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    Comparison of the endovascular therapy with drug-coated balloon and bypass surgery for Trans-Atlantic Inter-Society Consensus II C and D femoropopliteal lesions
    (Bayrakol Medical Publishing, 2021) Özcan, Sedat; Khalil, Emced
    Aim: The optimal revascularization strategy with the greatest durability and the lowest morbidity in femoropopliteal artery occlusions still remains debated. This study aimed to compare 2-year follow up after endovascular therapy (EVT) and femoropopliteal bypass in subjects with TASC II C and D femoropopliteal artery occlusions. Material and Methods: This study included 92 patients with extensive (TASC II C and D) de novo femoropopliteal occlusion who underwent EVT or femoropop-liteal bypass surgery. Drug coated balloons competent with target vessel diameter were used for PTA interventions. Results: A total of 92 subjects with 92 limbs treated were included in the study. Fifty-one of the study subjects received EVT and 41 underwent femoropopliteal bypass surgery. The primary patency rate was higher in the femoropopliteal bypass group compared to the PTA group at 6th, 12th, and 24th -month follow-up studies. Discusion: We compared the early and mid-term clinical outcomes of EVT and femoropopliteal bypass for TASC II C and D lesions of the femoropopliteal artery. We hypothesized that, given the superiority of drug-coated balloons compared to uncoated balloons in terms of postoperative outcomes, EVT with drug-coated balloons would provide superior primary patency compared to femoropopliteal bypass in subjects with complex femoropopliteal artery disease. However, our findings failed to demonstrate the superiority of EVT with drug-coated balloons over femoropopliteal bypass. This result supports the evidence derived from previous studies comparing the two treatment strategies for TASC II C and D lesions of the femoropopliteal artery. Our results indicate that postoperative ABI is also higher in subjects undergoing femoropopliteal bypass than those receiving EVT. Femoropopliteal bypass surgery provides a higher primary patency rate and a more significant improvement in ABI in subjects with TASC II C and D femoropopliteal artery occlusions with similar complication rates for the two treatment strategies.
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    COMPARISON OF THE NUMBER OF CARDIOVASCULAR ADMISSIONS BEFORE AND AFTER COVID-19: EXPERIENCE FROM TURKEY
    (Carbone Editore, 2020) Khalil, Emced; Ozcan, Sedat
    Background: The frequency of cardiovascular problems in patients with COVID-19 could be interpreted to suggest an increase in the number of cardiovascular admissions in the COVID-19 era. However, almost all countries announced social restrictions and distancing measures which could unintentionally lead to a decline in admissions to the hospital for acute disorders other than those associated with pneumonia. This study aimed to compare cardiovascular admissions before and after COVID-19 at the emergency department of secondary and tertiary centers in Turkey. Methods: We analyzed emergency department referrals to secondary and tertiary centers in Ordu province, Turkey for subjects with acute chest pain, shortness of breath, palpitation, leg swelling, and acute limb ischemia from March 10, 2020 to April 30, 2020. Also, we recorded the number of diagnostic coronary angiographies, peripheral endovascular interventions, and cardiac surgeries performed at our institute. The difference in the frequency of emergency department referrals due to acute cardiovascular disorders before and after COVID-19 was the primary outcome measure of this study. Results: Our findings show that, following the establishment of social restrictions 1918 patients were admitted to the emergency department with acute chest pain, shortness of breath, palpitation, leg swelling, and acute limb ischemia. Compared to the last five years (2105-2019) there was a decline in numbers of the patients admitted to the emergency department with acute coronary syndromes, and acute heart failure. There was also a dramatic decline in number of diagnostic coronary angiographies, peripheral interventions and cardiac surgeries. Finally, the number of lower extremity amputations from peripheral artery disease was increased. Conclusion: Our findings show that, compared to the same intervals in the last five years, a critical decline has occurred in the number of patients admitted to our emergency department with cardiovascular symptoms, acute heart failure, acute coronary syndrome, STEM1, while the number of diagnostic angiographies, peripheral endovascular interventions and cardiac surgeries were also decreased. The state of alarm declared by many countries may have caused a higher threshold for hospital application in patients with cardiovascular problems, possibly due to social distancing measures and concerns of contracting COVID-19 in the hospital.
