Clinical Efficacy of Successful Angioplasty in Critical Ischemia - A Cohort Study.
ABSTRACT to evaluate the impact of the initial result of percutaneous angioplasty (PA), objectively assessed with duplex-ultrasound, in the three-years clinical outcome.
thirty-nine patients with atherosclerotic disease successfully treated by PA were included (40 limbs). All patients had critical ischemia with rest pain and ischemic ulcers due to infrainguinal obstructions alone. The patients were submitted to duplex-ultrasound examination on the day before and on the first or second day after the procedure. Peak systolic velocities (PSV) was recorded in the anterior tibial, posterior tibial and fibular arteries at the level of distal third of the leg. All patients were followed for 3 years. Comparison between good and bad groups were based on perioperative VPS gradient (GPSV) of the mean of the VPS in the 3 arteries. After 3-years good result were defined as good when the patient had no pain and complete healing of a previous ulcer or minor amputations.
Mean age was 68,5 ± 8,1 years-old with no difference in demographic characteristics (p>0,05). In 26 cases the long-term result was good. Healing time ranged from 4 to 130 weeks (median 26.5). Bad long-term results were observed in 12 cases. Two lesions had persisted unhealed despite patent angioplasty. In 10 cases a second procedure was carried out (redo angioplasty in 6 and bypass in 4). TASCII A/B registered better clinical success then TASCII C/D (p<0,05) at 1-year follow-up but not at 3-years (p=0,36). Two-year limb salvage was 92,5% ± 4,2%. Primary patency was 52,5% ± 9,5% in 3-years. GVPS was 21,9 cm/s in good group and 24,7cm/s in bad group (p>0,05). The quality of the initial result, as measured by GPSV, was not associated with a good or bad long-term success (p>0,05).
once the procedure was successfully performed, the degree of increase in flow is not related to the long-term durability and ulcer healing. Descriptors: Angioplasty; Lower extremity; Ultrasonography Doppler; Surveillance; Postoperative period; Atherosclerosis; Leg ulcer; Wound healing.
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ABSTRACT: To evaluate the long-term outcome of infrainguinal percutaneous transluminal angioplasty (PTA). Between 1991 and 1994, 77 patients (45 men; mean age 70 years, range 41-85) underwent infrainguinal PTA for occlusive disease. Patient records and angiographic examinations were reviewed to extract data to a patient register. A long-term (mean 9.3 years) follow-up examination of survivors was performed, including physical evaluation, walking impairment questionnaire (WIQ), and duplex ultrasound. Cumulative primary and secondary patency rates, respectively, were 81% and 86% at 1 year, 65% and 73% at 5 years, and 12% and 17% at 10 years. Patency rates were better for patients with claudication than critical ischemia (p=0.02). Stenoses had better primary patency than occlusions (p=0.001), but there was no difference between stenoses <2 cm versus >/=2 cm. At long-term follow-up, patients with patent vessels (50%) had better ankle-brachial indices (p=0.01) and less pain in their calves (p=0.04) compared to patients with non-patent vessels, but there was no difference in walking capacity or quality of life. Generalized femoral artery disease (p=0.03) and diabetes mellitus (p=0.03) predicted poor survival. Although the overall long-term patency of infrainguinal PTA is poor, the technique has a low morbidity and can be performed in selected patients with a reasonable long-term result.Journal of Endovascular Therapy 06/2004; 11(3):287-93. · 3.59 Impact Factor
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ABSTRACT: The treatment of rest pain, ulceration, and gangrene of the leg (severe limb ischaemia) remains controversial. We instigated the BASIL trial to compare the outcome of bypass surgery and balloon angioplasty in such patients. We randomly assigned 452 patients, who presented to 27 UK hospitals with severe limb ischaemia due to infra-inguinal disease, to receive a surgery-first (n=228) or an angioplasty-first (n=224) strategy. The primary endpoint was amputation (of trial leg) free survival. Analysis was by intention to treat. The BASIL trial is registered with the National Research Register (NRR) and as an International Standard Randomised Controlled Trial, number ISRCTN45398889. The trial ran for 5.5 years, and follow-up finished when patients reached an endpoint (amputation of trial leg above the ankle or death). Seven individuals were lost to follow-up after randomisation (three assigned angioplasty, two surgery); of these, three were lost (one angioplasty, two surgery) during the first year of follow-up. 195 (86%) of 228 patients assigned to bypass surgery and 216 (96%) of 224 to balloon angioplasty underwent an attempt at their allocated intervention at a median (IQR) of 6 (3-16) and 6 (2-20) days after randomisation, respectively. At the end of follow-up, 248 (55%) patients were alive without amputation (of trial leg), 38 (8%) alive with amputation, 36 (8%) dead after amputation, and 130 (29%) dead without amputation. After 6 months, the two strategies did not differ significantly in amputation-free survival (48 vs 60 patients; unadjusted hazard ratio 1.07, 95% CI 0.72-1.6; adjusted hazard ratio 0.73, 0.49-1.07). We saw no difference in health-related quality of life between the two strategies, but for the first year the hospital costs associated with a surgery-first strategy were about one third higher than those with an angioplasty-first strategy. In patients presenting with severe limb ischaemia due to infra-inguinal disease and who are suitable for surgery and angioplasty, a bypass-surgery-first and a balloon-angioplasty-first strategy are associated with broadly similar outcomes in terms of amputation-free survival, and in the short-term, surgery is more expensive than angioplasty.The Lancet 01/2006; 366(9501):1925-34. · 39.21 Impact Factor
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ABSTRACT: Despite recent studies highlighting the advantages of endoluminal intervention in the management of chronic limb ischemia (CLI), outcomes following failed peripheral angioplasty remain less well described. We present a retrospective analysis of failed transluminal infrainguinal percutaneous arterial angioplasty with or without stenting (PTA/S) in patients with CLI. A database of patients undergoing infrainguinal PTA/S between 2002 and 2005 was maintained. Patients underwent duplex scanning follow-up at 2 weeks, 3 months, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics. Results were standardized to current Transatlantic Inter-Society Consensus (TASC) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. In total, our analysis involved 246 patients who underwent treatment for CLI using PTA/S. Eighteen percent of procedures (n = 46) were considered an intervention failure secondary to restenosis by duplex ultrasound, returning clinical symptoms, a nonhealing foot lesion, or the absence of a prior palpable pulse. Indications for the original procedure in patients whose PTA/S failed were tissue loss in 44%, claudication in 44%, and rest pain in 12%, while TASC lesion grades were A (0%), B (18%), C (18%), and D (64%). Of patients failing PTA/S, 4% failed in the first 30 days, 78% failed between 1 and 18 months, while 18% failed following 18 months, with a mean time to failure of 8.7 months. Also, 82% of PTA/S failures were candidates for a second endovascular procedure, 11% were suitable for only traditional open bypass, and 4% demonstrated progression of disease necessitating amputation. Of patients undergoing a second endovascular procedure, limb salvage rates were 86% at 12-month follow-up and there was a single periprocedural mortality and complication rate of 6.6%. Of patients requiring open surgical bypass after failed PTA/S, 20% (n = 1) required a major amputation and there were no mortalities. Failure of endoluminal therapy for treatment of lower extremity arterial occlusive disease is amenable to subsequent endovascular intervention for limb salvage with limited morbidity and mortality.Annals of Vascular Surgery 08/2006; 20(4):440-6. · 1.03 Impact Factor