Outcomes of revascularization of stenotic inframalleolar lesions in chronic limb-threatening ischemia

BACKGROUND

For chronic limb-threatening ischemia, revascularization has been reported for occlusions but not for stenosis in the inframalleolar (IM) lesions. We investigated the clinical outcomes of balloon dilation for stenotic IM lesions distal to the treatment target in the infrapopliteal (IP) legion.

METHODS

We conducted a retrospective analysis of patients who had chronic limb-threatening ischemia and underwent revascularization of stenotic IM lesions distal to the target IP lesions between January 2015 and August 2022. The outcome measures were amputation-free survival, wound healing rate, and freedom from target IM reintervention.

RESULTS

The 87 patients had a mean age of 72.7 ± 10.7 years and comprised 67.8% men, 74.7% with diabetes mellitus, 55.2% on dialysis, 33.3% who had Rutherford six classification. The amputation-free survival (AFS), wound healing, and freedom from target IM reintervention rates at 1 year were 82.9%, 53.3%, and 58.4%, respectively. On Cox proportional multivariate analysis, the predictors were Wound, Ischemia, and foot Infection (WIfI) ≥3 and diffuse stenosis in the target IM vessels for delayed wound healing and Global Limb Anatomic Staging System stage Ⅲ and ≥3 diseased IM vessels before endovascular therapy for target IM reintervention. At the time of reintervention, the lesion morphology had progressed from stenosis to occlusion in 50% of cases.

CONCLUSIONS

In patients with chronic limb-threatening ischemia, revascularization of stenosis in IM lesions showed a high reintervention rate and progression of lesion morphology, although AFS and wound-healing rates were acceptable.

Chronic Clinical Findings after Rheocarna® Therapy in a Chronic Limb-threatening Ischemia Patient with Inframalleolar Lesions

An 87-year-old man was referred to our hospital for non-healing ulcers on the right third, fourth, and fifth toes. The patient was diagnosed with chronic limb-threatening ischemia. Pre-treatment angiography of the right lower extremity revealed inframalleolar lesions. We failed to perform endovascular treatment because of severe calcification. Therefore, we treated the patient with a novel low-density lipoprotein apheresis device (Rheocarna®; Kaneka, Osaka, Japan). Angiography performed four days after therapy revealed significant improvement in microcirculation. One year after therapy, he managed to avoid major amputation and achieve wound healing. In addition, angiography revealed that the microcirculation was maintained.

From a Spark to a Flame: The Evolution of Diabetic Foot Disease in the Last Two Decades

Despite many improvements have been achieved, diabetic foot disease (DFD) remains a clinical, social, and economic burden. In the last years, DFD showed an evolution of its characteristics with an increase of the ischaemic/neuro-ischaemic foot in comparison to the pure neuropathic foot. Simultaneously, there was and increased incidence of concomitant cardiovascular co-morbidities, which influences the higher fragility of patients with DFS. Peripheral arterial disease (PAD) in subjects with diabetic foot seems to show a more aggressive pattern, being more distal and difficult to treat. Untreatable PAD remains the unmet need for clinicians and the main risk factor of major amputation in patients with diabetic foot ulcers. Authors aimed to describe the evolution of diabetic foot patients in the last two decades, describing also the current and future treatment which may improve outcomes in the next generations.

CIRSE Standards of Practice on Below-the-Knee Revascularisation

The CIRSE Standards of Practice Committee established a writing group that was tasked with producing up-to-date recommendations for performing below-the-knee revascularisation, taking into account data on novel techniques, devices, and long-term outcomes that have emerged over the last decade. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature. This document is not intended to impose a standard of clinical patient care but recommends a reasonable approach to and best practices for performing below-the-knee revascularisation.

Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

Medial-to-lateral plantar loop technique for retrograde transcollateral recanalization of the lateral plantar artery in patients with type 3 plantar arch

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.