Atherosclerosis 235 (2014) 110e115
Contents lists available at ScienceDirect
Atherosclerosis journal homepage: www.elsevier.com/locate/atherosclerosis
Clinical results of percutaneous transluminal angioplasty for thromboangiitis obliterans in arteries above the knee Liangxi Yuan, Junmin Bao*, Zhiqing Zhao, Qingsheng Lu, Xiang Feng, Zaiping Jing** Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, PR China
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 November 2013 Received in revised form 3 March 2014 Accepted 9 April 2014 Available online 26 April 2014
Objective: This study was designed to retrospectively investigate whether percutaneous transluminal angioplasty (PTA) is efficacious and safe for the treatment of atypical thromboangiitis obliterans (ATAO) in arteries with occlusion of long segments. Methods: From January 2011 to July 2013, 9 consecutive male patients with ATAO involving the external iliac and superficial femoral arteries were treated by PTA alone, without stent placement. Their mean age was 35 years (range, 24e47 years). Preoperative symptoms included severe claudication (n ¼ 2), ischemic pain at rest (n ¼ 4), and ischemic ulcers (n ¼ 3). No any infrapopliteal interventions were performed besides the proximal intervention. Results: Technical success using PTA was achieved in 100% of cases with occluded arteries, and there were no periprocedural complications. Clinical improvement was observed postoperatively with a significant improvement in Rutherford categories (range, 2e3) and significantly increased ankle-brachial indexes, from 0.59 0.14 to 0.91 0.17 (p < 0.01). Ischemic ulcers in three patients healed 3e5 months postoperatively. No recurrent ischemic ulcer was observed, and no amputation was performed in these patients. At follow-up examination (average, 20.9 months), restenosis of the superficial femoral artery was diagnosed in only one patient who continued with a conservative medication regimen and refused additional interventional treatment because his physical symptoms were minor. Conclusion: PTA might be feasible and safe for the treatment of ATAO patients, and appears to provide positive clinical results at an average follow-up of 20.9 months. Ó 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Atypical thromboangiitis obliterans (ATAO) Endovascular treatment Percutaneous transluminal angioplasty
1. Introduction Thromboangiitis obliterans (TAO), also known as Buerger’s disease, is a non-atherosclerotic, segmental, occlusive, and inflammatory disease that affects small- and medium-sized distal arteries, vein and nerves of predominantly young men who are heavy tobacco smokers [1]. TAO may present initially as episodic pain and coldness in the fingers. As the disease progresses, intermittent claudication, rest pain, ischemic pain at rest, ischemic ulcerations, and gangrene of the critical limb can develop, which can lead to eventual amputation [2]. Although TAO usually begins with
* Corresponding author. Department of Vascular Surgery, Changhai Hospital, No. 168 Changhai Road, Shanghai 200433, PR China. Tel.: þ86 (0)21 31161666/ 13818213341. ** Corresponding author. E-mail addresses: [email protected] (L. Yuan), [email protected] (J. Bao), [email protected] (Z. Zhao), [email protected] (Q. Lu), [email protected] (X. Feng), [email protected] (Z. Jing). http://dx.doi.org/10.1016/j.atherosclerosis.2014.04.006 0021-9150/Ó 2014 Elsevier Ireland Ltd. All rights reserved.
ischemia of the distal small vessels, it may also involve several proximal arteries, including the femoral and iliac arteries [3e5]. Dilege et al. reported that in addition to an occlusive lesion in the lower limb arteries, 25% of TAO patients had superficial femoral artery occlusion [5]. In a study by Shionoya et al., 6.8% of patients had iliac artery occlusion [3]. In the present study, TAO involving the iliac or femoral artery, with a partly patent distal artery, was designated as atypical thromboangiitis obliterans (ATAO). To prevent progression of the disease and amputation, various strategies have been used, including calcium channel blockers, anticoagulants, thrombolytics, prostaglandin analogs, sympathectomy, adrenalectomy, spinal cord stimulators, and omental transfers [5e8]. However, follow-up results are generally poor since TAO is histologically a panarteritis disease, and the neighboring vein and nerve may be involved. Surgical revascularization is often not very feasible for typical TAO because of the frequent lack of sufficient distal runoff and the diffuse segmental involvement [9,10]. Surgical bypass is a less effective treatment in ATAO patients with distal runoff and restenosis [3,5]. Considering these disadvantages, recent
L. Yuan et al. / Atherosclerosis 235 (2014) 110e115
studies have proposed treating TAO using angioplasty, which has proved to be effective, with high technical success and sustained clinical improvement rates [11,12]. However, it remains unclear whether percutaneous transluminal angioplasty (PTA) is adequate in cases of ATAO involving the iliac artery and/or superficial femoral arteries. This study aimed to review outcomes in 9 ATAO patients who underwent PTA treatment in our hospital from January 2011 to July 2013. We hypothesized that PTA alone would be also efficacious and safe for treating ATAO.
