Chapter 110 - Infrainguinal disease endovascular Flashcards
NICE guidelines on IC
1) supervised exercise program with 2 hours supervised / week for 3 months and exercise to point of max pain 2) angioplasty only after failed supevised exercise and modifiable risk factors addressed 3) no primary stent (unless total occlusion AIOD then use bare stent) 4) bypass only if angioplasty unsuccessful/unsuitable 5) use vein for bypass 6) naftidrofuryl oxalate if exercise fail and pt does not want angio or bypass 7) discontinue naftidrofuryl oxalate if no symptom benefit in 6 months
What is naftidrofuryl oxalate
1) Praxilene 2) vasodilator 3) selective 5HT2 receptor antagonist
Most important outcome measure for intermittent claudication
Treadmill walking distance objective quantifiable clinical improvement
EUCLID trial
ticagrelor vs clopidogrel in symptomatic PAD primary outcome = CV death, MI, stroke no difference 10.6 vs 10.8% in 30 months major bleed 1.6% in each
COMPASS trial
27395 patients rivaroxaban 2.5 BID + ASA 100 rivaroxaban 5 BID ASA 100 primary: CV death, MI, stroke rivaroxaban + ASA over ASA 4.7 vs 5.9% 20% decrease rivaroxaban alone not better than ASA alone
VOYAGER trial
pending results rivaroxaban 2.5 BID vs placebo in patients who had PAD treatment primary: MI, stroke, CV death, ALI, major amp major bleed 2 years
2013 ACC AHA on statin
improve survival and MALE in patients underoing intervention for CLTI
Cochrane on cilostazol
1) improves walking distance in IC 2) mild and treatable SE only no clear evidence on mortality and QOL improvements
ZEPHYR study subanalysis on cilostazol
1) lower incidence of restenosis 1 year after DES for FP lesions
CLEVER study US
1) AI segments 2) supervised exercise + stent revasc better than med therapy alone at 18 months 3) not difference in functional status or QOL
BASIL-1
1) 27 UK hospitals 1999-2004 2) 452 patients with CLTI 3) suitable for both bypass and POBA 4) primary = amputation free survival 5) surgery = lower immediate failure, higher 30 day mortality, lower 12 month reintervention 6) beyond 2 year, hazard ratio lower for surgery compared to POBA for AFS and overall survival 7) no difference in cost at 3 and 7 years 8) bypass after POBA much worse than bypass first
BASIL-1 recommendations
1) pt with > 2 year life expectance should get vein bypass 2) pt with < 2 year life should get endo first 3) pts that cannot have vein bypass should get endo before prosthetic 4) endo is not a free-shot as it compromises outcome of subsequent bypass
BASIL-1 shortcomings
1) old study, things have improved 2) anes and bypasses have improved 3) endo techniques have advanced 4) endo now used to treat otherwise amputation patients 5) prosthetic use was 25% which is likely not anymore
BASIL 3
New study patient with CLTI randomized to 3 arms 1) PBA +/- BMS 2) DCB +/- BMS 3) DES
BASIL-1 infrapopliteal subgroup key points
vein bypass did better in survival and amputation free survival
BASIL 2
on going study 1) 600 patients needing infrapopliteal disease 2) VB first vs best ET 3) primary: major amputation, death
BEST CLI
1) 100 sites NA and europe 2) yes GSV will be bohort 1, no GSV is cohort 2 3) MALE-free survival 4) best open vs best endo
Global vascular guidelines
Collaborative effort between 1) SVS 2) ESVS 3) WFVS
GVG PLAN principles
Patient risk estimation 1) candidacy for limb salvage 2) periprocedural risk 3) life expectancy Limbe threat severity using SVS WIfI staging ANatomic pattern of disease using global anatomic staging system GLASS
GLASS
TABLE 110.2 TABLE 110.3
new concept of GLASS classification
Target artery path
GLASS stage and failure
STAGE 1: tech failure < 10%; 1 year LBP > 70% STAGE 2: tech failure < 20%; 1 year LBP 50-70% STAGE 3: tech failure > 20%; 1 year LBP < 50%
Limb based patency
LBP = ability to maintain inline flow
smoking on PAD post-op mortality
Current HR 2.45 former HR 1.62
DM on PAD and treatment
more likely to undergo intervention no effect on 1 year primary patency, major amp or mortality
FAIR trial
119 patients with in-stent restenosis rancomize to DCB or PBA DCB better in SFA
PACUBA trial
74 with in-stent stenosis randomized to DCB or PBA DCB better patency but no clinical benefit
Rate of readmission after CLTI treatment
20% in 30 days
Risk factors of readmission after CLTI treatment
1) ulcer/gangrene 2) age > 65 3) female 4) large hospital size 5) teaching hospital 6) CAD 7) heart failure 8) DM 9) CKD 10) anemia 11) coagulopathy 12) obesity 13) major bleed 14) MI 15) sepsis 16) vascular complication
Most common readmission reasons
1) infection 23.5% 2) persistent/recurrent PAD 22.2% 3) cardiac 11.4% 4) procedural complication 11% 5) endocrine problem 5.7%
Stenting of CFA results
5 year mortality 38% 5 year clinical improvement 73% freedom from TLR 79% Instent restenosis 28%
Risk of CFA stent failure
1) PFA stenting 2) type 3 lesions
Treating angiosome for wound healing
conflicting evidence makes sense for direct or indirect with collateral option if possible
Treatment of multiple tibial vessels
Unnecessary but conflicting evidence
RENDEZVOUS registry
257 CLTI patients in Japan Pedal arch angioplasty vs not higher wound healing and shorter time in pedal artery angioplasty group in moderate risk patients
Japan viabahn trial
multicenter looking at vaibahn for SFA long lesion patency 88-92% 1 year improved QOL most were IC though no cost effectiveness data
Efficacy vs effectiveness
EFFICACY: important clinical benefit in select group of homogenous patients when performed by select group of clinician - explanatory trial EFFECTIVENESS: important clinical beneft for many patients when done in most healthcare setting - pragmatic trial
GLASS staging key
TABLE
