Balloon angioplasty in chronic critical limb ischemia: factors affecting clinical and angiographic outcome

In-hospital outcomes of endovascular versus surgical revascularization for chronic total occlusion in peripheral artery disease

BACKGROUND

The outcome of endovascular intervention (EVI) compared vs. surgical revascularization in patients with peripheral artery disease (PAD) due to chronic total occlusion (CTO) is unknown.

METHODS

Using the National Inpatient Sample database between 2007 and 2014, we identified all PAD patients with CTO who had limb revascularization. Multivariate analysis was performed to estimate the odds of in-hospital mortality and adverse outcomes between both groups.

RESULTS

A total of 168,420 patients who had peripheral CTO and underwent limb revascularization were identified. 99,279 underwent EVI, and 69,141 underwent surgical revascularization. The patients who underwent EVI were younger, more likely to be women and African American, and less likely to be white (p < 0.001 for all). EVI was associated with lower in-hospital mortality (1.2% vs 1.7%, adjusted odds ratio [aOR]: 0.54; 95% confidence interval [CI] 0.50-0.59). The EVI group had higher vascular complications, major bleeding, acute kidney injury (AKI), and major amputation compared with surgical revascularization. A subgroup analysis on patients with critical limb ischemia showed lower mortality in the EVI group (1.4% vs. 1.9, aOR 0.56; 95% CI 0.50-0.63). Although there was no difference in the incidence of AKI or major amputation between the two groups, the EVI group had higher vascular complication rates and major bleeding events.

CONCLUSION

EVI in PAD with CTO is associated with lower in-hospital mortality, likely due to the procedure's less-invasive nature; however, it is associated with higher postprocedural complications likely due to the CTO's complexity.

In-Hospital Outcomes and Trends of Endovascular Intervention vs Surgical Revascularization in Octogenarians With Peripheral Artery Disease

It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.

Efficacy Outcomes of Endovascular Versus Surgical Revascularization in Critical Limb Ischemia: Results From a Prospective Cohort Study

Data on efficacy outcomes of endovascular versus surgical revascularization in patients with critical limb ischemia (CLI) in contemporary practice are limited. In this prospective cohort study, 353 consecutive patients with CLI were enrolled and allocated to endovascular (PTA [percutaneous transluminal angioplasty]), surgical (SURG), or no revascularization (No REVASC) after interdisciplinary consensus. Outcome measures were sustained primary clinical success (sPCS; survival without major amputation, repeated target extremity revascularization, and freedom from CLI), limb salvage, and amputation-free survival. Propensity-matched Kaplan-Meier analyses and stratified log-rank tests were performed. The PTA, SURG, and No REVASC groups consisted of 264, 62, and 27 patients, respectively. Compared to SURG patients, PTA patients were significantly older, had more risk factors, and more often had ischemic lesions. Propensity score-adjusted analyses showed no significant differences: sPCS was 51.3%/52.2%, limb salvage rate 91.5%/93.7%, and major amputation-free survival 90.5%/87.2% at 12 months for PTA and SURG, respectively. Amputation-free survival for the No REVASC group was 69% at 12 months. In conclusion, endovascular and surgical revascularization in CLI has comparable efficacy outcomes after 12 months. Contemporary overall outcome of patients with CLI is considerably better compared to earlier studies.

Coronary Artery Disease in Patients with Critical Limb Ischemia Undergoing Major Amputation or Not

Background:

Due to the increase of elderly and diabetes patients, surgeons encounter patients requiring treatment of critical limb ischemia (CLI) in the presence of systemic arteriosclerotic diseases. In this study, we retrospectively investigated the prevalence of coronary artery disease (CAD) in patients with CLI who underwent major (above-the-ankle) amputation or nonmajor amputation (below-the-ankle amputation or debridement of wound).

Methods:

We retrospectively investigated 129 consecutive patients surgically managed for CLI in our institution between January 2013 and December 2015. The prevalence of CAD was defined as a cardiac treatment history or significant vascular stenosis (stenosis of > 75%). The outcomes were compared between patients who underwent major amputation (n = 36) and nonmajor amputation (n = 93). Additionally, archived record of 566 patients treated nonsurgically by percutaneous transluminal angioplasty in our institution was investigated to evaluate patients with milder peripheral artery disease.

