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The advancement in the endovascular treatment and the introduction of novel techniques allowed treatment of more complex and longer femoropopliteal lesions. However, the optimal treatment modality is still a source of controversy. The use of bare metal stents (BMS) showed good results for long femoropopliteal lesions. In this review, we summarized all available data on the different treatment strategies of long femoro-popliteal lesions using BMS. Nevertheless, RCTs with head-to-head comparison between BMS strategies are still needed to have more clarification on the best strategy for the endovascular treatment of long femoropopliteal occlusive lesions.

Treatment of long femoropopliteal lesions remains a challenge for vascular physicians as patients often present with multilevel complex pathologies and consequently face a high amputation risk and associated mortality. This review aimed to assess the current state of optimal revascularizations for the treatment of long femoropopliteal lesions.An online literature research of medical databases for original articles and review articles on open and endovascular revascularization of femoropopliteal lesions was conducted using mesh terms.There has been an accumulation of evidence over the last years that endovascular treatment is a feasible and enduring alternative to open surgery for treatment of long femoropopliteal lesions if the lesions are restricted to the superficial femoral artery. But when disease extends to the infragenual level venous bypass remains superior with regards to long-term patency, clinical improvement and limb-salvage.While the role of venous bypass as a first-line treatment might be declining, especially in frail patients or claudicants, the superior clinical improvement and amputation-free survival highlighted in several trials, demonstrate the relevance of bypass surgery. More randomized clinical trials are needed to verify the non-inferiority of endovascular treatment options to open surgery, especially when arterial disease extends below the knee.

Introduction Endovascular methods have emerged as an appealing alternative to bypass for the treatment of patients not suitable for surgery. Drug eluting stents (DES) have been developed to address the limitations of angioplasty and stenting. There is a paucity of data in the literature on their performance for the treatment of patients with long femoro- popliteal segment lesions. We aimed to analyse the evidence supporting the use of DES in patients with complex femoro-popliteal disease. Evidence acquisition A systematic review and meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta- Analyses (PRISMA) statement. Evidence synthesis A total of 1255 potentially relevant articles were initially selected. After reviewing at title or abstract level, 22 articles were read in full and 10 were included. These studies reported on the use of DES for 1539 patients. In all studies the DES that was employed was a paclitaxel-eluting stent (Zilver PTX, Cook Medical). Average lesion length ranged from 114mm to 400mm. The pooled technical success rate was 0.964 (95% confidence interval [CI]: 0.936 - 0.980). The pooled estimate of limb loss at 12 months was 0.019 (95% CI: 0.012 - 0.030), stent fracture at 12 months 0.035 (95% CI: 0.007 - 0.155), primary patency at 12 months 0.705 (95% CI: 0.576 - 0.807) and secondary patency at 12 months 0.898 (95% CI: 0.815 - 0.946). Conclusions The short-term outcomes of DES for TASC C & D femoro-popliteal lesions are encouraging. Caution is advised in extrapolating the results of the included studies due to the large heterogeneity and lack of reporting of subgroup specific outcomes.

Recent meta-analysis of randomized-controlled trials reported an increased risk of long-term mortality in patients treated with paclitaxel-coated devices (PCD) for femoropopliteal arteries (FP) lesions. However, real-life data on the subject is contradictory and data from CLTI patients is missing. The authors aim to evaluate the impact of PCD for the treatment of FP lesions on long-term mortality and amputation on a real-life cohort up to 5 years.All patients treated for FP lesions with endovascular devices from January 2013 to December 2016 were included, irrespective of clinical presentation. Primary endpoint is overall survival. Secondary endpoints are freedom-from major amputation and amputation-free survival. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for relevant baseline differences.From 2013 to 2016, 351 patients with FP lesions were treated, 250 with uncoated devices (nPCD) and 101 with PCD. Patients treated with nPCD were significantly older, more often female and with more severe degrees of ischemia. Median follow-up was 55(20-71) months. Overall survival and amputation-free survival were significantly higher in patients treated with PCD. Survival at one-year was 79% vs. 92%, at two-years 69% vs. 79% and at five-years 50% vs. 65% (P=0.02). AFS was 43% vs. 57% at 5-years (P=0.016). Freedom-from major amputation was similar between groups. After correction for relevant baseline differences on multivariable analysis, the survival advantage for patients treated with PCD was lost at 2 and 5 years.Our results do not confirm the findings of increased mortality associated with PCD. However, no improvement in amputation rate was found. For the time, our institutional data does not support withholding PCD to reduce mortality but suggests that the benefit in preventing amputation is not significant.

Introduction To assess whether intravascular ultrasound (IVUS)-guided angioplasty in femoropopliteal lesions would improve clinical outcomes and predict restenosis. Evidence acquisition Studies in which IVUS-guided angioplasty was used for femoropopliteal lesions were searched from the MEDLINE, Embase, Web of Science, and Cochrane databases; articles with the full text were included. The primary endpoint of this study was primary patency at 12 months, while the secondary endpoints were primary patency at 24 months, freedom from target lesion revascularization (TLR) at 12 months, and correlation of restenosis with the distal external elastic membrane (EEM) area, post-intervention minimum lumen area, lesion length, dissection, and calcification. Evidence synthesis Altogether, 11 observational studies involving 1521 patients (1703 lesions) were analyzed. The quality of the evidence for 7 main outcomes was assessed as "very low" by The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) classification. The mean follow-up period was 1.5 years. The pooled rates were: 78% for 12-month primary patency (95% confidence interval [CI], 0.72-0.83), 74.3% for 24-month primary patency (95% CI, 0.71-0.78), and 80% for 12-month freedom from TLR (95% CI, 0.74-0.86). The 12-month primary patency of IVUS use (relative risk [RR], 2.01; 95% CI, 1.48-2.74) was higher compared to non-IVUS use. The minimum lumen (stent) area (standard mean difference (SMD) = -0.30; 95% CI, -0.46 to -0.15) and dissection (OR 1.58; 95% CI, 1.01-2.49, P = 0.047), were associated with midterm patency in terms of restenosis. Conclusions In IVUS-guided angioplasty in patients with femoropopliteal lesions, the minimum lumen (stent) area and dissection were associated with restenosis. Nevertheless, there is limited and heterogeneous evidence regarding the usefulness and Predictability of IVUS in patients with peripheral arterial disease in the femoropopliteal artery, especially in long-term patency and as a predictor of declining patency. The optimal role of IVUS in such patients should be elucidated in the future.

BACKGROUND The aim of MERLION (NCT04073121) was to evaluate the outcomes of the mono or combination therapy of the iVascular Luminor™ drug-coated balloon (DCB) and Angiolite™ drug-eluting stent for treatment of TASC II C/D tibial occlusive lesions in Asian patients presenting with chronic limb threatening ischemia (CLTI) from Singapore. METHODS MERLION was a prospective, non-randomized, single arm, observational, multicenter clinical study. Complication-free survival at one month was the safety endpoint. Immediate technical success, 12-month primary vessel patency, limb salvage, freedom from target lesion revascularization (TLR) and amputation free survival (AFS) were the efficacy endpoints of interest. RESULTS Fifty patients were included. There were 32 males (64% males; mean age 66.4±8.9 years). Majority were Rutherford 5 severity (41/50; 82%). Co-morbidities included diabetes mellitus (47/50; 94.0%), end-stage renal failure (25/50; 50.0%), and hypertension (44/50; 88%). 66 atherosclerotic lesions were treated (47 de novo and 19 restenotic; 60.6% TASC C and 39.4% TASC D). Mean lesion length treated was 13.7±9.5 cm. There was 100% technical success. There were 3/66 (4.5%) bailout stenting for severe flow limiting dissections. Twelve-month primary tibial patency was 34/49 (69.4%) and freedom from TLR was 40/49 (81.5%). AFS was 74.0% (37/50). At 12 months, mean Rutherford scores improved from 100% (Rutherford score >3) at baseline to 31% at 12 months (P

BACKGROUND The aim of this study was to investigate the efficacy of the balloon expandable Promus Element and Promus Element Plus stents (both Boston Scientific, Marlborough, MA, USA), coated with everolimus, in the treatment of short, focal infrapopliteal lesions. METHODS The PREVENT study was a prospective, multicenter, non-randomized, single arm study evaluating the safety and efficacy of the Promus Element and Promus Element Plus stent in the treatment of stenotic or occlusive lesions ≤40 mm long in the tibioperoneal arteries of patients with critical limb ischemia (CLI). A total of 70 study subjects were enrolled in a period of 26 months, between November 2012 and December 2014. The mean age was 77.84±6.62 years (62-90 years) and 47 patients were men (67.1%). Mean lesion length was 22.83±8.78 mm (5-40 mm). Twenty percent of the lesions were occluded, whereas 80.00% were stenotic. Primary endpoint was primary patency at 12 months, defined as absence of restenosis (≥50% stenosis) or occlusion within the originally treated lesion based on angiography. Secondary outcomes included hemodynamic primary patency on duplex ultrasound (PSV ratio ≤2.4), limb salvage and freedom from target lesion revascularization (TLR). RESULTS Technical and procedural success (

This report describes the successful use of a new hybrid vascular graft as a conduit for above knee femoro-popliteal bypass surgery. The graft consists of a proximal (heparin coated) expanded polytetrafluoroethylene section but ends distally as a nitinol reinforced self-expandable stent that is covered and constrained, allowing a sutureless distal anastamosis. With this graft the creation of above knee bypasses in situations where lesions extend to the popliteal artery behind the knee, or in cases where the above knee popliteal artery is severely calcified is still possible. This avoids the necessity of an infragenicular bypass with potentially inferior long-term patency rates, especially when no autologous venous bypass material is available.

