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Purpose: The underlying difference between intermittent claudication (IC) and critical limb-threatening ischemia (CLTI) still remains unclear. This prospective multicenter observational study aimed to clarify differences in clinical features and prognostic outcomes between IC and CLTI, and prognostic factors in patients undergoing endovascular therapy (EVT)., Materials and Methods: A total of 692 patients with 808 limbs were enrolled from 20 institutions in Japan. The primary measurements were the 3-year rates of major adverse cardiovascular event (MACE) and reintervention., Results: Among patients, 79.0% had IC and 21.0% had CLTI. Patients with CLTI were more frequently women and more likely to have impaired functional status, undernutrition, comorbidities, hypercoagulation, hyperinflammation, distal artery disease, short single antiplatelet and long anticoagulation therapies, and late cilostazol than patients with IC. Aortoiliac and femoropopliteal diseases were dominant in patients with IC and infrapopliteal disease was dominant in patients with CLTI. Patients with CLTI underwent less frequently aortoiliac intervention and more frequently infrapopliteal intervention than patients with IC. Longitudinal change of ankle-brachial index (ABI) exhibited different patterns between IC and CLTI (pinteraction=0.002), but ABI improved after EVT both in IC and in CLTI (p<0.001), which was sustained over time. Dorsal and plantar skin perfusion pressure in CLTI showed a similar improvement pattern (pinteraction=0.181). Distribution of Rutherford category improved both in IC and in CLTI (each p<0.001). Three-year MACE rates were 20.4% and 42.3% and 3-year reintervention rates were 22.1% and 46.8% for patients with IC and CLTI, respectively (log-rank p<0.001). Elevated D-dimer (p=0.001), age (p=0.043), impaired functional status (p=0.018), and end-stage renal disease (p=0.019) were independently associated with MACE. After considering competing risks of death and major amputation for reintervention, elevated erythrocyte sedimentation rate (p=0.003) and infrainguinal intervention (p=0.002) were independently associated with reintervention. Patients with CLTI merely showed borderline significance for MACE (adjusted hazard ratio 1.700, 95% confidence interval 0.950-3.042, p=0.074) and reintervention (adjusted hazard ratio 1.976, 95% confidence interval 0.999-3.909, p=0.05)., Conclusions: The CLTI is characterized not only by more systemic comorbidities and distal disease but also by more inflammatory coagulation disorder compared with IC. Also, CLTI has approximately twice MACE and reintervention rates than IC, and the underlying inflammatory coagulation disorder per se is associated with these outcomes., Clinical Impact: The underlying difference between intermittent claudication (IC) and critical limb-threatening ischemia (CLTI) still remains unclear. This prospective multicenter observational study, JPASSION study found that CLTI was characterized not only by more systemic comorbidities and distal disease but also by more inflammatory coagulation disorder compared to IC. Also, CLTI had approximately twice major adverse cardiovascular event (MACE) and reintervention rates than IC. Intriguingly, the underlying inflammatory coagulation disorder per se was independently associated with MACE and reintervention. Further studies to clarify the role of anticoagulation and anti-inflammatory therapies will contribute to the development of post-interventional therapeutics in the context of peripheral artery disease., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: O.K. has received a research grant and consulting fees from Terumo and has received lecture fees from Medicon, Otsuka Pharmaceutical, and Kowa Pharmaceutical. H.O. has received lecture fees from Bayer Pharmaceutical, Bristol-Meyers Squibb, Eisai, Novartis Pharma, Pfizer, Towa Pharmaceutical, and Toa Eiyo. S.Y. has received remuneration for lecture from Bristol-Meyers, Bayer, and Daiichi-Sankyo; has received trust research/joint research funds from Takeda, NEC, Daiichi-Sankyo, Bayer, and Abbott; and is affiliated with endowed department sponsored by Abbott, Terumo, Nihon-Kohden, Medtronic, Japan Lifeline, Otsuka, Ono, Boehringer Ingelheim, Takeda, Kowa, Zeon, Shionogi, Nippon-Shinyaku, Mochida, and Tesco. The remaining authors have nothing to disclose.

