Contemporary results of angioplasty-based infrainguinal percutaneous interventions

Abstract

Introduction: Although lower-extremity bypass grafting has been the gold standard for infrainguinal revascularization, endovascular therapies have been increasingly applied to avoid operative morbidities. This study addresses the initial results of an implementation of infrainguinal percutaneous transluminal angioplasty (PTA) performed by vascular surgeons to treat lower-extremity ischemia.

Methods: From January 2002 to July 2003, 95 consecutive patients presenting with the spectrum of lower-extremity ischemic manifestations, in whom infrainguinal PTA was the initial choice of treatment, were assessed for treatment efficacy by clinical and noninvasive evaluation. Study end points of angiographic, hemodynamic, and clinical successes (Society of Vascular Surgery reporting standards) were recorded, and variables associated with ischemic category improvement were analyzed by univariate and multivariate analysis. During the same study interval, 87 patients underwent bypass grafting (not further considered).

Results: PTA was used to treat 100 limbs in 95 consecutive patients: 63 limbs (63%) had femoropopliteal PTA, 17 limbs (17%) had tibioperoneal PTA, and 20 limbs (20%) had multilevel PTA. Tissue-threatening ischemia was present in 47% of patients, and 53% were treated for claudication. Complications (no mortality) included one myocardial infarction (1%) and two access site hematomas (2%). Angiographic and hemodynamic success (a .10 increase in ankle-brachial index) was obtained in 97% and 90% of the treated limbs, respectively. With a mean follow-up of 14 months, clinical success was obtained in 85% of the treated limbs, and limb salvage for critical ischemia was achieved in 75% (30/40 limbs). Of the PTA failures, five patients (5%) underwent bypass grafting, and five patients (5%) underwent major amputation because of no further reconstructive options or extensive necrosis. Insulin-dependent diabetes mellitus (risk ratio [RR], 3.1; 95% confidence interval [CI], 1.1 to 8.7, P = .02), poor runoff into the foot (RR, 3.7; 95% CI, 1.6 to 8.6, P = .001), and renal insufficiency (serum creatinine >1.5 mg/dL) (RR, 3.7; 95% CI, 1.8 to 7.6, P = .001) were predictive of PTA failure.

Conclusion: Infrainguinal percutaneous transluminal angioplasty for lower-extremity ischemia is feasible, safe and provides acceptable hemodynamic and clinical results. PTA will become the initial treatment for most patients requiring lower-extremity revascularization.