The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: A 10-year experience

The Importance of Patency in Patients with Critical Limb Ischemia Undergoing Endovascular Revascularization for Infrapopliteal Arterial Disease

Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease (PAD) and frequently occurs in medically frail patients. CLI patients frequently exhibit multi-segmental PAD commonly including the tibial arterial segment. Endovascular therapy has been established as first-line revascularization strategy for most CLI patients. Restenosis was reported to occur in up to more than two-thirds of CLI patients undergoing angioplasty of complex tibial arterial obstructions. Nevertheless, favorable clinical outcomes were observed for infrapopliteal angioplasty when compared with bypass surgery, despite higher patency rates for the latter. Based on these observations, infrapopliteal patency was considered to be only of secondary importance upon clinical outcomes in CLI patients. In contrast to these earlier observations, however, recent findings from two randomized clinical trials indicate that infrapopliteal patency does impact on clinical outcomes in CLI patients. The purpose of the present manuscript is to provide a critical reappraisal of the present literature on the clinical importance of tibial arterial patency in CLI patients undergoing endovascular revascularization and to discuss utility and limitations of currently available anti-restenosis technologies.

Long-term outcomes of infrainguinal bypass surgery for patients with diabetes mellitus and tissue loss

Purpose

To determine the long-term outcomes of patients with diabetes mellitus (DM) and tissue loss who have undergone infrainguinal bypass surgery (IBS).

Methods

We retrospectively reviewed the medical records of 91 patients with DM and tissue loss who underwent IBS between July 2003 and December 2013. We determined the rates of overall survival (OS), amputation-free survival (AFS), limb salvage (LS), and graft patency (GP). In addition, we evaluated data to identify risk factors that affected long-term outcomes.

Results

The mean age of patients was 66 ± 8 years, and 78 patients (85.7%) were men. The locations of tissue loss were toe on 76 limbs (71.6%), heel on 6 limbs (5.7%) and others on 24 limbs (22.6%). Single lesions were found in 81 limbs (76.4%). According to categorization by distal anastomosis artery, there were 57 popliteal (53.8%) and 49 infrapopliteal bypasses (46.2%). Among infrapopliteal bypasses, 5 cases (10.2%) were sequential bypasses. The OS at 1, 3, and 5 years was 90.5%, 70.9%, and 44.2%, respectively. At 1, 3, and 5 years, the LS was 92.1%, 88.9%, 88.9%, respectively; and AFS was 84.4%, 67.6%, 45.7%, respectively. At 1, 3, and 5 years, the GP was 84.8%, 74.5%, and 69.8%, respectively. Renal failure was a negative predictor for OS, and female gender was a negative predictor for GP.

Conclusion

IBS for patients with DM and tissue loss led to acceptable OS, AFS, LS, and GP. Active revascularization for patients with DM and tissue loss can reduce the risk of major amputation.

Drug-eluting balloon versus standard balloon angioplasty for infrapopliteal arterial revascularization in critical limb ischemia: 12-month results from the IN.PACT DEEP randomized trial

BACKGROUND

Drug-eluting balloons (DEB) may reduce infrapopliteal restenosis and reintervention rates versus percutaneous transluminal angioplasty (PTA) and improve wound healing/limb preservation.

OBJECTIVES

The goal of this clinical trial was to assess the efficacy and safety of IN.PACT Amphirion drug-eluting balloons (IA-DEB) compared to PTA for infrapopliteal arterial revascularization in patients with critical limb ischemia (CLI).

METHODS

Within a prospective, multicenter, randomized, controlled trial with independent clinical event adjudication and angiographic and wound core laboratories 358 CLI patients were randomized 2:1 to IA-DEB or PTA. The 2 coprimary efficacy endpoints through 12 months were clinically driven target lesion revascularization (CD-TLR) and late lumen loss (LLL). The primary safety endpoint through 6 months was a composite of all-cause mortality, major amputation, and CD-TLR.

RESULTS

Clinical characteristics were similar between the 2 groups. Significant baseline differences between the IA-DEB and PTA arms included mean lesion length (10.2 cm vs. 12.9 cm; p = 0.002), impaired inflow (40.7% vs. 28.8%; p = 0.035), and previous target limb revascularization (32.2% vs. 21.8%; p = 0.047). Primary efficacy results of IA-DEB versus PTA were CD-TLR of 9.2% versus 13.1% (p = 0.291) and LLL of 0.61 ± 0.78 mm versus 0.62 ± 0.78 mm (p = 0.950). Primary safety endpoints were 17.7% versus 15.8% (p = 0.021) and met the noninferiority hypothesis. A safety signal driven by major amputations through 12 months was observed in the IA-DEB arm versus the PTA arm (8.8% vs. 3.6%; p = 0.080).

CONCLUSIONS

In patients with CLI, IA-DEB had comparable efficacy to PTA. While primary safety was met, there was a trend towards an increased major amputation rate through 12 months compared to PTA. (Study of IN.PACT Amphirion™ Drug Eluting Balloon vs. Standard PTA for the Treatment of Below the Knee Critical Limb Ischemia [INPACT-DEEP]; NCT00941733).

The factors affecting recurrence of symptoms after infrainguinal arterial endovascular angioplasty

Background

This study reports the result of endovascular treatment for arterial occlusive disease limited to femoropopliteal lesions, focusing on the recurrence of symptoms instead of patency.

