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PubMed2003

The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study.

BACKGROUND: Cholesterol embolization syndrome is a systemic disease caused by distal showering of cholesterol crystals after angiography, major vessel surgery, or thrombolysis. METHODS: We prospectively evaluated a total of 1,786 consecutive patients 40 years of age and older, who underwent left-heart catheterization at 11 participating hospitals. The diagnosis of CES was made when patients had peripheral cutaneous involvement (livedo reticularis, blue toe syndrome, and digital gangrene) or renal dysfunction. RESULTS: Twenty-five patients (1.4%) were diagnosed as having CES. Twelve patients (48%) had cutaneous signs, and 16 patients (64%) had renal insufficiency. Eosinophil counts were significantly higher in CES patients than in non-CES patients before and after cardiac catheterization. The in-hospital mortality rate was 16.0% (4 patients), which was significantly higher than that without CES (0.5%, p < 0.01). All four patients with CES who died after cardiac catheterization had progressive renal dysfunction. The incidence of CES increased in patients with atherosclerotic disease, hypertension, a history of smoking, and the elevation of baseline plasma C-reactive protein (CRP) by univariate analysis. The femoral approach did not increase the incidence, suggesting a possibility that the ascending aorta may be a potential embolic source. As an independent predictor of CES, multivariate regression analysis identified only the elevation of pre-procedural CRP levels (odds ratio 4.6, P = 0.01). CONCLUSIONS: Cholesterol embolization syndrome is a relatively rare but serious complication after cardiac catheterization. Elevated plasma levels of pre-procedural CRP are associated with subsequent CES in patients who undergo vascular procedures.

Acute Kidney Injury↗

PubMed1996

Microembolization from atheroembolic disease or aneurysm. A case study.

Cyanosis of the digits may have several etiologies ranging from trauma to connective tissue disease; however, the most common cause of the so-called blue toe syndrome is atheroembolic disease or aneurysm and is frequently misdiagnosed on initial presentation. Pedal pulses are often palpable which may misdirect the physician from a diagnosis of vascular pathology. Furthermore, the proximal source of embolic shower may be far from the sight of symptoms. Noninvasive vascular testing, peripheral angiography, abdominal and popliteal ultrasonography, and echocardiography are all techniques that may be beneficial in discovering the origin of emboli. Atheroembolisms and aneurysms can be limb-threatening or life-threatening and hence early diagnosis is imperative.

Adult↗

PubMed1996

Surgical treatment of systemic atheroembolism from the thoracic aorta.

BACKGROUND: Surgical procedures performed exclusively for atheroembolic events arising from the thoracic aorta rarely have been reported. Presented here are 2 patients who underwent successful operation for these problems. METHODS: The clinical presentation, diagnostic evaluation and surgical approach to 2 patients with different embolic sources in the thoracic aorta are presented. One patient had experienced three strokes and was noted by multiplane transesophageal echocardiography to have protruding atheromas with ulcerations in the transverse arch and origin of the brachiocephalic vessels. The transverse arch was replaced using hypothermic circulatory arrest with individual reimplantation of the brachiocephalic vessels. The second patient presented with "blue toe" syndrome from mobile atheromas in the mid-descending thoracic aorta defined by transesophageal echocardiography. A localized debridement was performed using simple aortic cross-clamping. RESULTS: Both patients had uneventful postoperative courses and had no further atheroembolic events. CONCLUSIONS: When standard diagnostic modalities do not delineate an embolic source for either stroke or peripheral embolization, transesophageal echocardiography is recommended as an excellent means of identifying atheromas in the thoracic aorta that could be the source for emboli. Once these lesions are identified, a surgical procedure should be performed to prevent further embolization.

Aorta↗

PubMedDate not supplied

Disseminated cholesterol embolism after coronary artery bypass grafting.

Blue toe syndrome caused by cholesterol emboli is a relatively benign disease. However, disseminated cholesterol embolism is a life-threatening condition. We describe here the case of a 71-year-old female admitted because of anterior chest pain and intermittent claudication. Following cardiac catheterization, warfarin potassium was administered. However, the patient's toes soon darkened bilaterally, and BUN and creatinine levels increased from the normal value. Skin discoloration and renal failure were improved after stopping warfarin potassium administration. The patient underwent coronary artery bypass grafting and left femoropopliteal bypass. Cerebral infarction and renal failure occurred postoperatively due to disseminated cholesterol embolism. The patient died from renal failure on the 16th postoperative day without regaining consciousness following surgery. For high risk patients, interventional procedures to the ascending aorta must be avoided. When CABG cannot be avoided for coronary revascularization, off-pump bypass and use of arterial grafts are recommended.

