Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia

Söderström, Mats; Arvela, E.; Korhonen, M.; Halmesmäki, Karoliina; Albäck, Anders; Biancari, Fausto; Lepäntalo, Mauri; Venermo, Maarit

doi:10.1097/sla.0b013e3181fc3c73

Cited by 144 publications

(41 citation statements)

References 20 publications

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“…As percutaneous transluminal angioplasty (PTA) is increasingly used as an alternative primary therapy for critical limb ischemia 4–7 , a growing body of literature has accumulated comparing PTA to bypass. To date, there has only been one large randomized control trial comparing PTA to bypass for CLI 3 , which suggested that bypass should be offered first over balloon angioplasty in patients with available venous conduit who are expected to live longer than 2 years.…”

Section: Discussionmentioning

confidence: 99%

“…Citing lower perioperative morbidity and mortality, high technical success, and equivalent rates of limb salvage, some groups now endorse PTA as a comparable, if not preferred first-line therapy for patients with critical limb ischemia (CLI) 4–8 . Guidelines for PTA of the infrapopliteal vessels are less well defined than those for the iliac or femoropopliteal segments and in fact, the original TransAtlantic Inter-Society Consensus (TASC) I classification of infrapopliteal lesions 9 are notably absent from the TASC II guidelines, which offer no specific recommendations on the management of these lesions 10 .…”

Section: Introductionmentioning

confidence: 99%

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Outcomes following infrapopliteal angioplasty for critical limb ischemia

Darling

Bensley

et al. 2013

Journal of Vascular Surgery

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Objectives Infrapopliteal angioplasty (PTA) is routinely used to treat critical limb ischemia (CLI) despite limited data on long-term outcomes. Methods We reviewed all patients undergoing infrapopliteal PTA for CLI from 2004–2012 stratified by TASC class. Outcomes included restenosis, primary patency, reintervention (w/ PTA or bypass), amputation, procedural complications, wound healing, and survival. Results Infrapopliteal PTA (stenting 14%, multilevel intervention 50%) was performed in 459 limbs of 413 patients (59% male) with technical success of 93% and perioperative complications in 11%. TASC class was 16% A, 22% B, 27% C, and 34% D. Multilevel interventions were performed in 50% of limbs and were evenly distributed among all TASC classes. All technical failures were TASC D lesions. Mean follow-up was 15 months. 5-year survival was 49%. One- and 5-year primary patency was 57% & 38% and limb salvage was 84% & 81%. Restenosis was associated with TASC C (HR 2.2, 95% CI 1.2–3.9, P=.010) and TASC D (HR 2.4, 95% CI 1.3–4.4, P=.004) lesions. Amputation rates were higher in patients who were not candidates for bypass (HR 4.4, 95% CI 2.6–7.5, P<.001) and with TASC D lesions (HR 3.8, 95% CI 1.1–12.5, P=.03). Unsuitability for bypass was also predictive of repeat PTA (HR 1.8, 95% CI 1.0–3.4, P=.047). Postoperative clopidogrel use was associated with lower rates of any revascularization (HR .46, 95% CI .25–.83, P=.011). Conclusions Infrapopliteal PTA is effective primary therapy for TASC A, B, and C lesions. Surgical bypass should be offered to patients with TASC D disease who are suitable candidates. Multilevel intervention does not adversely affect outcome.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Outcomes following infrapopliteal angioplasty for critical limb ischemia

Darling

Bensley

et al. 2013

Journal of Vascular Surgery

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“…[84][85][86] Although higher complexity tibial disease has been traditionally treated surgically, Schmidt et al 87 reported 95.6% limb salvage at 12 months for complicated (average length 184 mm with 64.9% occlusions) infrapopliteal disease. A recent meta-analysis showed that even with severe tibial disease and poor distal run-off, reasonable rates of limb salvage can be achieved with angioplasty alone.…”

Section: Infrapopliteal Balloon Angioplasty For CLImentioning

confidence: 99%

Endovascular Intervention for Peripheral Artery Disease

Thukkani

Kinlay

2015

Circulation Research

220

158

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Advances in endovascular therapies during the past decade have broadened the options for treating peripheral vascular disease percutaneously. Endovascular treatment offers a lower risk alternative to open surgery in many patients with multiple comorbidities. Noninvasive physiological tests and arterial imaging precede an endovascular intervention and help localize the disease and plan the procedure. The timing and need for revascularization are broadly related to the 3 main clinical presentations of claudication, critical limb ischemia, and acute limb ischemia. Many patients with claudication can be treated by exercise and medical therapy. Endovascular procedures are considered when these fail to improve quality of life and function. In contrast, critical limb ischemia and acute limb ischemia threaten the limb and require more urgent revascularization. In general, endovascular treatments have greater long-term durability for aortoiliac disease than femoral popliteal disease. Infrapopliteal revascularization is generally reserved for critical and acute limb ischemia. Balloon angioplasty and stenting are the mainstays of endovascular therapy. New well-tested innovations include drug-eluting stents and drug-coated balloons. Adjunctive devices for crossing chronic total occlusions or debulking plaque with atherectomy are less rigorously studied and have niche roles. Patients receiving endovascular procedures need a structured surveillance plan for follow-up care. This includes intensive treatment of cardiovascular risk factors to prevent myocardial infarction and stroke, which are the main causes of death. Limb surveillance aims to identify restenosis and new disease beyond the intervened segments, both of which may jeopardize patency and lead to recurrent symptoms, functional impairment, or a threatened limb.

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“…Peripheral percutaneous transluminal angioplasty is a method for treating CLI, especially infrapopliteal level, with outcomes similar to those of bypass surgery 4,5. Ultimate aim of revascularization in patients with CLI is to prevent limb loss, including major amputation to improve patient's quality of life, and to prolong survival.…”

Section: Discussionmentioning

confidence: 99%

Dorsal-Plantar Loop Technique Using Chronic Total Occlusion Devices via Anterior Tibial Artery

et al. 2013

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The effectiveness of below-the-knee (BTK) percutaneous transluminal angioplasty to obtain successful revascularization in patients with critical limb ischemia has been well established, and many of these patients with chronic lower-extremity disease have been treated by endovascular intervention as the firstline treatment. Dorsal-plantaer loop technique is one of the new BTK interventional techiniques, and includes recanalization of both pedal and plantar arteries and their anatomical anastomoses. This method generally needs two approaches simultaneously, including antegrade and retrograde. In this report, however, we describe a case in which dorsal-plantar loop technique with only one antegrade approach, using chronic total occlusion devices via anterior tibial artery, was used to successfully recanalize BTK arteries. We think that this new technique, which may represent a safe and feasible endovascular option to avoid more invasive, time-consuming, and riskier surgical procedures, especially in end-stage renal disease and diabetes, should be considered whenever the foot is at risk, and results of above-the-ankle percutaneous transluminal angioplasty remain unsatisfactory or insufficient to achieve limb salvage.

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Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia

Abstract: When feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized.

Cited by 144 publications

References 20 publications

Outcomes following infrapopliteal angioplasty for critical limb ischemia

Outcomes following infrapopliteal angioplasty for critical limb ischemia

Endovascular Intervention for Peripheral Artery Disease

Dorsal-Plantar Loop Technique Using Chronic Total Occlusion Devices via Anterior Tibial Artery

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