PTA and thrombolysis in leg salvage

The goals of any treatment for ischemic vascular disease are to relieve pain, allow wound healing, and regain/maintain ambulatory abilities. To determine if endovascular therapy could accomplish these goals in patients with limbs at risk, we undertook a retrospective analysis of the results of percutaneous transluminal angioplasty (PTA) and thrombolysis in leg salvage.

Over an 8-year period ending in 1993, 327 patients (209 males, 118 females) with limb-threatening ischemia (defined as one or more of the following: ischemic rest pain, ischemic ulceration, or gangrene) in 361 limbs were seen. These patients had an ankle-brachial index < or = 0.40 in nondiabetic patients and/or toe-brachial index < or = 0.30 in diabetic patients. The patients were treated with thrombolysis and/or PTA according to standard techniques; intravascular stenting was used occasionally as required to treat PTA deficiencies or inadequate recanalization.

Among the 327 patients, 805 arteries and 25 thrombosed arterial grafts were treated. The arteries treated were: 6 aorta (0.75%), 75 iliac (9.3%), 34 common femoral (4.2%), 3 deep femoral (0.4%), 235 superficial femoral (29.2%), 219 popliteal (27.2%), 193 infrapopliteal (24.0%), and 40 pedal (5.0%). The patients were treated primarily with PTA (n = 307); urokinase thrombolysis (n = 99) and stents (n = 12) were used less frequently. Procedural success was 92.5%. Patients were followed from 6 months to 8 years (mean 3 years). Eighty-three patients were retreated during this time. Of the 249 patients available for this follow-up, total salvage was achieved in 181 (72.7%). Nineteen patients (7.6%) underwent minor amputations (e.g., toes); 4 patients (1.6%) had transmetatarsal amputation. Fifteen patients (3.6%) had above-knee amputation despite successful recanalization. In all, 32 patients (8.8%) had the amputation level extended from above to below knee, bringing the total leg salvage rate to 82% (defined as patients able to ambulate without any prosthesis). Using life-table analysis, the 5 year survival rate was 71%.

This study shows that endovascular therapy for leg salvage is as effective as reconstructive vascular surgery in achieving wound healing and maintaining ambulation and has a more favorable 5-year survival rate.