Angiographic patterns of restenosis after drug-coated balloon angioplasty for femoropopliteal lesions and 1-year prognosis after repeat endovascular therapy.

AIM: The aim of the current study sought to investigate the angiographic patterns of restenosis after drug-coated balloon (DCB) angioplasty for femoropopliteal (FP) lesions and which repeat endovascular therapy (EVT) for DCB restenosis would provide more freedom from recurrent restenosis. METHODS: This retrospective multicenter study included 119 limbs (chronic limb-threatening ischemia [CLTI]: 55%, lesion length: 136.9 ± 89.6 mm, chronic total occlusion: 25%) of 95 patients (diabetes mellitus: 70%, hemodialysis: 56%) who were diagnosed with DCB restenosis between January 2018 and December 2019. The cases were classified into three groups based on angiographic patterns of restenosis: Class I: focal lesions ≤50 mm, Class II: diffuse lesions >50 mm, and Class III: totally occluded lesions. The DCB restenosis patterns and frequency and predictors of recurrent restenosis after repeated EVT (re-EVT) were investigated. RESULTS: The mean follow-up duration was 29.8 ± 9.5 months. Groups I, II, and III comprised of 30 (25.2%), 55 (46.2%), and 34 (29.0%) cases, respectively. The overall rate of 1-year freedom from recurrent restenosis was 58.2%. One-year rate of freedom from recurrent restenosis after repeat DCB was not statistically different from that after scaffolding (71.1% vs. 74.6%, respectively, p = 0.911); however, it was significantly better than that after noncoated balloon angioplasty (repeat DCB vs. noncoated balloon angioplasty: 71.1% vs. 25.7%, respectively, p < 0.001). Multivariate analysis demonstrated that CLTI (hazard ratio [HR]: 5.15, p < 0.001) and re-EVT with noncoated balloon (HR: 3.16, p < 0.001) were significantly associated with recurrent restenosis; however, Class III pattern of DCB restenosis was not associated with recurrent restenosis (HR: 1.04, p = 0.918). CONCLUSIONS: This study revealed the angiographic patterns of restenosis after DCB therapy for FP lesions and the 1-year rate of recurrent restenosis after repeat revascularization. Repeat DCB therapy demonstrated acceptable 1-year recurrent restenosis rates.

The Effect of Clinical Frailty on Wound Healing in Patients With Chronic Limb-Threatening Ischemia.

PURPOSE: Clinical frailty increases the risk of adverse outcomes in older people. Patients with Chronic limb-threatening ischemia (CLTI) also had several clinical frailties. The aim of this study was to investigate the correlation between clinical frailty scales (CFS) at discharge and wound healing rate in patients with tissue loss. METHODS: A total of 510 limbs in 431 CLTI patients who were undergone endovascular treatment (EVT) from January 2013 to November 2018 were enrolled in this study. Patients were categorized into 4-groups based on the CFS stages: CFS 1 to 4 (well), CFS 5 (mild), CFS 6 (moderate) and CFS ≥7 (severe). And the change in patient's activities during hospitalize was classified into 3 groups based on CFS; improve, stable, worse. Primary endpoint was correlation between CFS at discharge and wound healing rate. Secondary endpoint was relationship between the changes in patient's activities and wound healing rate. RESULTS: A total of 365 limbs were obtained complete wound healing during this study period. Patient distribution into the 4 CFS groups was as follows: 13.3% (well), 21.8% (mild), 25.3% (moderate) and 39.6% (severe). Wound healing rate in severe CFS group was significantly lower than that in other CFS groups (p<0.0001). Wound healing rate in the patients who achieved improvement of activity was significantly higher than that in the other groups (p=0.008). CONCLUSIONS: CFS might be useful for risk stratification in patients with tissue loss. And improvement of activity during hospitalization might lead to increase the wound healing rate. CLINICAL IMPACT: Although the association between clinical frailty and prognosis outcome of Chronic limb-threatening ischemia (CLTI) has been reported, the effect of clinical frailty on wound healing remains unclear. Clinical frailty scale is independently associated with wound healing and might be useful for risk stratification in patients with tissue loss. Improvement of activity during hospitalization might lead to increase the wound healing rate.

Factors Associated With Early and Late Restenosis Following Drug-Coated Balloon Treatment for Patients With Femoropopliteal Lesions.

PURPOSE: Clinical trials have demonstrated the superiority of drug-coated balloon (DCB) to noncoated balloon angioplasty for the treatment of femoropopliteal (FP) lesions. In those trials, the difference of primary patency between DCB and noncoated angioplasty widens especially after 6 months, speculating that the antirestenosis effect of paclitaxel is manifested after 6 months. Factors associated with restenosis after 6 months differ from those associated with restenosis within 6 months. This study aimed to elucidate the prognostic factors associated with early (within 6 months) and late (after 6 months) restenosis following DCB treatment in real-world FP practice. MATERIALS AND METHODS: This multicenter, retrospective study analyzed 486 FP lesions (mean lesion length, 11.9±10.1 cm; chronic total occlusion, 21.0%) in 423 patients (diabetes mellitus, 59.3%; hemodialysis, 37.1%; chronic limb-threatening ischemia, 41.6%) who underwent successful DCB treatment between January 2018 and December 2019. The outcome measure was restenosis which is defined as a peak systolic velocity ratio >2.4 based on duplex ultrasound findings. Early and late restenosis were classified by the cutoff period of 6 months after the procedure. The associations of baseline and procedural characteristics with early and late restenosis were explored using Cox proportional hazards regression analysis. RESULTS: The mean follow-up period was 25.3±12.1 months. The 6, 12, 18, and 24 month cumulative incidences of restenosis were 7.4%±2.4%, 20.9%±3.9%, 29.9%±4.5%, and 38.4%±5.1%, respectively. During the follow-up period, early and late restenosis was evident in a total of 31 lesions and 138 lesions, respectively. Multivariate analysis revealed that chronic total occlusion (hazard ratio [HR], 2.29; 95% confidence interval [CI], 1.07-4.92; p=0.033) and superficial femoral artery ostial lesion (HR, 2.73; 95% CI, 1.28-5.80; p=0.009) were significantly associated with early restenosis. On the other hand, calcification circumference over 270° (HR, 1.67; 95% CI, 1.17-2.37; p=0.004), distal external elastic membrane diameter under 5 mm assessed by intravascular ultrasound (HR, 1.90; 95% CI, 1.29-2.79; p=0.001), and involving popliteal arterial lesion (HR, 1.54; 95% CI, 1.08-2.21; p=0.017) were significantly associated with late restenosis. CONCLUSION: The prognostic factors associated with late restenosis differed from those associated with early restenosis in the real-world FP-DCB practice. CLINICAL IMPACT: The current multicenter, retrospective study revealed that factors associated with early restenosis differed from those with late restenosis in the real-world FP-DCB practice. CTO and SFA ostial lesion were associated with early restenosis, while severe calcification, smaller vessel, and involving popliteal arterial lesions were associated with late restenosis.Early restenosis indicates "balloon failure" and would potentially result from recoil, which primary stent implantation might be required. On the other hand, late restenosis after 6 months would be attributed to "DCB failure", with inadequate drug uptake into the arterial wall, which might be minimized by the use of atherectomy devices.

Impact of Peak Systolic Velocity Ratio after Drug-Coated Balloon for Femoropopliteal Disease: Three-Month Serial Observation Vessel Echo Study.

AIM: No flow-limiting dissection after drug-coated balloon (DCB) treatment for femoropopliteal (FP) lesions is considered as one of the endpoints, but it has not investigated the difference between each vessel dissection. This study aimed to clarify whether there is a difference between no dissection and type C dissection without flow-limiting dissection for 3 months by peak systolic velocity ratio (PSVR) based on duplex ultrasonography. METHODS: Between February 2020 and April 2021, 44 consecutive de novo FP diseases that underwent endovascular therapy (EVT) with DCB were enrolled in this study. 65.9% of the patients had intermittent claudication, and mean lesion lengths were 194±107 mm. The chronic total occlusion was 38.6%. After DCB treatment, vessel dissection pattern was categorized by angiography. The minimum lumen area (MLA) identified by intravascular ultrasound was serially evaluated with PSVRs at 1 day, 1 month, and 3 months after EVT. RESULT: All lesions were treated with DCB without provisional stents. The vessel dissection pattern after DCB treatment showed that types D, E, and F were not observed, 9% were no dissection, 27% were type A, 32% were type B, and 32% were type C. In all cases, the PSVR values of MLA site were less than 2.6 at 3 months, and there were no significant differences between no dissection and type C dissection. CONCLUSION: Up to dissection pattern "C" is considered acceptable as one of the endpoints to determine the need for provisional stenting after DCB treatment.

Catheter-induced aortocoronary dissection at the ostium of anomalous left coronary artery during percutaneous coronary intervention for acute inferior myocardial infarction.

We report a case of catheter-induced aortocoronary dissection at the ostium of anomalous left coronary artery (LCA) during percutaneous coronary intervention (PCI) for acute inferior myocardial infarction (MI). Urgent coronary angiography revealed the culprit lesion of MI was the proximal segment of the right coronary artery (RCA). The anomalous LCA arose from the right sinus of Valsalva the same as the RCA. Catheter-induced aortocoronary dissection at the ostium of RCA was extended to the ostium of anomalous LCA by contrast injection. The patient fell into hemodynamic collapse due to acute occlusion of the anomalous LCA. The patient underwent successful bailout stenting at the ostium of anomalous LCA under percutaneous cardiopulmonary support (PCPS). He was weaned from PCPS system five days after PCI and was discharged. This is the first report about bailout procedure for catheter-induced aortocoronary dissection at the ostium of anomalous LCA. .

Aspiration thrombectomy in a patient with suprarenal inferior vena cava thrombosis.

DVT has rarely been observed in the inferior vena cava (IVC). Pulmonary embolism (PE), which can be life-threatening, often occurred in patients with IVC thrombosis. Therefore, an IVC filter is frequently used in those patients for the prevention of PE. A case of successful endovascular treatment of an IVC thrombus in a patient with relative contraindications to implantation of an IVC filter is presented. This case report shows that aspiration of thrombi caught in the removable IVC filter may be an alternative to surgery in high-risk patients with catheter-related suprarenal inferior vena cava thrombosis.