Methods

This was a retrospective, single-center study. From April 2007 to November 2011, 48 limbs in 38 patients underwent endovascular stenting or balloon angioplasty to treat femoropopliteal arterial occlusive disease. The factors affecting the recurrence of symptoms were analyzed.

Results

The mean age of the patients was 69.60±7.62 years. Among the baseline characteristics of the patients, initial hyperlipidemia was the most important factor affecting the recurrence of symptoms (relative risk=5.810, p=0.031). The presence of a dorsal arch was also a significant factor (relative risk=0.675, p=0.047).

Conclusion

The major factors that affect the recurrence of symptoms after endovascular treatment for femoropopliteal arterial occlusive lesions are hyperlipidemia and the presence of a dorsal arch. Therefore, the usage of lipid-lowering agents after endovascular treatment and taking the presence of a dorsal arch into consideration are important elements of managing the recurrence of symptoms.

Chronic critical ischaemia of the legs

Chronic critical ischaemia of the lower limb is the most severe form of peripheral arterial occlusive disease. It is characterised by acral rest pain and an ankle arterial pressure <50 mmHg and a toe arterial pressure of <30 mmHg for at least two weeks. If trophic lesions are present, then an ankle pressure <70 mmHg and a toe pressure < 50 mmHg are already sufficient for diagnosis of chronic critical ischaemia. The aim of treatment is limb preservation and a reduction in the cardiovascular mortality and morbidity. For this to be achieved, the time to diagnosis and the time to revascularisation must be as short as possible. It is therefore important that patients with foot pain at rest undergo angiological work-up as rapidly as possible, especially if they also have risk factors for critical ischaemia (diabetes, renal failure). The same applies to patients with trophic skin lesions (fissure, ulcer) that do not heal within three weeks.

Revascularisation is the most important therapeutic measure. Inhibition of platelet aggregation, optimum analgesia and early use of antibiotics if signs of an infection are present, are further important measures in addition to the treatment of cardiovascular risk factors. Amputation is the last therapeutic option.

Contemporary outcomes with percutaneous vascular interventions for peripheral critical limb ischemia in those with and without poly-vascular disease

Given the very ill nature of patients with critical limb ischemia (CLI), the use of percutaneous vascular interventions (PVIs) for limb salvage may or may not be efficacious; in particular, for those with polyvascular arterial disease. Herein, we reviewed large, multi-institutional outcomes of PVI in polyvascular and peripheral arterial disease (PAD) patients with CLI. An 18-hospital consortium collected prospective data on patients undergoing endovascular interventions for PAD with 6-month follow-up from January 2008 to December 2011. The patient cohort included 4459 patients with CLI; of those, 3141 patients had polyvascular (coronary artery disease, cerebrovascular disease and PAD) disease, whereas 1318 patients suffered from only PAD. All patients were elderly and with significant comorbidities. The mean ankle–brachial index (ABI) was 0.44 and was not different between those with and without polyvascular disease. Polyvascular patients had more femoropopliteal and infra-inguinal interventions and less aortoiliac interventions than PAD patients. Pre- and post-procedural cardioprotective medication use was less in the PAD patients as compared with polyvascular patients. Vascular complications requiring surgery were higher in PAD patients whereas other access complications were similar between groups. At 6-month follow-up, death was more common in the polyvascular group (6.7% vs 4.1%, p<0.001) as was repeat PVI, but no difference was found in the amputation rate. Considering the group as a whole at the 6-month follow-up, predictors of amputation/death included age (HR=1.01; 95% CI=1.002–1.02), anemia (HR=2.6; 95% CI=2.1–3.2), diabetes mellitus (HR=1.6; 95% CI=1.3–1.9), congestive heart failure (HR=1.6; 95% CI=1.4–1.9), and end-stage renal failure (HR=1.9; 95% CI=1.5–2.3), while female sex was protective (HR=0.7; 95% CI=0.6–0.8). In conclusion, from examination of this large, multicenter, multi-specialist practice registry, patients with polyvascular disease had higher 6-month mortality than PAD patients, but this was not a factor in 6-month limb amputation outcomes. This study also underscores that PAD patients still lag in cardioprotective medication use as compared with polyvascular patients.

Management of critical lower limb ischemia in endovascular era: experience from 511 patients

This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.

Endovascular techniques in limb salvage: infrapopliteal angioplasty

Critical limb ischemia (CLI) results from inadequate blood flow to supply and sustain the metabolic needs of resting muscle and tissue. Infragenicular atherosclerosis is the most common cause of CLI, and it is more likely to develop when multilevel or diffuse arterial disease coincides with compromised run-off to the foot. Reports of good technical and clinical outcomes have advanced the endovascular treatment options, which have gained a growing acceptance as the primary therapeutic strategy for CLI, especially in patients with significant risk factors for open surgical bypass. In fact, endovascular recanalization of below-the-knee arteries has proven to be feasible and safe, reduce the need for amputation, and improve wound healing. The distribution of various vascular territories or angiosomes in the foot has been recognized, and it appears advantageous to revascularize the artery supplying the territory directly associated with tissue loss. In addition, the targeted application and local delivery of drugs using drug-coated balloons (DCB) during angioplasty has the potential to improve patency rates compared to balloon angioplasty alone.

IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial

BACKGROUND

The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate "patient-centric" outcomes of functional limb preservation, mobility and quality of life (QoL).

METHODS/DESIGN

IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI.

DISCUSSION

This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014.

TRIAL REGISTRATION

NCT00941733.

IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial

Background

The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate “patient-centric” outcomes of functional limb preservation, mobility and quality of life (QoL).

Methods/Design

IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI.

Discussion

This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014.

Trial registration

NCT00941733

Predictors of improved quality of life and claudication in patients undergoing spinal cord stimulation for critical lower limb ischemia

BACKGROUND

The aim of this study was to determine predictors of improved quality of life and claudication in patients undergoing spinal cord stimulation (SCS) for critical lower limb ischemia.

METHODS

We retrospectively analyzed 101 consecutive patients with few meter claudication and nonhealing ulcer who underwent definitive SCS. These patients were selected among 274 SCS patients treated at our center from 1995 to 2012. All presented with non-reconstructable critical leg ischemia (NR-CLI) and underwent supervised exercise therapy, best medical care and regular ulcers standard or advanced medications for at least 1 month before SCS implantation. We measured self-perceived quality of life using the SF-36 questionnaire. Patients with an improved walking distance of at least 30 meters after SCS had significant improvement on SF-36 questionnaire scores. We considered 30 meters as the cut-off for clinically significant improvement in pain-free walking distance, and we defined this value as functional success. Logistic regression was applied to assess baseline and other patient variables as possible predictors of functional success.

RESULTS

Neither perioperative mortality nor significant complications were found. At a median follow-up of 69 months (range 1-202 months), mortality, major amputation, and minor amputation were 8.9%, 5.9%, and 6.9%, respectively. Functional clinical success was reported in 25.7% of cases. Independent predictors of functional success at univariate analysis included delay between the onset of the ulcer and SCS (P < 0.001) and the pain-free walking distance before SCS (P < 0.002). The only predictive factor of functional success at multivariate analysis was the delay between the onset of ulcer and SCS (median delay in patients with and without functional success was 3 and 15 months, respectively). In particular, comparable to pain-free walking distance before SCS, the success rate decreased by 40% for each month elapsed from onset of ulcer to SCS.

CONCLUSIONS

In our series of patients who underwent SCS, reduced delay between the onset of ulcer and SCS was associated with improved quality of life and walking distance. Larger series are required to confirm these data and to assess clinical implications.

Stem cells of the lower limb: Their role and potential in management of critical limb ischemia

Peripheral arterial occlusive disease (PAOD) contributes to decreased exercise tolerance, poor balance, impaired proprioception, muscle atrophy and weakness, with advanced cases resulting in critical limb ischemia (CLI) where the viability of the limb is threatened. Patients with a diagnosis of CLI have a poor life expectancy due to concomitant cardio and cerebrovascular diseases. The current treatment options to avoid major amputation by re-establishing a blood supply to the limb generally have poor outcomes. Human skeletal muscle contains both multipotent stem cells and progenitor cells and thus has a capacity for regeneration. Phase I and II studies involving transplantation of bone marrow-derived progenitor cells into CLI limbs show positive effects on wound healing and angiogenesis; the increase in quiescent satellite cell numbers observed in CLI muscle may also provide a sufficient in vivo source of resident stem cells. These indigenous cells have been shown to be capable of forming multiple mesodermal cell lineages aiding the repair and regeneration of chronically ischemic muscle. They may also serve as a repository for autologous transplantation. The behavior and responses of the stem cell population in CLI is poorly understood and this review tries to elucidate the potential of these cells and their future role in the management of CLI.

Endovascular treatment for extensive aortoiliac artery reconstruction: a single-center experience based on 1712 interventions

PURPOSE

To determine the clinical and technical outcomes following endovascular therapy for aortoiliac occlusive disease, including complex reconstruction of the aortic bifurcation.

METHODS

A retrospective database search identified 1184 consecutive patients (864 men; mean age 64±10 years) who underwent 1712 procedures to treat target lesions in the distal aorta and iliac arteries from September 1996 to December 2006. The intended strategy was to open only one femoral access site primarily, so a second puncture was needed only for the kissing balloon technique at the aortic bifurcation. The primary endpoint was a 1-year duplex-based primary patency; secondary endpoints included acute technical success (residual stenosis <30%), secondary patency, and target lesion revascularization (TLR). Results were stratified by lesion morphology, which was classified according to the TransAtlantic Inter-Society Consensus (TASC II) document.

RESULTS

Most of the interventions were done in the iliac arteries (n=1337); 292 cases involved the aortic bifurcation, and 83 cases were in the distal aorta/aortic bifurcation. The mean follow-up was 3.24 years (range 0-12.7). In the entire study cohort, the 12- and 24-month restenosis, TLR, and primary/secondary patency rates did not differ among TASC II A-D subgroups. The symptom-driven TLR in the entire cohort was 8% and 9% at the 12- and 24-month follow-up, leading to secondary patency rates of 96% and 91% in the entire cohort. Outcomes for complex interventions in the distal aorta or aortic bifurcation did not differ significantly compared to the total cohort. The overall survival without restenosis, amputation, or surgery in TASC II subgroups A+B was higher (69.6%±1.5%) compared to TASC II C+D lesions (62.8%±1.9%, p=0.001).

CONCLUSION

The indication for percutaneous intervention in aortoiliac occlusive disease can be extended to complex TASC C and D lesions in experienced endovascular centers, even if complex reconstruction of the distal aorta or the aortic bifurcation is indicated.

Atherectomy offers no benefits over balloon angioplasty in tibial interventions for critical limb ischemia

BACKGROUND

Endovascular adjuncts, like atherectomy, were developed to improve outcomes of endovascular arterial interventions. The true impact of atherectomy on endovascular outcomes remains to be determined, and little data exist on the influence of atherectomy on tibial interventions. Our study compares early and late outcomes of tibial intervention with angioplasty vs atherectomy-assisted interventions.

METHODS

We completed a retrospective review of all tibial interventions between 2008 and 2010. Outcomes were analyzed using single and multivariate analysis, Cox regression, and Kaplan-Meier curves. Primary outcomes were primary, primary assisted, and secondary patency rates, as well as limb salvage and survival rates.

RESULTS

Over a 2-year period, 480 tibial interventions were completed for 421 patients. Eighty-seven percent (n = 418) of interventions were performed for critical limb ischemia (CLI) and 13% (n = 62) for claudication. The CLI cohort of 418 interventions was analyzed. These patients had a mean age of 71 years with a mean follow-up time of 16 ± 15 months (range, 0-59 months). Of the 418 interventions, 339 underwent percutaneous transluminal angioplasty (PTA): 333 PTA alone, six PTA + stent. The remaining 79 interventions received atherectomy: 33 laser, 13 directional, and 33 orbital either alone or in conjunction with PTA (11 atherectomy only, 68 atherectomy + PTA). The groups did not differ significantly in terms of demographics, risk factors, or technical success. The atherectomy group had more TASC B lesions (54% vs 38%; P = .013), while the PTA-alone group had more TASC D lesions (25% vs 13%; P = .004). TASC A and C lesions did not differ significantly between the groups. No significant differences existed with respect to the early (30-day) outcomes of loss of patency (11% vs 13%; P = .699), complications (8% vs 13%; P = .292), or major amputation (17% vs 13%; P = .344) in the PTA-alone group vs the atherectomy-assisted group. Kaplan-Meier analysis revealed no difference for all primary outcomes of PTA alone vs the atherectomy-assisted group at 12 and 36 months: primary patency (69%, 55% vs 61%, 46%; P = .158), primary assisted patency (83%, 71% vs 85%, 67%; P = .801), secondary patency (94%, 89% vs 95%, 89%; P = .892), limb salvage (79%, 70% vs 81%, 77%; P = .485), or survival (77%, 56% vs 80%, 50%; P = .944).

CONCLUSIONS

The adjunctive use of atherectomy offered no improvement in primary outcomes over PTA alone in either early or late outcomes in CLI patients who underwent endovascular tibial interventions. Considering the additional cost and increased procedural time, these findings put into question the routine use of adjunctive atherectomy.

Endovascular revascularization for patients with critical limb ischemia: impact on wound healing and long term clinical results in 189 limbs

Objective

To evaluate the impact on wound healing and long-term clinical outcomes of endovascular revascularization in patients with critical limb ischemia (CLI).

Materials and Methods

This is a retrospective study on 189 limbs with CLI treated with endovascular revascularization between 2008 and 2010 and followed for a mean 21 months. Angiographic outcome was graded to technical success (TS), partial failure (PF) and complete technical failure. The impact on wound healing of revascularization was assessed with univariate analysis and multivariate logistic regression models. Analysis of long-term event-free limb survival, and limb salvage rate (LSR) was performed by Kaplan-Meier method.

Results

TS was achieved in 89% of treated limbs, whereas PF and CF were achieved in 9% and 2% of the limbs, respectively. Major complications occurred in 6% of treated limbs. The 30-day mortality was 2%. Wound healing was successful in 85% and failed in 15%. Impact of angiographic outcome on wound healing was statistically significant. The event-free limb survival was 79.3% and 69.5% at 1- and 3-years, respectively. The LSR was 94.8% and 92.0% at 1- and 3-years, respectively.

Conclusion

Endovascular revascularization improve wound healing rate and provide good long-term LSRs in CLI.

Age, male gender, and atrial fibrillation predict lower extremity amputation or revascularization in patients with peripheral artery diseases: a population-based investigation

By using the National Health Insurance (NHI) claim data of Taiwan, we sought to determine the predictors for nontraumatic lower extremity amputation (LEA) or peripheral revascularization procedures (PRP) in patients with peripheral artery disease (PAD). From the NHI claim data, we identified 12,206 patients with newly diagnosed PAD between 1998 and 2008, and followed them up to 2008. We explored the age, gender, and whether the patients had concomitant comorbid conditions, such as diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AF), stroke, hospitalization for coronary artery disease (CAD), myocardial infarction (MI), or heart failure (HF), and whether they were taking cilostazol at the time of recruitment. We searched for clinical parameters that might be important determinants for LEA or PRP in the study population. Of the 12,206 patients, 150 (1.2%) were found to undergo either LEA or PRP or both (LEA 81, PRP 53, both PRP and LEA 16). Old age, male gender, and history of hospitalization for CAD or MI and AF were found to be risk predictors for both procedures. Patients with DM were at lower risk for PRP (odds ratio 0.418, p = 0.001). Patients who were taking cilostazol had higher risk for LEA or PRP. HTN was not a risk predictor for LEA or PRP. From this nationwide study, we found that among PAD patients in Taiwan, age, male gender, AF, and hospitalization for CAD or MI are risk predictors for future LEA or PRP. DM is a negative predictor for PRP while both DM and HTN are not risk predictors for LEA.

Outcomes following infrapopliteal angioplasty for critical limb ischemia

OBJECTIVE

Infrapopliteal angioplasty (percutaneous transluminal angioplasty [PTA]) is routinely used to treat critical limb ischemia (CLI) despite limited data on long-term outcomes.

METHODS

We reviewed all patients undergoing infrapopliteal PTA for CLI from 2004 to 2012 stratified by TransAtlantic Inter-Society Consensus (TASC) class. Outcomes included restenosis, primary patency, reintervention (w/PTA or bypass), amputation, procedural complications, wound healing, and survival.

RESULTS

Infrapopliteal PTA (stenting 14%, multilevel intervention 50%) was performed in 459 limbs of 413 patients (59% male) with a technical success of 93% and perioperative complications in 11%. TASC class was 16% A, 22% B, 27% C, and 34% D. Multilevel interventions were performed in 50% of limbs and were evenly distributed among all TASC classes. All technical failures were TASC D lesions. Mean follow-up was 15 months; 5-year survival was 49%. One- and 5-year primary patency was 57% and 38% and limb salvage was 84% and 81%, respectively. Restenosis was associated with TASC C (hazard ratio [HR], 2.2; 95% CI, 1.2-3.9; P = .010) and TASC D (HR, 2.4; 95% CI, 1.3-4.4; P = .004) lesions. Amputation rates were higher in patients who were not candidates for bypass (HR, 4.4; 95% CI, 2.6-7.5; P < .001) and with TASC D lesions (HR, 3.8; 95% CI, 1.1-12.5; P = .03). Unsuitability for bypass was also predictive of repeat PTA (HR, 1.8; 95% CI, 1.0-3.4; P = .047). Postoperative clopidogrel use was associated with lower rates of any revascularization (HR, 0.46; 95% CI, 0.25-0.83; P = .011).

CONCLUSIONS

Infrapopliteal PTA is effective primary therapy for TASC A, B, and C lesions. Surgical bypass should be offered to patients with TASC D disease who are suitable candidates. Multilevel intervention does not adversely affect outcome.

Predictors and outcomes of restenosis following tibial artery endovascular interventions for critical limb ischemia

OBJECTIVE

Restenosis following tibial artery endovascular interventions (TAEIs) is thought to be benign but is not well characterized. This study examines the consequences and predictors of recurrent stenosis of TAEIs for critical limb ischemia.

METHODS

All TAEIs for critical limb ischemia performed between 2004 and 2010 were retrospectively reviewed. Restenosis was detected by noninvasive imaging and angiography when indicated. Restenoses were identified and the limb outcomes recorded. Tibial reinterventions were performed only for persistent, worsening, or recurrent tissue loss or rest pain with evidence of recurrence on duplex ultrasound or hemodynamic imaging. The χ test and logistic regression were applied as indicated. One-year patency rates were calculated using the Kaplan-Meier method.

RESULTS

A total of 235 limbs in 210 patients were treated for critical limb ischemia (70% tissue loss, 30% rest pain). Tissue loss included gangrene (49%) and ulcers (51%), and involved the forefoot (80%), the heel (14%), or both (6%). Seventy-eight percent of limbs had Trans-Atlantic InterSociety Consensus C/D lesions, with mean preoperative runoff score of 12. Interventions were isolated tibial (45%) or multilevel (55%) (including tibial). Mean postoperative runoff score improved to 6.6, but restenosis occurred in 96 limbs (41%) at a mean of 4 months. The 1-year primary patency was 59% with a mean follow-up of 9 months. Restenosis presented with a persistent wound (32%), worsened wound (42%), rest pain (16%), or no symptoms (10%). A repeat TAEI was performed in 42 (44%), major amputation in 26 (27%), open bypass in 20 (21%), and observation in eight (8%). The overall amputation rate was 13%, but limb loss was significantly higher in patients with restenosis (n = 26 [27%]) than in patients with no restenosis (n = 5 [4%]; P < .001). Patients with restenosis and tissue loss were more likely to have presented with gangrene (63% vs 38%; P = .0003) but had comparable wound distribution (P = NS). There was a trend toward a higher restenosis rate in patients with renal insufficiency (odds ratio, 5.57; P = .08), but this was unaffected by diabetes, statin therapy, or smoking (P = NS). The rate of repeat intervention after the first reintervention was 36%, with an 87% overall limb salvage rate.

CONCLUSIONS

TAEIs can be used successfully to treat patients with critical limb ischemia with acceptable limb salvage rates. Special attention should be given to patients with extensive tissue loss or gangrene because they are at risk for early restenosis and subsequent limb loss. Strict wound and hemodynamic surveillance, wound care, and timely reinterventions are crucial to achieve successful outcomes in this patient population. Amputation or alternative revascularization options, when feasible, should be considered in patients with restenosis and tissue loss given the high rate of limb loss with tibial reinterventions.

Endovascular intervention in Taiwanese patients with critical limb ischemia: patient outcomes in 333 consecutive limb procedures with a 3-year follow-up

BACKGROUND/PURPOSE

Midterm outcomes of endovascular intervention (EVI) for critical limb ischemia (CLI) have not been previously reported in Taiwan. This study assessed the safety, feasibility, and patient-oriented outcomes for CLI patients after EVI.

METHODS

From June 2005 to December 2011, 270 patients underwent EVI for CLI of 333 limbs. Primary patency (PP), assisted primary patency (AP), limb salvage, sustained clinical success (SCS), secondary SCS (SSCS), and survival were assessed using Kaplan-Meier analysis.

RESULTS

The procedural success rate was 89%, and the periprocedural mortality and major complication rates within 30 days were 0.6% and 6.9%, respectively. During the mean follow-up time of 27 ± 20 months (1-77), 64 patients died and 25 legs required major amputation. Eighty-one percent of the patients with tissue loss had wound healing at 6 months and 75% of the patients were ambulatory, with or without assisting devices, at 1 year. The overall survival and limb salvage rates at 3 years were 70% and 90%, respectively. The PP and AP at 1 and 3 years were 58% and 37% and 79% and 61%, respectively. The SCS and SSCS were 65% and 46% and 80% and 64% at 1 and 3 years, respectively.

CONCLUSION

In Taiwan, EVI was a safe and feasible procedure for CLI patients, with a high procedural success rate and lower complication rate. Sustained limb salvage and clinical success can be afforded with an active surveillance program and prompt intervention during midterm follow-up.

Surgical bypass: when is it best and do angiosomes play a role?

The etiology of foot lesions in diabetics is multifactorial. Arterial insufficiency, neuropathy, and susceptibility to infection are major factors contributing to the formation of nonhealing diabetic foot lesions. These factors lead to a 15% ulceration rate in diabetics with 20% resulting in amputation. This amputation rate, 4.1 per 1,000 per year, represents a risk 40 times greater for diabetics, with a subsequent second amputation in 60% by 5 years. Conversely, more than half of all lower-extremity amputations are performed in diabetic patients. Therefore, the primary goal in diabetic lower-extremity care is to heal foot ulcerations and prevent amputations and major disabilities. Lower-extremity revascularization is a major facet of achieving the goal of healing and amputation prevention. Due to the severity, distribution, and complexity of diabetic vascular disease, surgical bypass continues to play a role in attaining this goal. Surgical bypass might be the best option for diabetic patients with significant tissue loss or to revascularize the appropriate angiosome of the foot and maximize healing potential. In order to offer surgical bypass to these patients, innovative techniques might need to be considered, including venous patches and cuffs, heparin-bonded grafts, and adjunctive distal arteriovenous fistulas.

Endovascular revascularization of symptomatic infrapopliteal arteriosclerotic occlusive disease: comparison of atherectomy and angioplasty

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.

Neo-intimal hyperplasia, diabetes and endovascular injury

Diabetes is a significant major risk factor for peripheral arterial disease (PAD) and critical limb ischaemia (CLI), the latter which is also the most common cause of amputation in these patients. Revascularisation of the lower extremities of such patients is imperative for limb salvage and has become First-line therapy. However, the incidence of restenosis following endovascular stenting is very high and is largely due to neo-intimal hyperplasia (NIH), the regulation of which is for the greater part not understood. This article therefore reviews our understanding on the regulation of NIH following stent-induced vascular injury, and highlights the importance of future studies to investigate whether the profile of vascular progenitor cell differentiation, neo-intimal growth factors and lumen diameters predict the severity of post-stent NIH in the peripheral arteries. Results from future studies will (1) better our understanding of the regulation of NIH in general, (2) determine whether combinations of any of the vascular factors discussed are predictive of the extent of NIH postoperatively, and (3) potentially facilitate future therapeutic targets and/or change preventive strategies.

Clinical outcomes of infrapopliteal angioplasty in patients with critical limb ischemia

Background and Objectives

With recent advances in equipment and techniques, infrapopliteal angioplasty has shown results that are comparable to those of surgical bypass in patients with critical limb ischemia (CLI). In this study, we evaluated the efficacy and the feasibility of infrapopliteal angioplasty in patients with CLI.

Subjects and Methods

Between March 2002 and May 2008, infrapopliteal angioplasty was performed on 118 limbs of 101 patients (79 males; mean age 66 years) with CLI (Rutherford category 4, 5 or 6). Freedom from reintervention, limb salvage, and overall survival were analyzed.

Results

The median follow-up duration was 30 months. Initial technical and clinical success rates were 69.5% and 83.1%, respectively. No major complication requiring surgical intervention developed after angioplasty. Among 82 limbs with initial technical success, the rate of freedom from any reintervention at 2 years was 70.7% and that from limb salvage was 97.6%. Young age and Rutherford category 6 at initial presentation were independent predictors associated with poor 2 year primary patency in these patients with CLI. Overall survival at 1 year was 86.4% and that at 2 years 76.3%. A history of cerebrovascular accident was an independent predictor associated with poor 2 year survival in these patients.