2. Materials and methods From January 2011 to July 2013, 70 TAO patients underwent treatment in our hospital. Endovascular treatment (including PTA and catheter directed alprostadil infusion) only for infrapopliteal arteries was performed for 40 patients and, sympathectomy and stem cell transplantation were carried out for an additional 30 patients. ATAO represents a specific type of TAO, in which not only the infrapopliteal arteries but also the iliac or femoral arteries are involved; these patients were treated using PTA. Thus, 9 consecutive symptomatic male ATAO patients (mean age, 35 years; range, 24e47 years) were enrolled here based on the clinical criteria of Shionoya et al. [3] for TAO and iliac and/or superficial femoral arteries involvement (Table 1). Cessation of tobacco use and conservative medication regimens including aspirin and cilostazol were attempted but failed to improve symptoms. None of the patients had a history of surgical or endovascular intervention in the aortic, iliac or femoral artery. According to the Rutherford classification [13], our clinical indications for endovascular therapy were severe claudication (class III, n ¼ 2), resting pain (class IV, n ¼ 4), or ischemic ulcers (class V, n ¼ 3) (Table 2). Pre-procedural assessment was performed for all patients using computed tomographic angiography (CTA) or magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) was used to evaluate the site and length of the lesion, corkscrew collaterals, and distal runoff vessels. Corkscrew collaterals, which were confirmed on angiographic findings in all patients, were classified into 4 types according to method described by Fujii et al. [14] (Table 3). Written informed consent was obtained from each patient after providing a detailed explanation of the risks and benefits of the procedure. All procedures were approved by the local ethics committee and performed in the angiography unit under local anesthesia by senior vascular surgeons. Contralateral access with the crossover technique was used in all patients [15]. Heparin was administered intra-arterially at a dose of 125 IU/kg after placing a 6-F 45 cm-long vascular sheath (Cook, Bloomington, IN, USA). After withdrawing the guidewire, the iliac, femoral artery and infrapopliteal arteries were assessed by angiography using contrast media injected through the vascular sheath.
Table 1 Diagnostic criteria for atypical thromboangiitis obliterans. Smoking history Onset before the age of 50 years Partial infrapopliteal arterial occlusions Iliac and/or superficial femoral artery involvement Either upper limb involvement or phlebitis migrans Absence of atherosclerotic risk factors (such as hypertension, diabetes mellitus, hyperlipidemia, or cardiovascular disease) other than smoking Exclusion of other vasculitis or hypercoagulable states by investigations for rheumatoid factor and lupus anticoagulants, or serologic investigations
111
A soft 0.035-inch hydrophilic guidewire (Terumo, Tokyo, Japan), a 4-F angled catheter (Cordis, Miami Lakes, FL, US) or a 4 mm 120 mm balloons (Medtronic Invatec, Frauenfeld, Switzerland) were used to cross all occluded lesions with the guidewire looping technique [16]. Recanalization was achieved by PTA for 3 min using 4e8 mm 80e220 mm balloons (Medtronic Invatec, Frauenfeld, Switzerland; or ReeKross Clearstream, Enniscorthy, Ireland). Balloon diameter was selected based on the angiographic measurements of the non-diseased artery proximal and distal to the lesions. All target lesions in the iliac and superficial femoral arteries were treated with PTA alone. Stent placement and/ or catheter-directed thrombolysis were not required to restore vessel patency in this patient cohort. No any infrapopliteal interventions were performed besides the proximal intervention. Complete cessation of any tobacco use was emphasized in all patients postoperatively. Patients were discharged on an oral regimen of aspirin (100 mg/day) and clopidogrel (75 mg/day). Clinical examination and duplex ultrasonography were performed before discharge; at 1, 3 and 6 months after discharge; and every 6 months thereafter. Success of PTA was defined by anatomical, hemodynamical, and clinical parameters according to the Society for Vascular Surgery and the International Society for Cardiovascular Surgery reporting standards [17,18]: (1) Technical success was defined as reestablishment of direct flow to the distal artery with residual stenosis of 2.4 of peak systolic velocity ratio determined by duplex ultrasonography. Statistical analysis was performed using SPSS 18.0 software (SPSS Inc., Chicago, IL, USA). Differences in ABI and Rutherford category between pre-interventional and post-interventional procedures were analyzed using the Wilcoxon test. A value of p < 0.05 was considered statistically significant. 