Percutaneous intentional extraluminal recanalization in patients with chronic critical limb ischemia.
OBJECTIVE
To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI).


METHODS
Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival.


RESULTS
Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%).


CONCLUSIONS
PIER is a useful percutaneous technique for limb salvage in patients with CCLI.
Department of Radiology, University of Virginia Health Science Center, PO Box 170, Charlottesville, VA 22909, USA. djs4m@hscmail.mcc.virginia.edu
David J
DJ
Spinosa
Daniel A
DA
Leung
Alan H
AH
Matsumoto
Eric A
EA
Bissonette
Dorothy
D
Cage
Nancy L
NL
Harthun
John A
JA
Kern
John F
JF
Angle
Klaus D
KD
Hagspiel
Ivan K
IK
Crosby
Harry A
HA
Wellons
Curtis G
CG
Tribble
Gary D
GD
Hartwell
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000706:statistics & numerical data; D000800:Angioplasty, Balloon / Q000295:instrumentation*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D001161:Arteriosclerosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D002908:Chronic Disease; D018572:Disease-Free Survival; D005260:Female; D005528:Foot / Q000098:blood supply*; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D007866:Leg / Q000098:blood supply*; D023821:Limb Salvage / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D017539:Tunica Intima / Q000000981:diagnostic imaging