What's Next after Optimal Infrapopliteal Angioplasty? Clinical and Ultrasonographic Results of a Prospective Single-Center Study

Abstract

Purpose:

To evaluate arterial patency and factors influencing outcomes after successful tibial artery angioplasty in patients with critical limb ischemia (CLI).

Methods:

From January 2005 to August 2007, a prospective single-center study was conducted involving 80 CLI patients (56 men; mean age 71.7±8.8 years) who underwent successful tibial artery angioplasty (<30% residual stenosis) in 87 limbs. Eighty (92%) limbs showed ischemic ulcers or gangrene at baseline. In two thirds, a more proximal lesion was treated, and a secondary stent was implanted in 14 (16%). Follow-up included clinical examination for wound healing (WH), limb salvage (LS), and duplex-documented target vessel patency or restenosis at discharge and at 1, 3, 6, 9, 12, 18, and then every 6 months. Patency rates, WH, and LS were assessed with the Kaplan-Meier method, and factors influencing these outcomes were analyzed using Cox proportional hazards models.

Results:

Mean follow-up was 10.9 months (range 2 days — 29 months). At 12 months, the primary and assisted primary patency rates were 37.9% and 71.2%, respectively. Restenosis was significantly correlated with smoking (HR 3.58, 95% CI 1.15 to 11.18; p=0.02), infected ulcers (HR 2.04, 95% CI 1.02 to 4.09; p=0.04), and posterior tibial artery angioplasty (HR 3.76, 95% CI 1.59 to 8.87; p=0.003). Rates of LS and WH at 12 months were 92.7% and 74.9%, respectively. Peroneal angioplasty was significantly correlated with WH (HR 1.83, 95% CI 1.04 to 3.25; p=0.03), and wound healing increased with classes of age (HR 1.60, 95% CI 1.07 to 2.39; p=0.02).

Conclusion:

One-year restenosis after optimal tibial artery angioplasty is significant and positively correlated with smoking, infection of trophic lesions, and posterior tibial artery angioplasty. Close ultrasound surveillance provides good limb salvage after optimal infrapopliteal angioplasty in patients with CLI.

Keywords

tibial artery critical limb ischemia angioplasty restenosis duplex sonography

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References

Söder

Manninen

Jaakkola

. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: Angiographic and clinical results. J Vasc Interv Radiol. 2000; 11: 1021–1031.

Boyer

Therre

Garcier

. Infrapopliteal percutaneous transluminal angioplasty for limb salvage. Acta Radiol. 2000; 41: 73–77.

Dorros

Jaff

Dorros

. Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia. Circulation. 2001; 104: 2057–2062.

Brillu

Picquet

Villapadierna

. Percutaneous angioplasty for management of critical ischemia in arteries below the knee. Ann Vasc Surg. 2001; 15: 175–181.

Stella

Gargiulo

Rumolo

. Angioplastica delle arterie tibiali nell'ischemia critica del paziente diabetico. In: Stella

Gargiulo

, eds. Arteriopatia Diabetica degli Arti Inferiori. Torino, Italy: Edizioni Minerva Medica; 2004: 93–99.

Faglia

Paola

Dalla L

Clerici

. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: Prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg. 2005; 29: 620–627.

Atar

Siegel

Avrahami

. Balloon angioplasty of popliteal and crural arteries in elderly with critical chronic limb ischemia. Eur J Radiol. 2005; 53: 287–292.

Sigala

Menenakos

Sigalas

. Transluminal angioplasty of isolated crural arterial lesions in diabetics with critical limb ischemia. Vasa. 2005; 34: 186–191.

Karacagil

Lofberg

Granbo

. Value of duplex scanning in evaluation of crural and foot arteries in limbs with severe lower limb ischemia. A prospective comparison with angiography. Eur J Vasc Endovasc Surg. 1996; 12: 300–303.

10.

Sensier

Fishwick

Owen

. A comparison between colour duplex ultrasonography and arteriography for imaging infrapopliteal arterial lesions. Eur J Vasc Endovasc Surg. 1998; 15: 44–50.

11.

Hofmann

Forstner

Kofler

. Pedal artery imaging. A comparison of selective digital subtraction angiography, contrast enhanced magnetic resonance angiography and duplex ultrasound. Eur J Vasc Endovasc Surg. 2002; 24: 287–292.

12.

Grassbaugh

Nelson

Rzucidlo

. Blinded comparison of preoperative duplex ultrasound scanning and contrast arteriography for planning revascularization at the level of the tibia. J Vasc Surg. 2003; 37: 1186–1190.

13.

Hingorani

Ascher

Markevich

. Magnetic resonance angiography versus duplex arteriography in patients undergoing lower extremity revascularization: Which is the best replacement for contrast arteriography? J Vasc Surg. 2004; 39: 717–722.

14.

Hofmann

Walter

Ugurluoglu

. Preoperative high-frequency duplex scanning of potential pedal target vessels. J Vasc Surg. 2004; 39: 169–175.

15.

Hingorani

Ascher

Marks

. Duplex arteriography for lower extremity revascularization. Perspect Vasc Surg Endovasc Ther. 2007; 19: 6–20.

16.

Armstrong

Lavery

Harkless

. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998; 21: 855–859.

17.

Norgren

Hiatt

Dormandy

. Intersociety consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg. 2007; 33(Suppl 1): S1–75.

18.

Ranke

Creutzig

Alexander

. Duplex scanning of the peripheral arteries: Correlation of the peak velocity ratio with angiographic diameter reduction. Ultrasound Med Biol. 1992; 18: 433–440.

19.

Menard

Belkin

. Infrapopliteal intervention for the treatment of the claudicant. Semin Vasc Surg. 2007; 20: 42–53.

20.

Management of peripheral arterial disease (PAD). TransAtlantic Inter-Society Consensus (TASC). Eur J Vasc Endovasc Surg. 2000; 19(Suppl A): S194–197.

21.

Danielsson

Albrechtsson

Norgren

. Percutaneous transluminal angioplasty of crural arteries: Diabetes and others factors influencing outcome. Eur J Vasc Endovasc Surg. 2001; 21: 432–436.

22.

Aulivola

Gargiulo

Stella

. Infrapopliteal angioplasty for limb salvage in the setting of renal failure: Do results justify its use? Ann Vasc Surg. 2005; 19: 762–768.

23.

Kickuth

Keo

Triller

. Initial clinical experience with the 4-F self-expanding XPERT stent system for infrapopliteal treatment of patients with severe claudication and critical limb ischemia. J Vasc Interv Radiol. 2007; 18: 703–708.

24.

Peregrin

Smirova

Koznar

. Self-expandable stent placement in infrapopliteal arteries after unsuccessful angioplasty failure: One-year follow up. Cardiovasc Intervent Radiol. 2008 [Epub ahead of print].

25.

Mlekusch

Schillinger

Sabeti

. Clinical outcome and prognostic factors for ischemic ulcers treated with PTA in lower limbs. Eur J Vasc Endovasc Surg. 2002; 24: 176–181.

26.

Jacqueminet

Hartemann-Heurtier

Izzillo

. Percutaneous transluminal angioplasty in severe diabetic foot ischemia: Outcomes and prognostic factors. Diabetes Metab. 2005; 31: 370–375.

27.

Faglia

Mantero

Caminiti

. Extensive use of peripheral angioplasty, particularly infrapopliteal in the treatment of ischemia diabetic foot ulcers: Clinical results of a multi-centric study of 221 consecutive diabetic subjects. J Intern Med. 2002; 252: 225–232.