Percutaneous intentional extraluminal recanalization in patients with chronic critical limb ischemia
David J Spinosa1, Daniel A Leung, Alan H Matsumoto
1Department of Radiology, University of Virginia Health Science Center, PO Box 170, Charlottesville, VA 22909, USA. djs4m@hscmail.mcc.virginia.edu
Insights
Percutaneous intentional extraluminal recanalization (PIER) offers a viable endovascular option for limb salvage in patients with chronic critical limb ischemia (CCLI) who are unsuitable for bypass surgery. This technique demonstrated significant limb salvage rates, providing a crucial alternative for complex arterial occlusions.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Endovascular Therapy
Background:
- Chronic critical limb ischemia (CCLI) poses a significant challenge, particularly for patients deemed poor candidates for traditional infrainguinal arterial bypass surgery (IABS).
- Arterial occlusive disease in the lower extremities necessitates advanced treatment strategies to prevent limb loss.
Purpose of the Study:
- To evaluate the efficacy and outcomes of percutaneous intentional extraluminal recanalization (PIER) as a treatment modality for CCLI.
- To assess PIER's role in limb salvage for patients with complex arterial occlusions unsuitable for IABS.
Main Methods:
- A cohort of 40 patients with CCLI and poor IABS candidacy underwent PIER procedures.
- The study involved 50 procedures across 44 limbs, focusing on infrainguinal arterial occlusions, including tibial and SFA/popliteal vessels.
- Kaplan-Meier analysis was used to determine limb salvage, survival, and amputation-free survival rates.
Main Results:
- Technical success was achieved in 86% of PIER procedures, with 91% of treated limbs presenting with tissue loss.
- At 12 months post-procedure, limb salvage was 66%, survival was 71%, and amputation-free survival was 48%.
- The 30-day mortality rate was 2.5%, with major and minor complications occurring in 10% of patients each.
Conclusions:
- Percutaneous intentional extraluminal recanalization (PIER) is a valuable endovascular technique for limb salvage in patients suffering from CCLI.
- PIER provides a necessary alternative for limb salvage when conventional bypass surgery is not feasible.
Purpose:
To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI).
Materials And Methods:
Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival.
Results:
Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%).
Conclusion:
PIER is a useful percutaneous technique for limb salvage in patients with CCLI.
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