Multilevel versus isolated endovascular tibial interventions for critical limb ischemia

Influence of preprocedural statin usage on primary patency and amputation in patients undergoing lower limb peripheral angioplasty

BACKGROUND

Peripheral arterial disease can progress to critical limb ischemia, which is associated with high amputation rates and requires revascularization. The endovascular approach has lower long-term patency because of restenosis due to neointimal hyperplasia. Statins are significantly advantageous for patients undergoing percutaneous interventions; however, only few studies have reported surgical improvements with statin therapy after endovascular treatment in such patients. This retrospective cohort study assessed the effects of preprocedural statins on lower limb arterial angioplasty outcomes by evaluating patency and amputation rates and comparing with those without statins.

METHODS

Patients who underwent percutaneous transluminal angioplasty of the lower limbs for critical ischemia of the lower limbs or for limiting claudication were included in this retrospective cohort study. Patients were categorized according to statin use prior to and during hospitalization. Patient demographics, lesion morphology, primary patency, and limb salvage rates were compared between these groups. Statistical analyses were performed using Kaplan-Meier and multivariate regression analysis.

RESULTS

A total of 178 patients undergoing endovascular intervention by critical ischemia or limiting claudication were included. Approximately 80% of the procedures were ballon angioplasty. Primary patency was 73% in 1 year and preprocedural statin usage was not associated with improved primary patency rates (p = 0.2798). After adjusting the amputation outcomes for pre-established variables, such as prehospitalization statin use, diabetes, procedure indication, disease location, TASC classification, and current smoking, there was no statistically significant difference associated with preprocedural statin use in primary patency (HR: 0.87 (0.33-2.29), p = 0.79) or amputation (HR: 0.70 (0.40-1.23), p = 0.22).

CONCLUSIONS

The use of preprocedural statin did not improve primary patency or amputation rates in patients undergoing peripheral angioplasty.

Endovascular Management of Chronic Limb-Threatening Ischemia (CLTI) in the Elderly: A Focus on Frailty, Wound Healing and Outcomes

BACKGROUND

In India, a significant scarcity of published data exists regarding chronic limb-threatening ischemia (CLTI) and its management, especially among the elderly population. CLTI, often accompanied by frailty poses a significant healthcare challenge. While endovascular interventions offer hope, there remains a dearth of outcome data for this age group. This study seeks to address this critical gap by investigating the impact of frailty on outcomes, emphasizing amputation-free survival (AFS), wound healing, and health-related quality of life (HRQoL).

METHODS

Our study included 131 elderly CLTI patients aged ≥70 years who underwent infrainguinal endovascular interventions between April 2018 and August 2021, with a follow-up period of 2 years. Among the patients, 93.9% had diabetes mellitus and 82.4% had hypertension. Clinical frailty was assessed using the Clinical Frailty Scale (CFS). Patients were categorized into Group 1 (CFS 1-5) and Group 2 (CFS 6-9). Primary outcomes were AFS, wound healing, HRQoL, and their association with frailty. Secondary outcomes included technical success, procedure-related complications, major adverse limb events (MALE), major adverse cardiovascular events (MACE), vessel patency, re-intervention rates, and mortality rates including peri-procedural and overall mortality.

RESULTS

Technical success was achieved in 86.3% of patients, with frailty significantly influencing this outcome. Group 2 exhibited reduced technical success (80.8%) compared to Group 1 (93.1%). The major amputation rate was 9.2%, with higher rates in Group 2 [univariate Hazard Ratio (HR): 5.20; p=0.033]. Similarly, Group 2 showed elevated overall mortality [univariate HR: 5.18; p < 0.001]. AFS at 1 and 2 years were 67.9% and 55% respectively, with higher rates in Group 1. Wound healing was achieved in 76.1% of patients (83/109), with frailty significantly associated with delayed wound healing (p < 0.001). Vessel patency at 1 year was observed in 88.8% of patients. HRQoL significantly improved post-intervention, with VascuQol-6 scores increasing from an average of 9 of 24 at baseline to 20 of 24 at 2 years. Frailty score significantly correlated with VascuQol-6 scores at 1 and 2 years (p < 0.0012). Group 1 exhibited higher VascuQol-6 scores compared to Group 2, indicating improved HRQoL during follow-up.

CONCLUSION

Successful endovascular treatments in high-risk CLTI patients promote improved wound healing and post-treatment quality of life (QoL). Frailty should be assessed before endovascular interventions as it correlates with adverse outcomes, including amputations and mortality. While revascularization holds promise, caution is advised for frailer patients, emphasizing the importance of personalized care and tailored treatments for elderly CLTI patients.

Retrograde distal access versus femoral access for below the knee angioplasty

BACKGROUND

The prevalence of peripheral artery disease (PAD) in the general population is about 12% to 14% and it increases with age. PAD increased from 164 million people in 2000 to 202 million people in 2010. More than two-thirds of people with PAD are based in low- or middle-income countries. Critical limb ischaemia (CLI) occurs in 1% to 2% of people with intermittent claudication over five years. One third of people with CLI have isolated below the knee (BTK) lesions. CLI and isolated BTK lesions are associated with a higher incidence of limb loss when compared with people with multilevel arterial disease. Endovascular procedures such as angioplasty (with or without stenting) are widely used to treat isolated BTK lesions, aiming to improve blood flow and limb salvage. The technical success of any angioplasty procedure depends on the ability to cross the target lesion. Failed attempts are underestimated in the literature and failures in the real world appear to be higher than reported. People with isolated BTK lesions undergoing angioplasty by conventional femoral access present a high failure rate to cross these lesions. Retrograde distal access may provide some advantages that can lead to successful crossing of the target lesion.

OBJECTIVES

To evaluate the benefits and harms of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 September 2022.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised controlled trials comparing people undergoing retrograde distal access versus people undergoing conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. Our primary outcomes were technical success of angioplasty procedure and major procedural complications. Our secondary outcomes were mortality rate, amputation-free survival, primary patency, minor procedural complications and wound healing. We planned to use GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We identified no randomised or quasi-randomised controlled trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We identified no randomised or quasi-randomised controlled trials that compared retrograde distal access versus femoral access for BTK angioplasty. High-quality studies that compare retrograde distal access versus conventional femoral access for BTK angioplasty are needed.

Endovascular Interventions for Peripheral Artery Disease: A Contemporary Review

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is an increasingly prevalent but frequently underdiagnosed condition that can be associated with high rates of morbidity and mortality. While an initial noninvasive approach is the cornerstone of management, revascularization is often pursued for patients with treatment-refractory claudication or chronic limb-threatening ischemia (CLTI). In this review, we discuss the current state of endovascular interventions for PAD and explore the many new emerging technologies.

