title: Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy.
abstract: OBJECTIVE
  To evaluate the role of endovascular therapy in the management of infrainguinal arterial chronic total occlusions (CTOs).
  
  
  METHODS
  Data on all patients with CTOs treated at a single center from 2004 to 2010 were extracted from a prospectively maintained database for retrospective analysis. Patient demographics, angiographic studies, noninvasive vascular test results, and clinical outcomes were evaluated. In this time frame, 481 patients (283 men; mean age 71.7±11.5 years, range 52-85) with claudication (n = 177) or critical limb ischemia (CLI, n = 304) were treated for 688 CTOs. Lesions were segregated according to location [SFA (n = 193), popliteal (n = 67), tibial (n = 217), and multilevel (n = 211)] and analyzed based on treatment mode (angioplasty, angioplasty with stenting, or atherectomy) and clinical indication. Primary patency, assisted primary patency, and secondary patency, as well as limb salvage rates for CLI patients, were calculated.
  
  
  RESULTS
  At 2 years in claudicants with CTOs confined to the SFA, primary patency ranged from 44% to 58% and secondary patency to 92% depending on treatment type; there were no significant differences among the treatments. However, in CLI patients with SFA CTOs, atherectomy produced better outcomes at 2 years (p = 0.002 for primary and p = 0.012 for secondary patency) than angioplasty alone. The limb salvage rates ranged from 73% to 91% (no differences among treatment types). In diabetics, CTOs treated with angioplasty and stent had improved secondary patency rates over angioplasty alone.
  
  
  CONCLUSIONS
  The endovascular management of CTO results in reasonable primary patency; moreover, secondary patency at 2 years is excellent. Endovascular therapy should be the first-line option for many patients with peripheral artery disease, including those with CLI, claudicants with poor bypass conduit, or patients at high medical risk for surgery. The presence of CTOs does not appear to change these recommendations. Although multiple reinterventions may be required, endovascular therapies can be considered a primary therapy for many patients with CTO.
authors: Division of Vascular Surgery, University of Michigan Hospitals, Ann Arbor, Michigan, USA.
authors: Katherine A
authors: KA
authors: Gallagher
authors: Andrew J
authors: AJ
authors: Meltzer
authors: Reid A
authors: RA
authors: Ravin
authors: Ashley
authors: A
authors: Graham
authors: Gautam
authors: G
authors: Shrikhande
authors: Peter H
authors: PH
authors: Connolly
authors: Francesco
authors: F
authors: Aiello
authors: Rajeev
authors: R
authors: Dayal
authors: James F
authors: JF
authors: McKinsey
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D001157:Arterial Occlusive Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D017073:Atherectomy / Q000009:adverse effects / Q000401:mortality; D002908:Chronic Disease; D003251:Constriction, Pathologic; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D009519:New York City; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency