Catheterization and Cardiovascular Interventions 85:868–869 (2015)
Editorial Comment What’s Past is Prologue Robert M. Schainfeld,1* DO, and Manu Rajachandran,2 MD 1 Section of Vascular Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA, 02114 2 Department of Cardiology, Memorial Hospital, York, PA 17403
Key Points
Above knee and below knee patency for synthetic endografts are vastly different. Long-term data is encouragingly similar to synthetic bypass grafting. Optimize use of synthetic endografts in above knee femoropopliteal segments in non-critical limb ischemia patients.
“The Past is Never Dead. It’s Not Even Past.” —William Faulkner The vascular conundrum of synthetic conduit below the knee is not new. An ongoing procedural dilemma well documented in the surgical literature more than 30 years ago, the disappointing performance of synthetic material after it crosses the knee joint has been linked to various causative factors such as increased thrombogenicity, mechanical stress imposed by multidirectional forces across the joint, and intimal hyperplasia ultimately leading to conduit failure [1,2]. In this issue of CCI, Shackles and coworker’s meticulous retrospective analysis of their single center experience of stent graft placement in the above and below knee popliteal segment continues to reaffirm this well known theme. One hundred and fourteen limbs in 127 patients were treated with Viahbahn stent grafting, with an approximate 2:1 above to below knee stent placement distribution. The vast majority of lesions in both groups were TransAtlantic Inter-Society Consensus (TASC D) in Rutherford classification. There was a fairly even distribution of patients whose indication for the procedure were claudication and critical limb ischemia, with the latter having a slight preponderance. Patients were C 2015 Wiley Periodicals, Inc. V
evaluated at fairly frequent intervals for the first year post-stenting, using clinical parameters on vascular examination, and ankle-brachial indices. Duplex scanning of the conduits were performed only if indicated by the clinical examination. Patients were then followed at yearly intervals. Mean follow-up was 14.4 months and study endpoints were loss of primary, primary-assisted, and secondary patency. One year patency rates were higher in the above knee than the below knee group, across all endpoints. Moreover, univariate and multivariate analysis of clinical predictors of endograft performance both identified extension of the graft across the knee joint, as a predictor of subsequent graft failure. Multivariate analysis also identified advanced Rutherford ischemia class (5– 6) as a risk for loss of endograft patency. Certainly, further insights into graft behavior may have been obtained, if longer term duplex graft interrogation had routinely been performed and if the duration of dual antiplatelet therapy had been uniformly extended past the 6 month minimum. The results of this study were at least comparable to, and in some cases, superior to the results obtained in other studies of Viabahn stent grafting for femoropopliteal disease [3,4]. In addition, a brief glance at the surgical literature reveals that the current results were comparable to one year primary and secondary patency rates noted in several large surgical studies of polytetrafluoroethylene (PTFE) bypass [1,2,5]. Rather than being another cautionary tale in the use of synthetic grafts in this particularly troublesome vascular segment, this study, along with others of its kind, seems to mandate a “back to the future” type of reassessment of endovascular treatment options for femoropopliteal disease. Covered stent grafting seems to be a reasonable endovascular strategy for the treatment of above knee TASC C-D lesions, in the setting of critical Conflict of interest: Nothing to report. *Correspondence to: Robert M. Schainfeld, Section of Vascular Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. E-mail: [email protected] Received 2 February 2015; Revision accepted 5 February 2015 DOI: 10.1002/ccd.25883 Published online 18 March 2015 in Wiley Online Library (wileyonlinelibrary.com)
What’s Past is Prologue
limb ischemia and limb salvage. Its routine first line use for the treatment of TASC A-B lesions, and in moderate claudication without tissue loss, is more problematic, especially when the endograft is extended below the knee. Vascular surgeons, who have long known the particular idiosyncrasies of synthetic graft, based on a now robust surgical database, have altered their surgical strategy over recent decades, to emphasize a “vein first” approach in the management of this disease. It may be prudent for endovascular specialists to similarly consider a “stent last” philosophy when dealing with infrageniculate disease, unless a clear limb salvage indication is present. Newer modalities such as drug eluting balloons with or without adjunctive debulking strategies, may offer a superior approach to ensuring long-term patency in this vascular segment, with stent grafting judiciously employed in the above knee femoropopliteal segment, where its impact is greatest. Perhaps Faulkner, in the end, was just borrowing from the wisdom of others before him. “Plus c¸a
869
change, plus c’est la m^eme chose.” Interventionalists may be wise to take heed. REFERENCES 1. Albers M, Battistellaa VM, Pereira CAB, et al. Meta-analysis of polytetrafluoroethylene bypass grafts to infrapopliteal arteries. J Vasc Surg 2003;37:1263–1269. 2. Veith FJ, Gupta SK, Ascher E, Bergan JJ, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg 1986;3:104–114. 3. Kedora J, Hohmann S, Gable D. Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease. J Vasc Surg 2007;45:10–16. 4. Schneider JR Verta MJ, Alonzo M, et al. Results with Viabahnassisted subintimal recanalization for TASC C and TASC D superficial femoral artery occlusive disease. J Vasc Endovasc Surg 2011;45:391–397. 5. Pereira CE, Albers M, Bragana˛a Pereira CA, et al. Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency. J Vasc Surg 2006;44:510–517.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Editorial Comment What’s Past is Prologue Robert M. Schainfeld,1* DO, and Manu Rajachandran,2 MD 1 Section of Vascular Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA, 02114 2 Department of Cardiology, Memorial Hospital, York, PA 17403
Key Points
Above knee and below knee patency for synthetic endografts are vastly different. Long-term data is encouragingly similar to synthetic bypass grafting. Optimize use of synthetic endografts in above knee femoropopliteal segments in non-critical limb ischemia patients.
