Percutaneous transluminal angioplasty versus surgery for limb-threatening ischemia

This retrospective study compared the results of percutaneous transluminal angioplasty (PTA) with those of infrainguinal bypass procedures in patients with critical arterial ischemia to determine which procedure had superior patency, limb salvage, and durability. The records of 54 patients who underwent 54 PTAs and 56 patients who underwent 63 infrainguinal bypasses (29 femoropopliteal and 34 femorodistal) from 1981 to 1987 were reviewed. In each patient PTA or bypass was the initial vascular procedure. Patients in both groups were comparable with respect to age, sex, and the presence of diabetes, hypertension, obesity, hypercholesterolemia, and smoking. Mean follow-up was 40 months (4 to 88 months) for the PTA group and 28 months (6 to 78 months) for the surgery group. Thirty-nine of the 54 patients (72%) were initially improved after PTA, whereas 15 patients (28%) showed no improvement. During follow-up, 20 initially successful PTAs reoccluded. Thirty-two of 54 patients (59%) underwent subsequent procedures, which included repeat PTA (10) and distal bypass (14). Patency determined by noninvasive Doppler studies was 18% at 2 years. Limb salvage, which included such secondary procedures, was 78%. Two-year patency for femoropopliteal bypasses was 68% with a limb salvage of 90%. Femorodistal bypasses had a 2-year patency of 47% and a limb salvage of 74%. No perioperative deaths occurred. Twenty-one of the 63 patients (33%) had subsequent procedures, which included thrombectomy (5) and bypass revision (9). In patients treated for limb-threatening ischemia the 2-year patency after femoropopliteal bypass (68%) or femorodistal bypass (47%) is significantly better than that from PTA (18%, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Predicting outcome of angioplasty and selective stenting of multisegment iliac artery occlusive disease

BACKGROUND: Patients who require angioplasty and stenting of multiple iliac arterial segments often require reintervention to maintain long-term patency. Morphologic predictors and causes of failure are unknown. The purpose of the current study was to define arteriographic predictors of angioplasty and selective stent failure in the treatment of multisegment iliac occlusive disease. METHODS: All iliac segments (two common and two external) of 75 patients who underwent angioplasty and selective stent placement for multisegment iliac occlusive disease (>/= two segments) were scored through use of a modification of the Society of Cardiovascular and Interventional Radiology classification for iliac angioplasty (0 = no lesion; 4 = most severe). Total iliac score was calculated by summing scores from each segment. A separate external iliac score was calculated by adding only the external iliac scores. Arteriograms were reviewed initially and at the time of lesion recurrence and stratified by lesion location and previous intervention. RESULTS: The area of previous endovascular intervention was the site of recurrence in 75% of patients. New lesions, presumably a result of progressive atherosclerosis, occurred in 15% of patients, and lesions occurred in both new and previously treated iliac segments in 10% of patients. Only the external iliac score was an independent predictor of failed endovascular therapy despite reintervention. For patients with an external iliac score of 2 or less, the endovascular primary-assisted patency rates at 6, 12, and 24 months were 96%, 92%, and 89%, respectively. This was improved in comparison with the 90%, 63%, and 45% patency rates observed in patients with an external iliac score of 3 or more (P =.001). Patients with an external iliac score of 3 or more had a significantly lower incidence of hemodynamic and clinical improvement after intervention and a threefold higher need for surgical inflow procedures than patients with an external iliac score of 2 or less. CONCLUSIONS: Lesion formation after treatment of multisegment iliac occlusive disease typically occurs in areas of prior intervention. The extent of external iliac disease can be used to stratify patients with multisegment iliac occlusive disease who will likely respond to endovascular treatment with a durable result. Patients with extensive external iliac disease (score >/= 3) have poor results after angioplasty and selective stenting as applied in this study, even with endovascular reintervention. They are ideal subjects for prospective comparative studies of competing initial therapies, including stenting, endografting, and aortobifemoral bypass grafting.     

