title: Endovascular treatment of lesions in the below-knee popliteal artery.
abstract: BACKGROUND
  Endovascular interventions are increasing; however, there are little data regarding outcomes of complex interventions involving the below-knee popliteal/P3 artery. This study evaluated the short-term and long-term results and predictors of success of below-knee popliteal artery endovascular interventions.
  
  
  METHODS
  This was a retrospective review of a prospectively maintained endovascular lower extremity database of all patients with below-knee popliteal interventions from 2004 to 2012. Patient demographics, angiographic findings, interventions, primary and secondary patency, limb loss, and mortality were recorded. Analysis was performed using Kaplan-Meier life-table and multivariate analysis, with P < .05 indicating significance.
  
  
  RESULTS
  There were 221 patients (56% male) with below-knee popliteal/P3 artery lesions. Mean age was 73 ± 11.2 years. Claudication was present in 22% and critical limb ischemia (CLI) in 78%. Mean lesion length was 10 ± 8.5 cm, with 45% having total occlusions. Treatment included percutaneous transluminal angioplasty (PTA) with or without a stent (47%), atherectomy (ATH) with or without PTA/stent (52%), and stenting with PTA and ATH (3%). Complications included embolization (0.4%), hematoma (2.7%), pseudoaneurysm (1.3%), and dissection (7%). Freedom from restenosis (peak systolic velocity ratio >2.4) was 65% at 1 year. Independent predictors of restenosis were CLI (hazard risk [HR], 4.4; 95% confidence interval [CI], 1.9-9.9) and stenting combined with PTA and ATH (HR, 2.7; 95% CI, 1.01-7.4). Primary assisted and secondary patencies were 95% and 85% at 1 year. ATH with PTA had lower short-term restenosis in diabetic patients compared with nondiabetic patients (95% vs 78% at 4 months). Limb loss was 18% at 4 years. Mortality was 24% at 4 years. Statin use was protective against primary restenosis (HR, 0.39; 95% CI, 0.23-0.67) and death (HR, 0.5; 95% CI, 0.28-1.0).
  
  
  CONCLUSIONS
  Endovascular intervention for lesions involving the below-knee popliteal artery is a safe and effective therapy for claudication and CLI. Diabetic patients benefit most from ATH with PTA. Statin use is protective against restenosis and mortality and should be the standard of care in patients undergoing peripheral endovascular interventions.
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY. Electronic address: jes9061@nyp.org.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Siracuse
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Gill
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Cassidy
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Messina
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: Diana
authors.initials: D
authors.lastname: Catz
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: Natalia
authors.initials: N
authors.lastname: Egorova
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: Inkyong
authors.initials: I
authors.lastname: Parrack
authors.affiliation: Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
authors.forename: James F
authors.initials: JF
authors.lastname: McKinsey
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D017073:Atherectomy / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D003251:Constriction, Pathologic; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D016016:Proportional Hazards Models; D011859:Radiography; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency