Effect of Endovascular Treatment on Urinary Obstruction Caused by Iliac Artery Aneurysm: A Case Series and Review of the Literature.

BACKGROUND: Endovascular aneurysm repair is superior to open surgical repair (OSR) in multiple aspects and is the mainstay for noninflammatory iliac artery aneurysm (IAA) treatment. However, for noninflammatory IAAs with neighboring structures compressed, the experience of endovascular treatment is limited. This case series study aimed to describe the experience of endovascular aneurysm repair of noninflammatory IAAs with urinary obstruction and to review the limited reports in the literature. METHODS: From December 2012 to July 2020, we reported 7 cases of noninflammatory IAAs combined with urinary obstruction that was treated successfully with endovascular treatment. The literature on noninflammatory IAAs combined with urinary obstruction was reviewed using the online databases PubMed, Embase, and the Cochrane Library. RESULTS: Thirty nine articles were found in the literature. OSR accounted for 80% of the treatment options in previous publications, while only 20% of patients accepted endovascular treatment. Hydronephrosis remission was observed in all patients treated by OSR, while the endovascular treatment group lacked long-term follow-up. In our retrospective study containing 7 cases, no complications, reintervention, or mortality was observed, all stents were patent, and all symptoms were relieved after the operation. Diameter reduction of the aneurysms was observed in 6/7 cases and the average aneurysm reduction was -24.1 ± 15.8 mm (P = 0.0097). Urinary obstruction faded in 5/7 cases where aneurysm shrinking was found simultaneously. CONCLUSIONS: This case series and literature review on noninflammatory IAAs combined with urinary obstruction suggests that the diameter of the responsible aneurysm may be reduced after endovascular treatment, which may also alleviate symptoms of urinary obstruction caused by noninflammatory IAAs.

Infrapopliteal endovascular intervention and the angiosome concept: intraoperative real-time assessment of foot regions' blood volume guides and improves direct revascularization.

OBJECTIVE: There is no consensus for determining which vessel should be revascularized in patients with multiple diseased infrapopliteal arteries. The angiosome concept may guide a more efficient targeted direct revascularization. Therefore, we conducted a study to assess whether the regional evaluation of foot blood volume may guide direct revascularization (DR) and if it will lead to better perfusion improvement than indirect revascularization (IR). METHODS: We performed a prospective single-center observational cohort study in patients treated in the Department of Vascular Surgery of Peking Union Medical College Hospital from November 2016 to April 2019. Twenty-seven patients treated with endovascular intervention were included. The intraoperative parenchymal blood volume of different foot regions was obtained for each patient using C-arm CT before and after intervention. RESULTS: The intervention procedure significantly increased the overall blood volume (48.95 versus 81.97 ml/1000 ml, p = 0.002). Patients with direct revascularization had a 197% blood volume increase while patients with indirect revascularization had a 39% increase (p = 0.028). The preoperative blood volume was higher in patients with mild symptoms than in patients with severe symptoms (58.20 versus 30.45 ml/1000 ml, p = 0.039). However, in regard to postoperative blood volume, no significant difference was discovered between these two groups (75.05 versus 95.01 ml/1000 ml, p = 0.275). CONCLUSION: Based on quantitative measurements, we conclude that overall blood volume can rise significantly after the intervention. Revascularizing the supplying vessel of the ischemic area directly will result in better perfusion improvement than restoring blood supply through the collateral circulation. Preoperative blood volume is associated with preoperative symptoms. KEY POINTS: • Flat panel detector CT can obtain intraoperative perfusion status and guide treatment in endovascular intervention. • Revascularizing the supplying vessel of the ischemic area directly will result in better perfusion improvement than restoring the blood supply through the collateral circulation. • Patients with severer clinical manifestations have lower blood volumes.

One-year outcomes of drug-coated balloon treatment for long femoropopliteal lesions: a multicentre cohort and real-world study.

BACKGROUND: Drug-coated balloons (DCBs) have shown superiority in the endovascular treatment of short femoropopliteal artery disease. Few studies have focused on outcomes in long lesions. This study aimed to evaluate the safety and effectiveness of Orchid® DCBs in long lesions over 1 year of follow-up. METHODS: This study is a multicentre cohort and real-world study. The patients had lesions longer than or equal to 150 mm of the femoropopliteal artery and were revascularized with DCBs. The primary endpoints were primary patency, freedom from clinically driven target lesion revascularization (TLR) at 12 months and major adverse events (all-cause death and major target limb amputation). The secondary endpoints were the changes in Rutherford classification and the ankle brachial index (ABI). RESULTS: One hundred fifteen lesions in 109 patients (mean age 67 ± 11 years, male proportion 71.6%) were included in this study. The mean lesion length was 252.3 ± 55.4 mm, and 78.3% of the lesions were chronic total occlusion (CTO). Primary patency by Kaplan-Meier estimation was 98.1% at 6 months and 82.1% at 12 months. The rate of freedom from TLR by Kaplan-Meier estimation was 88.4% through 12 months. There were no procedure- or device-related deaths through 12 months. The rate of all-cause death was 2.8%. Cox regression analysis suggested that renal failure and critical limb ischaemia (CLI) were statistically significant predictors of the primary patency endpoint. CONCLUSION: In our real-world study, DCBs were safe and effective when used in long femoropopliteal lesions, and the primary patency rate at 12 months by Kaplan-Meier estimation was 82.1%.

Angiosome-directed endovascular intervention and infrapopliteal disease: Intraoperative evaluation of distal hemodynamic changes and foot blood volume of lower extremity.

Objectives: To evaluate foot blood volume and hemodynamics and explore whether quantitative techniques can guide revascularization. Materials and methods: A prospective single-center cohort study included thirty-three patients with infrapopliteal artery occlusion who underwent percutaneous transluminal angioplasty (PTA) between November 2016 and May 2020. The time-to-peak (TTP) from color-coded quantitative digital subtraction angiography (CCQ-DSA) and parenchymal blood volume (PBV) were used to evaluate the blood volume and hemodynamic changes in different regions of the foot before and after the operation. Results: After the intervention procedure, the overall blood volume significantly increased from 25.15 ± 21.1 ml/1,000 ml to 72.33 ± 29.3 ml/1,000 ml (p < 0.001, with an average increase of 47.18 ml/1,000 ml. The overall TTP decrease rate, postoperative blood flow time significantly faster than those preoperatively, from 22.93 ± 7.83 to 14.85 ± 5.9 s (p < 0.001, with an average decrease of 8.08 s). Direct revascularization (DR) resulted in significant blood volume improvement than compared with indirect revascularization (IR) [188% (28, 320) vs.51% (10, 110), p = 0.029]. Patients with DR had a significantly faster blood flow time than those with IR [80% (12, 180) vs. 26% (5, 80), p = 0.032]. The ankle-brachial index (ABI) of the affected extremity also showed an significant change from 0.49 ± 0.3 to 0.63 ± 0.24 (p < 0.001) after the intervention. The relative values of ΔTTP and ΔABI showed a weak correlation (r = -0.330). Conclusions: The quantitative measurement results based on PBV and CCQ-DSA techniques showed that the overall blood volume increased significantly and that the foot distal hemodynamics were significantly improved after endovascular treatment. DR in the ischemic area could r improve foot perfusion.

Impaired pedal arch affects the treatment effect in patients with single tibial artery revascularization demonstrated by intraoperative perfusion.

Background: The treatment strategy for patients with multiple infrapopliteal artery occlusions remains controversial. In this study, we investigated how anatomic factors affect the treatment effect of infrapopliteal artery intervention and identified suitable intervention strategies for patients with multiple infrapopliteal artery occlusions. Methods: This was a prospective, single-center, observational cohort study. For each patient, the intrainterventional blood volume improvement of the dorsum and plantar surface was measured and classified into the direct perfused region (DR) or indirect perfused region (IR) on the basis of whether the supplying artery was revascularized. Digital subtraction angiography was performed to analyze how pedal arch patency affects blood communication between DR and IR. Results: A total of 38 patients treated with infrapopliteal intervention at the Department of Vascular Surgery of Peking Union Medical College Hospital from November 2016 to November 2020 were considered for inclusion in this study. Finally, 26 patients were included in the analysis. In patients with type III pedal arch, blood volume improvements for DR and IR were 70.50 (17.50, 191.75) and 11.25 (-10.25, 50.25) mL/1,000 mL, respectively (P=0.018). No significant difference was found between DR and IR in patients with type I pedal arch (P=0.208) and type II pedal arch (P=0.110). Conclusions: Impaired pedal arch has an adverse impact on foot collateral circulation. Patients with these conditions are more suitable for direct revascularization than other patients. Trial Registration: ClinicalTrials.gov identifier: NCT03248323.