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Infrapopliteal Angioplasty For Critical Limb Ischemia and Relation Of TASC Class

Objective
Recent data suggests that angioplasty may be appropriate primary therapy for critical limb ischemia. However, there is little data regarding infrapopliteal angioplasty outcomes based on TASC classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification.
Methods
From July 2004 to April 2006, 99 consecutive patients (105 limbs) with CLI underwent infrapopliteal angioplasty. 58% were male, 73% diabetic and 21% had renal failure. Stents were placed for lesions refractory to PTA or flow limiting dissections. We reviewed technical success(< 30% residual stenosis), complications, patency, limb salvage and survival. Patency was determined by duplex (3-fold velocity step up or occlusion) and freedom from intervention, bypass or amputation; and included technical failures.
Results
Technical success was 90% and predicted by TASC (100% A&B, 96% C, and 53% D, p<.0001 test for trend). Infrapopliteal stents were used in 8% of limbs. The 30-day mortality was 6% (6/104). No bypass options were compromised. Postoperative complications occurred in 16% (4 groin hematomas, 3 pseudoaneurysms, 5 transient contrast nephropathy, 3 CHF and 2 MI). Average follow-up was 11mos. 1-year primary patency was 40%. Limb salvage at one year was 78%. Survival was 86% and 77% at 1 and 2 years respectively. Of the 10 technical failures 1 underwent bypass, 1 had repeat angioplasty, 2 underwent amputation, 1 died without further intervention and 5 had no further treatment. Of 37 restenoses, 7 underwent bypass, 9 repeat angioplasty, 9 had amputation, 10 received no further treatment and 2 died without further therapy. With regards to the 11 amputations,10 were not candidates for bypass and one was amputated with a patent bypass.
Conclusion
TASC predicts technical success. Although primary patency is inferior to bypass, limb salvage is similar. Infrapopliteal angioplasty may be appropriate primary therapy, particular in those with suboptimal bypass options.