Study Supports Endovascular-First Approach for Infrapopliteal Occlusions in Patients With CLI

April 29, 2014—In the Journal of Vascular Surgery, Gagan D. Singh, MD, et al published findings from a study that sought to describe the procedural characteristics and outcomes of patients with infrapopliteal (IP) occlusions who underwent endovascular intervention for the treatment of critical limb ischemia (CLI) (2014;59:1300–1307). The investigators noted that IP occlusions are common in CLI patients, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel.

As summarized in the Journal of Vascular Surgery, the study included all patients who underwent IP interventions for treatment of CLI from 2006 to 2012. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions versus IP stenoses. Restenosis was determined by Doppler ultrasound imaging. The limb salvage rate was the primary endpoint of the study. Additional endpoints included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival.

The investigators reported that a total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients who underwent intervention for IP occlusions were more likely to have zero- or one-vessel runoff (83% vs 56%; P < .001) compared with interventions for stenosis. 

In comparison to IP stenoses, IP occlusions were longer (118 ± 86 mm vs 73 ± 67 mm; P < .001) and had smaller vessel diameters (2.5 ± 0.8 mm vs 2.7 ± 0.5 mm; P = .02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success rate for IP occlusion treatment 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 intervention group, and lowest in the failed occlusion intervention group (92% vs 75% vs 58%, respectively; P = .02). 

Finally, 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), according to the investigators.