Regarding “Limb-salvage angioplasty in vascular surgery practice”

Abstract

We read with great interest the article on infrainguinal angioplasty for limb salvage by Tefera et al.1Tefera G. Hoch J. Turnipseed W.D. Limb-salvage angioplasty in vascular surgery practice.J Vasc Surg. 2005; 41: 988-993Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Although distal bypasses are considered as the most durable revascularization procedures for patients with chronic critical limb ischemia secondary to infrapopliteal occlusive disease,2Pomposelli F.B. Kansal N. Hamdan A.D. Belfield A. Sheahan M. Campbell D.R. et al.A decade of experience with dorsalis pedis artery bypass Analysis of outcome in more than 1000 cases.J Vasc Surg. 2003; 37: 307-315Abstract Full Text PDF PubMed Scopus (320) Google Scholar there is increasing evidence of usefulness of endovascular techniques. We would like to make some necessary comments regarding this study, which adds to the growing literature on infrapopliteal angioplasty. 1There is frequently a multisegmental or multivessel involvement (ie, two or three crural arteries) in these patients.3Soder H.K. Manninen H.I. Jaakkola P. Matsi P.J. Rasanen H.T. Kaukanen E. et al.Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia angiographic and clinical results.J Vasc Interv Radiol. 2000; 11: 1021-1031Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar Did the authors consider recanalization of one patent vessel as a technical success, or was an attempt made to open up more than one vessel in the leg? 2Complications such as major dissection or plaque disruption with subsequent thrombosis may result in an acute deterioration in the severity of ischemia, especially so if the major collaterals are involved. As the “bail-out” option of stent is not applicable to these vessels, what was the treatment protocol for such events? 3Was surgical revascularization needed on an emergent basis? This would mandate a good surgical backup for endovascular procedures. 4We agree with the authors that ankle-brachial index measurements may not be helpful in more than 50% of patients during the follow-up period. What was their method of evaluation in patients with non-compressible leg vessels? We remain enthusiastic about this procedure and, like others,4Kudo T. Chandra F.A. Ahn S.S. The effectiveness of percutaneous angioplasty for the treatment of critical limb ischemia a 0-year experience.J Vasc Surg. 2005; 41: 423-435Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar, 5Faglia E. Paola L.D. Clerici G. Clerissi J. Graziani L. Fusaro M. et al.Peripheral angioplasty as the first choice revascularisation procedure in diabetic patients with critical limb ischemia Prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003.Eur J Vasc Endovasc Surg. 2005; 29: 620-627Abstract Full Text Full Text PDF PubMed Scopus (364) Google Scholar consider infrapopliteal angioplasty to be the initial choice for management of critical limb ischemia. We are a group of vascular surgeons who realized the magnitude of endovascular options more than 14 years ago and use subintimal angioplasty especially in diabetic patients with significant comorbidities. Long-term patency rates may not be as high or comparable with surgical revascularization, but if relief of rest pain wound healing and limb salvage can be achieved by a nonsurgical, minimally invasive option, the procedure has a good future. ReplyJournal of Vascular SurgeryVol. 43Issue 1PreviewWe agree with Dr Parakh in that percutaneous infrainguinal revascularization is an important adjunct and that there is growing evidence about its usefulness in a selected group of patients. Short of good prospective studies, however, some important questions (such as durability) may not be easily answered. Dr Parakh raises some important questions. Full-Text PDF Open Archive