November 04, 2009

Immunosuppression After Cardiac Transplantation Improves Patency of Percutaneous Lower Extremity Arterial Interventions

Nicholas J. Morrissey, MD¹, Hafiz Hussain, MD¹, Susan Restaino, MD², Donna Mancini, MD², Mary Jane Farr, MD², James McKinsey, MD¹.
¹Columbia/Weill Cornell Division of Vascular Surgery, New York, NY, USA, ²Columbia University Division of Cardiology, New York, NY, USA.

Ojectives. Restenosis following percutaneous lower extremity arterial intervention limits the success of these procedures. Success of drug eluting stents in coronary arteries has led to enthusiasm for use in the lower extremity. Cardiac transplant patients (OHTx) represent a unique population who are at risk for PVD while simultaneously being chronically pharmacologically immunosuppressed. We reviewed our experience in this population to determine if immunosuppression improves patency of lower extremity interventions.
Methods All patients undergoing lower extremity percutaneous intervention are prospectively enrolled into a database. Preoperative data are collected and lesion characteristics and procedural details are determined at time of treatment. Patients are followed clinically and with duplex ultrasound and pulse volume recordings. In some cases, angiographic follow-up is available. We selected patients from the database who previously underwent OHTx for the present study. Patency rates were calculated using Kaplan-Meier survival analysis.
Results 34 lesions were treated in 20 patients. There were 19 men and 1 woman all of whom were on immunosuppressive medications. All patients had OHTx for ischemic cardiomyopathy. Twenty-six lesions were femoropopliteal, 7 were iliac, 1 was tibial. Mean follow-up was 15.4 months (2-64 months). Preoperative mean creatinine was 1.57mg/dl and postoperative mean was 1.45. Thirty-two (94%) lesions were treated with PTA/stent and 2 were treated with atherectomy. Further results are summarized in the table.



	12 months	24 months	TASC = n (%)
Primary patency	88.4 +/- 7.4%	88.4 +/-7.4%	A= 4 (11.7)
Assisted primary patency	100%	100%	B= 12 (35.3)
Secondary patency	100%	100%	C=14 (41.2)
Clinical success	100%	100%	D= 4 (11.7)

Conclusion Primary patency of lower extremity interventions in OHTx patients is excellent at 24 months. This exceptional patency is seen even with a high percentage of TASC C and D lesions. Clinical success of 100% is seen at long-term follow-up. Chronic immunosuppression may prevent intimal hyperplasia and result in higher patency as seen in this study. In spite of baseline chronic renal insufficiency the procedures were well tolerated without significant deterioration of renal function postoperatively.

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