Editor's choice - thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.

OBJECTIVE: To compare 30 day outcomes and costs of fenestrated and branched stent grafts (f/b EVAR) and open surgery (OSR) for the treatment of complex abdominal aortic aneurysms (AAA) and thoraco-abdominal aortic aneurysms (TAAA). METHODS: The multicenter prospective registry WINDOW was set up to evaluate f/b EVAR in high risk patients with para/juxtarenal AAA, and infradiaphragmatic and supradiaphragmatic TAAA. A control group of patients treated by OSR was extracted from the national hospital discharge database. The primary endpoint was 30 day mortality. Secondary endpoints included severe complications, length of stay, and costs. Mortality was assessed by survival analysis and uni/multivariate Cox regression analyses using pre- and post-operative characteristics. Bootstrap methods were used to estimate the cost-effectiveness of f/b EVAR versus OSR. RESULTS: Two hundred and sixty eight cases and 1,678 controls were included. There was no difference in 30 day mortality (6.7% vs. 5.4%, p = 0.40), but costs were higher with f/b EVAR (€38,212 vs. €16,497, p < .001). After group stratification, mortality was similar with both treatments for para/juxtarenal AAA (4.3% vs. 5.8%, p = .26) and supradiaphragmatic TAAA (11.9% vs. 19.7%, p = .70), and higher with f/b EVAR for infradiaphragmatic TAAA (11.9% vs. 4.0%, p = .010). Costs were higher with f/b EVAR for para/juxtarenal AAA (€34,425 vs. €14,907, p < .0001) and infradiaphragmatic TAAA (€37,927 vs. €17,530, p < .0001), but not different for supradiaphragmatic TAAA (€54,710 vs. €44,163, p = .18). CONCLUSION: f/b EVAR does not appear justified for patients with para/juxtarenal AAA and infradiaphragmatic TAAA fit for OSR but may be an attractive option for patients with para/juxtarenal AAA not eligible for surgery and patients with supradiaphragmatic TAAA. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov/ct2/show/NCT01168037; identifier: NCT01168037 (WINDOW registry).

Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Results and factors affecting early outcome of fenestrated and/or branched stent grafts for aortic aneurysms: a multicenter prospective study.

OBJECTIVE: To present results and to identify predictive factors of early outcome after fenestrated and/or branched endovascular repair (f/b-EVAR) for complex aortic aneurysms, abdominal (AAA) and thoracoabdominal (TAAA). BACKGROUND: Feasibility of f/b-EVAR for complex aneurysms is now established, but little is known about which patients will benefit from this technique. METHODS: Univariate and multivariate analysis of preoperative and intraoperative factors on postoperative mortality and complications was performed on 268 patients (group 1: juxta- and pararenal AAA; group 2: suprarenal and TAAA IV; group 3: TAAA I, II, III) enrolled in a prospective multicenter trial of f/b-EVAR. RESULTS: Thirty-day mortality, in-hospital mortality (IM), and combined mortality and severe complications (CMSC) rates were 6.7%, 10.1%, and 22.0%, respectively. Group belonging (2 or 3 vs 1) was the only preoperative predictive factor of CMSC [hazard ratio (HR) = 2.10; 95% confidence interval (CI): 1.26-3.48; P = 0.0043]. Occurrence of a technical complication and duration of intervention significantly influenced both IM (HR = 4.39; 95% CI: 2.05-9.38; P = 0.0001) and CMSC (HR = 3.07; 95% CI: 1.84-5.11; P < 0.0001). Postoperative events associated with increased IM were spinal cord ischemia (HR = 9.46; 95% CI: 3.98-22.47; P < 0.0001), hemodialysis (HR = 27.44; 95% CI: 12.63-59.61; P < 0.0001), and reintervention (HR = 4.45; 95% CI: 2.03-9.73; P = 0.0002). CONCLUSIONS: Although promising, f/b-EVAR still carries a significant rate of mortality and complications, mostly related to the complexity of the procedure. In these complex cases, new strategies should be investigated to improve outcomes.

Inter-observer variability in sizing fenestrated and/or branched aortic stent-grafts.

