Infrapopliteal angioplasty for critical limb ischemia: Relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs

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.

Popliteo-pedal bypass surgery for critical limb ischemia

BACKGROUND

Critical limb ischaemia due to distal arterial disease represents a significant challenge. Randomised controlled evidence suggests that open surgery may be superior to endovascular intervention but there is limited data on the specific clinical cohort with exclusively infra-popliteal disease.

AIM

We analysed indications for, and outcome from all, popliteo-pedal bypass procedures performed between July 1998 to November 2008.

PATIENTS AND METHODS

Twenty-eight bypass procedures were performed in 24 patients. Autologous vein was used exclusively. The proximal anastomosis was to the below-knee popliteal artery in all the patients; the distal anastomosis was to plantar artery (n = 15) or dorsalis pedis artery (n = 13). Mean patient age was 63.Eight years of age (range 37-92 years). Indications for surgery were tissue loss (n = 21) and rest pain (n = 7). Ultrasound graft surveillance was performed every 6-months.

RESULTS

Using life table analysis, primary graft patency was 63.3% at 1-, 3- and 5-years and secondary patency (after three interventions) was 74.6% at 1-, 3- and 5-years. Limb salvage rate was 81.8% after 1-, 3- and 5-years as all five limb amputations were performed in the first 3-months following the surgery. Overall survival was 75, 75 and 47.1% at 1-, 3- and 5-years, respectively. The major amputation free survival rate was 54.2, 54.2 and 21.3% at 1-, 3- and 5-years, respectively. Seventy-nine percent (n = 19) patients were diabetic.

CONCLUSION

Our data supports popliteo-pedal bypass as an effective treatment for distal vascular disease. Comparison with endovascular treatment in a randomised trial needs to be performed.

Lower extremity vascular stenting for a post-traumatic pseudoaneurysm in a young trauma patient

Endovascular treatment of post-traumatic pseudoaneurysms has become a viable, less invasive option when compared to open repair. Due to the relative youth of this technology, studies have yet to be concluded on the long-term patency of stent grafts in this population. For this reason, concern exists with endovascular stent placement in the young trauma patient. In this study, we present a case and review the literature on a post-traumatic pseudoaneurysm of the posterior tibial artery in a 19-year-old man treated with an endovascular stent.

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.

Update on biological therapies for critical limb ischemia

Gene and stem cell therapies have been shown to be safe and well tolerated. Early trial results using these therapies have had promising results on important clinical end points such as wound healing, ischemic pain, and major amputation. Despite this, there have been no pivotal trials to date that have proved the benefit of biological therapy, although there are numerous pivotal trials in progress or about to initiate enrollment. Persistent obstacles exist with current study designs that complicate the ability to successfully perform clinical critical limb ischemia trials.

Autologous bone marrow mononuclear cell therapy is safe and promotes amputation-free survival in patients with critical limb ischemia

OBJECTIVE

The purpose of this Phase I open label nonrandomized trial was to assess the safety and efficacy of autologous bone marrow mononuclear cell (ABMNC) therapy in promoting amputation-free survival (AFS) in patients with critical limb ischemia (CLI).

METHODS

Between September 2005 and March 2009, 29 patients (30 limbs), with a median age of 66 years (range, 23-84 years; 14 male, 15 female) with CLI were enrolled. Twenty-one limbs presented with rest pain (RP), six with RP and ulceration, and three with ulcer only. All patients were not candidates for surgical bypass due to absence of a patent artery below the knee and/or endovascular approaches to improving perfusion was not possible as determined by an independent vascular surgeon. Patients were treated with an average dose of 1.7 ± 0.7 × 10(9) ABMNC injected intramuscularly in the index limb distal to the anterior tibial tuberosity. The primary safety end point was accumulation of serious adverse events, and the primary efficacy end point was AFS at 1 year. Secondary end points at 12 weeks posttreatment were changes in first toe pressure (FTP), toe-brachial index (TBI), ankle-brachial index (ABI), and transcutaneous oxygen measurements (TcPO(2)). Perfusion of the index limb was measured with positron emission tomography-computed tomography (PET-CT) with intra-arterial infusion of H(2)O(15). RP, using a 10-cm visual analogue scale, quality of life using the VascuQuol questionnaire, and ulcer healing were assessed at each follow-up interval. Subpopulations of endothelial progenitor cells were quantified prior to ABMNC administration using immunocytochemistry and fluorescent-activated cell sorting.

