Chapter 110 - Infrainguinal disease endovascular

Question 1

NICE guidelines on IC

Answer 1

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

Question 2

What is naftidrofuryl oxalate

Answer 2

1) Praxilene 2) vasodilator 3) selective 5HT2 receptor antagonist

Question 3

Most important outcome measure for intermittent claudication

Answer 3

Treadmill walking distance objective quantifiable clinical improvement

Question 4

EUCLID trial

Answer 4

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

Question 5

COMPASS trial

Answer 5

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

Question 6

VOYAGER trial

Answer 6

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

Question 7

2013 ACC AHA on statin

Answer 7

improve survival and MALE in patients underoing intervention for CLTI

Question 8

Cochrane on cilostazol

Answer 8

1) improves walking distance in IC 2) mild and treatable SE only no clear evidence on mortality and QOL improvements

Question 9

ZEPHYR study subanalysis on cilostazol

Answer 9

1) lower incidence of restenosis 1 year after DES for FP lesions

Question 10

CLEVER study US

Answer 10

1) AI segments 2) supervised exercise + stent revasc better than med therapy alone at 18 months 3) not difference in functional status or QOL

Question 11

BASIL-1

Answer 11

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

Question 12

BASIL-1 recommendations

Answer 12

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

Question 13

BASIL-1 shortcomings

Answer 13

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

Question 14

BASIL 3

Answer 14

New study patient with CLTI randomized to 3 arms 1) PBA +/- BMS 2) DCB +/- BMS 3) DES

Question 15

BASIL-1 infrapopliteal subgroup key points

Answer 15

vein bypass did better in survival and amputation free survival

Question 16

BASIL 2

Answer 16

on going study 1) 600 patients needing infrapopliteal disease 2) VB first vs best ET 3) primary: major amputation, death

Question 17

BEST CLI

Answer 17

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

Question 18

Global vascular guidelines

Answer 18

Collaborative effort between 1) SVS 2) ESVS 3) WFVS

Question 19

GVG PLAN principles

Answer 19

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

Question 20

GLASS

Answer 20

TABLE 110.2 TABLE 110.3

Question 21

new concept of GLASS classification

Answer 21

Target artery path

Question 22

GLASS stage and failure

Answer 22

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%

Question 23

Limb based patency

Answer 23

LBP = ability to maintain inline flow

Question 24

smoking on PAD post-op mortality

Answer 24

Current HR 2.45 former HR 1.62

Question 25

DM on PAD and treatment

Answer 25

more likely to undergo intervention no effect on 1 year primary patency, major amp or mortality

Question 26

FAIR trial

Answer 26

119 patients with in-stent restenosis rancomize to DCB or PBA DCB better in SFA

Question 27

PACUBA trial

Answer 27

74 with in-stent stenosis randomized to DCB or PBA DCB better patency but no clinical benefit

Question 28

Rate of readmission after CLTI treatment

Answer 28

20% in 30 days

Question 29

Risk factors of readmission after CLTI treatment

Answer 29

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

Question 30

Most common readmission reasons

Answer 30

1) infection 23.5% 2) persistent/recurrent PAD 22.2% 3) cardiac 11.4% 4) procedural complication 11% 5) endocrine problem 5.7%

Question 31

Stenting of CFA results

Answer 31

5 year mortality 38% 5 year clinical improvement 73% freedom from TLR 79% Instent restenosis 28%

Question 32

Risk of CFA stent failure

Answer 32

1) PFA stenting 2) type 3 lesions

Question 33

Treating angiosome for wound healing

Answer 33

conflicting evidence makes sense for direct or indirect with collateral option if possible

Question 34

Treatment of multiple tibial vessels

Answer 34

Unnecessary but conflicting evidence

Question 35

RENDEZVOUS registry

Answer 35

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

Question 36

Japan viabahn trial

Answer 36

multicenter looking at vaibahn for SFA long lesion patency 88-92% 1 year improved QOL most were IC though no cost effectiveness data

Question 37

Efficacy vs effectiveness

Answer 37

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

Question 38

GLASS staging key

Answer 38

TABLE