Title: Percutaneous Endovascular Treatment for Chronic Limb Ischemia
Authors: Mousa et al.
Source: Annals of Vascular Surgery. Vol. 19, No.2 , 2005
PODIATRIC RELEVANCE:
Peripheral vascular disease is a complex condition that frequently complicates the management of chronic wounds, many of which are treated by the podiatric medical profession. Often, multiple comorbidities preclude traditional surgical interventions. Advances in endovascular techniques offer an alternative to achieving prompt revascularization and limb salvage, especially in patients with critical limb ischemia. Studies have shown that critical limb ischemia (CLI) can be successfully treated with minimally invasive techniques via the use of cold lasers, balloon angioplasty, stenting and arthrectomy through a simple femoral approach, thereby decreasing morbidity and mortality in this patient population.
METHODS:
A retrospective review of records of 66 patients (mean age 71.3 years) from a single institution, New York Presbyterian Hospital via the vascular surgery database, were reviewed for vessel patency and limb salvage following endovascular treatment of severe claudication, rest pain and gangrene. 31 patients had severe disabling claudication symptoms, 15 had rest pain, 17 had minor tissue loss and 3 had major tissue loss. Of the 66 limbs studied, 94 lesions were identified, 55 exhibiting stenosis and 39 exhibiting complete occlusion. 45 were located in the superficial femoral artery, 28 in the popliteal and 21 in the tibial arteries. Areas of stenosis were treated via percutaneous transluminal angioplasty, with occlusive lesions treated via subintimal angioplasty. 47 patients were treated through a contralateral approach, 16 through an ipsilateral approach. All were performed via an inguinal stick under local anesthesia. 46 stents were placed in 32 patients following angioplasty while 34 patients required no stenting.
RESULTS:
Average follow-up was 6 months (range 6 weeks-15 months). and included a clinical exam, ABI, duplex ultrasonography, PVR’s and grading of symptoms. ASA and clopidogrel were employed as adjunct therapy in all patients. Clopidogrel was administered for 5 days prior to surgery and for a minimum of 30 days post-procedure. Angiography was repeated if symptoms worsened or if the ABI dropped by more than 0.15.
The average improvement in ABI postoperatively was 0.35 from 0.65 to 1.01. The endovascular procedure was technically successful in 65 of 66 patients. Primary patency was 89% at 6 months and 68% at 12 months. Of the 6 patients who were not patent at 6 months, 4 suffered re-stenosis of >50% and 2 suffered occlusion. Reintervention in these patients resulted in 96% success rate. 3 patients necessitated open bypass at 12 months. Overall limb salvage at 6 months was 97%, 91% in patients with severe limb-threatening conditions. However, at 10 months, 3 patients required below knee amputation, despite the fact that 2 of which had patent vessels. No patient was prevented from undergoing subsequent open bypass due to prior endovascular procedure.
COMMENTS:
Endovascular therapy for critical limb ischemia has recently become an area of interest in podiatric surgery and limb salvage. New technology offers a less invasive means of restoring circulation in compromised limbs while lessening morbidity and mortality when compared to traditional open bypass procedures. Though long-term studies are needed to assess long term patency rates, limb salvage rates at 6 months are indeed promising. It is likely that further advancements in endovascular techniques will only improve the short term and long term outcomes and thus significantly impact amputation rates worldwide. The improvement in quality of life that can be expected in a formerly somewhat doomed patient population is likely to be significantly improved.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.