Aged↗

PubMed2002

Early experience using the Wallgraft in the management of distal microembolism from common iliac artery patholology.

Blue toe syndrome commonly occurs as a result of aneurysmal or atherosclerotic disease in the iliac arteries. Surgery, angioplasty, or intraarterial stent placement are the most common treatment options but the optimal management has not been defined. Here we report managing distal microembolization from iliac artery atherosclerosis associated with aneurysmal dilation with the Wallgraft Endoprosthesis, a self-expanding metallic stent covered with Dacron. Three common iliac arteries in two patients were treated using this device. A 79-year-old male presented with unilateral symptoms and an 83-year-old female with bilateral disease. Arteriography demonstrated complex plaque at the aortic bifurcation associated with aneurysmal dilation of the distal common iliac artery in both patients. This complex disease was successfully covered using the Wallgraft Endoprosthesis. Postoperatively the patients received aspirin, their toe lesions healed, and neither has had a recurrence after 16 months. Covered stents offer the theoretic advantage of completely excluding the diseased segment, preventing the escape of thrombus or plaque debris, and covering aneurysmal dilation in the artery.

Aged↗

PubMed1987

[Emboli-forming arteriopathies of the limbs].

Atheromatous embolism disease is a recently defined entity of still to be determined prevalence. This complication can develop during the course of any arterial disease by overload or dystrophy in lower limbs, and is certainly responsible for many cases of worsening of subacute ischemias occurring during arterial disease for which it is not always possible to affirm the embolic origin. It is in no way a rare syndrome and the true frequency of this affection can only be underestimated. If arterial dystrophies are excluded, the primum movens is ulceration of an atherosclerotic plaque. Two types of emboli have been described as originating in these plaques. First, small cholesterol crystal emboli containing fibrino-platelet material that are the cause of very distal arterial occlusion, notably in the foot: the most typical corresponding clinical condition is the so-called blue toe syndrome. Second, larger emboli due to formation and migration of a fibrino-platelet thrombus in contact with the atheromatous ulcer. They consist mainly of fibrino-platelet material with variable quantities of atheromatous debris. They may be of moderate size, occluding a collateral of the deep femoral artery or a leg artery usually in an asymptomatic manner, or larger and provoking occlusion of main trunks. Diagnostic difficulties emphasize the importance of referring all embolectomy products for histopathology. One of the essential problems of this disease is that of diagnostic criteria. When confronted with the previously evoked picture of peripheral ischemia and/or a peripheral arterial occlusive lesion, how can this distal accident be related to a subjacent arterial lesion suspected of possessing an emboli-forming nature?(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriosclerosis↗

PubMed1992

[Chilblains].

Chilblains represents an idiopathic vascular cutaneous benign acral syndrome. Epidemiology and basic mechanisms remain hypothetic and the treatment is controversial. The patients exhibit pruritic, redness painful, burning acral patches or plaques on the toes and/or fingers. The disease is bilateral, youthful and influenced by exposure to cold. Spontaneous healing is common when spring arrives and relapse is frequent on the following winters. There is no systemic symptom and laboratory studies are normal. The physical examination is sufficient for diagnosis. Histologic examination shows vascular and perivascular capillary and venular lymphocyte infiltrates without necrosis nor leukocytoclasia. The differential diagnosis includes: lupus, cold urticaria, acrocyanosis, erythermalgia, vasculitis and the Blue Toe Syndrome. Treatment includes prophylactic measures against cold and calcium channel inhibiting drug. In more severe cases thyrocalcitonin and hemodilution might be helpful.

Chilblains↗

PubMed1996

Young women with advanced aortoiliac occlusive disease: new insights.

