Extreme endovascular revascularization for limb salvage in critical limb ischemia
T Mandolfino1, A Canciglia, S Lamberto
1Section of Vascular Surgery, Department of Surgery, University of Messina, Messina, Italy. tommasomandolfino@libero.it
Insights
Percutaneous transluminal angioplasty (PTA) offers a safe and effective endovascular treatment for critical limb ischemia (CLI) in patients with occluded bypass grafts. This approach provides a viable alternative to amputation, achieving good limb salvage rates.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Distal bypass is a primary treatment for critical limb ischemia (CLI).
- High amputation rates occur following bypass graft failure in CLI patients with comorbidities.
- Percutaneous transluminal angioplasty (PTA) is effective for CLI, even after bypass failure.
Purpose of the Study:
- To review the experience and outcomes of endovascular revascularization in patients with CLI and occluded lower limb bypass grafts.
- To evaluate the safety and feasibility of PTA in this challenging patient population.
Main Methods:
- Retrospective review of 36 patients with CLI and occluded bypass grafts undergoing PTA (2005-2008).
- Duplex scanning and dual-energy computed tomographic angiography (DE-CTA) used for assessment.
- Technical success defined as <30% residual stenosis; stents used for residual stenosis or dissection.
Main Results:
- 91% technical success rate achieved.
- At 24 months, secondary patency was 83%, limb salvage was 70%, and overall survival was 58%.
- Despite 19 PTA failures, limb salvage remained high, with PTA as a crucial alternative to amputation.
Conclusions:
- Endovascular revascularization via PTA is safe and feasible for CLI patients with occluded bypass grafts.
- The procedure offers reasonable technical success, clinical outcomes, and limb salvage.
- PTA serves as a vital alternative to amputation for patients with extensive comorbidities and limited life expectancy.
Aim:
Distal bypass has been considered as a primary choice for the treatment of critical limb ischemia (CLI). When bypass failed with limb threatening ischemia, the amputation rate is high in patients with increased surgical risks and lack of conduit. Percutaneous transluminal angioplasty (PTA) has been shown to be effective and safe in the setting of CLI even in patients with failed bypass graft. The aim of this study was to review our experience and results of extreme endovascular revascularization in patients with CLI following occluded lower limb bypass graft.
Methods:
Retrospective review from January 2005 to June 2008 of patients with CLI following occluded bypass graft who underwent PTA was performed. All patients were studied by Duplex scanning and dual-energy computed tomographic angiography (DE-CTA) bone removal technique. Stents were used in cases of residual stenosis or dissection. Technical success was defined as a residual stenosis less than 30%. Demographics, comorbidities, functional status, details of the procedure information were recorded. Descriptive, logistic regression and life-table analyses performed.
Results:
Thirty-six patients with occluded bypass grafts were treated. The mean age was 69 years (range 56-89), 44% were older than 80 years, 83% had diabetes mellitus, 88% of limbs treated had multiple lesions included Tasc C and D lesions. Technical success was achieved in 91%. Mean follow-up was 24 months. At follow-up, there were 19 PTA failures which were followed by subsequent procedures: redo PTA in 16 limbs, redo bypass in 2, amputation in 5. Cumulative primary patency was 60% (±0.08 SE) and 24% (±0.07 SE). Secondary patency was 96% (±0.03 SE) and 83% (±0.08 SE). Limb salvage was 84% (±0.06 SE) and 70% (±0.10 SE). Freedom from surgical revision was 78% (±0.07 SE) and 54% (±0.11 SE). Overall survival was 89% (±0.05 SE) and 58% (±0.11 SE) at 12 and 24 months, respectively.
Conclusion:
Endovascular revascularization of patients with CLI and occluded bypass graft is a safe and feasible procedure with reasonable technical and clinical success and limb salvage. PTA may be the only alternative to amputation in these patients with extensive comorbidities and limited life expectancy.
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