Dorsalis pedis artery stenting for limb salvage

Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care

The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.

Contemporary crossing techniques for infrapopliteal chronic total occlusions

The synergism of technical refinement and advanced technology has significantly increased the popularity of infrapopliteal intervention. Since chronic total occlusion (CTO) is a common disorder among patients with symptomatic infrapopliteal artery disease, infrapopliteal CTO intervention is now evolving rapidly in the field of endovascular intervention. Guidewire crossing through the CTO is essential for a successful procedure. We review up-to-date infrapopliteal CTO crossing techniques based on the current literature.

Treatment of infrapopliteal critical limb ischemia in 2013: the wound perfusion approach

The primary goals of treatment for critical limb ischemia (CLI) are alleviation of ischemic rest pain, healing of arterial insufficiency ulcers, and improving quality of life. These goals are directed toward preventing limb loss and CLI-related mortality. Arterial revascularization serves as the foundation of a contemporary approach to promote amputation-free survival. Mounting evidence supports a wound-directed angiosome revascularization approach, increasingly achieved with endovascular techniques. Innovations in technology and wound-perfusion strategy have advanced patient care and are accelerating the pace of CLI treatment. The evolving angiosome revascularization approach has been augmented with a multidisciplinary wound care strategy that deserves particular emphasis. These state-of-the-art advances in CLI management are reported herein with considerations for the future treatment of CLI.

Stent-assisted below-the-ankle angioplasty for limb salvage

PURPOSE

To report the clinical outcome of stent-assisted below-the-ankle angioplasty for limb salvage in the setting of critical limb ischemia (CLI).

METHODS

A retrospective single-center study was conducted of 40 critical ischemic limbs in 31 patients (mean age 67 ± 8 years, range 46-94) undergoing below-the-ankle stent-assisted angioplasty between April 2006 and April 2009. Coronary bare metal stents were implanted in cases of failed balloon angioplasty due to significant recoil, flow-limiting dissection, abrupt closure, or repeat early reocclusion.

RESULTS

Technical success was 93% (37 limbs), with 3 failures to cross the occlusive lesions. Acute or subacute occlusion was evident in 9 (23%) limbs. The number of runoff vessels increased significantly (p < 0.001) from 0.6 ± 0.8 to 1.8 ± 0.8. During a clinical follow-up of 19.3 ± 11.4 months (range 1-48), the number of repeat interventions for limb salvage was 2.2 ± 1.6 (range 1-9), and a total of 1.6 ± 0.9 stents (range 1-3) were implanted in 8 dorsalis pedis arteries. Acute or subacute stent thrombosis after stenting was observed in 2 of these, and symptomatic in-stent restenosis was detected in 4, which were all treated by repeat intervention. At 6, 12, and 24 months, the freedom from repeat intervention was 39.6%, 39.6%, and 35.2%, respectively. Amputation-free survival was 80.0%, 69.7%, and 62.7%, and limb salvage was 94.7%, 91.4%, and 82.1% at the same time points. Patient survival rates were 77.4%, 71.0%, and 71.0%, respectively. During a mean follow-up of 13.4 ± 12.7 months (range 1-31 months) in 7 of the 8 stented arteries, all examined stents were deformed: stent compression was evident in 5 and stent fracture in 5. However, 7 limbs undergoing dorsalis pedis artery stenting showed complete wound healing; 1 limb had a resistant wound in the heel.

CONCLUSION

Stent-assisted below-the-ankle angioplasty produced a satisfactory clinical outcome but with the need for repeat intervention. Thus, further refinement in endovascular technology is mandatory to reduce the need for repeat interventions and to resolve stent deformity issues.

Awareness of anatomical variations for infrapopliteral intervention

With the tremendous advancement and accumulated expertise of endovascular techniques, infrapopliteal intervention is emerging as an alternative therapeutic option to distal bypass surgery for limb salvage in the setting of critical limb ischemia (CLI). However, though much attention has been given to infrapopliteal intervention, the importance of identifying preprocedural infrapopliteal variants remains underappreciated. Becoming more aware of these anatomical variants will translate to increased clinical effectiveness for the patient with infrapopliteal artery disease. Therefore, this review will highlight the fundamental aspects of infrapopliteal variant anatomy for the catheter-based treatment of CLI patients with symptomatic infrapopliteal artery disease.

Angioplasty of ulnar or radial arteries to treat critical hand ischemia: use of 3- and 4-French systems

OBJECTIVES

The aim of this preliminary study is to report the results of catheter-based treatment for isolated distal upper extremity artery disease with CHI.

BACKGROUND

Critical hand ischemia (CHI) is a rare but potentially devastating condition.

METHODS

The study consisted of five critically ischemic hands (Rutherford category 4: 2, Rutherford category 5: 3) in four patients undergoing catheter intervention for isolated distal upper extremity artery disease between November 2007 and April 2009.

RESULTS

Balloon angioplasty via an antegrade brachial approach was performed with a 3Fr or 4Fr sheath to achieve the principal endpoint of the establishment of one straight-line flow to the palmar arch. All patients had end-stage renal disease requiring chronic hemodialysis. The target vessels were the ulnar artery in four cases, the radial artery in one, and the palmar arch in two. Four cases had a stenotic lesion and one had chronic total occlusion. Technical success was achieved in all cases without complications, and skin perfusion pressure of the hand improved significantly from 39 ± 20 to 52 ± 16 (P = 0.019) on the palmar side and from 40 ± 18 to 60 ± 29 on the dorsal side (P = 0.046). Clinical success was achieved in all cases during a mean follow-up period of 11 ± 8 (2-19) months.

CONCLUSIONS

Percutaneous angioplasty using contemporary dedicated devices could be a potentially useful option for CHI patients with isolated distal upper extremity artery disease.

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.