Contemporary Management of Infrapopliteal Peripheral Arterial Disease

Abstract

Peripheral arterial disease (PAD) is a common manifestation of atherosclerotic vascular disease and the incidence of infrapopliteal PAD continues to rise in the population. The historical experience with surgical and endovascular interventions for infrapopliteal stenosis was disappointing as operators experienced high rates of early technical failures and procedural complications, coupled with high rates of restenosis in this vascular territory when compared with more proximal vascular beds. While patients with infrapopliteal PAD may be asymptomatic, the majority would ultimately develop intermittent claudication or may also present with critical limb ischemia. In this article, we review the current literature, and discuss some of the technical aspects of endovascular therapy in this vascular bed. We also emphasize the importance of adjunctive evidence-based therapies such as antiplatelet agents, statins, and lifestyle modification such as smoking cessation in this particularly high-risk cohort to optimize clinical outcomes.

Cellular Therapy With Ixmyelocel-T to Treat Critical Limb Ischemia: The Randomized, Double-blind, Placebo-controlled RESTORE-CLI Trial

“…After undergoing a major amputation, these patients often suffer from surgical complications either from the amputation procedure itself or from their postoperative clinical state. 5,14 Less invasive medical therapies efficacious in the treatment of CLI are, therefore, desirable. Treatment with ixmyelocel-T would require patients to undergo a small volume bone marrow aspiration under conscious sedation followed by intramuscular injections into the affected limb.…”

“…4 Although revascularization is a mainstay of treatment, it often is not feasible due to medical comorbidities or no anatomic options, and is associated with significant rates of complications. [5][6][7] In addition, in CLI patients with tissue loss, survival and limb-related outcomes are poor as compared with CLI patients with rest pain only. 8 Patients with severe ischemia who are unable to undergo revascularization or with a failed revascularization have limited options and amputation is often necessary.…”

Peripheral Arterial Disease

“…The mainstay of the therapeutic approach of patients with PAD consists of measures aimed at reducing the global atherosclerotic burden. 30 These include smoking cessation, a structured exercise program, aggressive pharmacologic management of dyslipidemia, initiation of antiplatelet and antihypertensive treatment as well as control of hyperglycemia. 30 The results of the various surgical 31,32 and endovascular interventions 33,34 are considerably poorer if they are not coupled with these measures.…”

“…Finally, the treatment of PAD should not be limited to the peripheral circulation, but should extend to manage and decrease the systemic atherosclerotic burden of the patient. 30…”