Background: Juxtarenal aortic occlusion (JRAO), in which the occlusion of the aorta extends to just below the renal artery, is often treated by bypass surgery because of concerns about the risk of procedural failure and fatal embolization to abdominal organs when treated with endovascular treatment (EVT). This study assessed the outcome of EVT for JRAO compared with aorto-biiliac /aorto-bifemoral (AOB) or axillo-bifemoral (AXB) bypass., Methods: A retrospective review of an international database created by 30 centers in Asia (CHronic Abdominal Aortic Occlusion, ASian Multicenter registry) was performed for patients who underwent revascularization for chronic total occlusion of the infrarenal aorta from 2007 to 2017. Of the 436 patients, 130 with JRAO (Forty-seven AOBs, 32 AXBs, and 51 EVTs) from 25 institutions were included in this study., Results: Patients were significantly older in the AXB and EVT groups and more malnourished in the EVT group than the AOB group. EVT was attempted but failed in 1 patient. Seven patients (1 [2.1%] in the AOB group, 1 [3.1%] in the AXB group, and 5 [9.8%] in the EVT group) died during hospitalization, but most of the causes in the EVT group were not related to the revascularization procedure. No visceral embolism was observed, which had been concerned, even though protection was performed only in 2 cases of the EVT group. At the latest follow-up (median duration 3.0 years), the ankle-brachial pressure index was significantly higher in the order of AOB, EVT, and AXB. At 4 years, the estimated primary and secondary patency rates of the AOB group (87.5% and 90.3%, respectively) were significantly higher than the AXB group (66.7% and 68.6%, respectively)., Conclusions: AOB remains the gold standard and should be the first choice for acceptable risk patients. For frail patients, EVT is a good option and likely preferable as a first-line treatment compared to AXB., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA)., Materials and Methods: In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term., Results: Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240-345] minutes vs EVT; 159 [100-205] minutes, p<0.001) and length of hospital stay (17 [12-23] days vs 5 [4-13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096)., Conclusion: Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Naoki Fujimura receives consulting fees from Cook Medical, Endologix, Medtronic, and W.L. Gore. Terutoshi Yamaoka receives a consulting fee from the Japan Lifeline. Osami Kawarada receives a research grant and consulting fee from Terumo and remuneration for lectures from Medicon, Otsuka, and Kowa. All other authors declare no conflicts of interest.

Background: Mechanism of femoropopliteal in-stent restenosis has been underappreciated., Aim: The aim of this animal study was to elucidate vascular response after femoropopliteal bare nitinol self-expanding stents (SESs) implantation., Methods: Misago, Smart Flex, or Innova stent was randomly implanted in 36 swine femoropopliteal arteries. At week 4, quantitative vessel analysis (QVA) was performed on 36 legs, of which 18 underwent histological evaluation after angiography. The remaining 18 legs underwent QVA and histological evaluation at week 13., Results: Fibrin deposition was excessive at week 4. Internal elastic lamina (IEL) progressively enlarged over time, and vessel injury developed from mild level at week 4 to moderate level at week 13. Vessel inflammatory reaction was mild to moderate at week 4, and was moderate to severe at week 13. Increased fibrin deposition was an early-acting, IEL enlargement and increased vessel inflammation were long-acting, and increased vessel injury and giant cells infiltration were late-acting contributors to neointimal hyperplasia (NIH). Stent type altered time-dependent process of vessel injury, vessel inflammation, eosinophils and giant cells infiltration. Misago had less fibrin deposition and vessel enlargement, and less progressive vessel injury, vessel inflammation, and eosinophils and giant cells infiltration. Net lumen as assessed by percent diameter stenosis or minimum lumen diameter was preserved with Misago, but was not preserved with the other stents., Conclusions: In the context of bare nitinol SES platform with less progressive mechanical stress and inflammatory reaction, the advantage of less NIH outweighed the disadvantage of less vessel enlargement, leading to net lumen preservation., (© 2022. The Author(s).)

