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PVSS16. Infra-Geniculate Interventions For Critical Limb Ischemia As An Alternative To Surgical Bypass In High Risk Patients

Chandra Cherukupalli, Ashish Bedi, Sudhakar Ayilam, Ravi Pulipati, Toufic Safa, Krishnasastry KV, Rajeev Dayal.
North Shore University Hospital, Lake Success, N.Y. 

OBJECTIVES: The purpose of this study was to analyze the patency and limb salvage rates after percutaneous intervention for popliteal and crural disease in high-risk patients with critical limb ischemia (CLI).

METHODS: 110 lesions were treated percutaneously in 63 limbs of 54 patients (mean age 72, range 49-91) between July 2005 and December 2006. Lesion locations were: 6 iliac, 31 SFA, 22 popliteal, 51 tibial/peroneal. 33% of lesions were TASC C and 67% TASC D in the popliteal and infrapopliteal vessels. Indications were rest pain (SVS/ISCVS category 4) in 42% and tissue loss (SVS/ISCVS category 5) in 58%. Co-morbidities included coronary artery disease (44%), diabetes (60%), hypertension (80%), chronic obstructive pulmonary disease (34%), end stage renal disease (ESRD) (30%), congestive heart failure (28%), and tobacco use (18%). 90% of patients had 2 or more co-morbidities, and 52% had inadequate conduit. Treatment included angioplasty (22 popliteal, 51 tibial/peroneal), angioplasty and stent (1 popliteal, 1 tibial), or atherectomy (12 popliteal, 23 tibial/peroneal). 54% of patients received concurrent iliac and/or SFA intervention. Patients were followed with ABI/PVR, or duplex at 1, 3, 6 and 12 months, and the mean length of follow-up was 10 months (range 1-18 months).

RESULTS: Percutaneous intervention was technically successful in 95% of limbs. Failure resulted from inability to cross the lesion or to re-enter the true lumen distally. After intervention, the mean ankle-brachial index improved from 0.32±0.19 to 0.68±0.16 (p< 0.05). Primary patency at 6 and 12 months were 88% and 68%. Limb salvage was 82% at 12 months. 18% required a major amputation, and 8% required subsequent bypass. One patient required a more distal bypass as a result of intervention. Incomplete wound healing was noted in 19.6%. Complications were hematoma (8%), immediate thrombosis (3%), embolization (4.5%), perforation (1.5%), contrast nephropathy (1.5%), and pseudoaneurysm (1.5%). Risk factors for limb loss included ESRD, heel ulcer and severe inframalleolar disease.

CONCLUSIONS: Percutaneous intervention is safe and feasible as primary therapy for CLI in high risk patients and does not adversely affect the potential for subsequent bypass. Patients with ESRD, heel ulcers, and inframalleolar disease have lower success rates.