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Published on: September 22, 2020
Outcomes following infrapopliteal angioplasty for critical limb ischemia
Ruby C Lo1, Jeremy Darling, Rodney P Bensley
1Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass 02215, USA.
Insights
Infrapopliteal angioplasty is effective for critical limb ischemia (CLI) TASC A-C lesions. Bypass surgery is recommended for TASC D patients unsuitable for angioplasty, with multilevel intervention showing no adverse outcomes.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Critical limb ischemia (CLI) management often involves infrapopliteal angioplasty (percutaneous transluminal angioplasty [PTA]).
- Long-term outcome data for infrapopliteal PTA in CLI patients remain limited.
Purpose of the Study:
- To evaluate the long-term effectiveness and outcomes of infrapopliteal PTA in patients with CLI.
- To stratify outcomes based on TransAtlantic Inter-Society Consensus (TASC) classification.
Main Methods:
- Retrospective review of 459 limbs in 413 CLI patients undergoing infrapopliteal PTA from 2004-2012.
- Outcomes assessed included restenosis, patency, reintervention, amputation, complications, wound healing, and survival.
- Patients were stratified by TASC class (A, B, C, D).
Main Results:
- Technical success rate was 93% with 11% perioperative complications.
- Five-year survival was 49%; one- and five-year primary patency rates were 57% and 38%, respectively.
- Restenosis and amputation rates were higher for TASC C and D lesions, and for patients unsuitable for bypass surgery. Postoperative clopidogrel use correlated with lower revascularization rates.
Conclusions:
- Infrapopliteal PTA serves as an effective primary treatment for TASC A, B, and C CLI lesions.
- Surgical bypass should be prioritized for TASC D patients amenable to surgery.
- Multilevel interventions did not negatively impact outcomes.
Objective:
Infrapopliteal angioplasty (percutaneous transluminal angioplasty [PTA]) is routinely used to treat critical limb ischemia (CLI) despite limited data on long-term outcomes.
Methods:
We reviewed all patients undergoing infrapopliteal PTA for CLI from 2004 to 2012 stratified by TransAtlantic Inter-Society Consensus (TASC) class. Outcomes included restenosis, primary patency, reintervention (w/PTA or bypass), amputation, procedural complications, wound healing, and survival.
Results:
Infrapopliteal PTA (stenting 14%, multilevel intervention 50%) was performed in 459 limbs of 413 patients (59% male) with a technical success of 93% and perioperative complications in 11%. TASC class was 16% A, 22% B, 27% C, and 34% D. Multilevel interventions were performed in 50% of limbs and were evenly distributed among all TASC classes. All technical failures were TASC D lesions. Mean follow-up was 15 months; 5-year survival was 49%. One- and 5-year primary patency was 57% and 38% and limb salvage was 84% and 81%, respectively. Restenosis was associated with TASC C (hazard ratio [HR], 2.2; 95% CI, 1.2-3.9; P = .010) and TASC D (HR, 2.4; 95% CI, 1.3-4.4; P = .004) lesions. Amputation rates were higher in patients who were not candidates for bypass (HR, 4.4; 95% CI, 2.6-7.5; P < .001) and with TASC D lesions (HR, 3.8; 95% CI, 1.1-12.5; P = .03). Unsuitability for bypass was also predictive of repeat PTA (HR, 1.8; 95% CI, 1.0-3.4; P = .047). Postoperative clopidogrel use was associated with lower rates of any revascularization (HR, 0.46; 95% CI, 0.25-0.83; P = .011).
Conclusions:
Infrapopliteal PTA is effective primary therapy for TASC A, B, and C lesions. Surgical bypass should be offered to patients with TASC D disease who are suitable candidates. Multilevel intervention does not adversely affect outcome.
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