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Clinical and vascular laboratory determinants for outcome after infrainguinal atherectomy
K A Myers1, G H Zeng, R W Ziegenbein
1Department of Surgery, Monash University, Melbourne, Victoria, Australia.
Insights
Vascular laboratory surveillance, particularly peak systolic velocity, can predict outcomes after atherectomy. High velocities indicate potential failure due to residual or recurrent stenosis, questioning atherectomy
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Diagnostic Imaging
Background:
- Atherectomy is a common procedure for peripheral artery disease.
- Long-term outcomes and predictors of failure require further investigation.
Purpose of the Study:
- To evaluate the effectiveness of vascular laboratory surveillance in predicting outcomes after atherectomy.
- To identify factors associated with atherectomy failure.
Main Methods:
- 180 atherectomy procedures were performed using Transluminal Extraction Catheter and Auth Rotablator.
- Vascular laboratory surveillance, including duplex scans and ankle/brachial pressure index, was conducted.
- Multivariate Cox regression and receiver operating characteristic (ROC) curve analyses were used.
Main Results:
- Primary patency rates were 55% at 1 year and 46% at 2 years.
- Failure was attributed to stenosis (15.6%) and occlusion (33.7%).
- Maximum peak systolic velocity (>250 cm/s) from duplex scans significantly predicted late failure (sensitivity 72%, specificity 84%).
Conclusions:
- Vascular laboratory surveillance, especially peak systolic velocity, is valuable for predicting atherectomy outcomes.
- High velocities suggest residual or recurrent stenosis, raising questions about atherectomy's benefit over balloon angioplasty alone.
Abstract:
Three surgeons performed 180 atherectomy procedures in 161 patients using the Transluminal Extraction Catheter in 144 and the Auth Rotablator in 36. The primary patency rate was 55% at 1 year and 46% at 2 years, and failure was caused by stenosis in 28 (15.6%) and occlusion in 61 (33.7%) limbs. Multivariate Cox regression analysis showed significantly better outcome if the indication was claudication, the lesion was short or there was associated stenting. Vascular laboratory surveillance was performed in 93 limbs in 83 patients. Cox regression analysis in this subgroup also showed a significant relationship between outcome and the maximum peak systolic velocity from a duplex scan at the last study performed. Receiver operating characteristics curves showed that a raised maximum peak systolic velocity best predicted late failure (sensitivity 84%, specificity 66% for > 200 cm/s; sensitivity 72%, specificity 84% for > 250 cm/s); the velocity ratio at the stenosis to that in the segment above or the resting ankle/brachial pressure index were less predictive. For 50 procedures studied in the vascular laboratory which remained successful to the end of the study, maximum peak systolic velocities were > 250 cm/s from the first postoperative study, suggesting residual stenosis in 6%, or increased to become > 250 cm/s by the last study, suggesting recurrent stenoses in 12%. For 43 procedures which were studied and later failed, velocities were > 250 cm/s from the first test in 26% or increased to > 250 cm/s by the last test before failure in 40%. Vascular laboratory surveillance helps to predict outcome after atherectomy. Failure may be a result of residual disease from the time of the procedure or from restenosis. The apparent high incidence of clinically manifest or developing stenoses raises doubts as to the benefit of atherectomy over balloon dilatation alone.