Print this pageThe Role of Subintimal Angioplasty (S-PTA) For Limb Salvage in Lower Extremities (LE) with Severe Chronic Ischemia
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Stuart I. Myers, MD.
Virginia Commonwealth University, Richmond, VA, USA.
BACKGROUND: Use of endovasacular techniques in patients with severe chronic leg ischemia due to arterial occlusive disease has been controversial. This study examined the hypothesis that use of lower extremity (LE) subintimal angioplasty (S-PTA) can maintain limb salvage with minimal morbidity and mortality in patients with severe LE chronic ischemia and occlusive arterial disease.
METHODS: From 3/1/04 until 8/27/05, 52 patients with rest pain (60%), gangrene (20%) or severe progressive claudication (20%) were prospectively treated for infra-inguinal occlusive arterial disease. All patients underwent attempts at S-PTA of either superficial femoral artery (48, SFA) or tibial (4) occlusions. All patients were treated in the operating suite under local anesthesia. The patients were followed at 1day, 1 month, then every 3 months post S-PTA with physical exam and arterial non-invasive testing.
RESULTS: Mean age was 59+/-1.6 years and 15 patients were female (29%). The following risk factors were present: Tobacco - 88.4%; Diabetes Mellitus- 71%; Coronary artery Disease - 46%; High blood pressure - 75%; History of stroke - 9.5%; Serum Lipid abnormality - 57% and the serum creatinine was 1.5 +/- .18 mg/dL. 46 of 52 patients underwent successful LE SI-PTA ( 88.5%). 42 of these 46 patients had an an occluded superficial femoral artery (SFA) and successfully underwent SFA S-PTA of which 25 required a stent (59.5%.). 21 of these 42 patients required an additional PTA or S-PTA of the iliac artery (6), proximal SFA (3), popliteal artery (7) or infra-popliteal arteries (5). Four patients successfully underwent S-PTA of an isolated occlusion of the peroneal artery (3) or anterior tibial artery (1), none of these patients required a stent. The ABI increased from .45+/-.02 to .88+/-.02 with resolution of all symptoms and have remained stable during follow-up. S-PTA angioplasty of the SFA failed in 6 patients, 4 due to inability to pass a wire through the arterial occlusion and 2 failed due to the inability to follow successful wire placement with catheter advancement. Four of the 6 patients were female, 2 of which reported active cocaine use. Five of the 6 S-PTA failures underwent leg amputation within 30 days, one patient refused amputation and was lost to follow-up. Of the 46 patients successfully treated with lower extremity S-PTA, 2 patients occluded their patent S-PTA SFA reconstruction within 30 days (and were treated successfully with bypass surgery) and 1 occluded at 7 months and refused further reconstruction. The remaining 43 S-PTAs have remained patent (mean follow-up 8+/-.7 months) with 2 patients requiring limited PTA of asymptomatic re-stenosis as identified by non-invasive testing 6 and 7 months post SFA S-PTA. No local or systemic complications were found. Three patients died during follow-up, 2 from cancer (7 and 9 months post S-PTA) and 1 from an MI (12 months post S-PTA), all of whom died with a patent SFA S-PTA.
CONCLUSIONS: These data suggest that S-PTA can be successfully used for limb salvage in a high risk group of patients with severe lower extremity occlusive vascular disease with minimal morbidity and mortality.
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