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Infrapopliteal Balloon Angioplasty For The Treatment Of Chronic Occlusive Disease: Intermediate-Term Results Of A Contemporary Series

Mark F Conrad, Jeanwan Kang, Richard P Cambria, David C Brewster, Michael T Watkins, Christopher J Kwolek, Glenn M LaMuraglia.
Massachusetts General Hospital, Boston, MA.

OBJECTIVES: The utility of balloon angioplasty (PTA) of crural vessels for treatment of chronic lower extremity ischemia is poorly documented. The goal of this study was to review of our recent experience with infrapopliteal PTA.

METHODS: All patients undergoing primary crural PTA from 3/02-6/06 were included. Primary study end points included: 1ºpatency, assisted patency, limb salvage and patient survival assessed by Kaplan-Meier life-table analysis. Factors predictive of PTA failure and patient longevity were evaluated by multivariate methods.

RESULTS: There were 155 PTA undertaken in 144 patients: mean age 74 yrs, male 70%, critical limb ischemia 86%, diabetes 66%, renal insufficiency 45%. The infrapopliteal lesions were classified as TASC A(7%), B(18%), C(39%) and D(35%). PTA was confined to the infrapopliteal segment in 40 (26%) cases, and infrapopliteal stents were placed in 5 (3%) patients. Concomitant above knee PTA was undertaken in 85 (55%) patients in whom crural PTA was felt to be crucial to success. Technical success was 95% with a 30-day mortality of 2% and a major morbidity of 3%. The mean follow-up was 22 months (0-54 months). The 40-month actuarial 1ºpatency was 62% (standard error 5%) with assisted patency of 90%(infrapopliteal re-PTA, 25(16%)). Interval conversion to bypass surgery occurred in 7(5%) patients. There were 118(76%) patients who presented with tissue necrosis, of which 76(64%) healed during follow-up. Major amputations were required in 18 patients (7 for advanced wounds despite a functioning revascularization) yielding a 40-month limb salvage of 86.2%. Multivariate negative predictors of 1ºpatency included: 0/1 vessel runoff (OR= 1.55, p=0.01), critical limb ischemia(OR = 11.4, p=0.002) and dialysis (OR = 1.61, p=0.03). Negative predictors of limb salvage included dialysis (OR = 2.26, p=0.007) and failure to improve runoff to the foot (OR = 2.50, p=0.006). At 40-months, actuarial survival was 54%.

CONCLUSIONS: Infrapopliteal angioplasty can be performed safely with favorable results. Primary patency is related to disease extent and secondary interventions may be necessary to maintain clinical success. These data indicate that PTA is appropriate initial therapy for such patients whose overall life expectancy is poor.