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    Health-related quality of life after vascular surgery and endovascular treatment in subjects with critical limb ischemia
    (Professional Medical Publications, 2020) Khalil, Emced; Ozcan, Sedat
    Background & Objective: Revascularization of the target vessel and restoration of distal flow is critical not only to reduce mortality and morbidity but also improve health-related quality of life (HRQoL) in patients with critical limb ischemia. However, data concerning the impact of surgical bypass and percutaneous transluminal angioplasty (PTA) on HRQoL is limited. This study aimed to compare the impact of surgical bypass and PTA on HRQoL in subjects undergoing superficial femoral artery (SFA) or popliteal artery revascularization. Methods: Seventy-one subjects who underwent successful revascularization of the SFA or popliteal artery either with surgical revascularization or PTA were enrolled in this study. Three months after revascularization, all subjects underwent ankle-brachial index (ABI) measurement, 6-minute walking test and completed the Nottingham Health Profile (NHP) questionnaire. The NHP score differences (measured at the post-procedural 3rd month) between subjects undergoing surgical or endovascular (PTA) revascularization subjects was the primary outcome measure of the study. Results: Both groups experienced significant improvements in ABI and 6-minute walking distance at post-procedure three months. NHP total scores of Part I and Part II at post-procedural six months were similar in the two groups. However, social isolation [77.98 (0 - 85) vs. 22.53 (0 - 100), p=0.002] and physical abilities [78.7 (30.31 - 87.7) vs. 54.47 (0 - 100), P=0.014] domain scores of the surgical revascularization group were significantly higher than that of the endovascular treatment group. Conclusion: This study shows that total scores obtained from the NHP questionnaire applied three months after revascularization of SFA stenosis are similar in subjects undergoing surgical revascularization or PTA. However, the social isolation and physical abilities domains of the NHP are significantly higher in subjects receiving surgical revascularization compared to those receiving PTA.
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    Retrograde Versus Antegrade Approach for the Endovascular Treatment of Symptomatic Femoropopliteal Disease: Results of the 2-Year Follow Up
    (Forum Multimedia Publishing, Llc, 2020) Khalil, Emced; Ozcan, Sedat
    Objective: To compare the antegrade and retrograde approaches, in terms of access site complications and long-term patency in subjects undergoing EVT for symptomatic SFA or popliteal artery stenosis or occlusions. Methods: All consecutive patients who underwent retrograde recanalization for partial stenosis or chronic total occlusion of the SFA or PA at 2 centers were enrolled in this retrospective analysis. Subjects were divided into 2 groups, according to the approach selected for EVT as antegrade approach group or retrograde approach group. The rate of primary patency, which was defined as the lack of restenosis at the target lesion, was the primary outcome measure, during the follow-up evaluations. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were secondary outcome measures. Results: A significant improvement occurred in ABI, following the intervention in both the antegrade approach group [0.7 (0.3 - 1.1) versus 0.85 (0.4 - 1.3), P < 0.001] and retrograde approach group [0.5 (0.3 - 1.1) versus 0.8 (0.3 - 1.3), P < .001]. The primary patency rate at the 1st, 6th, 12th and 24th months of the intervention in the antegrade approach group were 94.85%, 83.82%, 74.26%, and 66.91%, respectively. The primary patency rate at the 1st, 6th, 12th, and 24th months of the intervention in the retrograde approach group were 93.33%, 86.67%, 84.44%, and 71.11%, respectively. The groups were similar with respect to the primary patency rates. The rate of complications, including hematoma, bleeding, and distal embolization was similar in the 2 groups. Conclusion: Antegrade approach and retrograde approach provide a similar safety profile in the EVT of SFA and popliteal artery stenosis and occlusion. The primary patency rates at the 1st, 6th, 12th, and 24th months of follow up also were similar in the 2 groups. However, the significant difference in the lesion characteristics of the subjects undergoing retrograde or antegrade approach complicates the ability to reach a clear conclusion, regarding the superiority of one technique over the other.
