W' Anthony Lee, M'D'

1
Critical Lower Extremity Ischemia
Goals and Techniques for Tibioperoneal
Revascularization

• W. Anthony Lee, M.D.
• Assistant Professor of Surgery and Radiology
• Division of Vascular Surgery and Endovascular
  Therapy
• University of Florida

2
Indications

• Critical limb ischemia
• Rest pain (Fontaine III, Rutherford Grade
  II-Category 4)
• Tissue loss (Fontaine IV, Rutherford Grade
  III-Categories 5, 6)

3
Goals

• Relieve pain
• Heal ischemic ulcers/wounds
• Prevent limb loss

4
Background

• Presentation
• Asymptomatic PAD 50
• Atypical leg pain 25
• Claudication 20-25
• Critical limb ischemia 1-2
• Untreated CLI 25 amputation, 25 CV-related
  death _at_ 6-months

5
Management

• Detailed HP
• Biochemical testing
• CBC-P, fasting blood glucose, Hgb A1c, Cr,
  fasting lipid profile, U/A (for glucosuria,
  proteinuria)
• ABI/Toe pressures
• Anatomic imaging?endovascular vs. surgical
  revascularization
• /- carotid evaluation
• /- coronary evaluation

6
Outcomes

• Endovascular tibial interventions
• Intraluminal PTA /- stent
• Subintimal PTA
• Cryoplasty
• Excimer laser
• Directional atherectomy (e.g. Silverhawk)

7
Outcomes

• Conventional PTA (Dorros, et al. Circ 2001)
• 284 limbs (529 tibioperoneal lesions) w/ CLI
• Lesion length lt10-cm w/ distal vessel
  visualization
• Results
• 270 limbs (95) clinical success
• 165 of 166 (99) Fontaine III
• 105 of 118 (90) Fontaine IV
• 486 (92) successful PTA (lt50 residual stenosis)
• 370 of 376 stenoses (98)
• 116 of 153 occlusions (73)
• Complications
• Contrast nephropathy (7), emergency surgery
  (0.7), death (0.4), amputation (0.4),
  compartment syndrome (0.4)

8
Outcomes

• Dorros et al. (cont)
• 5 yr followup (266 of 270 revascularized limbs)
• Survival 56
• Fontaine III 58 vs. IV 33
• Late surgical bypass in 8
• Fontaine III 3 vs. IV 16
• Amputation in 9
• Limb salvage in 91

9
Outcomes

• Primary tibioperoneal stenting (Feiring, et al. J
  Am Coll Cardiol 2004)
• 82 patients (92 limbs)
• 86 limbs (93) technical success (straight
  inline flow)
• ABI increase
• Fontaine II pre?post 0.3
• Fontaine III/IV pre?post 0.6
• 47 of 49 limbs (96) w/ CLI clinically improved

10
Outcomes

• Excimer laser (Bosiers, et al. Eur J Vasc
  Endovasc Surg 2005)
• 48 patients (51 limbs)
• Excimer laser /- adjunctive PTA /- stent
• 100 technical success
• Limb salvage 91 _at_ 6 months
• 4 major amputations, 4 minor amputations

11
Outcomes

• Subintimal PTA for tibial CTO (Ingle, et al. J
  Endovasc Ther 2002)
• 67 patients (70 limbs)
• Occlusion lengths 4-20 cm
• Technical success 86
• Limb salvage 94 _at_ 36 months
• Mortality 51 _at_ 36 months

12
Outcomes

• Directional atherectomy (Zeller, et al. J Vasc
  Interv Radiol 2004)
• 33 patients (52 lesions)
• Mean lesion length 5 cm
• 98 technical success
• 71 primary atherectomy (29 adjunctive PTA /-
  stent)
• Mean 7.2 passes per lesion
• Mean ABI increase 0.34
• Restenosis (duplex) 22 _at_ 6 months

13
Outcomes

• Risk factors for suboptimal outcome
• Diabetes
• Renal failure
• Severe calcification

14
Summary

• Stenoses better outcome than occlusions
• Possible role for salvage stenting for occlusions
• All the techniques similar acute outcomes
  (slightly less for subintimal angioplasty)
• Rest pain better outcome than tissue loss
• 3 yr survival 50

15
Technique

• Contralateral (up-and-over) vs. Ipsilateral
  (antegrade)
• 6 Fr x 55 cm sheath
• 0.014
• Monorail vs. OTW
• Balloon catheters
• 120-130 cm vs. 70-80 cm
• 2.5-4.0 mm (0.5 increments) x 15-60 mm lengths

16
Technique

• Adjunctive equipment
• 0.035, 0.018 angled Glidewire
• 4 Fr angled hydrophilic catheter
• Balloon expandable stents (2.5-4.0 mm x 8-14 mm)
• Angiojet
• Thrombolysis

17
Technique

• Obtain femoral access
• Complete inflow-outflow angiography
• Treat inflow lesions first
• Iliac?femoral?popliteal
• Cross tibial lesion
• Treat target
• Single vessel vs. multivessel revascularization

18
3x30 pta
pre
post
61 yo M w/ CAD, DM, ESRF, L great toe dry gangrene
19
66 yo F, DM, ESRF, HTN, L great toe ulcer and
rest pain
0.014 Thruway
Treat upstream first (5.5mm PTA)
20
Treat upstream first (5.5mm PTA)
59 yo F w/ 40-pack year smoking, R foot rest pain
21
82 yo M w/ HTN, R LE short distance claudication
22
4x15 CB
56 yo M, s/p R fem-AT bypass w/ vein, elevated
velocities (450 cm/sec) at distal anastomosis