Background According to the guidelines, bypass surgery is still the golden standard treatment in patients with femoropopliteal TASC C and D lesions and life-style limiting claudication or critical limb ischemia. Over the past few decades, endovascular therapy has made great advancements. However, the success rates of surgical and endovascular procedures cannot be directly compared. According to the surgical term "patency," vessel patency can be maintained even in case of a high grade stenosis, whereas according to the endovascular primary patency definition, being binary restenosis, patency is lost from the moment there is a re-narrowing at any location within the treated segment. Methods One hundred consecutive patients with a previously implanted femoropopliteal bypass which was primary patent according to the surgical definition were included in this study. Once enrolled, duplex ultrasonography was performed, measuring the Peak Systolic Velocity Ratio for proximal and distal anastomosis. Results Out of the 100 bypasses that were considered patent according to the surgical definition, Peak Velocity Ratio of ≥2.4 were detected in 11 patients. Conclusions Based on these findings a 78% primary patency according to the open vascular criteria turned into ~70% primary patency using the stricter endovascular criteria. In the light of these findings, one might conclude that modern endovascular treatment of long TASC C and D femoropopliteal lesions yielded similar results in terms of primary patency as above-the-knee bypasses.

BACKGROUND: The aim of this study was to evaluate the safety and performance of the sinus-SuperFlex-635 self-expandable nitinol stent (Optimed GmbH) for the treatment of steno-occlusive lesions in the superficial femoral artery (SFA) and proximal popliteal artery (PPA). METHODS: The prospective, multicenter, observational HERO study recruited 117 eligible patients (83 men; mean age 69.4±9.7y) from 7 centers in Belgium. RESULTS: A total of 129 stents were successfully deployed in 121 lesions in 117 patients (100%). The patients presented with symptomatic ≥50% stenosis or chronic total occlusion (CTO) (30.6%). Mean lesion length was 71.4±56.3 mm. Moderate to severe calcification was present in 82.6% of the lesions. Acute lesion success (

INTRODUCTION Endovascular treatment represents nowadays the preferred therapeutic approach for disabling femoro-popliteal arterial occlusive disease in fit patients. In the latest years, in order to improve short- and long-term outcomes, drug eluting devices have been developed. Drug coated balloons (DCB) and drug eluting stents (DES) are today employed in clinical practice, and several studies has been completed to assess their performance in different clinical scenarios. Objective of the present review and meta-analysis is to compare clinical results of different endovascular treatment modalities in the published literature in the last 10 years. EVIDENCE ACQUISITION A systematic review and meta-analysis following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement on the literature regarding direct comparisons between DCB, DES, bare metal stents (BMS) and Plain Old Balloon Angioplasty (POBA) has been conducted. Primary outcomes were considered Primary Patency and Target Lesion Revascularization (TLR) at 12 months. Analysis of late survival in different treatment groups was outside the scope of the present study and was therefore not included as main end point. EVIDENCE SYNTHESIS Meta analysis results confirm that DCB outperforms POBA in both primary patency (estimate OR=3.17, 95% CI: 2.10-4.76) and TLR (POBA estimate OR=3.59, 95% CI= 2.31-5.56). No clear evidences emerged comparing DES and BMS; however, DES were shown to fare better than BMS in terms of TLR when analyzing lesions

BACKGROUND Self-expandable stents, Absolute Pro® (ABS) and Complete SE® (COM), demonstrated safety and efficacy in previous studies. We aimed to determine which stent is more effective for the endovascular treatment of femoropopliteal artery disease. METHODS We enrolled patients who underwent endovascular intervention from 2010 to 2015 in our hospital. The primary endpoint was clinical primary patency, which is a composite of freedom from restenosis or clinically driven target lesion revascularization (TLR). RESULTS A total of 197 patients and 210 limbs were analyzed, with 96 limbs of 88 patients assigned to the ABS group and 114 limbs of 109 patients assigned to the COM group. Baseline and lesion characteristics were similar between the two groups. The number of stents per limbs were 1.28±0.55 and 1.29±0.51 in the ABS and COM groups, respectively (P=0.92). The postprocedure ankle-brachial index was significantly improved in both groups compared with the preprocedural one (P

Considerable advances have been made over the last decade in the management of patients with peripheral artery disease. Historically, endovascular treatment has been the accepted approach for short lesions and surgical bypass for long, complex femoropopliteal lesions. However, bypass surgery holds significant risk of mortality and morbidity for the patient. That toll includes prolonged hospitalization, as well as the potential for wound healing and systemic complications, all of which are intensified by the ageing population. Advances in endovascular devices, such as drug eluting stents present an alternative, minimally invasive treatment option which may more suitable for complex lesions in a high-risk population. The aim of this review is to discuss the current literature which addresses surgical bypass and drug eluting stents, particularly for the treatment of long, complex femoropopliteal disease.