RECENT FINDINGS

The last decade has resulted in numerous advances in PAD interventions including the ongoing evolution of drug-coated devices, novel approaches to complex lesions, and contemporary evidence from large clinical trials for CLTI. Advances in endovascular management have allowed for increasingly complex lesions to be tackled percutaneously. Future directions for the field include the continued evolution in device technology, continued development of state-of-the-art techniques to revascularization of complex lesions, and increased collaboration between a largely multidisciplinary field.

Prediction of Wound Recurrence in Patients With Chronic Limb-Threatening Ischemia Undergoing Endovascular Treatment

PURPOSE

Chronic limb-threatening ischemia due to isolated below-the-knee lesions is a factor associated with wound recurrence. However, there is a lack of data regarding wound recurrence in such cases. This study aimed to determine the predictors of wound recurrence in patients with chronic limb-threatening ischemia undergoing endovascular treatment.

PATIENTS AND METHODS

This was a single-center, retrospective, observational study. We enrolled 152 consecutive patients with chronic limb-threatening ischemia (172 limbs) who achieved complete wound healing after undergoing endovascular treatment for isolated below-the-knee lesions between February 2008 and December 2017. Of these, the wound had recurred in 56 limbs (33%), and we divided the patients into 2 groups based on wound recurrence. We evaluated the recurrence rate of chronic limb-threatening ischemia and predictors of wound recurrence. Wound recurrence was defined as recurrence of the wound within 2 years of complete wound healing.

RESULTS

Patients' backgrounds were similar in both groups, including mean age (72±9 vs 72±11; p=0.76) and hemodialysis (43% vs 40%; p=0.66). Pre-pedal arch type 2 (52% vs 8%; p<0.01), infrapopliteal grade 4 of the Global Limb Anatomic Staging System (77% vs 59%; p=0.02), and Wound, Ischemia, and foot Infection criteria stage 4 (43% vs 28%; p=0.04) were more common in the wound recurrence group. Multivariate Cox proportional hazard analysis identified pre-pedal arch type 2 (hazard ratio, 5.28; 95% confidence interval, 3.08-9.10; p<0.01) and Wound, Ischemia, and foot Infection criteria stage 4 (hazard ratio, 1.98; 95% confidence interval, 1.15-3.36; p=0.01) as predictors of wound recurrence after complete wound healing.

CONCLUSION

Pre-pedal arch type 2 and Wound, Ischemia, and foot Infection classification system stage 4 were associated with wound recurrence in patients with chronic limb-threatening ischemia who achieved complete wound healing after undergoing endovascular treatment for isolated below-the-knee lesions.

Association of 2D Perfusion Angiography and Wound Healing Rate in Combined Femoro-popliteal and Below-the-Knee Lesions in Ischemic Patients Undergoing Isolated Femoro-popliteal Endovascular Revascularization

The aim of this study was to demonstrate the association between 2-dimensional (2D) perfusion angiography and wound healing rate in patients with combined femoro-popliteal and below-the-knee lesions in critical limb-threatening ischemia (CLTI) and foot wounds undergoing isolated femoro-popliteal endovascular revascularization. Between January and June 2019, 24 patients with multilevel CLTI and foot wounds underwent isolated femoro-popliteal endovascular revascularization. In all of them, an assessment of foot perfusion by 2D perfusion angiography was performed. To evaluate the foot perfusion, a region of interest was identified, and time-density curves were calculated. Changes of the overall time-density curves were evaluated together with transcutaneous oximetry (TcPO2) using bivariate correlation (Pearson correlation coefficient) and associated with 6-month wound healing. The mean increase of time-density curves was 212.2% (range from +9.8% to +1984.9%) and the mean increase of TcPO2 was 116.4% (range from -4.7% to 485.7%). No significant association between time-density curves and TcPO2 values (Pearson correlation coefficient: -0.24) was observed (P = .3). At 6 months, wound healing occurred in 15 of 24 (62.5%) patients. In conclusion, this preliminary experience confirmed that 2D perfusion angiography associates with wound healing rate in CLTI patients with ischemic foot wounds and combined femoro-popliteal and below-the-knee lesions who are undergoing isolated femoro-popliteal endovascular revascularization. No association between time-density curves and TcPO2 values was observed.

Effects of Infra-malleolar Status According to Global Limb Anatomic Staging System on Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia

The global vascular guideline proposed a novel anatomical classification of infra-malleolar (IM) arterial lesions. We aimed to investigate the association of IM classification with clinical outcomes in patients with chronic limb-threatening ischemia (CLTI) due to isolated infrapopliteal (IP) lesions. We retrospectively analyzed 509 limbs with tissue loss in 357 patients due to isolated IP lesions who underwent endovascular therapy (EVT) between April 2010 and December 2018. The primary outcome was 1-year wound healing rate. The association of patient and anatomic characteristics with non-healing was evaluated using Cox proportional hazards regression analysis. The 1-year cumulative wound healing rate was 59.7%. Multivariable analysis demonstrated that IM grade 2 (hazard ratio [HR], 1.41; P = .044), non-ambulatory status (HR, 1.49; P = .008), hemodialysis (HR, 1.37; P = .020), left ventricular ejection fraction < 50% (HR, 1.72; P = .030), and wound, ischemia, and foot infection (WIfI) classification 4 (HR, 1.33; P = .032) were significantly associated with non-healing, whereas no below-the-ankle (BTA), below-the-knee (BTK) runoff, and Global Limb Anatomic Staging System (GLASS) IP grade had no statistically significant association with non-healing. Global Limb Anatomic Staging System IM grade 2 was an independent risk factor for wound healing in patients who underwent EVT with CLTI due to isolated IP disease.

[Hybrid interventions for atherosclerotic lesions of the lower limb arteries]

Treatment of multilevel atherosclerotic lesions of the lower limb arteries is an acute problem in modern medicine. There is no a single treatment algorithm. Hybrid technologies are one of the possible treatment options. There are reasonable assumptions that these technologies can at least partially solve this problem. Minor trauma is an undoubted advantage of hybrid technologies. Therefore, these approaches are advisable in severe patients with various comorbidities and contraindications for traditional methods. Therefore, analysis of hybrid methods is of great interest for cardiovascular surgeons. Hybrid method is now recognized as one of the most effective and minimally traumatic treatment for patients with atherosclerotic lesions of the lower extremities.

