[Retrograde tibial approach for endovascular recanalization of popliteal and tibioperoneal artery occlusion].

OBJECTIVES: To describe a procedure of the retrograde approach for endovascular treatment of complex popliteal and/or infrapopliteal occlusions and to determine its safety and efficacy in minimizing failure rates. METHODS: Between January 2010 and March 2012, 28 patients (16 male and 12 female patients) received retrograde tibial approach after failure of antegrade intervention. There were 3 patients with severe claudication (Rutherford category 3) and 25 patients with critical limb ischemia (Rutherford category 4 to 6). From this group, two techniques were employed. Twenty-four patients were treated via a retrograde transpedal access site and 4 patients via a transcollateral loop technique. The clinical and follow-up data of these patients were analyzed retrospectively. RESULTS: The technique success rates were 92.8% (26/28). No major complications and 3 (10.7%) minor sequelaes were documented in this study. Twenty-three patients were followed up for 3 to 29 months, with a mean of (14 ± 9) months. Overall patency was 73.9% (17/23) and 47.8% (11/23) at 6 and 12 months. Overall survival and limb salvage was 95.7% (22/23), ulcer were healed in 9/10 patients. CONCLUSION: The use of retrograde tibial or pedal approach seems feasible and safety in case of failure in antegrade revascularization of popliteal and/or infrapopliteal occlusions.

[Subintimal arterial flossing with antegrade-retrograde intervention technique to treat long-segment occlusion of peripheral artery].

OBJECTIVE: To discuss the technique details of subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to improve technical success in the treatment of chronic total occlusions (CTO) diseases in lower extremity when there is failure to reenter the distal true lumen. METHODS: Between May 2009 and Aug 2010, 15 patients underwent endovascular recanalization with SAFARI technique. There were 8 male and 7 female patients with a mean age of 74.9 years. There were 3 patients with severe claudication (Rutherford category 3) and 12 patients with critical limb ischemia (Rutherford category 4 to 6). The clinical and follow-up data of these patients were analyzed retrospectively. RESULTS: Fourteen patients were treated with SAFARI technique successfully. The technique success rates were 93.3%. The mean ankle brachial index increased from 0.39 to 0.83.Symptoms were relieved in 86.6% patients, Ulcer were healed in 93.3%patients. CONCLUSIONS: SAFARI technique is a safe and effective method in treating CTO diseases, when it is failure to renter the distal true lumen with subintimal angioplasty technique.

[The efficacy analysis of endovascular intervention therapy for transatlantic inter society consensus type C and type D femoropopliteal arteriosclerosis lesion].

OBJECTIVE: To evaluate the efficacy of the endovascular intervention for transatlantic inter society consensus (TASC) type C and type D femoropopliteal artery disease. METHODS: We conducted a retrospective analysis on 95 cases (98 lower limbs) with TASC type C and type D femoropopliteal artery arteriosclerosis lesion treated by percutaneous transluminal angioplasty and/or primary stent implantation from January 2007 to April 2009. We used ankle brachial index (ABI), Fontaine stages, limb salvage percentage and primary patency to evaluate the efficacy of the endovascular intervention therapy. RESULTS: The technical success rate of the 98 limbs was 94.9%, the perioperation mortality was 4.2% and the total amputation rate was 5.1%. 81 cases (84 limbs) were followed-up for a mean time of (13 ± 7) months, whose average ABI in dorsalis pedis artery and posterior tibial artery were 0.58 ± 0.22 and 0.60 ± 0.21 and increased 0.14 ± 0.25 and 0.13 ± 0.22 respectively than the ABI before intervention therapy. The statistical analysis showed a significant difference in ABI. The limbs of critical limb ischemia (CLI) were of 16.4% in the follow-up period and of 73.5% before the intervention therapy. The statistical results showed a significant difference in the percentage of CLI. CONCLUSION: Percutaneous endovascular intervention is an effective and minimally invasive method, and has a curative clinical efficacy to treat TASC type C and type D femoropopliteal artery disease.

[The analysis of the follow-up results for the crural artery bypass].

OBJECTIVE: To review the follow-up results of the crural artery bypass. METHODS: Sixty-five limbs in 64 patients with long stenosis or occlusion in femoral artery and popliteal artery were performed 65 times femoral-crural artery bypass surgery or femoral-popliteal-crural bypass surgery during April 2001 to July 2007. The ankle-brachial index before bypass surgery was 0.35 +/- 0.20 in anterior tibial artery and 0.38 +/- 0.21 in posterior tibial artery. Critical limb ischemia was 93.8%. RESULTS: The ankle-brachial index after bypass surgery was 0.84 +/- 0.26 in anterior tibial artery and 0.83 +/- 0.22 in posterior tibial artery. The perioperative mortality rate was 1.6%, the perioperative amputation rate was 1.5%. Fifty-four patients 54 limbs were followed up. The average follow-up time was (24.1 +/- 16.6) months. The follow-up limb salvage rate was 85.2%. The follow-up mortality rate was 25.9%. Critical limb ischemia decreased as 13.0%. The follow-up ankle-brachial index was difference with before and after bypass surgery as 0.66 +/- 0.26 in anterior tibial artery and 0.64 +/- 0.25 in posterior tibial artery. It was no difference in cumulative limb salvage rate, cumulative primary and secondary patency rate by comparing autogenous vein with composite vascular as graft and comparing femoral-crural artery bypass surgery with femoral-popliteal-crural bypass surgery as surgical method. CONCLUSIONS: When the patients are failed in endovascular intervention or have long stenosis or occlusion in femoral artery and popliteal artery to face to amputation, the crural artery bypass is a feasible method. It's helpful to improve the secondary patency rate and limb salvage rate by enhancing the follow-up after operation and early intervention.

