Critical limb ischemia: does long-term patency matter?

In critical limb ischemia (CLI), an underlying principle of treatment is that it takes more oxygenated blood to heal a wound than to maintain tissue integrity. Urgent restoration of perfusion to the ischemic territory, not long-term patency of the target vessel, is the primary treatment goal. However, in patients with CLI treated by surgical bypass, loss of graft patency is associated with poor outcomes. We decided to address the conventional wisdom that restenosis is not a major concern in CLI as long as tissue healing occurs in patients undergoing endovascular revascularization. We retrospectively reviewed the records of consecutive patients treated for CLI with infra-popliteal percutaneous revascularization from 2007 to 2009. Those with prior ipsilateral percutaneous revascularization for CLI formed the study population. Among 29 CLI patients treated for infra-popliteal revascularization, six patients had a history of prior successful ipsilateral revascularization for CLI. All six patients were free of rest pain and ulcers at the 60-day follow-up. The median time interval between the two percutaneous revascularization procedures was 21 months (quartile ranges: 25th = 4.5 months, 75th = 36 months). Five of the six patients had restenosis of a previous lesion, while the sixth patient had a de novo lesion causing recurrent CLI. In conclusion, we found that one in five patients receiving infra-popliteal angioplasty for CLI has had a similar percutaneous revascularization procedure in the past. Among these patients most cases were for restenosis rather than de novo lesions. Further research is needed to determine whether the incidence of recurrent CLI is due to de novo lesions or restenosis. Close clinical follow-up of these patients and maintaining long-term patency with endovascular techniques will likely reduce CLI recurrence.