We identified a group of 24 young (less than 50 years of age) women with isolated, premature atherosclerotic aortoiliac occlusive disease and attempted to identify distinguishing hemostatic characteristics. Most of these patients (62%) presented with acute thromboembolic events (blue toe syndrome, n = 6; macroemboli, n = 6; or aortoiliac thrombosis, n = 3). Aortoiliac reconstruction (aortoiliac endarterectomy, n = 10, aortobifurcation bypass grafts, n = 6; and percutaneous angioplasty, n = 4) was complicated by early thrombosis in 6 of 20 cases (30%), (1 of 10 endarterectomies, 4 of 6 bypass grafts, and 1 of 4 angioplasties). Fresh thrombus overlying an atherosclerotic plaque was a common finding at surgery. This observation and the relatively high incidence of thromboembolic events led us to hypothesize that a characteristic hemostatic profile might underlie the remarkably similar clinical presentations of these women. Levels of antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant), plasminogen activator inhibitor-1, fibrinogen, antithrombin III, protein C, protein S, plasminogen, prothrombin fragment F1 + 2, and D-dimer were determined for these young women and for 21 age-matched white female control subjects without vascular disease and nine white male patients with aortoiliac occlusive disease (mean 61 years, range 43 to 74 years). The incidence of anticardiolipin antibodies was 42% (8 of 19) in the female patients, which was significantly elevated (p = 0.028). The female (62.5%) and male (100%) patients had significantly elevated D-dimer levels (p < 0.001). Deficiencies of antithrombin III, protein C, and protein S were rare. A unique pattern of premature aortoiliac atherosclerosis exists in some young women. Intra-arterial thromboembolic events are common at presentation and complicate surgical management. The role of antiphospholipid antibodies remains uncertain.

Adult↗

PubMed2003

Surgical outcome of abdominal aortic aneurysm repair in patients undergoing chronic hemodialysis.

Abdominal aortic aneurysm repair in patients undergoing chronic hemodialysis presents several surgical difficulties due to tissue fragility, accelerated atherosclerosis, and calcification of the aorta. In addition to these surgical procedure-related problems, anemia, electrolyte abnormalities, bleeding tendency, and susceptibility to infection were also critical issues in perioperative management. The aim of this study was to examine the surgical outcome of abdominal aortic aneurysm repair in patients undergoing chronic hemodialysis. Between January 1988 and August 2001, six patients undergoing chronic hemodialysis underwent repair of an abdominal aortic aneurysm. There were five males and one female, and the mean age was 65 years. Two of the six patients had bilateral common iliac artery aneurysms in addition to the abdominal aortic aneurysm. At the time of abdominal aortic aneurysm repair, the duration of hemodialysis had ranged from 3 to 109 months, with a mean of 34 months. All patients underwent hemodialysis on the day prior to the abdominal aortic aneurysm repair operation. The first postoperative hemodialysis was scheduled to be performed on the day after operation or later. The mean duration of operation was 291 min. Blood transfusion was required in all patients. The first postoperative hemodialysis was performed between the first and third postoperative days. Postoperative complications were: ileus in one, and atrial fibrillation and blue toe syndrome just after operation in one. There was no hospital death. The follow-up period was 56 months. One patient died of lingual cancer at 102 months after operation. Five patients are alive. Abdominal aortic aneurysm repair can be done in patients on chronic hemodialysis with an acceptable early and long-term outcome.

Aged↗

PubMed2003

Endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta: long-term outcome.

The purpose of this multicenter study was to assess the long-term outcome of endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta on the basis of clinical and ultrasound examination. Clinical, ultrasound, and angiographic findings from 36 women and 50 men (mean age, 53.2 years) treated for atherosclerotic stenosis of the infrarenal abdominal aorta were reviewed. Patients had claudication in 74 cases and rest pain in 4. Seven patients presented trophic manifestations and one had blue toe syndrome. Mean preoperative systolic index was 0.71. Mean diameter reduction was 77%. Circumferential calcification was partial in 36 cases (41%) and complete in 30 cases (35%). Percutaneous transluminal angioplasty was performed using the single-balloon technique in 60 cases and double-balloon technique in 26 cases. A stent was placed in 76 cases (88%) by necessity in 34% of cases (22 residual stenoses, 4 dissections). Completion angiographic findings were considered good in 82 cases (95%). The remaining four patients had residual stenosis with a diameter reduction >30%. One patient died during the immediate postoperative period from septicemia unrelated to treatment (early mortality, 1.2%). Aortic angioplasty was complicated by stent detachment from the angioplasty balloon in two patients, retroperitoneal hematoma in one, peripheral embolism in two, puncture-site hematoma in three, myocardial infarction in one, and thrombophlebitis of deep femoral artery in one patient (early morbidity, 9.3%). All patients underwent follow-up with clinical and hemodynamic evaluation (mean follow-up, 31 months). Actuarial survival at 3 years was 91%. Primary actuarial patency was 94% at 1 year, 89% at 3 years, and 77% at 5 years. Aortic restenosis occurred in seven patients and was treated by angioplasty in two, aortobifemoral bypass in four, and surveillance in one. Mean systolic index was 0.89. Statistical analysis of patency demonstrated no factor predictive of long-term complication. From the long-term follow-up findings in this study, we conclude that aortic angioplasty is a reliable minimally invasive technique for treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta.

