Endovascular treatment for symptomatic stent failures in long-segment chronic total occlusion of femoropopliteal arteries

J Vasc Surg. 2014 Aug;60(2):362-8. doi: 10.1016/j.jvs.2014.02.051. Epub 2014 Mar 26.

Abstract

Objective: The objective of this study was to evaluate the outcomes of the secondary endovascular treatment (SEVT) for symptomatic recurrences in long-segment chronic total occlusion (CTO) of femoropopliteal arteries (FPAs) and to investigate the factors affecting the outcomes.

Methods: Data of patients undergoing FPA stent implantation for primary, long-segment (>10 cm) CTO lesions and receiving endovascular intervention for symptomatic recurrences more than once in our institution from July 1, 2008, to September 1, 2012, were reviewed. Follow-up results referring to SEVT procedures were analyzed, including primary patency, limb salvage (LS) rate, technical success rate, and prevalence of procedure-related complications. Primary patency and LS were analyzed with Kaplan-Meier curves. Univariate and multivariable analyses were performed to identify factors associated with recurrent restenosis with a Cox proportional hazards model.

Results: Ninety-one patients (mean age, 75.1 years) were included. The indications for SEVT were claudication (38.5%) and critical limb ischemia (61.5%). Preprocedural ankle-brachial index was 0.37 ± 0.16. The median time between initial endovascular treatment and SEVT was 6.5 months (range, 1.0-24.4 months). The arteries in 63 limbs were totally occluded. Fractures were found in 30 (18.8%) of the initially placed stents. Successful recanalization was achieved in 82 limbs (90.1%). The mean postprocedural ankle-brachial index was 0.84 ± 0.15 in those limbs that were successfully recanalized. The complication rate was 9.9%. One patient died of cerebral hemorrhage during catheter-directed thrombolysis. Other complications included the development of a groin hematoma (n = 5), distal embolization (n = 1), formation of a femoral pseudoaneurysm (n = 1), and development of acute heart failure (n = 1). The mean follow-up period was 11.0 ± 5.6 months. The cumulative primary patency rate after SEVT was 66.9% and 52.0% at 12 and 24 months. The LS rate since SEVT was 91.2% and 81.1% at 12 and 24 months. The multivariate analysis showed that stent fracture and stent overlap were independent predictors of recurrent restenosis (hazard ratio, 3.07; 95% confidence interval, 1.40-6.74; P = .005; hazard ratio, 4.75; 95% confidence interval, 1.77-12.75; P = .002).

Conclusions: Endovascular treatment is feasible for FPA stent failure in long-segment CTO. However, SEVT does not achieve durable patency. Stent fracture and overlap are related to recurrent restenosis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Ankle Brachial Index
  • Chronic Disease
  • Constriction, Pathologic
  • Endovascular Procedures / adverse effects
  • Endovascular Procedures / instrumentation*
  • Endovascular Procedures / mortality
  • Feasibility Studies
  • Female
  • Femoral Artery* / diagnostic imaging
  • Femoral Artery* / physiopathology
  • Humans
  • Intermittent Claudication / diagnosis
  • Intermittent Claudication / mortality
  • Intermittent Claudication / physiopathology
  • Intermittent Claudication / therapy*
  • Ischemia / diagnosis
  • Ischemia / mortality
  • Ischemia / physiopathology
  • Ischemia / therapy*
  • Kaplan-Meier Estimate
  • Male
  • Multivariate Analysis
  • Peripheral Arterial Disease / diagnosis
  • Peripheral Arterial Disease / mortality
  • Peripheral Arterial Disease / physiopathology
  • Peripheral Arterial Disease / therapy*
  • Popliteal Artery* / diagnostic imaging
  • Popliteal Artery* / physiopathology
  • Proportional Hazards Models
  • Prosthesis Design
  • Prosthesis Failure*
  • Radiography
  • Recurrence
  • Retreatment
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Treatment Failure
  • Vascular Patency