Predictive impact of the Global Limb Anatomic Staging System (GLASS) on perioperative outcomes in patients with chronic limb-threatening ischaemia with isolated below-the-knee lesions

Although the global vascular guidelines recently proposed the Global Limb Anatomic Staging System (GLASS) as an anatomical classification for chronic limb-threatening ischaemia (CLTI), prediction of perioperative outcomes using the GLASS classification in patients with CLTI due to isolated below-the-knee (BTK) lesions has not been well studied.This retrospective study included 585 patients with CLTI due to isolated BTK lesions who underwent endovascular therapy (EVT). The severity of arterial lesions was graded using the GLASS infrapopliteal (IP) and inframalleolar (IM) classifications and defined as follows: non-severe IP, 0-3; severe IP, 4; non-severe IM, P0-1; and severe IM, P2. The outcome measures were technical failure, defined as recanalisation failure of the target artery path, and perioperative failure, defined as a composite of all-cause death, major amputation, or repeat revascularisation within 30 days.Technical and perioperative failures occurred in 9.4% (n = 55) and 9.9% (n = 58) patients, respectively. Compared to patients with non-severe IP and IM, those with both severe IP and IM were significantly associated with technical and perioperative failures (odds ratio [OR]: 13.87 [95% confidence interval (CI) 4.69-41.02, P < 0.001] and OR: 2.18 [95% CI 1.08-4.38, P = 0.041], respectively).The GLASS classification may have predictive value for technical and perioperative failure in patients with CLTI due to isolated BTK lesions after EVT.

Orbital Atherectomy Prior to Drug-Coated Balloon Angioplasty in Calcified Infrapopliteal Lesions: A Randomized, Multicenter Pilot Study

PURPOSE

Optimal balloon angioplasty for infrapopliteal lesions is often limited by severe calcification, which has been associated with decreased procedural success and lower long-term patency.

MATERIALS AND METHODS

This was a prospective, randomized, multicenter pilot trial that included adult subjects with calcified lesions located from the popliteal segment below the knee (BTK) joint to within 5 cm above the ankle with ≥70% diameter stenosis by angiography. Patients were randomized 1:1 to undergo orbital atherectomy (OA) with adjunctive drug-coated balloon (DCB) angioplasty versus plain balloon angioplasty (BA) and DCB angioplasty (control). The periprocedural and 12 month outcomes of both procedures were compared.

RESULTS

Overall, 66 subjects (OA + DCB = 32 vs control = 34) were included in an intention to treat analysis. Baseline demographics and lesion characteristics were well-balanced. The mean lesion length was 101.3 mm (SD = 72.8 mm) and 78.8 (SD = 61.0 mm) in the OA + DCB and control groups, respectively, with almost all lesions having severe calcification per the Peripheral Academic Research Consortium (PARC) criteria. Chronic total occlusions (CTOs) were present in 43.8% and 35.3% of the patients in the OA + DCB and control groups, respectively. The technical success of OA + DCB versus DCB was 81.8% and 89.2%, respectively, with 3 slow flow/no reflow, 1 perforation, 1 severe dissection occurred in OA + DCB group, and one distal embolization occurred in the control group. The target lesion primary patency rate was numerically higher in the OA + DCB versus control group at 6 (88.2% vs 50.0%, p=0.065) and 12 month follow-up (88.2% vs 54.5%, p=0.076). The 12 month freedom from major adverse events, clinically-driven target lesion revascularization, major amputation, and all-cause mortality rates were similar between both groups.

CONCLUSION

The results of the Orbital Vessel PreparaTIon to MaximIZe Dcb Efficacy in Calcified BTK (OPTIMIZE BTK) pilot study indicated that utilization of OA + DCB is safe for infrapopliteal disease. Further prospective adequately powered studies should investigate the potential benefit of combined OA + DCB for BTK lesions.

The Global Anatomic Staging System Does Not Predict Limb Based Patency of Tibial Endovascular Interventions

OBJECTIVE

Anatomic grading systems have historically been poor predictors of patency after endovascular tibial interventions. The Global Vascular Guidelines proposed a new Global Anatomic Staging System (GLASS) to estimate one-year limb-based patency (LBP). The purpose of this study was to determine the association of GLASS with LBP following endovascular tibial interventions.

METHODS

We included all patients presenting to our multidisciplinary diabetic limb preservation service between 01/2012 and 8/2020 who underwent first-time endovascular tibial revascularization for chronic limb-threatening ischemia. Diagnostic angiograms were reviewed to define the preferred target artery pathway and assign a GLASS stage to each treated limb. One-year LBP was calculated and compared across GLASS stages using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models.

RESULTS

We performed tibial revascularization in 96 limbs (5.2% rest pain, 56.3% ulcer, 37.5% gangrene), including isolated tibial interventions in 61.5% and tibial + femoropopliteal interventions in 38.5%. 15.6% of limbs were GLASS stage 1, 28.1% were GLASS stage 2, and 56.3% were GLASS stage 3. Overall, one-year LBP was 43.2 ± 6.3%, and did not differ significantly across GLASS stages (P = 0.42). The hazard ratio for failed LBP was 1.94 (95% CI 0.70-5.41) for GLASS stage 2 and 1.49 (95% CI 0.56-3.94) for GLASS stage 3 limbs (versus GLASS stage 1). When analyzed excluding the calcium modifier, LBP remained similar across GLASS stages (P = 0.72). Major amputation was uncommon, occurring in 9.3 ± 3.4% of limbs at one year, and did not significantly differ by GLASS stage (P = 0.98).

CONCLUSION

The Global Anatomic Staging System did not predict limb-based patency following tibial endovascular interventions. Given the low major amputation rates in this cohort, anatomic complexity should not preclude endovascular limb salvage efforts below the knee.

Anterior, posterior, or all-vessel infrapopliteal revascularization in patients with moderate-severe claudication: Insights from the LIBERTY 360 study

BACKGROUND

Little data guides revascularization of infrapopliteal peripheral arterial disease (PAD) in patients with claudication. We assessed outcomes after infrapopliteal-only intervention for claudication in the LIBERTY 360 observational study.

METHODS

In this post hoc analysis, LIBERTY 360 patients (N = 128) with claudication and isolated infrapopliteal disease undergoing endovascular revascularization were divided by territory into anterior-vessel, posterior-vessel, or all-vessel groups. Patients were followed for periprocedural, in-hospital, and long-term outcomes. Logistic regression for odds ratios, Cox proportional hazard models, ANOVA, and Kaplan-Meier estimates were utilized to compare outcomes.

RESULTS

Patients underwent anterior (N = 37), posterior (N = 76), or all-vessel (N = 15) infrapopliteal revascularization. Initial procedural success was 86%, 86%, and 69% for anterior, posterior, and all-vessel groups, respectively. Each group had improvements in Rutherford classification (RC) from baseline to 2 years (mean RC change: -1.3, -1.5, and -1.5, respectively). Compared with all-vessel intervention, both anterior and posterior groups had lower rate of major adverse events (MAE) and target vessel revascularization (TVR) at 3 years (MAE: 12% and 15% in anterior and posterior groups, respectively compared with 51% in the all-vessel group; hazard ratios and 95% CIs 0.22 [0.06-0.74], p = .015; 0.24 [0.09-0.64], p = .004). Other outcomes were similar among the three groups. The anterior group showed more improvement in pain subdomain and total VascuQoL scores compared with posterior and all-vessel groups at 2 years (p = .016, p = .020 and p = .068, p = .009, respectively).

