Management of isolated femoropopliteal in-stent restenosis.

OBJECTIVE: The optimal catheter-directed therapy for femoropopliteal in-stent restenosis (ISR) remains controversial with limited durability. The natural history of untreated ISR is not well characterized. We evaluated the midterm outcomes of patients with asymptomatic isolated femoropopliteal ISR who were observed under a surveillance program. METHODS: Patients treated with isolated femoropopliteal stents from January 2009 to December 2013 were retrospectively investigated for the development of ISR. ISR was classified on the basis of duplex ultrasound criteria, with >50% defined as peak systolic velocity (PSV) twice that of the normal vessel and >75% as PSV >400 cm/s or four times the normal PSV. Asymptomatic patients with ISR of >50% were tracked for progression to high-grade (>75%) stenosis, occlusion, need for reintervention, and amputation. RESULTS: Asymptomatic ISR of >50% was identified in 62 (15.3%) of 402 patients with isolated femoropopliteal stents. The mean time for development of ISR was 22.1 (±20.1) months. The mean age was 72 (±9.7) years, and 34 (55.7%) patients were female. Thirty-one (50%) patients were diabetic, 18 (29.1%) were smokers, and 8 (12.9%) had chronic kidney disease. Indications for treatment were claudication in 49 (79.0%), tissue loss in 9 (14.5%), and rest pain in 4 (6.4%) patients. TransAtlantic Inter-Society Consensus (TASC) A lesions were treated in 13 (21%) patients, TASC B lesions in 24 (38.7%), and TASC C lesions in 25 (40.3%). Three-vessel runoff was identified in 25 (40.3%) patients, two-vessel runoff in 18 (29.0%), and one-vessel runoff in 19 (30.6%). Under surveillance, ISR of >50% progressed to >75% or occlusion in 20 (32.3%) patients. The mean time to progression was 17.4 months, and the mean overall follow-up was 33.1 months. Reintervention was required in 22 (35.0%) patients, with an average of 1.95 (range, 1-4) interventions per patient. Reintervention was undertaken in 19 (86%) patients for claudication and in 3 (18%) patients for critical limb ischemia. One patient required an amputation despite previous reintervention for progression. Progression to >75% stenosis was predictive of need for reintervention (P = .004). CONCLUSIONS: Under a surveillance program, asymptomatic patients with femoropopliteal ISR of >50% may be observed with a low risk of limb loss. Given the slow rate of progression and the poor durability of reintervention, surveillance with delayed intervention may be warranted.

Outcomes of thoracic endovascular aortic repair for chronic aortic dissections.

BACKGROUND: Open surgical repair remains the "gold standard" treatment for chronic type B aortic dissection (cTBD) with aneurysm. Thoracic endovascular aortic repair (TEVAR) has gained popularity in recent years for the treatment of thoracic aortic diseases, including cTBD. We assessed the effectiveness of TEVAR in the treatment of cTBD using the Vascular Quality Initiative (VQI) database. METHODS: The VQI registry identified 4713 patients treated with TEVAR from July 2010 to November 2015, including 125 repairs for cTBD. We analyzed TEVAR outcomes in this cohort per the Society for Vascular Surgery reporting standards for TEVAR. RESULTS: Median age was 65.0 years (interquartile range [IQR], 56.0-72.0 years), and 85 (68.0%) were male. Median aneurysm diameter was 5.5 cm (IQR, 4.8-6.3 cm). Sixty-two (49.6%) patients were asymptomatic on presentation, 57 (45.6%) were symptomatic, and 6 (4.8%) presented with rupture. Median length of stay was 8.0 days (IQR, 4.0-11.0 days). Fluoroscopy time was 17.3 minutes (IQR, 10.5-25.6 minutes). The distal landing zone was aortic zone 4 in 27 (21.6%) and aortic zone 5 and distal in 98 (78.4%) patients. Successful device delivery occurred in 123 (98.4%) patients. Conversion to open repair occurred in one (0.8%) patient. A type IA endoleak was present in 2 (1.6%), type IB endoleak in 2 (1.6%), and type II endoleak in 2 (1.6%) patients. Perioperative complications included stroke in 1 (0.8%), respiratory complications in 6 (4.8%), and spinal cord ischemia symptoms present at discharge in 3 (2.4%) patients. In-hospital mortality occurred in three (2.4%) patients. Reintervention was required in two (1.6%) patients for false lumen perfusion and in two (1.6%) patients for extension of the dissection. Follow-up was available for 43 patients at a median time of 239 days (IQR, 38-377 days). Median change in sac diameter was -0.2 cm (IQR, -0.5 to 0.1 cm). Sac shrinkage of 0.5 cm was noted in 12 (27.9%), with sac growth >0.5 cm in four (9.3%) patients. Extent of stent graft coverage did not affect sac shrinkage (P = .65). Patients with aneurysms ≥5.5 cm compared with <5.5 cm were more likely to demonstrate shrinkage (-0.6 cm vs 0.0 cm; 95% confidence interval, 0.3-11.7; P = .04). CONCLUSIONS: TEVAR for cTBD may be performed with acceptable rates of morbidity and mortality. Changes in sac diameter in the midterm are promising. Long-term data are needed to determine whether this approach is durable.