Results:

CAD was present in 83 patients (69%), including 82% of patients who underwent major amputation and 63% of nonmajor amputation group. The prevalence of CAD was significantly higher in the major amputation group (P = 0.042). Ejection fraction was not significantly different (P > 0.05). Among the 566 CLI patients treated by only percutaneous transluminal angioplasty, 227 (40%) had CAD, which was a significantly lower prevalence than those surgically treated (P < 0.001).

Conclusions:

The presence of CAD is more frequent in CLI patients who require extended surgical management of the limb than in those who do not. Evaluation of CAD and careful perioperative management are important for patients with CLI patients.

The diabetic foot

Diabetic foot problems are responsible for nearly 50% of all diabetes-related hospital bed days. Approximately 10-15% of diabetic patients developed foot ulcers at some state in their life and 15% of all load in amputations are performed in patients with diabetes. There is a need to provide extensive education to both primary care physicians and the patients regarding the relationship between glucose control and complications encountered in the foot and ankle. The management of diabetic foot disease is focussed primarily on avoiding amputation of lower extremities and should be carried out through three main strategies; identification of the "at risk" foot, treatment of acutely diseased foot, and prevention of further problems. These are several obstacles in the management of DFI that include poor knowledge and awareness of diabetes and its complications, lack of appropriate podiatry services. These goals are possible only by the establishment of a dedicated team of podiatrist, endocrinologist, vascular surgeon and a pedorthist. The plastic surgeons, orthopaedic surgeons & diabetes teaching nurses/educator dedicated to foot care could be a part of the team. Identifying the patients with diabetes at risk for ulceration requires feet examination, including the vascular & neurological systems, skin conditions, and foot structure. Conservative management of foot problems has dramatically reduced the risk of amputation by simple procedures, such as appropriate foot wear, cleanliness, aggressive surgical debridement, regular wound dressing by simple wet-to-dry saline guage, and ulcer management.

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.

Isolated Endarterectomy of Femoral Bifurcation in Critical Limb Ischemia: Is Restoration of Inline Flow Essential?

This retrospective study reviews clinical outcomes of isolated common femoral endarterectomy (CFE) for critical limb ischemia (CLI), in particular whether poor runoff and inability to restore inline flow has negative impact. In 30 patients, runoff was assessed on preoperative angiograms and categorized into groups based on Society of Vascular Surgery criteria. Data were evaluated using Cox Regression survival analysis. Freedom from secondary revascularization was not affected by runoff score (hazard ratio for compromised and poor groups being 1.8 (95% CI 0.16 to 20.8) and 1.47 (95% CI 0.09 to 24.3), respectively; P = .894). Distal inline flow was not achieved in 25 (83%) patients, but this was not associated with significantly worse outcome (P = .295, log-rank test). In conclusion, CFE can be performed in CLI with high technical success and there is no significant effect of runoff score on recurrence of symptoms. Limb salvage can be achieved even if options to restore inline flow are limited.

Five-year retrograde transpopliteal angioplasty results compared with antegrade angioplasty

INTRODUCTION

Retrograde transpopliteal angioplasty (PA) is a potentially useful alternative technique for endovascular treatment of infra-inguinal arterial disease when antegrade transfemoral puncture (FA) is technically not possible or appropriate. This study aimed to investigate the outcomes of PA compared with FA during a 5-year period.

PATIENTS AND METHODS

A retrospective study was performed to assess 88 PA and 275 FA performed between January 2003 and January 2008. Assessments of patients, indication for procedure, disease site, stenosis severity, procedure outcomes and time to further intervention were recorded.

RESULTS

FA was used to treat more patients with critical ischaemia (42.2% vs 30.7%; P = 0.014)). PA was used to treat more proximal superficial femoral lesions (P < 0.001) and occlusive lesions (P = 0.001). Overall, 84.1% of PA and 82.5 % of FA were technically successful. There was no difference in local puncture site complication rates. Significantly more FA resulted in distal thrombus/embolism (8.4% vs 3.4%; P = 0.044). Further intervention was required in 27.3% of PA and 36.0% of FA. The time interval to re-intervention was not different between the groups.

CONCLUSIONS

PA is safe with comparable success rates and long-term outcomes to an FA. PA is a useful alternative approach for treating occlusive, proximal disease.

Indications and clinical outcomes for below knee endovascular therapy: review article

Chronic critical limb ischemia (CLI) still represents the most common cause for amputation and frequently the possibility for peripheral revascularization, particularly in below knee (BK) arteries, is not adequately evaluated before amputation. This may also be due to the fact that even today, there's some confusion about results of the endovascular treatment in this territory. Diabetics, representing the population most frequently affected by CLI, have specific clinical characteristics, the so called diabetic foot syndrome, which cannot be compared with the situation in nondiabetic patients with ischemic ulcers. Measuring the success of BK endovascular therapy can be a difficult issue, considering that it is often the work of a multidisciplinary team. The clinical benefit of BK endovascular therapy often shows a large discrepancy from the primary patency. While ulcer healing, limb salvage, and reintervention rates are usually low after BK endovascular therapy, rates of restenosis remain excessively high. Nevertheless, the positive impact of revascularization on mortality, which mainly depends on the major amputation rate reduction, is also evident. This review article summarizes indications and clinical outcomes after BK endovascular therapy with special attention to the role of diabetes mellitus in patients with CLI.

[S3 guidelines for diagnostics and treatment of peripheral arterial occlusive disease]

This report summarizes the most important aspects of the new German S3 guidelines for the diagnostics and treatment of peripheral arterial occlusive disease (PAOD) from March 2009. The guidelines include definitions and epidemiology of peripheral arterial occlusive disease, diagnostic methods including clinical and technical procedures as well as imaging methods, treatment by non-invasive, interventional and surgical methods and patient care during follow-up. In key messages recommendations are given which are graded corresponding to the scientific evidence concluded from the literature.

The evaluation of primary stenting of sirolimus-eluting versus bare-metal stents in the treatment of atherosclerotic lesions of crural arteries

A comparison was made of sirolimus-eluting stents and bare stents as an effective means of treatment of stenosis in crural arteries. Patients were randomly divided into two groups: (1) patients treated with sirolimus-eluting stents and (2) patients treated with bare stents. Each group consisted of 25 patients, and every patient had one stent implanted. All patients showed symptoms of ischemia of the peripheral arteries, classified according to the Rutherford scale into categories 3, 4, and 5. All patients were examined 24 h before and 24 h and 6 months after the intervention. The results were analyzed according to clinical, hemodynamic, and angiographic criteria. Technically, the procedure was successful in 100% of cases, and both groups presented an equal improvement in clinical and hemodynamic parameters. The follow-up angiographic examination demonstrated a significantly lower rate of restenosis among the sirolimus-eluting stent group (4, 16%) versus the bare stent group (19, 76%) (p < 0.001), with lower target lesion revascularization in 3 (12%) versus 14 (56%) (p < 0.05), respectively. Quantitative angiography demonstrated that all variables used to assess restenosis were superior for sirolimus-eluting stents 6 months after intervention: late lumen loss 0.46 +/- 0.72 versus 1.70 +/- 0.94 (p < 0.001) and minimal lumen diameter 2.25 +/- 0.82 versus 0.99 +/- 1.08 (p < 0.001). Results of this study reveal that the use of sirolimus-eluting stents decreases the risk of restenosis in comparison to standard stents.

Treatment of severe infrapopliteal vascular disease using a novel atherectomy device: a case report

We report two first in man cases of percutaneous revascularization for severe intrapopliteal arterial disease using the novel PV atherectomy device.

Surgical or endovascular revascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome

OBJECTIVE

The optimal revascularization strategy in diabetic patients with chronic critical limb ischemia (CLI) is unclear. This study assessed the efficacy of tailored endovascular-first vs surgical-first revascularization stratified for the presence of diabetes.

METHODS

This prospective cohort study, with 1-year follow up, was conducted in a tertiary referral center in a consecutive series of 383 patients (45.7% had diabetes) presenting 426 limbs with chronic CLI. Interventions were endovascular (PTA cohort, 207 limbs) or surgical (SURG cohort, 85 limbs) revascularization. Conservatively treated patients without revascularization (NON REVASC cohort, 108 limbs) were used as a reference. The main outcome measures were sustained clinical success, defined as survival without major amputation or repeated target extremity revascularization (TER), and a categoric upward shift in clinical symptoms according to the Rutherford classification.

RESULTS

Sustained clinical success of revascularization was significantly better in nondiabetic patients (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.29 to 0.72; P = .001 [SURG cohort]; HR, 0.53; 95% CI, 0.35 to 0.78; P = .002 [PTA cohort]) compared with diabetic patients (HR, 0.78; 95% CI, 0.44 to 1.43, P = .45 [SURG cohort]; HR, 0.83; 95% CI, 0.55 to 1.27, P = .40 [PTA cohort]). Repeated TER significantly improved clinical success, which became equivalent between diabetic and nondiabetic patients (HR, 1.02; 95% CI, 0.7 to 1.4). In multivariate analysis, treatment success was not influenced by mode of initial revascularization, neither in diabetic nor in nondiabetic patients. Cumulative 1-year mortality was 30.4%, with a trend of increased mortality in patients with diabetes (HR, 1.45; 95% CI, 0.98 to 2.17; P = .064). Limb salvage rates were similar in treatment cohorts, also if stratified for diabetes (HR, 1.04; 95% CI, 0.62 to 1.75).

CONCLUSION

Diabetic patients with chronic CLI benefit from early revascularization. To achieve this benefit, multiple revascularization procedures may be required, and close surveillance is therefore mandatory. Choice of initial revascularization modality seems not to influence clinical success.

Plaque excision with the Silverhawk catheter: Early results in patients with claudication or critical limb ischemia

OBJECTIVE

This study was conducted to detail the early experience after infrainguinal atherectomy using the Silverhawk plaque excision catheter for the treatment of symptomatic peripheral vascular disease.

METHODS

A prospective database was established in August 2004 in which data for operations, outcomes, and follow-up were recorded for patients undergoing percutaneous plaque excision for peripheral arterial occlusive disease. Society for Vascular Surgery (SVS) ischemia scores and femoropopliteal TransAtlantic Inter-Society Consensus (TASC) criteria were assigned. A follow-up protocol included duplex ultrasound surveillance at 1, 3, and 6 months and then yearly thereafter. Standard statistical analyses were performed.

RESULTS

During a 17-month period, 66 limbs of 60 patients (37 men [61.7%]) underwent 70 plaque excisions (four repeat procedures). Indications included tissue loss based on SVS ischemia at grades 5 and 6 (25/70), rest pain at grade 4 (22/70), and claudication at grades 2 to 3 (23/70). The mean lesion length was 8.8 +/- 0.7 cm. The technical success rate was 87.1% (61/70). Adjunctive treatment was required in 17 procedures (24.3%), consisting of 14 balloon angioplasties and three stents. Femoropopliteal TASC criteria included 5 TASC A lesions, 14 TASC B lesions, 32 TASC C lesions, and 19 TASC D lesions. Although 17 plaque excisions included a tibial vessel, no patient underwent isolated tibial atherectomy. The mean increase in ankle-brachial index was 0.27 +/- 0.04 and in toe pressure, 20.3 +/- 6.9 mm Hg. Mean duplex ultrasound follow-up was 5.2 months (range, 1 to 17 months). One-year primary, primary assisted, and secondary patency was 61.7%, 64.1%, and 76.4%, respectively. Restenosis or occlusion developed in 12 patients (16.7%) and was detected at a mean of 2.8 +/- 0.7 months. Restenosis or occlusion was significantly more common (P < .05) in patients with TASC C and D lesions compared with patients with TASC A and B lesions. Six (8.3%) of 12 patients underwent reintervention on the basis of duplex ultrasound surveillance results. Four (33.3%) of 12 patients experienced reocclusion during the same hospitalization, and amputation and open revascularization were required in two patients each.

CONCLUSIONS

Percutaneous plaque excision is a viable treatment option for lower extremity revascularization. Outcomes are related to ischemia and lesion severity. Patency and limb salvage rates are equivalent to other endovascular modalities.

Subintimal Angioplasty of Tibial Vessel Occlusions in Critical Limb Ischaemia: A Good Opportunity?

OBJECTIVES

To evaluate the feasibility and the mid-term results of subintimal angioplasty (SA) in the treatment of critical limb ischaemia (CLI) with tibial vessels occlusions.

MATERIALS AND METHODS

Between August 2000 and March 2005, we attempted to treat 46 patients (23 men, 23 women, median age of 75 years; range 35-92) and 50 limbs by SA of occluded tibial vessels. Twenty-one had gangrene, 25 ulcerations and 4 had rest pain. Thirty-nine occlusions (78%) were more than 10 cm in length, 28 (56%) involved popliteal and tibial artery and distal re-entry was at the ankle level in 18 cases (36%). Twenty-eight patients (61%) were diabetics.

RESULTS

There were nine technical failures. Five of these patients were successfully treated medically (1), by conventional surgery (1) or by conventional angioplasty of another diseased tibial vessel (3). The four remaining patients had major amputation and 3 died within 3 months. There were 7 complications including 2 embolisms, 1 perforation and 4 haematomas. By intention to treat, one-year primary, secondary and clinical patency rates were 46%, 55% and 63%, respectively. One and two-year limb salvage rates were 87%. One and two-year survival rates were 74% and 64%, respectively.

CONCLUSIONS

SA of tibial vessel occlusions is a valuable treatment of CLI. Technical failures do not preclude conventional surgery when there is a valuable outflow. Complications may often be treated medically or by endovascular procedures. Results have to be confirmed by long-term follow up. Both techniques should be considered as complementary techniques in the management of CLI.

Cardiac function, inflammatory mediators and mortality in critical limb ischemia

Patients with critical limb ischemia (CLI) have a high frequency of concomitant coronary heart disease and congestive heart failure. The aim of the study was to evaluate cardiac function in relation to inflammatory markers and 1-year mortality rate among patients with CLI. The authors investigated 232 consecutive patients with CLI by means of electrocardiogram (ECG), and measurements of endothelin (ET)-1, tumor necrosis factor alpha (TNF)alpha, interleukin (IL)-6, neopterin, CD40 ligand, and 8-epi-prostaglandin (PG)F2alpha in plasma. Echocardiography (echo) was performed in 88 (38%) patients. One-year mortality rate was assessed after prospective follow-up. One hundred and eighty-six (80%) patients had sinus rhythm (SR), 36 (16%) had atrial fibrillation or flutter (AF), and 10 (4%) pacemaker rhythm. Ischemic ECG changes occurred in 143 (62%) patients. Patients with AF showed higher IL-6 (p = 0.0296) and neopterin (p = 0.0494) concentrations. Patients with ischemic ECG changes showed higher ET-1 (p = 0.0303), 8-epi-PGF2alpha (p = 0.0027), neopterin (p = 0.0004) concentrations and 1-year mortality rate (p = 0.0105). The difference in ET-1 remained in logistic regression (p = 0.0152). Internal diameter of the left ventricle on echo correlated with IL-6 (r = 0.345, p = 0.0017), TNFalpha (r = 0.240, p = 0.0273), and neopterin (r = 0.327, p = 0.0028). Internal diameter of the left atrium correlated with TNFalpha (r = 0.384, p = 0.0092) and neopterin (r = 0.526, p = 0.0004), and ejection fraction (EF) correlated inversely with IL-6 (r = -0.380, p = 0.0015) and neopterin (r = -0.346, p = 0.0038). Patients with EF <40% showed higher (p = 0.0462) 1-year mortality rate than patients with EF >40%. In conclusion, in critical limb ischemia, cardiac rhythm disturbances and ischemic ECG changes were related to inflammatory mediators and predicted 1-year mortality rate. The inflammatory mediators correlated with echocardiographic signs of congestive heart failure.

Managing Risk Factors for Atherosclerosis in Critical Limb Ischaemia

OBJECTIVE

To review the best medical management of critical limb ischaemia (CLI).

METHODS

Published studies dealing with CLI and risk factors were searched for via PUBMED.

FINDINGS AND CONCLUSIONS

Patients with critical limb ischaemia (CLI) have a one and ten year mortality of approximately 20% and 75% respectively. Risk factors for the development of peripheral atherosclerosis are the same as for coronary and cerebrovascular atherosclerosis namely diabetes mellitus, hyperlipidaemia, arterial hypertension, and smoking. As there are few studies of risk factor for peripheral arterial occlusive disease (PAOD), treatment recommendations are often based on studies in patients with coronary or cerebrovascular atherosclerosis. While waiting for specific studies, CLI patients should be treated according to current guidelines for other atherosclerotic patients.

Preliminary results after application of absorbable metal stents in patients with critical limb ischemia

PURPOSE

To report the preliminary 3-month follow-up of a recently developed absorbable metal stent (AMS) for treatment of infrapopliteal lesions in patients with critical limb ischemia (CLI).

