Browsing by Subject "Endovascular Procedures"
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Item Prescription Trends During Lower Extremity Peripheral Artery Endovascular Interventions: Insights from the XPLAD Registry(2016-01-19) Kocak, Denizen; Planchard, Kyle; Das, Thomas M.; Mohammad, Atif; Armstrong, Ehrin J.; Shammas, Nicholas W.; Gigliotti, Osvaldo; Klein, Andrew; Brilakis, Emmanouil S.; Banerjee, SubhashDespite peripheral arterial intervention procedures (PAI) becoming the most utilized treatment in the symptomatic peripheral artery disease patient population, adherence to guideline management therapy (GMT) has not been well described. PAIs (n=1532) registered in the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) from 13 U.S. centers between 2005 and 2013 were evaluated for adherence to GMT at discharge post-PAI, which is comprised of antiplatelet therapy (APT), lipid-lowering therapy (LLT), and renin-angiotensin pathway inhibitors (RAI) including angiotensin receptor blockers (ARB) and angiotensin converting enzyme inhibitors (ACEI). In addition, a subset of patients (n=365) were tracked over a three year period and adherence to GMT and adverse events were analyzed in SAS using a Cox proportional hazard ratio adjusted for baseline characteristics. Analysis of 1532 PAI in the study periods (n=55 in 2005-2007, n=314 in 2008-2010, and n=1,163 in 2011-2013) demonstrates an exponential rise in PAIs, consistent with national U.S. trends. This rise in PAI was not accompanied with an equally robust adherence to GMT. Excluding the limited number of patients enrolled from 2005-2007, the period between 2008 and 2013 demonstrates suboptimal adherence to GMT across all therapy groups. APT prescriptions fell from 90% to 77%, between 2008-2010 and 2011-2013 (p<0.001), and dual-APT prescriptions remained consistently low during the periods (53% vs. 48%). Consistent with the overall trend of falling adherence to GMT between 2008-2010 and 2011-2013 (55% vs. 42%; p<0.001), individual prescriptions of LLT and RAI were also significantly lower (83% vs. 66% for LLT; p<0.001 and 62% vs. 49% for RAI; p<0.001), respectively. Analysis of prescription therapy course in a subset (n=365) patients over time showed a statistically significant drops in APT (95.9% vs. 83.8%; p<0.0001) and dual-APT (74.8% vs. 31.1%; p<0.0001) therapy at one year post-PAI and a significant decrease in dual-APT therapy between one and two years post-PAI (31.1% vs. 18.9%; p=.001) (Figure 3). Cox proportional analysis in these patients showed that APT and dual-APT prescription both significantly decreased the risk of Major Adverse Cardiovascular Events (MACE) but had little effect on Major Adverse Limb Events (MALE) (Figures 1 & 2).Item Technical Success Rates of Endovascular Treatment of Femoropopliteal Chronic Total Occlusions(2016-01-19) Das, Thomas M.; Kocak, Denizen; Planchard, Kyle; Mohammad, Atif; Brilakis, Emmanouil S.; Banerjee, SubhashBACKGROUND: There is limited data on immediate and longerterm outcomes of crossing femoropopliteal (FP) chronic total occlusions (CTO). METHODS: Consecutive patients between January 2006 and March 2015 undergoing endovascular revascularization for symptomatic peripheral artery disease with FP CTO were analyzed as part of the Excellence in Peripheral Artery Disease (XLPAD) registry. Procedural success was defined as restoration of flow through the lesion with ≤30% residual stenosis. Procedural failures included technical failures (defined as failure to cross the CTO or failure to renter the true lumen from the subintimal space) and treatment failures (defined as >30% residual stenosis after successful crossing). One year outcomes were analyzed. RESULTS: A total of 1100 CTO lesions from 948 patients were included in the analysis. Procedural success was achieved in 989 (89.9%) CTO, while procedural failure occurred in 111 (10.1%). Treatment failures comprised 23 (2.1%) and technical failures 88 (8.0%), with 59 (5.4%) intraluminal failures to cross and 29 (2.6%) failures to re-enter from subintimal space. There were significantly more surgical revascularizations following failed procedures compared to successful (13.5% vs. 3.9%;p<0.01), although with a lower need for repeat revascularization procedures (6.3% vs. 20.5%; p<0.01). Need for amputations were similar for patients with failed or successful procedures (5.4% vs. 3.3%; p=.26). Multivariable analysis showed lesion calcification to be an independent predictor of procedural success (p=.03) and multilevel FP disease an independent predictor of procedural failure (p=.03). CONCLUSION: Patients experiencing procedural failures undergo significantly higher rates of surgical revascularization, albeit with lower need for repeat revascularization. Multilevel disease and lesion calcification should both be considered when planning procedural strategy in crossing FP CTO. Further analysis will explore a link between procedural success in calcified lesions and the use of dedicated CTO crossing devices.