3. Results The general characteristics of the 9 ATAO patients are shown in Table 2. Infrapopliteal angiography indicated that only 1 patent artery was present in 6 patients and two patent arteries were present in 3 patients. DSA showed that in addition to infrapopliteal arteries, lesions were also present simultaneously in the external iliac artery and superficial femoral artery in 4 patients, and the superficial femoral artery alone in 5 patients (Fig. 1). All these 13 occlusions in 9 patients were treated by PTA. Corkscrew collaterals were present around occluded vessels in all patients. Corkscrew collaterals were predominantly of types III and IV in patient 6, types I and II in patients 2 and 7, and types II and III in the other 6 patients (Table 2). Crossing the occluded artery was difficult in patient 6, who had types III and IV corkscrew collateral arteries, and was easy in patients 2 and 7, who had types I and II. In all patients, direct flow to the infrapopliteal arteries was reestablished in the iliac and/or femoral artery, with a residual stenosis of less than 30% and no dissections were present in the recanalized arteries. After successful recanalization of chronic total occlusion, the number of corkscrew collaterals decreased significantly, with no development of collaterals or slow blood flow (Fig. 2). Complete DSA showed direct blood flow to the anterior tibial artery in 4 (44.4%) patients, peroneal artery in 1 (11.1%) patient, posterior tibial artery in 2 (22.2%) patients, and both anterior
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Table 2 Patients’ characteristics. Pat. Age (y) Sex Clinical symptoms
RC Pre- Post-
1 2 3 4 5 6 7 8 9
43 38 42 28 47 24 27 36 29
M M M M M M M M M
Rest pain Rest pain Ischemic ulcers Rest pain Severe claudication Ischemic ulcers Severe claudication Ischemic ulcers Rest pain
IV IV V IV III V IV V IV
II II II I I II II II I
Follow up (mo) Above-knee Type of corkscrew Balloon size (mm) artery involved collaterals 37 35 29 26 24 21 11 4 2
EIA, SFA EIA, SFA EIA, SFA SFA SFA EIA,
SFA SFA SFA
SFA
II, III I, II II, III II, III II, III III, IV I, II II, III II, III
4 4 4 4 4 4 4 4 4
120; 120; 120; 120; 120; 120; 120; 120; 120;
7 5 6 5 8 5 5 5 7
Operation Distal runoff time (min) PrePost-
80; 5 150 102 150 77 100; 5 150 115 150 69 80; 6 150 95 150 71 220 53 220 66 80; 6 150 92
ATA ATA, PTA PTA PTA, PA PA ATA ATA ATA, PTA ATA
ATA ATA, PTA PTA PTA, PA PA ATA ATA ATA, PTA ATA
RC: Rutherford category; EIA: external-iliac artery; SFA: superficial femoral artery; ATA: anterior tibial artery; PTA: posterior tibial artery; PA: peroneal artery.
Table 3 Classification of corkscrew collaterals [14]. Type Type Type Type
I II III IV
Artery diameter > 2 mm, large helical sign Diameter > 1.5 mm and 2 mm, medium helical sign Diameter > 1 mm and 1.5 mm, small helical sign Diameter < 1 mm, tiny helical sign
and posterior tibial arteries in 2 (22.2%) patients (Table 2). No access site complications, distal embolization, vessel-specific complications, organ-specific complications (neurological, cardiovascular, respiratory, or gastrointestinal), systemic complications, or death were reported during the follow-up. After a mean follow-up of 20.9 months (range 2e37), the clinical status of all 9 patients had been improved by an average 2.6 Rutherford categories (range 2e3). Three patients (33.3%) were now in Rutherford category I (mild claudication) and 6 patients (66.7%) were in Rutherford category II (moderate claudication), which corresponded to an improvement by 3 categories in 5 patients and by 2 categories in 4 patients. The difference in the distributions of Rutherford category at baseline and at final follow-up was statistically significant (p < 0.01). Six patients with intermittent claudication or resting pain showed obvious improvements in
walking distance during follow-up. Ischemic ulcers in 3 patients healed at 3 or 5 months postoperatively. No reoccurrence of ischemic ulcers was observed, and no amputations were performed in these patients. The mean ABI improved significantly from 0.59 0.14 preoperatively to 0.91 0.17 at final follow-up (p < 0.01). Duplex ultrasonography performed at 24 months showed that restenosis of the superficial femoral artery was diagnosed in patient 3. The patient continued a conservative medication regimen including aspirin, clopidogrel and cilostazol and refused reinterventional treatment because he experienced only minor physical compromise (walking distance over 500 m), and his ischemic ulcer had healed at 4 months postoperatively.