Actuarial Analysis↗

PubMedDate not supplied

Angioplasty of the terminal aorta: follow-up of 20 patients treated by PTA or PTA with stents.

Twenty patients with distal aortic stenosis were treated by PTA for intermittent claudication and, in 3, 'blue toe' syndrome. Additionally, a self-expandable endoprosthesis (stent) was inserted into the aorta in three of the patients. The overall primary success rate (including those with a stent) was 100% with all patients becoming free of symptoms. Mean arm-ankle pressure difference decreased from 48 mmHg to 9 mmHg (P less than 0.01). During a median follow-up period of 15 months no patient had recurrence of claudication, embolism, or deterioration of the non-invasive parameters. Thus, PTA seems suitable for treating stenoses of the abdominal aorta, even in the presence of distal microembolization. Balloon dilatation, with the addition of stents in resistant cases, offers a valuable alternative to surgery in distal aortic stenosis.

Adult↗

PubMed2003

Iliac artery stenting versus surgical reconstruction for TASC (TransAtlantic Inter-Society Consensus) type B and type C iliac lesions.

OBJECTIVE: The TransAtlantic Inter-Society Consensus (TASC) document did not define the best treatment for moderately severe iliac artery lesions, ie, TASC type B and type C iliac lesions, because of insufficient solid evidence to make firm recommendations. The purpose of this study was to evaluate the influence of risk factors on outcome of iliac stenting and operative procedures used to treat TASC type B and type C lesions. METHODS: Over the 5 years from 1996 to 2001, 188 endovascular and direct aortoiliac surgical reconstruction procedures were performed in 87 women and 101 men with TASC type B and type C iliac lesions and chronic limb ischemia. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) were followed to define variables. Both univariate analysis (Kaplan-Meier method) and multivariate analysis (Cox proportional hazards model) were used to determine the association between variables, cumulative patency rate, limb salvage, and survival. RESULTS: Indications for revascularization were disabling claudication (73%), limb salvage (25%), and blue toe syndrome (2%). Patients in the surgery group (n = 52) had significantly higher primary patency rates compared with patients in the stent group (n = 136) at univariate analysis (Kaplan-Meier method, log-rank test; P =.015). Primary patency rates at 1, 3, and 5 years were 85%, 72%, and 64% after iliac stenting, and 89%, 86%, and 86% after surgical reconstruction, respectively. Univariate and multivariate Cox regression analysis enabled identification of poor runoff (ie, runoff score >5 for unilateral procedures or >2.5 for bilateral outflow procedures; relative risk, 2.5; 95% confidence interval [CI], 1.4-4.2; P =.001) as the only independent predictor of decreased primary patency in all patients. However, stratified analysis including only patients with poor runoff revealed that patients undergoing iliac stenting had significantly lower primary patency rates compared with those undergoing surgical reconstruction (Kaplan-Meier method, log-rank test; P =.05). External iliac artery disease and female gender were also identified as independent predictors of decreased primary stent patency. CONCLUSIONS: Poor infrainguinal runoff is the main risk factor for decreased primary patency after surgical reconstruction and iliac stenting to treat TASC type B and type C iliac lesions. However, primary patency is less affected by poor runoff in patients undergoing surgical procedures. The presence of poor runoff, external iliac artery disease, and female gender are independent predictors of poor outcome after iliac stenting, and therefore these risk factors should determine the need for surgical reconstruction.

Angioplasty↗

PubMed1990

Selective use of arteriography in the assessment of aortic aneurysm repair.

Routine preoperative arteriography is advocated by many vascular surgeons before abdominal aortic aneurysm repair. We have used a selective approach based on the facts that arteriography is expensive, time-consuming, potentially hazardous, and often unwarranted. Based on preoperative indications, arteriography was used selectively in 41 of 100 consecutive patients prior to abdominal aortic aneurysmectomy. Many patients had more than one indication. A total of 82 specific indications were recognized. The most frequent indications were diminished lower extremity pulses (24), claudication (20), severe coronary artery disease (11), cerebrovascular disease (7), prior arterial reconstruction (8), hypertension in patients 60 years of age or less (5), evidence of other aneurysms (4), major renal anomaly (1), blue toe syndrome (1), and thoracic aneurysm (1). The 41 arteriograms produced 125 specific arteriographic abnormalities with an average of three per study. The most arteriographic abnormalities were in those patients with claudication and the least for those with hypertension. The arteriogram revealed information that would not have been obvious at operation, nor would it have led to operative procedure modification in only 10 patients. In the 59 patients not having arteriography, three had intraoperative findings which demanded a modification of the operative procedure. Thus, in only 13 patients was arteriography definitely useful. Presumably it was not indicated in the other 87. By comparing the cases in which the operation was modified with the presence of a specific indication, we have developed a predictability index as a guide for performing arteriography. Multiple indications increased the likelihood of operation modification only if four or more indications were present.

