Southern Association for Vascular surgery

October 17, 2008

Incidence and Clinical Significance of Distal Embolization During Percutaneous Lower Extremity Arterial Interventions: Results in 1218 Consecutive Lesions

Nicholas Morrissey*, Cassandra Villegas*, Jeannine Giacovelli*, John Karwowski*, James McKinsey*, K Kent*
Columbia/Weill Cornell Division of Vascular Surgery, New York, NY

Background. Distal embolization following percutaneous arterial intervention may result in end organ ischemia and limb loss. Such risk has prompted some surgeons to use distal protection devices during lower extremity intervention in spite of an absence of data to support this practice. We analyzed 1218 consecutive lower extremity interventions for evidence of distal embolization and sought to determine the impact of such events on clinical outcomes.
Methods. 1218 consecutive lower extremity percutaneous interventions were entered into a prospective database. All angiograms had pre and postintervention runoff images and were reviewed for evidence of embolization during the procedure. In addition, all operative reports were analyzed to determine if embolization occurred during the procedure. Preoperative demographic and lesion characteristics were collected as was the intervention type that immediately preceded the embolization. Difference in embolization rates for atherectomy vs. angioplasty/stent were analyzed using Fisher’s exact test.
Results.. Lesion characteristics and primary treatment modality are shown in table 1. Embolization events are outlined in table 2. Claudication was the indication for treatment in 44% and limb threat was present in 56% of patients.



Lesion location (n)			Primary Treatment Modality
Iliac	Femoral/popliteal	Tibial	Atherectomy (n)	Angioplasty +/- stent (n)
74	826	318	575	643



Embolization Events n (%)				Embolization events after atherectomy N (%)	Embolization events after angioplasty +/- stent n (%)
Overall	Iliac	Fem/pop	Tibial	9 (1.5%)	3 (.4%)
12 (1)	0	9 (.8)	3 (.9)	P=0.25

Limb salvage was 92% in patients who had angiographically significant embolization, and 93% in those without embolization. Primary patency was 63% in patients without embolization events and 16% in the group with embolization. Of the 12 cases where angiographically apparent embolization or loss of runoff occurred, two patients left the operating room without reestablishment of preprocedural runoff (16%). One case of embolization occurred in a patient with suspected acute thrombosis and three occurred after treatment for in-stent restenosis .
Conclusion. Angiographically significant embolization is a rare event that does not increase risk of limb loss. There is a trend towards more embolization following atherectomy compared to angioplasty/stent however the events are too infrequent to prove statistical significance. There may be an increase in primary treatment failure following embolization in the long-term, however the number of events is too small to prove significance. The low rate of embolization seen without distal protection combined with the cost of these devices, suggests that their use be limited to high-risk cases. This supports the need for a large registry to track patients and allow for risk stratification to determine which patients may benefit from distal protection during lower extremity intervention.

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