CONCLUSIONS

Both anterior or posterior revascularization have favorable outcomes and may be beneficial for improvement of symptoms in claudicants with isolated infrapopliteal PAD.

Clinical considerations after endovascular therapy of peripheral artery disease

Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.

Revascularization of multiple tibial arteries is not associated with improved limb salvage

OBJECTIVE

We sought to determine the benefit of performing multiple tibial artery revascularization compared with single vessel revascularization for patients with chronic limb-threatening ischemia (CLTI).

METHODS

We performed a single-center, retrospective cohort study of all patients with CLTI treated with below-the-knee endovascular intervention from 2012 to 2019. Group 1 included patients who had undergone single tibial artery revascularization. Group 2 included patients who had undergone multiple (two or more) tibial artery revascularization. More proximal disease, if present, was treated, in addition to the tibial disease. The primary endpoint was freedom from amputation. The secondary endpoints included the reintervention rates and all-cause mortality.

RESULTS

A total of 527 limbs in 470 patients with CLTI (nonhealing ulcers, 62%; gangrene, 33%; and ischemic rest pain, 5%) were included in the present study. Of the 527 limbs, 245 (46%) had undergone single vessel revascularization and 282 (54%) had undergone multiple vessel revascularization. The mean follow-up was 19 ± 18 months. No difference was found in freedom from amputation between the two groups (68% vs 63%; P = .109). On multivariable analysis, the factors associated with amputation included dialysis (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.16-2.45), dyslipidemia (OR, 1.37; 95% CI, 0.96-1.94), and gangrene (OR, 2.08; 95% CI, 1.50-2.98). No differences were found in the reintervention rates between the two groups (21.2% vs 16.7%; P = .13). The overall survival rate was 73% in both study groups.

CONCLUSIONS

The results from the present large, single-center study have demonstrated that multiple below-the-knee vessel revascularization is not associated with improved limb salvage compared with single vessel revascularization.

CHRONIC LIMB THREATENING ISCHEMIA AND DIABETES MELLITUS: THE SEVERITY OF TIBIAL ATHEROSCLEROSIS AND OUTCOME AFTER INFRAPOPLITEAL REVASCULARIZATION

Background and objective:

Diabetes mellitus associates with poor outcomes in chronic limb threatening ischemia but data on different hypoglycemic regimens and outcomes are lacking. We analyzed insulin-treated diabetes mellitus, non-insulin-treated diabetes mellitus, and patients without diabetes mellitus.

Methods:

All patients with peripheral artery disease and/or diabetes mellitus and infrapopliteal revascularization in the Department of Vascular Surgery, Turku University Hospital during 2007–2015 were included. Tibial atherosclerosis was categorized into crural index classes of I–IV.

Results:

Of the 497 patients, 180 were insulin-treated diabetes mellitus, 94 non-insulin-treated diabetes mellitus, and 223 patients without diabetes mellitus groups (diabetes mellitus 55.1%). Insulin-treated diabetes mellitus was the most ill, youngest (insulin-treated diabetes mellitus—median: 72.4, interquartile range: 64.0–79.5 versus non-insulin-treated diabetes mellitus—76.0, interquartile range: 67.9–83.6 versus patients without diabetes mellitus—77.3, interquartile range: 68.5–83.7, p < 0.001), had the highest body mass index (insulin-treated diabetes mellitus—median: 27.7, interquartile range: 24.0–31.8 versus non-insulin-treated diabetes mellitus—26.3, interquartile range: 23.2–30.3 versus patients without diabetes mellitus—23.9, interquartile range: 21.5–26.9, p < 0.001), and Charlson comorbidity index (insulin-treated diabetes mellitus—65.6% versus non-insulin-treated diabetes mellitus—46.8% versus patients without diabetes mellitus—10.8%, p < 0.001). After endovascular revascularization, limb salvage was poorer for insulin-treated diabetes mellitus (p = 0.046) and non-insulin-treated diabetes mellitus groups (p = 0.011) compared to surgery, but not for patients without diabetes mellitus (p = 0.15). Patients with crural index IV in insulin-treated diabetes mellitus (p = 0.001) and non-insulin-treated diabetes mellitus (p = 0.013) had higher mortality after revascularization. Crural index IV was a risk factor for limb loss (hazard ratio: 1.37, 95% confidence interval: 1.08–1.74, p = 0.008).

Conclusions:

Limb salvage after bypass is better for insulin and non-insulin diabetics, compared to the endovascular approach. Extensive tibial atherosclerosis is an independent risk factor for limb loss. It associates with increased mortality in both insulin and non-insulin diabetics.

Single versus Multiple Vessel Endovascular Tibial Artery Revascularization for Critical Limb Ischemia: A Review of the Literature

Vascular interventionalists have long debated on whether one or multiple patent tibial arteries (run-off) are necessary to treat critical limb ischemia, including ischemic rest pain and tissue loss. This review article seeks to clarify data surrounding this topic by including literature from retrospective studies, prospective studies, meta-analyses, and randomized controlled trials. Our conclusion is that revascularizing a single tibial artery to the foot is adequate for wound healing.

Sex-Related Differences in the Outcomes of Endovascular Interventions for Chronic Limb-Threatening Ischemia: Results from the LIBERTY 360 Study

INTRODUCTION

Previous studies have suggested that women with chroniclimb-threatening ischemia (CLTI) may have worse outcomes than men. The aim of this study was to determine whether there are sex-related differences in outcomes of patients with CLTI undergoing endovascular treatment with current endovascular technologies.

PATIENTS AND METHODS

Data were derived from the LIBERTY 360 study (NCT01855412). Hazard ratios and the respective 95% confidence intervals were synthesized to examine the association between sex and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE) and major amputation/death up to 3 years of follow-up.

RESULTS

A total of 689 patients with CLTI (female: N=252 vs male: N=437) treated with any FDA approved or cleared device were included. The mean lesion length was 126.9±117.3mm and 127.4±113.3mm for the female and male patients, respectively. Although a slightly higher incidence of in-hospital mortality was observed in the female group (1.2% vs 0.0%, p=0.049), there was no difference in female vs male survival rates during follow-up. However, the risk of major amputation at 18 months was higher for the male group (male vs female: HR: 2.36; 95% CI: 1.09-5.12; p=0.030). No difference between the two groups was detected in terms of TVR or MAE during follow-up.

DISCUSSION

Data regarding sex-related disparity in outcomes after endovascular therapy of patients with CLTI are conflicting. Gender-related characteristics rather than biological sex characteristics might be the cause of these conflicting findings. Further studies are needed to evaluate the role of sex in revascularization outcomes among this high-risk population.

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

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.

