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Scatena A, Apicella M, Mantuano M, Liistro F, Ventoruzzo G, Petruzzi P, Miranda C, Monge L, Ragghianti B, Silverii A, Ferraro I, Uccioli L, Vermigli C, Mannucci E, Scevola G, Stabile E, Gargiulo M, Monami M. Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome. Acta Diabetol 2024; 61:19-28. [PMID: 37792028 DOI: 10.1007/s00592-023-02185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023]
Abstract
To report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients. Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up.
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Affiliation(s)
- Alessia Scatena
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy.
| | - Matteo Apicella
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Michele Mantuano
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Francesco Liistro
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Giorgio Ventoruzzo
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Pasquale Petruzzi
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | | | - Luca Monge
- AMD - Italian Association of Clinical Diabetologists, Rome, Italy
| | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Antonio Silverii
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | - Luigi Uccioli
- Diabetes Section CTO Hospital and Dept of Biomedicine and Prevention Tor Vergata, University of Rome, Rome, Italy
| | | | - Edoardo Mannucci
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | | | - Mauro Gargiulo
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Metser G, Puma J, Mustapha J, Adams GL, Ratcliffe J, Khullar P, Rosero JHC, Armstrong EJ, Zayed M, Green P. Clinical Outcomes of Additional Below-The-Ankle Intervention Compared to Below-The-Knee Intervention Alone: A Post-Hoc Analysis of a Prospective Multicenter Study. J Endovasc Ther 2023; 30:711-720. [PMID: 35503774 DOI: 10.1177/15266028221092981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To investigate the clinical implication of additional below-the-ankle (BTA) intervention in patients with chronic limb-threatening ischemia (CLTI) undergoing below-the-knee (BTK) intervention. MATERIALS AND METHODS A sub-analysis was performed using data from the LIBERTY trial (ClinicalTrials.gov identifier NCT01855412), a prospective, observational, core-laboratory adjudicated, multicenter study of endovascular intervention in 1204 patients. Patients with CLTI (Rutherford Classification 4-6) who underwent BTK intervention were included in this sub-analysis. Participants were then stratified into 2 treatment groups according to whether at least one lesion intervened on was BTA (n=66) or not (n=273). The decision on whether and where to intervene was made during the procedure. The main outcome measures included major amputation, target vessel revascularization (TVR), major adverse events (MAE), survival, amputation-free survival, major adverse limb events or peri-operative death (MALE-POD), and all-cause death. Other outcome measures included procedural success, procedural complications, and wound healing rate. RESULTS There were no differences in procedural success or severe angiographic complications between the 2 groups. At 1-year post-procedure, patients in the BTK group had a higher rate of freedom from major amputation (95.0% vs. 86.9%, respectively; HR: 2.87, 95% CI: 1.17-7.03), a higher rate of freedom from TVR (80.1% vs. 66.9%, respectively; HR: 1.94, 95% CI: 1.14-3.32), a higher rate of freedom from MALE-POD (94.6% vs. 86.9%, respectively; HR: 2.65, 95% CI: 1.10-6.41), and a higher rate of freedom from MAE at both 1 (76.0% vs. 60.1%, respectively; HR: 2.00, 95% CI: 1.24-3.22) and 3 years post procedure (67.5% vs. 55.8%, respectively; HR: 1.69, 95% CI: 1.08-2.65). There was a significantly lower rate of survival in the BTK group at 3 years (74.3% vs. 91.1%, respectively; HR: 0.35, 95% CI: 0.14-0.87). After risk adjustment, there was a higher rate of all-cause death in the BTK group at 3 years (19.4% vs. 9.1%, respectively; p=0.023) post-intervention. CONCLUSION Patients with disease requiring intervention to BTA lesions have a potential increased amputation rate in the short term, but BTA intervention carries a potential survival benefit in the long term when compared to BTK intervention alone.
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Affiliation(s)
- Gil Metser
- Division of General Internal Medicine, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Joseph Puma
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jihad Mustapha
- Advanced Cardiac and Vascular Centers, Grand Rapids, MI, USA
| | | | - Justin Ratcliffe
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pankaj Khullar
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua H C Rosero
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- Adventist Heart and Vascular Institute, Adventist Health St. Helena, St. Helena, CA, USA
| | - Mohamed Zayed
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Philip Green
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Li MX, Tu HX, Yin MC. Meta-analysis of outcomes from drug-eluting stent implantation in infrapopliteal arteries. World J Clin Cases 2023; 11:5273-5287. [PMID: 37621588 PMCID: PMC10445070 DOI: 10.12998/wjcc.v11.i22.5273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Percutaneous drug-eluting stent implantation (DESI) is an emerging and promising treatment modality for infrapopliteal artery diseases (IPADs). This systematic review and meta-analysis summarizes and quantitatively analyzes the outcomes of DESI in IPADs considering the hazard ratio (HR), which is a more accurate and appropriate outcome measure than the more commonly used relative risk and odds ratio. AIM To explore the superiority of drug-eluting stents (DESs) vs traditional treatment modalities for IPADs. METHODS The following postoperative indicators were the outcomes of interest: All-cause death (ACD)-free survival, major amputation (MA)-free survival, target lesion revascularization (TLR)-free survival, adverse event (AE)-free survival, and primary patency (PP) survival. The outcome measures were then compared according to their respective HRs with 95% confidence intervals (CIs). The participants were human IPAD patients who underwent treatments for infrapopliteal lesions. DESI was set as the intervention arm, and traditional percutaneous transluminal angioplasty (PTA) with or without bare metal stent implantation (BMSI) was set as the control arm. A systematic search in the Excerpta Medica Database (Embase), PubMed, Web of Science, and Cochrane Library was performed on November 29, 2022. All controlled studies published in English with sufficient data on outcomes of interest for extraction or conversion were included. When studies did not directly report the HRs but gave a corresponding survival curve, we utilized Engauge Digitizer software and standard formulas to convert the information and derive HRs. Then, meta-analyses were conducted using a random-effects model. RESULTS Five randomized controlled trials and three cohort studies involving 2639 participants were included. The ACD-free and MA-free survival HR values for DESI were not statistically significant from those of the control treatment (P > 0.05); however, the HR values for TLR-free, AE-free, and PP-survival differed significantly [2.65 (95%CI: 1.56-4.50), 1.57 (95%CI: 1.23-2.01), and 5.67 (95%CI: 3.56-9.03), respectively]. CONCLUSION Compared with traditional treatment modalities (i.e., PTA with or without BMSI), DESI for IPADs is superior in avoiding TLR and AEs and maintaining PP but shows no superiority or inferiority in avoiding ACD and MA.
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Affiliation(s)
- Ming-Xuan Li
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, Beijing 100069, China
| | - Hai-Xia Tu
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, Beijing 100069, China
| | - Meng-Chen Yin
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, Beijing 100069, China
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4
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Li MX, Tu HX, Yin MC. Meta-analysis of outcomes from drug-eluting stent implantation in infrapopliteal arteries. World J Clin Cases 2023; 11:5267-5281. [DOI: 10.12998/wjcc.v11.i22.5267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Percutaneous drug-eluting stent implantation (DESI) is an emerging and promising treatment modality for infrapopliteal artery diseases (IPADs). This systematic review and meta-analysis summarizes and quantitatively analyzes the outcomes of DESI in IPADs considering the hazard ratio (HR), which is a more accurate and appropriate outcome measure than the more commonly used relative risk and odds ratio.
