Subintimal Angioplasty of Tibial Vessel Occlusions in Critical Limb Ischaemia: A Good Opportunity?

OBJECTIVES: To evaluate the feasibility and the mid-term results of subintimal angioplasty (SA) in the treatment of critical limb ischaemia (CLI) with tibial vessels occlusions. MATERIALS AND METHODS: Between August 2000 and March 2005, we attempted to treat 46 patients (23 men, 23 women, median age of 75 years; range 35-92) and 50 limbs by SA of occluded tibial vessels. Twenty-one had gangrene, 25 ulcerations and 4 had rest pain. Thirty-nine occlusions (78%) were more than 10 cm in length, 28 (56%) involved popliteal and tibial artery and distal re-entry was at the ankle level in 18 cases (36%). Twenty-eight patients (61%) were diabetics. RESULTS: There were nine technical failures. Five of these patients were successfully treated medically (1), by conventional surgery (1) or by conventional angioplasty of another diseased tibial vessel (3). The four remaining patients had major amputation and 3 died within 3 months. There were 7 complications including 2 embolisms, 1 perforation and 4 haematomas. By intention to treat, one-year primary, secondary and clinical patency rates were 46%, 55% and 63%, respectively. One and two-year limb salvage rates were 87%. One and two-year survival rates were 74% and 64%, respectively. CONCLUSIONS: SA of tibial vessel occlusions is a valuable treatment of CLI. Technical failures do not preclude conventional surgery when there is a valuable outflow. Complications may often be treated medically or by endovascular procedures. Results have to be confirmed by long-term follow up. Both techniques should be considered as complementary techniques in the management of CLI.     

Subintimal Angioplasty as a Treatment of Femoropopliteal Artery Occlusions

OBJECTIVES: to report the results of subintimal PTA of femoropopliteal occlusions above the knee. DESIGN: a retrospective study. PATIENTS: in the period from January 1997 to January 2002, 109 patients were submitted to 124 interventions. The indication for treatment was intermittent claudication in 78 cases and critical ischaemia in 46. METHODS: all cases of subintimal angioplasty were prospectively registered. A review of all cases treated with subintimal PTA for above-knee femoropopliteal occlusions were done. Primary assisted haemodynamic patency rate was calculated on intention to treat basis and for successfully treated cases. Comparison of patency with respect to comorbidities, indication, runoff and occlusion length was done with univariate and multivariate analysis (Cox' regression). RESULTS: technical success rate was 90%. Primary assisted patency rates at 6, 12 and 18 months were 43, 37 and 31% calculated on basis of intention to treat and 48, 42 and 35% for successfully treated cases. Diabetes mellitus and critical ischaemia were found to be independent risk factors for re-occlusion. CONCLUSION: subintimal angioplasty is an alternative to open surgery for patients with femoropopliteal occlusions and intermittent claudication. The treatment is relatively atraumatic, complications are rare and in most cases treated with endovascular techniques. Patency rates are low. In cases of critical ischaemia, time can be important for outcome with respect to limb salvage. We therefore find that the poor patency rates of subintimal angioplasty of femoropopliteal occlusions contraindicate its use in the treatment of critical ischaemia with exception of cases unsuitable for surgical treatment.     

Subintimal angioplasty: feasible and durable.

OBJECTIVE: To assess prospectively the feasibility and durability of subintimal angioplasty (SA) clinically and by duplex scans every 3 months. PATIENTS AND METHODS: Within a period of 54 months, we selected 96 patients with 100 occlusions (mean length: 11.5 cm) of femoro-popliteal or tibial arteries, for SA. RESULTS: The technical success rate was 88% and seven out of 12 failures were treated by conventional surgery. Five below-the-knee amputations were performed despite a patent recanalization. The following complications occurred: arterial perforation (6), arterial thrombosis (4), extensions beyond the planned re-entry site (5), and arterial dissection (2). Primary, assisted-primary and secondary patency rates were 61, 68 and 74%, respectively at 24 months. The 24 month-limb salvage and survival rates were 78 and 85%, respectively. Duplex imaging demonstrated 10 restenosis (five symptomatic >70%, five asymptomatic 30-70%), seven occlusions (five asymptomatic, two symptomatic treated by a bypass) and one asymptomatic dilatation. CONCLUSION: In a selected group of patients SA is feasible with a high initial technical success rate. SA is a good alternative in patients who are poor candidates for bypass surgery.     

