Invited commentary

Abstract

The role of endoluminal therapy in the treatment of peripheral arterial disease is dramatically expanding.1Anderson P.L. Gelijns A. Moskowitz A. et al.Understanding trends in inpatient surgical volume vascular interventions, 1980–2000.J Vasc Surg. 2004; 39: 1200-1208Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar Skeptics of endovascular therapy oft opine that PTA [percutaneous transluminal angioplasty] works best for those least in need of intervention, thus suggesting that PTA is reasonable for claudicants with focal lesions but has little to offer patients with critical limb ischemia (CLI). Ahn et al report a 10-year experience with a cohort of CLI patients managed by endoluminal therapy. Over the study period, 111 patients (128 limbs; 63% of total) with CLI were treated by PTA alone, whereas 76 limbs (37%) required open surgery. Technical success was 96%, clinical success was 93%, 30-day mortality was 0.9%, and long-term limb salvage was 89%. At first glance, these results in CLI patients after PTA are quite comparable to those of open surgery and seem astonishing. However, the devil is in the details. The mean follow-up was short (14.7 months) and likely reflected not only a shift toward less invasive approaches in recent practice, but also the sobering reality that patients with CLI do not live long (5-year series mortality of 56%). Many malignancies have superior survival rates. In addition, 45% of patients had rest pain without tissue loss, and 33% required only iliac PTA. It is no surprise that PTA for hemodynamic iliac lesions often resolves ischemic rest pain. Results were predictably worse in patients with tissue loss and multiple, distal, or TransAtlantic Inter-Society Consensus D lesions. Primary patency was low (31% at 5 years), but secondary patency was 76%; this implies the necessity for reintervention. The authors do not provide the frequency, morbidity, or costs of repeat interventions. Primary patency, however, may not be the ultimate objective of CLI treatment. A 5-year clinical improvement rate (defined by Society of Vascular Surgery category) of 80% and a 6-year limb salvage rate of 89% are more meaningful end points. What are the implications of this report? First, it is imperative that vascular surgeons become facile with thrombolysis, conventional PTA, subintimal angioplasty, newer technologies such as cutting balloons, and stent placement. These evolving therapies are applicable to an increasing percentage of our patients. Second, treatment outcomes require redefinition. Long-term patency should not be the Holy Grail of outcome assessment, particularly for CLI, in which symptom relief, lesion healing, and limb salvage, with minimal morbidity, are more critical end points. Open surgery offers excellent patency rates, but morbidity is significant.2Goshima K. Mills J.L. Hughes J.D. A new look at outcomes after infrainguinal bypass surgery traditional reporting standards systematically underestimate the expenditure of effort required to attain limb salvage.J Vasc Surg. 2004; 39: 330-335Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar Finally, it is clear that as the proportion of peripheral arterial disease patients effectively treated by endoluminal therapy expands, the numbers of open cases for practicing vascular surgeons and resident trainees will continue to wane. A recent report identified the difficulty in providing adequate numbers of open distal reconstructions for vascular surgical trainees because of the shift toward subintimal angioplasty.3Nasr M.K. Taylor P.J. Horrocks M. Vascular training in the UK femorodistal bypass, an index procedure?.Eur J Vasc Endovasc Surg. 2003; 25: 135-138Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar New clinical training paradigms for residents and changes in the residency review committee case volume and distribution (open vs PTA) requirements will need to be rapidly implemented. Although there will be a role for tibial bypasses and complex, open reconstructions for the foreseeable future, “admit that the waters, around you have grown … for the times they are a changin’.”4Dylan B. The. Columbia Records, New York1964Google Scholar The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: A 10-year experienceJournal of Vascular SurgeryVol. 41Issue 3PreviewTo determine the efficacy, safety, and long-term results, including continued clinical improvement and limb salvage, of percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). Full-Text PDF Open Archive