BACKGROUND: Several studies have examined inter-observer variability in measurements for standard EVAR, but little is known about measurements for complex aortic aneurysm. METHODS: Two independent observers reviewed all preoperative CT scans of 268 patients in a French trial of fenestrated and/or branched aortic stent-grafts (f/b-EVAR). Those data were compared with those obtained (1) by investigators (extent of aneurysm, target vessel stenosis, and aortic diameters), and (2) from manufacturers (proximal landing zone, device diameter, and target vessel position). We assessed the reproducibility using kappa statistics for qualitative data and both Bland-Altman plot and Passing-Bablok regression analysis for quantitative data. RESULTS: Reproducibility was moderate to almost perfect for all factors. However, a few critical discrepancies were found, such as target vessel clock position (≥45 minutes) and location (≥5 mm), level of proximal landing zone, and diameters of the endograft. CONCLUSIONS: This is the first large-scale analysis focused on inter-observer variability in sizing for f/b-EVAR. The measurement data showed good agreement, but there were some critical discrepancies between observers that may affect clinical results.

New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience.

OBJECTIVES: To assess causative pathogens and surgical outcomes in patients with primary infected aorto-iliac aneurysms at our institution. DESIGN: Retrospective study of patients treated at a university hospital between 1992 and 2009. RESULTS: We identified 26 patients (median age, 63 years) with primary infected aneurysms on the aorta (descending thoracic, n = 2; thoraco-abdominal, n = 3; suprarenal, n = 2; infrarenal, n = 15) or iliac arteries (n = 4). Among them, 22 were symptomatic, including 13 with ruptured aneurysms. The causative organisms, identified in 25/26 patients, were Campylobacter fetus, n = 6; Streptococcus pneumoniae, n = 4; Listeria, n = 3; Salmonella, n = 2; Mycobacterium tuberculosis, n = 2; Staphylococcus aureus, n = 1; and other, n = 7. Immune suppression was a feature in 10 (38.4%) patients. Revascularisation was performed in situ in 23 patients (10 allografts, eight grafts, three superficial femoral veins, and 2 stentgrafts) and by extra-anatomic bypass in three patients. Hospital mortality was 23% (in situ group, 17.4%; extra-anatomic group, 66.7%; χ(2)(Yates), P = 0.24). During follow-up in the 20 survivors (median, 48.5 months), there were two non-infection-related deaths (five and 24 months) and six (30%) vascular complications. CONCLUSIONS: The bacteriological spectrum of primary infected aorto-iliac aneurysms was wider than previously reported. The availability of new diagnostic tests and increased prevalence of immunosuppression may explain this finding.

Abdominal aortic aneurysm sac behavior following Cook Zenith graft implantation: a five-year follow-up assessment of 212 cases.

