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For the treatment of peripheral arterial disease, drug-eluting technology is a widely accepted therapeutic option, with significant reduction in intimal hyperplasia and, consequently, use of target lesion revascularization. Nevertheless, the reputation of such devices was damaged after a meta-analysis, published in December 2018, showed increased mortality in patients receiving paclitaxel-eluting devices. Although subsequent studies have failed to establish such correlation, the use of paclitaxel-eluting devices remains heavily restricted. As such, other options and drugs have been developed, for instance sirolimus. In this article we present the available data on drug-eluting technology., Competing Interests: Disclosures: Leonardo Marques, Silke Hopf-Jensen, Michael Preiss and Stefan Mueller-Huelsbeck have no financial or non-financial relationships or activities to declare in relation to this article., (© Touch Medical Media 2021.)

Purpose: The hypothesis that covered stents are superior to bare-metal stents (BMS) in long femoropopliteal artery disease was tested. The one-year results of the VIASTAR trial revealed a patency benefit of covered stents in the treatment-per-protocol (TPP) analysis only., Methods: A prospective, randomized, single-blind, multicenter study evaluated 141 patients with symptomatic peripheral arterial disease (PAD) after treatment with heparin-bonded covered stents (VIABAHN(®) Endoprosthesis) or BMS. Clinical outcomes and patency rates were assessed at 1, 6, 12, and 24 months. Mean lesion length was 19.0 ± 6.3 cm in the VIABAHN(®) versus 17.3 ± 6.6 cm in the BMS group., Results: The 24-month primary patency rates in the VIABAHN(®) and BMS group were: intention-to-treat 63.1 (95 % CI 0.52-0.76) versus 41.2 % (95 % CI 0.29-0.57; log rank p = 0.04) and TPP 69.4 (95 % CI 0.58-0.83) versus 40.0 % (95 % CI 0.28-0.56; log rank p = 0.004). Freedom from target-lesion-revascularization (TLR) was 79.4 (95 % CI 0.70-0.90) versus 73.0 % (95 % CI 0.63-0.85) for VIABAHN(®) versus BMS (log rank p = 0.37). For the TPP group in lesions ≥20 cm, the 24-month patency rates were 65.2 (95 % CI 0.50-0.85) versus 26.7 % (95 % CI 0.12-0.59; log rank p = 0.004) for VIABAHN(®) versus BMS, and freedom from TLR was 80.0 (95 % CI 0.68-0.94) versus 61.9 % (95 % CI 0.44-0.87; log rank p = 0.13). The ankle brachial index was 0.89 ± 0.18 versus 0.91 ± 0.17 (p = 0.76) at 24-month in the VIABAHN(®) versus the BMS group, respectively., Conclusion: At 24-month, this trial in PAD patients with long femoropopliteal lesions demonstrated a significantly improved primary patency rate for heparin-bonded covered stents compared to BMS, however, without a significant impact on clinical outcomes and TLR rate (Reg. Nr. ISRCTN48164244).

Objectives: The hypothesis that endovascular treatment with covered stents has equal risks but higher efficacy than bare-metal stents (BMS) in long femoropopliteal artery disease was tested., Background: Although endovascular treatment of short superficial femoral artery lesions revealed excellent results, efficacy in long lesions remains unsatisfactory., Methods: In a prospective, randomized, single-blind, multicenter study, 141 patients with symptomatic peripheral arterial disease were assigned to treatment with heparin-bonded, covered stents (Viabahn 72 patients) or BMS (69 patients). Clinical outcomes and patency rates were assessed at 1, 6, and 12 months., Results: Mean ± SD lesion length was 19.0 ± 6.3 cm in the Viabahn group and 17.3 ± 6.6 cm in the BMS group. Major complications within 30 days were observed in 1.4%. The 12-month primary patency rates in the Viabahn and BMS groups were: intention-to-treat (ITT) 70.9% (95% confidence interval [CI]: 0.58 to 0.80) and 55.1% (95% CI: 0.41 to 0.67) (log-rank test p = 0.11); treatment per-protocol (TPP) 78.1% (95% CI: 0.65 to 0.86) and 53.5% (95% CI: 0.39 to 0.65) (hazard ratio: 2.23 [95% CI: 1.14 to 4.34) (log-rank test p = 0.009). In lesions ≥20 cm, (TransAtlantic Inter-Society Consensus class D), the 12-month patency rate was significantly longer in VIA patients in the ITT analysis (VIA 71.3% vs. BMS 36.8%; p = 0.01) and the TPP analysis (VIA 73.3% vs. BMS 33.3%; p = 0.004). Freedom from target lesion revascularization was 84.6% for Viabahn (95% CI: 0.72 to 0.91) versus 77.0% for BMS (95% CI: 0.63 to 0.85; p = 0.37). The ankle-brachial index in the Viabahn group significantly increased to 0.94 ± 0.23 compared with the BMS group (0.85 ± 0.23; p < 0.05) at 12 months., Conclusions: This randomized trial in symptomatic patients with peripheral arterial disease who underwent endovascular treatment for long femoropopliteal lesions demonstrated significant clinical and patency benefits for heparin-bonded covered stents compared with BMS in lesions ≥20 cm and for all lesions in the TPP analysis. In the ITT analysis for all lesions, which was flawed by major protocol deviations in 8.5% of the patients, the difference was not significant. (GORE VIABAHN® endoprosthesis with bioactive propaten surface versus bare nitinol stent in the treatment of TASC B, C and D lesions in superficial femoral artery occlusive disease; ISRCTN48164244)., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