Calcified lesions still remain a technical challenge even in the treatment of infrainguinal artery disease. The aim of this retrospective, multicenter observational study was to investigate interventional outcomes of a high-speed rotational atherectomy device (Rotablator™) and to compare clinical outcomes in patients who underwent Rotablator and those who did not even after failed balloon angioplasty because of underlying calcified lesions. This study enrolled patients who underwent Rotablator (Rota group) and those who did not (Non-rota group) between January 2010 and 2014 December at 12 hospitals. A total of 67 limbs and 68 lesions in 65 patients were included (Rota group; 54 limbs and 55 lesions in 52 patients, Non-rota group; 13 limbs and 13 lesions in 13 patients). In the Rota group, a technical success rate was 94.5% with a complication rate of 1.8%, and all lesions underwent subsequent postdilatation following the adjunctive use of Rotablator, and approximately half of above-the-knee lesions underwent stent implantation. The Rota group had a significantly lower clinically driven reintervention rate at 12 months than the Non-rota group (26.5% vs. 58.3%, respectively, p = 0.046). In addition, Rota group showed a trend toward a higher amputation-free survival compared to the Non-rota group at 1 month (Rota; 98.0% vs. Non-rota; 84.6%, respectively, p = 0.10). Rotablator was used as an adjunctive device with a high technical success and a low complication rates, and Patients who underwent Rotablator yielded a significantly lower clinically driven reintervention rate at 12 months compared to those who did not even after failed balloon angioplasty.

Background: Endovascular treatment with balloon angioplasty plays a major role in revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI). However, with severely calcified lesions, achieving optimal revascularization with balloon angioplasty alone is difficult. Therefore, we are evaluating the safety and effectiveness of the Rotablator atherectomy system as an adjunctive device in the treatment of severely calcified lesions in BTK arteries in the RESCUE-BTK trial, a multicenter, single-arm, open-label, exploratory investigator-initiated clinical study of medical devices. In this paper we describe the design of the trial. Methods and Results: Seventeen patients with CLI in whom balloon angioplasty has failed are enrolled in the study. The primary endpoint is the procedural success rate of balloon angioplasty after rotational atherectomy. Success is defined as the fulfillment of 3 requirements upon assessment by the core laboratory: (1) final residual diameter stenosis <50%; (2) the absence of a delay in flow or vessel perforation in the target artery, or both; and (3) brisk antegrade flow to the foot. Key secondary endpoints are the number of complications associated with the trial procedures and the limb salvage rate. Participants are followed-up for 6 months after the trial procedures. Conclusions: The RESCUE-BTK trial will clarify the safety and effectiveness of the adjunctive use of the Rotablator system in severely calcified lesions of BTK arteries in patients with CLI., Competing Interests: The Rotablator atherectomy systems are being provided by Boston Scientific based on the policy of Japanese Good Clinical Practice. S.I. reports receiving a grant from the Japan Society for the Promotion of Science outside the submitted work. O.K. reports receiving honoraria for lectures and advisory board fees from Boston Scientific outside the submitted work. M.A. reports receiving personal fees from Daiichi Sankyo and Otsuka outside the submitted work. M.K. reports receiving grants and personal fees from Takeda, Astellas, Sanofi, Pfizer, Ono, Novartis, Mitsubishi Tanabe, Kyowa Hakko Kirin, Abbott, and Otsuka, grants from the Japanese government, Japan Heart Foundation, Japan Cardiovascular Research Foundation, Calpis, and Nihon Kohden, and personal fees from Daiichi-Sankyo, Bayer, Boehringer, Kowa, Sumitomo Dainippon, Sawai, MSD, Shionogi, AstraZeneca, Asahi Kasei Medical, Novo Nordisk, Fujifilm RI, and Japan Medical Data outside the submitted work. S.Y. reports receiving grant support from Takeda and Abbott and lecture fees from Daiichi Sankyo and Bristol-Myers Squibb outside the submitted work. S.I., S.Y. are members of Circulation Reports’ Editorial Team. The remaining authors report no conflicts of interest., (Copyright © 2020, THE JAPANESE CIRCULATION SOCIETY.)

With technological improvements in the endovascular armamentarium, there have been tremendous advances in catheter-based femoropopliteal artery intervention during the last decade. However, standardization of the methodology for assessing outcomes has been underappreciated, and unvalidated peak systolic velocity ratios (PSVRs) of 2.0, 2.4, and 2.5 on duplex ultrasonography have been arbitrarily but routinely used for assessing restenosis. Quantitative vessel analysis (QVA) is a widely accepted method to identify restenosis in a broad spectrum of cardiovascular interventions, and PSVR needs to be validated by QVA. This multidisciplinary review is intended to disseminate the importance of QVA and a validated PSVR based on QVA for binary restenosis in contemporary femoropopliteal intervention.

