Introduction

Carotid artery stenting (CAS) has variably fallen in and out of favor. Some have argued that CAS should be reserved for those patients who are at highest risk, not only for endartectomy (CEA), but if only treated medically. Unfortunately, none of the current trials or registries has been adequately designed to allow for equal comparison between the three treatment strategies — surgery, stenting, and medical therapy. Recent randomized trials comparing CAS and CEA contain significant methodological flaws and are thus inadequate for definitive comparisons, though they are thought provoking.

The popliteal artery aneurysm is the most common peripheral aneurysm, accounting for 70–80%. It is found mainly in male patients,^10-12 with 50% of all cases being bilateral.¹³ The pathogenesis is often atherosclerotic, however, generalized dilatation and elongation of other arteries, such as the abdominal aorta, suggest a systemic abnormality.¹⁴ Mechanical stresses like hypertension, which is present in many patients^15,16 and the fixation of the vessel at the adductor hiatus can contribute to aneurysm formation in the popliteal artery. Non-atherosclerotic popliteal aneurysm is very rare and may occur as a complication of inflammatory disorders or trauma. The natural history shows that popliteal aneurysms expand by approximately 10%/year and larger aneurysms enlarge more rapidly than smaller ones; aneurysms < 2 cm increased 1.5 mm/yr, and 2–3 cm grew by 3 mm/yr (Pittathankal).

Introduction

In recent years, increasing numbers of patients are choosing the option of gastric bypass for weight reduction. In 2004, 121,055 bariatric procedures were performed, a nine-fold increase compared to 1998, when 13,386 bariatric procedures were done.¹ This increase in bariatric procedures corresponds to an increase of national inpatient hospital costs by more than eight times, excluding physician costs, from $147 million in 1998 to $1.26 billion in 2004.² With the number of bariatric procedures expected to rise in the ensuing years, addressing the specific issues of the bariatric patient will become increasingly important.^3–6

Introduction

The number of percutaneous revascularization procedures performed for symptomatic peripheral arterial disease (PAD) has significantly increased over the past several years.¹ Traditionally, the use of percutaneous techniques were limited to certain anatomic subsets, such as stenosis or focal occlusions, with surgical treatment preferred for more extensive disease.² More recently, endovascular specialists are facing the challenges of treating commonly- encountered peripheral chronic total occlusions (CTOs). Furthermore, unlike the coronary circulation, these occlusions are often long and associated with other features of complexity. The two primary issues concerning these lesions are the ability to safely achieve initial angiographic success and the longterm durability of therapy. This article will focus on the current status of treating lower extremity peripheral CTOs and expected clinical outcomes. 

Recanalization of peripheral arterial total occlusion in lower extremities plays a pivotal role to improve claudication symptoms and limb salvage. Coronary chronic total occlusion (CTO) recanalization has recently gathered controversy with the publication of the occluded artery trial (OAT). However, in peripheral vasculature, specifically in the superficial femoral artery (SFA), occlusion predominates stenosis. The predominance of occlusion is due to limited collaterals, namely the profunda femoris artery and the diffuse nature of the disease.² The constant endothelial injury, due to twisting, contraction, and kinking of the arteries, results in accelerated atherosclerosis.

The idea for this editorial emerged in my mind while reviewing the article “A Comparison of Interventional Guidewires in a Canine Model” by Huang et al. The authors set out to test three different wires in the setting of an in vivo experiment. They used some of the most common maneuvers interventionists perform with guidewires in the course of endovascular procedures. Not surprisingly, the study showed the superiority of the GlideWire. I thought it was reassuring — at least to me!