Shifting paradigms in the treatment of lower extremity vascular disease: a report of 1000 percutaneous interventions

Abstract

Objectives: Catheter-based revascularization has emerged as an alternative to surgical bypass for lower extremity vascular disease and is a frequently used tool in the armamentarium of the vascular surgeon. In this study we report contemporary outcomes of 1000 percutaneous infra-inguinal interventions performed by a single vascular surgery division.

Methods: We evaluated a prospectively maintained database of 1000 consecutive percutaneous infra-inguinal interventions between 2001 and 2006 performed for claudication (46.3%) or limb-threatening ischemia (52.7%; rest pain in 27.7% and tissue loss in 72.3%). Treatments included angioplasty with or without stenting, laser angioplasty, and atherectomy of the femoral, popliteal, and tibial vessels.

Results: Mean age was 71.4 years and 57.3% were male; comorbidities included hypertension (84%), coronary artery disease (51%), diabetes (58%), tobacco use (52%), and chronic renal insufficiency (39%). Overall 30-day mortality was 0.5%. Two-year primary and secondary patencies and rate of amputation were 62.4%, 79.3%, and 0.5%, respectively, for patients with claudication. Two-year primary and secondary patencies and limb salvage rates were 37.4%, 55.4%, and 79.3% for patients with limb-threatening ischemia. By multivariable Cox PH modeling, limb-threat as procedural indication (P < 0.0001), diabetes (P = 0.003), hypercholesterolemia (P = 0.001), coronary artery disease (P = 0.047), and Transatlantic Inter-Society Consensus D lesion complexity (P = 0.050) were independent predictors of recurrent disease. For patients that developed recurrent disease, 7.5% required no further intervention, 60.3% underwent successful percutaneous reintervention, 11.7% underwent bypass and 20.5% underwent amputation. Patency rates were identical for the initial procedure and subsequent reinterventions (P = 0.97).

Conclusion: Percutaneous therapy for peripheral vascular disease is associated with minimal mortality and can achieve 2-year secondary patency rates of nearly 80% in patients with claudication. Although patency is diminished in patients with limb-threat, limb-salvage rates remain reasonable at close to 80% at 2 years. Percutaneous infra-inguinal revascularization carries a low risk of morbidity and mortality, and should be considered first-line therapy in patients with chronic lower extremity ischemia.

FIGURE 1. Primary and secondary patency rates for all interventions and limb-salvage rates for patients with limb-threatening ischemia (rest pain or tissue loss). Secondary patency was significantly higher than primary patency, reaching 66% at 2.5 years. Overall limb-salvage rate in patients with limb-threat was 79% at 2.5 years.

FIGURE 2. Primary and secondary patency rates for all interventions stratified by indication for procedure. Claudicants demonstrated significantly higher primary and secondary patency than patients with limb-threat.

FIGURE 3. Primary patency rates for all interventions stratified by risk factors for patency loss on univariate analysis including (A) diabetes, (B) coronary artery disease, and (C) lesions of increasing severity. Each of these factors was associated with decreased primary patency.

FIGURE 4. Primary patency rate of initial interventions compared with reinterventions. Reinterventions proved as durable as primary interventions.