Efficacy of Endovascular Percutaneous Transcatheter Balloon Angioplasty in the Treatment of Critical Foot Ischemia

Öz

Aim: The aim of this study was to evaluate the efficacy of percutaneous transcatheter angioplasty (PTA) in infrapopliteal arteries with
peripheral arterial disease (PAH).

Material and Methods: Between January 2018 and January 2019, the recorded findings and control Doppler ultrasonography (DUSG)
reports of patients undergoing endovascular PTA treatment for infrapopilteal PAH were obtained. Pre- and post-treatment recorded
DSA images were analyzed to list which vascular structures were diseased, their number and response to treatment. Patients who received
endovascular treatment due to critical foot ischemia, ischemic resting pain or foot wound were included in the study. The normal
clearance of the diseased vascular structure in DSA and the adequate passage of the contrast medium to this level were determined as the
technical success criteria of endovascular treatment. In control DUSG applications, a normal form of triphasic lower extremity arterial
flow was determined as the patency criterion. After provincial treatment, one-year stay with no endovascular treatment was accepted
as primary patency. Secondary patency was considered if additional treatment was needed for vascular exposure during this period.

Results: Data from 19 patients with a total of 27 infrapopliteal artery disease treated endovascularly were included in the study. 15
(78.9%) patients had hypertension, nine (47.3%) had diabetes, seven (36.8%) had smoking history. 68.4% of patients had ischemic
skin ulcers and 42% had rest pain. There was exercise-induced pain in all of them. There was no major complication requiring surgical
intervention in any patient after PTA. One-year primary patency rate was 73.6% (14/19) and secondary patency rate was 84.2% (16/19).

Conclusion: Endovascular PTA can be used safely in the treatment of infapopliteal PAH with low complication and high patency rates.

Anahtar Kelimeler

• critical foot ischemia
• percutaneous transcatheter balloon angioplasty
• peripheral artery disease

Kritik Ayak İskemisi Tedavisinde Endovasküler Perkütan Transkateter Balon Anjioplasti Yönteminin Etkinliği

Öz

Amaç: Bu çalışmanın amacı periferik arter hastalığı (PAH) bulunan infrapopliteal arterlerde uygulanan perkütan transkateter anjioplasti
(PTA) tedavisinin etkinliğini değerlendirmektir.

Gereç ve Yöntemler: Ocak 2018 ve Ocak 2019 tarihleri arasında, infrapopilteal PAH nedeni ile endovasküler PTA tedavisi uygulanan
hastaların kayıtlı olan bulguları ve kontrol Doppler ultrasonografi (DUSG) raporları elde edildi. Tedavi öncesi ve tedavi sonrası kayıtlı
DSA görüntüleri incelenerek hangi vasküler yapıların hastalıklı olduğu, sayısı ve tedaviye yanıtı listelendi. Kritik ayak iskemisi olan,
iskemik dinlenme ağrısı veya ayak yarası olan endovasküler tedavi uygulanmış hastalar çalışmaya dâhil edildi. Endovasküler tedavi
teknik başarı kriterlerleri olarak, DSA’da hastalıklı vasküler yapının normal açıklığa ulaşması, kontrast maddenin bu seviye distaline
geçişinin yeterli olması olarak belirlendi. Kontrol DUSG uygulamalarda normal formda trifazik alt ekstremite arteryal akım formu
olması patensi kriteri olarak belirlendi. İlk tedavi sonrasında, başka endovasküler tedaviye ihtiyaç olmadan bir yıllık süreli açık kalma
lma durumu primer patensi olarak kabul edildi. Bu süreçte vasküler açık kalma için ek tedavi ihtiyacı olmuş ise sekonder patensi olarak
kabul edildi.

Bulgular: Endovasküler olarak tedavi edilmiş toplamda, 27 infrapopliteal arter hastalığı olan 19 hastanın verileri çalışmaya dâhil
edildi. Hastaların 15 (%78,9)’inde hipertansiyon, dokuzunda (%47,3) diyabet ve yedisi (%36,8) sigara kullanımı hikayesi mevcuttu.
Hastaların %68,4’inde iskemik cilt ülseri ve %42’sinde istirahat ağrısı mevcuttu. Tamamında egzersiz ile ortaya çıkan ağrı semptomu
oldu. Uygulanan PTA sonrası herhangi bir hastada cerrahi müdahale gerektiren majör komplikasyon olmadı. Bir yıllık primer patensi
oranı %73,6 (14/19), sekonder patensi oranı %84,2 (16/19) oldu.

