Endovascular Revascularization of Symptomatic Infrapopliteal Arteriosclerotic Occlusive Disease: Comparison of Atherectomy and Angioplasty

ABSTRACT

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.

KEYWORDS

Angioplasty - atherectomy - atherosclerosis - infrapopliteal - plaque excision - tibial - stent

REFERENCES

• 1 Norgren L, Hiatt W R, Dormandy J A, Nehler M R, Harris K A, Fowkes F G. TASC II Working Group . Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).  J Vasc Surg. 2007;  45 (Suppl S) S5-S67
• 2 Menard M T, Belkin M, Gupta S K et al.. Infrapopliteal intervention for the treatment of the claudicant.  Semin Vasc Surg. 2007;  20 42-53
• 3 Nguyen L L, Brahmanandam S, Bandyk D F et al.. Female gender and oral anticoagulants are associated with wound complications in lower extremity vein bypass: an analysis of 1404 operations for critical limb ischemia.  J Vasc Surg. 2007;  46 1191-1197
• 4 Giles K A, Pomposelli F B, Spence T L et al.. Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs.  J Vasc Surg. 2008;  48 128-136
• 5 Bosiers M, Hart J P, Deloose K, Verbist J, Peeters P. Endovascular therapy as the primary approach for limb salvage in patients with critical limb ischemia: experience with 443 infrapopliteal procedures.  Vascular. 2006;  14 63-69
• 6 Kudo T, Chandra F A, Ahn S S. The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience.  J Vasc Surg. 2005;  41 423-435 discussion 435
• 7 Kudo T, Chandra F A, Kwun W H, Haas B T, Ahn S S. Changing pattern of surgical revascularization for critical limb ischemia over 12 years: endovascular vs. open bypass surgery.  J Vasc Surg. 2006;  44 304-313
• 8 Sadek M, Ellozy S H, Turnbull I C, Lookstein R A, Marin M L, Faries P L. Improved outcomes are associated with multilevel endovascular intervention involving the tibial vessels compared with isolated tibial intervention.  J Vasc Surg. 2009;  49 638-643 discussion 643-644
• 9 Zeller T, Sixt S, Schwarzwälder U et al.. Two-year results after directional atherectomy of infrapopliteal arteries with the SilverHawk device.  J Endovasc Ther. 2007;  14 232-240
• 10 Rutherford R B, Baker J D, Ernst C et al.. Recommended standards for reports dealing with lower extremity ischemia: revised version.  J Vasc Surg. 1997;  26 517-538
• 11 Conrad M F, Cambria R P, Stone D H et al.. Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: a contemporary series.  J Vasc Surg. 2006;  44 762-769
• 12 Zeller T, Sixt S, Schwarzwälder U et al.. Two-year results after directional atherectomy of infrapopliteal arteries with the SilverHawk device.  J Endovasc Ther. 2007;  14 232-240
• 13 Zeller T, Rastan A, Schwarzwälder U et al.. Midterm results after atherectomy-assisted angioplasty of below-knee arteries with use of the Silverhawk device.  J Vasc Interv Radiol. 2004;  15 1391-1397
• 14 Ramaiah V, Gammon R, Kiesz S TALON Registry et al. Midterm outcomes from the TALON Registry: treating peripherals with SilverHawk: outcomes collection.  J Endovasc Ther. 2006;  13 592-602
• 15 Keeling W B, Shames M L, Stone P A et al.. Plaque excision with the Silverhawk catheter: early results in patients with claudication or critical limb ischemia.  J Vasc Surg. 2007;  45 25-31
• 16 Söder H K, Manninen H I, Jaakkola P et al.. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: angiographic and clinical results.  J Vasc Interv Radiol. 2000;  11 1021-1031
• 17 Tsetis D, Belli A M. The role of infrapopliteal angioplasty.  Br J Radiol. 2004;  77 1007-1015