Primary iliac stenting versus transluminal angioplasty with selective stenting

BACKGROUND: The preferential use of primary iliac stenting vs selective stenting is controversial. This study compares the early and late clinical outcomes of primary vs selective iliac stenting at our institution. METHODS: A total of 110 consecutive patients with iliac stenosis (149 lesions) underwent primary stenting over a recent 5-year period (primary stent group). The early technical and clinical success and late clinical outcomes were compared with 41 patients (41 iliac lesions) who had percutaneous transluminal angioplasty (PTA) followed by selective stenting for suboptimal PTA (selective stent group). All patients were evaluated clinically and by duplex scanning with ankle-brachial indexes at 1, 6, and 12 months and every 12 months thereafter. RESULTS: The perioperative complication rate for the primary stent group was 2.7% (three minor hematomas) vs 24% for the selective stent group (P < .0001). The overall early clinical success rate was 97% for the primary stent group vs 83% for the selective stent group (P = .002), however, the rate was 100% for short stenosis (A and B lesions <5 cm TASC classification) in both groups; in contrast to 93% for the primary stent group vs 46% for the selective stent group for longer stenoses (TASC - C and D lesions, P = .0003). The overall late clinical success was comparable for both groups: 88% for the primary stent group vs 80% for the selective stent group, however, this rate was superior for the longer lesions in the primary stent group, 84% vs 46% (P = .007). The primary patency rates at 1, 2, 3, and 5 years were 98%, 94%, 87%, and 77% for the primary stent group vs 83%, 78%, 69%, and 69% for the selective stent group (P = .030). These rates were comparable in both groups for shorter lesions: 100%, 98%, 98%, and 87% for the primary stent group vs 100%, 93%, 85%, and 85% for the selective stent group (P = .637). However, they were superior for the primary stent group in longer lesions: 96%, 90%, and 72% vs 46%, 46%, and 28% for the selective stent group at 1, 2, and 3 years (P < .0001). CONCLUSIONS: The overall early clinical success rate was superior for the primary stent group. However, the initial (early) and late clinical success rates were comparable for short lesions (TASC - A and B lesions), but were inferior in selective stenting for longer lesions (TASC - C and D). Therefore, primary stenting should be offered to all TASC - C and D lesions.     

Comparison of outcomes for balloon angioplasty,atherectomy, and stenting in the treatment of infrapopliteal disease for chronic limb-threatening ischemia

ObjectiveWe evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI).MethodsAll index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS.ResultsThe 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P = .006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P = .08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P = .001; HR, 0.73; 95% CI, 0.60-0.90; P = .003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P = .11) and for stenting and atherectomy (87.6% vs 84.8%; P = .23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P = .07; HR, 0.71; 95% CI, 0.50-1.017; P = .062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P = .005; HR, 0.69; 95% CI, 0.54-0.89; P = .005). No significant differences were found between stenting and atherectomy (P = .21 for atherectomy; and P = .34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P = .001; stenting vs atherectomy, 13.5 months vs 6.8 months; P < .001).ConclusionsStenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment.     

Percutaneous transluminal angioplasty and stenting for iliac artery occlusive disease.

Atherosclerotic iliac artery stenoses respond well to simple balloon angioplasty and have the best results of all of the peripheral vessels. Nonetheless, initial technical failures occur in as many as 20% of patients, most of which can be salvaged with intravascular stenting, as can many of the potential complications; however, even though the initial technical success rates for stenting approach 100%, stenotic recurrences within stents are not infrequent. Whether promising new concepts, such as brachytherapy, gene therapy, and endoluminal grafting, will have a durable impact on the results of iliac angioplasty is yet to be seen. Meanwhile, the excellent results of endoluminal treatment of patients with iliac artery occlusive disease, combined with the relatively low risk for complications compared with surgical revascularization, ensure an enduring role for this modality of treatment and a diminution in the fraction of patients requiring surgery to correct their iliac artery occlusive disease.     