Aims: The aim of this study was to evaluate the clinical outcomes of endovascular treatment (EVT) for chronic aortic occlusion (CAO) using multicentre registry data., Methods and Results: From April 2003 to December 2015, data on 73 consecutive patients (55 men and 18 women; aged 70.7±12.2 years) who underwent EVT for CAO were collected retrospectively from 15 centres in Japan. The primary endpoint was the primary patency at 12 months after EVT. Secondary endpoints were procedural success and periprocedural complication rates. We analysed 67 patients who underwent complete endovascular revascularisation after 2007. Initial procedural success was achieved in 63 cases (94.0%). Complications occurred in three patients (4.5%) (stroke, n=1; distal embolism, n=1; access-site haematoma requiring blood transfusion, n=1). In patients after successful EVT (n=63), the primary and secondary patency rates at 12 months were 90.7% and 97.7%, respectively. During a mean follow-up period of 17.8 months, restenosis/re-occlusion was observed in eight patients (12.7%)., Conclusions: EVT for CAO could be performed safely with a high procedural success rate. The short-term clinical outcome was acceptable despite lesion complexity., Competing Interests: The authors have no conflicts of interest to declare.

Case presentation: A 59-year-old man with hypertension, dyslipidemia and a current smoking history had presented with bilateral painful finger ulcers (figure 1A). The patient was referred to our hospital for the diagnosis and treatment. On his arrival, his fingers showed the development from ulcer to necrosis during the 3 weeks (figure 1B). Diagnostic angiography at the previous hospital had revealed symmetrical occlusions of the forearm and crural arteries (figure 2). Laboratory blood tests demonstrated an eosinophilia (21 %, 1743 cells/µL) with marked elevation of IgE (4200 mg/dL) as well as inflammatory reaction such as erythrocyte sedimentation rate 84 mm/h and C-reactive protein 0.85 mg/dL. There was no evidence of thrombophilia, and autoantibodies were negative. A skin biopsy from the border of the necrosis demonstrated perivascular considerable infiltration of inflammatory cells including eosinophils (figure 3).Figure 1(A) Initial manifestation at the previous hospital. Note the ulcers in the bilateral fingers. (B) Development to finger necrosis on his admission in our hospital.Figure 2(A) Upper extremity angiography revealed extensive occlusions in the bilateral radial and ulnar arteries (arrow). (B) Lower extremity angiography revealed multiple occlusions in the right anterior tibial artery, the left anterior tibial artery and the left posterior tibial artery (arrow).Figure 3(A) Skin biopsy from the border of the finger necrosis demonstrated nodular inflammatory cell infiltration in dermis and subcutaneous tissue (H&E stain). (B) Magnified histopathological examination of the skin biopsy found eosinophilic infiltration (arrows) in granulomatous inflammation of upper dermis (H&E stain). Immunohistochemistry (inset) showing major basic protein of eosinophils (immunostaining)., Question: What is the most likely diagnosis?Buerger's diseaseEosinophilic vasculitisDrug abuseCholesterol embolisation syndromeParaneoplastic syndrome., Competing Interests: Competing interests: None declared.