“The Past is Never Dead. It’s Not Even Past.” —William Faulkner The vascular conundrum of synthetic conduit below the knee is not new. An ongoing procedural dilemma well documented in the surgical literature more than 30 years ago, the disappointing performance of synthetic material after it crosses the knee joint has been linked to various causative factors such as increased thrombogenicity, mechanical stress imposed by multidirectional forces across the joint, and intimal hyperplasia ultimately leading to conduit failure [1,2]. In this issue of CCI, Shackles and coworker’s meticulous retrospective analysis of their single center experience of stent graft placement in the above and below knee popliteal segment continues to reaffirm this well known theme. One hundred and fourteen limbs in 127 patients were treated with Viahbahn stent grafting, with an approximate 2:1 above to below knee stent placement distribution. The vast majority of lesions in both groups were TransAtlantic Inter-Society Consensus (TASC D) in Rutherford classification. There was a fairly even distribution of patients whose indication for the procedure were claudication and critical limb ischemia, with the latter having a slight preponderance. Patients were C 2015 Wiley Periodicals, Inc. V
evaluated at fairly frequent intervals for the first year post-stenting, using clinical parameters on vascular examination, and ankle-brachial indices. Duplex scanning of the conduits were performed only if indicated by the clinical examination. Patients were then followed at yearly intervals. Mean follow-up was 14.4 months and study endpoints were loss of primary, primary-assisted, and secondary patency. One year patency rates were higher in the above knee than the below knee group, across all endpoints. Moreover, univariate and multivariate analysis of clinical predictors of endograft performance both identified extension of the graft across the knee joint, as a predictor of subsequent graft failure. Multivariate analysis also identified advanced Rutherford ischemia class (5– 6) as a risk for loss of endograft patency. Certainly, further insights into graft behavior may have been obtained, if longer term duplex graft interrogation had routinely been performed and if the duration of dual antiplatelet therapy had been uniformly extended past the 6 month minimum. The results of this study were at least comparable to, and in some cases, superior to the results obtained in other studies of Viabahn stent grafting for femoropopliteal disease [3,4]. In addition, a brief glance at the surgical literature reveals that the current results were comparable to one year primary and secondary patency rates noted in several large surgical studies of polytetrafluoroethylene (PTFE) bypass [1,2,5]. Rather than being another cautionary tale in the use of synthetic grafts in this particularly troublesome vascular segment, this study, along with others of its kind, seems to mandate a “back to the future” type of reassessment of endovascular treatment options for femoropopliteal disease. Covered stent grafting seems to be a reasonable endovascular strategy for the treatment of above knee TASC C-D lesions, in the setting of critical Conflict of interest: Nothing to report. *Correspondence to: Robert M. Schainfeld, Section of Vascular Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. E-mail: [email protected] Received 2 February 2015; Revision accepted 5 February 2015 DOI: 10.1002/ccd.25883 Published online 18 March 2015 in Wiley Online Library (wileyonlinelibrary.com)
What’s Past is Prologue
limb ischemia and limb salvage. Its routine first line use for the treatment of TASC A-B lesions, and in moderate claudication without tissue loss, is more problematic, especially when the endograft is extended below the knee. Vascular surgeons, who have long known the particular idiosyncrasies of synthetic graft, based on a now robust surgical database, have altered their surgical strategy over recent decades, to emphasize a “vein first” approach in the management of this disease. It may be prudent for endovascular specialists to similarly consider a “stent last” philosophy when dealing with infrageniculate disease, unless a clear limb salvage indication is present. Newer modalities such as drug eluting balloons with or without adjunctive debulking strategies, may offer a superior approach to ensuring long-term patency in this vascular segment, with stent grafting judiciously employed in the above knee femoropopliteal segment, where its impact is greatest. Perhaps Faulkner, in the end, was just borrowing from the wisdom of others before him. “Plus c¸a
869
change, plus c’est la m^eme chose.” Interventionalists may be wise to take heed. REFERENCES 1. Albers M, Battistellaa VM, Pereira CAB, et al. Meta-analysis of polytetrafluoroethylene bypass grafts to infrapopliteal arteries. J Vasc Surg 2003;37:1263–1269. 2. Veith FJ, Gupta SK, Ascher E, Bergan JJ, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg 1986;3:104–114. 3. Kedora J, Hohmann S, Gable D. Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease. J Vasc Surg 2007;45:10–16. 4. Schneider JR Verta MJ, Alonzo M, et al. Results with Viabahnassisted subintimal recanalization for TASC C and TASC D superficial femoral artery occlusive disease. J Vasc Endovasc Surg 2011;45:391–397. 5. Pereira CE, Albers M, Bragana˛a Pereira CA, et al. Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency. J Vasc Surg 2006;44:510–517.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