AIM To explore the superiority of drug-eluting stents (DESs) vs traditional treatment modalities for IPADs.
METHODS The following postoperative indicators were the outcomes of interest: All-cause death (ACD)-free survival, major amputation (MA)-free survival, target lesion revascularization (TLR)-free survival, adverse event (AE)-free survival, and primary patency (PP) survival. The outcome measures were then compared according to their respective HRs with 95% confidence intervals (CIs). The participants were human IPAD patients who underwent treatments for infrapopliteal lesions. DESI was set as the intervention arm, and traditional percutaneous transluminal angioplasty (PTA) with or without bare metal stent implantation (BMSI) was set as the control arm. A systematic search in the Excerpta Medica Database (Embase), PubMed, Web of Science, and Cochrane Library was performed on November 29, 2022. All controlled studies published in English with sufficient data on outcomes of interest for extraction or conversion were included. When studies did not directly report the HRs but gave a corresponding survival curve, we utilized Engauge Digitizer software and standard formulas to convert the information and derive HRs. Then, meta-analyses were conducted using a random-effects model.
RESULTS Five randomized controlled trials and three cohort studies involving 2639 participants were included. The ACD-free and MA-free survival HR values for DESI were not statistically significant from those of the control treatment (P > 0.05); however, the HR values for TLR-free, AE-free, and PP-survival differed significantly [2.65 (95%CI: 1.56-4.50), 1.57 (95%CI: 1.23-2.01), and 5.67 (95%CI: 3.56-9.03), respectively].
CONCLUSION Compared with traditional treatment modalities (i.e., PTA with or without BMSI), DESI for IPADs is superior in avoiding TLR and AEs and maintaining PP but shows no superiority or inferiority in avoiding ACD and MA.
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Affiliation(s)
- Ming-Xuan Li
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, Beijing 100069, China
| | - Hai-Xia Tu
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, Beijing 100069, China
| | - Meng-Chen Yin
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, Beijing 100069, China
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5
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Safety of short 3-hour recovery and same-day discharge following lower-limb angioplasty in outpatients with intermittent claudication and critical limb ischaemia. Clin Radiol 2023; 78:e182-e189. [PMID: 36462943 DOI: 10.1016/j.crad.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/21/2022] [Accepted: 10/13/2022] [Indexed: 12/03/2022]
Abstract
AIM To investigate the safety and efficacy of short recovery day-case pathway following lower-limb angioplasty in both intermittent claudication and critical limb ischaemia patients. MATERIALS AND METHODS A retrospective analysis was undertaken of the medical records of consecutive outpatients treated with lower-limb angioplasty over a 1-year period within an interventional radiology (IR) day-case unit in a high-volume vascular centre. Standard post-angioplasty care at York Teaching Hospital is discharge 3 h after puncture site haemostasis without the routine use of closure devices. The rates of successful same-day discharge, procedure success, complications, and re-admissions were calculated with 30-day follow-up. RESULTS The cohort included 301 patients (57% intermittent claudication and 43% critical limb ischaemia) undergoing 605 angioplasties using access sheath size ranging from 4 to 7 F. Closure devices were used in only 7% of patients. Successful same-day discharge achieved in 98% of patients (294/301), with seven admitted overnight because of complications. Eleven patients (3.6%) were re-admitted within 30 days. Technical success rates were 92%, and 96% when including partially successful interventions, with 4% technical failure. Twelve patients (4%) developed minor complications and four major complications (1%). There were no significant differences in complication rates between small and larger sheath sizes (p>0.05). No procedure-related death was recorded within 30 days. CONCLUSION Lower-limb angioplasty can be performed safely as day-case procedure with a short recovery protocol within IR departments for both patients with intermittent claudication (IC) and critical limb ischaemia (CLI). This may significantly increase patient throughput and alleviate pressure on stretched hospital inpatient resources by safely discharging patients on the day of procedure.
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Technical Approach to Percutaneous Femoropopliteal Bypass and Deep Vein Arterialization. Tech Vasc Interv Radiol 2022; 25:100843. [DOI: 10.1016/j.tvir.2022.100843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ahn J, Byeon J, Choi BG, Choi SY, Byun JK, Cha J, Yu H, Lee C, Na JO, Choi CU, Kim EJ, Park CG, Seo HS, Choi WG, Rha SW. Stenting versus balloon angioplasty alone in patients with below-the-knee disease: A propensity score-matched analysis. PLoS One 2021; 16:e0251755. [PMID: 34111147 PMCID: PMC8191955 DOI: 10.1371/journal.pone.0251755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/01/2021] [Indexed: 11/19/2022] Open
Abstract
Percutaneous transluminal angioplasty (PTA) is considered an effective treatment in patients with critical limb ischemia (CLI). However, the long-term durability of below-the-knee (BTK) PTA is known to be limited. This study sought to compare the 1-year clinical outcomes following stenting versus balloon angioplasty alone in BTK lesions. This study included 357 consecutive patients (400 limbs, 697 lesions) with BTK lesions who underwent PTA from September 2010 to December 2016. All enrolled patients were treated either by stenting (stent group; 111 limbs of 102 patients) or plain old balloon angioplasty (POBA group; 289 limbs of 255 patients). Stent group includes both primary and provisional stenting. Angiographic outcomes, procedural success, complications, and clinical outcomes were compared between the two groups up to 1 year. After propensity score matching (PSM) analysis, 56 pairs were generated, and the baseline and angiographic characteristics were balanced. The procedural success and complications were similar between the two groups; however, the incidence of procedure-related perforation was higher in the POBA group than in the stenting group [5(11.9%) vs.1 (0.9%), P = 0.009]. Six- to 9-month computed tomography or angiographic follow-up showed similar incidences of binary restenosis, primary patency, and secondary patency. In the 1-year clinical follow-up, there were similar incidences of individual hard endpoints, including mortality, myocardial infarction, limb salvage, and amputation rate, with the exception of target extremity revascularization (TER), which tended to be higher in the stenting group than in the POBA group [21 (20.8%) vs. 11 (10.9%), P = 0.054]. Although there was a trend toward a higher incidence of TER risk in the stenting group, stent implantation, particularly in bail-out stenting seemed to have acceptable 1-year safety and efficacy compared to POBA alone in patients undergoing BTK PTA.
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Affiliation(s)
- Jihun Ahn
- Cardiovascular Center, Konkuk Univesrity Chungju Hospital, Chungju, Korea
| | - JinSu Byeon
- Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Byoung Geol Choi
- Cardiovascular Research Institute, Korea University, Seoul, Korea
| | - Se Yeon Choi
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Jae Kyeong Byun
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Jinah Cha
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - HyeYon Yu
- School of Nursing, College of Medicine, Soonchunhyang University, Asan, Korea
| | - Cheolho Lee
- Cardiovascular Center, Konkuk Univesrity Chungju Hospital, Chungju, Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Eung Ju Kim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Woong-gil Choi
- Cardiovascular Center, Konkuk Univesrity Chungju Hospital, Chungju, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
- * E-mail:
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Anantha-Narayanan M, Sheikh AB, Nagpal S, Jelani QUA, Smolderen KG, Regan C, Ionescu C, Ochoa Chaar CI, Schneider M, Llanos-Chea F, Mena-Hurtado C. Systematic review and meta-analysis of outcomes of lower extremity peripheral arterial interventions in patients with and without chronic kidney disease or end-stage renal disease. J Vasc Surg 2020; 73:331-340.e4. [PMID: 32889074 DOI: 10.1016/j.jvs.2020.08.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) have a greater risk of peripheral arterial disease (PAD). Although individual studies have documented an association between CKD and/or end-stage renal disease (ESRD) and adverse outcomes in patients undergoing PAD interventions in an era of technological advances in peripheral revascularization, the magnitude of the effect size is unknown. Therefore, we performed a meta-analysis to compare the outcomes of PAD interventions for patients with CKD/ESRD with those patients with normal renal function, stratified by intervention type (endovascular vs surgical), reflecting contemporary practice. METHODS Five databases were analyzed from January 2000 to June 2019 for studies that had compared the outcomes of lower extremity PAD interventions for patients with CKD/ESRD vs normal renal function. We included both endovascular and open interventions, with an indication of either claudication or critical limb ischemia. We analyzed the pooled odds ratios (ORs) across studies with 95% confidence intervals (CIs) using a random effects model. Funnel plot and exclusion sensitivity analyses were used for bias assessment. RESULTS Seventeen observational studies with 13,140 patients were included. All included studies, except for two, had accounted for unmeasured confounding using either multivariable regression analysis or case-control matching. The maximum follow-up period was 114 months (range, 0.5-114 months). The incidence of target lesion revascularization (TLR) was greater in those with CKD/ESRD than in those with normal renal function (OR, 1.68; 95% CI, 1.25-2.27; P = .001). The incidence of major amputations (OR, 1.97; 95% CI, 1.37-2.83; P < .001) and long-term mortality (OR, 2.28; 95% CI, 1.45-3.58; P < .001) was greater in those with CKD/ESRD. The greater TLR rates with CKD/ESRD vs normal renal function were only seen with endovascular interventions, with no differences for surgical interventions. The differences in rates of major amputations and long-term mortality between the CKD/ESRD and normal renal function groups were statistically significant, regardless of the intervention type. CONCLUSIONS Patients with CKD/ESRD who have undergone lower extremity PAD interventions had worse outcomes than those of patients with normal renal function. When stratifying our results by intervention (endovascular vs open surgery), greater rates of TLR for CKD/ESRD were only seen with endovascular and not with open surgical approaches. Major amputations and all-cause mortality were greater in the CKD/ESRD group, irrespective of the indication. Evidence-based strategies to manage this at-risk population who require PAD interventions are essential.
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Affiliation(s)
| | - Azfar Bilal Sheikh
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Sameer Nagpal
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Qurat-Ul-Ain Jelani
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Kim G Smolderen
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Christopher Regan
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Costin Ionescu
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | | | - Marabel Schneider
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | | | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
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Giannopoulos S, Ghanian S, Parikh SA, Secemsky EA, Schneider PA, Armstrong EJ. Safety and Efficacy of Drug-Coated Balloon Angioplasty for the Treatment of Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis. J Endovasc Ther 2020; 27:647-657. [PMID: 32508220 DOI: 10.1177/1526602820931559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the safety and efficacy of drug-coated balloons (DCB) for the treatment of femoropopliteal or infrapopliteal lesions in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: A systematic literature search was conducted in PubMed, Scopus, and Cochrane Central up to January 2020 to identify randomized trials and observational studies presenting data on the effectiveness and safety of DCBs in the treatment of femoropopliteal or infrapopliteal lesions. A meta-analysis utilizing random effects modeling was conducted to investigate primary patency and all-cause mortality at 12 months; the results are reported as the odds ratios (ORs) and 95% confidence intervals (CIs). Secondary outcomes were procedural success, bailout stenting, target lesion revascularization (TLR), reocclusion, major amputation, wound healing, and major adverse limb events. Results: Twenty-six studies, 12 retrospective and 14 prospective, comprising 2108 CLTI patients treated with DCBs for femoropopliteal (n=1315) or infrapopliteal (n=793) lesions were analyzed. The average lesion lengths were 121±44 and 135±53 mm, respectively. The overall 12-month all-cause mortality and major amputation rates were 9% (95% CI 6% to 13%) and 5% (95% CI 2% to 8%), respectively. Primary patency rates were 82% (95% CI 76% to 87%) and 64% (95% CI 58% to 70%), respectively. A sensitivity analysis of the infrapopliteal lesions demonstrated no difference between DCB and balloon angioplasty in terms of primary patency, TLR, major amputation, or mortality over 12 months. However, patients with infrapopliteal lesions undergoing DCB angioplasty did have a significantly lower risk for reocclusion (10% vs 25%; OR 0.38, 95% CI 0.21 to 0.70, p=0.002). Conclusion: DCB angioplasty of femoropopliteal and infrapopliteal lesions in patients with CLTI results in acceptable 12-month patency rates, although comparative data have not shown a patency benefit for infrapopliteal lesions. The 12-month mortality rate of DCB vs balloon angioplasty was not significantly different, but studies with longer-term outcomes are necessary to determine any association between DCB use and mortality in patients with CLTI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Sheila Ghanian
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Sahil A Parikh
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, NY, USA
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Medical Center, Boston, MA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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10
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Nishan B, Krishna KS, Hudgi VV, Ahsan VP, Anand V. Limb salvage following below-the-ankle angioplasty in critical limb ischemia. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_59_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Imaoka S, Sato K, Hurukawa M, Higashi T. Predictive factors for ambulatory state in critical limb ischemia patients at discharge. J Phys Ther Sci 2019; 31:629-632. [PMID: 31527999 PMCID: PMC6698463 DOI: 10.1589/jpts.31.629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/05/2019] [Indexed: 11/25/2022] Open
Abstract
[Purpose] In patients with critical limb ischemia, the ambulatory state often has a
lasting impact on recovery and wound healing. The aim of this study was to examine the
predictive factors connected with the ambulatory state in wounds with critical limb
ischemia. [Participants and Methods] This study included 125 inpatients with critical limb
ischemia, who underwent physical therapy between January 2015 and December 2018. We
retrospectively studied factors from the participant’s medical records and comparisons
were made between the ambulatory and non-ambulatory groups. Next, we analyzed the
differences between factors using multiple logistic regression analysis. [Results] The
factors associated with the ambulatory state in patients with critical limb ischemia, as
determined by multiple logistic regression analysis, were knee extension muscle strength,
off-loading the foot duration, and the presence or absence of heart disease. [Conclusion]
Shortening off-loading the foot period and intensive rehabilitation at an early stage
after amputation need to be prioritized to maintain the quality of life and ambulatory
status of patients with wounds in critical limb ischemia.