Aims: Consensus-derived guidelines recommend renal stenting for patients with atherosclerotic renal artery disease (ARAD) and heart failure (HF). The aim of this prospective multi-centre observational study was to verify our hypothesis that changes in E/e', an echocardiographic correlate of left ventricular (LV) filling pressure, following renal stenting may differ between ARAD patients with and without HF., Methods and Results: This study enrolled de novo ARAD patients undergoing renal stenting at 14 institutions. The primary endpoint was the difference in E/e' change between ARAD patients with and without HF. Clinical and echocardiographic data were prospectively collected at baseline, the day following renal stenting, and 1 month and 6 months afterwards. ARAD patients with HF were defined as patients with New York Heart Association (NYHA) Class 2 and more, or a history of HF hospitalization. A total of 76 patients were included, and 39% were ARAD patients with HF. ARAD patients with HF had significantly lower estimated glomerular filtration rate (P = 0.028) and higher NYHA functional class (P < 0.001) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (P = 0.001) than ARAD patients without HF. Also, ARAD patients with HF had significantly lower LV ejection fraction (P = 0.003) and e'-velocity (P = 0.003) and higher E/e' ratio (P = 0.001), left atrial volume index (LAVI) (P = 0.046), LV end-diastolic volume (LVEDV) (P = 0.001), LV end-systolic volume (LVESV) (P = 0.001), and LV mass index (P = 0.009) than ARAD patients without HF. All procedures were successful. In contrast to blood pressure and renal function, there was a significant interaction in E/e' (P interaction  < 0.001) between time and HF, and ARAD patients with HF showed a significant (P < 0.001) decrease in E/e' albeit those without HF. By the same token, there was a significant interaction in NYHA class (P interaction  < 0.001), MLHFQ score (P interaction  = 0.018), E-velocity (P interaction  = 0.002), LAVI (P interaction  = 0.001), LVEDV (P interaction  = 0.003), and LVESV (P interaction  = 0.001) between time and HF with a significant improvement in all these variables in ARAD patients with HF (NYHA class, P = 0.001; MLHFQ score, P = 0.002; E-velocity, P = 0.005; LAVI, P = 0.001; LVEDV, P = 0.017; and LVESV, P = 0.011)., Conclusions: Change in LV filling pressure after renal stenting differed between ARAD patients with and without HF, with a significant improvement in LV filling pressure in patients with HF-ARAD. These unique findings might support clinical cardiac benefits of renal stenting in ARAD patients with HF., (© 2019 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Objective: To investigate the effects of antithrombotic therapy on target lesion revascularisation (TLR) and major adverse cardiovascular and cerebrovascular events (MACCEs) at 12 months after femoropopliteal intervention with second-generation bare metal nitinol stents., Methods: A total of 277 lesions in 258 limbs of 248 patients with de novo atherosclerosis in the above-the-knee femoropopliteal segment were analysed from the Japan multicentre postmarketing surveillance., Results: At discharge, dual antiplatelet therapy (DAPT) was prescribed in 68.5% and cilostazol in 30.2% of patients. At 12 months of follow-up, prescriptions of DAPT significantly (p=0.0001) decreased to 51.2% and prescription of cilostazol remained unchanged (p=0.592) at 28.0%. Prescription of warfarin also remained unchanged (14.5% at discharge, 13.3% at 12 months, p=0.70). At 12 months, freedoms from TLR and MACCE were 89.4% and 89.7%, respectively. In a multivariate Cox proportional hazards model, neither DAPT nor cilostazol at discharge was associated with both TLR and MACCE at 12 months. However, warfarin at discharge was only independently associated with TLR at 12 months. Kaplan-Meier estimates demonstrated that warfarin at discharge yielded a significantly (p=0.013) lower freedom from TLR at 12 months than no warfarin at discharge. Freedom from TLR at 12 months by the Kaplan-Meier estimates was 77.8% (95% CI 59.0% to 88.8%) in patients with warfarin at discharge and 91.2% (95% CI 86.3% to 94.3%) in those without warfarin at discharge., Conclusions: Clinical benefits of DAPT or cilostazol might be small in terms of TLR and MACCE at 12 months. Anticoagulation with warfarin at discharge might increase TLR at 12 months., Competing Interests: Competing interests: OK reports honorarium of lectures and advisory board fees from Boston Scientific Corporation, honorarium of lectures and research grants from Terumo, and a consultancy fee from Medtronic. MN and KN report consigned research funds from Terumo. TN reports honorarium of lectures from Abbott Vascular, Boston Scientific and Medtronic and consulting fee from Boston Scientific and Century Medical Inc.