4. Discussion Typical TAO often affects infrapopliteal arteries. However, previous studies have reported that besides infrapopliteal arteries, the iliac or femoral artery can also be affected simultaneously [3,5], a condition termed ATAO in our study. To prevent progression of the disease, various treatment approaches are usually implemented, including smoking cessation, prostacyclin analogs, sympathectomy,
Fig. 1. Preoperative digital subtraction angiography (DSA) imaging of patient 4. DSA imaging (Patient 4) showed occlusions of the right superficial femoral artery and popliteal artery (A); The development of corkscrew collaterals around these arteries was also observed (B); Imaging of below-the-knee artery showed posterior tibial artery and partial peroneal artery (C).
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113
Fig. 2. Postoperative digital subtraction angiography imaging of the left lower extremity. Ballooning of superficial femoral artery and popliteal artery in patient 6 (AeB), and postoperative angiography showing a patent superficial femoral artery, popliteal artery, and anterior tibial artery, with decreased corkscrew collaterals (CeE). Computed tomographic angiography showed persistent interventional success at 1 year (F).
spinal cord stimulation, and treatment with prostacyclin analogs and vascular endothelial growth factors. In our study, 9 patients continued to have a poor quality of life because of severe intermittent claudication, resting pain or ischemic ulcers, despite complete cessation of tobacco use and treatment with conservative medication regimens including aspirin and cilostazol.
In previous studies, surgical sympathectomy and arterial reconstructive surgery have been the most commonly reported surgical treatments for ATAO [5,19,20]. However, ATAO patients who undergo arterial reconstruction of the lower limbs have suboptimal outcomes because of a frequent lack of an appropriate distal target vessels and the diffuse, segmental nature of these
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occlusive lesions. The primary patency rates were 41.3% at 1 year and 32.2% at 5 years [7]. All bypasses grafts (including prosthetic, bovine, or composite grafts) were found to be occluded within 10 months, and progression of proximal or distal disease (11/33) and stenosis of the anastomotic site (6/33) were the main reasons for graft failures. During a 36-month follow-up, the patency rates at the 12th, 24th, and 36th months were 59.2%, 48%, and 33.3%, respectively [5]. These suboptimal patency rates may be attributed to an inappropriate selection of patients, technical difficulties, or continuation of smoking by patients. To date, endovascular treatment for ATAO has been rarely reported [12]. The results from the present study demonstrated that the endovascular procedure was technically successful in 100% of our cases, which supports the hypothesis that extended endovascular recanalization is an effective procedure for treating ATAO disease. In our patients, angiography showed occlusion of vessels located above the popliteal fossa, with absence of arterial wall calcification and the development of a rich, typical subcutaneous network of collaterals, named as “corkscrew collaterals” [14,21]. Fujii et al. reported that ischemic severity and the amplitude of corkscrew collaterals, determined by color Doppler flow imaging, have clinical relevance [21]. Patients with small corkscrew collaterals of low amplitude (types III and IV) frequently have serious clinical manifestations, similar to patient 6 in our study, who had ischemic ulcers. A proximally occluded artery, surrounded by types III and IV corkscrew collateral arteries, was difficult to cross with a soft guidewire, whereas lesions in an artery surrounded by types I and II corkscrew collateral arteries were more easily penetrated, further confirming the relationship between the amplitude of corkscrew collaterals and the severity of the vessel blockage. During the endovascular recanalization using the guidewire looping technique [16], the distal portion of the lesion is often easier to cross after successfully crossing the more difficult proximal occluded artery. In our 9 patients, the occluded portion of the artery was very long, however only ballooning was used, but not stenting. This differed from the study by Graziani et al. who reported using extended angioplasty to treat the superficial femoral arteries in 2 ATAO patients: one was treated by PTA alone, and in the other, the femoral artery occlusion was treated with secondary stenting [12]. The reason was that direct flow to the infrapopliteal arteries was reestablished with a residual stenosis of
Contents lists available at ScienceDirect
Atherosclerosis journal homepage: www.elsevier.com/locate/atherosclerosis
Clinical results of percutaneous transluminal angioplasty for thromboangiitis obliterans in arteries above the knee Liangxi Yuan, Junmin Bao*, Zhiqing Zhao, Qingsheng Lu, Xiang Feng, Zaiping Jing** Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, PR China