METHODS

Between December 2003 and January 2004, 20 patients (10 men; mean age 76 years, range 59-96) with symptomatic critical limb ischemia (CLI) due to high-grade (80% to 100%) infrapopliteal stenoses received 1 or 2 AMS devices for suboptimal angioplasty. Clinical examination and color-flow duplex imaging were performed in all patients at discharge and at 1 and 3 months.

RESULTS

Angiographic procedural success was achieved in all 20 patients. One patient died (non-procedure-related) during the periprocedural period. Three months after the procedure, primary clinical patency was 89.5% (17/19). No major or minor amputation was necessary in any of the patients, yielding a limb salvage rate of 100%. The average improvement in Rutherford class was 2.3 at the 3-month assessment. A comparison of postprocedural and 1-month color-flow duplex ultrasound and magnetic resonance images clearly indicated the ongoing absorption process of the AMS.

CONCLUSIONS

After 3 months, the primary clinical patency and limb salvage rates suggest a potentially promising performance of these AMS devices in the treatment of below-knee lesions in CLI patients.

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

OBJECTIVE

To determine the efficacy, safety, and long-term results, including continued clinical improvement and limb salvage, of percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI).

METHODS

From August 1993 to March 2004, 138 limbs in 111 patients with CLI (rest pain in 62 [45%] and ulcer/gangrene in 76 [55%]) were treated by PTA. In iliac lesions, stents were placed selectively for primary PTA failure: residual stenosis (>30%) or pressure gradient (>5 mm Hg). Stent placement was limited in infrainguinal lesions. The most distal affected arteries treated with angioplasty were the iliac artery in 45 limbs (33%; iliac group), the femoropopliteal artery in 41 limbs (30%; FP group), and tibial arteries in 52 limbs (37%; BK group). All analysis was performed according to an intent-to-treat basis. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed to evaluate initial success, and late follow-up status was evaluated with the Kaplan-Meier method. Patency was evaluated by using ultrasound scanning and ankle-brachial pressure index measurement.

RESULTS

There was one (0.9%) perioperative death. Twenty stents were placed selectively in 14 iliac arteries. Mean follow-up was 14.7 months (range, 1-75 months). Overall, initial technical and clinical success rates were 96.4% and 92.8%, respectively. The cumulative primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates +/- SE at 5 years were 31.4% +/- 10.4%, 75.5% +/- 5.7%, 79.6% +/- 5.5%, 36.1% +/- 10.0%, and 89.1% +/- 4.0%, respectively. In each subgroup, the primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates at 3 years were 51.6%, 94.7%, 97.8%, 65.1%, and 95.0%, respectively, in the iliac group; 49.4%, 72.2%, 76.4%, 57.4%, and 92.7%, respectively, in the FP group; and 23.5%, 41.8%, 46.1%, 51.1%, and 77.3%, respectively, in the BK group. Of the 12 predictable variables, hypertension, multiple segment lesions, more distal lesions, and TransAtlantic Inter-Society Consensus classification type D were significant independent risk factors for the outcomes ( P < .05; univariate log-rank test and Cox regression multivariate analysis).

CONCLUSIONS

PTA is a feasible, safe, and effective procedure for the treatment of CLI. The high limb salvage rate is attributed to the high assisted primary and secondary patency rates despite the low primary patency rate. Angioplasty can be the primary choice for the treatment of CLI due to iliac and infrainguinal arterial occlusive disease.

