Division of Vascular Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
Division of Vascular Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
J Vasc Surg. 2018 Sep;68(3):807-810. doi: 10.1016/j.jvs.2018.01.030.
The optimal catheter-directed therapy for femoropopliteal in-stent restenosis (ISR) remains controversial with limited durability. The natural history of untreated ISR is not well characterized. We evaluated the midterm outcomes of patients with asymptomatic isolated femoropopliteal ISR who were observed under a surveillance program.
Patients treated with isolated femoropopliteal stents from January 2009 to December 2013 were retrospectively investigated for the development of ISR. ISR was classified on the basis of duplex ultrasound criteria, with >50% defined as peak systolic velocity (PSV) twice that of the normal vessel and >75% as PSV >400 cm/s or four times the normal PSV. Asymptomatic patients with ISR of >50% were tracked for progression to high-grade (>75%) stenosis, occlusion, need for reintervention, and amputation.
Asymptomatic ISR of >50% was identified in 62 (15.3%) of 402 patients with isolated femoropopliteal stents. The mean time for development of ISR was 22.1 (±20.1) months. The mean age was 72 (±9.7) years, and 34 (55.7%) patients were female. Thirty-one (50%) patients were diabetic, 18 (29.1%) were smokers, and 8 (12.9%) had chronic kidney disease. Indications for treatment were claudication in 49 (79.0%), tissue loss in 9 (14.5%), and rest pain in 4 (6.4%) patients. TransAtlantic Inter-Society Consensus (TASC) A lesions were treated in 13 (21%) patients, TASC B lesions in 24 (38.7%), and TASC C lesions in 25 (40.3%). Three-vessel runoff was identified in 25 (40.3%) patients, two-vessel runoff in 18 (29.0%), and one-vessel runoff in 19 (30.6%). Under surveillance, ISR of >50% progressed to >75% or occlusion in 20 (32.3%) patients. The mean time to progression was 17.4 months, and the mean overall follow-up was 33.1 months. Reintervention was required in 22 (35.0%) patients, with an average of 1.95 (range, 1-4) interventions per patient. Reintervention was undertaken in 19 (86%) patients for claudication and in 3 (18%) patients for critical limb ischemia. One patient required an amputation despite previous reintervention for progression. Progression to >75% stenosis was predictive of need for reintervention (P = .004).
Under a surveillance program, asymptomatic patients with femoropopliteal ISR of >50% may be observed with a low risk of limb loss. Given the slow rate of progression and the poor durability of reintervention, surveillance with delayed intervention may be warranted.
股腘段支架内再狭窄（ISR）的最佳导管定向治疗仍存在争议，且其耐久性有限。未经治疗的 ISR 的自然病程尚不清楚。我们评估了接受孤立股腘支架治疗的患者在监测计划下出现无症状孤立股腘段 ISR 的中期结果。
回顾性调查了 2009 年 1 月至 2013 年 12 月接受孤立股腘支架治疗的患者发生 ISR 的情况。根据双功能超声标准对 ISR 进行分类，以峰值收缩速度（PSV）超过正常血管的 2 倍（定义为 >50%）和 PSV>400cm/s 或超过正常 PSV 的 4 倍（定义为>75%）为标准。对无症状 ISR>50%的患者进行跟踪，以观察进展为重度（>75%）狭窄、闭塞、需要再次干预和截肢的情况。
402 例孤立股腘支架患者中发现无症状 ISR>50%的患者有 62 例（15.3%）。ISR 的平均发病时间为 22.1（±20.1）个月。患者平均年龄为 72（±9.7）岁，34 例（55.7%）为女性。31 例（50%）为糖尿病患者，18 例（29.1%）为吸烟者，8 例（12.9%）为慢性肾脏病患者。治疗的适应证为跛行 49 例（79.0%）、组织缺失 9 例（14.5%）和静息痛 4 例（6.4%）。TASC A 病变患者 13 例（21%），TASC B 病变患者 24 例（38.7%），TASC C 病变患者 25 例（40.3%）。三血管流出道患者 25 例（40.3%），双血管流出道患者 18 例（29.0%），单血管流出道患者 19 例（30.6%）。20 例（32.3%）无症状 ISR>50%进展为>75%或闭塞。平均进展时间为 17.4 个月，平均总随访时间为 33.1 个月。22 例（35.0%）患者需要再次干预，平均每位患者 1.95（范围，1-4）次干预。19 例（86%）患者因跛行而再次干预，3 例（18%）患者因严重肢体缺血而再次干预。尽管有先前的再介入治疗，但仍有 1 例患者因进展而需要截肢。进展为>75%狭窄是需要再次干预的预测因素（P=0.004）。
在监测计划下，无症状 ISR>50%的股腘段患者可观察到肢体丧失的风险较低。鉴于进展缓慢和再介入治疗的耐久性差，可能需要延迟干预的监测。
