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Published on: September 22, 2020
Stent-assisted below-the-ankle angioplasty for limb salvage
Osami Kawarada1, Yoshiaki Yokoi, Akihiro Higashimori
1Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada-city, Osaka, Japan. kawarada@stanford.edu
Insights
Stent-assisted angioplasty below the ankle offers limb salvage for critical limb ischemia, though repeat interventions are often necessary. Further technological advancements are needed to improve outcomes and reduce stent issues.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Critical limb ischemia (CLI) poses a significant threat to limb viability.
- Below-the-ankle angioplasty is a treatment option for CLI patients.
- Stent-assisted angioplasty aims to improve revascularization outcomes.
Purpose of the Study:
- To evaluate the clinical outcomes of stent-assisted below-the-ankle angioplasty for limb salvage in patients with CLI.
- To assess the efficacy and safety of this endovascular approach.
Main Methods:
- Retrospective single-center study of 40 limbs in 31 CLI patients.
- Below-the-ankle stent-assisted angioplasty performed between April 2006 and April 2009.
- Coronary bare metal stents used for failed balloon angioplasty cases.
Main Results:
- Technical success rate of 93% with improved runoff vessel count.
- Amputation-free survival at 24 months was 62.7%, and limb salvage was 82.1%.
- Stent deformation (compression/fracture) observed in stented arteries, yet 7/8 limbs showed wound healing.
Conclusions:
- Stent-assisted below-the-ankle angioplasty provides satisfactory limb salvage for CLI.
- Repeat interventions are frequently required, highlighting a need for improved techniques.
- Further advancements in endovascular technology are essential to minimize repeat procedures and address stent deformity.
Purpose:
To report the clinical outcome of stent-assisted below-the-ankle angioplasty for limb salvage in the setting of critical limb ischemia (CLI).
Methods:
A retrospective single-center study was conducted of 40 critical ischemic limbs in 31 patients (mean age 67 ± 8 years, range 46-94) undergoing below-the-ankle stent-assisted angioplasty between April 2006 and April 2009. Coronary bare metal stents were implanted in cases of failed balloon angioplasty due to significant recoil, flow-limiting dissection, abrupt closure, or repeat early reocclusion.
Results:
Technical success was 93% (37 limbs), with 3 failures to cross the occlusive lesions. Acute or subacute occlusion was evident in 9 (23%) limbs. The number of runoff vessels increased significantly (p < 0.001) from 0.6 ± 0.8 to 1.8 ± 0.8. During a clinical follow-up of 19.3 ± 11.4 months (range 1-48), the number of repeat interventions for limb salvage was 2.2 ± 1.6 (range 1-9), and a total of 1.6 ± 0.9 stents (range 1-3) were implanted in 8 dorsalis pedis arteries. Acute or subacute stent thrombosis after stenting was observed in 2 of these, and symptomatic in-stent restenosis was detected in 4, which were all treated by repeat intervention. At 6, 12, and 24 months, the freedom from repeat intervention was 39.6%, 39.6%, and 35.2%, respectively. Amputation-free survival was 80.0%, 69.7%, and 62.7%, and limb salvage was 94.7%, 91.4%, and 82.1% at the same time points. Patient survival rates were 77.4%, 71.0%, and 71.0%, respectively. During a mean follow-up of 13.4 ± 12.7 months (range 1-31 months) in 7 of the 8 stented arteries, all examined stents were deformed: stent compression was evident in 5 and stent fracture in 5. However, 7 limbs undergoing dorsalis pedis artery stenting showed complete wound healing; 1 limb had a resistant wound in the heel.
Conclusion:
Stent-assisted below-the-ankle angioplasty produced a satisfactory clinical outcome but with the need for repeat intervention. Thus, further refinement in endovascular technology is mandatory to reduce the need for repeat interventions and to resolve stent deformity issues.
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