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Affiliation(s)
- Shinsuke Imaoka
- Department of Rehabilitation, Oita Oka Hospital: 3-7-1 Sakamoto, Nagasaki, Nagasaki 852-8523, Japan.,Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Koji Sato
- Department of Rehabilitation, Oita Oka Hospital: 3-7-1 Sakamoto, Nagasaki, Nagasaki 852-8523, Japan
| | | | - Toshio Higashi
- Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
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12
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Teymen B, Aktürk S. Comparison of drug eluting balloon angioplasty to infrapopliteal artery critical lesions with or without additional pedal artery angioplasty in patients with diabetes mellitus and critical limb ischemia. J Interv Cardiol 2017; 31:400-406. [DOI: 10.1111/joic.12475] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Burak Teymen
- Emsey Hospital; Department of Cardiology; Istanbul Turkey
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13
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Teymen B, Aktürk S. Drug-Eluting Balloon Angioplasty for Below the Knee Lesions in End Stage Renal Disease Patients with Critical Limb Ischemia: Midterm Results. J Interv Cardiol 2016; 30:93-100. [PMID: 27910185 DOI: 10.1111/joic.12355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The 1-year restenosis rate after standard balloon angioplasty (BA) of long lesions in below-the-knee arteries may be as high as 70%. Our aim was to investigate the efficacy and safety of paclitaxel drug-eluting balloon (DEB) for treatment of below the knee lesions in end stage renal disease patients (ESRD) with critical limb ischemia (CLI). METHODS Our study is a retrospective, single-center study. Inclusion criteria were ESRD, critical limb ischemia (Rutherford class 4 or higher) and significant stenosis or occlusion of at least 1 below-the-knee vessel. Target vessel restenosis and reocclusion at 1-year follow-up was the primary end point. Major amputation, was the secondary end point. RESULTS From July 2012 to February 2015, 50 patients identified with ESRD, with CLI, treated with DEB angioplasty. Six patients were lost to follow-up, leaving 44 patients with 55 vessels (mean age, 58.0 ± 6.9 years; 54.5% male). The mean lesion length was 113.4 ± 55.4 mm. BA confined to the infra-popliteal segment alone in 81.8% of cases. Primary patency was 90.4% at 6 months and 62.2% at 12 months. At a mean follow-up of 13.9 ± 3.5 months all cause mortality was 8.1% (N = 3). The ankle brachial index increased from 0.45 ± 0.04 preoperative to 0.88 ± 0.07 postoperative. There was one major amputation (2.7%) and 5 minor amputations at one year (13.5%). CONCLUSION DEB is effective in the treatment of below the knee critical stenosis and occlusions in ESRD patients with critical limb ischemia.
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Affiliation(s)
- Burak Teymen
- Department of Cardiology, Emsey Hospital, Istanbul, Turkey
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14
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Spreen MI, Martens JM, Hansen BE, Knippenberg B, Verhey E, van Dijk LC, de Vries JPPM, Vos JA, de Borst GJ, Vonken EJPA, Wever JJ, Statius van Eps RG, Mali WPTM, van Overhagen H. Percutaneous Transluminal Angioplasty and Drug-Eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia (PADI) Trial. Circ Cardiovasc Interv 2016; 9:e002376. [PMID: 26861113 PMCID: PMC4753788 DOI: 10.1161/circinterventions.114.002376] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background— Endovascular infrapopliteal treatment of patients with critical limb ischemia using percutaneous transluminal angioplasty (PTA) and bail-out bare metal stenting (BMS) is hampered by restenosis. In interventional cardiology, drug-eluting stents (DES) have shown better patency rates and are standard practice nowadays. An investigator-initiated, multicenter, randomized trial was conducted to assess whether DES also improve patency and clinical outcome of infrapopliteal lesions. Methods and Results— Adults with critical limb ischemia (Rutherford category ≥4) and infrapopliteal lesions were randomized to receive PTA±BMS or DES with paclitaxel. Primary end point was 6-month primary binary patency of treated lesions, defined as ≤50% stenosis on computed tomographic angiography. Stenosis >50%, retreatment, major amputation, and critical limb ischemia–related death were regarded as treatment failure. Severity of failure was assessed with an ordinal score, ranging from vessel stenosis through occlusion to the clinical failures. Seventy-four limbs (73 patients) were treated with DES and 66 limbs (64 patients) received PTA±BMS. Six-month patency rates were 48.0% for DES and 35.1% for PTA±BMS (P=0.096) in the modified-intention-to-treat and 51.9% and 35.1% (P=0.037) in the per-protocol analysis. The ordinal score showed significantly worse treatment failure for PTA±BMS versus DES (P=0.041). The observed major amputation rate remained lower in the DES group until 2 years post-treatment, with a trend toward significance (P=0.066). Less minor amputations occurred after DES until 6 months post-treatment (P=0.03). Conclusions— In patients with critical limb ischemia caused by infrapopliteal lesions, DES provide better 6-month patency rates and less amputations after 6 and 12 months compared with PTA±BMS. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00471289.
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Affiliation(s)
- Marlon I Spreen
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasper M Martens
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bettina E Hansen
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bob Knippenberg
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elke Verhey
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lukas C van Dijk
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jean-Paul P M de Vries
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Albert Vos
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan de Borst
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evert-Jan P A Vonken
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan J Wever
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Randolph G Statius van Eps
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem P Th M Mali
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans van Overhagen
- From the Departments of Radiology (M.I.S., J.M.M., L.C.v.D., H.v.O.) and Vascular Surgery (B.K., J.J.W., R.G.S.v.E.), Haga Teaching Hospital, The Hague, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands (B.E.H., E.V.); Departments of Vascular Surgery (J.-P.P.M.d.V.) and Radiology (J.-A.V.), Sint Antonius Hospital, Nieuwegein, The Netherlands; and Departments of Vascular Surgery (G.J.d.B.) and Radiology (E.-J.P.A.V., W.P.T.M.M.), University Medical Center Utrecht, Utrecht, The Netherlands.
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Zhu YQ, Wang J, Tan HQ, Lu HT, Liu F, Cheng YS, Wei LM, Zhang PL, Zhao JG. Runoff Detected by Magnetic Resonance Angiography as an Indicator for Better Recanalization Outcomes in Below-the-Knee Chronic Total Occlusions in Diabetic Patients. J Endovasc Ther 2015; 22:243-51. [PMID: 25809370 DOI: 10.1177/1526602815573229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To compare the feasibility and efficacy of recanalizing below-the-knee (BTK) chronic total occlusions (CTOs) between patients with good or poor distal runoff based on magnetic resonance angiography (MRA) scans. Methods: Two hundred long-segment BTK CTOs in 171 limbs of 113 diabetic patients (58 men; mean age 69.8±1.9 years) were divided into good distal runoff (GDR: 119 lesions, 98 limbs) or poor distal runoff groups (PDR: 81 lesions, 73 limbs) based on baseline MRA findings. After angioplasty, modified thrombolysis in myocardial ischemia (mTIMI) grades and ankle-brachial index (ABI) were used to assess immediate outcomes. Regularly scheduled duplex or MRA imaging was performed in follow-up. The restenosis and limb salvage rates were compared. Results: The success rates were 93.3% and 87.7% in the GDR and PDR groups, respectively (p=0.21); subintimal angioplasty was more common in the PDR group (93.0% vs. 63.1%, p<0.01). Completion angiography indicated an mTIMI grade 3 blood flow in 71.2% lesions in the GDR patients and in 52.1% in the PDR (p=0.01) group. Improvement in the ABI was greater in the GDR limbs (p<0.001 vs. PDR). Mean imaging follow-up was 10.8±6.9 months in the GDR group and 11.1±6.6 months in the PDR group. Kaplan-Meier analysis showed a better restenosis-free rate in the GDR group (80.6% vs. 61.7%; p=0.02) at 12 months and for lesions with mTIMI grade 3 flow (p<0.01). At 24 months, Kaplan-Meier analysis revealed a better limb salvage rate in the GDR group (84.2% vs. 54.6%; p=0.02). Conclusion: Distal runoff detected using MRA could be a predictor for successful intraluminal recanalization, better distal tissue perfusion, improved long-term patency, and better limb salvage for patients with BTK CTOs.
