months. Kaplan–Meier analysis was used to describe survival, limb salvage, and wound healing over 24 months. Univariable and multivariable logistic regressions were used to identify factors associated with fixed‐time binary outcomes within 24 months, including wound healing, mortality, and major limb amputation. Results The mean age was 74.0 ± 11.6 years, and 82.4% were male. The ankle–brachial index improved significantly after intervention (0.2 vs. 0.5; p < 0.001). The mean follow‐up duration was 18.9 ± 8.3 months. At 24 months, mortality was 27.5%, major amputation occurred in 18.7% (limb salvage 81.3%), and 62.2% of patients with tissue loss achieved wound healing (median 5 months). Age ≥ 75 years and neutrophil‐to‐lymphocyte ratio ≥ 3.5 were independently associated with reduced wound healing. Wound healing was associated with lower mortality and amputation risk. Adjunctive open surgery reduced limb amputation. Conclusion An endovascular‐first revascularization strategy for multilevel PAD with CLTI achieved acceptable midterm limb salvage and wound healing, although mortality remained considerable. Risk stratification and multimodal care are essential to improve outcomes.

Treating More Than One Tibial Arteries in Patients with Chronic Limb Threatening Ischaemia is Associated with Fewer Major Re-interventions.

OBJECTIVE It is unclear whether treating multiple diseased tibial arteries at initial revascularisation improves outcomes with chronic limb threatening ischaemia (CLTI). Using data from the Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial this study aimed to compare single arterial intervention (SAI) with multiple arterial intervention (MAI) for infrapopliteal disease. METHODS A retrospective, as treated analysis of the endovascular dataset from the BEST-CLI trial was undertaken to compare SAI with MAI. Only patients with multiple tibial vessel arterial occlusive disease with > 50% stenosis were included. Evaluated outcomes included major re-interventions (new bypass, interposition graft, thrombectomy, or thrombolysis), major adverse limb events (MALE)/death, and above ankle amputations. Risk adjusted analysis was performed. RESULTS There were 324 patients included: 224 SAI and 100 MAI. On unadjusted analysis at 3 years, SAI had a higher rate of a major re-intervention (19.2% vs. 5.3%; p = .010) and MALE/death (56.4% vs. 43.6%; p = .030), while there was no difference for above ankle amputation (19.7% vs. 13.1%; p = .14), amputation/death (45.2% vs. 43%; p = .53), or all cause death (37.7% vs. 33.5%, p = .57). SAI and MAI were associated with similar rates of resolution of initial CLTI symptoms (75.9% vs. 86%; p = .60). On risk adjusted analysis, SAI was associated with a higher rate of major re-intervention (odds ratio [OR] 3.14, 95% confidence interval [CI] 1.2 - 8.2; p = .019) than MAI; however, there was no increase in any re-intervention (OR 0.95, 95% CI 0.6 - 1.49; p = .80), MALE/death (OR 1.27, 95% CI 0.86 - 1.89; p = .24), above ankle amputation (OR 1.53, 95% CI 0.74 - 3.19; p = .25), initial CLTI resolution (OR 1.16, 95% CI 0.85 - 1.59; p = .36), or death (OR 1.03, 95% CI 0.64 - 1.63; p = .90). CONCLUSION In patients with diffuse tibial arterial occlusive disease, treatment of multiple tibial arteries rather than just one at the time of index revascularisation was associated with fewer major re-interventions and should be considered.

Quantification of Hemodynamic Changes and Wound Healing Following Transcatheter Arterialization of the Deep Veins (TADV) in No-Option Chronic Limb-Threatening Ischemia.

