title: Endovascular treatment for symptomatic stent failures in long-segment chronic total occlusion of femoropopliteal arteries.
abstract: OBJECTIVE
  The objective of this study was to evaluate the outcomes of the secondary endovascular treatment (SEVT) for symptomatic recurrences in long-segment chronic total occlusion (CTO) of femoropopliteal arteries (FPAs) and to investigate the factors affecting the outcomes.
  
  
  METHODS
  Data of patients undergoing FPA stent implantation for primary, long-segment (>10 cm) CTO lesions and receiving endovascular intervention for symptomatic recurrences more than once in our institution from July 1, 2008, to September 1, 2012, were reviewed. Follow-up results referring to SEVT procedures were analyzed, including primary patency, limb salvage (LS) rate, technical success rate, and prevalence of procedure-related complications. Primary patency and LS were analyzed with Kaplan-Meier curves. Univariate and multivariable analyses were performed to identify factors associated with recurrent restenosis with a Cox proportional hazards model.
  
  
  RESULTS
  Ninety-one patients (mean age, 75.1 years) were included. The indications for SEVT were claudication (38.5%) and critical limb ischemia (61.5%). Preprocedural ankle-brachial index was 0.37 ± 0.16. The median time between initial endovascular treatment and SEVT was 6.5 months (range, 1.0-24.4 months). The arteries in 63 limbs were totally occluded. Fractures were found in 30 (18.8%) of the initially placed stents. Successful recanalization was achieved in 82 limbs (90.1%). The mean postprocedural ankle-brachial index was 0.84 ± 0.15 in those limbs that were successfully recanalized. The complication rate was 9.9%. One patient died of cerebral hemorrhage during catheter-directed thrombolysis. Other complications included the development of a groin hematoma (n = 5), distal embolization (n = 1), formation of a femoral pseudoaneurysm (n = 1), and development of acute heart failure (n = 1). The mean follow-up period was 11.0 ± 5.6 months. The cumulative primary patency rate after SEVT was 66.9% and 52.0% at 12 and 24 months. The LS rate since SEVT was 91.2% and 81.1% at 12 and 24 months. The multivariate analysis showed that stent fracture and stent overlap were independent predictors of recurrent restenosis (hazard ratio, 3.07; 95% confidence interval, 1.40-6.74; P = .005; hazard ratio, 4.75; 95% confidence interval, 1.77-12.75; P = .002).
  
  
  CONCLUSIONS
  Endovascular treatment is feasible for FPA stent failure in long-segment CTO. However, SEVT does not achieve durable patency. Stent fracture and overlap are related to recurrent restenosis.
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China.
authors.forename: Xinrui
authors.initials: X
authors.lastname: Yang
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China. Electronic address: luxinwu@aliyun.com.
authors.forename: Xinwu
authors.initials: X
authors.lastname: Lu
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China.
authors.forename: Weimin
authors.initials: W
authors.lastname: Li
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China.
authors.forename: Ying
authors.initials: Y
authors.lastname: Huang
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China.
authors.forename: Xintian
authors.initials: X
authors.lastname: Huang
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China.
authors.forename: Min
authors.initials: M
authors.lastname: Lu
authors.affiliation: Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, School of Medicine, and Vascular Center of Shanghai JiaoTong University, Shanghai, China.
authors.forename: Mi'er
authors.initials: M
authors.lastname: Jiang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D055109:Ankle Brachial Index; D002908:Chronic Disease; D003251:Constriction, Pathologic; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011859:Radiography; D012008:Recurrence; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency