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The Endovascular Approach to Treatment of Critical Limb Ischaemia
Patients with Below-knee Pathology
a report by
M a r c B o s i e r s 1, A l e s s a n d r a P u g g i o n i 1, K o e n D e l o o s e 1, J u r g e n V e r b i s t 2
and P a t r i c k P e e t e r s 2
1. Department of Vascular Surgery, AZ St-Blasius, Dendermonde and
2. Department of Cardiovascular and Thoracic Surgery, Imelda Hospital
The treatment of critical limb ischaemia (CLI), a
condition that may eventually lead to limb loss in a
substantial number of patients, consumes a significant
amount of healthcare resources. Distal bypass for limb
salvage with autogenous conduit has been considered
the procedure of choice for good-risk patients who also
have suitable veins and distal target arteries for bypass.
However, often one or more of these criteria are not
met, and a large number of patients would face a major
amputation with unfavourable outcome and poor
quality of life.
The endovascular approach offers the advantages of a
minimally invasive procedure that only requires local
anaesthesia and is associated with shorter procedure
time and hospital stay, as well as reduced morbidity
rates compared with bypass surgery.
Indications
The decision to perform any endovascular intervention
for tibial occlusive disease should be based on clinical
grounds rather than diagnostic imaging, as most
patients with significant tibial disease are asymptomatic.
These asymptomatic patients and claudicants can be
treated conservatively with lifestyle changes, an
exercise program and sometimes drug therapy;
revascularisation is indicated if ischaemic rest pain or
ulcerations develop.
Almost all CLI patients are threatened by other co-
morbidities related to the generalised atherosclerotic
process. This general poor-health status means shorter
life expectancy and high-risk for surgery, and, in the
authors’ opinion, supports the idea that endovascular
intervention may soon be considered the primary
treatment modality for CLI caused by infrapopliteal
occlusive disease.
Endovascular Treatment Strategy
The clinical success of any infrapopliteal intervention
for occlusive disease often depends on pre-procedure
patient optimisation and achievement of adequate
inflow into the infragenicular region by either an
endovascular or surgical approach.
INTERVENTIONAL CARDIOLOGY 2006
Peripheral Arterial Disease
The ideal goal would be to restore uninterrupted blood
flow down to the foot in at least one vessel.5 When this
is not achievable, which is often the case in diabetic
patients, therapy is targeted at maximising flow to the
trifurcation vessels and geniculate collaterals.
Crossing of the Lesion
Once arterial access is obtained, multi-planar angio- Marc Bosiers is Head of the
graphy with magnified views of the region of interest Department of Vascular Surgery at
the AZ St Blasius Hospital in
is performed. Dendermonde, Belgium, a position
he has held since 1993. He is the
author of over 60 research articles,
When passing a lesion seems particularly cumbersome, and has delivered over 250 lectures
subintimal lesion passage, (the Bolia technique), offers on the subject of endovascular
an effective alternative to the intraluminal approach. surgery. Dr. Bosiers is a member of
the European Society for Vascular
Surgery and the Belgian Society for
Another alternative approach is the step-by-step laser Vascular Surgery. Dr. Bosiers
graduated in 1983 Magna cum
ablation with a 0.9–1.4mm pulsed excimer laser
Laude with an MD from the
cath-eter. This short ablation allows the guidewire to Catholic University in Louvain. He
be further advanced into the occluded vessel. The then commenced his surgical
training at the Westfälische
laser catheter ablation is generally stopped one to two Wilhelms University in Munich.
cm before the end of the occlusion. From here the
lesion is best cross-ed with the guidewire in order to
prevent dissection.
Lesion Treatment
Percutaneous Transluminal Angioplasty
Infrapopliteal percutaneous transluminal angioplasty
(PTA) became feasible with the introduction of
low-profile peripheral balloon systems and the use of
coronary balloons. After a successful lesion passage, a
5–6F sheath is inserted into the popliteal artery. This
provides sufficient support for the balloon catheter to
pass the lesion. In order to prevent dissection,
hydrophilic-coated balloon catheters with a diameter
2.5–4.0mm are mostly used. A long stenosis is best
treated with a gentle PTA using a low-pressure
balloon with sizes ranging from eight to 10cm in
length and 2.5 to 3.5mm in diameter.
The Bypass versus Angioplasty in Severe Ischaemia of
the Leg (BASIL) trial was a randomised trial comparing
PTA with bypass in patients with CLI. They found
that in the short term, PTA is cheaper than surgery and
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Peripheral Arterial Disease
that 12-month amputation-free survival for bypass and
balloon angioplasty as first-line strategy were 68% and
71%, respectively. The published primary patency rates
for PTA are less uniform and range from 15% to 70%.
Cutting or Scoring Balloon
The mechanism of peripheral cutting or scoring
balloons has been referred to as atherotomy. With
these advanced PTA techniques, either atherotomy
blades are mounted on the surface of a non-compliant
balloon (Peripheral Cutting Balloon, Boston Scientific
Interventional Technologies, San Diego, CA, USA),
or a nitinol-scoring element encircles a minimally
compliant balloon (AngioSculpt, AngioScore,Inc,
Fremont, CA, USA). This technique decreases vessel
elastic recoil and perivascular injury by focal
concentration of the dilating force. Preliminary data
show that these devices appear to lower the need for
infrapopliteal stents.
Subintimal Angioplasty (SIA)
In some centres, SIA is gaining popularity for long
segment occlusions below the knee. The concept of
passing a wire into the subintimal space and inflating a
balloon to create a channel for blood flow seems to
violate the traditional endovascular principles.
However, Bolia et al. has reported significant technical
and clinical success with this procedure. Nydahl et al.
investigated the use of subintimal PTA for restoring
blood flow in the infrapopliteal vessels. After one year
they reported a limb salvage rate of 85%, even though
the subintimal canal was haemodynamically patent in
only 53% of the cases. Vraux et al. found comparably
low 12-month primary patency rates with a remarkably
better limb salvage rate.
Stenting
Stent implantation is generally reserved for cases with a
suboptimal outcome after PTA, as only limited
evidence is currently available on the need for stenting
in the infrapopliteal location. A recent study from the
Vienna group demonstrated that the angiographic
outcome after stenting is superior to PTA alone in the
infrapopliteal vessels. Different stent types have all
shown encouraging results: uncoated, stainless steel or
nitinol stents, stainless steel stents with a passive or active
coating and bioabsorbable magnesium alloy stents.
Excimer Laser
Excimer laser ablation is another treatment modality
for recanalising long lesions. Using a wavelength of
308nm, this cold-tipped, pulsed laser often opens
occlusions when other interventional endovascular
techniques have failed.
54
Post-procedural Surveillance
Post-operative patient education, focusing on
protection of the extremity, wound care
management and adoption to a healthier lifestyle
cannot be overemphasised. Also, it is the authors’
practice to prescribe lifelong clopidogrel (75mg
daily) and aspirin (160mg daily).
Standard follow-up visits are planned at one-,
three-, six- and 12-month intervals. Duplex
investigation for restenosis and flow assessment are
performed at the same time, and progress with pain
management and wound healing are evaluated.
Conclusion
Limb preservation should be the main goal in
patients with CLI due to tibial occlusive disease.
With a prompt diagnosis, treatment can be started
early and serious consequences may be avoided. Any
type of revascularisation that can prevent amputation
is the ultimate treatment strategy.
Morbidity and mortality rates associated with an
endovascular revascularisation are lower than with
surgical bypass; endovascular interventions do not
preclude future bypass procedures. Moreover,
some patients cannot be treated with surgery
because of the infected anastomosis area or the lack
of a healthy target vessel. Patency and limb salvage
rates after endovascular treatment tend to approach
the surgical results.
Patients with CLI require lifelong follow-up to
repeatedly assess the status of the limb after
intervention. Recurrent symptoms warrant an
immediate investigation and an aggressive re-
intervention strategy is indicated.
With the advent of minimally invasive techniques for
recanalisation of chronically occluded below-the-
knee vessels in patients with CLI, a new era has been
set and current reporting standards for lower
extremity revascularisation may need to be revised. ■
Acknowledgement
The authors take great pleasure in thanking the staff of
Flanders Medical Research Program (www.fmrp.be), with
special regards to Koen De Meester and Erwin Vinck, for
performing the systematic review of the literature and
providing substantial support to the data analysis and the
writing of the article.
A version of this article containing references can be found
in the Reference Section on the website supporting this
briefing (www.touchbriefings.com).
INTERVENTIONAL CARDIOLOGY 2006
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