As the minimal invasive procedures for the treatment of peripheral arterial disease grow at exponential rates, interventional radiologists and vascular surgeons are more often faced with the difficult decision of which devices are the most appropriate to bring the desired results. Under the light of the newest studies and always having in mind the concept of "leaving no metal behind", when focusing on the lesions within the superficial femoral artery and popliteal arteries, we try to answer the question: treating with an implant, bare metal stents or drug eluting stents?

Purpose: To evaluate safety and efficacy of cryoplasty versus conventional angioplasty for focal popliteal arterial occlusive disease., Materials and Methods: Patients with focal atherosclerotic stenoses and occlusions of the popliteal artery were randomized to cryoplasty or conventional angioplasty as the initial treatment strategy. The primary objective was target lesion patency. The secondary endpoint was treatment success without the need for stents. Duplex ultrasonography was performed at 3, 6, 9, and 15 months., Results: Eighty-six patients (mean age, 72 years; age range, 50-94 years) were enrolled in this study. Forty patients were randomized to cryoplasty and 46 to conventional angioplasty. Demographics, risk factors, clinical stage of disease, and lesion details were comparable. On intention-to-treat basis, initial success was 35% for cryoplasty versus 54% for conventional angioplasty (P = .02). The rate of grade C dissection was 35% after cryoplasty and 26% after conventional angioplasty (P = .4). Optional long-term percutaneous transluminal angioplasty (PTA) was performed in 58% of cryoplasty patients. The rate of stent placement for dissection and/or residual stenosis was 30% after cryoplasty (including long-term dilation) and 39% after conventional angioplasty (P = .34). The mean (+/-standard deviation) target lesion patency at 9 months was 79.3% +/- 7.5 for cryoplasty and 66.7% +/-8.1 for conventional angioplasty; however, the results are not significant (P = .14)., Conclusions: Cryoplasty of the popliteal artery alone showed a lower anatomic success when compared with conventional angioplasty. Combined with optional long-term PTA, however, stent placement was not needed more often. There was a trend toward higher patency after cryoplasty, but differences were not statistically significant and results of long-term follow-up have to be awaited., (Copyright (c) 2010 SIR. Published by Elsevier Inc. All rights reserved.)

We report a case of massive hemothorax due to inadvertent puncture of an aberrant right subclavian artery during central venous access. Iatrogenic laceration at the origin of the right internal thoracic artery was successfully treated with coil embolization of the internal thoracic artery followed by stent-graft placement into the subclavian artery. Due to its elongated and abnormal course, an aberrant right subclavian artery may predispose to inadvertent puncture during vein catheterization and should be recognized as a potential threat for such procedures. Our case emphasizes that ultrasound guidance should be used routinely for central venous lines wherever possible.

Purpose: To analyze the immediate and midterm success of low-profile stent placement in calcified ulcerated lesions of the infrarenal aorta in patients with arterial occlusive disease., Materials and Methods: In this prospective case series, 13 symptomatic patients (eight men, five women; mean age, 64.8 years +/- 12.1; age range, 44-84 years) with focal calcified ulcerated stenoses of the infrarenal aorta were treated with stent placement by using a low-profile technique in a radiology intervention center during a 4-year period. Clinical examinations and duplex ultrasonography were used to evaluate the stents? patency and clinical success. Kaplan-Meier graphs were calculated to analyze the freedom-of-symptom rate., Results: The initial technical success rate was 92% (12 of 13 patients). Due to extended calcifications, a residual stenosis of 50%-60% remained in one patient. No peri-interventional complications occurred. The mean follow-up was 26 months (range, 5-53 months). During follow-up, one patient had a restenosis after 7 months and presented clinically with Fontaine stage IIb. Two patients had iliac and/or femoral stenoses, and both presented with Fontaine stage IIb. One patient's symptoms originated from the lumbar spine. Primary patency and primary clinical success rates were 85% and 69%, respectively. According to Kaplan-Meier tables, the freedom-from-symptom rates were 92%, 84%, 73%, and 63% at 0, 7, 12, and 21 months, respectively., Conclusions: Low-profile stent placement in calcified, ulcerated lesions of the infrarenal aorta is an effective and safe treatment for symptomatic stenoses in patients with arterial occlusive disease after a mean follow-up of 26 months.

The objective of the study was to prove the value of single-dose contrast-enhanced magnetic resonance angiography [three-dimensional (3D) ceMRA] in abdominal and iliac arteries versus the reference standard intra-arterial digital subtraction angiography (i.a.DSA) when indicating a therapy. Patients suspected of having abdominal or iliac artery stenosis were included in this study. A positive vote of the local Ethics Committe was given. After written informed consent was obtained, 37 patients were enrolled, of which 34 were available for image evaluation. Both 3D ceMRA and i.a. DSA were performed for each patient. The dosage for 3D ceMRA was 0.1 mmol/kg body weight in a 1.5-T scanner with a phased-array coil. The parameters of the 3D-FLASH sequence were as follows: TR/TE 4.6/1.8 ms, effective thickness 3.5 mm, matrix 512 x 200, flip angle 30 degrees , field of view 420 mm, TA 23 s, coronal scan orientation. Totally, 476 vessel segments were evaluated for stenosis degree by two radiologists in a consensus fashion in a blinded read. For each patient, a therapy was proposed, if clinically indicated. Sensitivity, specificity, positive and negative predictive values, and accuracy for stenoses > or = 50% were 68%, 92%, 44%, 97%, and 90%, respectively. In 13/34 patients, a discrepancy was found concerning therapy decisions based on MRA findings versus therapy decisions based on the reference standard DSA. The results showed that the used MRA imaging technique of abdominal and iliac arteries is not competitive to i.a. DSA, with a high rate of misinterpretation of the MRAs resulting in incorrect therapies.

This article focuses on stent placement in mesenteric arteries in patients with the rare diagnosis of chronic mesenteric ischemia. We present a survey from the initial stage of recognition of this gastrointestinal disorder and its manifestations to treatment by stenting to avoid further ischemic episodes and bowel infarction and necrosis. The advantages of stent placement in splanchnic arteries are discussed in comparison to open surgical revascularization.

Purpose: To analyze the immediate and midterm success of stenting of mesenteric arteries by a monorail technique in patients with chronic mesenteric ischemia., Materials and Methods: In this prospective case series, 19 patients (11 male, 8 female; mean age, 62.9 +/- 10.4 y; range, 36-82 y) with 23 symptomatic stenoses of mesenteric arteries were treated with stent placement by a monorail technique in a radiologic intervention center over a period of 4.5 years. Clinical examinations and duplex sonography were used to evaluate the stents' patency and clinical success. Kaplan-Meier graphs were calculated to analyze the patency and freedom-from-symptom rate., Results: Initial technical success rate was 22/23 (96%). Mean follow-up was 17 months (range, 1-58 mo). Primary patency and primary clinical success rates were 82% and 78%, respectively. According to Kaplan-Meier tables, the patency rates were 96%, 87%, 76%, and 61% at 0, 1, 15, and 24 months, respectively, and the freedom-from-symptom rates were 95%, 90%, 72%, and 54% at 0, 1, 24, and 30 months, respectively. No peri-interventional complications occurred. Two patients died of cardiac failure in the hospital within 30 days after intervention; deaths were not related to the intervention., Conclusions: Stent placement by a monorail technique in mesenteric arteries is an effective and safe treatment for symptomatic stenoses in patients with chronic mesenteric ischemia after a mean follow-up of 17 months.

Micro-computed tomography (micro-CT) is a high-resolution, non-destructive tool for two- and three-dimensional imaging and quantification. The ability of this technique to assess atherosclerosis of the carotid artery was evaluated in three human cadaver samples based on the original axial acquisitions, multiplanar reconstructions and volume rendering techniques. Quantitative analysis included the calculation of: (1) the original lumen perimeter, original lumen area, plaque area, residual lumen area, calcified area and gross sectional area reduction of the vascular lumen from two-dimensional slices; (2) the total tissue volume, soft tissue volume and calcified tissue volume from the three-dimensional data set. This preliminary study demonstrates the potential of micro-CT as a supplementary method for the two- and three-dimensional ex vivo evaluation of carotid atherosclerosis.