AIM: Aneurysm shrinkage is an expected outcome after stent-grafting for abdominal aortic aneurysm (AAA). A worrying problem following repair is progressive enlargement indicating persistent sac pressurization: in this setting not all grafts are equal. The Cook Zenith device (CZ) became available on the European market in 1999. While multicenter studies on the device have shown favorable clinical results at mid-term follow-up, few have focused on sac behavior. This study evaluated AAA sac behavior and predictive factors of its evolution by assessing the five-year results obtained with the CZ graft in a single-institution experience. METHODS: All consecutive elective surgery patients treated with a CZ graft for infrarenal aortic or aortoiliac aneurysm repair from January 2000 to November 2004 in our institution were included prospectively in the study and followed at 1, 6, 12, 18, 24 months and yearly thereafter. Pre-, intra- and postoperative data were recorded in a computerized database. Computed tomography (CT) scans were reviewed by a senior radiologist to identify any abnormalities including endoleak and graft malfunction. Pre- and postoperative maximum sac diameters were derived from measurements of CT findings and then compared. A change of at least 8 mm in sac size was considered significant. Overall results are expressed according to the Committee on Reporting Standards of AAA treatment. Factors that may have influenced sac behavior were analyzed by dividing the patients into 3 groups according to whether the sac diameter remained unchanged (group 1), had increased (group 2) or regressed (group 3). Statistical analysis of the demographic and CT-scan data was then performed. RESULTS: The study sample was 212 consecutive patients (mean age 72.8+/-9.0 years); the mean aneurysm diameter before treatment was 55.5+/-9.8 mm. All stent grafts were successfully implanted. The 30-day mortality rate was 0.94% (2/212); the morbidity rate was 11.7% (25/212). The primary technical success rate was 93.40%; the assisted primary technical success and secondary technical success rates were 96.63% and 99.52%, respectively. The mean follow-up period was 17.7+/-14.7 (1-60) months. The cumulative survival probability was 94%, 84.2%, and 72.9% at 12, 24, and 36 months, respectively. The endoleak-free survival probabilities at 12 and 24 months were 75.7% and 62.8%, respectively. The free of intervention survival rates were 82.1%, 68.9% and 60.6% at 12, 24 and 38 months, respectively. At five years follow-up, the overall clinical success rate was 49.5%. If changes in sac diameter occurred, they were noted at 13 months on average. Sac size remained unchanged in 115 (54.3%) patients (group 1), increased in 9 (4.2%) (group 2), and regressed in 88 (41.5%) (group 3). Neither preoperative patient demographics nor aneurysm characteristics were found to be predictive of sac behavior. Aortouniliac graft configuration was predictive of sac shrinkage (P=0.020). Endoleak was more frequent among patients in groups 1 (27/115; 23%) and 2 (5/9; 56%) than among those in group 3 (9/88;10%) (P=0.001). Reduction in aneurysm sac diameter was less marked in patients with any type of endoleak (P=0.0003). CONCLUSION: The CZ grafts offered satisfactory overall results up to five years of follow-up; nevertheless, sac diameter increased in 4.25% of patients. Endoleak was a predictive factor of a lack of sac shrinkage, while aortouniliac graft configuration was predictive of sac shrinkage.

Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful?

INTRODUCTION: We hypothesized that the coverage of the hypogastric artery with a stent-graft causes an occlusion of the artery in its proximal segment, allowing collateral network formation in distal segments of the artery. In contrast, hypogastric embolisation may cause the formation of microthrombi that tend to disseminate leading to embolic occlusion of secondary branches and collaterals. This phenomenon worsens pelvic ischemia. To answer this question we compared two groups of patients with aortoiliac aneurysms treated with or without coil embolization to assess 1) The occurrence and evolution of buttock ischemia and 2) the effect on endoleak. MATERIALS/METHODS: Between October 1995 and January 2007, 147 out of 598 EVAR patients (24.6%) required occlusion of one or both hypogastric arteries. 101 were available for over one year of follow-up. Group A included 76 patients (75%) who underwent coil embolization before EVAR and group B 25 patients (25%) who had their hypogastric artery covered by the sole limb of the stent. Patient demographics, aneurysm characteristics, operative details, immediate and long term clinical outcomes, and CT-scan evaluation were stored prospectively in a specific data base and analyzed retrospectively. RESULTS: They were 96 males (95%). Mean age was 72.1+/-9.5 years. One month postoperatively, 51 patients (50.0%) suffered from buttock claudication. After six months, 34 patients were still disabled (34%), 32 in Group A (42%) and 2 in Group B (8%) (p=0.001). Post-operative sexual dysfunction occurred in 19 (19.6%) without statistical difference between the two groups. Type 2 endoleaks occurred in 12 patients (16.0%) in group A and 4 patients (16.0%) in group B (p=1). Endoleak from the hypogastric artery occurred in one patient in each group. Univariate analysis showed that predictive factors of long term (over six months) buttock claudication were embolization (p<0.001), younger age (p<0.03), coronary disease (p=0.06) and left ventricular dysfunction (p<0.01). The logistic regression analysis showed that buttock claudication was independently associated with embolization OR=9.1[95%CI=1.9-44] and left ventricular dysfunction OR=4.1[95%CI=1.3-12.7]. CONCLUSIONS: Coil embolization of hypogastric artery during EVAR is not an innocuous procedure and may not reduce the rate of type II endoleak.

Embolization of hypogastric artery aneurysm: 17 cases.