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Affiliation(s)
- Yue-Qi Zhu
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jue Wang
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Hua-Qiao Tan
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Hai-Tao Lu
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Fang Liu
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Ying-Sheng Cheng
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Li-Ming Wei
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Pei-Lei Zhang
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jun-Gong Zhao
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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Mustapha JA, Diaz-Sandoval LJ. Management of Infrapopliteal Arterial Disease: Critical Limb Ischemia. Interv Cardiol Clin 2014; 3:573-592. [PMID: 28582081 DOI: 10.1016/j.iccl.2014.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
According to the TransAtlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease, "there is increasing evidence to support a recommendation for angioplasty in patients with critical limb ischemia and infrapopliteal artery occlusion." Management of infrapopliteal artery disease starts with diagnosis using modern preprocedural noninvasive and invasive imaging. Interventionalists need to learn the role of chronic total occlusion cap analysis and collateral zone recognition in angiosome-directed interventions for management of critical limb ischemia and be familiar with equipment and device selection and a stepwise approach for endovascular interventions. Interventionalists need to know which crossing tools to use to successfully cross-complex chronic total occlusion caps.
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Affiliation(s)
- Jihad A Mustapha
- Department of Clinical Research, College of Osteopathic Medicine, Michigan State University, 5900 Byron Center Ave SW, Wyoming, MI 49519, USA; Department of Medicine, Metro Health Hospital, 5900 Byron Center Avenue, Southwest, Wyoming, MI 49519, USA.
| | - Larry J Diaz-Sandoval
- Department of Clinical Research, College of Osteopathic Medicine, Michigan State University, 5900 Byron Center Ave SW, Wyoming, MI 49519, USA; Department of Medicine, Metro Health Hospital, 5900 Byron Center Avenue, Southwest, Wyoming, MI 49519, USA
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17
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Mustapha J, Diaz-Sandoval LJ. Balloon Angioplasty in Tibioperoneal Interventions for Patients With Critical Limb Ischemia. Tech Vasc Interv Radiol 2014; 17:183-96. [DOI: 10.1053/j.tvir.2014.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Yen HT, Hsieh MJ, Wu CC, Lee FY. Effect of systemic urokinase infusion after lower limb percutaneous transluminal angioplasty on limb salvage rate in patients with late-stage critical limb ischemia. Eur J Vasc Endovasc Surg 2014; 48:414-22. [PMID: 24984839 DOI: 10.1016/j.ejvs.2014.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the effect of systemically administered urokinase (UK) after percutaneous transluminal angioplasty with or without stent (PTA ± stent) on the reduction in the rate and level of amputation in patients with critical limb ischemia (CLI) with tissue loss. METHODS This was an observational, nonrandomized, retrospective study of 183 Taiwanese patients with Rutherford stage 5 or 6, and Fontaine stage 4 lower extremity CLI. Patients received either PTA ± stent or PTA ± stent + UK infusion (250,000 IU, daily for 5 days). PTA of the iliac, femoral, anterior tibial artery, posterior tibial artery, and peroneal arteries was included. Amputation was classified as minor, with direct wound healing, and minor amputation or surgical debridement of toes and major, with below- (BKA) and above-knee amputation (AKA). RESULTS In groups of patients with comparable baseline characteristics, 85 and 90 patients received PTA ± stent and PTA ± stent + UK, respectively. There were 24 major limb amputations performed. A significant majority (20/24 (83.3%) were performed in patients who did not receive adjuvant urokinase, compared with 4/24 (16.7%) of patients who did receive urokinase (p = 0.000287). There was a significant increase in the limb salvage rate for infrapopliteal lesions in patients treated with PTA + UK (12/72 with UK; 60/72 without UK; p ≤ .0001). Intracranial hemorrhage (n = 1) and bleeding at the inguinal puncture site (n = 2) were reported in the PTA ± stent + UK group. Eight deaths (one in the PTA ± stent + UK group; seven in the PTA ± stent) occurred during the study. CONCLUSION Systemic administration of UK with the PTA ± stent procedure may reduce the requirement for major amputation in patients with CLI with tissue loss (Rutherford 5 or 6). The difference is more pronounced in patients undergoing infrapopliteal interventions. However, these findings need to be confirmed in a randomized prospective study.
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Affiliation(s)
- H-T Yen
- Division of Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - M-J Hsieh
- Division of Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-C Wu
- Division of Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - F-Y Lee
- Division of Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Katsanos K, Tepe G, Tsetis D, Fanelli F. Standards of Practice for Superficial Femoral and Popliteal Artery Angioplasty and Stenting. Cardiovasc Intervent Radiol 2014; 37:592-603. [DOI: 10.1007/s00270-014-0876-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 09/04/2013] [Indexed: 11/30/2022]
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Naoum JJ, Arbid EJ. Endovascular techniques in limb salvage: infrapopliteal angioplasty. Methodist Debakey Cardiovasc J 2014; 9:103-7. [PMID: 23805344 DOI: 10.14797/mdcj-9-2-103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Critical limb ischemia (CLI) results from inadequate blood flow to supply and sustain the metabolic needs of resting muscle and tissue. Infragenicular atherosclerosis is the most common cause of CLI, and it is more likely to develop when multilevel or diffuse arterial disease coincides with compromised run-off to the foot. Reports of good technical and clinical outcomes have advanced the endovascular treatment options, which have gained a growing acceptance as the primary therapeutic strategy for CLI, especially in patients with significant risk factors for open surgical bypass. In fact, endovascular recanalization of below-the-knee arteries has proven to be feasible and safe, reduce the need for amputation, and improve wound healing. The distribution of various vascular territories or angiosomes in the foot has been recognized, and it appears advantageous to revascularize the artery supplying the territory directly associated with tissue loss. In addition, the targeted application and local delivery of drugs using drug-coated balloons (DCB) during angioplasty has the potential to improve patency rates compared to balloon angioplasty alone.
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Stenting below-the-knee bifurcations with dedicated bifurcation stent BiOSS Lim - first in man case report. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 15:171-7. [PMID: 24157310 DOI: 10.1016/j.carrev.2013.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/10/2013] [Accepted: 09/13/2013] [Indexed: 11/24/2022]
Abstract
The best treatment strategy for below the knee bifurcation disease is not known. We present first two cases with successful implantation of dedicated coronary bifurcation sirolimus eluting stent BiOSS Lim (Balton, Poland) in complex bifurcation and trifurcation lesions of tibioperoneal trunk. Both implantations were uncomplicated with sustained short-term result at 30-day control Duplex ultrasound and remarkable clinical improvement. Our report demonstrates feasibility and short-term effectiveness of implantation of dedicated coronary bifurcation stent in below-the-knee bi- and tri-furcations.
