SIR 2024
Arterial Interventions and Peripheral Arterial Disease (PAD)
Richard Powell, MD
Director Heart and Vascular Center
Dartmouth Hitchcock Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Gheorghe Doros, PhD
Data Scientist
Boston University Medical Center
Disclosure information not submitted.
Michael D. Dake, MD (he/him/his)
Senior Vice President for Health Sciences
University of Arizona
Financial relationships: Full list of relationships is listed on the CME information page.
Sharon C. Kiang, M.D.
Associate Professor
VA Loma Linda Health Care
Disclosure information not submitted.
Matthew Menard, MD
Associate Professor of Surgery
Brigham and Women's Hospital
Disclosure information not submitted.
Kenneth Rosenfield, MD
Assistant Professor of Medicine
Massachusetts General Hospital
Disclosure information not submitted.
Palma Shaw, MD
Professor of Surgery
SUNY Upstate Medical Center
Disclosure information not submitted.
Michael Strong, BS
National Trial Manager
Brigham and Womans Hospital
Disclosure information not submitted.
Thomas Todoran, MD
Professor of Medicine
Medical University of South Carolina
Disclosure information not submitted.
Christopher White, MD
System Chairman for Cardiovascular Disease
Ochsner Clinic Foundation
Disclosure information not submitted.
The BEST-CLI trial compared endovascular therapy to bypass surgery in patients with chronic limb-threatening ischemia (CLTI). The purpose of this analysis was to evaluate the causes and impact of endovascular technical failure (ETF) on outcomes.
Materials and Methods: Patients with CLTI and were candidates for surgical bypass and endovascular therapy were enrolled in cohort 1 if they had good quality single segment great saphenous vein (SSGSV) or cohort 2 if they lacked SSGSV. Patients in each cohort were randomized to infrainguinal bypass or endovascular therapy. ETF was defined as the inability to successfully complete the initial endovascular procedure. Patients who suffered ETF were compared with those who did not. Causes for ETF were analyzed. Impact on major adverse limb event (MALE), above ankle amputation, death and major cardiovascular events (MACE: defined as myocardial infarction, stroke and serious cardiovascular adverse events) were analyzed.
Results: Technical failure occurred in 16% (146 of 896) of all endovascular procedures. Patients who experienced ETF were older (69 +10 vs 67+10 yrs, p=.007), more frequently had hyperlipidemia (84% vs 72%, p=.002), and had more complex infrainguinal vascular disease compared to patients who did not experience ETF. Patients with ETF had an increased incidence of multilevel arterial occlusions involving a combination of both the superficial femoral / popliteal segments and tibial arterial segments (52% vs 41%, p=.029) and specifically occlusion of the proximal SFA (37% vs 19%, p< .001). The causes of ETF included inability to cross the lesion in 82%, residual stenosis > 50% in 5%, target artery compromise (defined as dissection, arterial rupture, embolization or thrombosis) in 4% and other complications in 8%. Following ETF, 72% of patients underwent leg bypass surgery within two weeks of index endovascular procedure. Patients who had ETF had similar rates of above ankle amputation (18.7% vs 16.0%, p=0.52) or all cause death (38.6% vs 29.8%, p=0.26) at 3 years compared with those who did not have ETF. There was an increased incidence of recurrent MALE at 3 years in patients with ETF when compared to those who did not have ETF (38.7% vs 26.9%, p=.0025). There was a higher rate of MACE at 3 years in patients experiencing ETF (49.1% vs 38.4%, p=0.03)
Conclusion: Endovascular technical failure occurred in 16% of endovascular treated patients with CLTI and was associated with multilevel occlusions and particularly proximal SFA occlusion. It did not appear to impact long-term above-ankle amputation or death but was associated with higher rates of MACE.