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Predicting Success of Endovascular Intervention In Anatomically Unfavorable Femoropopliteal Disease
Andrew J. Meltzer, M.D., Gautam V. Shrikhande, M.D., In-Kyong Kim, M.D., Francesco A. Aiello, M.D., James F. McKinsey, M.D..
New York-Presbyterian Hospital, New York, NY, USA.

OBJECTIVES:
Guidelines addressing the appropriateness of endovascular therapy for peripheral arterial disease may lag behind contemporary practice patterns; endovascular therapy for TASC C/D femoropopliteal disease is frequently performed. Application of a comprehensive prediction model to anatomically unfavorable femoropopliteal disease may clarify the appropriateness of endovascular therapy in TASC C/D lesions.
METHODS:
Retrospective review of a prospectively maintained database identified 500 consecutive endovascular interventions for TASC C/D femoropopliteal interventions. A previously reported, comprehensive clinical prediction model for long-term patency after endovascular intervention based on 8 variables (runoff, % stenosis, complete occlusion, length, calcification, smoking status, diabetes, and heart failure) was applied. The predictive power of the 8-variable model was evaluated at defined endpoints (6 and 12 months). Comparisons were made using standard techniques (Chi-square, ROC curve analysis).
RESULTS:
Of 500 treated limbs, 375 (75%) were TASC C; 125 (25%) were TASC D. Overall primary patency was 54.4% and 32.6% at 6 and 12 months, respectively. At 12 months, there was no statistically significant difference between primary patency of TASC C vs. TASC D lesions (34.2% vs. 29.7%; P = 0.320). Mean endovascular disease severity score (DSS) was 7.2+2.7 points (of a maximum 16). Higher DSS (>8, n=254) was associated with reduced patency at 6 months (49.2% vs. 62%; P=0.005) and 12 months compared to DSS 9 (n=108) was associated with 24.6% 12-month primary patency, compared to 46.5% 12-month primary patency among those with DSS<4. While weakly correlated to TASC classification (R = 0.424), the endovascular disease severity score demonstrated improved discrimination of patency at 12 months compared to TASC classification by ROC comparison (C-index: 0.62, P < .001).
CONCLUSIONS:
Overall, endovascular therapy for TASC C/D femoropopliteal disease is associated with poor primary patency. There is, however, significant variability in outcomes after endovascular treatment of unfavorable lesions that is not predicted by TASC classification. Here, we validate a comprehensive clinical model on a sub-group of patients with severe femoropopliteal disease. Application of such disease scoring methods may be used to predict outcomes and guide choice of therapy.


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