title: Stent-assisted below-the-ankle angioplasty for limb salvage.
abstract: OBJECTIVE
  To report the clinical outcome of stent-assisted below-the-ankle angioplasty for limb salvage in the setting of critical limb ischemia (CLI).
  
  
  METHODS
  A retrospective single-center study was conducted of 40 critical ischemic limbs in 31 patients (mean age 67 ± 8 years, range 46-94) undergoing below-the-ankle stent-assisted angioplasty between April 2006 and April 2009. Coronary bare metal stents were implanted in cases of failed balloon angioplasty due to significant recoil, flow-limiting dissection, abrupt closure, or repeat early reocclusion.
  
  
  RESULTS
  Technical success was 93% (37 limbs), with 3 failures to cross the occlusive lesions. Acute or subacute occlusion was evident in 9 (23%) limbs. The number of runoff vessels increased significantly (p < 0.001) from 0.6 ± 0.8 to 1.8 ± 0.8. During a clinical follow-up of 19.3 ± 11.4 months (range 1-48), the number of repeat interventions for limb salvage was 2.2 ± 1.6 (range 1-9), and a total of 1.6 ± 0.9 stents (range 1-3) were implanted in 8 dorsalis pedis arteries. Acute or subacute stent thrombosis after stenting was observed in 2 of these, and symptomatic in-stent restenosis was detected in 4, which were all treated by repeat intervention. At 6, 12, and 24 months, the freedom from repeat intervention was 39.6%, 39.6%, and 35.2%, respectively. Amputation-free survival was 80.0%, 69.7%, and 62.7%, and limb salvage was 94.7%, 91.4%, and 82.1% at the same time points. Patient survival rates were 77.4%, 71.0%, and 71.0%, respectively. During a mean follow-up of 13.4 ± 12.7 months (range 1-31 months) in 7 of the 8 stented arteries, all examined stents were deformed: stent compression was evident in 5 and stent fracture in 5. However, 7 limbs undergoing dorsalis pedis artery stenting showed complete wound healing; 1 limb had a resistant wound in the heel.
  
  
  CONCLUSIONS
  Stent-assisted below-the-ankle angioplasty produced a satisfactory clinical outcome but with the need for repeat intervention. Thus, further refinement in endovascular technology is mandatory to reduce the need for repeat interventions and to resolve stent deformity issues.
authors.affiliation: Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada-city, Osaka, Japan. kawarada@stanford.edu
authors.forename: Osami
authors.initials: O
authors.lastname: Kawarada
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Yokoi
authors.forename: Akihiro
authors.initials: A
authors.lastname: Higashimori
authors.forename: Naoto
authors.initials: N
authors.lastname: Waratani
authors.forename: Katsuhisa
authors.initials: K
authors.lastname: Waseda
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Honda
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Fitzgerald
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D000842:Ankle / Q000098:blood supply*; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D002140:California; D016638:Critical Illness; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing