Endovascular Therapy as the Primary Approach for Limb Salvage in Patients with Critical Limb Ischemia: Experience with 443 Infrapopliteal Procedures

Abstract

Endovascular strategies for the treatment of critical infrageniculate peripheral arterial occlusive disease exist and are becoming the primary methodology for such lesions at many centers. Although technically feasible for experienced operators, the evidence to support this strategy for below the knee (BTK) interventions is still evolving. We studied the 6-month and 1-year outcomes of percutaneous transluminal angioplasty (PTA) alone, PTA with stenting, and excimer laser recanalization for BTK lesions in patients with critical limb ischemia. Between September 2002 and June 2005, 443 patients (355 Rutherford category 4, 82 category 5, 6 category 6) underwent intervention for 681 BTK lesions. Follow-up was performed at 6-month intervals after index intervention: limb salvage data were recorded and duplex ultrasonography was performed to measure the patency of treated areas. The primary patency and limb salvage rates of the entire population were 85.2% and 97.0% and 74.2% and 96.6% at 6 months and 1 year, respectively. Stratified for the treatment strategy (PTA alone in 79, PTA with stenting in 300 patients, and excimer laser in 64), 1-year primary patency rates were 68.6%, 75.5%, and 75.4%, whereas the limb salvage rates were 96.7%, 98.6%, and 87.9% for each modality, respectively. Endovascular intervention will become the primary treatment for BTK lesions in patients with critical limb ischemia, with 1-year primary patency and limb salvage rates that compare favorably with published surgical data. Prospective, randomized, multicenter trials will be needed to further establish the role of endovascular intervention in this challenging patient group.

Comparison of Clinical outcomes of Infragenicular Angioplasty between diabetic and non-diabetic patients with Peripheral Arterial Occlusive Disease

“…For these previous causes, infragenicular angioplasty is nowadays suggested to be the primary management of CLI in diabetic subjects [5,9,[13][14][15].…”

“…Although many literatures concerning diabetic CLI patients determined that infragenicular intervention in these patients may salvage many limbs under threat of amputation, these trials studied heterogeneous ischemia stages such as claudication, resting pain or tissue lesions and, in addition the most frequently managed arteries were the distal popliteal artery and the tibioperoneal trunk, with diameters more similar to those of above-knee than those of the smaller below-knee arteries [9][10][11][12][13][14][15][16].…”

The concept of surgical treatment of critical limb ischemia

“…Указанных 3 мес доста-точно для решения этого вопроса у большинства больных [7]. Сохранение конечности у больных КИНК отмечено в 96,7% после выполнения ЧКА на уровне голени [17].…”

Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective?

“…Several studies have demonstrated good results in terms of patency and limb salvage after endovascular treatment of diabetic foot [10][11][12][13][14]. Many, however, are limited by the presence of a heterogeneous population with different stages of ischemia (claudication, rest pain, trophic lesions) and different treatment modalities, with PTA performed both in the above-the-knee (ATK) and BTK areas [15][16][17]. It is well known that peripheral arterial disease in diabetic patients with critical limb ischemia (CLI) primarily involves the BTK area (anterior and posterior tibial arteries, peroneal artery, dorsalis pedis, medial and lateral plantar arteries) [18], but the efficacy of PTA in this group of BTK-only patients has not been fully evaluated, particularly regarding the different effectiveness of direct revascularization (DR) versus indirect revascularization (IR) according to the angiosome model [19].…”