Infrapopliteal Angioplasty of One or More than One Artery for Critical Limb Ischaemia: A Randomised Clinical Trial

Biagioni, Rodrigo Bruno; Biagioni, Luísa Ciucci; Nasser, Felipe; Burihan, Marcelo Calil; Ingrund, José Carlos; Neser, Adnan; Miranda, Fausto

doi:10.1016/j.ejvs.2017.12.022

Cited by 28 publications

(14 citation statements)

References 44 publications

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“…In 2018, Biagioni et al 11) reported on the clinical outcomes of 80 patients with CLI with popliteal lesions randomized into two groups: a multivessel treatment group and a single-vessel treatment group. The first artery to treat was selected on the basis of good outflow below the ankle, which made EVT feasible.…”

Section: Unfavorable Results Of Angiosome-guided Evtmentioning

confidence: 99%

Is Angiosome-Guided Endovascular Therapy Worthwhile?

Hata

Iida

Mano

2019

Annals of Vascular Diseases

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Endovascular therapy (EVT) plays a major role in the treatment of critical limb ischemia (CLI). The latest guidelines state that the angiosome concept should be considered when performing revascularization of infrapopliteal lesions in patients with CLI. There have been several reports both of favorable and unfavorable results of angiosome-guided EVT. Based on previous reports, angiosome-guided EVT tends to improve wound healing (WH) rather than amputation-free survival and overall survival. In addition, indirect revascularization based on the angiosome concept with a good collateral flow may achieve good WH comparable to that achieved by direct revascularization. In the future, rather than just debating the effectiveness/ineffectiveness of the angiosome concept, it will be desirable to investigate the patient and lesion characteristics that may have significant influences on WH after angiosome-guided EVT and to apply the results to clinical practice.

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Section: Unfavorable Results Of Angiosome-guided Evtmentioning

confidence: 99%

Is Angiosome-Guided Endovascular Therapy Worthwhile?

Hata

Iida

Mano

2019

Annals of Vascular Diseases

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“…7e9 However, there has been only one small prospective study. 7 It was also thought that multivessel recanalisation would be more advantageous for wound healing than single vessel revascularisation. In particular, in patients with ischaemic wounds, an attempt was made to revascularise as many tibial and pedal arteries as possible, whenever feasible.…”

Section: Discussionmentioning

confidence: 99%

Editor's Choice – Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia

Jung

Hong

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS Pedal arch patency has been associated with improved wound healing after revascularisation. However, limited data exist regarding the impact of endovascular pedal artery revascularisation (PAR) on clinical outcomes of patients with critical limb ischaemia (CLI). This study demonstrates that successful PAR in patients with CLI achieved higher rates of wound healing and freedom from major amputation than infrapopliteal revascularisation without PAR. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent in patients with CLI. Objective: The present study investigated the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with critical limb ischaemia (CLI). Methods: This retrospective analysis of a single centre cohort included 239 patients who underwent endovascular revascularisation of infrapopliteal arteries for a chronic ischaemic wound. PAR was attempted in 141 patients during the procedure. After propensity score matching, there were 87 pairs of patients with and without PAR. Results: After the matching, the two groups showed balanced baseline clinical and lesion characteristics. PAR was achieved in 60.9% of the PAR group. Direct angiosome flow was more frequently obtained in the PAR group than in the non-PAR group (81.6% vs. 34.5%; p < .001). Subintimal angioplasty (47.1% vs. 29.9%; p ¼ .019) and pedaleplantar loop technique (18.4% vs. 0%; p < .001) were more frequent in the PAR group. At the one year follow up, the PAR group showed greater freedom from major amputation (96.3% vs. 84.2%; p ¼ .009). The wound healing rate, overall survival, major adverse limb event, and freedom from re-intervention did not differ significantly between the two groups. However, the patient subgroup with successful PAR showed a higher wound healing rate than the non-PAR group (76.0% vs. 67.0%; p ¼ .031). In a multivariable Cox proportional hazards regression model, successful PAR (hazard ratio [HR] 1.564, 95% confidence interval [CI] 1.068e2.290; p ¼ .022) was identified as an independent factor associated with improved wound healing, whereas gangrene (HR 0.659, 95% confidence interval [CI] 0.471e0.923; p ¼ .015), C reactive protein >3 mg/ dL (HR 0.591, 95% CI 0.386e0.904; p ¼ .015), and pre-procedural absence of pedal arch (HR 0.628, 95% CI 0.431e0.916; p ¼ .016) were associated with impaired wound healing. Conclusion: Successful PAR significantly improved wound healing in patients with CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.

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“…A recent small randomised control trial (RCT) has suggested this correlation holds in a randomised cohort of patients undergoing tibial angioplasty, with patients undergoing more than one tibial artery angioplasty having quicker wound healing rates and a trend towards improved limb salvage than single vessel treatment. 63 The greater the number of tibial vessels opened the greater likelihood of revascularisation being direct, and the effect of this confounding variable is difficult to tease out in the literature. 64 Importantly in the above RCT, DR demonstrated no difference over IR in terms of wound healing and limb salvage, although numbers involved in this analysis were small.…”

Section: Explanation Of Findings and Implications For Practicementioning

confidence: 99%

Editor's Choice – Direct vs. Indirect Angiosomal Revascularisation of Infrapopliteal Arteries, an Updated Systematic Review and Meta-analysis

Dilaver

Twine

Bosanquet

2018

European Journal of Vascular and Endovascular Surgery

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Infrapopliteal Angioplasty of One or More than One Artery for Critical Limb Ischaemia: A Randomised Clinical Trial

Abstract: Endovascular treatment of more than one artery was associated with better wound healing rates but not with better limb salvage.

Cited by 28 publications

References 44 publications

Is Angiosome-Guided Endovascular Therapy Worthwhile?

Is Angiosome-Guided Endovascular Therapy Worthwhile?

Editor's Choice – Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia

Editor's Choice – Direct vs. Indirect Angiosomal Revascularisation of Infrapopliteal Arteries, an Updated Systematic Review and Meta-analysis

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