Our objective was to evaluate the hemolytic effect of stents and stent grafts in an in vitro flow model. The model consisted of silicone tubings. Pulsatile flow was delivered at 1170 ml/min. Diluted packed erythrocytes were used (hematocrit of 33%). The Palmaz, MegaLink stents or Passager, Hemobahn stent grafts were placed in the middle portion of the model; control experiments contained no implant ( n=10 each). Concentric stenosis of the implant was achieved by constricting the implant to 25, 50, or 70% (area, n=10 each). Samples were drawn at minute 1, 2, 4, 6, 8, 10, 15, and every 10 min up to 1 h. Hemolytic parameters were evaluated. All implants produced hemolysis, increasing in the course of time. Without deformation (0%) the Hemobahn stent causes less hemolysis compared with the other prostheses. At 25% no significant difference could be shown between all devices. At 50% constriction the Palmaz stent caused more hemolysis than the other grafts, and at 70% stenosis the Palmaz and Hemobahn caused more hemolysis than Passager or Megalink. A hemolytic effect was evaluable, probably due to mechanical stress and sheer forces, induced by turbulences in the proximity of the deformed stent. The stent grafts did not perform better than the stents. Differences in the design of a prosthesis and in the degree of stent deformation seem to have an influence on the hemolysis caused.

Purpose: The goal of this work was to test the ability of a combination of 2D phase-contrast MR angiography (2D-PC-MRA) and triggered 2D time-of-flight MRA (2D-TOF-MRA) in comparison to intraarterial digital subtraction angiography (DSA) to correctly diagnose the location and shape of occlusive lesions in the iliac and femoral arteries and to determine whether 2D-TOF-MRA is helpful to clarify questionable lesions demonstrated by 2D-PC-MRA., Methods: In 50 patients with claudication, 2D-PC-MRA was performed in three consecutive coronal positions from the aortic bifurcation to below the trifurcation. Axial 2D-TOF-MRA was performed additionally at the site of detected lesions of >50% and lesions in doubt to obtain more precise information about the stenosis. Lesions were classified as follows: low grade occlusion, <50%; high grade occlusion, >50%. MRA was performed within 24 h of a DSA examination., Results: In all patients, the arterial tree from the aortic bifurcation to the trifurcation could be visualized. One hundred twelve lesions were detected by MRA. Sensitivity was 96% and specificity was 92%. Sixty-two lesions were classified as high grade occlusion and reevaluated. In this category, sensitivity was 100% and specificity was 96%., Conclusion: The combination of 2D-PC-MRA with triggered 2D-TOF-MRA detects stenotic lesions in the lower extremity arterial system with high sensitivity and specificity.

Purpose: To determine whether spiral CT angiography allows accurate, quantitative evaluation of anatomic abnormalities, including detection of additional lesions, delineation of plaque morphology, and estimation of degree of internal carotid artery stenosis., Methods: Spiral CT angiography with a maximum intensity projection technique was compared with selective digital subtraction angiography (DSA) in 92 carotid arteries. The category of stenosis was determined according to the North American Symptomatic Carotid Endarterectomy Trial: mild (0% to 29%), moderate (30% to 69%), severe (70% to 99%), and occlusion (100%)., Results: In 78 (85%) of the 92 cases, spiral CT angiography and selective DSA demonstrated the same degree of stenosis. All occlusions (n = 19) were diagnosed correctly with spiral CT angiography. Spiral CT angiography agreed with selective DSA in the classification of stenosis in 59% of the group with mild stenosis, in 82% of the group with moderate stenosis, and in 90% of the group with severe stenosis. In the groups with mild (n = 13), moderate (n = 9), and severe (n = 27) stenosis, correlation of spiral CT angiography with selective DSA was significant. Calcified plaques were readily diagnosed with the use of spiral CT angiography but delineation of ulcers was poor. Tandem lesions were not visible owing to the limited coverage., Conclusion: Spiral CT angiography is useful for the detection of proximal internal carotid stenoses that are greater than 30%. Depiction of mild stenoses appears to be limited. CT is superior for the detection of calcified plaques but it is not useful for the detection of ulcers.

Purpose: To decide, whether spiral CT-angiography (CTA) in surface display (SSD)-technique is suitable for accurate quantification of carotid artery stenoses., Material and Methods: Forty-four patients (25 male, 19 females) with a total of 80 symptomatic carotid artery were studied prospectively with selective cerebral angiography and spiral CTA in SSD-technique. The degree of stenosis was determined according to the NASCET-study., Results: Assessment of the degree of stenoses with CTA and angiography was the same in 36% of mild stenoses, in 64% of moderate stenoses, in 68% of severe stenoses, and in 95% of the occluded internal carotid arteries. Overall, CTA in SSD-technique showed equivalent results as selective cerebral angiography in 65% of all cases., Conclusion: Spiral CTA in SSD-technique is inferior to selective cerebral angiography. Calcified plaques, vessel opacification and thresholding influence the most grading of stenosis.