Comparative study between simultaneous and two-stage revascularization in patients with multi -segmental lower limbs arterial occlusive disease

Abstract

Background: Peripheral arterial disease (PAD) is defined as a slowly progressing, occlusive vascular disease of the extremities primarily due to atherosclerosis which can involve vasculitis and thrombosis and diagnosed by an ankle-brachial index (ABI) less than 0.9. It may lead to intermittent claudication (IC) and with progression of the disease may lead to critical limb ischemia (CLI). Aim of the work: to compare the results between simultaneous revascularization of all level arterial lesions versus staged revascularization of the proximal or distal lesions regarding limb salvage rates, midterm primary patency rates, and secondary patency rates in multi-segment peripheral arterial disease Study Design and methodology: randomized comparative study. We randomly divided patients into two groups. Group A (20 patients: treated by total revascularization of all arterial lesions affecting the target limb) and Group B (20 patients: treated staged revascularization). Results: success rate after total revascularization (group A) reaching 82.5% success rate, success rate after staged revascularization (group B) reaching 65% success rate from inflow cases and 66.7% of the outflow repair. We achieved a limb salvage rate of 67.5% (27 patients). The difference between the groups was not statistically significant regarding amputation rates (P=0.99). Primary patency rate at 12 months was not significantly higher in group A than in group B (65% vs. 50%; P =0.98). Wound closure was statistically higher in group A than in group B (P=0.04). Reintervention was needed in 12 patients owing to restenosis or total occlusion of the treated lesions presenting with either lost pulses, rest pain, or deterioration of the wound healing. The secondary patency rates were non statistically significant between group A and group B at 12 months (3 patients 60%, 2 patients 28.6%) (P=0.56). Hospital mortality was 5% in Group A and 10% in Group B. Group A showed lower amputation rate but non-significantly different with group B (P=0.5). Conclusion: We conclude that multi-segmental reconstructions for multilevel occlusive arterial disease is a safe and effective method of treatment in the presence of CLI. Correction of the proximal lesions only cannot be considered satisfactory especially in patients presenting with tissue loss as it is usually associated with inferior patency rates and low overall limb salvage rates.