Factors Affecting Patency of Subintimal Infrainguinal Angioplasty in Patients with Critical Lower Limb Ischemia

BACKGROUND: Because subintimal angioplasty (SA) is a technique that can achieve recanalization of long arterial occlusions, it is considered an alternative to lower limb bypass operations. The aim of this prospective study was to identify the risk factors that affect patency of SA in patients suffering from critical limb ischemia (CLI). METHODS AND RESULTS: 51 consecutive infrainguinal SA were done in 46 patients suffered from CLI. The patients were followed-up with regular duplex scans up to 12 months post-intervention. Sex, atherosclerosis risk factors, and some technical details of the procedure (number of patent run-off vessels after the procedure, length and re-entry point of angioplasty) were examined as potential risk factors of patency, using survival analysis statistical techniques. The overall patency rate at 12 months post-intervention was 50%. According to Cox-regression analysis, the factors that affect patency were the number of run-off vessels and the length of occlusion. Patients with two or three run-off vessels had a hazard of occlusion of 0.30 (P = .027) compared to those who had one run-off vessel. The 12-months patency in patients with more than one run-off vessels was 81% vs. 25% in patients with one run-off vessel. Regarding the length of angioplasty, the hazard of reocclusion was 1.02 for every centimeter of occlusion (P = .049). CONCLUSIONS: The number of patent run-off crural vessels after the angioplasty and the length of occlusion are significant risk factors for reocclusion of infrainguinal SA in patients with CLI. Trying to recanalize more than one run-off vessels could raise the SA patency.     

胫腓动脉血管成形术治疗下肢严重缺血35例

目的 评价胫腓动脉经皮血管腔内成形术(percutaneous transluminal angioplasty,PTA)治疗下肢严重缺血的可行性、安全性和有效性.方法 对2004年6月至2007年5月收治的35例胫腓动脉闭塞的下肢严重缺血(critical limb ischemia,CLI)患者应用PTA治疗.评价的主要参数为:胫腓动脉PTA技术成功率、通畅率、救肢率和并发症.结果 胫腓动脉PTA的技术成功率为83%,平均随访11.5个月,通畅率为57%,救肢率82%.胫腓动脉平均扩张长度9.5 cm(4.5～14 cm),19例患者同时行髂或股胭动脉PTA或支架术.有3例并发症发生,其中1例动脉痉挛和血栓形成,经溶柃、解痉等治疗缓解;2例动脉穿孔,未有严重后果.结论 PTA治疗CLI合并胫腓动脉闭塞具有较高技术成功率和救肢率,较少发生严重并发症,是一种安全、有效可供选择的治疗方法.     

Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia

INTRODUCTION: Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique. METHODS: Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency. RESULTS: Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037). CONCLUSIONS: In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.     

Short-term results of femoropopliteal subintimal angioplasty

BACKGROUND: Subintimal angioplasty may be more successful than conventional (intraluminal) angioplasty for treatment of long femoropopliteal occlusions. This study assessed the clinical and haemodynamic outcome of subintimal angioplasty. METHODS: All patients with femoropopliteal occlusions treated by subintimal angioplasty over a 3-year period at two centres were reviewed. Clinical assessment and colour duplex imaging were carried out. RESULTS: Sixty-nine procedures were performed in 33 men and 33 women of median age 74 (range 47-92) years. Indications for treatment were intermittent claudication in 26 (38 per cent) and critical limb ischaemia in 43 (62 per cent). Median occlusion length was 10 (range 2-50) cm. Primary technical success was achieved in 51 occlusions (74 per cent). There were 11 complications (16 per cent); the majority were minor but surgical intervention was required in two patients (3 per cent). At 6 months the cumulative symptomatic and haemodynamic primary patency rates were 60 and 51 per cent respectively, analysed on an intention-to-treat basis. The symptomatic and haemodynamic patency rates for technically successful procedures were 80 and 77 per cent respectively. CONCLUSION: In this series the short-term clinical success of subintimal angioplasty was poor because of a high incidence of reocclusion and restenosis, despite a relatively high initial technical success rate.     

