Relationship of Walking Impairment and Ankle-Brachial Index Assessments with Peripheral Arterial Translesional Pressure Gradients
Subhash Banerjee, MD, Neeraj Badhey, MD, Christopher Lichtenwalter, MD, Cyril Varghese, MS, Emmanouil S. Brilakis, MD, PhD
Background. The relationship of peripheral arterial mean translesional pressure gradient to presenting symptom, functional impairment, and initial noninvasive ABI assessments has never been established.
Objectives. To evaluate the association between translesional pressure gradient, severity of walking impairment, rest and exercise ankle-brachial indices (ABI).
Methods. Translesional pressure gradient in 19 patients presenting with claudication and single superficial femoral artery lesion were measured invasively. The translesional pressure gradient was measured at rest and post-hyperemia induction with intra-arterial adenosine (100 and 200 µg), nitroglycerin (100 and 200 µg), and after 3 minutes of ipsilateral calf cuff pressure inflation-deflation sequence. For each patient, a walking impairment questionnaire (WIQ) was completed and rest and exercise ABI were measured prior to translesional pressure gradient assessment.
Results. Mean age was 60 ± 6 years, 89% were men. Mean WIQ score was 4817 ± 3549, mean rest and exercise ABI were 0.79 ± 0.14 and 0.59 ± 0.17, respectively, and mean exercise duration was 6.3 ± 3.4 minutes. TLG with 100 µg of adenosine strongly correlates with WIQ score (r = -0.723); rest ABI (r = -0.748); exercise ABI (r = -0.888), exercise duration (r = -0.711), and percent angiographic stenosis (r = -0.818), respectively (p < 0.01 for all). The translesional pressure gradient with adenosine 200 µg, nitroglycerin 100 and 200 µg and after cuff inflation-deflation also demonstrated significant correlation. Receiver operator curve analysis demonstrated that a translesional pressure gradient ≥ 11 mmHg post 100 µg adenosine administration had 71.43% sensitivity and 100% specificity for identifying patients with disease defining state of exercise ABI ≤ 0.70.
Conclusion. This study validates the utility of invasive translesional pressure gradient measurements using vasodilation for determining the functional and hemodynamic significance of superficial femoral artery lesions.
J INVASIVE CARDIOL 2011;23(9):352–356
Endoluminal Treatment of Peripheral Chronic Total Occlusions Using the Crosser Recanalization Catheter
Cezar S. Staniloae, MD, Kanika P. Mody, MD, Sidharth S. Yadav, DO, Seol Young Han, MD, Ravikiran Korabathina, MD
Purpose. Revascularization of lower extremity chronic total occlusions (CTOs) is technically challenging. The Crosser® recanalization catheter was designed to facilitate distal vessel intraluminal entry that is both rapid and safe. We present our experience with the Crosser device as primary therapy for peripheral CTOs.
Methods. Subjects undergoing evaluation for arterial insufficiency at our institution between 2008-2010 who were noted to have a CTO in the lower extremity by duplex ultrasonography and who subsequently underwent Crosser recanalization were enrolled. Clinical characteristics, ankle-brachial indices, Rutherford-Becker symptom category, and angiographic CTO parameters were collected. Primary technical success was intraluminal delivery of the guidewire into the distal vessel solely by the Crosser device. Secondary technical success was assisted delivery using the Outback LTD® re-entry device. Safety endpoints were the occurrence of dissections, thromboembolism, and perforations related to the Crosser device. Statistical analysis was performed to find independent predictors for failure to achieve Crosser recanalization.
Results. Fifty-six subjects with 73 CTOs were enrolled. The mean Crosser use time was 17.6 ± 12.7 minutes. The overall primary and secondary technical success rates for Crosser recanalization were 76.7% and 87.7%, respectively. Technical success was highest for CTOs located in the aorto-iliac (90.0%) and tibial (95.2%) arterial segments. There were no perforations related to the Crosser device. For successful cases, the mean ABI improved significantly from pre- to post-intervention (0.57 ± 0.13 to 0.89 ± 0.15, p < 0.001). The only predictors for failure were lesion length longer than 100 mm (p = 0.04) and calcification within 10 mm of the exit cap (p = 0.02).
Conclusion. The Crosser device is safe and shows excellent efficacy in facilitating guidewire distal lumen entry, especially for aorto-iliac and tibial occlusions. The technical success rate for the femoral and popliteal occlusions is comparable to those reported with other recanalization techniques.
J INVASIVE CARDIOL 2011;23(9):359–362
New Drug-Eluting Stent Implantation for Recalcitrant In-Stent Restenosis Treated with Drug-Eluting Stents. The Stent-in-Stent Cube (SIS3) Registry
Emanuele Meliga, MD, Mauro De Benedictis, MD, Andrea Gagnor, MD, Innocenzo Scrocca, MD, Primiano Lombardi, MD, Tiziana Aranzulla, MD, Ferdinando Varbella, MD, Maria Rosa Conte, MD
The best management for patients with recurrent in-stent restenosis is still not clear. The aim of the present study was to describe the long-term clinical results of re-DES (drug-eluting stent) implantation in patients suffering recurrences after stenting with DES for in-BMS (bare metal stent) restenosis.
Methods. All consecutive patients with in-BMS restenosis treated with DES and presenting with recurrent in-stent restenosis (in-DES restenosis) treated with re-DES in 3 tertiary care centers were retrospectively selected and analyzed.
Results. In the time period 2005-2009, 40 consecutive patients with recalcitrant in-stent restenosis were selected. At a mean follow-up of 701 ± 570 days, no patient died. The incidence of target lesion revascularization and target vessel revascularization was 12.5% and 17.5%, respectively. Survival free from composite endpoint (any death + MI + target lesion revascularization) was 82% at 2 years.
Conclusions. DES implantation for patients with recurrent in-stent restenosis offers good clinical outcomes at long-term follow up.
J INVASIVE CARDIOL 2011;23(9):365–368