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Katsanos K, Diamantopoulos A, Spiliopoulos S, Karnabatidis D, Siablis D. Below-the-ankle angioplasty and stenting for limb salvage: anatomical considerations and long-term outcomes. Cardiovasc Intervent Radiol 2013; 36:926-35. [PMID: 23152042 DOI: 10.1007/s00270-012-0514-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 09/29/2012] [Indexed: 02/08/2023]
Abstract
PURPOSE To report the long-term angiographic and clinical results in a series of below-the-ankle (BTA) angioplasty procedures and to present some biomechanical issues related to the unique anatomical geometry of the ankle. METHODS We performed a retrospective analysis of BTA angioplasty procedures. Clinical end points included technical success, patient mortality, salvage of the treated foot, and repeat target lesion revascularization. Imaging end points included primary patency, binary restenosis of the target lesion at the 50% threshold, and stent integrity (stent fracture, deformation, or collapse). Univariate subgroup analysis was performed. RESULTS In total, 40 limbs in 37 patients (age 73.5 ± 8.2 years) with critical limb ischemia were included and 42 inframalleolar lesions (4.2 ± 1.4 cm) were analyzed. Technical success was achieved in 95.2% (40 of 42). Provisional stent placement was performed in 45.2% (19 of 42). Two patients died, and two major amputations occurred up to 3 years. At 1 year, overall primary vessel patency was 50.4 ± 9.1%, lesion binary restenosis rate was 64.1 ± 8.3%, and repeat intervention-free survival was 93.6 ± 4.3% according to life table analysis of all treated lesions. Pairwise subgroup analysis showed that BTA self-expanding stents were associated with significantly higher restenosis and poorer primary patency compared to plain balloon angioplasty or sirolimus-eluting balloon-expandable stents. Significant deformation and/or fracture of balloon-expandable stents placed BTA were identified in five of 11. Dynamic imaging showed that the dorsalis pedis artery is kinked during foot dorsiflexion, whereas the distal posterior tibial artery is kinked during plantar flexion of the foot. CONCLUSION BTA angioplasty for critical limb ischemia treatment is safe and feasible with satisfactory long-term results. BTA stent placement must be reserved for bailout indications.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, 26504, Rion, Greece.
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Katsanos K, Spiliopoulos S, Diamantopoulos A, Karnabatidis D, Sabharwal T, Siablis D. Systematic review of infrapopliteal drug-eluting stents: a meta-analysis of randomized controlled trials. Cardiovasc Intervent Radiol 2013; 36:645-58. [PMID: 23435741 DOI: 10.1007/s00270-013-0578-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 01/13/2013] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Drug-eluting stents (DES) have been proposed for the treatment of infrapopliteal arterial disease. We performed a systematic review to provide a qualitative analysis and quantitative data synthesis of randomized controlled trials (RCTs) assessing infrapopliteal DES. MATERIALS AND METHODS PubMed (Medline), EMBASE (Excerpta Medical Database), AMED (Allied and Complementary medicine Database), Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), online content, and abstract meetings were searched in September 2012 for eligible RCTs according to the preferred reporting items for systematic reviews and meta-analyses selection process. Risk of bias was assessed using the Cochrane Collaboration's tool. Primary endpoint was primary patency defined as absence of ≥50 % vessel restenosis at 1 year. Secondary outcome measures included patient survival, limb amputations, change of Rutherford-Becker class, target lesion revascularization (TLR) events, complete wound healing, and event-free survival at 1 year. Risk ratio (RRs) were calculated using the Mantel-Haenszel fixed effects model, and number-needed-to-treat values are reported. RESULTS Three RCTs involving 501 patients with focal infrapopliteal lesions were analyzed (YUKON-BTX, DESTINY, and ACHILLES trials). All three RCTs included relatively short and focal infrapopliteal lesions. At 1 year, there was clear superiority of infrapopliteal DES compared with control treatments in terms of significantly higher primary patency (80.0 vs. 58.5 %; pooled RR = 1.37, 95 % confidence interval [CI] = 1.18-1.58, p < 0.0001; number-needed-to-treat (NNT) value = 4.8), improvement of Rutherford-Becker class (79.0 vs. 69.6 %; pooled RR = 1.13, 95 % CI = 1.002-1.275, p = 0.045; NNT = 11.1), decreased TLR events (9.9 vs. 22.0 %; pooled RR = 0.45, 95 % CI = 0.28-0.73, p = 0.001; NNT = 8.3), improved wound healing (76.8 vs. 59.7 %; pooled RR = 1.29, 95 % CI = 1.02-1.62, p = 0.04; NNT = 5.9), and better overall event-free survival (72.2 vs. 57.3 %; pooled RR = 1.26, 95 % CI = 1.10-1.44, p = 0.0006; NNT = 6.7). CONCLUSION DES for focal infrapopliteal lesions significantly inhibit vascular restenosis and thereby improve primary patency, decrease repeat procedures, improve wound healing, and prolong overall event-free survival.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, Guy's and St. Thomas' Hospitals, NHS Foundation Trust, King's Health Partners, London, SE1 7EH, UK.
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van Overhagen H, Spiliopoulos S, Tsetis D. Below-the-knee interventions. Cardiovasc Intervent Radiol 2013; 36:302-11. [PMID: 23354963 DOI: 10.1007/s00270-013-0550-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 12/13/2012] [Indexed: 02/05/2023]
Affiliation(s)
- H van Overhagen
- Department of Radiology, Hagaziekenhuis, Leyweg 275, 2545 CH, The Hague, The Netherlands.
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Bifurcated coronary stents for infrapopliteal angioplasty in critical limb ischemia. J Vasc Surg 2013; 57:1006-13. [DOI: 10.1016/j.jvs.2012.09.080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 09/25/2012] [Accepted: 09/30/2012] [Indexed: 11/21/2022]
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Tan TW, Semaan E, Nasr W, Eberhardt RT, Hamburg N, Doros G, Rybin D, Shaw PM, Farber A. Endovascular revascularization of symptomatic infrapopliteal arteriosclerotic occlusive disease: comparison of atherectomy and angioplasty. Int J Angiol 2012; 20:19-24. [PMID: 22532766 DOI: 10.1055/s-0031-1272545] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.
