CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 AFRICA 213 retrospective, descriptive study of standard treatment procedures using anonymised data, no ethical approval of the institutional ethics board was needed. In all patients, the diagnosis of LEAD was set clinically and confirmed with the measurement of ankle-brachial pressure index (ABI). The Fontaine stage of LEAD was recorded, namely, having disabling claudication, rest pain, ulceration or gangrene. Risk factors for LEAD were recorded, including arterial hypertension, defined as arterial blood pressure > 140/90 mmHg or using antihypertensive medication; hypercholesterolaemia, defined as having serum low-density lipoprotein cholesterol ≥ 130 mg/dl (3.37 mmol/l) or total cholesterol ≥ 200 mg/dl (5.18 mmol/l) or using lipolytic medication; diabetes, defined as having a fasting blood glucose level ≥ 126 mg/dl (6.99 mmol/l) or using antidiabetic medication; and self-reported past or current smoking. Prior to the endovascular procedure, computed tomographic angiography (CTA) was performed in all patients so that the most appropriate approach for the arterial system was chosen. Principles of endovascular treatment of symptomatic LEAD, as described in the European Society of Cardiology guidelines, were followed.4 Interventions were performed by two different interventionists in one angiography laboratory, using a Canon Infinix-I INFX 8000-V single-plane Toshiba angiography system on a movable interventional table. Patients in a supine or prone position according to the puncture point, were placed into the appropriate field of view by a manually controlled sliding table. A posterior– anterior projection was routinely used. An oblique projection was used occasionally, to confirm the presence of stenosis and/ or evaluate the result of angioplasty. Magnification was used only occasionally, mostly in below-knee interventions, at the discretion of the interventionist. A 6F sheath was used in all therapeutic interventions. In the therapeutic interventions with a retrograde approach, digital subtraction angiography (DSA) was performed through a pigtail catheter. Iohexol contrast medium of 350 mg/ml (Omnipaque 350, GE HealthCare, Ireland) was manually injected into the arterial system by the interventionist. On average, 100 mm3 (175 mg/ml) contrast medium was used for the patients who underwent aorto-iliac therapeutic interventions. When revascularisation was judged technically not possible, the intervention was completed following DSA as a diagnostic intervention and these patients were excluded from the study. In all other patients, an attempt at endovascular revascularisation was made and the intervention was categorised as a therapeutic intervention. Therapeutic interventions were defined as technically successful when recanalisation of the arterial lumen with a less than 30% residual stenosis and rapid contrast flow was achieved. In patients with combined iliofemoral lesions, the ipsilateral popliteal retrograde approach was performed with Doppler ultrasonography in the prone position. In therapeutic interventions, angioplasty was performed primarily on the lesion. In control imaging, if dissection was detected, bailout stenting was performed. Therapeutic interventions in the femoropopliteal region were generally performed with an antegrade ipsilateral approach. When recanalisation of the femoral artery was not successful (no re-entry), a retrograde ipsilateral–popliteal approach was performed. For analysis, interventions were categorised according to the following criteria: • anatomical region (pelvic, femoropopliteal ± below knee) • type of the intervention (angioplasty without stenting, angioplasty with stent implantation) • puncture point for approaching the arterial lesions. The patients were divided into groups according to their clinical status before the procedure, using the Fontaine classification. The DAP and FL time were recorded by the system DAP meter, which was an integral part of the angiography equipment. Statistical analysis All statistical analyses were made with the IBM SPSS Statistic version 23.0 for Windows. Data were tested in terms of normal distribution with the Kolmogorov–Smirnov test. DAP and FL time values with regard to the anatomical region were tested with the Mann–Whitney U-test due to continuous data without normal distribution. Kruskal–Wallis and Tukey tests were used for comparisons with regard to puncture point. The Spearman correlation test was used to measure the change in the values according to age and body mass index (BMI). Results Therapeutic peripheral endovascular arterial intervention was performed in 150 patients over a period of 23 months. The basic characteristics of the patients are shown in Table 1. All patients included in the study had ABI values before and after the procedure. It was observed that the mean ABI, which was 0.58 ± 0.17 before the procedure, increased to 0.93 ± 0.19 after the procedure. While evaluating our results, the mean DAP and FL time values were compared to show that there was no operator effect, and it was proved that there was no statistically significant difference (p = 0.042 for DAP, p = 0.066 for Fl time). The FL time and DAP values of the patients who underwent revascularisation with only balloon angioplasty and those who underwent stent implantation upon development of dissection during the procedure were higher in the stent-implanted group Table 1. Patient characteristics Variables Values Gender: male/female, n (%) 129/21 (86/14) Age, mean ± SD (min–max) 62 ± 8 (43–77) Hypertension, n (%) 72 (48) Hypercholesterolaemia, n (%) 63 (42) Diabetes mellitus, n (%) 81 (54) Current or former smoker, n (%) 108 (72) Body mass index (kg/m2), mean ± SD (min–max) 27 ± 4 (20–36) Bilateral extremity lesions, n (%) 33 (22) Angioplasty/angioplasty with stenting, n (%) 99/51 (66/34) Pre-op ABI, mean ± SD (min–max) 0.58 ± 0.17 (0.2–0.89) Postop ABI, mean ± SD (min–max) 0.93 ± 0.19 (0.43–1.3) Fluoro time (min) 11.6 ± 8.4 (3–39) (Op 1: 10.3 and Op 2: 12.7) DAP (Gycm2) 19.5 ± 24 (2–130) (Op1 18.2 and Op 2: 20.8) Fluoro time (min), median (IQR) 8.5 (9) DAP (Gycm2), median (IQR) 11 (20) SD: standard deviation, ABI: ankle-brachial index, DAP: dose area product, Op: operator.
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