External iliac and common iliac artery angioplasty and stenting in men and women

OBJECTIVE: The effect of anatomic location of stent placement on the outcome of iliac artery angioplasty and stenting is not defined. Analyses of patency rates of external iliac artery (EIA) and common iliac artery (CIA) stents have provided conflicting results and have not considered men and women independently. The purpose of this study was to estimate the influence of the anatomic location of stenting on the outcome of iliac angioplasty and stent placement in both men and women. METHODS: From 1995 to 1999, 247 iliac angioplasty and stent placement procedures (303 stents) were performed in 67 women and 122 men, and all were included in a retrospective cohort study. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Both univariate (Kaplan-Meier [KM]) and multivariate analyses (Cox proportional hazards model) were used to determine the association among the variables, cumulative patency, limb salvage, and survival. RESULTS: Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (33%), and blue toe syndrome (2%). Primary stenting was performed in 103 procedures (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Patients with EIA stents, as compared with those who had CIA stents, had more extensive lesions (TransAtlantic Inter-Society Consensus type C lesions), poorer runoff, smaller vessel size, and less frequency of hyperlipidemia (P <.05). Primary patency rates at 1, 3, and 5 years were 76%, 56%, and 56%, respectively, for patients with EIA stents and 92%, 85%, and 76%, respectively, for those with CIA stents. Although overall primary patency rates were significantly decreased in patients with EIA lesions (KM, log-rank test, P =.001), stratified analyses revealed that women with EIA stents had the poorest outcome, with 61%, 47%, and 23% primary patency rates at 1, 3, and 5 years, respectively, (KM, log-rank test, P <.001). Cox regression analysis identified EIA stenting (relative risk, 4.3; 95% CI, 2.3-7.9; P <.001) as an independent predictor of decreased primary patency in women but not in men. CONCLUSIONS: Women undergoing EIA angioplasty with stent placement have significantly reduced primary patency rates. Despite initial technical success, these patients are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. Conversely, men undergoing EIA stenting have a more favorable outcome than women.     

Effect and outcome of balloon angioplasty and stenting of the iliac arteries evaluated by intravascular ultrasound.

OBJECTIVES: To document the mechanism of percutaneous transluminal angioplasty (PTA) and stenting of the iliac arteries, and to relate the effect to patency. MATERIALS AND METHODS: Thirty-seven stenotic iliac arteries were examined by intravascular ultrasound (IVUS) and arteriography before and after PTA, and after stent deployment (n = 16). The patients were followed prospectively by duplex scanning at 3, 6, 12, 18 and 24 months after the intervention. RESULTS: The effect of PTA was established by both compression and stretching with the major contribution arising from stretching. There were differences in the effect of PTA dependent on plaque morphology: in homogeneous eccentric lesions, stretching contributed significantly more than compression to the luminal gain, while stretching and compression contributed equally in concentric or heterogeneous plaques. Stenting of the arteries had no effect on the free luminal area as measured by IVUS. The primary 1-year patency rate was 72%. The patency was related to the free luminal area and diameter and the heterogenicity of the plaque as evaluated by IVUS. The arteriographic measurements did not have any predictive value. CONCLUSION: IVUS was able to document the effect of PTA and stenting in the iliac arteries, and predict the outcome. The luminal gain and reduction in degree of stenosis seemed to be accomplished primarily by stretching of the arteries and to a lesser extent by plaque compression. Stenting did not change the IVUS measurements. Patency was related to the size of the free lumen and the heterogenicity of the plaque.     

Long-term outcomes and predictors of iliac angioplasty with selective stenting

OBJECTIVE: To review our 11-year experience of iliac angioplasty with selective stenting and to evaluate the safety, short- and long-term patency, clinical success rates, and predictive risk factors in patients with iliac artery occlusive disease. METHODS: From August 1993 to November 2004, 151 iliac lesions (149 stenoses, 2 occlusions) in 104 patients were treated by percutaneous transluminal angioplasty (PTA). The patients had chronic limb ischemia described as disabling claudication (the Society for Vascular Surgery clinical category 2 or 3) in 76 (50%), rest pain (category 4) in 38 (25%), and ulcer/gangrene (category 5) in 37 (25%). Forty-six limbs (30%) were treated with concomitant infrainguinal endovascular (36, 24%) or open procedures (10, 6%). Thirty-four limbs (23%) had one or more stents placed for primary PTA failure, including residual stenosis (> or =30%), mean pressure gradient (> or =5 mm Hg), or dissection (stent group); whereas, 117 limbs (77%) underwent PTA alone (PTA group). The affected arteries treated were 28 (19%) common iliac, 31 (20%) external iliac, and 92 (61%) both arteries. According to TransAtlantic Inter-Society Consensus (TASC) classification, 39 limbs (26%) were in type A, 71 (47%) in type B, 36 (24%) in type C, and 5 (3%) in type D. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed. RESULTS: There was no perioperative death. Total complication rate was 0.7% (one groin hematoma). The mean follow-up was 21 months (median, 10; range, 1 to 94 months). Only 9 (8%) of 117 of the PTA group had subsequent stent placement for recurrent stenosis. The iliac lesions were more severe and extensive in the stent group than those in the PTA group according to TASC classification (Mann-Whitney U test [M-W], P < .0001) and anatomic location (M-W, P = .0019). The technical success rate was 99%, and the initial clinical success rate was 99%. Overall, the cumulative primary patency rates at 1, 3, and 5 years were 76%, 59%, and 49% (Kaplan-Meier [K-M]). The cumulative assisted primary and secondary patency rates at 7 years were 98% and 99% (K-M). The mean number of subsequent iliac endovascular procedures was 1.4 per limb in patients with primary failure of iliac angioplasty/stenting. The continued clinical improvement rates at 1, 3, and 5 years were 81%, 67%, and 53% (K-M). The limb salvage rates at 7 year were 93% (K-M). Of 15 predictor variables studied in 151 iliac lesions, the significant independent predictors for adverse outcomes were smoking history (P = .0074), TASC type C/type D lesions (P = .0001), and stenotic ipsilateral superficial femoral artery (P = .0002) for the primary patency rates; chronic renal failure with hemodialysis (P = .014), ulcer/gangrene as an indication for PTA (P < .0001), and stenotic ipsilateral superficial femoral artery (P = .034) for the continued clinical improvement (K-M, log-rank test and Cox regression model). CONCLUSIONS: Although the primary patency rates were not high, the assisted primary and secondary patency rates were excellent without primary stenting. Overall, >70% of iliac lesions were treated successfully with PTA alone. The results of this study show that selective stenting offers satisfactory assisted primary and secondary long-term patency after iliac angioplasty. Patients with TASC type C/type D iliac lesions, a stenotic ipsilateral superficial femoral artery, ulcer/gangrene, smoking history, and chronic renal failure with hemodialysis should be followed carefully after endovascular iliac revascularization. These risk factors could be considered indications for primary stenting, although further studies are needed to confirm this.     

血管腔内成形术治疗髂动脉硬化闭塞症

目的 探讨血管腔内成形术治疗髂动脉硬化闭塞症的临床疗效.方法 回顾性分析2002年12月至2008年12月收治的61例(76条血管)髂动脉硬化闭塞症患者的临床资料,其中男46例,女15例.平均年龄(67±11)岁.主要临床症状包括严重的间歇性跛行(跛行距离<100 m)38例,静息痛13例,肢/趾端溃疡10例.TASC A型病变29例,B型16例,C型11例,D型5例.应用导丝导管或超声消融开通闭塞段,行腔内支架置入术后随访.结果 61例患者71条血管成功开通(共置入63枚支架),开通率93%(71/76).成功者临床症状改善率100%.踝肱指数(ABI)由术前0.33±0.17提高到术后0.72±0.20,差异有统计学意义(P<0.05).随访51例,随访率83%.随访时间6-60个月,平均(26±14)个月.1年通畅率90%(TASC A、B组92%;TASC C、D组84%).3年通畅率75%(TASC A、B组80%;TASC C、D组63%);5年通畅率72%.结论 髂动脉硬化闭塞的腔内成形术较传统的血管重建手术创伤小、并发症低,近、中期通畅率相当.     

Preliminary results of subintimal angioplasty for limb salvage in lower extremities with severe chronic ischemia and limb-threatening ischemia

OBJECTIVE: This study examined the hypothesis that superficial femoral artery (SFA) subintimal angioplasty (SI-PTA) can maintain limb salvage with minimal complications in patients with symptomatic occlusive arterial disease. METHODS: From March 1, 2004, until April 28, 2006, 78 patients with rest pain (62.2%), gangrene (25.6%), or severe progressive claudication (12.2%) were treated consecutively with 82 SFA SI-PTAs (4 bilateral). The mean age was 59 +/- 1.2 years, and 21 (27%) of the patients were female. All patients were treated in the operating room under local anesthesia by using fluoroscopic guidance, and the percentage SFA that was occluded was measured during the diagnostic portion of the procedure. Selective stent placement was performed after successful recanalization of the occluded arterial segments. Patients were treated with chronic aspirin and clopidogrel bisulfate for 3 months and followed up at 30 days and then every 3 months with physical examination and arterial duplex scan. RESULTS: Of the 82 SFA SI-PTA attempts, 76 (92%) were initially successful, with an increase in the ankle-brachial index from 0.46 +/- 0.02 to 0.88 +/- 0.01 (P < .001). Five of the six patients with a failed SFA SI-PTA were female, two of the six had had previous bypass attempts, and one of the six had had a previous SFA SI-PTA attempt by another physician. Forty-nine (64%) of the 76 initially successful SFA SI-PTAs required placement of a stent, and 43 (56.5%) of the successful 76 SFA SI-PTAs required additional PTA of 1 or more arterial segments. The group treated with a successful SFA SI-PTA had 42.5% +/- 3.5% SFA occlusion, compared with 82% +/- 10% (P < .05) in the group with a failed attempt at SFA SI-PTA. Two of the six patients with initial SI-PTA failure underwent leg amputation within 30 days, three were treated with successful leg bypass surgery, and one was lost to follow-up. Of the 76 successful SFA SI-PTAs, 5 (6.5%) failed within 90 days, and the patients were treated successfully with leg bypass surgery. Of the 71 limbs with patent SI-PTAs at 90 days, 68 have remained patent with a mean follow-up 10.4 +/- 0.7 months (range, 2-24 months). Three of the 71 SFA SI-PTAs failed between 4 and 7 months (mean, 5 +/- 0.7 months): 1 patient was treated with successful bypass surgery, 1 patient is currently considering further intervention, and 1 patient was treated with amputation. Ten (14%) of the 71 successful SFA SI-PTAs required limited PTA for asymptomatic restenosis, as identified by the arterial duplex scan (7.4 +/- 1.4 months; range, 2-16 months). There were no perioperative deaths, and three patients have died during follow-up with patent SFA SI-PTAs (9.3 +/- 1.4 months). CONCLUSIONS: These data suggest that SFA SI-PTA can be successfully used for limb salvage with minimal morbidity and mortality in a group of patients with severe lower extremity occlusive vascular disease.     

Popliteal-to-distal bypass for limb-threatening ischemia.

In a subset of patients requiring lower extremity revascularization, the popliteal artery may be used for inflow, thereby minimizing dissection and the length of vein required for bypass. This retrospective study was done to define the risks and benefits of arterial reconstruction in a population of patients having popliteal-to-distal bypass procedures. Between 1986 and 1990, 32 surgical procedures were performed on 29 patients. The patient's ages ranged from 46 to 86 years, with a mean age of 68 years. Twenty-four of 29 (83%) were men and 19 of the 29 (66%) had diabetes. Most patients had multiple indications for surgical intervention, and these included rest pain (54%), nonhealing ulcers (64%), and gangrene (29%). Arterial bypass with use of the popliteal artery for the proximal anastomosis was performed with in situ saphenous vein (50%), reversed saphenous vein (41%), and orthograde autologous vein (9%). Distal anastomoses were to the posterior tibial artery in 11 bypasses (33%), the peroneal artery in 10 (30%), the anterior tibial artery in two (6%), and the dorsal pedal artery in 10 (30%). Two deaths occurred in the perioperative period for an operative mortality rate of 6.9%. With use of life-table analysis, the cumulative graft patency rate was 97% at 1 year, 97% at 2 years, and 63.5% at 4 years. The overall cumulative limb salvage rate was 90.1% at 1 year, 90.1% at 2 years, and 78.8% at 4 years.(ABSTRACT TRUNCATED AT 400 WORDS)     

Percutaneous transluminal balloon angioplasty of the iliac artery for contralateral ischemia

The cases of three patients with lower extremity ischemia from ipsilateral iliac artery occlusion and contralateral iliac artery stenosis are presented. Planned treatment was percutaneous transluminal angioplasty (PTA) of the contralateral iliac artery, rendering it an adequate donor vessel for subsequent femorofemoral bypass. Because of adequate collateral vessels across the pelvis, cross-femoral bypass was unnecessary following PTA. Current technology allows simultaneous intraoperative PTA and femorofemoral bypass. We do not recommend this on the basis of our experience.     

Severe inframalleolar disease is an independent predictor of adverse limb outcomes after endovascular revascularization in chronic limb-threatening ischemia

ObjectiveIn the present study, we evaluated the effects of inframalleolar (IM) disease on the occurrence of major adverse limb events (MALE) in patients undergoing endovascular revascularization for chronic limb-threatening ischemia (CLTI).MethodsPatients who had undergone endovascular revascularization for CLTI between January 2015 and December 2019 at two university-affiliated hospitals were reviewed retrospectively. Patients with severe IM disease (pedal score of 2) were compared with those with mild to moderate IM disease (score of 0 or 1) using the Global Vascular Guidelines. The primary outcome was MALE (open revascularization, acute leg ischemia, major amputation). The secondary outcomes were mortality, reintervention, major adverse cardiac events, and perioperative complications ≤30 days after endovascular revascularization, primary limb-based patency, and the occurrence of any limb event (defined as any amputation, acute leg ischemia, or open revascularization). Kaplan-Meier estimates were used to compare the primary outcome, and the Cox proportion hazard model was used to assess the effects of IM disease.ResultsThe study included 167 limbs in 149 patients (36% female; mean age, 74 ± 12 years). Severe IM disease was identified in 71 limbs (43%). No differences were found in the baseline characteristics, except for a higher prevalence of dyslipidemia in the patients with severe IM disease (66% vs 43%; P = .003). Most patients in both groups had had a WIfI (Wound, Ischemia, foot Infection) score of 4 (severe IM disease, 64%; vs mild to moderate IM disease, 57%; P = .462) and GLASS (global limb anatomic severity scale) III anatomy (severe IM disease, 54%; vs mild to moderate IM disease, 48%; P = .752). The Kaplan-Meier estimates showed that severe IM disease was associated with lower freedom from MALE (69% vs 82%; P = .026). The Cox proportion hazard regression model showed that severe IM disease was an independent predictor of increased MALE and amputation risk (hazard ratio, 1.715; 95% confidence interval, 1.015-2.896; P = .044) after adjusting for covariates. During follow-up, patients with severe IM disease had had mortality (27% vs 31%; P = .567) and reintervention (42% vs 38%; P = .608) similar to those for patients with mild to moderate IM disease. Primary limb-based patency was also similar (79% vs 84%; P = .593) at a mean follow-up of 3.8 ± 0.8 years.ConclusionsSevere IM disease was prevalent in 43% of limbs that had undergone endovascular revascularization for CLTI and was associated with lower freedom from MALE. Severe IM disease also independently increased the hazard of adverse limb outcomes and amputations in patients with CLTI by >70%, highlighting its importance as a measure of foot perfusion.     

The costs of surgery for limb-threatening ischemia

The clinical courses of 106 patients with limb-threatening ischemia were traced for as long as 5 years to determine the cost of their care. Seventy-eight patients initially treated with vascular reconstruction accrued an average of $40,769 +/- $3726 in costs over a mean follow-up period of 805 +/- 57 days, during which they had an average of 2.4 +/- 0.2 hospitalizations or 67 +/- 6 inpatient days. Twenty-eight high-risk patients treated with primary amputation accrued $40,563 +/- $4729 in costs over a mean follow-up period of 663 +/- 97 days, during which they had an average of 2.2 +/- 0.3 hospitalizations or 85 +/- 10 inpatient days. Successful revascularization resulted in lower costs ($28,374) than did primary amputation ($40,563) or failed reconstruction ($56,809). Patients with ischemic tissue loss accrued costs more rapidly than did patients with rest pain only. The high cost of providing care for these patients and the advent of diagnosis related group reimbursement mandate that proposed treatment protocols be evaluated not only for their effectiveness but also for their cost-effectiveness.     

Outcomes with plantar bypass for limb-threatening ischemia

Patients with severely diseased or occluded infrageniculate arteries, limited runoff, and tissue loss may often present for primary amputation. In this study, we review our experience with plantar artery revascularization when no other bypass options are feasible. All patients requiring infrainguinal bypass to the plantar artery level over the last 3 years were prospectively entered into our vascular surgery database. Indications, demographics, length of stay (LOS), outcome, and patency were reviewed. Our results showed that plantar artery bypass is a safe and reasonable alternative to primary amputation. Excellent limb salvage can be achieved if the bypass remains patent through the initial 30 days postoperatively. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.     

Percutaneous transluminal angioplasty and primary stenting of the iliac arteries in 288 patients

Purpose: This study reports the initial and late results of percutaneous transluminal angioplasty (PTA) and intravascular stenting for atherosclerotic occlusive disease of the iliac arteries.Methods: The preprocedural and postprocedural clinical records, arteriograms, segmental limb pressure measurements (ankle-brachial [ABI] and thigh-brachial [TBI] indexes), and pulse volume recordings of 288 patients who underwent PTA and primary stenting of the common iliac (354, 69.4%) and external iliac (156, 30.6%) arteries were reviewed. Initial and late clinical, hemodynamic, and angiographic success were assessed by objective criteria. Data on patients who underwent unsuccessful attempts at iliac stent placement are unavailable; results are not reported on an intent-to-treat basis.Results: Clinical follow-up data (mean, 11.9 months) are available for 268 of 288 patients (93.1%) and for 394 of 424 limbs (92.9%). The initial success rates, as determined by TBI, ABI, and clinical limb status, were 90.2%, 87.8%, and 74.6%, respectively. The Kaplan-Meier estimates of angiographic patency (101 arteries) were 96%, 81%, and 73% at 6, 12, and 24 months. Cumulative patency rates were 84%, 76%, and 57% on the basis of TBI, ABI, and clinical limb status at 24 months. Factors associated with initial success included the need for multiple stents (p = 0.0001), a higher degree of initial stenosis (p = 0.0001), lower severity of baseline ischemia (p = 0.007), younger age (p = 0.0015), and the preprocedural patency of the ipsilateral superficial femoral artery (p = 0.002). A higher degree of initial stenosis (p < 0.001) and superficial femoral artery patency (p = 0.004) were also associated with late success.Conclusions: PTA and stenting of the iliac arteries is associated with reasonable angiographic, hemodynamic, and clinical success. The outcome is favorably affected by higher initial severity of stenosis and greater extent of disease, lower severity of baseline ischemia, younger age, and by patency of the ipsilateral superficial femoral artery. (J Vasc Surg 1997;25:829-39.)