Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review.

Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥ 45 mmHg) and transcutaneous pressure of oxygen (TcPO2 ) ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ankle brachial index (ABI) < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation.

Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review.

Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus are important to estimate the risk of amputation, ulceration, wound healing and the presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another and to evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction angiography and colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies instrument. Of the 6629 studies identified, ten met the criteria for inclusion. In these studies, the patients had a median age of 60-74 years and a median duration of diabetes of 9-24 years. Two studies reported exclusively on patients with symptomatic (ulcerated/infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio and negative likelihood ratio (NLR) of an ABI threshold <0.9 ranged from 2 to 25 (median 8) and <0.1 to 0.7 (median 0.3), respectively. In patients with neuropathy, the NLR of the ABI was generally higher (two out of three studies), indicating poorer performance, and ranged between 0.3 and 0.5. A toe brachial index <0.75 was associated with a median positive likelihood ratio and NLRs of 3 and ≤ 0.1, respectively, and was less affected by neuropathy in one study. Also, in two separate studies, pulse oximetry used to measure the oxygen saturation of peripheral blood and Doppler wave form analyses had NLRs of 0.2 and <0.1. The reported performance of ABI for the diagnosis of PAD in patients with diabetes mellitus is variable and is adversely affected by the presence of neuropathy. Limited evidence suggests that toe brachial index, pulse oximetry and wave form analysis may be superior to ABI for diagnosing PAD in patients with neuropathy with and without foot ulcers. There were insufficient data to support the adoption of one particular diagnostic modality over another and no comparisons existed with clinical examination. The quality of studies evaluating diagnostic techniques for the detection of PAD in individuals with diabetes is poor. Improved compliance with guidelines for methodological quality is needed in future studies.

Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review.

Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease.

In several large recent observational studies, peripheral arterial disease (PAD) was present in up to 50% of the patients with a diabetic foot ulcer and was an independent risk factor for amputation. The International Working Group on the Diabetic Foot therefore established a multidisciplinary working group to evaluate the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. A systematic search was performed for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980-June 2010. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 49 papers were eligible for full text review. There were no randomized controlled trials, but there were three nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70.5-85.5%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular revascularization. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of medically treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot.

The International Working Group on the Diabetic Foot (IWDGF) has produced in 2011 a guideline on the diagnosis and treatment of peripheral arterial disease in patients with diabetes and a foot ulcer. This document, together with a systematic review that provided the background information on management, was produced by a multidisciplinary working group of experts in the field and was endorsed by the IWDGF. This progress report is based on these two documents and earlier consensus texts of the IWDGF on the diagnosis and management of diabetic foot ulcers. Its aim is to give the clinician clear guidance on when and how to diagnose peripheral arterial disease in patients with diabetes and a foot ulcer and when and which treatment modalities should be considered, taking both risks and benefits into account.

Clinical and duplex ultrasound follow-up after balloon angioplasty for atherosclerotic renal artery stenosis.

