Impact of IVUS-Derived Vessel Size on Midterm Outcomes After Stent Implantation in Femoropopliteal Lesions

Abstract

Purpose: To identify intravascular ultrasound (IVUS) findings that predict midterm stent patency in femoropopliteal (FP) lesions. Materials and Methods: A retrospective analysis was undertaken of 335 de novo FP lesions in 274 consecutive patients (mean age 72.4±8.2 years; 210 men) who had IVUS assessment before and after successful stent implantation. The mean lesion length was 13.2±9.8 cm. The primary outcome was primary patency at 24 months, defined as freedom from major adverse limb event (MALE) and in-stent restenosis (ISR). MALE was defined as major amputation or any target lesion revascularization (TLR). ISR was defined by a peak systolic velocity ratio >2.4 by duplex ultrasonography. Logistic regression analyses were performed to identify independent predictors of stent patency at 24 months; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Receiver operator characteristic (ROC) curve analysis was performed to determine the optimal threshold for prediction of stent patency at 24 months. Results: Over the 24-month follow-up, 18 (7%) patients died and 43 (15%) of 286 lesions were responsible for MALE (42 TLRs and 1 major amputation). Primary patency was estimated at 82.5% (95% CI 78.1% to 86.9%) at 12 months and 73.2% (95% CI 67.9% to 78.5%) at 24 months. Multivariable analysis revealed that longer lesion length (OR 0.89, 95% CI 0.82 to 0.97, p<0.01) was an independent predictor of declining patency, while cilostazol use (OR 3.45, 95% CI 1.10 to 10.78, p=0.03) and increasing distal reference external elastic membrane (EEM) area (OR 1.18, 95% CI 1.02 to 1.37, p=0.03) were associated with midterm stent patency. ROC curve analysis identified a distal reference EEM area of 29.0 mm2 as the optimal cut-point for prediction of 24-month stent patency (area under the ROC curve 0.764). Kaplan-Meier estimates of 24-month primary patency were 83.7% (95% CI 78.3% to 89.2%) in lesions with a distal EEM area >29.0 mm2 vs 53.1% (95% CI 42.9% to 63.3%) in those with a distal EEM area ≤29.0 mm2 (p<0.001). Conclusion: In FP lesions with a larger distal vessel area estimated with IVUS, stent implantation can be considered as a reasonable treatment option, with the likelihood of acceptable midterm results.

Outcomes of Dissection Angles as Predictor of Restenosis after Drug-Coated Balloon Treatment

“…The primary patency and freedom from restenosis rates following EVT were analyzed using the Kaplan-Meier method. The association between IVUS-evaluated dissection and the risk of restenosis was investigated using the Cox proportional hazards regression model with a phy have been identified using IVUS studies following implantation of bare nitinol stents and drug-eluting stents 9,10) . The superiority of IVUS over angiography in detecting dissection has been previously reported 11) .…”

“…Female sex, diabetes, dialysis, critical limb ischemia, long lesion length, and poor run-off are known predictors of restenosis following self-expandable nitinol stenting for femoropopliteal lesions 20) . Another study used IVUS and reported that long lesion length, not taking cilostazol, and a small reference vessel diameter were associated with restenosis following selfexpandable nitinol stenting 9) . The Zephyr registry revealed that long lesion length, small distal reference vessel area, and small minimum stent area were predictors of restenosis following EVT with a drug-eluting stent 10) .…”

Intravascular ultrasound-based decision tree model for the optimal endovascular treatment strategy selection of femoropopliteal artery disease—results from the ONION Study-

“…Iida et al reported that IVUS use in femoropopliteal stenting appears to be associated not only with the procedure's success but also with a higher primary patency rate 56 . Previous reports were based on the IVUS evaluation methodology, such as vessel size, lumen area, wire route, calcification, lesion morphology, and vessel dissection after balloon angioplasty (Iida et al 2021;Kozuki et al 2021;Kurata et al 2020;Miki et al 2020a;Miki et al 2020b). Some parameters that influenced patency outcomes were shown, including calcification, vessel dissection, and post stent area and position (Iida et al 2015;Mori et al 2017;Norgren et al 2007).…”

Comparison of Angiographic Dissection Classification Systems in the Femoropopliteal Arteries Using IVUS Validation and Reliability Testing

“…The lack of difference in IVUS parameters between grades of dissection and the weak to moderate reliability revealed in the current study suggest that the current classification systems may be inadequate for reliably differentiating dissection severity. Recent studies have demonstrated that several IVUS parameters are independent predictors of clinical outcome of stenting in the femoropopliteal arteries 43,44 and IVUS may potentially be of similar use for identifying clinically important dissections. Further research in the form of adequately powered validation studies, including agreement testing, are required to establish if there are IVUS dissection parameters that can reliably predict poor clinical outcome.…”