Calcified lesions pose a technical challenge even in contemporary endovascular intervention. A 71-year-old man who had been receiving haemodialysis required infrapopliteal revascularisation for the treatment of ischaemic infectious gangrene of the right toes. Baseline angiography suggested that the multiple stenotic lesions in the anterior tibial artery were amenable to endovascular therapy for the purpose of establishing one straight-line flow to the foot. However, even a 1.25×15 mm semi-compliant balloon catheter failed to cross and dilate the focal lesion because of the underlying severe calcification in the mid segment of the anterior tibial artery. We adjunctively used high-speed rotational atherectomy with the ROTABLATOR device (1.5 mm burr) to ablate the focal calcified lesion while paying attention to minimise the ablation length and the ablation time. Subsequent balloon angioplasty with a 2.0×40 mm balloon catheter was successful. The skin perfusion pressure in the right foot increased from 32 to 48 mmHg, suggesting a high probability of wound healing. Pathological examination of the right toe amputated on schedule found non-clinically relevant microembolisation involving a couple of cholesterol crystals (20-30 µm) located in the arterioles and capillaries of the necrotic tissue. As an adjunctive device, the ROTABLATOR could provide a last resort for limb salvage, albeit that microembolisation can occur., Competing Interests: O. Kawarada reports receiving honoraria for lectures and advisory board fees from Boston Scientific Corporation, and honoraria for lectures and research grants from Terumo. The other authors have no conflicts of interest to declare.

The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.

Competing Interests: Competing interests: None declared.

Purpose: To report a percutaneous intravascular cracking with a guidewire tail (PICKING) technique to longitudinally crack the underlying calcification and facilitate the balloon catheter passage for the treatment of severely calcified chronic occlusions in the infrainguinal artery., Materials and Methods: Three patients underwent PICKING technique between November 2014 and March 2017. The PICKING technique with the stiff tail of 0.018-inch guidewire in the straight configuration was considered in cases of failed passage of the smallest balloon catheter because of the underlying severely calcified occlusion following passage of 0.014-inch guidewire., Results: All three patients were complicated by end-stage renal disease on hemodialysis. Treated vessels were superficial femoral artery in two cases and anterior tibial artery in one case. In all cases, successful passage and dilatation of the balloon catheter were achieved, and significant improvements in clinical symptoms were observed following subsequent optimal balloon angioplasty or stenting., Conclusions: The PICKING technique could increase the potential of endovascular solution for the treatment of severely calcified chronic occlusions in the infrainguinal artery.

Objectives: There have been limited data regarding the prediction of cardiac benefits after renal artery stenting for patients with atherosclerotic renal artery disease (ARAD). The aim of this multicentre retrospective study was to identify clinical or echocardiographic factors associated with improvements of cardiac symptoms after renal artery stenting., Methods: We enrolled 58 patients with de novo ARAD undergoing successful renal artery stenting for heart failure, angina or both between January 2000 and August 2015 at 13 hospitals., Results: Improvement of cardiac symptoms was observed in 86.2% of patients during a mean follow-up of 6.0±2.7 months. Responders demonstrated significantly lower New York Heart Association functional class, higher estimated glomerular filtration rate, lower serum creatinine and lower interventricular septal wall thickness (IVS), lower left ventricular mass index, lower left atrial dimension and lower E-velocity than non-responders. Backward stepwise multivariate analysis identified IVS as an independent predictor of improvement of cardiac symptoms (OR 0.451, 95% CI 0.209 to 0.976; p=0.043). According to receiver operating characteristic curve analysis, an IVS cut-off of 11.9 mm provided the best predictive value, with sensitivity of 71.4%, specificity of 75.5% and accuracy of 73.5%. The positive predictive value was 74.5% and the negative predictive value was 72.5%., Conclusions: This multicentre retrospective study shows that the echocardiographic index of IVS is an independent predictor for improvement of cardiac symptoms after renal artery stenting., Competing Interests: Competing interests: None declared.

Purpose: To investigate outcomes of contemporary endovascular therapy and intravascular ultrasound (IVUS) findings in thromboangiitis obliterans (TAO) patients., Methods: Between April 2007 and January 2016, 20 patients (mean age 45±8 years; 16 men) underwent endovascular therapy for TAO-related lesions in 25 consecutive limbs. Subjects exhibited a broad array of clinical symptoms, including critical limb ischemia (n=15) and claudication (10) in the lower (n=20) and upper (n=5) limbs., Results: Procedure success was achieved in 24 (96%) limbs (complete success in 16 and partial success in 8), all of which exhibited improvements of at least 1 grade of the Rutherford category. Kaplan-Meier analysis showed that reintervention-free rates were 81.9% (95% CI 0.586 to 0.928) at 6 months and 71.7% at 10 months (95% CI 0.473 to 0.862). IVUS was performed in 20 limbs and revealed unique findings, including the "bull's-eye" appearance, "lotus-root" appearance, and "bunch of grapes" appearance. During a mean follow-up of 26±19 months, the limb salvage rate was 100% with no deaths., Conclusion: Contemporary endovascular therapy might be able to serve as a potential option for TAO patients with lower and upper limb symptoms. Liberal application of IVUS could help us understand the pathology of TAO to support endovascular therapy for TAO.