Surgical management of hypogastric artery aneurysm is associated with high morbidity due to hemorrhage and ischemia. Occlusion by embolization is an attractive alternative treatment. Between 1991 and 1995, we used Gianturco coils to embolize 17 hypogastric aneurysms in 14 patients. All patients were men with a mean age of 77 years. Ten patients had previously undergone aortic repair. Complete occlusion of the aneurysm was achieved in 16 cases but placement of an iliac stent was required in 1 case. Embolization failed in one case involving rupture of a large aneurysm. No complications were observed. Moderate buttock claudication was noted after bilateral embolization in three cases. Embolization of hypogastric artery aneurysm using coils resolves the long-term problems associated with surgical ligation. Extensive aneurysm of the origin to the bifurcation is the main indication for nonresective treatment but embolization can also be a useful alternative to open surgery for high-risk patients. Availability of stent grafts may extend the indication for endovascular treatment.

[Pulmonary textiloma revealed by hemoptysis 12 years after thoracotomy]. / Textilome pulmonaire révélé par une hémoptysie 12 ans après thoracotomie.

INTRODUCTION: Pulmonary textiloma or retained surgical sponge is rare but can have detrimental consequences. Its diagnosis is difficult, even when using computerized tomography (CT) scan and is always a medical and legal problem. EXEGESIS: We report the case of a 46-year-old man with a history of pulmonary tuberculosis diagnosed by thoracotomy in 1986, who was admitted to hospital for hemoptysis. CT scan showed the existence of a pulmonary lesion. Clinical, radiological and fiberoptic endoscopy features mimicked an abscess or bronchiectasis. The patient underwent left inferior lobectomy. Anatomical findings led to the diagnosis of textiloma. CONCLUSION: This case shows the difficult in diagnosing pulmonary textiloma, even when using CT scan. Textiloma should be considered when an atypical pulmonary mass is found in a patient with past history of thoracotomy.

[Aneurysm of the iliac artery in an elderly subject. Role of treatment with covered endoprosthesis]. / Anévrysme de l'artère iliaque du sujet âgé. Place du traitement par endoprothèse couverte.

BACKGROUND: Coated stents can be an alternative to open surgery for arterial aneurysms, particularly in patients with high operative risk. CASE REPORT: A 90-year-old man with advanced stage cardiopathy developed a 52 mm aneurysm of the iliac artery. Perioperative imaging (arteriography with marked catheter, CT-scan and endovascular ultrasonography) provided a precise description. The material used (PTFE coated thermal memory endoprosthesis, balloon in the hypogastric) provided effective exclusion. DISCUSSION: Endovascular treatment can be a useful alternative to open surgery for arterial aneurysm in the very elderly.

[Long-term outcome of infra-inguinal endovascular surgery for critical ischemia]. / Résultats à long-terme de la chirurgie endovasculaire à l'étage infra-inguinal dans le cadre de l'ischémie critique.

STUDY AIM: Endovascular surgery can be proposed as an alternative to infrainguinal conventional surgery in critical ischemia. The aim of this study was to report the latest results of our series of 186 patients. MATERIALS AND METHODS: One hundred and eighty-six patients (100 women and 86 men; mean age 74.5 +/- 13 years) were treated for pain during rest (31.5%), gangrene (58%), or ischemic ulcer (10.5%). The lesions were unilateral (n = 172) or bilateral (n = 14). Two hundred eighty-seven target lesions were treated: for stenosis (n = 168) or occlusion (n = 119): of superficial femoral artery (31.7%), popliteal artery (40%) or tibial arteries (28.3%). RESULTS: Technical success was achieved in 81% (15% amputations). The in-hospital mortality rate was 6.5%. The cumulative patency rate was 61 +/- 3% at 12 months, and 52 +/- 6% at 48 months. The limb salvage rate was 87 +/- 3% at 12 months and 82 +/- 4% at 48 months. Thirteen potential factors of patency were analyzed: the only predictive factors affecting patency were occlusion versus stenosis, and the use of atherectomy (Log rank test: P < 0.001 and P < 0.0001). CONCLUSION: Despite a risk of technical failure and of mid-term restenosis, endovascular surgery for critical ischemia provides a fair long-term limb salvage rate.

Angioscopy in the operating room.

