Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement

Armstrong, Ehrin J.; Alam, Syed Intakhab; Henao, Steve; Lee, Arthur C.; DeRubertis, Brian G.; Montero-Baker, Miguel; Mena, Carlos; Cua, Bennett; Palena, Luis Mariano; Kovach, Richard; Chandra, Venita; AlMahameed, Amjad; Walker, Craig M.

doi:10.1177/1526602819826593

Cited by 30 publications

(24 citation statements)

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“…They include but are not limited to atherectomy and cutting/scoring/focal force devices. [97][98][99][100] The proposed mechanism of these techniques is to increase target lesion compliance, thereby reducing the risk of flow-limiting dissection and improving the immediate results of BA. 101 Cutting and scoring balloons may improve the outcomes of angioplasty compared with standard BA.…”

Section: Residual Stenosismentioning

confidence: 99%

“…Currently no standard exists for the treatment of infrapopliteal lesions, and as such treatment approaches in a systematic manner are missing from clinical practice. 98 The authors propose an optimal BA algorithm ( Figure 3) that includes (1) assessment of vessel calcification, (2) optimal balloon sizing, (3) prolonged balloon inflation, and (4) assessment of postangioplasty dissection and recoil. The goal of this algorithm is to optimize each step in angioplasty treatment and thereby ultimately improve patency.…”

Section: Optimal Ba For Infrapopliteal Lesions: a Proposed Algorithmmentioning

confidence: 99%

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Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy

et al. 2020

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Endovascular revascularization has been increasingly utilized to treat patients with chronic limb-threatening ischemia (CLTI), particularly atherosclerotic disease in the infrapopliteal arteries. Lesions of the infrapopliteal arteries are the result of 2 different etiologies: medial calcification and intimal atheromatous plaque. Although several devices are available for endovascular treatment of infrapopliteal lesions, balloon angioplasty still comprises the mainstay of therapy due to a lack of purpose-built devices. The mechanism of balloon angioplasty consists of adventitial stretching, medial necrosis, and dissection or plaque fracture. In many cases, the diffuse nature of infrapopliteal disease and plaque complexity may lead to dissection, recoil, and early restenosis. Optimal balloon angioplasty requires careful attention to assessment of vessel calcification, appropriate vessel sizing, and the use of long balloons with prolonged inflation times, as outlined in a treatment algorithm based on this systematic review. Further development of specific devices for this arterial segment are warranted, including devices for preventing recoil (eg, dedicated atherectomy devices), treating dissections (eg, tacks, stents), and preventing neointimal hyperplasia (eg, novel drug delivery techniques and drug-eluting stents). Further understanding of infrapopliteal disease, along with the development of new technologies, will help optimize the durability of endovascular interventions and ultimately improve the limb-related outcomes of patients with CLTI.

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Section: Residual Stenosismentioning

confidence: 99%

Section: Optimal Ba For Infrapopliteal Lesions: a Proposed Algorithmmentioning

confidence: 99%

Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy

et al. 2020

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“…CLI-specific antiplatelet/anticoagulant therapy is mainly extrapolated from studies of patients with asymptomatic PAD or claudication [27, 47]. Azarbal et al suggested the extrapolation of PAD to CLI is reasonable since the studies contain both PAD and CLI patients [27]; however, there are challenges with this extrapolation.…”

Section: Discussionmentioning

confidence: 99%

A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention

et al. 2019

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Endovascular intervention is often used to treat critical limb ischemia (CLI). Post-intervention treatment with antiplatelet and/or anticoagulant therapy has reduced morbidity and mortality due to cardiovascular complications. The purpose of this review is to shed light on the various pharmacologic treatment protocols for treating CLI following endovascular procedures. We reviewed the literature comparing outcomes after antithrombotic treatment for patients with CLI. We characterized antithrombotic therapies into three categories: (1) mono-antiplatelet therapy (MAPT) vs. dual antiplatelet therapy (DAPT), (2) MAPT vs. antiplatelet (AP) ? anticoagulant (AC) therapy, and (3) AC vs. AP ? AC therapy. Relevant results and statistics were extracted to determine differences in the rates of the following outcomes: (1) re-stenosis, (2) occlusion, (3) target limb revascularization (TLR), (4) major amputation, (5) major adverse cardiac events, (6) all-cause death, and (7) bleeding. Studies suggest that DAPT reduces post-surgical restenosis, TLR, and amputation for diabetic patients, without increasing major bleeding incidences, compared to MAPT. Also, AP ? AC therapy provides overall superior efficacy, with no difference in bleeding incidences, compared to antiplatelet alone. Additionally, the effects were significant for restenosis, limb salvage, survival rates, and cumulative rate of above ankle amputation or death. These results suggest that treatment with DAPT and AP ? AC might provide better outcomes than MAPT following the endovascular intervention for CLI, and that the ideal treatment may be related to the condition of the individual patient. However, the studies were few and heterogenous with small patient populations. Therefore, further large controlled studies are warranted to confirm these outcomes.

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“…34 Thus, vessel calcification is directly correlated to the overall implications of PAD. 35 , 36 As such, numerous treatment methods have been developed for plaque modification before angioplasty 31 , 37 – 41 in order to minimize periprocedural complications, enhance vessel patency, and minimize the need for provisional stenting. 42 …”

Section: Introductionmentioning

confidence: 99%

Three-Year Outcomes of Orbital Atherectomy for the Endovascular Treatment of Infrainguinal Claudication or Chronic Limb-Threatening Ischemia

Giannopoulos

Secemsky

Mustapha³

et al. 2020

J Endovasc Ther

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Purpose: To investigate the outcomes of orbital atherectomy (OA) for the treatment of patients with peripheral artery disease (PAD) manifesting as claudication or chronic limb-threatening ischemia (CLTI). Materials and Methods: The database from the LIBERTY study ( ClinicalTrials.gov identifier NCT01855412) was interrogated to identify 503 PAD patients treated with any commercially available endovascular devices and adjunctive OA for 617 femoropopliteal and/or infrapopliteal lesions. Cox regression analyses were employed to examine the association between baseline Rutherford category (RC) stratified as RC 2-3 (n=214), RC 4-5 (n=233), or RC 6 (n=56) and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE), and major amputation/death at up to 3 years of follow-up. The mean lesion lengths were 78.7±73.7, 131.4±119.0, and 95.2±83.9 mm, respectively, for the 3 groups. Results: After OA, balloon angioplasty was used in >98% of cases, with bailout stenting necessary in 2.0%, 2.8%, and 0% of the RC groups, respectively. A small proportion (10.8%) of patients developed angiographic complications, without differences based on presentation. During the 3-year follow-up, claudicants were at lower risk for MAE, death, and major amputation/death than patients with CLTI. The 3-year Kaplan-Meier survival estimates were 84.6% for the RC 2-3 group, 76.2% for the RC 4-5 group, and 63.7% for the RC 6 group. The 3-year freedom from major amputation was estimated as 100%, 95.3%, and 88.6%, respectively. Among CLTI patients only, the RC at baseline was correlated with the combined outcome of major amputation/death, whereas RC classification did not affect TVR, MAE, major amputation, or death rates. Conclusion: Peripheral artery angioplasty with adjunctive OA in patients with CLTI or claudication is safe and associated with low major amputation rates after 3 years of follow-up. These results demonstrate the utility of OA for patients across the spectrum of PAD.

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Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement

Cited by 30 publications

References 98 publications

Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy

Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy

A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention

Three-Year Outcomes of Orbital Atherectomy for the Endovascular Treatment of Infrainguinal Claudication or Chronic Limb-Threatening Ischemia

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