Angiography↗

PubMed2002

Results of iliac artery stent placement in patients younger than 50 years of age.

PURPOSE: To determine long-term outcome in patients 50 years of age or younger treated with iliac artery stent placement. MATERIALS AND METHODS: The records of 412 patients who underwent iliac artery stent placement during a 62-month study period were reviewed retrospectively. Forty-two patients younger than age 50 (mean age = 45 y) at the time of stent placement were included in the study population. Presenting symptoms included claudication (47%), rest pain (17%), ulceration/tissue loss (31%), and blue toe syndrome (5%). Anatomic, hemodynamic, and clinical success rates of the stent placement procedure were assessed. Stent patency rates were calculated by life-table methods. RESULTS: Fifty-nine iliac lesions were treated with stents; 62% of patients underwent treatment of a single lesion whereas 38% had multiple lesions treated. Thirty-one percent were treated after a failed angioplasty procedure and 69% were treated with stent placement primarily. After stent placement, 34 patients (82%) experienced symptomatic relief, although eight of these patients (19%) underwent a planned ipsilateral infrainguinal bypass procedure during the same hospitalization. During follow-up, five patients (12%) required a bypass procedure as a result of stent failure and two patients (5%) required below-knee amputation. Seven patients (17%) required endovascular stent revision, with none requiring additional surgery. At 1, 2, and 3 years, the primary patency rates were 86%, 72%, and 65%, and the secondary patency rates were 90%, 88%, and 88%, respectively. CONCLUSIONS: Iliac stent placement successfully addresses the presenting symptoms of young patients with peripheral vascular disease and results in patency rates that are similar to those reported in a more general population. With appropriate postprocedural surveillance, restenosis can be addressed in many patients with use of endovascular techniques, limiting the need for surgical revision.

Adult↗

PubMed1991

[Simpson's atherectomy in embolizing leg artery stenoses].

We report on the treatment and follow-up of six patients with an unilateral "blue toe" syndrome. This is caused by atheromatous micro-embolisation to the digital arteries and requires urgent attention due to the painful cutaneous necroses and impending digital gangrene. In all patients, Simpson's atherectomy of proximally situated femoropopliteal stenoses caused the pre-gangrenous digital changes to heal completely. In a mean observation period of ten months no relapse occurred. The embolising material was presumably parietal fibrino-platelet thrombi which could be observed with angioscopy and were regularly detectable histologically in the excised tissue.

Aged↗

PubMed2000

Mobile thrombi in the abdominal aorta in cases of lower extremity embolic arterial occlusion: value of extended transthoracic echocardiography.

BACKGROUND: Lower extremity embolic arterial occlusion is often associated with proximal atherosclerotic and/or aneurysmal disease. Fixed atherosclerotic disease of the abdominal aorta has been demonstrated by ultrasonography, tomographic studies, and aortography, but mobile debris has not previously been described. We report detection of mobile thrombi in the abdominal aorta during transthoracic echocardiography screening in 6 patients with lower extremity embolic arterial occlusion. METHODS: Six patients were referred to the echocardiography laboratory for evaluation of a source of peripheral arterial embolism. The transthoracic echocardiogram was extended to include longitudinal and transverse images of the abdominal aorta. Additional investigations included abdominal ultrasound (6 patients), computed tomography (2 patients), angiography (2 patients), and transesophageal echocardiography (4 patients). RESULTS: Six patients (4 men, 2 women, aged 46 to 79 years) presented with a blue toe syndrome consistent with atheroembolism. During transthoracic echocardiography with examination of the abdominal aorta, all were found to have significant atherosclerotic disease of the abdominal aorta with one or more mobile components. This finding had a significant impact on treatment of each patient. Surgical resection of the involved portion of the abdominal aorta in one patient demonstrated an ulcerated atheroma with overlying thrombus. CONCLUSION: In patients with lower extremity embolic arterial occlusion, evaluation of the abdominal aorta during transthoracic echocardiography should be a routine extension of the echocardiographic examination. The finding of mobile thrombi in the abdominal aorta identifies a potential source of embolism for which effective treatment exists.