腘以远动脉闭塞所致下肢严重缺血的血供重建

目的 评价腘以远动脉闭塞所致下肢严重缺血(critical limb ischemia,CLI)的血供重建.方法 回顾性分析2003年12月至2009年1月,腘以远动脉闭塞所致CLI行经皮血管腔内成形(percutaneous transluminal angioplasty,PTA)和开放性重建(open reconstruction,OR)术的患者,详细记录患者的病史、病变特点、手术过程、并发症和随访信息.采用Kaplan-Meier生存分析重建血管通畅率和救肢率.结果 本组腘以远动脉闭塞所致CLI患者共167例,182条患肢.123条动脉硬化闭塞(arterios-clerosis occlusions,ASO)的患肢行腘以远动脉PTA治疗,33条血栓闭塞性脉管炎(thromboangiitis obliterans,TAO)和23条ASO患肢行腘以远动脉OR手术.PTA再管化通道6、12、24个月的通畅率分别是67%、54%和49%,其救肢率分别是91%、85%和78%,OR术后移植物6、12、24个月的通畅率分别是90%、83%和79%,其救肢率分别是92%、87%和80%,PTA重建血管的通畅率低于开放性手术(P＜0.05),但PTA和OR术的救肢率差异无统计学意义(P＞0.05).结论 对腘以远动脉ASO的CLI患者,PTA有效、安全,可作为首选治疗方式.PTA治疗失败可选择OR术.对TAO患者腘以远动脉闭塞者OR术仍是最好的治疗选择.

Abstract：

Objective To assess reconstructive options for critical limb ischaemia in infrapopliteal arteries. Methods A retrospective review of all CLI patients who underwent infrapopliteal reconstruction was carried out. Patient history, demographics, procedure details, complications, and follow-up information were collected and analyzed. Patency, limb salvage rate was determined by Kaplan-Meier analysis. Results During the period (from December 2003 to January 2008 ), 123 CLI patients with arteriosclerosis occlusions were treated on an intention-to-treat basis with infrapopliteal percutaneous transluminal angioplasty (PTA).Thirty-three thromboangiitis obliterans and twenty-three arteriosclerosis occlusions suffering CLI were treated by infrapopliteal bypass procedures. Primary patency and limb salvage rate of infrapopliteal PTA at 6, 12 and 24 months was 67%, 54%, 49% and 91%, 85%, 78% respectively, Primary patency and limb salvage rate of infrapopliteal surgical bypass at 6, 12 and 24 months was 90%, 83%, 79% and 92%,87%, 80% respectively, the patency of infrapopliteal PTA was lower than infrapopliteal surgical bypass (P ＜0. 01 ), but the limb salvage rate of infrapopliteal PTA and open surgery was no significant difference (P ＞ 0. 05 ). Conclusion Endovascular treatment (PTA) in patients with infrapopliteal arteriosclerosis occlusions and critical ischaemia is safe, effective. Infrapopliteal PTA can be used as the choice of therapy and surgical bypass reserved in those endovascular treatment failed. While in CLI patients with thromboangiitis obliterans infrapopliteal artery bypass remains the best treatment option.     

Subintimal angioplasty as the first-choice revascularization technique for infrainguinal arterial occlusions in patients with critical limb ischemia

Our aim was to appraise the feasibility and outcomes of subintimal angioplasty (SA) for the percutaneous revascularization of infrainguinal arterial occlusions in patients with critical limb ischemia (CLI). We retrospectively assessed 117 SA procedures in 109 limbs with complete infrainguinal occlusions from 105 patients with CLI. Among these, the superficial femoral artery (SFA) was the only occluded vessel in 27 limbs, while infrapopliteal (IP) occlusions occurred in 82. Average clinical follow-up was 13.5 months (range 1-37). Outcomes were assessed according to the site of SA (SFA vs. IP) and the length of the occlusion (< vs. > or =10 cm). Univariate analyses for the rate of limb salvage and patient survival according to the Kaplan-Meier method were performed. SA-based revascularization had a success rate of 84.4% per limb (89% in SFA and 83% in IP occlusions). During follow-up 12 patients (11.3%) underwent major limb amputation, 11 (10.3%) underwent bypass surgery, and 14 (13.7%) died. Most amputations occurred in patients in whom SA had been unsuccessful and were associated with long (> or =10 cm) occlusions (p = 0.055). Clinical restenosis occurred in seven (6.6%) patients. Survival analysis showed at 6, 12, and 24 months limb salvage rates of 90%, 87%, and 85% and overall survival rates of 90%, 88%, and 83%, respectively. Complications of SA were uncommon (4.7%) and all were successfully managed percutaneously. Infrainguinal SA is an effective revascularization technique that provides a high likelihood of limb salvage and should be the first-choice strategy in the management of patients with CLI.     

