Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia
Gagan D Singh1, Ehrin J Armstrong1, Khung-Keong Yeo2
1Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
Insights
Endovascular intervention successfully restores arterial flow in infrapopliteal occlusions for critical limb ischemia patients. Successful treatment significantly improves limb salvage rates, while failed interventions increase amputation risk.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Critical limb ischemia (CLI) often involves infrapopliteal (IP) occlusions, necessitating revascularization for limb salvage.
- Endovascular therapies are increasingly utilized for CLI treatment, particularly for complex IP lesions.
Purpose of the Study:
- To describe procedural characteristics and outcomes of endovascular interventions for infrapopliteal occlusions in CLI patients.
- To compare outcomes between endovascular treatment of IP occlusions versus IP stenosis.
Main Methods:
- Retrospective analysis of 187 CLI patients undergoing 356 IP interventions (2006-2012).
- Comparison of angiographic and procedural data between IP occlusion and stenosis groups.
- Primary endpoint: limb salvage. Secondary endpoints: patency rates, occlusion crossing success, procedural success, and amputation-free survival.
Main Results:
- 77 patients (41%) had IP occlusions, characterized by poorer runoff, longer lesion length, and smaller diameter compared to stenoses.
- Successful wire crossing achieved in 83% of IP occlusions with 79% overall procedural success.
- 1-year limb salvage rate was 84%, with higher rates for stenosis (92%) vs. successful occlusion (75%) vs. failed occlusion (58%).
- Unsuccessful IP occlusion treatment significantly increased major amputation risk (HR 5.79) and major amputation or death (HR 2.69).
Conclusions:
- Endovascular recanalization of infrapopliteal occlusions is achievable using guidewire and support catheter techniques.
- An endovascular-first approach for IP occlusions in CLI patients can lead to favorable limb salvage rates when successful.
Background:
Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI.
Methods:
All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival.
Results:
A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P < .001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P < .001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P = .02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P = .02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63).
Conclusions:
Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.
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