What Is the Prognosis for Reinterventions in Critical Lower Limb Ischemia?

Infrapopliteal (below the knee, BTK) percutaneous transluminal angioplasty (PTA) has been acknowledged as a useful strategy in chronic critical limb ischemia (CLI), but artery calcification severity results in considerable restenosis. Repeat PTA and the management of trophic lesions help with wound healing. However, this conduct has not been extensively assessed.

This study enrolled 152 patients (175 limbs) who experienced CLI with ulcerated lesions that would not heal or gangrene (Rutherford classification 5 or 6). These patients underwent BTK PTA.

Patients were divided into 3 groups depending on their number of repeat PTA. The first group included 99 patients with no repeat of the procedure (NRP); the second, 41 patients who repeated it once or twice (1-2RP); the third, 12 patients who repeated the procedure thrice or more (≥3RP).

Patients were assessed by an interventional cardiologist and a plastic surgeon using the Wound, Ischemia, and Foot infection (WIFi) classification for the assessment of limb lesions.

Revascularization was performed following the angiosome principle.

Read also: Lesion Targeting Seems to Be the Secret in Critical Ischemia.

Patient characteristics were similar: mean age was 70 years old (although it was lower in the ≥3RP group) and most patients had diabetes (30% of them were insulin-requiring patients). Groups 1-2RP and ≥3RP had more patients who underwent hemodialysis and who were smokers.

While lesion location was similar among groups, the presence of Rutherford 6 lesions and lesions in the highest WIFi stage was higher among patients in the ≥3RP group, and the presence of gangrene was higher in the NRP group. No difference was observed as regards the prescription of antibiotics before hospitalization.

Angiographies did not show differences as regards the presence of chronic occlusions, but the presence of multivessel lesions was higher among patients in the ≥3RP group.

Read also: Critical Lower Limb Ischemia Should Be Taken into Account in TAVR.

Wound healing rates at 1 year were higher for patients in the NRP group: NRP, 93.9%; 1-2RP, 77.1%; ≥3RP, 27.3% (log-rank test: NRP vs. 1-2RP, p > 0.001; 1-2RP vs. ≥3RP, p = 0.0019; NRP vs. ≥3RP, p > 0.001). Limb salvage rates and amputation-free survival rates at 3 years were higher in the NRP group: 93%, 88.5%, and 57.1% (p > 0.001); 60.8%, 51.2%, and 29% (p = 0.0019), respectively.

Age, hemodialysis, low ejection fraction, and WIFi stage were predictors of repeat intervention.

Read also: Angioplasty vs. Surgery in Long-Term Critical Ischemia.

The need for repeat revascularization was directly related to WIFi stage.

Conclusion

Clinical outcomes in patients with critical lower limb ischemia are poor for those who repeat angioplasty revascularization thrice or more. The WIFi classification may be useful to predict the need for repeat angioplasty revascularization.

Editorial Comment

In this study, revascularization was based on the angiosomes involved. While this brings blood flow to the compromised area, several studies have shown no benefit from it for patients with diabetes, with success rates around 60%. Nowadays, revascularization using the extensor digitorum brevis muscle and revascularization beyond said muscle to reach the interdigital arteries are the treatment options proposed in CLI, particularly for patients with diabetes.

The WIFi classification is very simple and can be carried out at the bedside, providing much information as regards the prognosis.

Another important piece of information is that patients with acute arterial disease can undergo several interventions, even if we pay their price in poorer outcomes. Surely, this will always buy some time before amputation, a traumatic event for the patient.

Courtesy of Dr. Carlos Fava.

Original title: Characteristics and Clinical Outcomes of Repeat Endovascular Therapy After Infrapopliteal Balloon Angioplasty in Patients with Critical Limb Ischemia.

Reference: Norihiro Kabayashi et al. Catheterization and Cardiovascular Interventions 2018;91:505-514.

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