OBJECTIVE Transcatheter arterialization of the deep veins (TADV) is a novel therapy for no-option chronic limb-threatening ischemia (CLTI) that delivers oxygenated blood to the foot via the venous system and has demonstrated favorable limb salvage outcomes in several studies, including the PROMISE II trial. The present study characterizes circuit maturation in the PROMISE II cohort by examining its longitudinal hemodynamic development and associated wound healing, with the goal of better defining the mechanism of action of TADV. METHODS PROMISE II (NCT03970538) was a prospective, multicenter study on TADV in patients with no-option CLTI due to "desert foot" arterial anatomy. The objective was to evaluate longitudinal changes following TADV including hemodynamics from duplex ultrasound, distal perfusion, and wound healing over time. Clinical outcomes, perfusion metrics, and serial duplex ultrasound data were collected through 1 year using standardized protocols. Duplex studies evaluated volume flow and spectral Doppler parameters across the TADV circuit. Distal perfusion was assessed using toe-brachial index (TBI) and toe pressures. Duplex-derived waveforms were categorized as low- or high-resistance, and longitudinal hemodynamic changes were analyzed. Circuit maturation was assessed using characteristics such as waveform achieving high-resistance configuration and decreased acceleration time indicating vascular remodeling. RESULTS A total of 105 patients from PROMISE II were included in the analysis. Limb salvage was 68.7% at 1 year. Among patients with adjudicated wound data, 75.5% were healed/healing at 1 year; patients with worsening status decreased from 52.6% to 14.3%, while complete healing increased to 46.9%. Circuits transitioned from low- to high-resistance waveforms (7.9% at baseline, 24.6% at 3 months, 37.7% at 6 months, 81.1% at 1 year, p<0.0001). At 1 year, in patients with high-resistance circuits, healed/healing wound status was 86.7%, TBI ≥0.3 was 57.1%, and toe pressure ≥40 mmHg was 78.3% indicating greater distal perfusion. CONCLUSIONS TADV promotes limb salvage through staged hemodynamic maturation demonstrated with duplex, microvascular remodeling, sustaining perfusion, and supporting its durable benefit in no-option CLTI.

The diagnosis and current treatment of chronic lower extremity arterial disease.

Chronic lower extremity arterial disease (PAD) can be categorized into three subsets: Asymptomatic PAD, Chronic Symptomatic PAD, and Chronic Limb Threatening Ischemia (CLTI). Symptoms, signs and treatment of patients in each category are presented. Ankle Brachial Pressure index and Doppler ultrasound should be measured and individuals with chronic symptomatic PAD and CLTI should undergo computed tomographic angiography (CTA), magnetic resonance angiography (MRA), or contrast peripheral vascular angiography for arterial revascularization evaluation. Medical therapy is initial treatment for asymptomatic and symptomatic chronic PAD and CLTI and should include a statin, antihypertensive medications, antiplatelet and antithrombotic therapy, and management of diabetes. American and European Society of Cardiology guidelines for CLTI with endovascular or surgical arterial revascularization are reviewed. Guidelines provide a Class 1 (strong) recommendation for endovascular therapy for patients with symptomatic claudication with hemodynamically significant aortoiliac or femoral popliteal disease who fail medical therapy and a structured exercise program. A Class 2 recommendation (i.e. reasonable) is given to surgical revascularization if preoperative risk is acceptable, technical factors suggest specific advantages over endovascular procedures, and an autologous saphenous vein is available for grafting. Rivaroxaban + Aspirin or a purinergic receptor P2Y G-protein coupled inhibitor + ASA and an exercise program are recommended for patients with chronic PAD.

TPTh 5.03 Outcomes Following Common Femoral Endarterectomy Without Distal Revascularisation: A Five-Year Cohort

Peripheral arterial disease involving the common femoral artery can cause chronic limb-threatening ischaemia (CLTI) and intermittent claudication (IC). Common femoral endarterectomy (CFE) +/- iliac intervention (inflow restoration) can alleviate symptoms, although may be inadequate for advanced CLTI or significant disease distal to this (femoro-popliteal/infra-popliteal). This study reports clinical outcomes following CFE without simultaneous distal intervention. Retrospective observational study of patients with CLTI and (IC) undergoing CFE +/- iliac intervention over a five-year period in a tertiary vascular unit was performed. Patient characteristics, Rutherford scores, Global Limb Anatomic Staging System (GLASS), operative details, and post-operative complications were collected. Outcomes were post-operative resolution of rest pain and healing, walking distance improvement for claudicants, major limb amputation (MLA) and 30-day mortality. There were 79 patients included: 49/79 (62%) were male, median age was 71 and 53/79 (57%) were from Scottish Index Multiple Deprivation (SIMD) quintiles 1-3. An iliac intervention was performed in 30/79 (38%) patients. CLTI (80.6%) predominated with Rutherford score (4-6) and 19.8% had IC (Rutherford score 1-3). Most patients had distal disease: 45/79 (57%) GLASS score III; 13/79 (16%) GLASS score II and 15/79 (19%) GLASS score I. For CLTI 57/62 (92%) reported rest pain resolution, 54/62 (87%) achieved wound healing and 8/62 (13%) progressed to MLA. All IC cases achieved improved walking distance. Thirty-day mortality was 5/79 (6%). In this study isolated inflow correction by CFE +/-iliac intervention can achieve good postoperative outcomes even with distal disease.