The purpose of this study was to investigate changes in blood pressure and renal function after percutaneous renal artery balloon angioplasty in hypertensive patients with atherosclerotic renal artery stenosis. Renal artery lesions were assessed by duplex ultrasound before and after renal artery balloon angioplasty. Renal arteries were classified as normal, < 60% stenosis, > or =60% stenosis, and occluded according to previously validated duplex criteria. Data regarding risk factors for atherosclerosis and years of hypertension were collected. Systolic and diastolic blood pressure, creatinine, and number of medications were obtained before and after intervention. The immediate technical outcome of renal artery angioplasty was classified based on the arteriographic result as follows: success (residual stenosis < or =30%), partial success (residual stenosis 31-50%), or unsuccessful (residual stenosis > 50%). For bilateral procedures, success required both renal arteries to be classified as technical successes; a technical success on one side only was classified as partial success. The blood pressure response to intervention was classified as follows: cure (diastolic blood pressure < or =95 mm Hg on no medications), improved (control of blood pressure with a significant reduction in number of medications or control of previously elevated blood pressure without a change in medications), or failed (all other responses). The study group included 28 patients (14 men, 14 women) with a mean age of 65 years. The preintervention and the first postintervention evaluations occurred within 180 days of the procedure. All patients were hypertensive, and all except one were under medical treatment. Mean duration of hypertension was 9.1 +/-8.8 years. There were 38 interventional procedures (28 unilateral, 10 bilateral) involving 41 renal arteries; seven arteries had two procedures done. Before angioplasty, all renal arteries had lesions of > or =60% diameter reduction by duplex scanning. Endovascular stents were deployed following angioplasty in 14 (34%) of the procedures. The technical result was classified as a success in 24 (63%), a partial success in 12 (32%) of the procedures, and two procedures (5%) were classed as technical failures. There were statistically significant reductions in blood pressure following successful and partially successful procedures, but cure of hypertension was achieved in only 11% of cases. There were no significant changes in creatinine in any of the technical result groups. Of the 38 renal arteries evaluated with duplex ultrasound following intervention, 39% were found to have stenosis of > or =0% involving a treated renal artery, including one postintervention occlusion. Cure of hypertension was rare in this patient population with atherosclerotic renal artery stenosis. More than one third of the treated renal arteries showed > or =0% lesions recurring after the procedure. Thirteen percent of those with technical success and 17% of those with partial technical success had creatinine improvement of at least 20% over the baseline value. Significant clinical and anatomic improvement were relatively uncommon following balloon angioplasty in this series of patients.

Is duplex scanning the best screening test for renal artery stenosis?

Screening for renal artery stenosis is indicated in patients with suspected renovascular hypertension or ischemic nephropathy to identify those who could benefit from renal artery interventions. The critical requirements for a clinically useful screening test include safety, low cost, and a high sensitivity or low false-negative rate. Arteriography remains the "gold standard" for the anatomic diagnosis of renal artery disease, but it is unsuitable for screening because of its high cost and invasive nature. Although renal duplex scanning technically is difficult, experienced laboratories have been able to achieve sensitivities and specificities in the range of 93% to 98% for identification of stenoses in the main renal arteries. Renal duplex scanning also provides a method for assessing the renal parenchyma and predicting the clinical outcome of renal revascularization. The principal limitation of renal duplex scanning is failure to identify accessory renal arteries. The finding of one or more widely patent main renal arteries makes ischemic nephropathy unlikely, because this condition results from "total" renal ischemia. However, renovascular hypertension can be present with normal main renal arteries when there are isolated stenoses involving accessory renal arteries, so further testing may be indicated in selected hypertensive patients with normal main renal arteries by duplex scanning. Currently, duplex scanning in a qualified vascular laboratory arguably is the best screening test for renal artery stenosis. Other methods for assessing the renal arteries, particularly spiral computed tomography and magnetic resonance angiography, are evolving rapidly and also may play a role in screening of selected patients.

Measurement of abdominal aortic aneurysms with three-dimensional ultrasound imaging: preliminary report.

OBJECTIVE: Accurate measurements of abdominal aortic aneurysms (AAAs) are required for surgical planning and monitoring over time. We have examined the feasibility of using a three-dimensional (3-D) ultrasound imaging system to derive quantitative measurements of interest from AAAs. METHODS: A normal aorta, a small AAA, and an AAA repaired with an endovascular stent graft were scanned with a 3-D ultrasound imaging system. For each case, a 3-D surface reconstruction was generated from manual outlines of a sequence of two-dimensional ultrasound images, registered in 3-D space with a magnetic tracking system. The surfaces were resampled in planes perpendicular to the vessel center axis to calculate cross-sectional area and maximum diameter as a function of distance along the length of the aorta. RESULTS: Cross-sectional area and maximum diameter were plotted along the length of the aneurysmal aortas from the renal arteries to the aortic bifurcation. The overall maximum diameter was found for both aneurysms. For the small AAA, the distances of the aneurysm from the renal arteries and the bifurcation were measured. For the repaired AAA, the location of the stent graft relative to the renal arteries was measured. CONCLUSIONS: 3-D surface reconstructions from ultrasound images show promise for quantitatively characterizing the geometry of AAAs both before surgery and after endovascular repair.

Blood pressure, antihypertensive medication, and atherosclerotic renal artery stenosis.

The relationship between atherosclerotic renal artery stenosis (ARAS) and blood pressure control remains poorly understood. Duplex ultrasonography is a noninvasive method for detecting and grading ARAS. The purpose of this study was to characterize the relationship between the degree of ARAS, levels of blood pressure, and control of blood pressure with antihypertensive medication. A cross-sectional analysis was performed on 139 patients with ARAS. All patients had at least one diseased renal artery by duplex ultrasound. Renal arteries were classified as normal, less than 60% stenosis, or 60% or greater (high-grade) stenosis. Data regarding blood pressure, coexisting risk factors, and medications were collected. The extent of ARAS was significantly associated with progressive elevation of the systolic blood pressure, whereas the diastolic component was elevated in the case of unilateral high-grade stenosis: no high-grade stenoses, 153 +/- 22/81 +/- 10 mm Hg; unilateral high-grade stenosis, 162 +/- 22/86 +/- 9 mm Hg; and bilateral high-grade stenoses, 174 +/- 27/82 +/- 9 mm Hg (P = 0.002 systolic; P = 0.02 diastolic). Eighty-two percent of the patients were taking known antihypertensive medications. Angiotensin-converting enzyme inhibitor (ACEI) usage versus nonusage was associated with a significantly lower systolic (157 +/- 27 v 169 +/- 22 mm Hg; P = 0.03) and diastolic (79 +/- 9 v 85 +/- 9 mm Hg; P = 0.001) blood pressure. The effect of ACEI usage was observed in patients with high-grade ARAS. None of the other classes of antihypertensive medications were associated with significantly lower blood pressure. In patients with ARAS, blood pressure levels were correlated with the severity of renal artery disease. Patients taking ACEIs had significantly lower blood pressures, and the effect of ACEI usage was strongest among patients with unilateral ARAS.

Vascular surgery without arteriography: use of Duplex ultrasound.

Although contrast arteriography has served as the historical 'gold standard' for diagnosis of arterial disease, recent improvements in noninvasive diagnostic methods have made it possible to plan surgical treatment without subjecting patients to this invasive procedure. This approach avoids both the risks and costs associated with arteriography. Duplex scanning has become the standard noninvasive test for extracranial carotid artery disease, and it can also be used to directly evaluate the lower extremity arteries. In addition to the standard duplex criteria for classification of carotid stenosis, new criteria are available that reflect the stenosis thresholds identified in randomized clinical trials. Clinical experience has clearly shown that carotid endarterectomy can be performed safely based on the duplex scan alone in the majority of patients: however, arteriography is still indicated in selected cases. The evaluation of lower extremity arterial disease requires examination of multiple arterial segments, and most vascular surgeons still rely on the anatomic detail provided by arteriography for preoperative planning. Still, it may be possible to avoid formal preoperative arteriography in selected patients by using a combination of lower extremity duplex scanning and intraoperative arteriography. Further developments in noninvasive testing will continue to reduce the need for diagnostic arteriography prior to direct arterial surgery.

Prospective study of atherosclerotic disease progression in the renal artery.

BACKGROUND: The aim of this study was to determine the incidence of and the risk factors associated with progression of renal artery disease in individuals with atherosclerotic renal artery stenosis (ARAS). METHODS AND RESULTS: Subjects with >/=1 ARAS were monitored with serial renal artery duplex scans. A total of 295 kidneys in 170 patients were monitored for a mean of 33 months. Overall, the cumulative incidence of ARAS progression was 35% at 3 years and 51% at 5 years. The 3-year cumulative incidence of renal artery disease progression stratified by baseline disease classification was 18%, 28%, and 49% for renal arteries initially classified as normal, <60% stenosis, and >/=60% stenosis, respectively (P=0.03, log-rank test). There were only 9 renal artery occlusions during the study, all of which occurred in renal arteries having >/=60% stenosis at the examination before the detection of occlusion. A stepwise Cox proportional hazards model included 4 baseline factors that were significantly associated with the risk of renal artery disease progression during follow-up: systolic blood pressure >/=160 mm Hg (relative risk [RR]=2.1; 95% CI, 1.2 to 3.5), diabetes mellitus (RR=2.0; 95% CI, 1.2 to 3.3), and high-grade (>60% stenosis or occlusion) disease in either the ipsilateral (RR=1.9; 95% CI, 1.2 to 3.0) or contralateral (RR=1.7; 95% CI, 1.0 to 2.8) renal artery. CONCLUSIONS: Although renal artery disease progression is a frequent occurrence, progression to total renal artery occlusion is not. The risk of renal artery disease progression is highest among individuals with preexisting high-grade stenosis in either renal artery, elevated systolic blood pressure, and diabetes mellitus.

Carotid and lower extremity arterial disease in patients with renal artery atherosclerosis.

BACKGROUND: Atherosclerotic lesions of the carotid and lower extremity arteries may be associated with renal artery stenosis and influence the management of patients with renal artery disease. OBJECTIVE: To document the prevalence and clinical features of carotid and lower extremity arterial disease in patients with renal artery atherosclerosis. METHODS: An analysis of baseline data on 149 patients enrolled in a prospective natural history study of atherosclerotic renal artery stenosis. Patients with at least 1 abnormal renal artery by duplex scanning were eligible. Carotid artery disease was evaluated by duplex scanning, and ankle/brachial indices were used to assess the lower extremity arteries. Disease at each of the 3 arterial sites was classified as mild, moderate, or severe based on the extent of involvement on both sides. Serum urea nitrogen, creatinine, and lipid levels were also measured. RESULTS: Severe renal, carotid, or lower extremity arterial disease was present in 44%, 19%, and 21% of the patients, respectively. There was a trend for patients with increasing degrees of renal artery disease to have increasing degrees of carotid and lower extremity arterial disease. The prevalence of severe carotid artery disease increased from 7% in the mild renal artery group to 28% in the severe renal artery group. Clinical factors that were most predictive of severe disease were elevated apolipoprotein B levels for the renal arteries, high serum urea nitrogen or creatinine levels for the carotid arteries, and smoking for the lower extremity arteries. CONCLUSIONS: There was a strong association between severe renal artery atherosclerosis and severe carotid artery disease. Patients with renal artery disease also had a high prevalence of lower extremity arterial disease. In this patient population, screening for lower extremity arterial disease can be reserved for those with signs or symptoms of peripheral ischemia. Noninvasive carotid screening is justified in patients with renal artery disease to detect asymptomatic lesions that require either immediate surgical treatment or serial follow-up for disease progression.

Risk of atrophy in kidneys with atherosclerotic renal artery stenosis.

The goal of this study was to determine the incidence of and risk factors for renal atrophy among kidneys with atherosclerotic renal artery stenosis (ARAS). Participants with at least one ARAS were followed prospectively with duplex scans performed every six months. Renal atrophy was defined as a reduction in renal length of greater than 1 cm. A total of 204 kidneys in 122 subjects were followed for a mean of 33 months. The two-year cumulative incidence (CI) of renal atrophy was 5.5%, 11.7%, and 20.8% in kidneys with a baseline renal artery disease classification of normal, <60% stenosis, and > or = 60% stenosis, respectively (P = 0.009, log rank test). Other baseline factors associated with a high risk of renal atrophy included a systolic blood pressure > 180 mm Hg (2-year CL = 35%, P = 0.01), a renal artery peak systolic velocity > 400 cm/second (2-year CI = 32%, P = 0.02), and a renal cortical end diastolic velocity < or = 5 cm/second (2-year CI = 29%, P = 0.046). The number of kidneys demonstrating atrophy per participant was correlated with elevations in the serum creatinine concentration (P = 0.03). In patients with ARAS, there is a significant risk of renal atrophy among kidneys exposed to elevated systolic blood pressure and among those with high-grade ARAS and low renal cortical blood flow velocity as assessed by renal duplex scanning. The occurrence of renal atrophy is well-correlated with changes in the serum creatinine concentration.

Clinical evidence of contralateral renal parenchymal injury in patients with unilateral atherosclerotic renal artery stenosis.