Retrograde distal access versus femoral access for below the knee angioplasty

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To compare the effectiveness and safety of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

Endovascular Therapy Provides Similar Results of Bypass Graft Surgery in the Treatment of Infrainguinal Multilevel Arterial Disease in Patients with Chronic Limb-Threatening Ischemia in All GLASS Stages

BACKGROUND

Extensive infrainguinal arterial disease still pose a challenge for technical and clinical success of percutaneous angioplasty. The purpose of this study was to compare the results of concomitant femoropopliteal and infrapopliteal percutaneous angioplasty/stenting (PTA/S) with distal bypass graft surgery (BGS) in patients with chronic limb-threatening ischemia (CLTI).

METHOD

In a single-center retrospective investigation between 2011 and 2017, 668 revascularization procedures for CLTI were reviewed. Concomitant femoropopliteal and infrapopliteal disease was identified in 153 CLTI patients, treated with BGS (48) using autogenous veins as substitute or PTA/S in a single procedure (105). A subgroup of patients with complex, extensive arterial lesions (GLASS stage III) received additional analysis. Primary outcomes were limb salvage and survival.

RESULTS

The mean follow-up time was 21.4 months. Patients treated with PTA/S were significantly older and with predominance of females, diabetes and chronic kidney disease. Smoking was more common in patients treated with BGS. The BGS group showed a 36-month survival rate of 73.4%, whereas the PTA/S group presented a survival of 61.3% in the same interval (P = 0.25). The 36-month cumulative limb salvage rate was 53.3 and 59.7% for BGS and PTA/S, respectively (P = 0.24). For GLASS stage III patients, 36-month limb salvage rates were 54.4% for the PTA/S group and 50.2% for the BGS group (P = 0.29). Multivariate analysis pointed poor runoff status (all endovascular patients) and diabetes (GLASS III endovascular patients) as risk factors for limb loss.

CONCLUSION

PTA/S and BGS presented similar results of limb salvage and survival in the treatment of concomitant femoropopliteal and infrapopliteal arterial disease in patients with CLTI, even for patients with extensive and complex arterial disease.

WITHDRAWN: One-Year Freedom from Amputation, Survival, and Cost of Care following Tibial and Pedal Endovascular Interventions for Critical Limb Ischemia: The Role of Atherectomy and Drug-Eluting Stents

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Multivessel tibial revascularization does not improve outcomes in patients with critical limb ischemia

OBJECTIVE

Multivessel tibial revascularization for critical limb ischemia (CLI) remains controversial. The purpose of this study was to evaluate single vs multiple tibial vessel interventions in patients with multivessel tibial disease. We hypothesized that there would be no difference in amputation-free survival between the groups.

METHODS

Using the Vascular Quality Initiative registry, we reviewed patients undergoing lower extremity endovascular interventions involving the tibial arteries. Patients with CLI were included only if at least two tibial vessels were diseased and adequate perioperative data and clinical follow-up were available for review. The primary outcome was amputation-free survival.

RESULTS

There were 10,849 CLI patients with multivessel tibial disease evaluated from 2002 to 2017; 761 limbs had adequate data and follow-up available for review. Mean follow-up was 337 ± 62 days. Of these, 473 (62.1%) underwent successful single-vessel tibial intervention (group SV), whereas 288 (37.9%) underwent successful multivessel (two or more) intervention (group MV). Patients in group MV were younger (69.1 vs 73.2 years; P < .001), with higher tobacco use (29.5% vs 18.2%; P < .001). Group SV more commonly had concurrent femoral or popliteal inflow interventions (83.7% vs 78.1%; P = .05). Multivessel runoff on completion was significantly greater for group MV (99.9% vs 39.9%; P < .001). No differences were observed between group SV and group MV for major amputation (9.0% and 7.6%; P = .6), with similar amputation-free survival at 1 year (90.6% vs 92.9%; P = .372). In a multivariate Cox model, loss of patency was the only significant predictor of major amputation (hazard ratio, 5.36 [2.7-10.6]; P = .01). A subgroup analysis of 355 (46.6%) patients with tissue loss data showed that tissue loss before intervention was not predictive of future major amputation.

CONCLUSIONS

In the Vascular Quality Initiative registry, patients with CLI and occlusive disease involving multiple tibial vessels did not appear to have a limb salvage benefit from multiple tibial revascularization compared with single tibial revascularization.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Angiosome-Guided Intervention in Critical Limb Ischemia

The goals of treatment for critical limb ischemia (CLI) are alleviation of ischemic rest pain, healing of arterial insufficiency ulcers, and improving quality of life, thereby preventing limb loss and CLI-related mortality. Arterial revascularization is the foundation of a contemporary approach to promote amputation-free survival. Angiosome-directed revascularization has become a popular theory of reperfusion, whereby anatomically directed arterial flow is restored straight to the wound bed. Innovations in endovascular revascularization combined with a multidisciplinary strategy of wound care accelerate progress in CLI management. This article highlights advances in CLI management, including the clinical relevance of angiosome-directed revascularization, and provides considerations for future treatment of CLI.

Efficacy Outcomes of Endovascular Versus Surgical Revascularization in Critical Limb Ischemia: Results From a Prospective Cohort Study

Data on efficacy outcomes of endovascular versus surgical revascularization in patients with critical limb ischemia (CLI) in contemporary practice are limited. In this prospective cohort study, 353 consecutive patients with CLI were enrolled and allocated to endovascular (PTA [percutaneous transluminal angioplasty]), surgical (SURG), or no revascularization (No REVASC) after interdisciplinary consensus. Outcome measures were sustained primary clinical success (sPCS; survival without major amputation, repeated target extremity revascularization, and freedom from CLI), limb salvage, and amputation-free survival. Propensity-matched Kaplan-Meier analyses and stratified log-rank tests were performed. The PTA, SURG, and No REVASC groups consisted of 264, 62, and 27 patients, respectively. Compared to SURG patients, PTA patients were significantly older, had more risk factors, and more often had ischemic lesions. Propensity score-adjusted analyses showed no significant differences: sPCS was 51.3%/52.2%, limb salvage rate 91.5%/93.7%, and major amputation-free survival 90.5%/87.2% at 12 months for PTA and SURG, respectively. Amputation-free survival for the No REVASC group was 69% at 12 months. In conclusion, endovascular and surgical revascularization in CLI has comparable efficacy outcomes after 12 months. Contemporary overall outcome of patients with CLI is considerably better compared to earlier studies.

Is the Endovascular Treatment of Mild Iliac Stenoses Worthwhile to Improve Wound Healing in Patients Undergoing Femorotibial Bypass?

BACKGROUND

After an infrapopliteal reconstruction, minor amputations are frequently required, but even in the case of successful revascularization, wound healing is a major concern. We studied the role of iliac artery inflow correction in patients undergoing infrapopliteal vein grafts to improve the heal of midfoot amputation.

