The Importance of Patency in Patients with Critical Limb Ischemia Undergoing Endovascular Revascularization for Infrapopliteal Arterial Disease

Abstract

Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease (PAD) and frequently occurs in medically frail patients. CLI patients frequently exhibit multi-segmental PAD commonly including the tibial arterial segment. Endovascular therapy has been established as first-line revascularization strategy for most CLI patients. Restenosis was reported to occur in up to more than two-thirds of CLI patients undergoing angioplasty of complex tibial arterial obstructions. Nevertheless, favorable clinical outcomes were observed for infrapopliteal angioplasty when compared with bypass surgery, despite higher patency rates for the latter. Based on these observations, infrapopliteal patency was considered to be only of secondary importance upon clinical outcomes in CLI patients. In contrast to these earlier observations, however, recent findings from two randomized clinical trials indicate that infrapopliteal patency does impact on clinical outcomes in CLI patients. The purpose of the present manuscript is to provide a critical reappraisal of the present literature on the clinical importance of tibial arterial patency in CLI patients undergoing endovascular revascularization and to discuss utility and limitations of currently available anti-restenosis technologies.

Did the Clinical Spectrum of Thromboangiitis Obliterans Change in the Past 40 Years?

“…As described in atherosclerotic disease, arterial patency seems to be critical for limb prognosis. 17,18…”

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

“…134,135 Vessel restenosis or reocclusion limits wound healing and clinical improvement and often leads to TLR and/or amputation. 88,136,137 The main mechanisms leading to restenosis include elastic recoil, neointimal hyperplasia, and vascular remodeling. 123,138 Angioplasty fractures the atherosclerotic plaque and promotes platelet adhesion and activation by exposing thrombogenic compounds.…”

Pro-resolving lipid mediators in vascular disease

“…The magnitude as well as temporal and spatial distribution of the ensuing inflammatory response in the vessel wall, and its resolution, are key drivers of vessel remodeling and downstream clinical outcomes (34)(35)(36)(37)(38). While often technically successful, the long-term outcomes of such procedures are limited by excessive vessel scarring or "restenosis" that may affect 50% or more of patients within 2 to 3 years (39)(40)(41). Elevated levels of proinflammatory cytokines have been associated with restenosis and adverse outcomes following peripheral interventions (42)(43)(44).…”