Below-The-Knee Angioplasty for Critical Limb Ischemia: Results of a Series of 157 Procedures and Impact of the Angiosome Concept

doi:10.1016/j.avsg.2016.03.032

Annals of Vascular Surgery

Volume 36, October 2016, Pages 199-207

https://doi.org/10.1016/j.avsg.2016.03.032 Get rights and content

Background

To evaluate the long-term clinical results of below-the-knee percutaneous transluminal angioplasty (BTK-PTA) with or without stenting, in patients with critical limb ischemia (CLI), and to determine factors affecting clinical results including the role of the angiosome concept.

Methods

All patients undergoing primary BTK-PTA from January 2007 to December 2011 were included. Primary patency, assisted patency, limb salvage, survival, and wound healing were assessed using the Kaplan–Meier method. Predictors of patency, limb salvage, survival, and wound healing, including the role of the angiosome theory, were determined using multivariate models.

Results

A total of 157 procedures were performed in 139 patients with CLI (Rutherford IV 10.8%; Rutherford V-VI 89.2%). Mean age was 74.2 years and 68.3% were men; 60% had diabetes and 31% renal insufficiency. PTA was confined to the infrapopliteal segment alone in 53.5% of cases. Technical success was 87.9%. Stents were placed in 42.6% of cases. The mean follow-up was 14.7 months (range, 1–67 months). Four-year primary and secondary patency were 51% and 61%, respectively. Limb salvage at 4 years was 68.8%. Complete wound healing was 52% at 4 years. Positive predictors of survival were the absence of renal insufficiency (P < 0.0001) and technical success (P = 0.029). Target vessel occlusion of >50% was a negative predictor of limb salvage (P = 0.0072). Positive predictors of wound healing were technical success (P = 0.0067), the absence of renal insufficiency (P < 0.0001) and continuity between a leg artery and a foot artery (P = 0.02).

Conclusions

BTK-PTA can be performed with favorable long-term results in patients with limited longevity. Secondary interventions may be necessary to maintain target vessel patency. In our experience, the angiosome concept had no impact on clinical success.

Introduction

Critical limb ischemia (CLI) due to atherosclerotic disease remains a significant problem associated with numerous hospitalizations and a high level of limb loss and mortality, in particular among diabetic patients. Most of these patients have extensive arterial disease, and the treatment of crural vessel lesions remains a challenge for vascular surgeons. Recent data suggest that percutaneous transluminal angioplasty (PTA) may be an appropriate primary therapy for CLI, including cases where below-the-knee (BTK) lesions are extensive.¹ In this context, we noticed that there is frequently a delay or a failure of wound healing in spite of successful revascularization. Some authors2, 3 think that these failures of wound healing are bound to a defect of blood supply in the diseased tissue sectors, according to the anatomic model of the angiosome, described by Taylor and Palmer⁴ and applied to the lower limbs by Attinger et al.⁵ According to this model, there are 5 angiosomes of the ankle and foot emerging from the 3 main calf vessels: the anterior and posterior tibial arteries joined to the peroneal arteries.

This study reviews our recent experience with BTK-PTA in a series of patients with CLI, to determine its efficacy and long-term clinical results. The aim of the study was 21 also to evaluate the clinical benefit in wound healing and limb preservation after BTK-PTA guided by an angiosome model of perfusion.

Section snippets

Material and Methods

This was a retrospective, single-center study performed over a period of 5 years. All patients with CLI (Rutherford classification 4–6)⁶ and BTK arterial occlusive disease who were hospitalized in the department of vascular surgery of Rouen University Hospital and managed with PTA and/or stent between January 2007 and December 2011 were identified retrospectively.