Sonuç: İnfrapopliteal PAH tedavisinde endovasküler PTA düşük komplikasyon ve yüksek patensi oranları ile güvenle kullanılabilir

Anahtar Kelimeler

• kritik ayak iskemisi
• perkütan transkateter balon anjiyoplasti
• periferik arter hastalığı

Kaynakça

1. Gray BH, Diaz-Sandoval LJ, Dieter RS, Jaff MR, White CJ; Peripheral Vascular Disease Committee for the Society for Cardiovascular Angiography and Interventions. SCAI expert consensus statement for infrapopliteal arterial intervention appropriate use. Catheter Cardiovasc Interv. 2014;84:539–545. doi: 10.1002/ccd.25395.
2. Price JF, Mowbray PI, Lee AJ, et al. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh Artery Study. Eur Heart J. 1999;20:344-353.
3. Rand T, Uberoi R. Current status of interventional radiology treatment of infrapopliteal arterial disease. Cardiovasc Intervent Radiol. 2013;36:588– 598. doi: 10.1007/s00270-012-0524-8.
4. Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of critical limb ischemia. J Endovasc Ther. 2009;16(2):31–62. doi: 10.1583/08-2657.1.
5. Aihara H, Soga Y, Mii S, et al. Comparison of long-term outcome after endovascular therapy versus bypass surgery in claudication patients with TransAtlantic Inter-Society Consensus-II C and D femoropopliteal disease. Circ J. 2014;78:457–464. doi: 10.1253/circj.CJ-13-1147.
6. Söderström MI, Arvela EM, Korhonen M, et al. Infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first-line strategies in critical leg ischemia: a propensity score analysis. Ann Surg. 2010;252:765–773. doi: 10.1097/SLA.0b013e3181fc3c73.
7. Ahn SS, Rutherford RB, Becker GJ, et al. Reporting standards for lower extremity arterial endovascular procedures. Society for Vascular Surgery/International Society for Cardiovascular Surgery. J Vasc Surg. 1993;17:1103-1107.
8. Marston WA, Davis SW, Armstrong B, et al. Natural history of limbs with arterial insufficiency and chronic ulcerations treated without revascularization. J Vasc Surg. 2006;44:108-114.

9. Wolfe JHN, Wyatt MG. Critical and subcritical ischaemia. Eur J Vasc Endovasc Surg. 1997;13:578-582.
10. Most RS, Sinnock P. The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care. 1983;6:87-91.
11. Kalbaugh CA, Taylor SM, Blackhurst DW, et al. One year prospective quality of life outcomes in patients treated with angioplasty for symptomatic peripheral arterial disease. J Vasc Surg. 2006;44:296-302.
12. Fraser SC, al-Kutoubi MA, Wolfe JH. Percutaneous transluminalangioplasty of the infrapopliteal vessels: The evidence. Radiology. 1996;200(1): 33-36.
13. Conrad MF, Cambria RP, Stone DH, et al. Intermediate results of percutaneous endovasculartherapy of femoropopliteal occlusive disease: A contemporaryseries. J Vascular Surgery. 2006;44:762–769.
14. Shiraki T, Iida O, Takahara M, et al. Predictors of delayed wound healing after endovascular therapy of isolated infrapopliteal lesions underlying critical limb ischemia inpatients with high prevalence of diabetes mellitus and hemodialysis. Eur J Vasc Endovasc Surg. 2015; 49:565–573.
15. Christenson B, Rochon P, Gipson M, Gupta R, Smith M. Treatment of infrapopliteal arterial occlusive disease in critical limb ischemia. Semin Intervent Radiol 2014; 31:370–374.
16. Romiti M, Maximiano M, Cardoso Brochado-Neto F, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008; 47:975–981.
17. Tartaglia E, Lejay A, Georg Y, et al. Results of isolated infrapopliteal percutaneous transluminal angioplasty for critical limb ischemia in high-risk diabetic patients. Vascular 2016;24:515–522.