Superficial femoral and popliteal artery disease are commonly involved in the development of symptomatic PAD. As time has gone on drug coated stents and drug coated balloons have supplanted the plain balloon angioplasty corner stone of therapy with superiority proven in randomized trials. Device approval trials are typically characterized by simple lesions that are less common than the longer complex disease. Registry data has demonstrated benefit of both technologies though drug coated balloons typically require a significant amount of adjunctive stenting in more complex disease. Recently published randomized data is starting to help proceduralists define when each therapy may be more optimal.

Background To evaluate the impact of iliac artery's diameters, tortuosity, and peripheral vascular patency on outcome of elective endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) in 2 high volume vascular centers' experience. Methods A retrospective study was conducted on a prospectively collected database between 2010 and 2012. Anatomical features at pre-operative computed tomography (CTA) considered as potentially influencing outcomes were: iliac diameters, tortuosity (expressed as a ratio), and calcifications, bilateral internal iliac artery (IIA) patency, and presence of Trans-Atlantic Inter-Societies Consensus (TASC) II C/D femoro-popliteal occlusive disease (PAD). Outcome measures were reintervention and mortality rates at follow-up. Results Two-hundred-eighty-nine patients' CTA preoperative images were reviewed with a mean of 1148±328 images per patient analyzed. Mean common iliac artery (CIA) diameters calculated in the narrowest point were 12.8±4 mm and 12.9±3.9 mm, and mean external iliac artery (EIA) diameters were 7.7±1.6 mm 7.8±1.7 mm, respectively on right and left side. Mean tortuosity ratios were 0.8±0.1 (0.40-0.91) and 0.8±0.1 (0.49-0.99), respectively on right and left side. PAD was present in 31 patients (10.7%). Technical success was achieved in all case, and bilateral IIA patency was preserved in 229 (79.2%) patients. No in hospital and 30-day mortality and complications were recorded. At a mean follow-up of 26 months, 30 reinterventions were required in 26 patients (8.9%), and 22 (7.6%) non AAA-related deaths were noted. Right EIA diameter ≤5 mm (P=0.0012, OR 5.2, 95% CI 1.73-15.57), and femoro-popliteal steno-obstructive disease (P=0.03, OR 3.06, 95% CI 1.02-9.20) were significantly related to reinterventions during follow-up. Iliac tortuosity ratio and calcification were not significant predictors of adverse events. Conclusions This preliminary experience suggests that diameters of access vessels and the presence of femoro-popliteal steno-obstructive disease could affect the outcome of EVAR.

INTRODUCTION Endovascular treatment below-the-knee is safe and effective but limited by poor patency. Coronary drug-eluting stents (DES) may play a role in providing mechanical scaffolding and deliver anti-proliferative drug to the site of vascular barotrauma to reduce the incidence of restenosis. Our aim was to evaluate and compare the use of contemporary DES with standard endovascular-therapies for atherosclerotic disease of infrapopliteal arteries. EVIDENCE ACQUISITION We performed a meta-analysis of randomized controlled trials comparing DES with conventional treatment for symptomatic peripheral artery disease (search date 30 August 2017). The primary endpoint was primary patency. Secondary endpoints were freedom from target lesion revascularization (TLR), major amputation, sustained Rutherford class improvement and mortality. EVIDENCE SYNTHESIS We identified 7 trials enrolling 801 randomly assigned patients (392 DES, 409 control). At the median follow-up of 12-months DES improved rates of primary patency (OR 3.49, 95%CI 2.38-5.12, I2=0%, P

Background Optical coherence tomography (OCT)-guided directional atherectomy enables a real-time visualization of the arterial wall during plaque debulking and might optimize vessel preparation prior to drug-coated balloon (DCB) angioplasty. Nonetheless there is a paucity of data reporting on the outcomes of OCT-guided directional atherectomy with antirestenotic therapy (DAART). Aim of this study was to evaluate the performance of OCT-guided DAART in the treatment of femoropopliteal atherosclerosis. Methods Patients treated by OCT-guided DAART for femoropopliteal occlusive disease between January 2015 and December 2016 were included into this retrospective, single-center, single-arm analysis. The primary measure outcome of this study was primary patency rate (PPR). Secondary outcomes were technical success rate (TSR), secondary patency rate (SPR) and freedom from target lesion revascularization (TLR). Results Thirty-three patients (N.=33, mean age 67±8 years) and 37 lesions were included into this analysis. The median follow-up time was 15 months (interquartile ratio (IQR): 4-21). The majority of patients presented with lifestyle limiting claudication (N.=25, 75%) and de novo atherosclerotic disease (N.=25, 68%). Median lesion length was 70 mm (IQR: 27-104), while 35% (N.=13) of the lesions were chronic total occlusions. Vessel wall calcification was present in 22% (N.=8) of the treated vessels. The mean luminal gain after atherectomy was 52±17% and the median gain after DAART amounted to 68% (IQR: 58-91). The TSR was 95%. The overall 12 months PPR was 93% whereas the SPR and the freedom from TLR at 12 months were 95% and 100% respectively. A single target vessel perforation (N.=1, 3%) and 2 peripheral embolizations (N.=2, 5%) were observed. The bailout stenting rate was 3% (N.=1) and the final angiography did not reveal any flow limiting dissection. An aneurysmatic degeneration of the target vessel was observed in 2 lesions (5%). Conclusions In this study, OCT-guided DAART was associated with sufficient luminal gain, low rates of bailout stenting and perioperative adverse events and led to very promising 12-month outcomes.

Although evidence supports that the performance of drug coated balloons seems to be lesion complexity independent, it is quite clear that in long lesions, severe calcified lesions and chronic total occlusions, the bail out stent ratio is very high and that the "leaving nothing behind" strategy remains a dream in a lot of our daily cases. On the other side of the spectrum, "full metal jackets" of nitinol stents are creating even more problems. Stent fractures, intimal hyperplasia and reintervention difficulties complicate the recurrent vascular disease treatment. The go-between with the "As Less As Reasonably Achievable Stenting" strategy (ALARAS), earlier named with a bad name "spot" stenting, seems the most attractive one. Scaffolding where needed and allowing freedom of vessel motion will lead to reduction of target lesion revascularization (TLR) rates. New technologies like the Tack Endovascular System and the Vascuflex MultiLOC MSD are responding very well tot this idea. Animal tests and pivotal trials (like TOBA and LOCOMOTIVE trials) already showed with both devices good results in terms of patencies and freedom from target lesion revascularizations, and with less metallic implants. Primary patency at 12 months was 76.4% and 85.7% in the TOBA and LOCOMOTIVE trial respectively. Target lesion revascularization at 12 months was 10.5% and 9.3%, respectively. In an era of "leaving nothing behind," post-angioplasty dissections are more frequent than ever. With a direct link between lesion complexity, dissections and increase of TLR rates, scaffolding solutions remains essential. The ALARAS strategy tries to leave as little metal behind as possible, minimizing the risk of stent fractures, allowing freedom of vessel motion and reducing TLR rates. However, the lack of clear strategies and guidelines in where to scaffold which kind of dissections is the biggest issue at the moment. More objective classifications based on newer types of imaging like intraoperative ultrasound, intravascular ultrasound, optical coherence tomography, and/or fractional flow reserve pressure wire gradient measurements will potentially offer more solutions in this interesting field.

While the field of endovascular interventions has evolved in the last decade, technological advancements have rendered drug-coated balloons (DCBs) to be the first line therapy for femoropopliteal artery disease. As the knowledge continues to advance, the application of DCB to the infrapopliteal segments as well as its role in in conjunction with plaque modification to minimize stent utilization, will be further elucidated.

BACKGROUND Recent advances in endovascular techniques have made it a seductive choice in the management of TASC C and D lesions. Currently, this tendency remains controversial, despite high success rates. The aim of the study was to regroup and harmonize the results of three surgical teams in 5 centers in order to obtain the largest series ever published on TASC C and D femoro-popliteal lesions primary stenting. METHODS Two hundred and three patients and 209 lower limbs were included from March 2008 to October 2013. Each patient underwent primary stenting for TASC C or D femoro-popliteal lesions. RESULTS Mean age was 70±10; 71.4% were male with a 39.8% rate of coronary heart disease, 20.1% of renal insufficiency and 35.9% of diabetes; 57,4% suffered from claudication and 42.6% from critical limb ischemia (CLI); 61.8% of the 144 limbs analyzed for run-off presented with 3 patent infra-popliteal arteries. Four hundred and three stents were implanted in the 209 limbs included. Median stented length was 252 mm. Associated procedures were performed in 35 patients (17.0%) including 4.3% minor amputations. The 30-day mortality rate was 1.4% (3 patients). Major complications occurred in 19 patients (9.3%) including 7 patients (3.4%) presented with early in-stent thrombosis. Median follow-up duration was 12 months (range 9.5-17.2 months). The 12-month mortality rate was 11.8% (24 patients). The 3, 6 and 12 months primary patency rates according to Kaplan Meier estimates were 98.1±0.9, 85.2±2.5 and 67.0±3.3% respectively. Secondary patency rates were 96.1±1.9, 89.3±3.0 and 75.7±4.2% respectively. A subgroup analysis reported significantly higher patency rates for TASC C lesions compared to TASC D lesions (82.1% vs. 44% respectively, P=0.009). The 12-month in-stent thrombosis and restenosis rates were 19.6% and 13.9% respectively. A subgroup analysis showed higher rates of in-stent restenosis for TASC D lesions compared to TASC C lesions (35% vs. 10% respectively, P=0.005). The stent fracture rate was equal to 10.2% (30 stents). Occurrence of in-stent thrombosis and restenosis were associated with 3 and 5 cases of stent fracture (type II to IV) respectively. Freedom from TLR was 70.5%. Rutherford class decreased from 3.7 to 0.9 (3.52±1.06 to 0.75±1.24) (P