METHODS

Thirty-eight patients affected with Rutherford grade III category 5 peripheral arterial disease, who underwent successful simultaneous iliac endovascular procedure, infrapopliteal reversed vein bypass graft, and minor amputation, were enrolled in this retrospective study. The population was divided in group 1 (20 patients) with inflow vessels Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) II type B atherosclerotic lesions and group 2 (18 patients) with TASC II type A atherosclerotic lesions determining an invasive pressure drop greater than 15 mm Hg. Fifteen patients (group 3) undergoing infrapopliteal reversed vein bypass graft without associated inflow procedures (TASC II type A and invasive pressure drop greater than 15 mm Hg) were matched with group 2 based on propensity score. Healing was calculated by subtracting the final ulcer area from the initial ulcer area and dividing by the number of follow-up months to obtain the total area healed per month (cm²/month). Stepwise logistic regression analysis adjusted for demographics and medical comorbid conditions was used to test the association between wound healing and treatment modalities.

RESULTS

Forty-three patients were available for further analysis. Ten patients were excluded because of graft occlusion with consequent impairment of wound healing. After midfoot amputations, mean wound diameter was 20 ± 8 cm², and mean healing time was 10 ± 4 months (range 3-20 months; median 9 months). Wounds of groups 1 and 2 healed faster than those of group 3 at 4 and 8 months (P < 0.02 and P < 0.001, respectively; P < 0.04 and P < 0.001, respectively). Multivariate analysis demonstrated the association between wound healing and inflow correction (P < 0.001).

CONCLUSIONS

An aggressive treatment is necessary to obtain the heal of the ischemic wounds. The most important predictive factor for nonhealing wounds is the absence of inflow correction. We demonstrated that the inflow should be also corrected in the presence of subclinical lesions.

Midterm Outcomes After Infrapopliteal Interventions in Patients With Critical Limb Ischemia Based on the TASC II Classification of Below-the-Knee Arteries

Purpose: To analyze the relationship between the new TransAtlantic Inter-Society Consensus (TASC II) infrapopliteal classification and limb outcomes among patients with critical limb ischemia (CLI). Methods: A single-center retrospective study was performed on 166 consecutive CLI patients (mean age 71 years; 113 men) undergoing endovascular treatment of 244 infrapopliteal lesions from 2006 to 2013. Patient, procedural, angiographic, and limb outcomes were compared for the new TASC A/B vs C/D classification for infrapopliteal lesions. Binary restenosis was determined by a peak systolic velocity ratio >2.0 by duplex ultrasound on follow-up at 1, 3, 6, and 12 months. Results: Seventy-two (43.4%) patients had TASC A/B lesions, while 94 (56.6%) had TASC C/D patterns of infrapopliteal disease. Baseline demographics and tissue loss (93% vs 94%, p=0.59) were similar between the groups. TASC A/B lesions were shorter (53±35 vs 170±83 mm, p<0.001), less severely stenosed (77%±24% vs 93%±14%, p<0.001), had a larger target vessel diameter (2.9±0.5 vs 2.6±0.5 mm, p<0.001), and were less frequently chronic total occlusions (24% vs 64%, p<0.001) compared with the TASC C/D group. Three-year freedom from both amputation (85% vs 67%, p=0.02) and major adverse limb events (79% vs 61%, p=0.02) were significantly higher in the TASC A/B group. Technical success rates (95% vs 80%, p<0.001) and 1-year primary patency (58% vs 51%, p=0.04) were higher in the A/B group. Overall 3-year survival was similar between the groups (96% A/B vs 88% C/D, p=0.2). Conclusion: TASC C/D infrapopliteal lesions are associated with higher amputation and major adverse limb events rates and lower primary patency compared with TASC A/B infrapopliteal lesions. Further studies are needed to assess the association between TASC C/D infrapopliteal lesions and clinical outcomes in patients with CLI.

Revascularization Surgery: Its Efficacy for Limb Salvage in Diabetic Foot

The estimated prevalence of diabetes is 9.78% in Taiwan. The lifetime risk for patients with diabetes to have foot ulcers might be as high as 25%. About 15% of these patients require major limb amputation because of ischemia and infection. Peripheral artery disease is still a major problem involved in diabetic foot disease and the cause for major amputation despite an increase in the prevalence of revascularization surgery and new revascularization techniques over the past 20 years. We investigated the major limb amputation rates in patients with diabetic foot and critical limb ischemia who had undergone revascularization surgery in our hospital. The records of 42 patients who had undergone revascularization surgery for diabetic foot were retrospectively reviewed. Nineteen patients (45%) required major limb amputation despite revascularization. The affected limbs of only 15 patients (36%) were salvaged. Four patients died soon after surgery because of comorbidities, and another 4 were lost to follow-up. Two patients died from procedure-related sepsis, and overall perioperative mortality was 4.8%. Ten predictive risk factors (duration of diabetes, history of smoking, coronary artery disease, congestive heart failure, cerebral vascular accident, contralateral amputation, end-stage renal disease, fever episode, wound infection severity score, and arterial obstruction level) were included for analysis. Although none was significant, long-duration diabetes (OR: 1.13), end-stage renal disease (OR: 10.02), wound infection (OR: 1.56), and infrapopliteal lesions (OR: 3.00) tended to be unfavorable predictive risk factors of limb amputation. Revascularization surgery is still potentially beneficial for these patients--eg, it decreases the contralateral limb amputation rate by 7.5%--if done early in high-risk patients.

Wound healing of critical limb ischemia with tissue loss in patients on hemodialysis

We assessed wound healing in patients on hemodialysis (HD) with critical limb ischemia (CLI). This study enrolled 267 patients (including 120 patients on HD and 147 patients not on HD) who underwent endovascular therapy (EVT) for CLI. The primary endpoint was wound-healing rate at two years. Secondary endpoints were time to wound healing, wound recurrence rate, and limb salvage at two years. The percentage of male and young patients was higher in the HD patients ( p < 0.01). A lower patency of the pedal arch after EVT was observed frequently in HD patients ( p < 0.01). The wound-healing rate was significantly lower in HD patients (79.5% vs. 92.4%, p < 0.001). Time to wound healing was significantly longer in HD patients (median 132 days vs. 82 days, p = 0.005). Wound recurrence was observed more frequently in HD patients (25.0% vs. 10.2%, p = 0.007). Limb salvage (72.8% vs. 86.4%, p = 0.002) was significantly lower in HD patients. In a cox proportional hazard model, HD was an independent predictor of wound healing (risk ratio (RR), 0.46; 95% confidence interval (CI), 0.33-0.62; p < 0.001) and wound recurrence (RR, 1.58; 95% CI, 1.11-2.22; p = 0.01). HD was independently associated with lower and delayed wound healing, and wound recurrence.

