Original title: Long-term outcomes following infrapopliteal angioplasty for critical limb ischemia. Reference: Ruby C. Lo et al. J Vasc Surg 2013;-:1-10.

Angioplasty has established itself as an alternative for the treatment of infrainguinal peripheral disease with comparable results in terms of limb salvage for surgery. 

However, this data refers to the iliac or femoral territory but it is not clear information as regards the infrapatellar, mainly for the long term. 413 consecutive patients were included in the registry showing infrapatellar disease and critical limb ischemia with a mean of 15 months. The intended treatment was balloon angioplasty unless dissection would present a compromised blood flow or residual injury > 30%. 

Most patients, (79%), presented active ulcers and fewer, (12%), just rest pain. Intervention in multiple segments, (infrapatellar + femoropopliteal or iliac), was performed on 50% of the population. Technical success was achieved in 93% of procedures and the most common reason for failure was the inability to cross the total occlusion guide. 15% required implantation of a stent for dissection with a compromised flow. 

Periprocedural complications occurred in 52 patients, (11%), being the most frequent vascular complication followed by acute kidney injury. Also significantly associated with these complications were prior use of warfarin, (23% versus 8%, p = 0.001), and antegrade access, (24% versus 10%, p = 0.025). In-hospital mortality was 2%, 17% after one year, 36% after three years and reaching 51% after five years. The limb salvage was 84% at one year and 81% for those who survived up to 5 years.

Conclusion: 

Infrapatellar angioplasty can achieve limb salvage and survival rates at 5 years similar to those reported for surgery and so can be considered a reasonable first choice of treatment.

Commentary: 

Although restenosis at 5 years reached 74%, (this could be high enough to rethink the strategy), it should not be forgotten that the objective for a patient with critical ischemia is to avoid amputation. This was achieved in 81% of the population in the same period of 5 years. If you get even a permeable vessel to the foot and heal wounds, the target has been reached, and perhaps, reestenosis will appear . Nor should we forget that the high mortality of these patients is where peripheral vascular disease is only one of multiple comorbidities. 

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