Angioscopy has been used in the superficial femoral artery for many years, as well as in the control of vascular surgery procedures. It is more reliable than angiography, which often misses such features as intimal flaps, residual valves in "in situ" vein bypasses or persisting thrombus after embolectomy. As fluid irrigation allows visualization of the iliac arteries, and as smaller atraumatic fibres allow safe visualization of the tibial arteries, new fields are opened for the use of angioscopy in peripheral vascular disease. This technique has been proved to be useful: (1) as a diagnostic tool, (2) as a control device in new endovascular procedures (percutaneous angioplasty, atherectomy and stents), and (3) as a therapeutic tool (thromboembolectomy, simplification of bypass procedures). In a modern operating room, angioscopy does not replace angiography, but these two imaging techniques are complementary, as they help the surgeon to provide the patients with a less invasive vascular surgery.

[Emboligenic aortopathies. Cholesterol embolisms: surgical treatment]. / Aortopathies emboligènes. embolies de cholesterol: traitement chirurgical.

Emboligenic aortopathies are defined as lesions of the aortic wall leading to the production of thromboatheromatous material which can migrate in fragments or entirely. Emboligenic aortopathy can occur in all parts of the aorta. Localized lesions are rare and usually involve the subrenal abdominal aorta or the isthma. Diffuse lesions involving several segments of the aorta are encountered more often. There are three anatomic types of lesions: ulcerated plaques, atheromatous ulcerations, an evrysmal disease of the aorta. Therapeutic indications depend on: 1) clinical presentation: fibrinocruoric emboli, distal microemboli, disseminated cholesterol emboli; 2) the unique or multiple nature of the emboli; 3) the anatomic lesion; 4) localization.

Infrapopliteal polytetrafluoroethylene and composite bypass: factors influencing patency.

Between January 1, 1979, and December 31, 1988, 149 infrapopliteal polytetrafluoroethylene (PTFE) bypasses were performed in 145 patients with chronic, critical, limb-threatening ischemia. These operations represented 27.9% of 534 infrapopliteal bypasses performed during the same period. There were 92 males and 53 females. Mean age was 71.8 +/- 12.3 years. Signs and symptoms of critical ischemia were gangrene, ulceration, and isolated rest pain in 101 (69%), 23 (15.3%), and 25 (16.7%) cases, respectively. A composite (PTFE-saphenous vein) graft was used in 53 (35%) cases. In 96 prosthetic bypasses the distal anastomosis was performed using vein patch angioplasty in 65 (44%) cases and directly in 31 (21%). The in-hospital mortality rate was 3.3%. Patency, limb salvage, and patient survival rates were plotted according to the actuarial method and the curves obtained were compared using the log-rank test. Actuarial survival rates were 68% +/- 5% and 57% +/- 7% at 3 and 5 years, respectively. Primary patency and lower limb salvage rates were 41% +/- 5% and 68% +/- 6% at 3 years and 35% +/- 9% and 65% +/- 10% at 5 years, respectively. There was no statistically significant difference noted in primary patency rates at 3 years according to the type of bypass (composite or all-prosthetic: 36% vs. 44%), the type of distal anastomosis (direct or vein patch angioplasty: 43% vs. 45%), the site of distal anastomosis (upper or lower half of the leg: 38% vs. 46%), lateral or medial placement of the bypass (39% vs. 43%), or according to whether or not it was a repeat operation (40% vs. 44%). In conclusion, patency rates using infrapopliteal PTFE bypasses are low. Certain technical approaches, although they do not seem to improve patency, definitely increase the feasibility of bypass and in our opinion decrease the risk of early failure in unfavorable anatomic settings. The limb salvage rates following infrapopliteal PTFE and composite bypass are encouraging and justify the use of routine distal revascularization, even in the absence of autogenous vein graft.

[Arterial disease of the lower limbs in diabetic patients]. / Artériopathie des membres inférieurs chez le sujet diabeétique.