New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease

Peripheral arterial disease (PAD) involving the lower extremity is a major source of morbidity and mortality. Clinical manifestations of PAD span the spectrum from lifestyle limiting claudication to ulceration and gangrene leading to amputation. Advancements including balloon angioplasty, self-expanding stents, drug-eluting stents, and atherectomy have resulted in high technical success rates for endovascular therapy in patients with PAD. However, these advances have been limited by somewhat high rates of clinical restenosis and clinically driven target lesion revascularization. The recent introduction of drug-coated balloon technology shows promise in limiting neointimal hyperplasia induced by vascular injury after endovascular therapies. This review summarizes the contemporary clinical data in the emerging area of drug-coated balloons.

Number of infrapopliteal arteries undergoing endovascular treatment is not associated with the limb salvage rate in patients with critical limb ischemia

OBJECTIVE

The objective of this study was to determine whether the number of infrapopliteal arteries undergoing endovascular treatment is associated with the limb salvage rate in patients with critical limb ischemia (CLI).

METHODS

This was a retrospective, consecutive cohort study of CLI patients who underwent infrapopliteal angioplasty at the Vascular and Endovascular Surgery Service of the Hospital do Servidor Público Estadual, São Paulo, between January 2009 and January 2013. The primary outcome variable was the limb salvage rate. The secondary outcome variables were patency, survival, plantar arch quality, and operative mortality rate.

RESULTS

Overall, 109 infrapopliteal angioplasties were performed in 92 patients, and the initial technical success rate was 95.6%. Based on the analyses of the arteriography of the endovascular procedures, the patients were classified into two groups according to whether they had undergone endovascular treatment of one artery (group 1) or two arteries (group 2). The mean outpatient follow-up time was 430 ± 377.5 days. The analyses were performed at 180 and 360 days. There were 72 angioplasties (66%) in group 1 and 37 (34%) in group 2. Hypertension was more frequent in group 1 (93.1%) than in group 2 (78.4%; P = .03). Other clinical characteristics were similar in both groups. Regarding postoperative complications, the incidence of acute kidney failure was lower in group 1 (0% vs 8.1%, respectively; P = .037). The limb salvage rate at 360 days was similar in groups 1 and 2 (89.4% vs 89.3%, respectively; P = .595). The secondary patency rate at 360 days was also similar in groups 1 and 2 (59.9% vs 60.9%, respectively; P = .571). The perioperative mortality rate was lower in group 1 (4.2% vs 16.2%, respectively; P = .039), but the survival rate at 360 days was similar in both groups (82.1% vs 75.1%, respectively; P = .931). The frequencies of complete, incomplete, and absent plantar arch were similar in both groups. The estimated limb salvage rates for patients with complete plantar arch or incomplete/absent plantar arch were 96.2% and 84.6%, respectively (P = .467), at 360 days.

CONCLUSIONS

Our results suggest that it is not necessary to treat the largest number of arteries possible in CLI patients. Instead, the most amenable artery for endovascular procedures should be treated to improve limb salvage and secondary patency rates.

The extent of atherosclerotic lesions in crural arteries predicts survival of patients with lower limb peripheral artery disease: A new classification of crural atherosclerosis

BACKGROUND AND AIMS

Several studies report correlation of ankle brachial index (ABI) values and mortality. However, no studies exist on the predictive value of anatomical distribution of atherosclerotic lesions and the extent of atherosclerosis at defined arterial segments on life expectancy. The aim of the present study was to evaluate the significance of both extent and localisation of atherosclerotic lesions to mid-term patient survival.

METHODS

Digital subtraction angiography (DSA) images of 887 consecutive patients admitted to the Department of Vascular Surgery at Turku University Hospital (Turku, Finland) were retrospectively analysed. Each angiography was classified according to the TASC II classification for aorto-iliac and femoro-popliteal segments, and a similar four-grade index was created for crural arteries. Patients were followed until 36-months post DSA.

RESULTS

During 36-month follow-up 295 (33%) deaths occurred. Death during follow-up was strongly associated with extensive crural disease, but not with extensive proximal disease (Crural Index III-IV, p = 0.044 and < 0.001, respectively). In a Cox regression analysis incorporating baseline variables, Crural Index IV and most severe atherosclerosis on crural vessels were the strongest predictors of poor prognosis (HR 2.20 95% CI 1.3-3.7, p = 0.003 and HR 2.45 95% CI 1.5-4.0, p < 0.001 respectively).

CONCLUSIONS

The extent of crural atherosclerosis is independently associated with poor mid term life expectancy. Therefore, a classification of the extent of crural atherosclerosis could serve as an indicator of mortality among PAD patients and aid in clinical decision making.

Costs of Real-Life Endovascular Treatment of Critical Limb Ischemia: Report from Poland-A European Union Country with a Low-Budget Health Care System

BACKGROUND

To analyze the costs of inhospital, percutaneous treatment of patients with critical limb ischemia (CLI) carried out in Poland, a European Union country with a low-budget national health system.

METHODS

A retrospective analysis of prospectively collected data on all patients admitted to a tertiary care hospital for endovascular treatment of CLI over 1 year.

SETTING

A single, large volume, tertiary angiology center located in Southern Poland.

PARTICIPANTS

CLI patients due to aortoiliac, femoropopliteal, or infrapopliteal arterial stenoses or occlusions with indications for first-line endovascular therapy or similar patients who refused open surgical procedure despite having primary indications for vascular surgery.

INTERVENTIONS

Direct stenting using bare-metal stents was the primary mode of treatment for lesions located within the aortoiliac and femoropopliteal arterial segments. Plain old balloon angioplasty (POBA) was the second most commonly used technique. For below-the-knee arteries, POBA was the mainstay of treatment, which was occasionally supported by drug-eluting stent angioplasty. Directional atherectomy, scoring balloon angioplasty, or local fibrinolysis was used infrequently. Drug-eluting balloon percutaneous transluminal angioplasty was not used.

MAIN OUTCOME MEASURES

The main outcome measures were the mean reimbursement of costs provided by the Polish National Health Fund (NHF) for inhospital treatment of patients for whom endovascular procedures were performed as initial treatment for CLI and the inhospital costs of endovascular treatment calculated by the caregiver in the 2 years since the first procedure. The average total number of days spent in hospital, amputation-free survival (AFS), overall survival (OS), and limb salvage rate (LSR) according to a life-table method were also calculated for the 2 years.

RESULTS

In the first year, there were 496 endovascular and 15 surgical hospitalizations for revascularization procedures to treat 340 limbs in 327 patients, with a further 53 revascularization procedures in the second year. There were an additional 90 hospitalizations over the first year and 38 over the second year for CLI-associated cardiovascular comorbidities. The mean reimbursement for hospitalizations of patients included into observation, provided by the NHF, was $4901.94 per patient for the first year and $833.57 per patient alive to the second year. The mean cost of hospitalization for percutaneous revascularization treatment was $3804.25 per patient for the first year and $3340.30 per patient requiring revascularization within the second year. All costs were calculated in constant 2011 USD. The average total number of days spent in hospital was 8.4 days for the first year and 1.97 days per patient alive to the second year. At 1 and 2 years, the AFS was 76.8% and 66.6%, the OS was 86.5% and 77.3%, and the LSR was 89.4% and 86%, respectively.

CONCLUSIONS

Endovascular therapy using the currently available techniques can be performed in almost all patients suffering from CLI at relatively low costs, and satisfactory results can be obtained. Physicians play a pivotal role in ensuring quality of treatment and the reduction of treatment cost in these patients.

Clinical characteristics of patients with Rutherford category IV, compared with V and VI

Objective:

Patients categorized Rutherford category IV might have different characteristics compared with Rutherford category V and VI. Our study aims were to estimate the clinical differences between Rutherford category IV and Rutherford category V and VI, for those underwent endovascular therapy for isolated infrapopliteal disease, and also to find risk factors for endovascular therapy in Rutherford category IV.

Methods:

Based on the Japanese multi-center registry data, 1091 patients with 1332 limbs (Rutherford category IV: 226 patients with 315 limbs, Rutherford category V and VI: 865 patients with 1017 limbs) were analyzed retrospectively.

Results:

Patients’ backgrounds and lesions’ characteristics had significant differences. Both freedom rate from major adverse limb event with perioperative death and amputation-free survival rate at 1 year were better in Rutherford category IV than Rutherford category V and VI (93.6% vs 78.3%, 87.7% vs 66.7%) and those maintained to 3 years (p < 0.0001). Significant predictors for major adverse limb event/perioperative death were small body mass index (<18.5 kg/m³) and initial endovascular therapy success, and those for amputation-free survival were small body mass index (<18.5 kg/m³), non-ambulatory status, high systematic inflammatory reaction (C-reactive protein > 3.0 mg/dL), chronic obstructive pulmonary disease, and coronary artery disease in Rutherford category IV.

Conclusion:

From the present results, Rutherford category IV should be recognized to have quite different backgrounds and better outcome from Rutherford category V and VI.

Endovascular intervention for peripheral artery disease

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.

Factors Affecting Medium-Term Outcomes After Crural Angioplasty in Critically Ischemic Legs

Objectives:

To study factors affecting patency and medium-term outcomes after crural angioplasty.

Materials and Methods:

All crural angioplasties between March 2003 and September 2010 were reviewed from a prospective database to analyze primary patency, amputation-free survival, and limb salvage.

Results:

Five hundred and twenty-seven limbs in 478 patients (58.7% male, mean age 73.9 ± 0.53 years) were treated. In all, 49.1% were diabetic patients and 7.4% were dialysis dependent. Primary patency was 65.5%, 57.8%, 48.5%, and 32.9% at 1, 6, 12, and 36 months, respectively. Amputation-free survival was 75.2% at 1 year and 59.0% at 3 years. Limb salvage at 3 years was 92.7%. Rutherford categories 5 and 6 had a consistent adverse effect on patency. This led to an adverse amputation-free survival and limb salvage at 3 years.

Conclusion:

Crural angioplasty is an effective treatment for limb salvage. Its outcomes are adversely affected by diabetes, renal disease, coronary disease, and worsening Rutherford grade.

Impact of angiosome-oriented revascularization on clinical outcomes in critical limb ischemia patients without concurrent wound infection and diabetes

PURPOSE

To investigate the impact of angiosome-oriented revascularization on clinical outcomes in critical limb ischemia (CLI) patients excluding those with both diabetes and wound infection.

METHODS

Using a retrospective multicenter database, a propensity score matching analysis was performed of 539 consecutive CLI patients (375 men; mean age 71±11 years) without concurrent wound infection and diabetes who underwent balloon angioplasty of isolated infrapopliteal lesions. Propensity score matching produced 2 groups of 182 patients each who underwent angiosome-oriented direct revascularization (123 men; mean age 72±11 years) or indirect revascularization (125 men; mean age 72±11 years). The groups were compared for wound healing rate, freedom from major adverse limb events (MALE), and amputation-free survival (AFS).

RESULTS

In the overall population, indirect revascularization was performed in 36.6% (n=197). In the propensity matching analysis, the complete wound healing rate at 12 months was higher in the direct group than the indirect revascularization patients (75% vs. 64%, p=0.01), while freedom from MALE (p=0.99) and AFS (p=0.17) were not significantly different at up to 24 months. In multivariate analysis, indirect revascularization had an independent negative impact on wound healing (adjusted hazard ratio 0.7, p=0.008).

CONCLUSION

After propensity matching analysis for CLI patients other than those with both diabetes and wound infection, the wound healing rate was higher after direct revascularization than after indirect revascularization, whereas MALE and AFS were not significantly different.

Comparison of hybrid procedure and open surgical revascularization for multilevel infrainguinal arterial occlusive disease

Objective

To compare outcomes of hybrid (combined surgical and endovascular) procedures (HYBRID) with open surgical reconstructions (OPEN) in patients with multilevel infrainguinal artery occlusive diseases.

Design

Case series study with retrospective analysis of prospectively collected nonrandomized data.

Methods

Between 2008 and 2012, 64 patients underwent OPEN and 43 underwent HYBRID. Patient characteristics, technique success, clinical improvement, and procedure-related morbidity were reviewed and compared. Patency rates and limb salvages were analyzed and compared using Kaplan–Meier life tables. Cox regression analyses were used to assess the influence of various risk factors on primary patency.

Results

HYBRID patients were older and presented with worse New York Heart Association function compared with OPEN patients. The increase in the ankle-brachial index and improvement of Ruthford category after procedures were equivalent between two groups, but HYBRID patients had shorter hospital length of stay (7.6±12.0 versus 15.5±17.3; P= 0.018) and less overall perioperative morbidity (12% versus 28%; P=0.042) compared with OPEN patients. No statistically significant difference in 36-month primary (47.1%±7.1% versus 50.1%±9.4%; P=0.418), assisted primary (57.0%±7.9% versus 62.4%±9.2%; P=0.517), or secondary (82.0%±6.8% versus 83.1%±7.3%; P=0.445) patency was seen between the two groups. Limb salvage rates of HYBRID vs OPEN at 3 years were similar (76.3%±9.3% versus 80.4%±8.2%; P=0.579). Critical limb ischemia was a negative predictor of long-term patency of patients in both the HYBRID and OPEN groups (P=0.012 and P<0.001, respectively), and the presence of diabetes and renal insufficiency were another two independent predictors of decreased primary patency for HYBRID (P=0.017 and P=0.019, respectively).

Conclusion

Multilevel infrainguinal artery occlusive diseases could be treated by hybrid procedure, with shorter hospitalization, less perioperative morbidity, and similar early- and long-term efficacy compared with open revascularization. A hybrid procedure should be considered for patients with high surgical risk, but critical limb ischemia, diabetes, and renal insufficiency could compromise its long-term patency.