Outcomes following infrapopliteal angioplasty for critical limb ischemia

Abstract

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.

Outcomes of infrapopliteal angioplasty for limb salvage based on the updated TASC II classification

“…Despite the overall complexity of treated lesions in our series, the overall limb salvage at 1 and 3 years following conventional PTA is comparable to other published results and to outcomes from surgical bypass with a relatively low secondary reintervention rate of 15% (2)(3)(4)(5)(7)(8)(9)(10)(11)(12)(13)(14)(15). Although newer technologies such as drug-coated angioplasty balloons (DCB) or drug-eluting stents (DES), and atherectomy devices were absent in our series, there has been recent interest in the use of DCB and DES in the treatment of infrapopliteal lesions (16)(17)(18)(19)(20).…”

“…A wide variety of factors influencing outcome following infrapopliteal PTA with varying impact have been proposed in the literature (3,5,10,14,15,25). The accurate outcome prediction from endovascular therapy allows interventionists to tailor appropriate management strategies to individual patients with greater confidence and may minimize morbidity or mortality from under or overtreatment.…”

“…nfrapopliteal percutaneous transluminal angioplasty (PTA) is an established treatment for lower limb salvage in critical limb ischemia (CLI) and is highly attractive given its minimally invasive nature and comparable outcomes to tibial bypass surgery (1)(2)(3)(4)(5). Previous studies have reported outcomes of infrapopliteal PTA based on stratification of lesions using the Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification (4,5).…”

“…Previous studies have reported outcomes of infrapopliteal PTA based on stratification of lesions using the Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification (4,5). However, this was updated in 2015 to include a new classification for infrapopliteal lesions reflecting recent technical advancements (Table 1) (6).…”

Evaluación de la permeabilidad posterior a procedimientos endovasculares para pacientes con obstrucciones arteriales en miembros inferiores

“…Así mismo, se observó mayor distribución del compromiso inicial en territorio vascular con nuevos episodios de estenosis presentados en mayor cantidad en pacientes con compromiso mixto (supra e infragenicular), seguido por los de compromiso infragenicular, con similares resultados respecto a las publicaciones de la literatura 1 , en las que, según Ruby, se presenta desde un 37 a 50 % de estenosis en el infrapoplíteo. El determinante final de aparición de reestenosis se presentó en menor frecuencia respecto al hallado en la literatura actual 1,4 , a excepción de la tasa reportada por Siracuse 14 , con poblaciones de características similares a la estudiada, logrando obtener un porcentaje libre de reestenosis mayor al 80 % dentro del año de seguimiento evaluado.…”