RESULTS

There were two serious adverse events; however, there were no procedure-related deaths. Amputation-free survival at 1 year was 86.3%. There was a significant increase in FTP (10.2 ± 6.2 mm Hg; P = .02) and TBI (0.10 ± 0.05;P = .02) and a trend in improvement in ABI (0.08 ± 0.04; P = .73). Perfusion index by PET-CT H(2)O(15) increased by 19.3 ± 3.1, and RP decreased significantly by 2.2 ± 0.6 cm (P = .02). The VascuQol questionnaire demonstrated significant improvement in quality of life, and three of nine ulcers (33%) healed completely. KDR(+) but not CD34(+) or CD133(+) subpopulations of ABMNC were associated with improvement in limb perfusion.

CONCLUSION

This Phase I study has demonstrated safety, and the AFS rates suggest efficacy of ABMNC in promoting limb salvage in "no option" CLI. Based on these results, we plan to test the concept that ABMNCs improve AFS at 1 year in a Phase III randomized, double-blinded, multicenter trial.

Critical evaluation of endovascular surgery for limb salvage

Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.

Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes

Endovascular therapy has increasingly become the initial clinical option for the treatment of lower-extremity peripheral arterial occlusive disease not only for patients with claudication but also for those with critical limb ischemia. Despite this major clinical practice paradigm shift, the outcomes of endovascular therapy for peripheral arterial disease are difficult to evaluate and compare with established surgical benchmarks because of the lack of prospective randomized trials, incomplete characterization of indications for intervention, mixing of arterial segments and extent of disease treated, the multiplicity of endovascular therapy techniques used, the exclusion of early treatment failures, crossover to open bypass during follow-up, and the frequent lack of intermediate and long-term patency and limb salvage rates in life-table format. These data limitations are especially problematic when one tries to assess the outcomes of endovascular therapy in patients with diabetes. The purpose of the present article is to succinctly review and objectively analyze available data regarding the results of endovascular therapy in patients with diabetes.

Challenges of distal bypass surgery in patients with diabetes: patient selection, techniques, and outcomes

Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to optimize long-term results. The diabetic patient with a critically ischemic limb offers some specific challenges; however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and define the standard of care. Technical factors, such as conduit and inflow/outflow artery selection, play a dominant role in determining clinical success. An adequate-caliber, good-quality great saphenous vein is the optimal graft for distal bypass in the leg. Alternative veins perform acceptably in the absence of the great saphenous vein, whereas prosthetic and other nonautogenous conduits have markedly inferior outcomes. Graft configuration (reversed, nonreversed, or in situ) seems to have little effect on outcome. Shorter grafts have improved patency. Inflow can be improved by surgical or endovascular means if necessary, and distal-origin grafts (eg, those arising from the superficial femoral or popliteal arteries) can perform as well as those originating from the common femoral artery. The selected outflow vessel should supply unimpeded runoff to the foot, conserve conduit length, and allow for adequate soft-tissue coverage of the graft and simplified surgical exposure. This review summarizes the available data linking patient selection and technical factors to outcomes and highlights the importance of surgical judgment and operative planning in the current practice of infrainguinal bypass surgery.

Endovascular management of patients with critical limb ischemia

BACKGROUND

Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined.

METHODS

From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models.

RESULTS

Demographics included age (70 ± 12 years old), diabetes (65.8%), and dialysis dependence (13%). The superficial femoral artery was treated in 58% of the patients, 16% were limited to the crural vessels, 38% had multilevel treatment, and stents were placed in 26%. Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31% ± 0.04 and 75% ± 0.04, respectively. Limb salvage at 5 years was 74% ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39% ± 0.03. Multivariate analysis identified dialysis dependence (P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff (P = .02; 1.5 [1.1-2.0]), and warfarin use (P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence (P = .006; 2.5 [1.3-4.8]), female gender (P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off (P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence (P = .0003; 2.3 [1.5-3.5]), diabetes (P = .04; 1.5 [0.5-2.1]), and poor run-off (P = .04; 1.6 [1.2-2.1]) were predictors of mortality.

CONCLUSION

Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12% annual death rate, validate PTA as first-line therapy in patients with CLI.

Safety and efficacy of patient specific intramuscular injection of HGF plasmid gene therapy on limb perfusion and wound healing in patients with ischemic lower extremity ulceration: results of the HGF-0205 trial

OBJECTIVES

We have previously reported the results of a dose-finding phase II trial showing that HGF angiogenic gene therapy can increase TcPO2 compared with placebo in patients with critical limb ischemia (CLI). The purpose of this randomized placebo controlled multi-center trial was to further assess the safety and clinical efficacy of a modified HGF gene delivery technique in patients with CLI and no revascularization options.

METHODS

Patients with lower extremity ischemic tissue loss (Rutherford 5 and 6) received three sets of eight intramuscular injections every 2 weeks of HGF plasmid under duplex ultrasound guidance. Injection locations were individualized for each patient based on arteriographically defined vascular anatomy. Primary safety end point was incidence of adverse events (AE) or serious adverse events (SAE). Clinical end points included change from baseline in toe brachial index (TBI), rest pain assessment by a 10 cm visual analogue scale (VAS) as well as wound healing, amputation, and survival at 3 and 6 months.

RESULTS

Randomization ratio was 3:1 HGF (n = 21) vs placebo (n = 6). Mean age was 76 ± 2 years, with 56% male and 59% diabetic. There was no difference in demographics between groups. There was no difference in AEs or SAEs, which consisted mostly of transient injection site discomfort, worsening of CLI, and intercurrent illnesses. Change in TBI significantly improved from baseline at 6 months in the HGF-treated group compared with placebo (0.05 ± 0.05 vs -0.17 ± 0.04; P = .047). Change in VAS from baseline at 6 months was also significantly improved in the HGF-treated group compared with placebo (-1.9 ± 1.3 vs +0.06 ± 0.2; P = .04). Complete ulcer healing at 12 months occurred in 31% of the HGF group and 0% of the placebo (P = .28) There was no difference in major amputation of the treated limb (HGF 29% vs placebo 33%) or mortality at 12 months (HGF 19% vs placebo 17%) between groups.

CONCLUSION

HGF gene therapy using a patient vascular anatomy specific delivery technique appears safe, maintained limb perfusion, and decreased rest pain in patients with CLI compared with placebo. A larger study to assess the efficacy of this therapy on more clinically relevant end points is warranted.

Predictors of failure and success of tibial interventions for critical limb ischemia

OBJECTIVE

The efficacy of tibial artery endovascular intervention (TAEI) for critical limb ischemia (CLI) and particularly for wound healing is not fully defined. The purpose of this study is to determine predictors of failure and success for TAEI in the setting of CLI.

METHODS

All TAEI for tissue loss or rest pain (Rutherford classes 4, 5, and 6) from 2004 to 2008 were retrospectively reviewed. Clinical outcomes and patency rates were analyzed by multivariable Cox proportional hazards regression and life table analysis.

RESULTS

One hundred twenty-three limbs in 111 patients (62% male, mean age 74) were treated. Sixty-seven percent of patients were diabetics, 55% had renal insufficiency, and 21% required hemodialysis. One hundred two limbs (83%) exhibited tissue loss; all others had ischemic rest pain. All patients underwent tibial angioplasty (PTA). Tibial excimer laser atherectomy was performed in 14% of the patients. Interventions were performed on multiple tibial vessels in 20% of limbs. Isolated tibial procedures were performed on 50 limbs (41%), while 73 patients had concurrent ipsilateral superficial femoral artery or popliteal interventions. The mean distal popliteal and tibial runoff score improved from 11.8 ± 3.6 to 6.7 ± 1.6 (P < .001), and the mean ankle-brachial index increased from 0.61 ± 0.26 to 0.85 ± 0.22 (P < .001). Surgical bypass was required in seven patients (6%). The mean follow up was 6.8 ± 6.6 months, while the 1-year primary, primary-assisted, and secondary patency rates were 33%, 50%, and 56% respectively. Limb salvage rate at 1 year was 75%. Factors found to be associated with impaired limb salvage included renal insufficiency (hazard ratio [HR] = 5.7; P = .03) and the need for pedal intervention (HR = 13.75; P = .04). TAEI in an isolated peroneal artery (odds ratio = 7.80; P = .01) was associated with impaired wound healing, whereas multilevel intervention (HR = 2.1; P = .009) and tibial laser atherectomy (HR = 3.1; P = .01) were predictors of wound healing. In patients with tissue loss, 41% achieved complete closure (mean time to healing, 10.7 ± 7.4 months), and 39% exhibited partial wound healing (mean follow up, 4.4 ± 4.8 months) at last follow up. Diabetes, smoking, statin therapy, and revascularization of > 1 tibial vessel had no impact on limb salvage or wound healing. Re-intervention rate was 50% at 1 year.

CONCLUSIONS

TAEI is an effective treatment for CLI with acceptable limb salvage and wound healing rates, but requires a high rate of reintervention. Patients with renal failure, pedal disease, or isolated peroneal runoff have poor outcomes with TAEI and should be considered for surgical bypass.

Early duplex scanning after infrainguinal endovascular therapy

OBJECTIVES

Duplex ultrasound scanning (DUS) has benefit for intraoperative and subsequent evaluation of surgical bypasses in the lower extremities. The utility of DUS after endovascular revascularizations is not established. This study was performed to evaluate whether DUS findings after infrainguinal endovascular interventions for critical limb ischemia (CLI) were predictive of need for reintervention or amputation.

METHODS

To identify the study cohort, peripheral interventions for CLI (Rutherford grades 4, 5, 6) over a 24-month period (2006-2007) were reviewed. DUS findings were considered indicative of hemodynamic stenosis if the peak systolic velocity (PSV) was ≥ 180 cm/s or the PSV velocity ratio was ≥ 2.0. Demographic, clinical, procedural, and outcomes were examined. SVS and TASC II classifications and reporting standards were used. Arteriograms were reviewed and treated segments were categorized as patent (<30% residual stenosis) or abnormal (≥ 30% residual stenosis).

RESULTS

There were 122 infrainguinal interventions for CLI in 113 patients (53% male; mean age 71 years). Risk factors included diabetes: 61%; renal failure: 20%; and smoking (within 1 year): 40%. DUS was performed within 30 days of the index procedure in 90 cases. Fifty patients had an abnormal early duplex and 40 patients had a normal duplex. In patients with a normal duplex ultrasound the amputation rate was 5% vs 20% in the group with an abnormal duplex (P = .04). Primary patency was 56% in the normal duplex group and 46% in the abnormal duplex group (P = .18). Early duplex ultrasound was able to identify a residual stenosis not seen on completion angiography in 56% of cases.

CONCLUSIONS

Duplex scanning detects residual stenosis missed with conventional angiography after infrainguinal interventions. An abnormal DUS in the first 30 days after an intervention is associated with an increased risk of amputation. This suggests a possible role for intraprocedural DUS, as well as routine postprocedure DUS, close clinical follow-up, and consideration of reintervention for residual abnormalities in patients treated for CLI.

Outcome analysis of infrapopliteal percutaneous transluminal angioplasty and bypass graft surgery with nonreversed saphenous vein for individuals with critical limb ischemia

OBJECTIVE

To compare the results of percutaneous transluminal angioplasty (PTA) and bypass graft surgery (BGS) for the treatment of infrapopliteal lesions in individuals presenting with critical limb ischemia (CLI).

METHOD

A total of 48 infrapopliteal PTAs and 50 infrapopliteal BGS were compared retrospectively. All grafts used nonreversed saphenous vein in a single length as a substitute.

RESULTS

Secondary patency and limb salvage rates in 24 months for the surgical group were 64.7% and 73.2%, respectively. For PTA group, these values were 63.7% and 68.2%, without differences between groups (log rank; P = .45 and .39, respectively). Bypass graft surgery presented better results of secondary patency (72.9% vs 57.1%) and limb salvage (83.5% vs 53.6%) than PTA for patients with Transatlantic Inter-Society Consensus (TASC) D lesions (P = .04 and P = .01, respectively).

CONCLUSIONS

Both BGS and PTA provided similar results of patency and limb salvage for individuals with infrapopliteal atherosclerotic disease presenting with CLI. Bypass graft surgery had better results than PTA when TASC D lesions were present.

Long-term outcomes of diabetic patients undergoing endovascular infrainguinal interventions

OBJECTIVE

Diabetes mellitus (DM) has traditionally predicted poor outcomes after lower extremity revascularization for peripheral vascular disease (PVD). This study assessed the influence of DM on long-term outcomes of percutaneous transluminal angioplasty, with or without stenting (PTA/stent), in patients with PVD.

METHODS

From January 2002 to December 2007, 920 patients underwent 1075 PTA/stent procedures. Patients were stratified into DM and non-DM cohorts. Study end points included primary patency (PP), assisted patency (AP), limb salvage, and survival and were evaluated using Kaplan-Meier and Cox regression analyses.

RESULTS

There were 533 DM and 542 non-DM limbs. Median follow-up was 34 months. Overall, the 5-year actuarial PP was 42% +/- 2.4%, AP was 81% +/- 2.0%, limb salvage was 89% +/- 1.6%, and survival was 60% +/- 2.4%. On univariate analysis, DM vs non-DM was associated with inferior 5-year PP (37% +/- 3.4% vs 46% +/- 3.3%; P = .009), limb salvage (84% +/- 2.6% vs 93% +/- 1.8%, P < .0001), and survival (52% +/- 3.5% vs 68% +/- 3.1%, P = .0001). AP did not differ between DM and non-DM patients (P = .18). In the entire cohort, DM (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.01-1.54; P = .04), single-vessel peroneal runoff (HR, 1.54; 95% CI, 1.16-2.08; P = .003), and dialysis (HR, 1.59; 95% CI, 1.10-2.33; P = .02) were associated with decreased PP on multivariate analysis. The only variables on multivariate analysis to predict limb loss and death were critical limb ischemia (HR, 9.09; 95% CI, 4.17-20.00; P < . 0001; HR, 2.99; 95% CI, 2.01-4.44; P < .0001, respectively) and dialysis (HR, 2.94; 95% CI, 1.39-5.00; P = .003; HR, 4.24; 95% CI 2.80-6.45; P < .0001, respectively).

CONCLUSIONS

DM is an independent predictor of decreased long-term primary patency after PTA/stent. Although acceptable assisted patency rates can be achieved with close surveillance and reintervention, long-term limb salvage remains inferior in diabetic patients compared with non-diabetic patients due to a more severe clinical presentation and poor runoff.

Critical limb ischemia

Critical limb ischemia (CLI), defined as chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease, is the most advanced form of peripheral arterial disease. Traditionally, open surgical bypass was the only effective treatment strategy for limb revascularization in this patient population. However, during the past decade, the introduction and evolution of endovascular procedures have significantly increased treatment options. In a certain subset of patients for whom either surgical or endovascular revascularization may not be appropriate, primary amputation remains a third treatment option. Definitive high-level evidence on which to base treatment decisions, with an emphasis on clinical and cost effectiveness, is still lacking. Treatment decisions in CLI are individualized, based on life expectancy, functional status, anatomy of the arterial occlusive disease, and surgical risk. For patients with aortoiliac disease, endovascular therapy has become first-line therapy for all but the most severe patterns of occlusion, and aortofemoral bypass surgery is a highly effective and durable treatment for the latter group. For infrainguinal disease, the available data suggest that surgical bypass with vein is the preferred therapy for CLI patients likely to survive 2 years or more, and for those with long segment occlusions or severe infrapopliteal disease who have an acceptable surgical risk. Endovascular therapy may be preferred in patients with reduced life expectancy, those who lack usable vein for bypass or who are at elevated risk for operation, and those with less severe arterial occlusions. Patients with unreconstructable disease, extensive necrosis involving weight-bearing areas, nonambulatory status, or other severe comorbidities may be considered for primary amputation or palliative measures.

Subintimal angioplasty for below-the-ankle arterial occlusions in diabetic patients with chronic critical limb ischemia

PURPOSE

To assess the feasibility and efficacy of subintimal angioplasty (SA) in the treatment of below-the-ankle arterial occlusion in diabetic patients with chronic critical limb ischemia (CLI).

METHODS

SA was applied in 37 diabetic patients (24 men; mean age 70.9+/-8.5 years, range 52-88) with chronic CLI and occlusive disease of the dorsalis pedis artery (DPA) and/or plantar artery (PA) but were poor candidates for intraluminal angioplasty or bypass surgery. Tissue loss was present in 31 (54.4%) of 57 afflicted limbs, and rest pain was reported in 51 (89.5%) limbs. SA was performed to create continuous arterial flow to the foot for limb salvage. The clinical symptoms, DPA or PA pulse volume scores, and ankle-brachial index (ABI) were compared before and after SA. Wound healing, amputation, and restenosis of target vessels were also evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and freedom from amputation.

RESULTS

Below-the-ankle SA was performed successfully in 55 (83.3%) of 66 arteries in 57 limbs. Median pulse volume scores and ABIs were 0.33+/-0.55 and 0.31+/-0.19 before SA and 2.04+/-1.05 and 0.80+/-0.14 after SA, respectively (p<0.0001 for both). The 30-day mortality was 2.7%. Median follow-up was 9.1+/-6.1 months (range 1-18). Major complications occurred in 1 (2.7%) patient and minor complications in 3 (8.1%). Twelve months after SA, Kaplan-Meier analysis showed that the limb salvage rate was 94.6%, the freedom from amputation was 89.2%, and the survival rate was 97.3%.

CONCLUSION

SA of the dorsalis pedis artery and/or plantar artery is a useful technique for lower limb salvage in diabetic patients with chronic CLI who are not candidates for bypass surgery.

[Recanalization of the lower leg: PTA or stent?]

Percutaneous transluminal angioplasty (PTA) and stent placement are currently accepted methods for endovascular treatment of critical limb ischemia, if infragenual vessels are involved. Outcome results in high technical success and satisfactory clinical results for treatment of infrapopliteal lesions with regard to patency rates and amputation-free survival. These treatment modalities are also safe for the patients. The question whether PAT alone or additional stent placement is the better choice, is still unanswered due to limited data.

Below knee angioplasty in elderly patients: predictors of major adverse clinical outcomes

AIM

To determine predictors of clinical outcome following percutaneous transluminal angioplasty (PTA) in elderly patients with below knee atherosclerotic lesions causing intermittent claudication (IC) or critical limb ischaemia (CLI).

MATERIALS AND METHODS

Over 7.5 years, 76 patients (CLI 72%, n = 55) underwent below knee PTA. The composite end-point of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up which was defined as clinical failure, need for subsequent endovascular or surgical revascularization or amputation. Actuarial freedom from MACO was assessed using Kaplan-Meier curves and multivariable Cox proportional hazards regression.