Reoperations for occluded arterial bypasses in the lower limbs.

BACKGROUND: We reviewed the outcomes of reoperations for 29 patients (30 limbs) who had undergone occluded arterial bypass in the lower limbs from May 1996 to September 2005. METHODS: The 30 lower limbs of the 29 patients with arteriosclerotic obstruction received 44 reoperations, including thrombectomy alone (group T, 27) and inflow or outflow reconstruction plus thrombectomy (group C, 17). Among the 17 operations in group C, 17.6% (3/17) were inflow reconstructions involving the axillary-femoral (1), aorta-iliac (1) and aorta-femoral (1) arteries, and 76.4% (13/17) outflow reconstructions involving the femoral-popliteal bypass-tibial (8), femoral-tibial (1), femoral-popliteal bypass-popliteal arteries below the knee (2), and the femoral-popliteal bypass-tibial-peroneal trunk (2). One patient (1 limb) underwent both inflow and outflow reconstructions with an iliac arterial stent and a graft-popliteal anastomosis patch. Polytetrafluoroethylene (PTFE) grafts were used in the inflow or outflow reconstructions above the knee. Autovenous grafts or autovenously combined PTFE grafts were used in the outflow reconstructions below the knee. RESULTS: The percentages of Fontaine stage III and IV before primary operation and reoperation were 60% (18/30) and 86.7% (26/30), respectively (P < 0.05). Four patients died of heart attack (2), stroke (1) and multiple organ failure (1) after reoperations. Among them, only 1 patient underwent occluded bypass, and others, patent bypass. Five patients after patent bypass are still alive. The accumulative patent rate was 28.6% (8/28). The average duration of patency in groups T and C was (4.16 +/- 5.68) (0.13 - 24) months and (7.14 +/- 6.37) (0.26 - 21) months, respectively (P > 0.05). Among 42 reoperations, 19 failed within 1 month in groups T (16) and C (3) (P < 0.01). Nine patients had limb amputated (10/28 limbs, 35.71%) because of graft infection (2 limbs), pseudo aneurysm at anastomosis (1 limb), and gangrene caused by failed grafts (7 limbs). The amputation was performed on 6 limbs within 1 month and on 4 limbs 1 month after reoperation (P > 0.05). The rate of limb salvage was 64.29% (18/28). CONCLUSIONS: The percentages of Fontaine stage III and IV before reoperation may be much higher than those before primary operation. Thrombectomy plus inflow/outflow reconstruction creates patency better than thrombectomy alone for re-occluded bypass.

Endovascular treatment of central venous stenosis and obstruction in hemodialysis patients.

BACKGROUND: Central venous stenosis and obstruction (CVD) is a serious and prevalent challenge to both resolve the venous hypertension symptoms and maintain the pantency of the ipsilateral hemodialysis access in hemodialysis patients. This study aimed to summarize our experience of the endovascular management of the central venous stenosis or obstruction in hemodialysis patients. METHODS: Twenty-four haemodialysis cases of central vein stenosis or obstruction with ipsilateral functional vascular access in our hospital between July 2006 and February 2012 were treated by interventional therapy and the data were analyzed retrospectively. RESULTS: Eighteen males and six females with mean age of (66.4 ± 13.8) years and manifesting with arm swelling and venous hypertension were enrolled; 62.5% of them had a history of catheterization. Venography showed stenotic lesion in 10 cases including eight cases of brachiocephalic vein stenosis and two cases of subclavian vein stenosis and 14 cases of obstruction lesions including seven cases of short brachiocephalic obstruction and seven cases of long segment obstruction. Interventional therapy was performed and the technique success rate was 83.3%. Percutaneous transluminal angioplasty (PTA) was performed in nine cases and stent was performed in 11 cases firstly. The symptoms of venous hypertension were resolved after intervention in all the cases. There was no major complication and death perioperatively. During follow-up, reintervention was done, the primary patency rates were (88.9 ± 10.5)%, (64.8 ± 10.5)% and (48.6 ± 18.7)% at 3 months, 6 months and 1 year after treatment in the PTA group; (90.0 ± 9.5)% and (77.1 ± 14.4)% at 6 months and 1 year after treatment in the stent group, respectively. The secondary patency rates were (48.6 ± 18.7)% in the PTA group and (83.3 ± 15.2)% in the stent group 1 year after treatment, respectively. There was no significant difference between the two groups (primary patency, P = 0.20; secondary patency, P = 0.10). CONCLUSIONS: The endovascular intervention is a safe and effective method for CVD in short term; enhanced follow-up and repeated interventions are required to maintain patency for long term. The prevention is most important. Avoiding and minimizing the placement of the central venous catheter may be the key point for the prevention.

Endovascular recanalization of superior vena cava, brachiocephalic, and subclavian venous occlusions caused by nonmalignant lesions.

BACKGROUND: Endovascular recanalization (EVR) is becoming the primary therapy for patients with central venous (brachiocephalic, subclavian, and superior vena cava) occlusion (CVO) caused by benign etiology. In this study, we retrospectively analyzed our experience in using EVR to treat benign CVO in 10 patients between April 2005 and September 2010. METHODS: The mean age of the patients was 65.3 years, 2/10 cases were female, and the origin of cause of CVO in 7/10 cases was the hemodialysis access in the upper extremity. The patients were treated with primary stent placement and evaluated with immediate technical success rate and post-interventional patency rate after the procedure. RESULTS: Eight patients were treated successfully with stent placement and experienced symptomatic relief immediately. No technical complications were observed during EVR treatment. Patients were followed up by ultrasonography and venography. Median follow-up was 13 months. Three patients required secondary procedures to maintain patency. CONCLUSIONS: EVR is an effective and safe treatment in patients with benign CVO. It provides immediate symptom relief and maintains a continuous access for hemodialysis.