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    The safety and efficacy of pharmaco-mechanical thrombolysis in lower-extremity deep venous thrombosis
    (Clinics Cardive Publ Pty Ltd, 2020) Khalil, Emced; Ozcan, Sedat
    Objectisve: The aim of this study was to investigate the impact of accelerated pharmaco-mechanical thrombolysis (PMT) with low-dose second-generation urokinase for the management of cases with lower-extremity deep venous thrombosis (DVT), and to compare its efficacy in subjects with acute and subacute DVT. Methods: Thirty-five patients with acute (< 15 days) or subacute (15 30 days) DVT who underwent PMT in a tertiary centre were enrolled in this single-arm, prospective study. Following the placement of a temporary Sena cava filter, urokinase (200 000 IU) was administered into the occlusion through a multi-hole catheter for 15 to 20 minutes. Control venography was performed to assess venous flow and the rate of acute recanalisation. Percutaneous balloon dilatation and stent placement were carried out in case of a residual iliac vein stenosis of > 50%. Any residual thrombi were suctioned with an aspiration catheter. The primary outcome measures of this study were the percentages of vessel potency and PTS in the third month after PMT. Results: Complete recanalisation was noted in 23 (66% patients, while two (6%) had poor recanalisation. The rate or minor complications was 14%. None of the subjects exper ienced major complications, such as intracranial haemorrhage or pulmonary embolism. No mortality was recorded during the three months of follow up. Control duplex ultrasonography in the third month revealed that the target vein was patent in all subjects. None of the subjects experienced PTS during follow up. In addition, the percentage of acute complete recanalisation was significantly higher in subjects with acute DVT compared to those with subacute DVT (95 vs 27%, p < 0.001). Conclusion: PMT with an accelerated regimen of low-dose urokinase provided excellent efficacy in the resolution of thrombus and prevented the development of PTS in the mid-term when used for the management of lower-extremity DVT.
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    Two-Year Follow-Up After Endovascular Therapy of Superficial Femoral Arteries with Retrograde Popliteal Approach: Single-Center Experience
    (Forum Multimedia Publishing, Llc, 2020) Khalil, Emced; Ozcan, Sedat
    Objective: Popliteal artery puncture, which makes possible the use of lower profile sheaths and devices, has gained popularity as an alternative to the antegrade approach, due to the reduction in vascular complications at the access site. The present study aimed to analyze the safety of the procedure and long-term patency of the superficial femoral artery (SFA) and popliteal artery (PA) and in subjects undergoing recanalization with the popliteal retrograde approach. Methods: Forty-three subjects, who underwent endovascular therapy (EVT) of the SFA or PA with retrograde popliteal approach, were enrolled in this retrospective study. The decision for the retrograde approach was made according to pre-intervention CT angiography results (severe calcification and relatively long CTO segment) in 20 of the subjects. The remaining 23 subjects underwent SFA or PA recanalization with the retrograde approach, due to failed antegrade recanalization attempt. All patients underwent color duplex ultrasound at the first, sixth, 12th, and 24th months to determine patency. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were recorded for all subjects. Results: Technical success was achieved in all cases. Access site complications, including hematoma and bleeding, were observed in 2 subjects (4.66%). Transfusion or surgical treatments were not required in any cases with access site complications. The acute success rate was defined as the recovery of good blood flow evaluated by angiography after EVT was 100%. Distal embolization, which did not cause any limitations in distal flow, occurred in 1 subject (2.33%). Ankle-brachial index (ABI) calculated at 1 month post-intervention was significantly higher than pre-intervention ABI [0.9 (0.59 - 1.3) versus 0.7 (0.4 - 1.1), P < .001]. Patency rates, as determined by ultrasonographic assessment at post-interventional first, sixth, 12th, and 24th months, were 100%, 95.34%, 88.37%, and 86.04%, respectively. Conclusion: Our findings demonstrate that retrograde popliteal artery puncture can be used as a safe and effective technique for recanalization of SFA and PA stenosis and occlusions. The retrograde popliteal approach provides excellent long-term primary patency rates.