During the study interval, data from patients who underwent a PTA with or without stenting for CLI were collected. The decision to

Results

During the study period, 139 patients underwent 157 procedures of PTA on 149 limbs. There were 144 anterograde punctures of the ipsilateral superficial femoral artery, 12 retrograde punctures of contralateral common femoral artery, and 1 left humeral puncture. The additional use of a retrograde approach was required to treat 1 artery occlusion. The mean operating time was 110 min. The average dose of contrast was 120 mL. Sheaths were removed under manual compression or stitch, and closure

Discussion

This study reviewed our experience with BTK-PTA during a 4-year period. Our data confirm that PTA and/or stenting can be performed with low morbidity. The major limiting factors of the present study are its retrospective nature and the small number of cases. The retrospective nature of the study is in particular damaging to the assessment of wound healing. It implies a cautious reading of the results. It is indeed very difficult to evaluate the progress of a wound on file without photography,

Conclusions

BTK-PTA may offer the option of multiple repeatable gestures on distal arteries with low complication incidence. Good patency and limb salvage can be achieved with close follow-up and additional PTA if necessary. However, limb salvage may likely be improved with the development of new devices and techniques, allowing the treatment of more complex and more distal lesions. Other devices such as drug-eluting stents and balloons may prove beneficial in preventing restenosis. Regarding the choice of

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Cited by (19)

Angiosome concept for vascular interventions
2022, The Vasculome: From Many, One
Studies published in the last decade in the field of vascular pathology revealed a potential benefit of the angiosome-concept for wound healing and limb salvage, since diligently applied in the management of chronic limb-threatening ischemia (CLTI). However, true concept's applicability for current bypass or transcatheter techniques began only in recent years. There are still unanswered questions about the common technical feasibility of this strategy in contemporary CLTI management, about standardized definitions required for direct versus indirect revascularization, and regarding precise indications for the use of bypass versus endovascular techniques in specific-risk groups of patients.
Uniform guidelines from larger multicentric and prospective studies based on equal clinical interpretation, consistent anatomic and functional diagnostic methods, and unitary treatment indications are yet still needed.
In this chapter, we performed a succinct review of the main characteristics and benefits of the angiosome concept conceived as angiosome-guided direct revascularization method, at the best contemporary knowledge and application.
Below-the-knee arteries—the why and how of endovascular treatment
2021, Vascular Surgery: A Clinical Guide to Decision-making
Critical limb ischemia (CLI) patients with infrapopliteal arterial occlusive disease often have challenging extensive multivessel lesions, particularly in diabetic and renal failure patients. The symptoms are a result of impaired blood flow to the leg and the foot due to narrowing of the arteries by atherosclerosis. The tissue perfusion is decreased, clinically resulting into rest pain, or when an ulcer is present, impaired ulcer healing with possible secondary infection and gangrene. CLI represents the end-stage of Peripheral arterial disease (PAD). The treatment goal for CLI is to relieve the ischemic pain, prevent amputation by promoting wound healing, and improve patients’ functionality, thereby improving the quality of life and preventing death.
Midterm Outcomes of Common Femoral Endarterectomy Combined with Inflow and Outflow Endovascular Treatment for Chronic Limb Threatening Ischaemia
2020, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Cox regression multivariable analysis in the current series yielded other significant predictors such as dyslipidaemia, lesion severity, extensive vessel calcification in the treatment zone, and incomplete revascularisation ending the procedure with poor runoff. Several studies reported better revascularisation results with improving the runoff, through SFA and profunda for inflow lesions,22–24 and leg and pedal arteries for outflow lesions.25,26 The association between dyslipidaemia and the development or progression of atherosclerosis has been studied extensively.
To assess mid term outcomes of common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with chronic limb threatening ischaemia (CLTI).
This was a prospective study. All patients who, for the first time, underwent planned one stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularisation procedure to achieve limb salvage in patients with CLTI due to multilevel disease were included between January 2015 and May 2017. Demographics, and clinical and lesion characteristics for each patient were reported. The primary outcome was primary patency. Secondary outcomes were technical success, peri-operative morbidity and mortality, assisted primary patency, secondary patency, clinically driven target lesion revascularisation and amputation free survival.
Three groups were created according to the endovascular treatment zone: group 1 (inflow, n = 60); group 2 (outflow, n = 46); and group 3 (combined inflow and outflow, n = 53). CFA endarterectomy was a fixed step in all cases. The overall technical success was 98%. The peri-operative complication rate was 14% and the mortality rate was 2%. Patients in group 3 demonstrated a significantly lower primary patency rate (53.9% ± 7.1%; p < .001) at 24 months but improved secondary patency rate of (94.0% ± 3.4%). Based on the outcomes of the Cox regression multivariable analysis, lesion length (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.06–1.14; p < .001), chronic total occlusion (CTO) (HR 0.50, 95% CI 0.25–0.98; p = .046), peripheral artery calcium scoring system (PACSS) grade 4 (HR 2.44, 95% CI 1.27–4.68; p = .008), incomplete revascularisation (HR 3.32, 95% CI 1.64–6.73; p = .001), and dyslipidaemia (HR 0.50, 95% CI 0.27–0.93; p = .031) were the only significant independent predictors of loss of primary patency.
Common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with CLTI is safe, with acceptable patency rates, despite the need for secondary interventions. Dyslipidaemia, lesion length, CTO, PACSS grade 4, and incomplete revascularisation are independent predictors of primary patency loss. The current study analysis supports the recommendation to stage the procedure based on patient risk and degree of limb threat.
Factors affecting outcomes after endovascular treatment for femoropopliteal atherosclerotic lesions
2019, Asian Journal of Surgery
Citation Excerpt :
We calculated the tibial runoff score from the angiographic results by attributing to the three leg arteries (anterior tibial, posterior tibial, and peroneal arteries) a value between 0 and 3 (0 = normal artery, minimal lesion; 1 = artery permeable with stenosis between 20% and 49% of its diameter; 2 = artery permeable with stenosis between 50% and 99% of its diameter; 2.5 = thrombosed artery of less than 50% of the height of the artery; 3 = thrombosed artery of more than 50% of the height of the artery). The sum of the three values plus 1 was determined to be the tibial runoff score.24 We considered a good runoff as a score <7 and a poor runoff as a score ≥7.
: This study aimed to investigate the outcomes of femoropopliteal interventions in relation to various influencing factors.
A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed.
In patients with claudication, the TLR free rates at 1-, 3-, and 5-year intervals were 89.1%, 82.2%, and 78.9%, respectively. Amputation-free survival rates in the claudicants at 1-, 3-, and 5-year intervals were 95.3%, 81.1%, and 65.2%, respectively. Freedom from ischemia at 1-, 3-, and 5-year follow-ups was 77.8%, 69.0%, and 61.3%, respectively. In patients with critical limb ischemia, the TLR free rates at 1-, 3-, and 5-year intervals were 91.3%, 87.4%, and 65.4%, respectively, amputation free survival rates were 72.5%, 44.2%, and 36.8%, respectively, and their freedom from ischemia was 64.6%, 63.4%, and 49.7%, respectively. In the multivariate analysis of influencing factors related to freedom from ischemia, renal insufficiency (hazard ratio [HR] 1.623; 95% confidence interval [CI] 0.999–2.636; p = 0.050), TASC C/D lesion (HR 1.903; 95% CI 1.151–3.148; p = 0.012), and poor tibial runoff (HR 1.770; 95% CI 1.037–3.023; p = 0.036) were statistically significant risk factors. TASC C/D lesion and poor tibial runoff were significant risk factors for recurrent or persistent ischemia in claudication (p = 0.015) and in critical limb ischemia (p = 0.05), respectively.
Endovascular treatment for femoropopliteal atherosclerotic lesions showed acceptable intermediate-term and long-term outcomes. Renal insufficiency, TASC C/D lesions, and poor tibial runoff adversely affected freedom from ischemia.
Editor's Choice – Direct vs. Indirect Angiosomal Revascularisation of Infrapopliteal Arteries, an Updated Systematic Review and Meta-analysis
2018, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Only 22 patients were available for CR data specifically, and because of low numbers were not extracted for separate analysis. Excluded papers of note included seven duplicate publications,40–46 two with un-extractable data,47,48 and one with non-clinical outcome measures only.49 Two groups presented different outcome data in a similar clinical group.28,37,42,46
The importance of the angiosome concept in tibial artery revascularisation remains controversial. The aim of this review was to assess the outcomes of direct revascularisation (revascularisation to the angiosome of tissue loss; DR) versus indirect revascularisation (IR) in infrapopliteal arteries.
A previously conducted systematic review was updated according to PRISMA guidelines. Studies comparing DR with IR by both endovascular and surgical means for patients with localised tissue loss were included. Meta-analyses were performed to assess the effect of DR versus IR on wound healing (total and time to healing), limb salvage, mortality, and re-intervention rates, with multiple sensitivity analyses. Outcome data quality was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.
Seven studies (2278 limbs) were identified in the updated search, which when combined with the previous search resulted in 22 studies, comprising 4146 limbs, being included. Wound healing rates (odds ratio [OR] 0.51; 95% CI 0.39–0.68, p < 0.001), time to wound healing (standard mean difference [SMD] −1.70; 95% CI –3.34 to −0.07, p = .04) and limb salvage (OR 0.37; 95% CI 0.24–0.58, p < .0001) were significantly better with DR compared with IR. Sensitivity analyses were concordant with the primary analysis for these outcomes, with the exception of the effect of wound healing rates between DR and IR, which was lost on sensitivity analysis for bypass surgery. Mode of revascularisation had no effect on mortality or on re-intervention rates. GRADE outcomes were very low.
DR of the tibial vessels appears to result in improved wound healing and limb salvage rates compared with IR, with no effect on mortality or re-intervention rates. For surgical revascularisation the importance of DR appears to be lost for wound healing. When possible, these low quality data suggests DR should be undertaken in preference to IR.
Angiosome perfusion of the foot: An old theory or a new issue?
2018, Seminars in Vascular Surgery
Citation Excerpt :
In this study, all patients in the indirect group only had one crural artery, which may have influenced outcomes. A study from France that reported on the outcomes of 157 endovascular procedures (slightly more than half of these procedures were limited to the infrapopliteal segment alone) showed favorable long-term results and failed to demonstrate any impact of the angiosome concept on clinical success [31]. The fact that multi-segment pathology was treated in slightly fewer than half of the patients may have confounded the outcome (for this reason, this study was probably excluded from the most recent meta-analysis described hereafter).
The angiosome concept of foot perfusion was conceived based on anatomical studies of arterial circulation and used for planning surgical procedures, tissue reconstruction, and amputation. Its application is relevant in diabetic patients with critical limb ischemia and nonhealing foot ulcer or amputation. An understanding of foot angiosome anatomy is useful for predicting healing and planning arterial revascularization. A review of the literature, including the most recent systematic reviews and meta-analyses, indicates improved wound healing is achieved when the angiosome concept is followed. The greatest value of angiosome-based revascularization is in patients with lesion(s) limited to a single angiosome, or to achieve optimal healing of amputation sites. Future research should focus on proper identification of (imaging) modalities to determine the hemodynamic and functional changes before and after revascularization, thus identifying the “real” angiosome and directing optimal therapy.

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: The authors have no commercial, proprietary, or financial interest in any products or companies described in this article.

: There is no prior presentation of this article.

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Clinical ResearchBelow-The-Knee Angioplasty for Critical Limb Ischemia: Results of a Series of 157 Procedures and Impact of the Angiosome Concept

Background

Methods

Results

Conclusions

Introduction

Section snippets

Material and Methods

Results

Discussion

Conclusions

Br J Plast Surg

J Vasc Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

J Vasc Surg

J Am Coll Cardiol

Ann Vasc Surg

Ann Vasc Surg

J Am Coll Cardiol

J Vasc Surg

J Am Coll Cardiol

J Vasc Surg

J Am Coll Cardiol

J Vasc Surg

J Vasc Surg

Ann Vasc Surg

Lancet

Clinical Research
Below-The-Knee Angioplasty for Critical Limb Ischemia: Results of a Series of 157 Procedures and Impact of the Angiosome Concept