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 November 2013 Received in revised form 3 March 2014 Accepted 9 April 2014 Available online 26 April 2014
Objective: This study was designed to retrospectively investigate whether percutaneous transluminal angioplasty (PTA) is efficacious and safe for the treatment of atypical thromboangiitis obliterans (ATAO) in arteries with occlusion of long segments. Methods: From January 2011 to July 2013, 9 consecutive male patients with ATAO involving the external iliac and superficial femoral arteries were treated by PTA alone, without stent placement. Their mean age was 35 years (range, 24e47 years). Preoperative symptoms included severe claudication (n ¼ 2), ischemic pain at rest (n ¼ 4), and ischemic ulcers (n ¼ 3). No any infrapopliteal interventions were performed besides the proximal intervention. Results: Technical success using PTA was achieved in 100% of cases with occluded arteries, and there were no periprocedural complications. Clinical improvement was observed postoperatively with a significant improvement in Rutherford categories (range, 2e3) and significantly increased ankle-brachial indexes, from 0.59 0.14 to 0.91 0.17 (p < 0.01). Ischemic ulcers in three patients healed 3e5 months postoperatively. No recurrent ischemic ulcer was observed, and no amputation was performed in these patients. At follow-up examination (average, 20.9 months), restenosis of the superficial femoral artery was diagnosed in only one patient who continued with a conservative medication regimen and refused additional interventional treatment because his physical symptoms were minor. Conclusion: PTA might be feasible and safe for the treatment of ATAO patients, and appears to provide positive clinical results at an average follow-up of 20.9 months. Ó 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Atypical thromboangiitis obliterans (ATAO) Endovascular treatment Percutaneous transluminal angioplasty
1. Introduction Thromboangiitis obliterans (TAO), also known as Buerger’s disease, is a non-atherosclerotic, segmental, occlusive, and inflammatory disease that affects small- and medium-sized distal arteries, vein and nerves of predominantly young men who are heavy tobacco smokers [1]. TAO may present initially as episodic pain and coldness in the fingers. As the disease progresses, intermittent claudication, rest pain, ischemic pain at rest, ischemic ulcerations, and gangrene of the critical limb can develop, which can lead to eventual amputation [2]. Although TAO usually begins with
* Corresponding author. Department of Vascular Surgery, Changhai Hospital, No. 168 Changhai Road, Shanghai 200433, PR China. Tel.: þ86 (0)21 31161666/ 13818213341. ** Corresponding author. E-mail addresses: [email protected] (L. Yuan), [email protected] (J. Bao), [email protected] (Z. Zhao), [email protected] (Q. Lu), [email protected] (X. Feng), [email protected] (Z. Jing). http://dx.doi.org/10.1016/j.atherosclerosis.2014.04.006 0021-9150/Ó 2014 Elsevier Ireland Ltd. All rights reserved.
ischemia of the distal small vessels, it may also involve several proximal arteries, including the femoral and iliac arteries [3e5]. Dilege et al. reported that in addition to an occlusive lesion in the lower limb arteries, 25% of TAO patients had superficial femoral artery occlusion [5]. In a study by Shionoya et al., 6.8% of patients had iliac artery occlusion [3]. In the present study, TAO involving the iliac or femoral artery, with a partly patent distal artery, was designated as atypical thromboangiitis obliterans (ATAO). To prevent progression of the disease and amputation, various strategies have been used, including calcium channel blockers, anticoagulants, thrombolytics, prostaglandin analogs, sympathectomy, adrenalectomy, spinal cord stimulators, and omental transfers [5e8]. However, follow-up results are generally poor since TAO is histologically a panarteritis disease, and the neighboring vein and nerve may be involved. Surgical revascularization is often not very feasible for typical TAO because of the frequent lack of sufficient distal runoff and the diffuse segmental involvement [9,10]. Surgical bypass is a less effective treatment in ATAO patients with distal runoff and restenosis [3,5]. Considering these disadvantages, recent
L. Yuan et al. / Atherosclerosis 235 (2014) 110e115
studies have proposed treating TAO using angioplasty, which has proved to be effective, with high technical success and sustained clinical improvement rates [11,12]. However, it remains unclear whether percutaneous transluminal angioplasty (PTA) is adequate in cases of ATAO involving the iliac artery and/or superficial femoral arteries. This study aimed to review outcomes in 9 ATAO patients who underwent PTA treatment in our hospital from January 2011 to July 2013. We hypothesized that PTA alone would be also efficacious and safe for treating ATAO.
2. Materials and methods From January 2011 to July 2013, 70 TAO patients underwent treatment in our hospital. Endovascular treatment (including PTA and catheter directed alprostadil infusion) only for infrapopliteal arteries was performed for 40 patients and, sympathectomy and stem cell transplantation were carried out for an additional 30 patients. ATAO represents a specific type of TAO, in which not only the infrapopliteal arteries but also the iliac or femoral arteries are involved; these patients were treated using PTA. Thus, 9 consecutive symptomatic male ATAO patients (mean age, 35 years; range, 24e47 years) were enrolled here based on the clinical criteria of Shionoya et al. [3] for TAO and iliac and/or superficial femoral arteries involvement (Table 1). Cessation of tobacco use and conservative medication regimens including aspirin and cilostazol were attempted but failed to improve symptoms. None of the patients had a history of surgical or endovascular intervention in the aortic, iliac or femoral artery. According to the Rutherford classification [13], our clinical indications for endovascular therapy were severe claudication (class III, n ¼ 2), resting pain (class IV, n ¼ 4), or ischemic ulcers (class V, n ¼ 3) (Table 2). Pre-procedural assessment was performed for all patients using computed tomographic angiography (CTA) or magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) was used to evaluate the site and length of the lesion, corkscrew collaterals, and distal runoff vessels. Corkscrew collaterals, which were confirmed on angiographic findings in all patients, were classified into 4 types according to method described by Fujii et al. [14] (Table 3). Written informed consent was obtained from each patient after providing a detailed explanation of the risks and benefits of the procedure. All procedures were approved by the local ethics committee and performed in the angiography unit under local anesthesia by senior vascular surgeons. Contralateral access with the crossover technique was used in all patients [15]. Heparin was administered intra-arterially at a dose of 125 IU/kg after placing a 6-F 45 cm-long vascular sheath (Cook, Bloomington, IN, USA). After withdrawing the guidewire, the iliac, femoral artery and infrapopliteal arteries were assessed by angiography using contrast media injected through the vascular sheath.
Table 1 Diagnostic criteria for atypical thromboangiitis obliterans. Smoking history Onset before the age of 50 years Partial infrapopliteal arterial occlusions Iliac and/or superficial femoral artery involvement Either upper limb involvement or phlebitis migrans Absence of atherosclerotic risk factors (such as hypertension, diabetes mellitus, hyperlipidemia, or cardiovascular disease) other than smoking Exclusion of other vasculitis or hypercoagulable states by investigations for rheumatoid factor and lupus anticoagulants, or serologic investigations
111
A soft 0.035-inch hydrophilic guidewire (Terumo, Tokyo, Japan), a 4-F angled catheter (Cordis, Miami Lakes, FL, US) or a 4 mm 120 mm balloons (Medtronic Invatec, Frauenfeld, Switzerland) were used to cross all occluded lesions with the guidewire looping technique [16]. Recanalization was achieved by PTA for 3 min using 4e8 mm 80e220 mm balloons (Medtronic Invatec, Frauenfeld, Switzerland; or ReeKross Clearstream, Enniscorthy, Ireland). Balloon diameter was selected based on the angiographic measurements of the non-diseased artery proximal and distal to the lesions. All target lesions in the iliac and superficial femoral arteries were treated with PTA alone. Stent placement and/ or catheter-directed thrombolysis were not required to restore vessel patency in this patient cohort. No any infrapopliteal interventions were performed besides the proximal intervention. Complete cessation of any tobacco use was emphasized in all patients postoperatively. Patients were discharged on an oral regimen of aspirin (100 mg/day) and clopidogrel (75 mg/day). Clinical examination and duplex ultrasonography were performed before discharge; at 1, 3 and 6 months after discharge; and every 6 months thereafter. Success of PTA was defined by anatomical, hemodynamical, and clinical parameters according to the Society for Vascular Surgery and the International Society for Cardiovascular Surgery reporting standards [17,18]: (1) Technical success was defined as reestablishment of direct flow to the distal artery with residual stenosis of 2.4 of peak systolic velocity ratio determined by duplex ultrasonography. Statistical analysis was performed using SPSS 18.0 software (SPSS Inc., Chicago, IL, USA). Differences in ABI and Rutherford category between pre-interventional and post-interventional procedures were analyzed using the Wilcoxon test. A value of p < 0.05 was considered statistically significant. 