RESULTS

IC was improved in 95% at mean 3.4 years (range 0.5-108 months). Successful limb salvage and ulcer healing were seen in 73% with CLI. Most failures were in the CLI group (27% CLI vs. 5% IC), with an amputation rate of 16% for CLI vs. 5% for IC and persistent ulceration in 24% of CLI. Significant independent predictors of MACO were ulceration (hazard ratio 4.02, 95% CI = 1.55-10.38) and family history of atherosclerosis (hazard ratio 2.53, 95% CI = 1.1-5.92).

CONCLUSION

Primary below knee PTA is a feasible therapeutic option in this elderly population. Limb ulceration and family history of atherosclerosis may be independent predictors of adverse outcome.

Restenosis after lower extremity interventions: current status and future directions

The incidence of restenosis after percutaneous peripheral interventions (PPI) varies considerably depending upon the vascular bed but appears to be highest in the femoropopliteal and tibioperoneal arteries. The restenosis process in the periphery does not appear to stop at the 6-month mark, as seen with bare metal stents in the coronary arteries, but continues for a longer time, possibly years, after the intervention. This review evaluates the incidence of restenosis following lower extremity arterial interventions and potential drugs or devices that could alter this process, including nonpharmacological (stents, cryoplasty, Cutting Balloon angioplasty, atherectomy, brachytherapy, and photodynamic therapy) and pharmacological (systemic and direct drug delivery) approaches. A global strategy to achieve optimal outcome with PPI is offered: (1) obtain excellent acute angiographic results with less dissection and recoil, (2) protect the distal tibial vascular bed, and (3) reduce smooth muscle cell proliferation with pharmacological intervention.

Always contact a vascular interventional specialist before amputating a patient with critical limb ischemia

Patients with severe critical limb ischemia (CLI) due to long tibial artery occlusions are often poor candidates for surgical revascularization and frequently end up with a lower limb amputation. Subintimal angioplasty (SA) offers a minimally invasive alternative for limb salvage in this severely compromised patient population. The objective of this study was to evaluate the results of SA in patients with CLI caused by long tibial occlusions who have no surgical options for revascularization and are facing amputation. We retrospectively reviewed all consecutive patients with CLI due to long tibial occlusions who were scheduled for amputation because they had no surgical options for revascularization and who were treated by SA. A total of 26 procedures in 25 patients (14 males; mean age, 70 ± 15 [SD] years) were evaluated. Technical success rate was 88% (23/26). There were four complications, which were treated conservatively. Finally, in 10 of 26 limbs, no amputation was needed. A major amputation was needed in 10 limbs (7 below-knee amputations and 3 above-knee amputations). Half of the major amputations took place within 3 months after the procedure. Cumulative freedom of major amputation after 12 months was 59% (SE = 11%). In six limbs, amputation was limited to a minor amputation. Seven patients (28%) died during follow-up. In conclusion, SA of the tibial arteries seem to be a valuable treatment option to prevent major amputation in patients with CLI who are facing amputation due to lack of surgical options.

Is atherectomy the best first-line therapy for limb salvage in patients with critical limb ischemia?

OBJECTIVE

To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia.

METHODS

Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed.

RESULTS

A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04).

CONCLUSIONS

Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.

Review: Peripheral Arterial Disease and Diabetes: A Clinical Update

Peripheral arterial disease is characterized by a gradual reduction in blood to the extremities secondary to atherosclerosis. In diabetes, the pattern of atherosclerotic occlusion typically shows a propensity toward the infrapopliteal vessels. Additionally, impairment of the microcirculation manifests in diminished vasoreactivity and a functional ischemia that is not always correctable with surgery. However, when a nonhealing wound is complicated by peripheral arterial disease, revascularization is paramount to wound healing. Revascularization can be accomplished through traditional bypass surgery or newer endovascular interventions, such as angioplasty and stenting. These less invasive techniques of revascularization offer the advantages of quicker recovery and lower morbidity but durability may be compromised. Ultimately, the choice of revascularization procedure should be based on the clinical characteristics of the atherosclerotic lesion along with the individual patient history.

Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia

CONTEXT

Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented.

AIMS

To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions.

METHODS

A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time.

RESULTS

Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI - preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention.

CONCLUSION

Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.