Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia

Gagan D. Singh, Ehrin J. Armstrong, Khung Keong Yeo, Satinder Singh, Gregory G. Westin, William C. Pevec, David L. Dawson, John R. Laird

Research output: Contribution to journalArticle

Abstract

Background Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. Methods All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. Results A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P <.001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P <.001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P =.02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P =.02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63). Conclusions Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.

Original languageEnglish (US)
Pages (from-to)1300-1307
Number of pages8
JournalJournal of vascular surgery
Volume59
Issue number5
DOIs
StatePublished - May 2014
Externally publishedYes

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Ischemia
Extremities
Limb Salvage
Pathologic Constriction
Amputation
Confidence Intervals
Doppler Ultrasonography
Therapeutics
Catheters
Survival

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia. / Singh, Gagan D.; Armstrong, Ehrin J.; Yeo, Khung Keong; Singh, Satinder; Westin, Gregory G.; Pevec, William C.; Dawson, David L.; Laird, John R.

In: Journal of vascular surgery, Vol. 59, No. 5, 05.2014, p. 1300-1307.

Research output: Contribution to journalArticle

Singh, GD, Armstrong, EJ, Yeo, KK, Singh, S, Westin, GG, Pevec, WC, Dawson, DL & Laird, JR 2014, 'Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia', Journal of vascular surgery, vol. 59, no. 5, pp. 1300-1307. https://doi.org/10.1016/j.jvs.2013.11.061
Singh, Gagan D. ; Armstrong, Ehrin J. ; Yeo, Khung Keong ; Singh, Satinder ; Westin, Gregory G. ; Pevec, William C. ; Dawson, David L. ; Laird, John R. / Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia. In: Journal of vascular surgery. 2014 ; Vol. 59, No. 5. pp. 1300-1307.
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abstract = "Background Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. Methods All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. Results A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41{\%}) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83{\%} vs 56{\%}; P <.001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P <.001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P =.02). Wire crossing was achieved in 83{\%} of IP occlusions, and the overall procedural success for IP occlusions was 79{\%}. The overall 1-year limb salvage rate was 84{\%}. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92{\%} vs 75{\%} vs 58{\%}, respectively; P =.02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95{\%} confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95{\%} confidence interval, 1.09-6.63). Conclusions Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.",
author = "Singh, {Gagan D.} and Armstrong, {Ehrin J.} and Yeo, {Khung Keong} and Satinder Singh and Westin, {Gregory G.} and Pevec, {William C.} and Dawson, {David L.} and Laird, {John R.}",
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T1 - Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia

AU - Singh, Gagan D.

AU - Armstrong, Ehrin J.

AU - Yeo, Khung Keong

AU - Singh, Satinder

AU - Westin, Gregory G.

AU - Pevec, William C.

AU - Dawson, David L.

AU - Laird, John R.

PY - 2014/5

Y1 - 2014/5

N2 - Background Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. Methods All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. Results A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P <.001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P <.001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P =.02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P =.02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63). Conclusions Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.

AB - Background Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. Methods All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. Results A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P <.001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P <.001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P =.02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P =.02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63). Conclusions Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.

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