It has been postulated that the kidney contralateral to a significant renal artery stenosis may be at risk for accelerated arteriolar nephrosclerosis. Duplex ultrasound is capable of detecting and classifying renal artery stenosis and examining parenchymal flow. Renal flow patterns are a reflection of resistance, which increases with parenchymal pathology. One-hundred fifty-one patients with atherosclerotic renal artery stenosis (ARAS) were prospectively studied with duplex ultrasonography. Renal arteries were classified as normal, <60% stenosis, > or =60% stenosis, or occluded. The renal artery end-diastolic ratio (EDR) (end-diastolic velocity/peak systolic velocity) was measured. EDR decreases as resistance to flow increases. There were 81 patients with a unilateral > or =60% ARAS. The EDR was significantly lower in the kidney contralateral to the > or =60% ARAS (0.27 +/- 0.08 versus 0.30 +/- 0.08; p = 0.001, paired t-test). The absolute difference in EDR was even more pronounced in the subgroup of 15 diabetic patients with a > or =60% ARAS (0.22 +/- 0.08 versus 0.27 +/- 0.08; p = 0.004). This study offers clinical evidence that a unilateral hemodynamically significant ARAS is associated with the development of arteriolar nephrosclerosis in the contralateral kidney. These results have important implications on blood pressure control, renal function, and response to renal revascularization in this patient population.

Duplex sonography of lower extremity arteries.

Although indirect noninvasive tests continue to play a role in the evaluation of patients with lower extremity arterial disease, the direct approach of duplex scanning provides both anatomic and physiological information directly from the involved arterial sites. Experience has shown that the results of duplex scanning are comparable with those of arteriography. The addition of color Doppler imaging to standard duplex scanning expedites the examination by helping to identify vessels and localize flow disturbances. However, precise classification of disease severity still requires spectral waveform analysis. Initial screening of patients with duplex scanning can determine the severity of arterial occlusive disease, the location of the lesions, and which interventional techniques are most appropriate. Arteriography can then be reserved for those patients who are being considered for therapeutic interventions. Duplex scanning has become the primary diagnostic test for follow-up of patients after radiological or surgical procedures and should be considered as an essential component of care for patients with infrainguinal bypass grafts. It has also proven to be valuable for intraoperative assessment and the initial evaluation of suspected vascular trauma in the extremities. Finally, new applications such as compression therapy for pseudoaneurysms continue to evolve and expand the role of duplex scanning in the management of patients with vascular problems.

Results of percutaneous transluminal angioplasty for atherosclerotic renal artery stenosis: a follow-up study with duplex ultrasonography.

PURPOSE: The short and long-term anatomic results of percutaneous transluminal renal angioplasty (PTRA) in the treatment of atherosclerotic renovascular disease have been poorly documented because of a lack of follow-up arteriography. The purpose of this study was to evaluate the anatomic results of PTRA with serial duplex examinations. METHODS: The records of 41 patients who underwent 52 primary PTRA procedures and had subsequent duplex follow-up of at least 6 months were reviewed. After PTRA, renal arteries were classified as normal, < 60% stenosis, > or = 60% stenosis, or occluded on the basis of previously validated duplex criteria. RESULTS: The study group included 26 men and 15 women with a mean age of 65 years, who were observed for a mean interval of 34 months. Endovascular stents were placed in 12 of the 52 arteries. The initial post-PTRA renal artery stenosis classification (based on arteriography or duplex scan) was normal in 23, < 60% in 19, and > or = 60% in 10. The cumulative incidence of restenosis from normal to > or = 60% was 13% at 1 year and 19% at 2 years. The cumulative incidence of restenosis from < 60% to > or = 60% was 44% at 1 year and 55% at 2 years. The cumulative incidence of progression from > or = 60% to occlusion was 10% at 2 years. Although 83% of the 12 stented arteries and only 33% of the 40 nonstented arteries were normal immediately after PTRA, after 1 year the stented renal arteries showed a 44% restenosis rate, whereas the nonstented renal arteries showed a 18% restenosis rate (p = 0.087). CONCLUSIONS: Restenosis after PTRA for atherosclerotic disease is relatively common and correlates with the initial anatomic result. Although PTRA with stent placement yields superior immediate technical results, the high early restenosis rate is disturbing.