Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 376-379

Limb salvage following below-the-ankle angioplasty in critical limb ischemia


Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Submission11-May-2020
Date of Acceptance09-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
B Nishan
Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_59_20

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  Abstract 


Aim: The aim was to report limb salvage following below-the-ankle (BTA) angioplasty as an adjunct to proximal angioplasty in patients with critical limb ischemia (CLI). Methods: We performed a retrospective analysis of CLI patients who underwent BTA angioplasty as an adjunct to proximal angioplasty between 2013 and 2018 and followed for 6 months. Patient demographics and outcomes were recorded. Outcomes were determined by major amputation (primary outcome), wound healing, and mortality (secondary outcome). Results: Between 2013 and 2018, 59 BTA angioplasties were performed in 52 patients. Patients were divided into two groups based on the results of BTA angioplasty. Successful BTA angioplasty was accessed using post angioplasty angiogram showing a complete plantar arch and improved TcPO2 measurements (preoperative and postoperative). Group 1 (41) includes patients with successful BTA angioplasty and Group 2 (11) includes patients with unsuccessful BTA angioplasty. Patients were followed up for 6 months. Demographics and comorbidities did not influence outcomes in both groups. At the end of 6 months, wound healing, major amputation, and mortality were 92%, 4%, and 4%, respectively, in Group 1 and 9%, 90%, and 54%, respectively, in Group 2. Successful BTA angioplasty has a significant role in preventing major amputation, improved wound healing, and decreased mortality (P < 0.001 [significant]). Conclusions: BTA angioplasty for CLI is technically safe and feasible with satisfactory results for limb salvage.

Keywords: Below-the-ankle angioplasty, critical limb ischemia, major amputation


How to cite this article:
Nishan B, Krishna K S, Hudgi V V, Ahsan V P, Anand V. Limb salvage following below-the-ankle angioplasty in critical limb ischemia. Indian J Vasc Endovasc Surg 2020;7:376-9

How to cite this URL:
Nishan B, Krishna K S, Hudgi V V, Ahsan V P, Anand V. Limb salvage following below-the-ankle angioplasty in critical limb ischemia. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 28];7:376-9. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/376/304639




  Introduction Top


Critical limb ischemia (CLI) represents the terminal stage of obstructive, atherosclerotic peripheral arterial disease (PAD).[1] Patients with CLI frequently present with complex disease, characterized by diffuse, multilevel, and multivessel calcific involvement.[1] Arterial obstructions may affect the distal tibial arteries at the ankle, or even extend below the ankle (BTA) and involve the dorsalis pedis and plantar arteries.[2] Distal anastomosis during bypass surgery may be technically challenging in case of extensive medial wall calcifications or even impossible if an appropriately healthy distal vessel conduit is absent.[3] The development seen in the technical and technological advancements in endovascular intervention, namely the introduction of extremely low-profile and dedicated devices and increasing expertise allowed the feasibility of BTA angioplasty.[4],[5],[6],[7],[8]

The aim of this study is to present the outcomes of BTA angioplasty in patients who presented to JIVAS between 2013 and 2018 and followed up for 6 months. Outcomes were determined by major amputation (primary outcome), wound healing, and mortality (secondary outcome).


  Methods Top


Overview

We performed a retrospective review of all patients who underwent BTA angioplasty at JIVAS from 2013 to 2018 and followed up for 6 months. Demographics (age and sex) and comorbidities (diabetes mellitus/hypertension [DM/HTN], renal insufficiency, coronary artery disease, and smoking) are noted. Patients who underwent BTA angioplasty as an adjunct to proximal angioplasty were included and outcomes were determined by major amputation (primary outcome), wound healing, and mortality (secondary outcome).

Procedure

We performed angioplasty for the diseased dorsalis pedis and plantar arteries, if the lesion is suitable, to restore the continuity of blood flow to the foot following proximal angioplasty. The indications of BTA angioplasty are the presence of tight stenosis (>60%–70%) and/or a segmental occlusion where there is at least some filling of the target vessel beyond the occluded segment. We would not normally tackle a foot where there is no filling of named vessels beyond the occlusion. Percutaneous angioplasty was performed under local anesthesia through an ipsilateral femoral approach. Vessel recanalization was considered successful if the direct flow was restored in the treated vessel with no residual stenosis >30% of the vessel diameter along the artery. During the procedure, sodium heparin (5000 IU) bolus was infused into the arterial lumen; if vessel spasm occurred, papaverine/ Nitroglycerin (NTG) bolus was injected intraarterially. Patients were prescribed dual antiplatelet therapy (aspirin + clopidogrel) as per standard protocol unless contraindicated.