Background and Aims: The aim of this study was to investigate the impact of attenuated-signal plaque (ASP) observed by intravascular ultrasound (IVUS) on vessel response after drug-eluting stent implantation., Methods: Data were derived from the IVUS cohort of the J-DESsERT trial comparing paclitaxel- and sirolimus-eluting stents. Serial IVUS analysis (pre- and post-intervention, and 8-month follow-up) was performed in 136 non-AMI lesions. ASP was defined as hypoechoic plaque with ultrasound attenuation without calcification. Calcified plaque (CP) was defined as brightly echoreflective plaque with acoustic shadowing. ASP and CP scores were calculated by grading their measured angle as 0 to 4 for 0°, <90°, 90-180°, 180-270° and >270°, respectively. The entire stented segment was analyzed at 1-mm intervals., Results: At pre-intervention, ASP was observed in 40.4% of lesions, and this group had greater % neointimal volume (%NIV) at follow-up than the no-ASP group (p = 0.011). ASP score at pre-intervention positively correlated with %NIV (p = 0.023). During the follow-up, ASP score significantly decreased (p < 0.001), and CP score significantly increased (p < 0.001), with a negative correlation between them (p < 0.001). A decrease in the ASP score was associated with less %NIV in PES (p = 0.031), but not in SES (p = 0.229)., Conclusions: The greater extent of plaque with IVUS-signal attenuation at pre-intervention and its persistence during follow-up were associated with neointimal proliferation, possibly representing sustained inflammatory status, depending on the type of DES used., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Competing Interests: Conflicts of Interest: None declared.

The transcollateral approach is a contemporary crossing technique for treating infrapopliteal chronic occlusion. However, in the setting of critical limb ischemia with multilevel disease, angiographically occult collateral vessels may be missed as a treatment opportunity. Herein, we report the potential of using occult collateral vessels for transcollateral intervention in infrapopliteal chronic occlusion., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Subclavian artery stenosis can cause a flow reversal-so-called steal-not only in the ipsilateral vertebral artery, but also in the internal mammary artery in patients with a history of coronary-artery bypass grafting. Subclavian artery stenosis is also associated with peripheral artery disease elsewhere. We report a novel finding of axillo-femoral bypass steal due to subclavian artery stenosis identified by vascular ultrasonography.

Atherosclerotic renal artery disease presents with a broad spectrum of clinical features, including heart failure as well as hypertension, and renal failure. Although recent randomized controlled trials failed to demonstrate renal artery stenting can reduce blood pressure or the number of cardiovascular or renal events more so than medical therapy, increasing attention has been paid to flash pulmonary edema and congestive heart failure associated with atherosclerotic renal artery disease. This clinical entity "renovascular heart failure" is diagnosed retrospectively. Given the increasing global burden of heart failure, this review highlights the background and catheter-based therapeutic aspects for renovascular heart failure.

Recurrent congestive heart failure related to renal artery disease is an important clinical entity that is typically observed in bilateral renal artery stenosis or solitary functioning kidney. However, the relationship between heart failure and unilateral renal artery disease, especially that with total occlusion, remains unclear. We report a successful management by unilateral renal artery total occlusion stenting with an evidence of improvement of left ventricular filling and pulmonary artery pressure in case of a patient suffering from medical therapy resistant recurrent congestive heart failure with preserved ejection fraction.

An increasing attention has been paid to endovascular therapy for lower limb ischemia in patients with Buerger's disease. However, critical hand ischemia in Buerger's disease patients has been underappreciated despite a tremendous advancement of endovascular therapy for peripheral arterial disease. Herein, we describe endovascular "hand" salvage with a below-the-elbow intervention.

