Transcatheter Interventions for the Treatment of Peripheral Atherosclerotic Lesions: Part I

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Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This two-part review identifies the existing evidence supportive of the application of transcatheter treatments for peripheral atherosclerotic lesions. The first part addresses the treatment of obstructive lesions that cause limb claudication and critical ischemia, renovascular hypertension and azotemia, and mesenteric ischemia. Studies were identified via a search of MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, a preference was given to studies with at least 50 patients per treated group and a minimum mean follow-up duration of 6 months. Data presented in tables are proportionally weighted averages from included studies. For each application, the authors assessed the quality of evidence (QOE; efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. There is higher QOE supporting the more established treatments such as lower limb percutaneous transluminal angioplasty (PTA) with stent placement and thrombolysis. Treatments such as renal artery PTA and stent placement and mesenteric and brachiocephalic PTA are in wide use, but high QOE supporting general application is lacking. Blanket recommendations based on established efficacy and cost-effectiveness cannot be made. However, the use of transcatheter therapies can be supported in specific circumstances based on an expected reduction in procedure-related morbidity and/or mortality rates. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.

Section snippets

INTRODUCTION

SVEN Ivar Seldinger's elegantly simple technique for introducing catheters into arteries began a revolution in the diagnosis and treatment of cardiovascular disease (1) The subsequent contributions of Charles Dotter (2), Kurt Amplatz (3), Andreas Gruntzig (4), Julio Palmaz (5) and others accelerated the development of image-guided endovascular interventions and changed forever the course of cardiovascular medicine. These were the first of the “minimally invasive therapies,” a term now applied

MATERIALS AND METHODS

In this review of transcatheter endovascular procedures, we have attempted to include reports that provide high quality of evidence (QOE) for decision-making concerning therapy. The quality of evidence is based on safety, efficacy, and, where available, cost-effectiveness. Unfortunately, existing QOE is not uniform across all procedures. There are few properly randomized controlled trials (RCTs; US Preventive Services Task Force QOE Level I, see Appendix); for many of the procedures discussed

Balloon PTA and Stent Placement

Several percutaneous revascularization techniques exist for the treatment of PAD of the lower extremities. Because the associated risks of periprocedural mortality and morbidity are low, revascularization for intermittent claudication, even at an early stage, is a viable alternative. However, percutaneous techniques generally yield lower patency rates than surgery, and both percutaneous and surgical procedures are expensive. Therefore, an understanding of the tradeoffs helps to determine

DISCUSSION

Considerable progress has been made in generating supporting evidence for the appropriate application of transcatheter treatment for peripheral atherosclerosis, but there are significant gaps in our knowledge. For treatment such as lower extremity PTA and thrombolytic therapy, a higher quality of evidence (Level I) exists, and early medical decision models and cost-effectiveness data are emerging. There is good evidence to recommend these therapies for the specific indications discussed herein.

Acknowledgments

Editors: Drs. Kandarpa and Becker. Section authors and guarantors of data integrity: lower extremity angioplasty and stent placement, Dr. Hunink; Lower extremity thrombolysis, Drs. Kandarpa and Semba; Upper extremity angioplasty and stent placement, Dr. McNamara; Renal artery angioplasty and stent placement, Drs. Rundback, Sos, and Trost; Mesenteric artery interventions, Drs. Rundback and Poplausky. Literature research and manuscript preparation, Ms. Landow.

We thank Cathy Mendelsohn and Chris

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    This paper was supported in part by a Cardiovascular and Interventional Radiology Research and Education Foundation (CIRREF) grant and an in-kind contribution by the Society of Cardiovascular & Interventional Radiology (SCVIR), Fairfax, Virginia.

    Assessment of Radiological Technology and Department of Radiology and Department of Epidemiology & Biostatistics (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands.

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