Follow-up

All patients who underwent BTA angioplasty were followed up for 6 months (immediate postoperative, 1st, 3rd, and 6th months). BTA angioplasty results were analyzed using post angioplasty angiogram showing a complete plantar arch and improved TcPO2 measurements (preoperative and postoperative). Outcomes were determined by major amputation (primary outcome), wound healing, and mortality (secondary outcome).

Statistical analysis

The data were summarized by frequency and percentages for categorical parameters and mean with standard deviation for quantitatively measured parameters. The association of the risk factor with the desired outcome was assessed by the Chi-square test of independence. P < 0.05 was considered as the statistical significance. The statistical software R version 3.6.2 R Foundation for Statistical Computing, Vienna, Austria (R Core Team, 2019) was used for statistical analysis.


  Results Top


We performed a retrospective review of 52 patients who underwent BTA angioplasty as an adjunct to proximal angioplasty at JIVAS from 2013 to 2018 and followed up for 6 months. Patients were divided into two groups based on the results of BTA angioplasty. Group 1 includes patients with successful BTA angioplasty and Group 2 includes patients with unsuccessful BTA angioplasty. Demographics (age and sex) and comorbidities (DM, HTN, renal insufficiency, coronary artery disease, and smoking) of both groups are summarized [Table 1].
Table 1: Demographic data

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Fifty-nine BTA angioplasties were performed in 52 patients (both DP and plantar arteries were targeted in seven patients) as an adjunct to proximal angioplasty. Angioplasty of proximal lesions (above the ankle) of both groups is summarized [Table 2].
Table 2: Angioplasty of proximal lesions (above the ankle)

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BTA angioplasty of DPA, plantar artery, and both were performed in both the groups based on the intraoperative angiogram findings. Success was noted in 41 patients with a complete plantar arch in postplasty angiogram and improvement in TcPO2 measurements [Table 3].
Table 3: BTA angioplasty

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The mean TcPo2 improved from 20.1 to 36.6 in patients with successful BTA angioplasty [Table 4].
Table 4: Comparison of TcPO2 measurements

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Patients underwent wound debridement/toe/transmetatarsal amputation based on preoperative wound condition, had healthy wound at the time of discharge, and were followed up for regular dressings. At the end of 6 months, wound healing, major amputation, and mortality were 92%, 4%, and 4%, respectively, in Group 1 and 9%, 90%, and 54%, respectively, in Group 2 [Table 5].
Table 5: Follow up of patients who underwent BTA angioplasty

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  Discussion Top


Revascularization by means of percutaneous transluminal angioplasty has become the first line of management for patients with PAD. In patients with CLI, the aim of revascularization is to provide sufficient blood flow to allow healing of the ischemic foot lesion.[9],[10] Patients with CLI commonly present with lesions in BTA arteries. This anatomical pattern may prohibit distal bypass for limb salvage or render it unsafe.[7],[11] According to Wolfe and Wyatt, 73%–95% of all CLI patients will experience a major amputation at 1 year without prompt revascularization. However, recanalization and reperfusion of the distal ischemic foot will reduce the major amputation rate at 25% during the same follow-up period.[12]

Hasanadka et al. proposed that BTA angioplasty should also be performed as an adjunct to below-the-knee angioplasty to improve runoff hemodynamics. The dorsalis pedis, the distal posterior tibial artery, or both may be afflicted by focal or usually diffuse atherosclerosis and are involved in the ischemic manifestations of CLI.[13]

Nakama et al. report on the outcomes of a retrospective analysis of prospectively collected data from 257 patients with CLI with tibiopedal disease enrolled in the multicenter rendezvous (retrospective analysis for the clinical impact of pedal artery revascularization versus nonrevascularization strategy for patients with CLI)

Nakama et al . reported that adjunctive pedal artery angioplasty improved wound healing rates and time to wound healing.[14],[15] Higashimori et al. studied the impact of having a patent plantar arch among patients with CLI who had only 1-vessel runoff to the foot. They found significant improvements in amputation-free survival (88.2% vs. 65.6%, P < 0.01) and limb salvage (98.4% vs. 89.3%,P ¼ 0.03) rates, but no difference in wound healing rates (89.4% vs. 80.6%,P ¼ 0.11) compared with patients in whom the plantar arch was not patent.[16]

Rashid et al. reported that amputation-free survival was similar, whereas wound healing rates were better if the plantar arch was patent, in their study of 154 patients with CLI who underwent infrapopliteal bypass.[17]

Fusaro et al. restored the continuity between plantar and dorsalis pedis arteries, described as the pedal-plantar loop technique. They used a perforator branch to create a connection between dorsalis pedis and plantar arteries.[4]