Aims: This study aimed to investigate the impact of end-stage renal disease (ESRD) on clinical outcomes following infrapopliteal intervention in critical limb ischaemia patients with tissue loss. This retrospective single-centre study enrolled 92 consecutive patients (117 limbs) undergoing infrapopliteal intervention for the treatment of ischaemic tissue loss. The primary outcomes were the wound healing rate, the clinically driven reintervention rate and the limb salvage rate. The secondary outcome was amputation-free survival. The pedal arch was significantly (p=0.002) more diseased in ESRD patients than in non-ESRD patients. ESRD patients demonstrated a significantly lower wound healing rate (hazard ratio [HR], 0.552; 95% CI: 0.319-0.957; p=0.034) and a higher reintervention rate (HR, 1.988; 95% CI: 1.135-3.482; p=0.016). However, there was no significant difference in limb salvage rate between patients with and without ESRD. Age (HR, 1.056; 95% CI: 1.020-1.094; p=0.002), ESRD (HR, 2.239; 95% CI: 1.138-4.407; p=0.020), heart failure (HR, 2.360; 95% CI: 1.295-4.302; p=0.005) and infectious wound (HR, 2.017; 95% CI: 1.145-3.552; p=0.015) were independently associated with death or major amputation. ESRD patients yielded a more affected pedal arch and were at approximately twice the risk of wound healing failure, need for reintervention, and death or major amputation compared to non-ESRD patients.

Background: Benefits of 2-dimensional (2D) angiosome-oriented infrapopliteal revascularization remain controversial. The aim of this retrospective study was to clarify the effect of single tibial artery revascularization on the dorsal and plantar microcirculation of critically ischemic limbs based on skin perfusion pressure (SPP)., Methods and Results: Fifty-seven interventions that only involved either anterior tibial artery (ATA) or posterior tibial artery (PTA) revascularization were included in this study. SPP was measured on the dorsal side (theoretically ATA perfusion area) and the plantar side (theoretically PTA perfusion area) before and after the procedure. Dorsal and plantar SPP increased significantly, from 33 (IQR 23-40.5) to 52 (IQR 32.5-65) mm Hg (P<0.0001) and 31.6±16.1 to 44.8±19.2 mm Hg (P=0.001) after ATA revascularization, respectively, and from 29.3±14.0 to 42.4±19.7 mm Hg (P=0.003) and 29.3±9.8 to 43.5±15.9 mm Hg (P<0.001) after PTA revascularization, respectively. Both ATA and PTA revascularization were not associated with any significant differences in ΔSPP between the dorsal and the plantar regions of the foot. Only 64% and 58% of ATA revascularization cases showed higher post-SPP and ΔSPP on the dorsal side than on the plantar side, respectively. Also, only 47% and 40% of PTA revascularization cases showed higher post-SPP and ΔSPP on the plantar side than on the dorsal side, respectively., Conclusions: Single tibial artery revascularization, whether of the ATA or PTA, yielded comparable improvements in microcirculation of the dorsal and plantar foot. Approximately half of the feet revascularized had a change in microcirculation that was not consistent with the 2D angiosome theory., (© 2014 American Heart Association, Inc.)

In the treatment of Buerger's disease, bypass surgery with the use of an autologous vein has served as a treatment option in cases in which distal target vessel has been available. However, failed bypass occlusion can result in a devastating clinical scenario. Herein, we report a successful endovascular revascularization of failed distal bypass graft as a last resort for a patient with Burger's disease with ischemic rest pain and extensive tissue loss.

Infrapopliteal arterial disease is a significant cause of critical limb ischemia (CLI), whether single-segment or multisegment disease. The collaboration between the tremendous advancements in endovascular technology and the refinement of endovascular techniques has renewed the classic infrapopliteal interventions during the past decade. With this paradigm shift in the treatment of CLI, the role of a comprehensive approach of different disciplines for tissue loss is becoming greater. Given the increasing global burden of CLI, we review the cutting-edge diagnostic and endovascular approaches to infrapopliteal artery disease, and the importance of wound management in optimizing clinical outcomes.

The synergism of technical refinement and advanced technology has significantly increased the popularity of infrapopliteal intervention. Since chronic total occlusion (CTO) is a common disorder among patients with symptomatic infrapopliteal artery disease, infrapopliteal CTO intervention is now evolving rapidly in the field of endovascular intervention. Guidewire crossing through the CTO is essential for a successful procedure. We review up-to-date infrapopliteal CTO crossing techniques based on the current literature.