The Endovascular Therapy Using Excimer Laser Atherectomy for Complex Femoropopliteal In-Stent Restenosis Lesions
Kazunori Horie1, Mitsuyoshi Takahara2, Shin Takiuchi3
1Department of Cardiovascular Medicine, Sendai Kousei Hospital, Miyagi, Japan.
Insights
Excimer laser atherectomy (ELA) showed acceptable technical success for femoropopliteal in-stent restenosis (ISR) but suboptimal 1-year freedom from re-restenosis. Slow blood flow and dialysis-dependent renal failure were key risk factors for restenosis.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Guidelines suggest excimer laser atherectomy (ELA) for femoropopliteal in-stent restenosis (ISR).
- Efficacy of ELA in ISR not related to bare-metal stents (BMS) remains unclear.
Purpose of the Study:
- To assess 1-year clinical outcomes of endovascular therapy (EVT) using ELA for femoropopliteal ISR.
- Evaluate ELA's effectiveness in diverse ISR lesion types.
Main Methods:
- Retrospective multicenter registry of 166 patients with femoropopliteal ISR lesions treated with ELA (2020-2024).
- Primary outcome: 1-year re-restenosis rate.
- Multivariate analysis identified independent risk factors for restenosis.
Main Results:
- Technical success rate was 83.7%.
- 1-year freedom from re-restenosis was 67.6%.
- Slow flow post-EVT and dialysis-dependent chronic renal failure independently predicted re-restenosis.
Conclusions:
- ELA offers acceptable technical success for femoropopliteal ISR.
- 1-year clinical outcomes are suboptimal, with significant restenosis rates.
- Identifying and managing risk factors like slow flow and renal failure is crucial for improving outcomes.
Purpose:
The guidelines recommend excimer laser atherectomy (ELA) for in-stent restenosis (ISR) lesions in femoropopliteal arteries. However, its efficacy is still unknown in ISR related to scaffolds other than bare-metal stent (BMS). This study aimed to evaluate the 1-year clinical outcomes in patients with femoropopliteal ISR lesions treated with endovascular therapy (EVT) using ELA.
Materials And Methods:
This retrospective multicenter registry analyzed patients who presented with peripheral artery disease caused by femoropopliteal ISR lesions undergoing EVT with ELA between 2020 and 2024. The primary outcome was re-restenosis 1-year following EVT.
Results:
Overall, consecutive 166 patients with femoropopliteal ISR lesions were enrolled. The rates of in-stent occlusion and ISR related to scaffolds other than BMS were found in 88.6% and 52.4% of the lesions, respectively. Technical success was achieved in 83.7%. The 1-year Kaplan-Meier estimate of freedom from re-restenosis was 67.6% (95% confidence interval [CI] 60.0-75.5). The primary-assisted patency and secondary patency rate was 72.7% (95% CI 65.8-80.3) and 81.5% (95% CI 76.6-88.0), respectively. In the multivariate analysis, slow flow observed in the completion angiography of EVT (adjusted hazard ratio, 2.32; P = .024) and chronic renal failure requiring dialysis (1.72; P = .036) were independently associated with re-restenosis risk. The accumulation of these factors was associated with a lower rate of freedom from re-restenosis; Kaplan-Meier estimates of the rates were 46.6% in subgroups with 1 or 2 risk factors, whereas it was 77.8% in the absence of risk factors. The Kaplan-Meier estimate shows a comparable primary patency rate between ISR related to BMS and drug-eluting stent at 1 year.
Conclusion:
ELA provided acceptable technical success in current femoropopliteal ISR lesions; however, the long-term result was clinically suboptimal.Clinical ImpactThis retrospective multicenter registry enrolled 166 patients with in-stent restenosis/in-stent occlusion lesions in femoropopliteal arteries treated with endovascular therapy using excimer laser atherectomy. The technical success rate was acceptable at 83.7%; however, 1-year estimate of freedom from restenosis was clinically suboptimal at 67.6%. The multivariate analysis showed incomplete antegrade blood flow and dialysis-dependent chronic renal failure were independently associated with re-restenosis risk.
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