In the present study, 59 BTA angioplasties were performed in 52 patients. Patients underwent BTA angioplasty in addition to proximal (femoral, popliteal, and tibial) angioplasty because localized disease affecting foot arteries with no proximal disease did not exist in our patients. Patients were divided into two groups based on the results of BTA angioplasty. Successful BTA angioplasty was accessed using post angioplasty angiogram showing complete plantar arch and improved TcPo2 measurements (preoperative and postoperative). Group 1 (41) includes patients with successful BTA angioplasty and Group 2 (11) includes patients with unsuccessful BTA angioplasty. Patients were followed up for 6 months. Demographics and comorbidities had no influence on outcomes in both the groups. At the end of 6 months, wound healing, major amputation, and mortality were 92%, 4%, and 4%, respectively, in Group 1 and 9%, 90%, and 54%, respectively, in Group 2. Successful BTA angioplasty has a significant role in preventing major amputation, improved wound healing, and decreased mortality (P < 0.001 [significant]).

We believe that both proximal and successful BTA angioplasty contribute to clinical improvement because most patients who had failed BTA angioplasty required major amputation (90%) when compared to successful BTA angioplasty (4%).


  Conclusions Top


BTA angioplasty is safe and feasible and provides good clinical outcome in a group of patients with limited treatment options. It is useful as an adjunct to proximal angioplasty to improve the limb salvage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rilke RM. Letters to a Young Poet. Soulard R Jr., ed. Malden, MA: Scriptor Press; 1903.  Back to cited text no. 1
    
2.
Tsetis D, Belli AM. The role of infrapopliteal angioplasty. Br J Radiol 2004;77:1007-15.  Back to cited text no. 2
    
3.
Katsanos K, Karnabatidis D, Siablis D. Commentary: Below-the-ankle angioplasty: To stent or not to stent. J Endovasc Ther 2011;18:43-5.  Back to cited text no. 3
    
4.
Fusaro M, Dalla Paola L, Biondi-Zoccai G. Pedal-plantar loop technique for a challenging below-the-knee chronic total occlusion: A novel approach to percutaneous revascularization in critical lower limb ischemia. J Invasive Cardiol 2007;19:E34-7.  Back to cited text no. 4
    
5.
Faglia E, Dalla Paola L, Clerici G, Clerissi J, Graziani L, Fusaro M, et al. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: Prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg 2005;29:620-7.  Back to cited text no. 5
    
6.
Bolia A, Brennan J, Bell PR. Recanalisation of femoro-popliteal occlusions: Improving success rate by subintimal recanalization. Clin Radiol 1989;40:325.  Back to cited text no. 6
    
7.
Graziani L. Improving infra-popliteal balloon angioplasty results. Endovasc Today;2007:61e3.  Back to cited text no. 7
    
8.
Kawarada O, Yokoi Y. Dorsalispedis artery stenting for limb salvage. Catheter Cardiovasc Interv 2008;71:976e82.  Back to cited text no. 8
    
9.
Levin ME. Preventing amputation in the patient with diabetes. Diabetes Care 1995;18:1383-94.  Back to cited text no. 9
    
10.
Ouriel K. Peripheral arterial disease. Lancet 2001;358:1257e64.  Back to cited text no. 10
    
11.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: Revised version. J Vasc Surg 1997;26:517-38.  Back to cited text no. 11
    
12.
Wolfe JH, Wyatt MG. Critical and subcritical ischaemia. J Vasc Endovasc Surg 1997;13:578-82.  Back to cited text no. 12
    
13.
Hasanadka R, Brown KR, Rilling WS, Rossi PJ, Hieb RA, Hohenwalter EJ, et al. The extent of lower extremity occlusive disease predicts short- and long-term patency following endovascular infrainguinal arterial intervention. Am J Surg 2008;196:629-33.  Back to cited text no. 13
    
14.
Nakama T, Watanabe N, Haraguchi T, Sakamoto H, Kamoi D, Tsubakimoto Y, et al. Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry. JACC Cardiovasc Interv 2017;10:79-90.  Back to cited text no. 14
    
15.
Nakama T, Watanabe N, Kimura T, Ogata K, Nishino S, Furugen M, et al. Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease. J Endovasc Ther 2016;23:83-91.  Back to cited text no. 15
    
16.
Higashimori A, Iida O, Yamauchi Y, Kawasaki D, Nakamura M, Soga Y, et al. Outcomes of One straight-line flow with and without pedal arch in patients with critical limb ischemia. Catheter Cardiovasc Interv 2016;87:129-33.  Back to cited text no. 16
    
17.
Rashid H, Slim H, Zayed H, Huang DY, Wilkins CJ, Evans DR, et al. The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. J Vasc Surg 2013;57:1219-26.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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