Aged↗

PubMed2001

Influence of hormone replacement therapy on the outcome of iliac angioplasty and stenting.

OBJECTIVE: Thromboembolic events are more frequent in women with established cardiovascular disease taking hormone replacement therapy (HRT). The effect of HRT on the outcome of women with aortoiliac occlusive disease is unknown. The purpose of this study was to estimate the influence of risk factors, including HRT, on the outcome of women undergoing iliac artery angioplasty and stent placement. METHODS: During a 5-year period (between 1994 and 1999), 126 iliac angioplasties with stent placement (144 stents) were performed in 88 women. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed to define the variables. Both univariate (Kaplan-Meier) and multivariate analyses (Cox proportional hazards model) were used to determine the association among preoperative variables, cumulative patency, limb salvage, and survival. RESULTS: The patients' average age was 63.2 years with 43% of the patients taking HRT. Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (32%), and blue toe syndrome (3%). The technical success rate was 95% (120 of 126 procedures). Primary stenting was performed in 28 patients (22%). Stents were placed selectively after iliac angioplasty for residual stenosis or pressure gradient (57%), iliac dissection (8%), long-segment occlusions (8%), or eccentric lesions (5%). There were no significant differences between HRT users and nonusers with regard to risk factors, except there was a higher frequency of diabetes in women taking HRT. Overall, the primary patency rate was 76% at 1 year, 67% at 3 years, and 62% at 5 years. Primary patency rates at 1, 3, and 5 years were 75%, 57%, and 49% for users of HRT and 77%, 74%, and 74%, respectively, for nonusers. Limb salvage rates were not statistically different between users and nonusers of HRT at 5 years (95% vs 96%). Univariate and Cox regression analyses identified HRT use (Kaplan-Meier, log-rank test, P = .02; relative risk, 2.4; 95% CI, 1.3-4.5; P = .006) and stent placement in the external iliac artery (relative risk, 4.3; 95% CI, 2.3-7.9; P < .001) as independent predictors of decreased primary patency. CONCLUSIONS: Women undergoing iliac angioplasty with stent placement who are taking HRT have significantly reduced primary patency rates. Despite initial technical success, HRT users are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. External iliac angioplasty and stenting are also associated with decreased primary stent patency in women.

Adult↗

PubMed2001

External iliac and common iliac artery angioplasty and stenting in men and women.

OBJECTIVE: The effect of anatomic location of stent placement on the outcome of iliac artery angioplasty and stenting is not defined. Analyses of patency rates of external iliac artery (EIA) and common iliac artery (CIA) stents have provided conflicting results and have not considered men and women independently. The purpose of this study was to estimate the influence of the anatomic location of stenting on the outcome of iliac angioplasty and stent placement in both men and women. METHODS: From 1995 to 1999, 247 iliac angioplasty and stent placement procedures (303 stents) were performed in 67 women and 122 men, and all were included in a retrospective cohort study. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Both univariate (Kaplan-Meier [KM]) and multivariate analyses (Cox proportional hazards model) were used to determine the association among the variables, cumulative patency, limb salvage, and survival. RESULTS: Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (33%), and blue toe syndrome (2%). Primary stenting was performed in 103 procedures (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Patients with EIA stents, as compared with those who had CIA stents, had more extensive lesions (TransAtlantic Inter-Society Consensus type C lesions), poorer runoff, smaller vessel size, and less frequency of hyperlipidemia (P <.05). Primary patency rates at 1, 3, and 5 years were 76%, 56%, and 56%, respectively, for patients with EIA stents and 92%, 85%, and 76%, respectively, for those with CIA stents. Although overall primary patency rates were significantly decreased in patients with EIA lesions (KM, log-rank test, P =.001), stratified analyses revealed that women with EIA stents had the poorest outcome, with 61%, 47%, and 23% primary patency rates at 1, 3, and 5 years, respectively, (KM, log-rank test, P <.001). Cox regression analysis identified EIA stenting (relative risk, 4.3; 95% CI, 2.3-7.9; P <.001) as an independent predictor of decreased primary patency in women but not in men. CONCLUSIONS: Women undergoing EIA angioplasty with stent placement have significantly reduced primary patency rates. Despite initial technical success, these patients are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. Conversely, men undergoing EIA stenting have a more favorable outcome than women.

Adult↗