内膜下血管成形术治疗下肢动脉慢性缺血

目的 探讨内膜下血管成形术治疗下肢动脉慢性缺血的技术可行性、通畅率和临床效果.方法 回顾性分析2003年12月至2008年8月应用内膜下血管成形术(subintimal angioplasty,SIA)治疗的112例患者的122条动脉硬化闭塞患肢的临床资料,动脉闭塞平均长度为10.25 cm(4.5～28 cm),其中23条肢体为生活方式受限性间歇性跛行,99条为严重性缺血.详细纪录患者的病史、病变特点、操作技术过程、并发症和随访信息.采用Kaplan-Meier生存分析法分析患肢通畅率和临床效果(救肢和症状改善).结果 SIA技术成功率为83%,成功进行SIA的患者平均踝肱指数从0.19±0.11增加到0.67±0.29(P<0.01),1年、2年冉管化通道的通畅率和临床有效率分别是54%±5%、45%±4%和82%±5%、79%±4%.没有严重后果的并发症发生. 结论 SIA技术成功率高,临床效果满意,本组无严重并发症,是一种治疗下肢动脉粥样硬化闭塞所致慢性缺血较好可供选择的治疗手段.     

血管腔内治疗慢性下肢缺血时的溶栓治疗

目的 探讨导管溶栓在慢性下肢缺血腔内成形治疗时的可行性、疗效及安全性.方法 回顾性分析2009年2月～2011年2月在广州市中医院接受治疗的11例慢性下肢缺血(TASC Ⅱ D级)患者的临床资料.采用尿激酶(UK)溶栓,然后再行血管腔内治疗,对治疗后临床疗效及动脉通畅率进行统计分析.结果 9例患者(81.8％)血管成形技术获得成功,无并发症发生;2例(18.2％)未溶栓成功.8例患者获得随访,随访率为88.9％,平均随访时间14.5个月.术后1年一期通畅率、辅助一期通畅率和二期通畅率分别为80％、88％及92％,2年为67％、84％及88％.结论 对慢性下肢缺血TASC Ⅱ D级病变进行血管腔内成形时的溶栓是可行、安全且有效的.     

The Results of Subintimal Angioplasty in a District General Hospital

Objectives and Design: we report a prospective study to determine if subintimal angioplasty can be performed in non-teaching centres and to establish its learning curve.Materials and Methods: subintimal angioplasty was performed on 50 limbs in 46 patients (34 male) with a median age of 72 years (range 45–93 years). Indication was critical limb ischaemia (27 limbs) or intermittent claudication (23 limbs). Occlusions were located in the superficial femoral artery in 44 limbs, popliteal artery in 4 limbs and the peroneal artery in two limbs. At a median of 7.9 months patients had colour duplex imaging of the vessels that underwent angioplasty to assess vessel patency.Results: primary technical success was achieved in 39 cases (78%). Primary technical success was greater in the second group of 25 consecutive limbs to undergo angioplasty at 92% (23 cases) compared with the first 25 consecutive limbs at 64% (16 cases). At 6 months the overall vessel patency rate on duplex imaging was 57%, improving to 64% in the group having a primarily successful procedure. The equivalent rate of symptomatic improvement was 59 and 66% respectively. Complications occurred in five procedures, most were minor, but a single fatality was directly attributable to the procedure.Conclusion: subintimal angioplasty can reasonably be performed outside major teaching institutions. There is a short learning curve associated with the procedure.     

经腘动脉入路逆行内膜下血管成形术治疗股浅动脉长段硬化性闭塞症的临床研究

目的:探讨经腘动脉入路逆行内膜下血管成形术/支架置入术处理常规入路腔内顺行开通失败的股浅动脉长段硬化性闭塞症的疗效及可行性。方法:50例股浅动脉长段硬化性闭塞症患者行股动脉病侧顺行或健侧逆行推进导丝、导管时无法通过病变动脉到达闭塞段远端的真腔,遂行经腘动脉逆行入路完成内膜下血管成形术。结果:手术即刻支架置入成功率100%,12个月一期通畅率48.0%,二期通畅率92.0%。与术前比较,患者术后踝肱指数(ABI)明显升高,Rutherford分级明显改善(均P0.05)。5例患者术后出现肢体肿胀,3例患者于术后3个月出现腘动脉假性动脉瘤,经治疗均好转。术后1年,再狭窄患者16例(32.0%)。结论:常规入路腔内顺行开通失败的股浅动脉长段硬化性闭塞症患者转行经腘动脉入路逆行内膜下血管成形术/支架置入术有效、可行。     

True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: Initial report

OBJECTIVE: The acute technical failure of endovascular treatment of chronic total occlusions (CTOs) is most often due to the inability to re-enter the true lumen after occlusion is crossed in a subintimal plane. This study reports our initial experience with true lumen re-entry devices in the treatment of CTOs. METHODS: Patients with treatment of CTOs were identified from our vascular registry. All patients in whom the Pioneer catheter or the Outback catheter were used were also identified from a prospectively maintained separate database of cases in which true lumen re-entry devices were used. We used procedural data from the prospective database and reviewed the medical records. Lesion character and location, access type, location of true lumen re-entry, stent usage, procedural times, and complications, were tabulated. RESULTS: From August 2003 to December 2004, endovascular techniques were used to treat 87 CTOs in 58 iliac and 29 superficial femoral arteries. In 24 (26%), the true lumen could not be re-entered by using standard catheter and wire techniques. The true lumen was not initially re-entered in 20 (34%) of 58 of treated iliac CTOs and four (13%) of 29 of treated superficial femoral artery CTOs (73% TASC C and D lesions). Intravascular ultrasound-guided true lumen re-entry using the Pioneer catheter (21 CTOs), or fluoroscopic-guided true lumen re-entry using the Outback catheter (3 CTOs) was successful in achieving true lumen re-entry in all cases at the location desired. Total time of re-entry catheter manipulation required to achieve re-entry was <10 minutes and was routinely accomplished in <3 minutes. All occlusions were stented. No cases were converted to open repair. Bleeding from the recanalization and angioplasty site occurred in four patients (15%). It was controlled with use of covered stents in two cases, and resolved after placement of uncovered stents in the other two. No significant bleeding occurred at the sites of true lumen re-entry needle deployment. All occlusions treated with true lumen re-entry devices remain clinically patent at a mean follow-up of 5.8 months. CONCLUSIONS: Endovascular treatment of chronic total occlusions is often limited by the inability to re-enter the true lumen after subintimal crossing of the occluded segment. This occurs more commonly with treatment of iliac occlusions than in superficial femoral artery occlusions. True lumen re-entry catheters are very effective at gaining wire passage back to the true lumen and facilitating successful endovascular treatment of chronic total occlusions that would otherwise require open bypass.     

Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity.

OBJECTIVES: Arteriographic lesions of diabetic subjects with critical limb ischemia (CLI) and ischemic foot ulcer were reviewed retrospectively, to provide new criteria for stratification of these patients on the basis of their vascular involvement. PATIENTS: In 417 consecutive CLI diabetic subjects with ischemic foot ulcer undergoing lower limb angiography, lesions were defined as stenosis or occlusion, localization, and length (<5 cm, 5-10 cm, >10 cm). In a subgroup of 389 subjects, foot arteries also were evaluated. Patients then were categorized into 7 classes of progressive vascular involvement based on angiographic findings. RESULTS: Of the 2893 found lesions (55% occlusions) 1% were in the iliac arteries, whereas 74% were in below-the-knee (BTK) arteries. Sixty-six % of all BTK lesions were occlusions, and 50% were occlusions >10 cm (p<0.001 vs proximal segments). Occlusions of all BTK were present in 28% of patients, although there was patency of at least one foot artery in 55% of patients. The morphologic Class 4 (two arteries occluded and multiple stenoses of tibial/peroneal and/or femoral/popliteal vessels) was the most common (36%). An inverse correlation between morphologic class and TcPO2 was observed (r=-0.187, p=0.003). CONCLUSIONS: In CLI diabetic subjects with ischemic foot ulcer, the vascular involvement is extremely diffuse and particularly severe in tibial arteries, with high prevalence of long occlusions. A new morphologic categorization of these patients is proposed.     

腔内血管成形术治疗髂动脉长段慢性完全闭塞性病变

目的 评价腔内血管成形术治疗髂动脉长段慢性完全闭塞性病变(CTO)的可行性、有效性及安全性.方法 回顾性分析2006年1月至2010年12月经腔内血管成形术治疗的病变长度＞5 cm的髂动脉CTO患者139例(157条患肢)的临床资料.其中男性93例(105条患肢),女性46例(52条患肢);年龄50 ～96岁,平均年龄(77±10)岁.TASCⅡ分型:B型18例,C型89例,D型32例.采用左肱动脉和(或)股动脉穿刺经内膜下或血管内行髂动脉闭塞的球囊血管成形联合支架植入术治疗.结果 技术成功率96.2％ (151/157).踝肱指数由术前的0.42±0.19上升到术后的0.81±0.26.随访6～53个月,平均随访(30±7)个月,髂动脉支架畅通率94.1％ (111/118),7例发生支架内再狭窄或闭塞,无髂动脉破裂、支架移位、穿刺动脉假性动脉瘤及动静脉瘘的发生.结论 腔内血管成形术治疗髂动脉长段CTO安全、有效,术后支架通畅率高,联合肱动脉和股动脉双向穿刺技术能够显著提高技术成功率.     