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Affiliation(s)
- Tze-Woei Tan
- Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Massachusetts
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Fernández-Samos Gutiérrez R. El modelo angiosoma en la estrategia de revascularización de la isquemia crítica. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ryu HM, Kim JS, Ko YG, Hong MK, Jang Y, Choi D. Clinical outcomes of infrapopliteal angioplasty in patients with critical limb ischemia. Korean Circ J 2012; 42:259-65. [PMID: 22563339 PMCID: PMC3341423 DOI: 10.4070/kcj.2012.42.4.259] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 10/05/2011] [Accepted: 10/20/2011] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Hyeon Min Ryu
- Gumi CHA Medical Center, CHA University, Gumi, Korea
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Sigala F, Kontis E, Hepp W, Filis K, Melissas J, Mirilas P. Long-term outcomes following 282 consecutive cases of infrapopliteal PTA and association of risk factors with primary patency and limb salvage. Vasc Endovascular Surg 2012; 46:123-30. [PMID: 22344984 DOI: 10.1177/1538574411432161] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We aimed to determine the long-term results after infrapopliteal PTA (primary patency, limb salvage, survival) and examine for association with risk factors (e.g. diabetes, infection, etc). We studied 268 patients with 282 critically ischemic limbs treated with PTA of at least one crural artery during a six-year period. Data included TASC II morphological classification of lesions and risk factors. Technical success rate was 97.2%, and overall mortality 0.7%. Patients with milder TASC lesions preserved primary patency longer than patients with more severe lesions. Similar results were obtained for limb salvage and survival. Fontaine stage, TASC class and postoperative infection of operated limb increased the risk for loss of primary patency and major amputation. Concomitant carotid stenosis was associated with loss of primary patency. Diabetes mellitus, preoperative ulcer or gangrene were associated with need of major amputation. PTA was a safe and effective treatment for CLI due to lesions of infrapopliteal vessels.
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Affiliation(s)
- Fragiska Sigala
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Athens, Greece
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Karnabatidis D, Spiliopoulos S, Katsanos K, Siablis D. Below-the-knee drug-eluting stents and drug-coated balloons. Expert Rev Med Devices 2012; 9:85-94. [PMID: 22145843 DOI: 10.1586/erd.11.67] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Endovascular procedures have evolved to the mainstream treatment of choice for revascularization of infrapopliteal obstructive disease, especially in patients suffering from critical limb ischemia and multiple comorbidities. However, standard balloon angioplasty is limited by the potential of a suboptimal acute outcome due to elastic recoil and/or flow-limiting dissection, followed by neointimal hyperplasia and progressive vascular restenosis even in the case of bare-metal stent use. Drug-eluting stents and drug-coated balloons are emerging endovascular technologies with the promise of significant inhibition of vessel restenosis and improved clinical outcomes. The current review outlines the drug-eluting properties of those instruments and summarizes the currently available clinical data. The authors critically appraise the current status and also provide a glimpse of the near future of endovascular below-the-knee treatments.
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Affiliation(s)
- Dimitris Karnabatidis
- Department of Radiology, Angiography Suite, Patras University Hospital, Rion, Greece.
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Abstract
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.
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Karnabatidis D, Spiliopoulos S, Diamantopoulos A, Katsanos K, Kagadis GC, Kakkos S, Siablis D. Primary everolimus-eluting stenting versus balloon angioplasty with bailout bare metal stenting of long infrapopliteal lesions for treatment of critical limb ischemia. J Endovasc Ther 2011; 18:1-12. [PMID: 21314342 DOI: 10.1583/10-3242.1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To report the long-term outcomes of a single-center prospective study investigating primary placement of everolimus-eluting metal stents for recanalization of long infrapopliteal lesions compared to a matched historical control group treated with plain balloon angioplasty and provisional placement of bare metal stents in a bailout manner. METHODS The study included 81 patients (63 men; mean age 71 years, range 45-85) suffering from critical limb ischemia (CLI) and angiographically proven long-segment (at least 1 lesion >4.5 cm) de novo infrapopliteal artery disease who underwent below-the-knee revascularization with either primary placement of everolimus-eluting stents (n = 47, 51 limbs, 102 lesions) or angioplasty and bailout bare metal stenting (n = 34, 36 limbs, 72 lesions). Clinical and angiographic follow-up was collected at regular time intervals. Primary clinical and angiographic endpoints included patient survival, major amputation-free survival, angiographic primary patency, angiographic binary restenosis (>50%), and overall event-free survival. Results were stratified according to endovascular treatment received. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding factors of heterogeneity. RESULTS Baseline demographics were well matched. No significant differences were identified between the 2 groups with regard to overall 3-year patient survival (82.2% versus 65.7%; p = 0.90) and amputation-free survival (77.1% versus 86.9%; p = 0.20). Up to 3 years, lesions fully covered with everolimus-eluting stents were associated with significantly higher primary patency [hazard ratio (HR) 7.98, 95% CI 3.69 to 17.25, p < 0.0001], reduced binary restenosis (HR 2.94, 95% CI 1.74 to 4.99, p < 0.0001), and improved overall event-free survival (HR 2.19, 95% CI 1.16 to 4.13, p = 0.015) versus the matched historical control group. CONCLUSION Primary infrapopliteal everolimus-eluting stenting for CLI treatment significantly inhibits restenosis and improves long-term angiographic patency and overall patient event-free survival compared to balloon angioplasty and bailout bare metal stenting.
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Affiliation(s)
- Dimitris Karnabatidis
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece.
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Zhu YQ, Zhao JG, Li MH, Liu F, Wang JB, Cheng YS, Wang J, Li J. Retrograde Transdorsal-to-Plantar or Transplantar-to-Dorsal Intraluminal Re-Entry Following Unsuccessful Subintimal Angioplasty for Below-the-Ankle Arterial Occlusion. J Endovasc Ther 2010; 17:712-21. [DOI: 10.1583/10-3207.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Redlich U, Xiong YY, Pech M, Tautenhahn J, Halloul Z, Lobmann R, Adolf D, Ricke J, Dudeck O. Superiority of Transcutaneous Oxygen Tension Measurements in Predicting Limb Salvage After Below-the-Knee Angioplasty: A Prospective Trial in Diabetic Patients With Critical Limb Ischemia. Cardiovasc Intervent Radiol 2010; 34:271-9. [DOI: 10.1007/s00270-010-9968-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 07/13/2010] [Indexed: 11/29/2022]
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Siablis D, Katsanos K, Karnabatidis D. Commentary: Infrapopliteal Angioplasty With Drug-Eluting Stents: From Heart to Toe. J Endovasc Ther 2010; 17:488-91. [DOI: 10.1583/10-3073c.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Six-month clinical outcomes after below-the-knee angioplasty for critical limb ischemia in patients on hemodialysis. Cardiovasc Interv Ther 2010; 25:91-7. [DOI: 10.1007/s12928-010-0018-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Accepted: 04/07/2010] [Indexed: 10/19/2022]
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Zander T, Rabellino M, Baldi S, Blasco O, Maynar M. Infrainguinal revascularization using the Crosser®vibrational system. MINIM INVASIV THER 2010; 19:231-6. [DOI: 10.3109/13645701003644137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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38
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Zhu YQ, Zhao JG, Liu F, Wang JB, Cheng YS, Li MH, Wang J, Li J. Subintimal angioplasty for below-the-ankle arterial occlusions in diabetic patients with chronic critical limb ischemia. J Endovasc Ther 2010; 16:604-12. [PMID: 19842730 DOI: 10.1583/09-2793.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Yue-Qi Zhu
- Department of Radiology, The Sixth Affiliated People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
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Allaqaband S, Kirvaitis R, Jan F, Bajwa T. Endovascular treatment of peripheral vascular disease. Curr Probl Cardiol 2009; 34:359-476. [PMID: 19664498 DOI: 10.1016/j.cpcardiol.2009.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.
