Clinical Outcomes of the Intraluminal Approach for Long Occlusive Femoropopliteal Lesions Assessed by Intravascular Ultrasound

Abstract

Aim: To investigate the relationship between intravascular ultrasound (IVUS) findings and restenosis after stent implantation for long occlusive femoropopliteal (FP) lesions using the intraluminal approach.Methods: This was a single-center retrospective study of 45 patients (49 lesions) with de novo long occlusive FP lesions treated with bare metal stents implanted using the intraluminal approach under IVUS guidance from April 2007 to December 2014. All patients were followed up at least 12 months. The preprocedural and postprocedural IVUS findings were compared for patients with and without restenosis, which was defined as a peak systolic velocity ratio of > 2.4 on duplex ultrasonography or > 50% diameter stenosis on angiography.Results: Within 12 months, 13 patients (14 lesions) developed restenosis, whereas 32 patients (35 lesions) did not (restenosis rate = 29%). The male:female ratio and the prevalence of diabetes mellitus, hemodialysis, and critical limb ischemia were similar between the two groups. No significant differences were observed in lesion length, chronic total occlusion (CTO) length, and the percentage of involving popliteal lesion between the two groups. A whole intraplaque route was gained in 15 lesions (31%). Multivariate analysis revealed that the within-CTO intramedial route proportion and the distal lumen cross-sectional area (CSA) were independent predictors of restenosis. Receiver operating characteristic analysis showed that the best cutoff values of these parameters were 14.4% and 17.7 mm2, respectively.Conclusions: In patients with long occlusive FP lesions undergoing stent placement using the intraluminal approach, a whole intraplaque route was gained in 31%. Restenosis is more likely if IVUS shows a within-CTO intramedial route proportion of > 14.4% or distal lumen CSA of < 17.7 mm2.

Successful re-entry using the outback® elite catheter via retrograde popliteal access with IVUS guidance for femoropopliteal occlusion: a case report

“…For femoropopliteal CTO, the likelihood of restenosis in the remote phase increases in tandem with the length passed through by the subintimal route (Mori et al 2017 ). In contrast, some studies have reported the success of the subintimal approach (Ishihara et al 2016 ).…”

IVUS Assessment of the Crossing Pathway of an Intraluminal Reentry Device Used in the Primary Treatment of Infrainguinal Chronic Total Occlusions

“…In a study of cases with long occlusive length (mean of 177 mm), however, the intraplaque route accounted for only 73% of the total distance. 9 Nonetheless, even in cases with longer CTO length, the reentry device achieved a predominantly intraplaque route. One possible explanation is the inclusion of an alarm system, which rang mainly in subintimal locations according to IVUS assessment.…”

“…5 The proportion of total distance within the plaque may affect the final CTO patency. 9 Specifically, a primary crossing device approach with a high proportion of intraplaque crossing may improve patency and reduce the risk of reintervention. However, the aforementioned report was from a retrospective registry, 5 so additional follow-up of the present study cohort is required to verify whether the primary reentry device approach for CTOs improves patency, freedom from reintervention, and amputation rates.…”

“…8 A previous report evaluating intraluminal wire crossing of CTOs with IVUS assessment found that the proportion of plaque crossings (relative to total route distance) may affect primary patency. 9 Therefore, this study employed IVUS to fully assess the crossing pathway of an established transluminal crossing device used for primary antegrade recanalization of infrainguinal CTOs.…”

Primary Use of the TruePath Crossing Device for Infrainguinal Chronic Total Occlusions With Intravascular Ultrasound Evaluation

“…IVUS assessment of the intraluminal approach for long femoropopliteal CTOs has shown that a within-CTO intramedial route proportion >14.4% was likely to affect 12-month restenosis. 10 That is why the operator must maximize intraluminal crossing length within limited time constraints. Even if the complete CTO is difficult to cross using the TruePath, simply reducing the length of the occlusion is meaningful.…”