Background First-line treatment for patients with superficial femoral arterial (SFA) occlusive disease has yet to be determined. This study compared long-term outcomes between primary SFA stent placement and primary femoral-popliteal bypass. Periprocedural patient factors were examined to determine their effect on these results. Methods All femoral-popliteal bypasses and SFA interventions performed in consecutive patients with symptoms Rutherford 3 to 6 between 2001 and 2008 were reviewed. Time-dependent outcomes were analyzed using the Kaplan-Meier method and log-rank test. Cox proportional hazards were performed to determine predictors of graft patency. Multivariate analysis was completed to identify patient covariates most often associated with the primary therapy. Results A total of 152 limbs in 141 patients (66% male; mean age, 66 ± 22 years) underwent femoral-popliteal bypass, and 233 limbs in 204 patients (49% male; mean age, 70 ± 11 years) underwent SFA interventions. Four-year primary, primary-assisted, and secondary patency rates were 69%, 78%, and 83%, respectively, for bypass patients and 66%, 91%, and 95%, respectively, for SFA interventions. Six-year limb salvage was 80% for bypass vs 92% for stenting (P = .04). Critical limb ischemia (CLI) and renal insufficiency were predictors of bypass failure. Claudication was a predictor of success for SFA stenting. Three-year limb salvage rates for CLI patients undergoing surgery and SFA stenting were 83%. Amputation-free survival at 3 years for CLI patients was 55% for bypass and 59% for SFA interventions. Multivariate predictors (odds ratios and 95% confidence intervals) of covariates most frequently associated with first-line SFA stenting were TransAtlantic Inter-Society Consensus II A and B lesions (5.9 [3.4-9.1], P < .001), age >70 years (2.1 [1.4-3.1], P< .001), and claudication (1.7 [1.1-2.7], P= .01). Regarding bypass as first-line therapy, claudicant patients were more likely to have nondiabetic status (5.6 [3.3-9.4], P < .001), creatinine <1.8 mg/dL (4.6 [1.5-14.9], P = .01), age <70 years (2.7 [CI, 1.6-8.3], P < .001), and presence of an above-knee popliteal artery target vessel (1.9 [CI, 1.1-3.4] P = .02). Conclusion Indication, patient-specific covariates, and anatomic lesion classification have significant association when determining surgeon selection of SFA stenting or femoral-popliteal bypass as first-line therapy. Patients with SFA disease can have comparable long-term results when treatment options are well matched to patient-specific and anatomic characteristics. (J Vasc Surg 2011;54:714-21.)

Durable long-term functional outcomes can be achieved predicated on a highly selective approach to the surgical management of patients with NTOS. A majority of operated patients will not require adjunctive procedures or chronic narcotic utilization. Patients who undergo surgery can expect to return to work with little or no functional impairment.

percutaneous lower extremity procedures at a single institution from 2002 and 2007 identified 73 SPTAS in 73 limbs. Patient comorbidities, anatomic, and procedural characteristics were analyzed with respect to outcomes with descriptive statistics, life-table analysis, and Cox proportional hazards modeling. Patency rates were determined from the time of SPTAS.Results: Patients included 39 men (64%) and 22 women (36%) at a mean age of 70 Ϯ 10 years. Indications included claudication in 56 limbs (77%) and critical limb ischemia in 17 (23%). Median time from the initial endoluminal intervention to SPTAS was 322 days. Twenty limbs (27%) had TransAtlantic Inter-Society Consensus II (TASCII) category D lesions; the rest were treated for TASCII A, B, and C disease. Technical success was achieved in 72 patients (99%) and initial clinical improvement in 64 (89%). During a mean follow-up of 15.3 months, 2-year primary patency, assisted primary patency, secondary patency, limb salvage, and survival were, respectively, 66% Ϯ 8%, 86% Ϯ 4%, 86% Ϯ 4%, 97%, and 89%. Cox proportional hazard modeling showed that SPTAS Յ180 days of the initial endovascular intervention was the only significant predictor of failure of SPTAS primary patency (hazard ratio, 3.5; 95% confidence interval, 1.1-11). TASCII D classification was associated with failure of assisted primary and secondary patency.Conclusions: Second-time femoropopliteal angioplasty/stenting has excellent initial success but limited midterm primary patency. The need for early SPTAS is highly associated with failure of primary patency and the need for additional interventions. With vigilance, good midterm assisted primary and secondary patency in those with limited extent of disease as well as excellent limb salvage can be achieved.

Male Gender BSA (m 2 ) BMI Cannula Size (Fr) Mortality (%) Limb ischemia 36 Ϯ 18 7/7 2.09 Ϯ 0.29 29.5 Ϯ 10.0 16.9 Ϯ 1.1 4/7 (57) No limb ischemia 58 Ϯ 14 20/26 2.13 Ϯ 0.27 30.8 Ϯ 5.4 18.0 Ϯ 1.7 23/26 (88) Prophylactic-Y 44 Ϯ 16 7/10 2.06 Ϯ 0.23 29.4 Ϯ 9.0 17.7 Ϯ 1.8 7/10 (70) P-value* 0.001 0.30 0.57 0.65 0.09 0.09 BMI, Body mass index; BSA, body surface area. *Between "limb ischemia" and "no limb ischemia" groups. Does the Addition of Routine IVC/Iliac Vein and Infrapopliteal Duplex Scan Confer any Benefit? Alhabouni S, Hingorani A, Ascher E, et al Objectives:The routine evaluation for lower extremity deep vein thromboses (DVT) usually involves the femoral and popliteal veins with no regard to the more proximal (Iliac and inferior vena cava [IVC]) veins or the more distal (infra-popliteal) veins. In this study, we attempted to evaluate the benefits of routine scanning of these segments.Methods: We reviewed 1624 consecutive lower extremity venous duplex studies performed for 1513 of our in-house patients between January 2008 and July 2008. All studies included routine evaluation of the IVC/iliac and infra-popliteal vein segments. All studies were also evaluated for any evidence of pulmonary embolism (PE).Results: The IVC/iliac vein segments were completely evaluated in 1270 duplex studies with evidence of IVC/iliac vein DVTs in 37 (2.9%). In 354 studies, the evaluation was incomplete due to improper visualization of the IVC mostly due to bowel gas. Despite that, evidence of iliac vein DVT was noted in 18 (5.1%) of these studies. In total, the addition of routine iliac vein/IVC duplex scan resulted in the detection of 55 (3.38%) DVTs with evidence of PE in five (incidence of 9.1%). In five of those 55 duplex studies, the IVC/iliac vein DVT was the only DVT detected, with evidence of PE in one (incidence of 20%). The rest of the study population had evidence of DVT in 244 studies (15.55%) with evidence of PE in 32 (incidence of 13.1%) of them (P ϭ .59). Infra-popliteal segment: 145 infra-popliteal DVTs were detected, of which 50 (34.5%) were isolated to the infrapopliteal segments with evidence of PE in three (incidence of 6%). The rest of the study population showed evidence of DVT in 98 with evidence of PE in 14 (incidence of 14.3%) (P ϭ .135).Conclusions: Although routine scanning of the IVC/Iliac veins resulted in detection rate of 3.38%, the detection of an isolated DVT in those veins was very low (0.3%). However, isolated DVT of the iliac veins had a PE rate of 20%. As for the routine scanning for infra-popliteal DVTs, 50 additional DVTs were detected with a PE rate of 6%, with no statistical difference from the rate of PE from more proximal segments (P ϭ .135).Hence infra-popliteal DVTs should be regarded as risky as more proximal DVTs and should therefore be treated similarly.BMI, Body mass index; DM, diabetes mellitus; HTN, hypertension. Multilevel Versus Isolated Tibial Interventions for Critical Limb IschemiaFernandez N, Marone L, Rhee R, Leers S, Makaroun MS, Chaer R Objectives: Endovascular interventio...

number of surgeries on patients age 80ϩ with CI has increased, rate per capita decreased by 14%, compared to a 20% decline in other age groups. The incidence of significant comorbidities has substantially increased; for claudicants: diabetes by 19%, HTP 30%, COPD 40%, CAD 21% and renal 230%; for patients with CI: HTP, COPD, and CAD incidence was higher (23%, 32%, 8% respectively) but diabetics decreased by 6%. Cardiac, respiratory and infection complications after amputation have increased by 29%, 28% and 10%. For LER, respiratory complications increased 9% but cardiac and infection complications actually decreased (8 and 27%) Similar trends were observed for patients with combined LER and amputation. Length of stay (LOS) declined significantly in all groups with an overall decrease of 30% (pϽ.05).Conclusion: Despite the fact that patients, whether treated for claudication or CI, are sicker, older and have more complications, the rate of major amputations and LOS has significantly decreased due presumably to widespread and successful use of endo LER and/or to earlier interventions driven by the safety of endo LER.Purpose: To introduce an algorithm which has been successful in minimizing complications related to the use of percutaneous closure devices.