3. Results The general characteristics of the 9 ATAO patients are shown in Table 2. Infrapopliteal angiography indicated that only 1 patent artery was present in 6 patients and two patent arteries were present in 3 patients. DSA showed that in addition to infrapopliteal arteries, lesions were also present simultaneously in the external iliac artery and superficial femoral artery in 4 patients, and the superficial femoral artery alone in 5 patients (Fig. 1). All these 13 occlusions in 9 patients were treated by PTA. Corkscrew collaterals were present around occluded vessels in all patients. Corkscrew collaterals were predominantly of types III and IV in patient 6, types I and II in patients 2 and 7, and types II and III in the other 6 patients (Table 2). Crossing the occluded artery was difficult in patient 6, who had types III and IV corkscrew collateral arteries, and was easy in patients 2 and 7, who had types I and II. In all patients, direct flow to the infrapopliteal arteries was reestablished in the iliac and/or femoral artery, with a residual stenosis of less than 30% and no dissections were present in the recanalized arteries. After successful recanalization of chronic total occlusion, the number of corkscrew collaterals decreased significantly, with no development of collaterals or slow blood flow (Fig. 2). Complete DSA showed direct blood flow to the anterior tibial artery in 4 (44.4%) patients, peroneal artery in 1 (11.1%) patient, posterior tibial artery in 2 (22.2%) patients, and both anterior
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Table 2 Patients’ characteristics. Pat. Age (y) Sex Clinical symptoms
RC Pre- Post-
1 2 3 4 5 6 7 8 9
43 38 42 28 47 24 27 36 29
M M M M M M M M M
Rest pain Rest pain Ischemic ulcers Rest pain Severe claudication Ischemic ulcers Severe claudication Ischemic ulcers Rest pain
IV IV V IV III V IV V IV
II II II I I II II II I
Follow up (mo) Above-knee Type of corkscrew Balloon size (mm) artery involved collaterals 37 35 29 26 24 21 11 4 2
EIA, SFA EIA, SFA EIA, SFA SFA SFA EIA,
SFA SFA SFA
SFA
II, III I, II II, III II, III II, III III, IV I, II II, III II, III
4 4 4 4 4 4 4 4 4
120; 120; 120; 120; 120; 120; 120; 120; 120;
7 5 6 5 8 5 5 5 7
Operation Distal runoff time (min) PrePost-
80; 5 150 102 150 77 100; 5 150 115 150 69 80; 6 150 95 150 71 220 53 220 66 80; 6 150 92
ATA ATA, PTA PTA PTA, PA PA ATA ATA ATA, PTA ATA
ATA ATA, PTA PTA PTA, PA PA ATA ATA ATA, PTA ATA
RC: Rutherford category; EIA: external-iliac artery; SFA: superficial femoral artery; ATA: anterior tibial artery; PTA: posterior tibial artery; PA: peroneal artery.
Table 3 Classification of corkscrew collaterals [14]. Type Type Type Type
I II III IV
Artery diameter > 2 mm, large helical sign Diameter > 1.5 mm and 2 mm, medium helical sign Diameter > 1 mm and 1.5 mm, small helical sign Diameter < 1 mm, tiny helical sign
and posterior tibial arteries in 2 (22.2%) patients (Table 2). No access site complications, distal embolization, vessel-specific complications, organ-specific complications (neurological, cardiovascular, respiratory, or gastrointestinal), systemic complications, or death were reported during the follow-up. After a mean follow-up of 20.9 months (range 2e37), the clinical status of all 9 patients had been improved by an average 2.6 Rutherford categories (range 2e3). Three patients (33.3%) were now in Rutherford category I (mild claudication) and 6 patients (66.7%) were in Rutherford category II (moderate claudication), which corresponded to an improvement by 3 categories in 5 patients and by 2 categories in 4 patients. The difference in the distributions of Rutherford category at baseline and at final follow-up was statistically significant (p < 0.01). Six patients with intermittent claudication or resting pain showed obvious improvements in
walking distance during follow-up. Ischemic ulcers in 3 patients healed at 3 or 5 months postoperatively. No reoccurrence of ischemic ulcers was observed, and no amputations were performed in these patients. The mean ABI improved significantly from 0.59 0.14 preoperatively to 0.91 0.17 at final follow-up (p < 0.01). Duplex ultrasonography performed at 24 months showed that restenosis of the superficial femoral artery was diagnosed in patient 3. The patient continued a conservative medication regimen including aspirin, clopidogrel and cilostazol and refused reinterventional treatment because he experienced only minor physical compromise (walking distance over 500 m), and his ischemic ulcer had healed at 4 months postoperatively.
