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Value of C-Arm Computed Tomography to Evaluate Stent Deployment During Femoro-Popliteal Revascularization

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To compare the accuracy of C-arm computed tomography (CT) and digital subtraction angiography (DSA) in detecting incomplete stent expansion (ISE) after superficial femoral artery (SFA) stenting using intravascular ultrasound (IVUS) as a gold standard.


Fifty patients with symptomatic SFA occlusive disease requiring angioplasty were prospectively included. Once technical success (<30 % residual stenosis) was obtained on post-procedural DSA, C-arm CT and IVUS were acquired. DSA and C-arm CT examinations were reviewed by 2 investigators and correlated with IVUS. C-arm CT image quality was rated on a four-point scale. Doppler ultrasound was performed at 1-year follow-up.


The ankle-brachial index was 0.69 ± 0.10 and 0.99 ± 0.40, respectively, pre- and post-procedure. C-arm CT imaging quality was rated as good or excellent in 80 %. In-stent minimal luminal diameter (MLD) was evaluated at 4.71 ± 0.7 mm on DSA, 3.39 ± 0.6 mm on IVUS, and 3.12 ± 0.9 mm on C-arm CT. Compared to IVUS, DSA demonstrated an overestimation of MLD (p = 0.0001), an underestimation of ISE (DSA = 18.8 % ± 7.6; IVUS = 29.8 % ± 9) (p < 0.0001), and a poor inter-technique intra-class correlation coefficient (ICC = 0.24). No difference was observed between IVUS and C-arm CT in ISE as calculated by diameter (29.8 ± 9 vs. 28.2 ± 12.5 %, p = 0.5) and area (30.2 ± 8.4 vs. 33.3 ± 9.5 %, p = 0.2). Inter-technique ICC between C-arm CT and IVUS was 0.72 [95 %CI 0.49; 0.85] for MLA measurements. The inter-observer ICC for MLD and MLA measurements on C-arm CT were, respectively, estimated at 0.75 [95 % CI 0.40, 0.89] and 0.77 [95 % CI 0.43, 0.90)].


C-arm CT presents a better correlation with IVUS than DSA to determine lumen diameter and ISE immediately after percutaneous revascularization.

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  1. Dorrucci V. Treatment of superficial femoral artery occlusive disease. J Cardiovasc Surg (Torino). 2004;45(3):193–201.

    CAS  Google Scholar 

  2. Dick P, Wallner H, Sabeti S, Loewe C, Mlekusch W, Lammer J, Koppensteiner R, Minar E, Schillinger M. Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial femoral artery lesions. Catheter Cardiovasc Interv. 2009;74(7):1090–5.

    Article  PubMed  Google Scholar 

  3. Lyden SP, Shimshak TM. Contemporary endovascular treatment for disease of the superficial femoral and popliteal arteries: an integrated device-based strategy. J Endovasc Ther. 2006;13(Suppl 2):II41–51.

    Article  PubMed  Google Scholar 

  4. Rosenfield K, Schainfeld R, Pieczek A, Haley L, Isner JM. Restenosis of endovascular stents from stent compression. J Am Coll Cardiol. 1997;29(2):328–38.

    Article  CAS  PubMed  Google Scholar 

  5. Buckley CJ, Arko FR, Lee S, Mettauer M, Little D, Atkins M, Manning LG, Patterson DE. Intravascular ultrasound scanning improves long-term patency of iliac lesions treated with balloon angioplasty and primary stenting. J Vasc Surg. 2002;35(2):316–23.

    Article  PubMed  Google Scholar 

  6. Willoteaux S, Moranne O, Duda SH, Lions C, Gaxotte V, Durand F, Negawi Z, Beregi JP. Multislice computed tomographic angiography versus digital subtraction angiography in the follow-up of nitinol stents in the superficial femoral artery. J Endovasc Ther. 2006;13(5):609–15.

    Article  PubMed  Google Scholar 

  7. Arthurs ZM, Bishop PD, Feiten LE, Eagleton MJ, Clair DG, Kashyap VS. Evaluation of peripheral atherosclerosis: a comparative analysis of angiography and intravascular ultrasound imaging. J Vasc Surg. 2010;51(4):933–8 (discussion 939).

    Article  PubMed Central  PubMed  Google Scholar 

  8. Laird JR, Katzen BT, Scheinert D, Lammer J, Carpenter J, Buchbinder M, Dave R, Ansel G, Lansky A, Cristea E, Collins TJ, Goldstein J, Cao AY, Jaff MR, Investigators R. Nitinol stent implantation vs. Balloon angioplasty for lesions in the superficial femoral and proximal popliteal arteries of patients with claudication: three-year follow-up from the resilient randomized trial. J Endovasc Ther. 2012;19(1):1–9.

    Article  PubMed  Google Scholar 

  9. Laird JR, Katzen BT, Scheinert D, Lammer J, Carpenter J, Buchbinder M, Dave R, Ansel G, Lansky A, Cristea E, Collins TJ, Goldstein J, Jaff MR, Investigators R. Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the resilient randomized trial. Circ Cardiovasc Interv. 2010;3(3):267–76.

    Article  PubMed  Google Scholar 

  10. Kuribayashi S, Takamiya M, Homma S. Intravascular ultrasound observations during iliac stent deployment. Int Angiol. 1999;18(4):263–70.

    CAS  PubMed  Google Scholar 

  11. Gaster AL, Slothuus U, Larsen J, Thayssen P, Haghfelt T. Cost-effectiveness analysis of intravascular ultrasound guided percutaneous coronary intervention versus conventional percutaneous coronary intervention. Scand Cardiovasc J. 2001;35(2):80–5.

    Article  CAS  PubMed  Google Scholar 

  12. Akpek S, Brunner T, Benndorf G, Strother C. Three-dimensional imaging and cone beam volume ct in c-arm angiography with flat panel detector. Diagn Interv Radiol. 2005;11(1):10–3.

    PubMed  Google Scholar 

  13. Wallace MJ, Kuo MD, Glaiberman C, Binkert CA, Orth RC, Soulez G. Three-dimensional c-arm cone-beam ct: applications in the interventional suite. J Vasc Interv Radiol. 2009;20(7 suppl):S523–37.

    Article  PubMed  Google Scholar 

  14. Wallace MJ, Kuo MD, Glaiberman C, Binkert CA, Orth RC, Soulez G. Three-dimensional c-arm cone-beam ct: applications in the interventional suite. J Vasc Interv Radiol. 2008;19(6):799–813.

    Article  PubMed  Google Scholar 

  15. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-society consensus for the management of peripheral arterial disease (TASCII). J Vasc Surg. 2007;45(Suppl S):S5–67.

    Article  PubMed  Google Scholar 

  16. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM Jr, White CJ, White J, White RA, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA task force on practice guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease). Circulation. 2006;113(11):e463–654.

    Article  PubMed  Google Scholar 

  17. Singh H, Cardella JF, Cole PE, Grassi CJ, McCowan TC, Swan TL, Sacks D, Lewis CA. Quality improvement guidelines for diagnostic arteriography. J Vasc Interv Radiol. 2003;14(9 Pt2):S283–8.

    PubMed  Google Scholar 

  18. Berry C, L’Allier PL, Gregoire J, Lesperance J, Levesque S, Ibrahim R, Tardif JC. Comparison of intravascular ultrasound and quantitative coronary angiography for the assessment of coronary artery disease progression. Circulation. 2007;115(14):1851–7.

    Article  PubMed  Google Scholar 

  19. Cardinal MH, Meunier J, Soulez G, Maurice RL, Therasse E, Cloutier G. Intravascular ultrasound image segmentation: a three-dimensional fast-marching method based on gray level distributions. IEEE Transmed Imaging. 2006;25(5):590–601.

    Article  Google Scholar 

  20. Schwartz RS, Edelman ER, Carter A, Chronos N, Rogers C, Robinson KA, Waksman R, Weinberger J, Wilensky RL, Jensen DN, Zuckerman BD, Virmani R. Consensus Committee. Drug-eluting stents in preclinical studies: recommended evaluation from a consensus group. Circulation. 2002;106(14):1867–73.

    Article  PubMed  Google Scholar 

  21. Schlager O, Dick P, Sabeti S, Amighi J, Mlekusch W, Minar E, Schillinger M. Long-segment SFA stenting–the dark sides: in-stent restenosis, clinical deterioration, and stent fractures. J Endovasc Therapy. 2005;12(6):676–84.

    Article  Google Scholar 

  22. Duda SH, Bosiers M, Lammer J, Scheinert D, Zeller T, Tielbeek A, Anderson J, Wiesinger B, Tepe G, Lansky A, Mudde C, Tielemans H, Beregi JP. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the sirocco ii trial. J Vasc Interv Radiol. 2005;3(16):331–8.

    Article  Google Scholar 

  23. Bland JM, Altman DG. Comparing methods of measurement: why plotting difference against standard method is misleading. Lancet. 1995;346(8982):1085–7.

    Article  CAS  PubMed  Google Scholar 

  24. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1(8476):307–10.

    Article  CAS  PubMed  Google Scholar 

  25. Baril DT, Marone LK, Kim J, Go MR, Chaer RA, Rhee RY. Outcomes of endovascular interventions for TASC II B and C femoropopliteal lesions. J Vasc Surg. 2008;48(3):627–33.

    Article  PubMed  Google Scholar 

  26. Bosiers M, Deloose K, Callaert J, Moreels N, Keirse K, Verbist J, Peeters P. Results of the protege everflex 200-mm-long nitinol stent (ev3) in TASC C and D femoropopliteal lesions. J Vasc Surg. 2011;54(4):1042–50.

    Article  PubMed  Google Scholar 

  27. Scheinert D, Grummt L, Piorkowski M, Sax J, Scheinert S, Ulrich M, Werner M, Bausback Y, Braunlich S, Schmidt A. A novel self-expanding interwoven nitinol stent for complex femoropopliteal lesions: 24-month results of the supera sfa registry. J Endovasc Ther. 2011;18(6):745–52.

    Article  PubMed  Google Scholar 

  28. Ebrahimi N, Claus B, Lee CY, Biondi A, Benndorf G. Stent conformity in curved vascular models with simulated aneurysm necks using flat-panel ct: an in vitro study. Am J Neuroradiol. 2007;28(5):823–9.

    CAS  PubMed  Google Scholar 

  29. Ferreira M, Lanziotti L, Monteiro M, Abuhadba G, Capotorto LF, Nolte L, Fearnot N. Superficial femoral artery recanalization with self-expanding nitinol stents: long-term follow-up results. Eur J Vasc Endovasc Surg. 2007;34(6):702–8.

    Article  CAS  PubMed  Google Scholar 

  30. Kastrati A, Schomig A, Dietz R, Neumann FJ, Richardt G. Time course of restenosis during the first year after emergency coronary stenting. Circulation. 1993;87(5):1498–505.

    Article  CAS  PubMed  Google Scholar 

  31. Schillinger M, Mlekusch W, Haumer M, Sabeti S, Ahmadi R, Minar E. Angioplasty and elective stenting of de novo versus recurrent femoropopliteal lesions: 1-year follow-up. J Endovasc Therapy. 2003;10(2):288–97.

    Article  Google Scholar 

  32. Schillinger M, Minar E. Endovascular stent implantation for treatment of peripheral artery disease. Eur J Clin Invest. 2007;37(3):165–70.

    Article  CAS  PubMed  Google Scholar 

  33. Fahrig R, Dixon R, Payne T, Morin RL, Ganguly A, Strobel N. Dose and image quality for a cone-beam c-arm CT system. Med Phys. 2006;33(12):4541–50.

    Article  PubMed  Google Scholar 

  34. Coyne KS, Margolis MK, Gilchrist KA, Grandy SP, Hiatt WR, Ratchford A, Revicki DA, Weintraub WS, Regensteiner JG. Evaluating effects of method of administration on walking impairment questionnaire. J Vasc Surg. 2003;8(2):296–304.

    Article  Google Scholar 

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Gilles Soulez was supported for this work by the Canadian Institutes of Health Research through a collaborative research program with Siemens Medical Germany (Grant Number: CIHR ISO-83052), and a senior clinical research scholarship (to Gilles Soulez from the Fonds de la Recherche en Santé du Québec (FRSQ, Grant Ref: 9958)).

Conflict of Interest

Gerald Gahide, Sofian Hadjaj, Eric Therasse, Claude Kauffmann, Patrick Gilbert, Vincent L Oliva, Jean-Claude Tardif, Jacques Lesperance, and Guy Cloutier have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Gahide, G., Hadjadj, S., Therasse, E. et al. Value of C-Arm Computed Tomography to Evaluate Stent Deployment During Femoro-Popliteal Revascularization. Cardiovasc Intervent Radiol 38, 1458–1467 (2015).

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