Conclusion

Infrapopliteal angioplasty as a primary choice of treatment in CLI patients showed favorable clinical outcomes and feasibility.

Patients' perspective about risks and benefits of treatment for peripheral arterial disease

PURPOSE

To report the results of a standard gamble-type survey conducted to explore patients' heuristics in regard to therapy for peripheral arterial disease (PAD).

MATERIALS AND METHODS

Patients presenting to a vascular and interventional radiology practice because of suspected PAD were asked to indicate their threshold for risk of amputation during a curative procedure for intermittent claudication (IC) and for risk of death from a curative medication for critical limb ischemia (CLI). Possible relationships of risk threshold with age, gender, ankle-brachial index (ABI), and functional claudication distance were assessed with univariate statistics followed by multivariable generalized linear mixed models of risk acceptance at various risk levels.

RESULTS

Study participants were 20 patients (40% women), with median age of 64 years, functional claudication distance of 1 block, and ABI of 0.72. In the IC scenario, up to 1% risk of above-knee amputation was found to be the median risk acceptable to patients for undergoing a curative procedure. In the CLI scenario, the median risk acceptance for mortality from a curative medication was up to 1%. The multivariable model for the IC scenario revealed significantly greater acceptance of risk at a given level among older patients and women. No significant predictor was delineated by the multivariable model for the CLI scenario.

CONCLUSIONS

Overall, patients have a low threshold for complications of PAD therapy, consistent with endovascular but not with open surgical strategies. However, considerable variation in preferences underlines the value of individualized treatment strategies.

Efficacy of endoluminal interventional therapy in diabetic peripheral arterial occlusive disease: a retrospective trial

Background

The purpose of this study was to assess the efficacy of interventional therapy for peripheral arterial occlusive disease and the difference between diabetic patients and non-diabetic patients.

Methods

139 consecutive patients between September 2006 and September 2010 who underwent percutaneous lower extremity revascularization for arterial lesions were divided into diabetes group (n = 62) and non-diabetes group (n = 77). Before intervention, rest ankle brachial indexes and three dimensional computed tomography angiography from abdominal aorta to tiptoe were performed. The interventional treatments included angioplasty with or without stenting. The clinical outcomes included rest ankle-brachial indexes, primary patency rates, secondary patency rates and limb-salvage rates for 6-month, 12-month, 24-month and 36-month after treatment. The primary and secondary patency rates of all interventions and the limb-salvage rates of the patients are illustrated by Kaplan-Meier curves and compared by log-rank analysis.

Results

The interventional operation success rates were 98.4% (61/62) in diabetes group and 100% (77/77) in non-diabetes group. The re-interventional operation success rates were 85.7% (18/21) in diabetes group and 76.9% (20/26) in non-diabetes group. The mean value of ankle brachial indexes was significantly increased after intervention (0.397 ± 0.125 versus 0.779 ± 0.137, t = -25.780, P < 0.001) in diabetes group and (0.406 ± 0.101 versus 0.786 ± 0.121, t = -37.221, P < 0.001) in non-diabetes group. Perioperative 30-day mortality was 0%. Major complications included groin hematoma in 7.2%, and pseudoaneurysm formation 2.2%. In diabetes group, 6, 12, 24, and 36-month primary patency rates were 88.7% ± 4.0%, 62.3% ± 6.6%, 55.3% ± 7.0%, and 46.5% ± 7.5%; secondary patency rates were 93.5% ± 3.1%, 82.3% ± 5.1%, 70.8% ± 6.5%, and 65.7% ± 7%; limb-salvage rates were 95.2% ± 2.7%, 87.7% ± 4.4%, 85.5% ± 4.8%, and 81.9% ± 5.8%. In non-diabetes group, 6, 12, 24, and 36-month primary patency rates were 90.9% ± 3.3%, 71.8% ± 5.4%, 71.8% ± 5.4%, and 60.9% ± 6.2%; secondary patency rates were 96.1% ± 2.2%, 91.6% ± 3.3%, 82.7% ± 4.8%, and 71.8% ± 6.2%; limb-salvage rates were 97.4% ± 1.8%, 94.4% ± 2.7%, 90.6% ± 3.7%, and 83.1% ± 5.4%. The differences between two groups were not significant (P > 0.05).

Conclusion

With a low risk of morbidity and mortality, the percutaneous revascularization accepted by patients does not affect ultimate necessary surgical revascularization and consequently should be considered as the preferred therapy for chronic lower extremity ischemia. The efficacy and prognosis of interventional therapy in diabetic patients is similar that in non-diabetic patients.

Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease

OBJECTIVE

Critical limb ischemia, the most severe form of peripheral arterial disease, results in extremity amputation if left untreated. Endovascular recanalization of stenotic or occluded infrapopliteal arteries has recently emerged as an effective form of therapy, although the duration of patency is typically limited by restenosis. Recently, it has been suggested that drug-eluting stents originally developed for the coronary arteries might also be effective in preventing restenosis in the infrapopliteal arteries. This prospective, randomized, controlled clinical trial tested the hypothesis that treatment of infrapopliteal arterial occlusive lesions with an everolimus-eluting stent (Xience V) would provide superior patency to treatment with a bare-metal stent (Multi-Link Vision).