4. Discussion Typical TAO often affects infrapopliteal arteries. However, previous studies have reported that besides infrapopliteal arteries, the iliac or femoral artery can also be affected simultaneously [3,5], a condition termed ATAO in our study. To prevent progression of the disease, various treatment approaches are usually implemented, including smoking cessation, prostacyclin analogs, sympathectomy,
Fig. 1. Preoperative digital subtraction angiography (DSA) imaging of patient 4. DSA imaging (Patient 4) showed occlusions of the right superficial femoral artery and popliteal artery (A); The development of corkscrew collaterals around these arteries was also observed (B); Imaging of below-the-knee artery showed posterior tibial artery and partial peroneal artery (C).
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Fig. 2. Postoperative digital subtraction angiography imaging of the left lower extremity. Ballooning of superficial femoral artery and popliteal artery in patient 6 (AeB), and postoperative angiography showing a patent superficial femoral artery, popliteal artery, and anterior tibial artery, with decreased corkscrew collaterals (CeE). Computed tomographic angiography showed persistent interventional success at 1 year (F).
spinal cord stimulation, and treatment with prostacyclin analogs and vascular endothelial growth factors. In our study, 9 patients continued to have a poor quality of life because of severe intermittent claudication, resting pain or ischemic ulcers, despite complete cessation of tobacco use and treatment with conservative medication regimens including aspirin and cilostazol.
In previous studies, surgical sympathectomy and arterial reconstructive surgery have been the most commonly reported surgical treatments for ATAO [5,19,20]. However, ATAO patients who undergo arterial reconstruction of the lower limbs have suboptimal outcomes because of a frequent lack of an appropriate distal target vessels and the diffuse, segmental nature of these
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occlusive lesions. The primary patency rates were 41.3% at 1 year and 32.2% at 5 years [7]. All bypasses grafts (including prosthetic, bovine, or composite grafts) were found to be occluded within 10 months, and progression of proximal or distal disease (11/33) and stenosis of the anastomotic site (6/33) were the main reasons for graft failures. During a 36-month follow-up, the patency rates at the 12th, 24th, and 36th months were 59.2%, 48%, and 33.3%, respectively [5]. These suboptimal patency rates may be attributed to an inappropriate selection of patients, technical difficulties, or continuation of smoking by patients. To date, endovascular treatment for ATAO has been rarely reported [12]. The results from the present study demonstrated that the endovascular procedure was technically successful in 100% of our cases, which supports the hypothesis that extended endovascular recanalization is an effective procedure for treating ATAO disease. In our patients, angiography showed occlusion of vessels located above the popliteal fossa, with absence of arterial wall calcification and the development of a rich, typical subcutaneous network of collaterals, named as “corkscrew collaterals” [14,21]. Fujii et al. reported that ischemic severity and the amplitude of corkscrew collaterals, determined by color Doppler flow imaging, have clinical relevance [21]. Patients with small corkscrew collaterals of low amplitude (types III and IV) frequently have serious clinical manifestations, similar to patient 6 in our study, who had ischemic ulcers. A proximally occluded artery, surrounded by types III and IV corkscrew collateral arteries, was difficult to cross with a soft guidewire, whereas lesions in an artery surrounded by types I and II corkscrew collateral arteries were more easily penetrated, further confirming the relationship between the amplitude of corkscrew collaterals and the severity of the vessel blockage. During the endovascular recanalization using the guidewire looping technique [16], the distal portion of the lesion is often easier to cross after successfully crossing the more difficult proximal occluded artery. In our 9 patients, the occluded portion of the artery was very long, however only ballooning was used, but not stenting. This differed from the study by Graziani et al. who reported using extended angioplasty to treat the superficial femoral arteries in 2 ATAO patients: one was treated by PTA alone, and in the other, the femoral artery occlusion was treated with secondary stenting [12]. The reason was that direct flow to the infrapopliteal arteries was reestablished with a residual stenosis of