Percutaneous Endovascular Treatment for Chronic Limb Ischemia

Percutaneous transluminal methods of revascularization for chronic limb ischemia have traditionally been used as an adjunctive or secondary mode of treatment. This study examines the outcomes of patients treated via endovascular methods as the primary form of treatment. The records of 66 patients (average age, 71.3 years; range, 53 to 92) with chronic limb ischemia treated from November 2000 to January 2002 at a single institution with endovascular methods were retrospectively reviewed. Thirty-one patients had disabling claudication, 15 had rest pain, 17 had minor tissue loss, and 3 had major tissue loss. There were 94 lesions in the 66 limbs: 45 lesions in the superficial femoral artery, 28 lesions in the popliteal artery, and 21 lesions in tibial arteries. Occlusive lesions were treated by subintimal angioplasty. Stenoses were treated by percutaneous transluminal angioplasty (PTA). The median length of the lesions was 12 cm. Forty-six stents were placed in 32 patients; 34 patients did not receive stents. The approach was contralateral in 71% (47/66) and ipsilateral in 29% (19/66) of cases. Patients were followed up with physical exam, anklebrachial index (ABI), and duplex ultrasonography. Post-intervention medical treatment included aspirin and clopidogrel. Long-term patency was correlated with age, comorbidities, risk factors, and the use of stents in addition to angioplasty. Endovascular treatment was technically successful in 65 of 66 patients (98%). Residual stenosis (<30%) was found in three cases, two in patients with PTA alone and one patient with PTA and a stent. Mean length of follow-up was 6.3 months (range, 6 weeks to 15 months). Post-intervention ABI improved from a mean of 0.65 to a mean of 1.01 (p < 30.05). The perioperative complication rate was 9% and included three cases of hematoma and one case each of thrombosis, lymphocele, and rash reaction to medications. Outcome measures included primary patency (89%), assisted primary patency (96%), and limb salvage (97%) at 6 months. Restenosis of >50% occurred in four patients and occlusion occurred in two. At 6 months, patients with one or more stents had a patency rate of 84% (27/32), whereas those without a stent had a patency rate of 94% (32/34) (p = NS). Endovascular treatment is a safe, feasible, and effective method with a high short-term patency rate and may be used as an alternative to bypass for chronic limb ischemia.

Endovascular placement of an extraluminal femoropopliteal bypass graft in human cadavers

PURPOSE

A method to create an extraluminal femoropopliteal bypass graft using endovascular techniques was evaluated in situ on cadaver extremities in an attempt to develop a minimally invasive alternative technique for the management of infrainguinal occlusive arterial disease.

METHODS

The endovascular placement of an extraluminal femoropopliteal bypass graft was undertaken in 5 cadaver legs. Following percutaneous access to the popliteal artery (PA) or common femoral artery (CFA), a Rosch-Uchida needle was used to perforate the vascular wall, followed by the creation of an extraluminal tract using a looped wire and catheter. Once the desired level was reached the needle was again used to perforate the vascular wall of the proximal superficial femoral artery (SFA) or PA depending on the access used. Self-expanding expanded polytetrafluoroethylene (ePTFE) stent-grafts were then deployed to establish the extraluminal femoropopliteal bypass connecting the two arterial puncture sites. Following dilatation of the stent-graft, angiography was performed to assess the endoprostheses and to look for contrast leaks.

RESULTS

Technical success was achieved in all 5 legs. Procedure time varied from 15 to 30 min. The angiographic studies performed immediately after completion of the bypass procedure showed patency of the grafts with no evidence of kinking or leakage in any of the cases.

CONCLUSION

This study has proved that the endovascular placement of an extraluminal femoropopliteal bypass graft in human cadaver legs using endovascular techniques under fluoroscopic control is technically feasible.

Tibial Angioplasty as an Alternative Strategy in Patients with Limb-Threatening Ischemia

The purpose of this study was to assess the technical feasibility and early outcome of tibial angioplasty for a subset of patients with limb-threatening ischemia who were not candidates for bypass grafting. A retrospective analysis was conducted of 19 patients (7 male, 12 female) who underwent crural angioplasty for limb-threatening ischemia using 0.018- or 0.014 inch-based systems. Contraindications to bypass were insufficient conduit in 7 patients and severe comorbid illness in 12. Concurrent treatment of inflow lesions was performed in 12 of 20 limbs via either angioplasty alone (5) or combined with stenting (12). Outcome measures were ankle-brachial indices (ABI), relief of rest pain, and healing or healed wounds. Twenty-three vessels were treated, including 14 tibial occlusions and 9 stenoses. The average length of diseased segment was 11 cm (range, 3-25 cm). Thirteen of 14 occlusions were treated with subintimal recanalization, the remainder with laser recanalization. Technical success was achieved in 22 of 23 treated vessels. Mean preoperative ABI was 0.53 and mean postoperative ABI was 0.85. Palpable pulses were present in 11 of 20 limbs (55%). There was one perioperative mortality (5.2%). Mean follow-up was 3 months. Three failures occurred requiring amputation (15.8%). The remaining 16 patients were improved with healing (8) or healed (4) wounds and relief of rest pain (4). These results indicate that technical success may be achieved with outflow lesion angioplasty in the majority of patients encountered. The durability of this method of therapy is unknown, and our length of follow-up is not sufficient to answer this question. However, an attempt at angioplasty appears justified before primary amputation and before surgical bypass in those patients at high risk for intervention.