title: Alternative techniques for treatment of complex below-the knee arterial occlusions in diabetic patients with critical limb ischemia.
abstract: OBJECTIVE
  The purpose of this study was to describe alternative endovascular (EV) techniques and assess their feasibility and efficacy in minimizing failure rates in limb salvage for the treatment of complex below-the knee (BTK) occlusions that could not be crossed with a conventional antegrade access.
  
  
  METHODS
  Between December 2007 and November 2010, 1,035 patients (557 male) underwent EV treatment for critical limb ischemia in our institution. In 124 (12% [83 male], mean age 68.2 ± 0.5 years) patients, transfemoral antegrade revascularization attempt failed, and an alternative approach was used. Follow-up was performed at 1 and 6 months. Results were compared with 56 patients treated between November 2002 and November 2007, in whom conventional technique was unsuccessful and unconventional techniques were not adopted.
  
  
  RESULTS
  Technical success was achieved in 119 (96%) patients. The limb-salvage rates were 96.8% and 83% at 1- and 6-month follow-up, respectively. Sixteen (12.9%) and 33 (26.6%) patients underwent reintervention at 1- and 6-month follow-up, respectively. Transcutaneous oxygen tension increased at 1 month (44.7 ± 1.1 vs. 15.7 ± 0.8 mmHg; p < 0.001) and remained stable at follow-up. Twenty (16.1%) patients required major amputation. Thirteen (10.4%) patients died during follow-up. In our previous experience, percutaneous transluminal angioplasty failure, amputation, and death rates were 10.9, 39.2, and 23.2%, respectively. Alternative techniques allowed a significant decrease of major amputation and death rates (p = 0.0001 and p = 0.02, respectively).
  
  
  CONCLUSIONS
  The use of alternative techniques seems feasible in case of a failed antegrade BTK revascularization attempt and could minimize failure rates in the treatment of complex occlusions while providing satisfying clinical success rates at 6 months.
authors.affiliation: Department of Diagnostic Imaging, Interventional Radiology, Radiotherapy, and Nuclear Medicine, IRCCS Policlinico di Tor Vergata, 00133, Rome, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Gandini
authors.forename: Luigi
authors.initials: L
authors.lastname: Uccioli
authors.forename: Alessio
authors.initials: A
authors.lastname: Spinelli
authors.forename: Costantino
authors.initials: C
authors.lastname: Del Giudice
authors.forename: Valerio
authors.initials: V
authors.lastname: Da Ros
authors.forename: Tommaso
authors.initials: T
authors.lastname: Volpi
authors.forename: Marco
authors.initials: M
authors.lastname: Meloni
authors.forename: Giovanni
authors.initials: G
authors.lastname: Simonetti
mesh_terms: D000368:Aged; D000671:Amputation, Surgical / Q000379:methods; D000792:Angiography / Q000379:methods; D017130:Angioplasty / Q000379:methods*; D015331:Cohort Studies; D003925:Diabetic Angiopathies / Q000000981:diagnostic imaging / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D007719:Knee Joint; D007866:Leg / Q000098:blood supply*; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000628:therapy*; D015641:Radiography, Interventional / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed / Q000379:methods; D017211:Treatment Failure; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology