Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery

Lam, Russell C.; Shah, Syed G.; Faries, Peter L.; McKinsey, James F.; Kent, K. Craig; Morrissey, Nicholas J.

doi:10.1016/j.jvs.2007.07.058

Cited by 132 publications

(46 citation statements)

References 22 publications

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“…67 Its predictors are long occlusions, thrombotic lesions, 67 mechanical thrombectomy, 26 directional atherectomy, 6,65 and laser atherectomy. 9,27,29,68 The occurrence of DE is associated with limb loss independent of preoperative runoff and subsequent intervention. 37 Patients with no DE during FP procedures had shorter procedure times, less contrast use, and reduced fluoroscopy exposure.…”

Section: Procedural Factorsmentioning

confidence: 99%

An Overview of Optimal Endovascular Strategy in Treating the Femoropopliteal Artery: Mechanical, Biological, and Procedural Factors

Shammas¹

2013

Int J Angiol

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ReviewPeripheral arterial disease is highly prevalent in the general population affecting 12 to 14% of people and leading to claudication or threatened limb ischemia. 1 Endovascular lower extremity arterial interventions have increased exponentially over the past decade. 2 The femoropopliteal (FP) segment represents 40% of vessels treated and its treatment continues to be a challenge to the endovascular specialist. Despite a high rate of acute procedural success, target lesion revascularization (TLR) and target vessel revascularization remain elevated. 3,4 We have previously proposed a triad of optimal peripheral vascular revascularization strategy (►Fig. 1) 5 with an emphasis on three key principles: (1) Mechanical, improve vessel compliance to allow dilatation of a stenotic segment at low balloon inflation pressure and reduce dissection and recoil. Low balloon inflation pressure would theoretically preserve vessel integrity by minimizing barotrauma and bailout stenting. (2) Biological, inhibit smooth muscle cell (SMC) proliferation to improve patency rates and reduce repeat revascularization. (3) Procedural, preserve the outflow vessels by minimizing distal embolization (DE) and reduce procedural time and radiation exposure to both operator and patient.In this overview, we examine these principles to determine whether current data support their validity. We recognize the lack of uniform performance criteria and reporting standards in clinical trials in peripheral arterial disease. This unfortunately makes comparisons across studies difficult. Mechanical FactorsThe concept of improving vessel compliance as a prerequisite to a more definitive treatment of the FP artery has gained more attention over the past few years. Measurement of vessel compliance in vivo is difficult to obtain. One surrogate endpoint is the minimum balloon pressure (MBP) needed to fully stretch the artery to a lumen diameter equal to a normal reference segment with the use of a noncompliant balloon sized 1:1 to the reference vessel. The balloon is typically inflated to two atmospheres then the inflation pressure is increased by increment of one atmosphere at a time until full balloon expansion is achieved. 6,7 According to Laplace's law, tension (T) in the vessel wall is equal to (pressure (P) gradient across the arterial wall * radius (R) of artery)/wall thickening (M), or (T¼ [P * R]/M). In order for MBP change to reflect on compliance, the segments under comparison need to have similar radius and lesion Keywords AbstractTreatment of the femoropopliteal (FP) artery remains a challenge to the endovascular specialist. Long-term patency is low with a high rate of target lesion revascularization. The true patency rate varies considerably between studies partly because there is a lack of uniform performance criteria and reporting standards in peripheral arterial interventions. Literature review supports three principles that emerge as important components of an optimal strategy in treating the FP artery: (1) improving vessel compliance and sub...

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Section: Procedural Factorsmentioning

confidence: 99%

An Overview of Optimal Endovascular Strategy in Treating the Femoropopliteal Artery: Mechanical, Biological, and Procedural Factors

Shammas¹

2013

Int J Angiol

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“…8–10 Clinical presentation is variable, ranging from asymptomatic emboli to major emboli with limb-threatening ischemia. Some patients who develop embolization may necessitate prolonged hospital stay, re-interventions to restore flow into the occluded artery, and the risk of limb loss has not been well described.…”

