title: Outcomes of reintervention for recurrent disease after percutaneous iliac angioplasty and stenting.
abstract: OBJECTIVE
  To evaluate the outcomes of percutaneous therapy for symptomatic >50% angiographic restenosis after iliac intervention versus outcomes of the primary procedure.
  
  
  METHODS
  A retrospective analysis was performed of 937 patients (733 men; mean age 65 years) who underwent 1532 endovascular interventions for symptomatic atherosclerotic iliac artery obstruction and were followed by duplex ultrasound between 1990 and 2009. In this population, 374 vessels restenosed (>50% on duplex); about half (176, 47%) were associated with recurrent symptoms. In 102 symptomatic patients (58 men; mean age 61 years), 147 limbs (84%) had repeat angioplasty/stenting and were compared to the primary treatment group.
  
  
  RESULTS
  Thirty-day mortality was <1% in both primary and recurrent treatment groups, but morbidity was doubled in the reintervention group (4% versus 8%; p<0.05). While the incidence of systemic complications was low in both groups, the drivers for increased morbidity in the recurrent group were lesion-specific and access-site complications. In the 937-patient cohort, the rate of >50% restenosis on duplex was 15%±1% at 5 years. Gender (p = 0.03), diabetes (p = 0.04), metabolic syndrome (p = 0.001), symptoms (p<0.001), angioplasty alone (p = 0.04), concurrent superficial femoral artery occlusion (p = 0.02), and increasing complexity of the iliac intervention (p = 0.02) were associated with primary failure. Patency rates at 10 years for primary versus recurrent treatment were 73%±2% versus 66±8% for primary patency (p = 0.004); 88%±2% versus 74%±7% for assisted primary patency (p = 0.005); and 90%±2% versus 78%±10% for secondary patency (p = 0.002). Female gender (p = 0.01), continued smoking (p = 0.02), eGFR <60 mL/min/1.73m(2) (p = 0.03), lesion length (p = 0.02), lesion calcification (p = 0.005), and TASC II category (p = 0.04) negatively influenced patency of recurrent lesions. Sustained clinical success (absence of recurrent symptoms) was 74%±2% in the primary group and 66%±8% in the restenotic group (p = 0.014) at 10 years. Symptoms (p = 0.04), female gender (p = 0.002), hypertension (p = 0.004), eGFR <60 mL/min/1.73 m(2) (p = 0.02), external iliac artery disease (p = 0.02), lesion length (p = 0.02), and poor immediate clinical outcome (p<0.001) negatively influenced clinical success of recurrent lesions.
  
  
  CONCLUSIONS
  Percutaneous reintervention for recurrent iliac artery disease has a higher procedure-related morbidity compared to primary intervention. Longer-term outcomes are also poorer than for primary lesions. The patients who present with restenosis are more likely to be younger and of female gender than patients presenting for primary intervention. Both patency and functional outcomes after reintervention are worse than those for primary interventions.
authors.affiliation: Methodist DeBakey Heart and Vascular Center, Department of Cardiovascular Surgery, The Methodist Hospital, 6550 Fannin, Houston, TX 77030, USA. MDavies@tmhs.org
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
authors.forename: Jean
authors.initials: J
authors.lastname: Bismuth
authors.forename: Wael E
authors.initials: WE
authors.lastname: Saad
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Naoum
authors.forename: Eric K
authors.initials: EK
authors.lastname: Peden
authors.forename: Alan B
authors.initials: AB
authors.lastname: Lumsden
mesh_terms: D000367:Age Factors; D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D003251:Constriction, Pathologic; D005260:Female; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D016016:Proportional Hazards Models; D011859:Radiography; D012008:Recurrence; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D015607:Stents; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency