Login to Download
PDF version

Index: WOUNDS 2011;23(12):357–363

  Abstract: Although operative bypass is still considered the “gold standard” for treating peripheral arterial disease, over the last decade endovascular interventions have become more popular and now represent the vast majority of peripheral arterial treatments being performed. Open bypass is associated with an unacceptable morbidity and mortality that is not encountered to the same extent with endovascular techniques. However, outcomes of endovascular intervention are dependent upon the location and nature of the lesion, as well as possibly the technologies available to treat the lesion and the experience of the interventionalist. In correctly selected patients, endovascular techniques should be the primary management employed for critical limb ischemia. The group of patients that would benefit from endovascular techniques continues to expand with new data constantly emerging. This article will review the current endovascular techniques currently being employed, focusing on the indication for specific intervention.

Introduction

  Critical limb ischemia (CLI) has been defined as patients with chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease.¹ CLI is a serious threat to life, and is associated with great morbidity and premature mortality. Within 3 months of presentation, 9% of patients will die, 1% will have a myocardial infarction, 1% will suffer from stroke, 12% will have an amputation, and 18% will have persistent CLI. CLI is a marker of premature death. Mortality rates are 21% at 1 year and 31.6% at 2 years.^1,2 Patients have chronic ischemic rest pain or gangrene due to arterial disease. Unfortunately, most of these patients will require a major amputation within 6 months to 1 year without undergoing hemodynamic improvement in their affected limb. Patients with CLI require life-prolonging intervention.¹

Indication for Endovascular Intervention

  Surgical intervention in CLI has long been the “gold standard” of improving hemodynamics, and ultimately, wound healing. Surgery is associated with significant morbidity and mortality. A randomized control trial comparing surgical bypass and angioplasty published in 2003 concluded that surgery is associated with a significantly higher rate of morbidity at 30 days (57% vs. 41%); however, after 2 years, surgery is associated with a reduced risk of future amputation, death, or both.³ Endovascular intervention in arterial disease is less invasive and therefore carries a lower risk profile. Endovascular approaches to limb salvage currently represent 70% of total interventions.^4,5 Endovascular treatment has multiple benefits. Patients with CLI may not have appropriate bypass targets due to the nature of their disease, or they may not have adequate saphenous vein to provide as a bypass conduit. Additionally, patients with CLI have abundant medical comorbidities that make them poor operative candidates. Therefore, endovascular therapy may be the only option for these patients who would otherwise not be amenable to surgical bypass. Most current endovascular therapies are designed for aortoiliac and superficial fermoral artery (SFA) segment disease. The role of endovascular intervention depends on the TransAtlantic Inter-Society Consensus (TASC) classification of lower extremity arterial lesions. TASC classification of lesions is based upon a review of the world literature, in regards to the quality of the literature (Grade A–C), and the success rates for types of procedures in various lower extremity vascular beds.