Favorable 15-Year Patency Seen With IVUS-Guided Stenting in Iliac Artery Lesions

Real-world data from a single Japanese center show that IVUS-guided stenting is associated with reasonable 15-year patency rates in older patients treated for iliac disease. Low overall survival rates, however, hint that stenting is not the only solution for these patients.

Describing the long-term patency as “favorable” regardless of lesion morphology, the researchers, led by Hisao Kumakura, MD, PhD, of the Kitakanto Cardiovascular Hospital in Shibukawa, also note: “Life expectancy after [endovascular treatment] was poor, but stenting is feasible for patients with PAD.

In all, 455 patients (mean age 72 years; 88% men) were stented under IVUS guidance in 507 lesions. Some cases with severely calcified lesions involved “minimal” predilatation, whereas most were done using direct stenting. Procedures were successful in 97.2%.

The retrospective cohort study assessed outcomes at 5, 10, 15 years. MACE included all-cause death, MI, cardiac revascularization, and stroke, whereas major adverse cardiovascular and limb events (MACLE) consisted of MACE plus any repeat revascularization for limb events and major amputation.

Neither patency nor the likelihood of survival, MACE, or MACLE differed by TransAtlantic Inter-Society Consensus (TASC) II classification (69% of patients had type A/B and 31% had type C/D lesions).

On Cox multivariate analysis, predictors of primary patency were post-procedural lumen area, in-stent thrombosis, antiplatelet discontinuation, and calcified lesions. Predictors of survival were age, critical limb ischemia, diabetes, hemodialysis, and D-dimer level (P < .05 for all).

Half of all deaths stemmed from cardiovascular disease, with another quarter due to malignancy and 20% to pneumonia. Notably, the “15-year survival rate was more favorable than the reported life expectancy in patients with PAD,” Kumakura and colleagues point out.

More Can Be Done to Help Patients

While the results for primary patency are “acceptable,” even more interesting is that there is no variation in this outcome among TASC categories, say Mehdi H Shishehbor, DO, MPH, PhD, and Shikhar Agarwal, MD, MPH, both of the Cleveland Clinic (Cleveland, OH). “Therefore, despite high complexity at the time of intervention, successful therapy, regardless of [baseline] severity, yielded similar patency,” they write, acknowledging that the study may be underpowered in later years when fewer patients were at risk.

Other lessons, the editorialists add, are the “clinical utility of adjunctive imaging when performing lower extremity endovascular interventions” and the “continuous need for more aggressive risk factor and lifestyle modification in these patients” after intervention.

“Although the impact of aggressive risk factor modification on long-term patency is controversial, there is little doubt that lipid lowering, smoking cessation, and antiplatelet therapy with reduce major adverse cardiovascular events in this population,” they comment.

Concerns have been raised recently about the “appropriateness of PAD interventions in several large clinical practices, leading to higher scrutiny of these procedures,” Shishehbor and Agarwal note, advising that adjunctive imaging such as IVUS or fractional flow reserve holds the potential to “make peripheral interventions more accurate, safer, and better.”

Sources: 
1. Kumakura H, Kanai H, Araki Y, et al. Fifteen-year patency and life expectancy after primary stenting guided by intravascular ultrasound for iliac artery lesions in peripheral arterial disease. J Am Coll Cardiol Intv. 2015;Epub ahead of print.
2. Shishehbor MH, Agarwal S. Imaging guided lower extremity endovascular interventions: is now the time [editorial]? J Am Coll Cardiol Intv. 2015;Epub ahead of print.

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