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目的探讨TASC-C、D型慢性主髂动脉病变腔内介入治疗的操作成功率、安全性和近期通畅率。方法2005年4月至2006年12月,上海交通大学医学院附属仁济医院血管外科采用血管腔内介入方法治疗TASC-C、D型慢性主髂动脉病变病人14例,其中2例接受了二期远端流出道重建。结果无围手术期死亡。血管腔内介入治疗成功率为93.7%,并发症发生率为7.1%。随访2~20个月(平均6.5个月),病人症状无加重或复发。结论血管腔内介入治疗TASC-C、D型慢性主髂动脉病变具有较高的操作成功率,围手术期并发症少,近期效果确切,其长期疗效尚须进一步随访观察。     

Subintimal angioplasty for femoro-popliteal occlusive disease

There has been a longstanding debate about the roles of surgical bypass graft, percutaneous transluminal angioplasty, subintimal angioplasty, and conservative management for femoro-popliteal occlusive disease. Subintimal angioplasty was first described in 1987 as a method of performing an endovascular arterial bypass. The subintimal space at the start of the occlusion is entered with a catheter and a wire loop is used to cross the occlusion and reenter the vessel lumen distally. In patients with critical limb ischemia, there is high quality evidence demonstrating that the limb salvage rate and amputation-free survival rates for surgery and endovascular treatment are similar, but surgery is more expensive than angioplasty in the short term. In patients with intermittent claudication, surgical bypass using an autologous saphenous vein graft is currently believed to be the gold standard, but this is increasingly questioned in the light of recent advances in endovascular techniques. Surgical bypass with vein graft offers a 2-year patency of 81%, compared with 67% for a polytetrafluoroethylene (PTFE) graft and at best 67% for subintimal angioplasty. The better patency offered by surgery must be balanced against a higher morbidity and mortality. To conclude, subintimal angioplasty is an extremely valuable technique in the management of critical limb ischemia. Based on the evidence to date, this technique is likely to have an increasing role in the management of intermittent claudication over the coming years, particularly if the risk of general anaesthesia is high or there is no suitable vein.     

The Occurrence of Arterio-venous Fistula during Lower Limb Subintimal Angioplasty: Treatment and Outcome

OBJECTIVES: To describe our experience with iatrogenic arterio-venous fistula (AVF) occurring during lower limb subintimal angioplasty, their management and the final clinical, radiological outcome. DESIGN: Retrospective review of case series from two centres, from a computerised database over a period of five years. MATERIAL: Twelve patients whose lower limb subintimal angioplasty was complicated by Iatrogenic AVF. RESULTS: The Majority of AVF occurred at the popliteal trifurcation vessels. And the incidence of this complication in our case series was 0.8%. This was managed with a variety of techniques-Coil embolisation, balloon tamponade, alternative dissection and stent placement. In one patient, the fistula was left open intentionally. All twelve patients had a successful angioplasty. The overall technical success rate for AVF ablation was eighty percent. CONCLUSIONS: AVF is a potential complication of angioplasty. The majority can be managed by endovascular means during the angioplasty procedure with good technical success.     

膝下血管成形术治疗重症肢体缺血的临床疗效

目的评价膝下经皮腔内血管成形术(PTA)治疗重症肢体缺血(CLI)的临床疗效。方法回顾性分析48例(50条患肢)接受膝下PTA治疗的下肢CLI患者,统计PTA的技术成功率、围术期并发症、PTA术后的缺血症状缓解情况、治疗血管的通畅情况和大截肢情况。结果共针对64条膝下动脉施行PTA,技术成功率为85.94%(55/64);围术期并发症发生率为12.50%(6/48)。平均随访(16.25±2.65)个月;PTA术后1、3、6、12、24、36个月的1期血管通畅率分别为92.0%、85.7%、79.0%、75.8%、59.8%、29.9%;保肢率分别为92.0%、92.0%、89.7%、86.4%、82.1%、72.9%。50条患肢中,1、3、6个月时的缺血症状缓解率分别为42.00%(21/50)、70.21%(33/47)和86.36%(38/44)。结论膝下PTA治疗CLI技术可行,安全性高,能有效缓解CLI的静息痛症状、促进肢体溃疡的愈合,避免大截肢的发生。