Angioplasty, Bypass Share Role In CLI

By Michel L. Zoler

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PHILADELPHIA -- Both endovascular angioplasty and open-surgery bypass have a role for restoring a pedal pulse in patients with critical limb ischemia.

In patients with Trans-Atlantic Society's Consensus (TASC) A or B lesions, percutaneous transluminal angioplasty (PTA) is the best option, Dr. Joseph L. Mills Sr. said at the Vascular Annual Meeting, sponsored by the Society for Vascular Surgery.

Patients with TASC D lesions with long-segment tibial disease who have a conduit are best treated using bypass surgery. In patients with TASC C lesions, the choice between bypass surgery and PTA depends on whether a suitable conduit exists, the patient's comorbidities, as well as the endovascular experience of the surgeon handling the case, said Dr. Mills, who is chief of vascular surgery and professor of surgery at the University of Arizona in Tucson.

This guide for balancing bypass surgery and PTA when treating critical limb ischemia is based largely on opinion, given that just one randomized, controlled trial has been reported so far that addresses the issue.

"We need real-life studies that look at clinical outcomes and quality of life," to supplement the results from studies that used vessel patency as their only outcome measure, Dr. Mills said.

The sole prospective, randomized trial that compared the two revascularization options was published last December.

A study done at 27 centers in the United Kingdom enrolled 452 with severe limb ischemia from infrainguinal disease to initial treatment with either bypass surgery or PTA. More than half of the patients in the study had diabetes. After 6 months of follow-up, the two strategies showed no significant difference in the incidence of amputation-free survival (Lancet 2005; 366:1925-34).

Dr. Mills' experience at his center in Tucson during the past 3 years has shown the same pattern of similar outcomes from bypass and PTA, although their 3-year series includes just 19 patients with true, critical-limb ischemia.

"There is no question that endovascular treatment allows physicians to do revascularization that's not possible with open surgery" but Dr. Mills posed the question of whether PTA really necessary for all patients.

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