Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs.
OBJECTIVE
Recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI). However, little data are available regarding infrapopliteal angioplasty outcomes based on TransAtlantic InterSociety Consensus (TASC) classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification.


METHODS
From February 2004 to March 2007, 176 consecutive limbs (163 patients) underwent infrapopliteal angioplasty for CLI. Stents were placed for lesions refractory to PTA or flow-limiting dissections. Patients were stratified by TASC classification and suitability for bypass grafting. Primary outcome was freedom from restenosis, reintervention, or amputation. Primary patency, freedom from secondary restenosis, limb salvage, reintervention by repeat angioplasty or bypass, and survival were determined.


RESULTS
Median age was 73 years (range, 39-94 years). Technical success was 93%. Average follow-up was 10 months (range, 1-41 months). At 1 and 2 years, freedom from restenosis, reintervention, or amputation was 39% and 35%, conventional primary patency was 53% and 51%, and freedom from secondary restenosis and reintervention were 63% and 61%, respectively. Limb salvage was 84% at 1, 2, and 3 years. Within 2 years, 15% underwent bypass and 18% underwent repeat infrapopliteal PTA. Postoperative complications occurred in 9% and intraprocedural complications in 10%. The 30-day mortality was 5% (9 of 181). Overall survival was 81%, 65%, and 54% at 1, 2, and 3 years. TASC D classification predicted diminished technical success (75% D vs 100% A, B, and C; P < .001), primary restenosis, reintervention, or amputation (hazard ratio [HR], 3.4; 95% confidence interval [CI], 2.1-5.5, P < .001), primary patency (HR, 2.2; 95% CI, 1.3-3.9, P < .004), secondary restenosis (HR, 3.2; 95% CI, 1.6-6.4, P = .001), and limb salvage (HR, 2.6; 95% CI, 1.1-6.3, P < .05). Unsuitability for surgical bypass also predicted restenosis, reintervention, or amputation, secondary restenosis, need for repeated angioplasty, and inferior primary patency and limb salvage rates.


CONCLUSIONS
Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.
Giles
Kristina A
KA
Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
Pomposelli
Frank B
FB
Spence
T L
TL
Hamdan
Allen D
AD
Blattman
Seth B
SB
Panossian
Haig
H
Schermerhorn
Marc L
ML
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000379:methods*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000628:therapy*; D007866:Leg / Q000098:blood supply*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D014654:Vascular Patency; D014945:Wound Healing