title: Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia.
abstract: BACKGROUND
  Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI.
  
  
  METHODS
  All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival.
  
  
  RESULTS
  A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P < .001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P < .001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P = .02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P = .02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63).
  
  
  CONCLUSIONS
  Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.
authors.affiliation: Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
authors.forename: Gagan D
authors.initials: GD
authors.lastname: Singh
authors.affiliation: Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
authors.forename: Ehrin J
authors.initials: EJ
authors.lastname: Armstrong
authors.affiliation: Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif; Division of Cardiovascular Medicine, National Heart Centre Singapore, Singapore.
authors.forename: Khung-Keong
authors.initials: KK
authors.lastname: Yeo
authors.affiliation: Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
authors.forename: Satinder
authors.initials: S
authors.lastname: Singh
authors.affiliation: Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Westin
authors.affiliation: Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
authors.forename: William C
authors.initials: WC
authors.lastname: Pevec
authors.affiliation: Division of Vascular and Endovascular Surgery and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif.
authors.forename: David L
authors.initials: DL
authors.lastname: Dawson
authors.affiliation: Division of Cardiovascular Medicine and the Vascular Center, University of California, Davis School of Medicine, Sacramento, Calif. Electronic address: john.laird@ucdmc.ucdavis.edu.
authors.forename: John R
authors.initials: JR
authors.lastname: Laird
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D003251:Constriction, Pathologic; D016638:Critical Illness; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D011859:Radiography; D012008:Recurrence; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014654:Vascular Patency