METHODS

A sample size of 140 patients was planned to be enrolled at five European investigative sites. The primary end point was arterial patency at 12 months, defined as the absence of ≥50% restenosis based on quantitative analysis of contrast angiography.

RESULTS

Between March of 2008 and September of 2009, 74 patients were treated with Xience V and 66 patients were treated with Vision. After 12 months, the primary patency rate after treatment with Xience V was 85% compared with 54% after treatment with Vision (P = .0001). Treatment with Xience V significantly reduced mean in-stent diameter stenosis (21% ± 21% vs 47% ± 27%; P < .0001) and mean in-stent late lumen loss (0.78 ± 0.63 vs 1.41 ± 0.89 mm; P = .001). There were no differences in the percentage of patients receiving a designation of Rutherford class 0 or 1 at the 12-month follow-up visit (56% for Vision, vs 60% for Xience V; P = .68). Major extremity amputations were rare in both groups (two for Vision and one for Xience V). The use of the Xience V stent significantly reduced the need for repeat intervention: freedom from target lesion revascularization was 91% for Xience V vs 66% for Vision (P = .001).

CONCLUSIONS

Treatment of the infrapopliteal occlusive lesions of critical limb ischemia with everolimus-eluting stents reduces restenosis and the need for reintervention compared with bare metal stents.

Critical limb ischemia: endovascular strategies for limb salvage

Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease, defined as the presence of chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The dominant pathology underlying CLI is atherosclerosis, distributed at multiple levels along the length of the lower extremity and with a propensity for involvement of the tibial vessels in the leg and the small vessels of the foot. To achieve limb salvage in patients with CLI, revascularization of the affected limb is generally required. In contemporary practice, endovascular techniques are rapidly replacing surgical bypass as the first option for revascularization for CLI based on high technical success rates and low rates of procedure-related morbidity and mortality. This review will describe the clinical strategy of the authors who have adopted an endovascular-first approach to revascularization in treating patients with CLI and summarize the clinical outcomes of endovascular therapy in this population.

Multilevel versus isolated endovascular tibial interventions for critical limb ischemia

OBJECTIVE

Endovascular interventions for critical limb ischemia (CLI) continue to have variable reported results. The purpose of this study is to determine the effect of disease level and distribution on the outcomes of tibial interventions.

METHODS

A retrospective analysis of all tibial interventions done for CLI between 2006 and 2009 was performed. Outcomes of isolated tibial (group I) and multilevel interventions (group II) (femoropopliteal and tibial) were compared.

RESULTS

Endovascular interventions were utilized to treat 136 limbs in 123 patients for CLI: 54 isolated tibial (85% tissue loss), and 82 multilevel (80% tissue loss). Mean age and baseline comorbidities were comparable. The mean ankle-brachial index (ABI) was significantly lower prior to intervention in group II (0.53 vs 0.74; P < .001) but was similar postintervention (0.86 vs 0.88; P = NS). Wound healing or improvement was achieved in 69% in group I and in 87% in group II (P = .05). Mean overall follow-up was 12.6 ± 5.3 months. Time to healing was significantly longer in group I: 11.5 ± 8.8 months vs 7.7 ± 6.6 months (P = .03). Limb salvage was achieved in 81% of group I and 95% of group II (P = .05). The rate of reintervention was similar (13% vs 18%, P = NS), so was the rate of late surgical conversion (0% vs 6%; P = NS). Limb loss resulted from lack of conduit or initial target vessel for bypass and high-risk systemic comorbidities. Overall mortality rates were similar among both groups. An isolated tibial intervention was a predictor of limb loss at 1 year on multivariate analysis and resulted in a lower rate of limb salvage at 1 year compared with multilevel interventions. Additionally, despite comparable primary patency rates, there was improved secondary patency with multilevel interventions compared with the isolated tibial interventions. Predictors of limb loss in patients treated with isolated tibial intervention included multiple synchronous tibial revascularization (P = .005) and advanced coronary artery disease requiring revascularization (P = .005).

CONCLUSIONS

Adequate rates of limb salvage can be achieved in patients undergoing multilevel interventions for CLI, and improved patency is seen with multilevel compared to isolated tibial interventions. Patients with isolated tibial disease appear to have a higher incidence of limb loss secondary to poor initial pedal runoff, more extensive distal disease, and severe comorbidities precluding surgical bypass. Other therapeutic strategies should be considered in these patients, including primary amputation or pedal bypass when applicable.

Tibial intervention for critical limb ischemia

Diagnosis and treatment of critical limb ischemia (CLI) is increasingly important as the average age of the world population and the incidence of diabetes and metabolic syndrome increases. Fortunately, most patients will not progress to this stage of peripheral arterial disease, yet if left untreated, there is a high risk of future cardiovascular events. At the point of ischemic rest pain or tissue loss, there are significant implications for morbidity and mortality. There is a high prevalence of multisegment occlusive disease in the CLI patient with the infrapopliteal vessels frequently involved. Revascularization of the affected limb is of utmost importance as the prospects of wound healing and relief of ischemic rest pain are poor without reestablishing continuous flow to the distal extremity. With the advent of endovascular devices designed to treat this vexing problem, the ability to successfully treat this difficult patient population with less procedural morbidity has been greatly enhanced.