Section: Introductionmentioning

confidence: 99%

Clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices

Mendes

Oderich

Fleming

et al. 2014

Journal of Vascular Surgery

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Objective The purpose of this study was to evaluate the incidence and clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices (EPDs). Methods We reviewed the clinical data of 566 patients treated by 836 endovascular femoropopliteal interventions for lower extremity claudication (46%) or critical limb ischemia (54%) from 2002 to 2012. Outcomes were analyzed in 74 patients/ 87 interventions performed with EPDs (Spider Rx, Covidien, Plymouth, MN) and 513 patients/ 749 interventions performed without EPDs. TASC classification, run-off scores and embolic events were analyzed. End-points were morbidity, mortality, re-intervention, patency and major amputation rates. Results Both groups had similar demographics, indications, cardiovascular risk factors and run-off scores, but patients treated with EPDs had significantly (P<0.05) longer lesions (109±94 vs 85±76mm) and more often had occlusions (64% vs 30%) and TASC C/D lesions (56% vs 30%). Embolic events occurred in 35 of 836 interventions (4%), including 2 (2%) performed with EPD and 33 (4%) without EPD (P=0.35). Macroscopic debris was noted in 59 (68%) filter baskets. Embolic events were not associated with lesion length, TASC classification, run-off scores, treatment type or indication, but were independently associated with occlusion. Patients who had embolization required more re-interventions (20% vs 3%, P<.001) and major amputations at 30-days (11% vs 3%, P=0.02). There was no difference in hospital stay (2.4±4 vs 1.6±2 days, P=0.08), re-intervention (2% vs 4%) and major amputation (1% vs 4%) among patients treated with or without EPD, respectively. The two patients who developed embolization with EPDs had no clinical sequela and required no re-intervention. Most emboli were successfully treated by catheter aspiration or thrombolysis, but 8 patients (24%) treated without EPD required prolonged hospital stay, 7 (21%) had multiple re-interventions, 1 (3%) had unanticipated major amputation, and 1 (3%) died from hemorrhagic complications of thrombolysis. Median follow up was 20 months. At 2-years, primary patency and freedom for re-intervention was similar for TASC A/B and TASC C/D lesions treated with or without EPDs. Conclusions Rates of embolization are low in patients undergoing endovascular femoropopliteal interventions with (4%) or without (2%) EPD. Embolization is more frequent in patients with occlusions. While emboli in patients with EPD had no clinical sequel, those treated without EPD require multiple re-interventions in 21% or resulted in major amputation or death in 3%. Late outcomes were similar in patients treated with or without EPDs.

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“…Contemporary studies have demonstrated a higher rate of DE in the filter of EPDs (20–58%) [3], [7], [11], or detected by Doppler ultrasound (100%) [8], [12], than angiographically (1%–5%) [1], [2]. The reported incidence of limb-threatening DE during routine lower extremity intervention is 1–2% [1], [13].…”

Section: Discussionmentioning

confidence: 99%

“…The concern for DE in lower extremity interventions has led to a debate [4]. Some recommend the use of a variety of embolic protection devices (EPDs) [5], [6], [7], while other evidence suggested that EPDs may be unnecessary [2], [8]. Clinical data have shown that the application of EPDs in lower extremity is generally safe [4].…”

Section: Introductionmentioning

confidence: 99%

Incidence, Risk Factors, Treatment and Prognosis of Popliteal Artery Embolization in the Superficial Femoral Artery Interventions

Hua

et al. 2014

PLoS ONE

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ObjectivePercutaneous transluminal angioplasty and stenting (PTA + stent) has gained acceptance as a primary treatment modality for the superficial femoral artery (SFA) diseases. Popliteal artery embolization (PAE) is a severe complication in SFA interventions. The purpose of this study was to evaluate the incidence, risk factors, treatment and prognosis of PAE in primary SFA PTA + stent.MethodsChronic SFA arteriosclerosis cases that underwent primary PTA + stent were reviewed from a retrospectively maintained database. Runoff vessels were evaluated in all cases before and after the interventions for PAE detection. The primary patency, secondary patency and limb salvage rates were calculated using Kaplan-Meier analysis and compared using log-rank analysis. Cox multivariate regression was performed to evaluate predictors of patency and limb salvage rates.ResultsThere were 436 lesions treated in 388 patients with 10 PAE events (2.3%) in total. PAE rate was significantly higher in Transatlantic Inter-Society Consensus (TASC) C/D group compared with TASC A/B group (OR = 8.91, P = .002), in chronic total occlusion (CTO) lesions compared with stenotic lesions (P<.0001), and in group with history of cerebral ischemic stroke (OR = 6.11, P = .007). PAE rates were not significantly affected by age, sex, smoking, hypertension, diabetes, hyperlipidemia and runoff status. The binary logistic regression showed that only the TASC C/D was an independent predictor of PAE (P = .031). The 12-month and 24-month primary patency, secondary patency and limb salvage rates in PAE group showed no significant differences comparing with non-PAE group.ConclusionsPAE is a rare event in primary SFA PTA + stent. TASC C/D lesion, CTO and cerebral ischemic stroke history are risk factors for PAE. PAE is typically reversible by comprehensive techniques. If the popliteal flow is restored in time, PAE has no significant effect on long-term patency and limb salvage rates.

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Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery

Cited by 132 publications

References 22 publications

An Overview of Optimal Endovascular Strategy in Treating the Femoropopliteal Artery: Mechanical, Biological, and Procedural Factors

An Overview of Optimal Endovascular Strategy in Treating the Femoropopliteal Artery: Mechanical, Biological, and Procedural Factors

Clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices

Incidence, Risk Factors, Treatment and Prognosis of Popliteal Artery Embolization in the Superficial Femoral Artery Interventions

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