Lower limb arterial disease in diabetics resembles that in non diabetics. However, some important differences include the vessels involved and the extent of the involvement. In the diabetic, the arteries most frequently involved are those below the knee. Arterial occlusions are bilateral, multisegmental, and involve unusual vessels such as the internal iliac artery, the deep femoral artery, the small branches and the collateral circulation. Arterial disease in the diabetic appears at a younger age, advances more rapidly, is more diffuse, and is almost as common in women as in men. Interaction of arterial disease, neuropathy and infection produces a wide away of clinical findings, including callus formation, foot ulcers, cellulitis, osteomyelitis and patchy areas of gangrene. Foot abscess and cellulitis require emergency debridement and drainage. Arterial reconstruction, including endovascular procedures, lessen the rate of amputation, allow partial foot amputation, and prevent from recurrent foot ulcer. Soft tissue repair, and especially fasciocutaneous flaps or musculocutaneous flaps, provide the means to heal most of the patients without infection, and avoid below-knee amputation.

[Disabling calf pain in the context of venous angiodysplasia: Contribution of dynamic exploration]. / Douleur du mollet invalidante dans le cadre d'une angiodysplasie veineuse: apport des explorations dynamiques.

We report the case of a 25-year old woman presenting with disabling pain of the left calf, associated with lower left limb angiodysplasia. Dynamic testing (duplex scan and phlebography) showed a popliteal vein ectasia, with reflux into an incompetent lesser saphenous vein: the venous drainage of this ectasia was an embryonic femoropopliteal vein going to the profunda femoris vein. As long as patency and competence of deep veins and of the superficial femoral vein were confirmed by dynamic testing with compressions, curative surgery was considered: en-bloc resection of lesser saphenous vein and of embryonic femoropopliteal vein combined with lateral suture of the popliteal vein. One-year follow-up confirms the absence of recurrent symptoms. Dynamic testing allows safe surgical therapy of persisting embryonic abnormalities associated with incompetent veins, in cases where such testing clearly demonstrates that a sufficient venous drainage of the affected limb will be provided after surgery.

Outcome of infrainguinal endovascular revascularization procedures for limb-threatening ischemia.

This report describes the results of 96 infrainguinal endovascular revascularization procedures performed in 86 patients with limb-threatening ischemia over a 3-year period. There were 41 women and 45 men (mean age 72.9 +/- 11.9 years) including 47 patients (51.1%) with diabetes and 13 (15.1%) with renal insufficiency. All patients had severe ischemia characterized by rest pain (18.8%), ulceration (12.5%), or gangrene (68.8%). Twelve procedures were carried out in association with conventional surgical reconstruction and in eight patients with mixed ulcers a venous procedure was performed during the same session. A total of 143 arterial lesions were treated including 61 occlusions (mean length 5.9 +/- 3.5 cm) and 82 stenoses (mean length 4.6 +/- 3 cm). The following techniques were used: transluminal angioplasty in 99 cases, laser in five cases, Rotablator in 24 cases, and aspiration thrombectomy in 15 cases. Nine patients (10.5%) died in the hospital. Initial failure was observed in 32 patients, of whom 18 underwent subsequent surgical revascularization and 14 required amputation of the extremity within 2 months. Analysis of variance was used to assess the following 12 risk factors for initial failure of endovascular revascularization: sex, age, diabetes, renal insufficiency, associated surgery, treatment of multiple lesions, artery treated, type of lesion, length of lesion, quality of runoff, use of an atherotome, and stent placement. Results showed a significant correlation between initial failure and both quality of runoff (12.9% in patients with two or more patent leg arteries vs. 36.5% in patients with one or fewer patent leg arteries; p < 0.05) and type of lesion (14.5% for stenosis vs. 45.9% for occlusion). Mean follow-up was 9.98 +/- 9.9 months and 4.7% of patients were lost. Restenosis was observed during follow-up of 16 of the 74 initially successful procedures. ANOVA was used to assess the same 12 risk factors for restenosis. Results showed a significant correlation between restenosis and both sex (10.8% in women vs. 32.4% in men; p < 0.05) and age (8% for patients > 80 years of age vs. 28.6% for patients < 80 years; p < 0.05). Primary patency, secondary patency and limb salvage rates calculated according to the actuarial method were 65%, 75%, and 84%, respectively, at 6 months and 47%, 67%, and 81%, respectively, at 1 year. Limb salvage rates for the endoluminal techniques used in this study were satisfactory, especially in elderly patients with either segmental lesions or contraindications for distal bypass.