BACKGROUND Critical limb ischemia (CLI) may be the consequence of chronic occluded popliteal artery aneurysm (PAA). Open repair (OR) offers better 5-year results than endovascular treatment, but in patients with severe comorbidities or unfit to OR, endovascular repair (ER) could represent a valid treatment option. The purpose of this retrospective study was to review our experience of endovascular popliteal aneurism repair (EVPAR) in patients with chronic occluded PAA. METHODS The endpoints assessed were: 1- and 3-year primary and secondary patency rates, technical success, 30-day major adverse events, major amputation free-survival, re-intervention and survival rates. RESULTS From May 2011 to April 2015, 25 patients (23 male), mean age of 74.4 years, underwent an EVPAR. No perioperative death and vascular access complications were recorded. Device technical success rate was 100%. The 30-day major adverse events rate was 4%: one stent graft occlusion with distal embolization was recorded. The 1- and 3-year primary and secondary patency rate were 79% and 85.8%, and 73.3% and 79.7%, respectively. At 3-year follow-up, the freedom from major amputation and survival rates were 100% and 96%. Stent-graft coverage length >20 cm (P=0.006), more than 2 stents used (P=0.005), and poor distal runoff (P=0.01) were negative predictors for patency. CONCLUSIONS The results of this retrospective study suggest that EVPAR seems a safe and efficacious treatment option in selected patients. Despite encouraging results, further research will be needed to assess long-terms results and to define the best treatment option for patient with chronic occluded PAA.

Background Long segment occlusive disease in the superficial femoral artery remains a treatment challenge despite advances in open surgical and endovascular approaches. We report initial clinical results of an entirely new procedure to perform percutaneous femoro-popliteal bypass using the DETOUR System. First-in-human patients were performed in New Zealand from December 2013 to June 2014. After modifications to the technique and devices had significantly refined the procedure, the Detour I Trial commenced. Methods Review of initial results in the first five patients treated at a single site enrolled in IRB-approved, prospective clinical study using the DETOUR System. All patients signed informed consent with planned 2-year follow-up. The DETOUR System was used to create a stent graft bypass which originates in the SFA, travels through the femoral vein, and ends in the popliteal artery, bypassing the diseased segment. Results A cohort of patients were treated in Latvia from January 2015 to October 2015. The initial five patients in this cohort (age 67.2±11.4 years) with long femoral artery occlusions (29.5±14.1 cm) were treated at a single clinical site. TORUS stent grafts were successfully implanted in all 5 patients (100%) using an 8F delivery system. There were no perioperative 30-day major adverse events (death, major bleeding, deep vein thrombosis, target vessel revascularization or major amputation) observed. At 24 months' follow-up, the primary patency rate was 80% (4/5) and primary assisted patency was 100% (5/5). Significant improvement in ankle-brachial index and Rutherford class were observed in all patients. There was a single secondary procedure performed in these patients (proximal stent edge stenosis at 24 months). The venous function has not been damaged or compromised in any patient. Conclusions Early results suggest that properly-selected patients with long-segment occlusive disease above the knee can be safely treated using the DETOUR System for percutaneous bypass, with favorable clinical outcomes extending to 2 years. Further clinical investigation is warranted to evaluate the role of this approach in the treatment of long femoral lesions.

Peripheral arterial disease (PAD) is associated with a substantial cardiovascular risk and secondary prevention is recommended for all patients. In this report, the literature on anticoagulant and antiplatelet drugs for patients with PAD in the femoro-popliteal segment is reviewed. PubMed/MEDLINE and Cochrane Database was searched for studies published between January 1966 and August 2017. Meta-analyses and randomized controlled trials describing outcome of anticoagulants or antiplatelet drugs for secondary prevention or following vascular interventions in patients with PAD were included. All patients with PAD should receive antiplatelet therapy to reduce cardiovascular risk with a slight preference for clopidogrel monotherapy. Following intervention, most patients will continue to benefit from this treatment. Patients receiving a venous bypass graft will benefit from VKA treatment and those with a below-knee prosthetic bypass graft should receive dual antiplatelet therapy (acetylsalicylic acid combined with clopidogrel). Further sufficiently powered studies are needed to further explore the optimal medical treatment for patients that undergo vascular interventions.

BACKGROUND Aim of this study was to evaluate the early and mid-term outcomes of drug-coated balloons (DCBs) in hemodialysis patients with recurrent stenosis of arteriovenous fistula and previously treated with plain balloon angioplasty (PBA). METHODS Between July 2013 and June 2016 38 hemodialysis patients with recurrent stenosis of arteriovenous fistula underwent endovascular treatment with a DCB at our center. All patients were previously treated at the target lesion with a PBA. The intervals in months between the standard PBA and the procedure with DCB (time PBA-DCB) and between the procedure with DCB and the restenosis at the target lesion (time DCB-restenosis) were evaluated and compared with T-test. Estimated outcomes at 2 years in terms of patient survival, primary patency, primary assisted patency, secondary patency, and freedom from target lesion restenosis were assessed with Kaplan-Meier curves. RESULTS Intraprocedural technical success was obtained in 97.4% of the cases. During the follow-up (mean duration 14.3 months, range 2-33) 19 patients (50%) developed a restenotic lesion at the target lesion with an estimated 2-year freedom from target lesion restenosis of 32.8%. Mean time PBA-DCB was 6.4 months, and the mean time DCB-restenosis was 7.9 months with a statistically significant difference at T-test (P

This paper will discuss the results from the most recent randomized trials and large registries for DCB's and atherectomy, and the drawbacks of these two therapeutic options. It will also discuss the results of combination therapy in complex femoropopliteal lesions. Several studies indicate that combining atherectomy and DCB yields better outcomes in complex calcified lesions, but the only randomized pilot study could not demonstrate a benefit of combination therapy in the mid-term follow-up. Larger, randomized studies are needed to define the role of atherectomy followed by DCB angioplasty further.

BACKGROUND The aim of this study was to evaluate 12-month effectiveness of the endovascular treatment of femoropopliteal (FP) atherosclerotic lesions with the Ranger drug-coated balloon (DCB) in a real-world setting. METHODS In this prospective, observational, multicenter trial (ClinicalTrials.gov Identifier: NCT02462005) 172 consecutive patients with 226 de novo, restenosed, or reoccluded native superficial femoral and/or popliteal artery lesions were treated with the Ranger paclitaxel-coated balloon angioplasty. Mean lesion length was 129 mm (5-400 mm). Fifty-nine (26%) of 226 lesions were moderately or heavily calcified. Provisional stenting was conducted in 55 (22%) of 226 lesions. Main effectiveness outcomes were procedural success, 6- and 12-month hemodynamic or clinical improvement, and primary patency based and clinically driven target lesion revascularization (TLR) at 6 and 12 months. RESULTS Procedural success (

Peripheral arterial disease (PAD) is a clinical manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. Vascular physicians come across PAD of different complexity and among them complex total occlusions present a formidable challenge to endovascular operators. Newer tools and techniques, particularly in the retrograde approach, have made endovascular therapy applicable to increasingly complex disease. In this article, we review various interventional devices and techniques that are key to achieving success in complex anatomic subsets.

BACKGROUND SilverHawk™ directional atherectomy has been used to treat more than 300 thousand cases of lower extremity atherosclerotic occlusive disease in the world since it was approved by FDA in 2003. This study aimed to analyze the safety and effectiveness of symptomatic femoral popliteal atherosclerotic disease treated by directional atherectomy (DA). METHODS Clinical data of all consecutive patients treated with percutaneous atherectomy utilizing the SilverHawk™ plaque excision was retrospectively analyzed. The anatomic criteria of the atherosclerotic lesions were divided into four types: type I stenosis; type II occlusion; type III in-stent restenosis; type IV stent occlusion. RESULTS There were 160 patients treated during the study period. Intermittent claudication in 75 patients (47%), rest pain in 55 patients (34.5%) and tissue loss in 30 patients (18.5%). The number of patients was 72, 15, 49 and 24 in type I, II, III and IV lesions, respectively. Technical success rate was 98.6%, 93.3%, 97.9% and 91.7% in type I, II, III and IV lesions, respectively. Debris of intimal plaque was captured by protection device in 92 patients (71.3%). The mean follow-up period was 23.5±10.4 months. Restenosis rate of type I to IV lesions was 21%, 36%, 36% and 40% respectively. Restenosis rate in type I lesion was significantly lower than that in type III and IV lesions (P

The use of drug-eluting stents and of drug-coated balloons have mitigated the prevalence of in-stent restenosis, however in-stent remains a problem that continues to affect the long-term outcomes of femoro-popliteal endovascular therapy. This paper will provide an overview on the latest data with regard to the treatment of femoro-popliteal in-stent restenosis.

BACKGROUND The aim of this paper is to explore the application and clinical significance of color Doppler ultrasound (CDU) in diagnosing lower extremity vascular disease in type 2 diabetes mellitus (T2DM) patients. METHODS The lower extremity arteries of 81 patients with T2DM and 50 control patients were examined by CDU for blood vessel diameter, intima-media thickness, plaque on the vessel wall, lumen stenosis and filling defect in blood flow. The occurrence of diabetes mellitus was investigated in additional T2DM patients of various ages. RESULTS Left popliteal artery, left and right dorsal artery of the foot; the incidence of atherosclerotic plaque, stenosis and occlusion of the lower extremity vascular lumen of T2DM patients was significantly higher than that in the control group. Vascular disease in the lower extremities was mainly small and medium vascular disease (lower than popliteal artery), especially the dorsal artery of the foot, for which the difference was statistically significant (P

Despite a constantly expanding spectrum of therapeutic options for lower limb artery disease, there is not yet a well-defined consensus on the specific type of endovascular treatment that is best suited. Clinical data on patients with femoropopliteal disease treated with drug-coated balloons have not been elaborated sufficiently, especially in the case of in-stent restenosis. For this review a systematic research of the medical databases (Pubmed) has been conducted. Keywords such as "drug-coated balloons" (DCB), "drug-eluting balloons," "in-stent restenosis", "de novo stenosis", "angioplasty", "superficial femoral artery," "popliteal artery," "above the knee," "below the knee," "peripheral artery disease" (PAD) have been used. Furthermore, data from reviews, original contributions regarding randomized controlled studies, observational studies, registries and single center experiences have been included. Many trials have shown superiority for DCB- over percutaneous transluminal angioplasty-treatment alone in TASC IIA and TASC IIB femoropopliteal lesions. However, the currently available DCB systems are different in terms of efficacy and long-term outcomes depending on their mechanical and pharmacological features. Moreover, angiographic characteristics of femoropopliteal lesions classified by Tosaka seem to influence subsequent outcomes of DCB treatment. Lastly, there is still lack of reliable prospective long-term data regarding DCB technology.

Critical limb ischemia (CLI) represents the terminal stage of peripheral arterial disease (PAD) and is characterized by multilevel and multivessel disease. Amongst patients with infrainguinal disease, approximately one third have predominantly isolated infrapopliteal disease and the remaining two thirds, a combination of femoropopliteal and infrapopliteal disease. Isolated infrapopliteal disease is mainly seen in the elderly, diabetic, or dialysis-dependent patients. These patients have higher risk of amputation and shorter amputation-free survival. Infrapopliteal disease presents with either complex high-grade calcified tandem lesions in multiple vessels or with long chronic total occlusion (CTO) segments with plaques characterized by higher calcium and lower fibro-fatty content than the inflow vessels, as arterial calcium deposition increases as we progress distally in the arterial tree. Vascular calcification occurs in both intima and media. Intimal calcification leads to development of calcified atheroma and occlusive lesions. Medial calcification leads to stiffening and decrease in arterial wall elasticity and compliance leading to atherosclerosis, reduced perfusion, and PAD, increasing cardiovascular mortality among patients with end-stage renal disease. This article attempts to review the implications of the diverse pathologic patterns of calcium distribution in infrapopliteal vessels of CLI patients, on the diagnostic modalities, technological developments, and the evolution of therapeutic approaches to improve outcomes among these patients. A critical analysis of the currently available data is provided, pointing to the surprising omission on the role of calcium on outcomes, and future directions are discussed. Is infrapopliteal calcium a roadblock or the avenue towards new paths? Necessity remains the mother of invention.

Aim. Feasibility of endovascular repair of popliteal artery aneurysms has been established. The results of this technique and the effect of the learning curve on the occurrence of complications were evaluated in a prospective cohort.Methods. Between June 1998 and February 2007,73 popliteal aneurysms were treated by endovascular means. Primary outcome was stent-graft patency. Secondary outcome was a combined end-point of stent-graft related complications, including occlusion, migration, stent-graft fracture, and stenosis. To study the learning curve, the cohort of patients was divided into 2 groups (group A from 1 to 23; group B from 24 to 73). Cut-off point chosen was the introduction of the more aggressive postoperative anticoagulation protocol with clopidogrel.Results. Eighteen (25%) stent-grafts occluded. This resulted in a reintervention in 11 patients. Migration, fracture, and stenosis were diagnosed in 9, 3 (2 leading to occlusion), and 2 limbs, respectively; these 14 complications accounted for reinterventions in 8 additional patients. In total, 19 of the 73 limbs (26%) required 20 reinterventions. Overall 3-and 5-year patency rates were 77% and 70% for primary patency, and 86% and 76% for secondary patency, respectively. There were more occlusions in group A (8/23, 35%) versus group B (10/50, 20%) (P= 0.22). With regard to the combined endpoint, there were more events in group A (14/23, 61%) than in group B (16/50, 32%) (P= 0.016).Conclusion. Results of endovascular repair of popliteal artery aneurysms are improving and in range with those of open repair.