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Conrad MF, Kang J, Cambria RP, Brewster DC, Watkins MT, Kwolek CJ, LaMuraglia GM. Infrapopliteal balloon angioplasty for the treatment of chronic occlusive disease. J Vasc Surg 2009; 50:799-805.e4. [DOI: 10.1016/j.jvs.2009.05.026] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 05/13/2009] [Accepted: 05/14/2009] [Indexed: 11/25/2022]
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Werneck CC, Lindsay TF. Tibial Angioplasty for Limb Salvage in High-Risk Patients and Cost Analysis. Ann Vasc Surg 2009; 23:554-9. [DOI: 10.1016/j.avsg.2009.05.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2008] [Revised: 03/31/2009] [Accepted: 05/21/2009] [Indexed: 11/28/2022]
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Siablis D, Karnabatidis D, Katsanos K, Diamantopoulos A, Spiliopoulos S, Kagadis GC, Tsolakis J. Infrapopliteal application of sirolimus-eluting versus bare metal stents for critical limb ischemia: analysis of long-term angiographic and clinical outcome. J Vasc Interv Radiol 2009; 20:1141-50. [PMID: 19620014 DOI: 10.1016/j.jvir.2009.05.031] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Revised: 05/12/2009] [Accepted: 05/28/2009] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To present the 3-year angiographic and clinical results of a prospective registry investigating the performance of sirolimus-eluting stents (SESs) versus bare metal stents (BMSs) for critical limb ischemia (CLI) treatment. MATERIALS AND METHODS A single-center double-arm prospective registry included patients with CLI who underwent infrapopliteal revascularization with angioplasty and "bailout" use of an SES or BMS. Clinical and angiographic follow-up was scheduled at regular time intervals. Primary clinical and angiographic endpoints included mortality, limb salvage, primary patency, binary angiographic restenosis (ie, >50%), and clinically driven repeat intervention-free survival. Results were stratified according to stent type, and cumulative proportion outcomes were determined by Kaplan-Meier plots. Multivariable Cox proportional-hazards regression analysis was applied to adjust for confounding factors of heterogeneity. RESULTS In total, 103 patients were included in the analysis; 41 (75.6% with diabetes) were treated with a BMS (47 limbs; 77 lesions) and 62 (87.1% with diabetes) with an SES (75 limbs; 153 lesions). At 3 years, SES-treated lesions were associated with significantly better primary patency (hazard ratio [HR], 4.81; 95% CI, 2.91-7.94; P < .001), reduced binary restenosis (HR, 0.38; 95% CI, 0.25-0.58; P < .001), and better repeat intervention-free survival (HR, 2.56; 95% CI, 1.30-5.00; P = .006) versus BMS-treated ones. No significant differences were identified between SESs and BMSs with regard to overall 3-year patient mortality (29.3% vs 32.0%; P = .205) and limb salvage (80.3% vs 82.0%; P = .507). CONCLUSIONS Infrapopliteal application of SESs for CLI significantly improves angiographic long-term patency and reduces infrapopliteal vascular restenosis versus BMSs, thereby lessening the rate of clinically driven repeat interventions.
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Affiliation(s)
- Dimitris Siablis
- Department of Radiology, University Hospital of Patras, GR 265 00, Rion, Greece.
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Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of critical limb ischemia. J Endovasc Ther 2009; 16:II31-62. [PMID: 19624074 DOI: 10.1583/08-2657.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.
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Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA.
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Das TS, McNamara T, Gray B, Sedillo GJ, Turley BR, Kollmeyer K, Rogoff M, Aruny JE. Primary cryoplasty therapy provides durable support for limb salvage in critical limb ischemia patients with infrapopliteal lesions: 12-month follow-up results from the BTK Chill Trial. J Endovasc Ther 2009; 16:II19-30. [PMID: 19624073 DOI: 10.1583/08-2652.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To report the 12-month follow-up data from the prospective 16-center Below-the-Knee (BTK) Chill Trial, which examined the use of primary cryoplasty for BTK occlusive disease in patients with critical limb ischemia (CLI). METHODS The trial included 108 patients (77 men; mean age 73 +/- 11 years, range 41-101) with CLI (Rutherford categories 4-6) involving 111 limbs with 115 target infrapopliteal lesions. Angiographic inclusion criteria were reference vessel diameter > or = 2.5 mm and < or = 5.0 mm and target lesion stenosis > or = 50%. The primary study endpoints were acute technical success (the ability to achieve < or = 50% residual stenosis and continuous inline flow to the foot) and absence of major amputation of the target limb at 6 months. Secondary endpoints were serious adverse events specifically related to use of primary cryoplasty and absence of major amputation of the target limb at 1, 3, and 12 months. RESULTS Acute technical success was achieved in 108 (97.3%) of treated limbs, with only 1 clinically significant dissection (> or = type C) and 2 residual stenoses >50%; stent placement was required following cryoplasty in only 3 (2.7%) procedures. At 6 months and 1 year, major amputation was avoided in 93.4% (85/91) and 85.2% (69/81) of patients, respectively. Through 1 year, 21% (17/81) of patients underwent target limb revascularization. Rates of major amputation and death at 1 year were 0% for limbs of patients with initial Rutherford category 4; 11.4% and 0%, respectively, for initial category 5; and 40.0% and 31.8% for initial category 6. One-year rates of major amputation and death were 20.4% and 8.8%, respectively, for diabetics, versus 4.0% and 10.7% for non-diabetics. At 1 year, major amputation occurred in 16.7% (2/12) of limbs that were expected to be amputated at the time of treatment. CONCLUSION Cryoplasty therapy is a safe and effective method of treating infrapopliteal disease, providing excellent results and a high rate of limb salvage in patients with CLI. Study outcomes through 1 year support the use of cryoplasty as a primary treatment option for patients with CLI secondary to BTK occlusive disease.
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Affiliation(s)
- Tony S Das
- Cardiology & Interventional Vascular Associates, Presbyterian Heart Institute, 7150 Greenville Avenue, Suite 500, Dallas, TX 75231, USA.
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Below-knee Bare Nitinol Stent Placement in High-risk Patients with Critical Limb Ischaemia and Unlimited Supragenicular Inflow as Treatment of Choice. Eur J Vasc Endovasc Surg 2009; 37:688-93. [DOI: 10.1016/j.ejvs.2009.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Accepted: 01/24/2009] [Indexed: 11/23/2022]
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Laird JR, Dawson DL. The Role for Cryoplasty in the Treatment of Infrainguinal Artery Disease:Case Studies. J Endovasc Ther 2009; 16:II116-28. [DOI: 10.1583/08-2653.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lyden SP, Smouse HB. TASC II and the Endovascular Management of Infrainguinal Disease. J Endovasc Ther 2009; 16:II5-18. [DOI: 10.1583/08-2659.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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NAIR VINOD, CHAISSON GARY, ABBEN RICHARD. Strategies in Infrapopliteal Intervention: Improving Outcomes in Challenging Patients. J Interv Cardiol 2009; 22:27-36. [DOI: 10.1111/j.1540-8183.2008.00412.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Karnabatidis D, Katsanos K, Siablis D. Infrapopliteal Stents:Overview and Unresolved Issues. J Endovasc Ther 2009; 16 Suppl 1:I153-62. [DOI: 10.1583/08-2593.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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