Subintimal Angioplasty for Below-the-Ankle Arterial Occlusions in Diabetic Patients With Chronic Critical Limb Ischemia

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 70.968.5 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 anklebrachial 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 0.3360.55 and 0.3160.19 before SA and 2.0461.05 and 0.8060.14 after SA, respectively (p,0.0001 for both). The 30-day mortality was 2.7%. Median follow-up was 9.166.1 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.

Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients

“…In the limited number of studies, including patients with diabetes with ischemic or neuroischemic ulcers, the focus is on limb salvage after a specific intervention and they often include patients with and without diabetes, and with and without ulcers. [21][22][23] However, our results with regard to healing are similar to other published results, 5,24 where healing rates were 70% to 73%. The present study was not designed to assess limb salvage but rate of ulcer healing in all consecutively presenting patients with diabetes and an ischemic or neuroischemic ulcer.…”

“…Our patients are comparable with regard to comorbidity and demographic data, but are somewhat older than patients in other studies regarding vascular intervention. 23,24,26 In large cohort studies of patients with diabetes and foot ulcers, the outcome has been measured with regard to the possibility of primary healing (healing without amputation) or of avoiding major amputation at or above the ankle. 15,25 In some studies of patients with diabetes, about 10% to 15% (and sometimes as many as 30%) of patients who were considered not suitable for vascular surgery have been shown to heal without any amputation or without a major amputation, which is confirmed by the present findings.…”

Patency of Reverse Saphenous Vein Graft for Revascularization of Lower Limbs in Diabetic Patients

“…The saphenous vein has been widely used as conduit [19]. And the reverse saphenous vein graft is considered the best method of revascularization [20]. The reported global quality of life after revascularization was similar in our study (74%) and previous studies (69 to 75%), and the long-term patency of the saphenous vein grafts also was similar (75% vs 72%).…”

Patency of runoff detected by MR angiography at 3.0 T with cuff-compression: a predictor of successful endovascular recanalization below the knee

“…Target vessels were approached as described in the DSA protocol. Initially, antegrade intraluminal angioplasty was attempted to recanalize the occlusive lesion; in cases where intraluminal angioplasty failed, subintimal angioplasty and retrograde revascularization via the pedal arch loop were performed subsequently, as reported previously [3,7] At the beginning of the percutaneous transluminal angioplasty (PTA) procedure, 4,000 IU of heparin was routinely administered intravenously, and 1,000 IU of heparin was given every hour. After the guidewire was passed through the lesion, dilatation was performed for up to 2 min under 6-12 atmospheres using a 2.0-mm or 2.5-mm-diameter and 120-cm or 150-cm-long balloon catheter (Amphirion Deep, Invatec, Italy).…”

“…According to the angiosome principle, endovascular recanalization (ER) is increasingly being used to restore blood flow to the area of ischemia, tissue loss, or gangrene [2][3][4][5]. The introduction of dedicated wires and balloon catheters has led to the development of more aggressive and technically demanding approaches for challenging cases; for example, direct retrograde puncture (retrograde puncture of the anterior tibial, peroneal, or posterior tibial arteries, and even the transmetatarsal or transplantar arch) and the transpedal-plantar loop technique [6][7][8][9][10].…”