LAUSR

In the August 2020 issue of the JEVT, Shammas et al1 highlighted a crucial point regarding the value of imaging in the treatment of infrapopliteal arterial occlusive disease. The authors compared angiography to intravascular ultrasound (IVUS) imaging in the evaluation of infrapopliteal vessel diameter and the presence and severity of dissections after balloon dilation alone or atherectomy followed by balloon dilation. The findings of their study are of outmost importance since technical details are crucial to success in a challenging vascular district. It is clear that angiography, as a diagnostic tool, is largely inadequate to provide all the necessary information for evaluating both preoperative conditions and treatment outcome. Too many aspects cannot be evaluated by simple contrast imaging, that is, hemodynamic pattern, 3-dimensional distribution of the lesion, and the condition of the arterial wall. Moreover, to characterize any lesion, angiography should be performed in a variety of projections, which has a series of drawbacks. First of all, the amount of contrast medium would increase significantly, with consequences on renal function, which is typically already impaired in atherosclerotic patients. Also, in some projections the target arterial segment may be hidden by bone margin or other arteries. Finally, the hemodynamic aspect cannot be evaluated.2 Up to now, no clear benefit of endovascular techniques has been demonstrated over surgical revascularization in infrainguinal disease.3,4 Plain balloon angioplasty, primary stenting, subintimal angioplasty, atherectomy, bailout stenting, drug-coated balloon (DCB) angioplasty, and so on, have been advocated as the method of choice in treating lower limb occlusive disease without reaching a consensus.5,6 The Shammas study1 focused on infrapopliteal treatment, which is still a particularly challenging field in peripheral revascularization and is associated with poor results. A study by Gargiulo et al7 assessing infrapopliteal plain balloon angioplasty reported a restenosis rate at 1 year as high as 62.1%. Similarly, Schmidt et al8 performed digital subtraction angiography (DSA) at 3 months following infrapopliteal angioplasty and found a restenosis rate of 68.8%. In addition, experiences with DCB angioplasty do not seem to enhance the outcomes of infrapopliteal revascularization. A recent meta-analysis by Ipema et al9 comparing outcomes of DCB vs balloon dilation in infrapopliteal disease showed similar limb salvage, target lesion revascularization (TLR), and restenosis rates between the 2 groups. It is therefore clear that we are missing something to achieve good results in infrapopliteal revascularization. As shown by previous work of Shammas and colleagues,10 angiography may have missed dissection in many instances, explaining the disappointing outcomes obtained. The current Shammas study1 is notably different in that it used IVUS intraoperatively at baseline and for quality control following treatment, demonstrating a 4-fold greater accuracy of IVUS over DSA in dissection detection. Normally, the diagnostic potential of IVUS is usually limited to postdilation segments since it cannot be advanced through a tight stenosis. It should therefore be considered an essential adjunctive tool, but it is in no way a substitute for other methods. Moreover, the operator experience with this diagnostic tool is of paramount importance, as stated by Shammas et al11 in previous work. 928087 JETXXX10.1177/1526602820928087Journal of Endovascular TherapyFaggioli et al article-commentary2020