Angioplasty Versus Stenting for Infrapopliteal Arterial Lesions in Chronic Limb-Threatening Ischaemia (Review)

Clinical question
Is there a benefit to percutaneous transluminal angioplasty (PTA) with stent placement versus PTA alone in the infrapopliteal arterial system in patients with Chronic Limb Threatening Ischemia (CLTI).

Take-away point
Based on review of available suitable studies, there is not enough evidence to suggest that stent placement in addition to PTA is superior to PTA alone the infrapopliteal arterial system provides added patency, and reduction in complications, mortality or amputation in patients with CLTI.

Reference
Hsu CCT et al. Angioplasty Versus Stenting for Infrapopliteal Arterial Lesions In Chronic Limb-Threatening Ischaemia (Review). Cochrane Database of Systematic Reviews 2018, Issue 12. Art No.: CD009195

Click here for abstract

Study design: Meta-analysis (other)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Summary

Comprehensive review was performed of studies and trials that examined PTA versus PTA with stent placement in the infrapopliteal arteries (anterior tibial, peroneal and posterior tibial arteries, and the tibioperoneal trunk in patients classified with CLTI. After sorting through approximately 14k results, after multifactorial analysis to filter down to randomized or quasi-randomized trials, a total of seven studies were included. These included a variety of stent types (structure/drug presence/permanence) and CLTI stage. The timeframe of the selected studies ranged from 2006-2016. Exclusion criteria included patients that underwent atherectomy.

After analysis of the seven studies, the authors deducted that there was increased technical success rates when stent scaffolding was used. However, they found no significant difference in short term patency, complications, mortality or amputations. A weakness identified in comparing these studies included lack of uniformity of anti-platelet/anti-coagulation regimens.

Commentary

This review attempts to determine if there is sufficient evidence that can help establish superiority of scaffold placement in the infrapopliteal arteries for patients with CLTI. Although patency is considered similar for the two, the 6-month follow-up of most of the included studies is not sufficient enough to draw conclusions. Technical success is considered better with stenting, however availability and experience with tibial stenting would already assume better outcomes. There is considerable variability between the studies, including one study looking at bio absorbable stents (incidentally industry funded), and another that demonstrated a 5-fold increase in size of ulcers that were treated in the stenting cohorts. The lack of uniformity in anti-platelet/anti-coagulation treatment also creates significant bias.

What is clear is that truly randomized studies are needed for this patient population that needs as much patent flow as possible to prevent major amputation and death. This is of particular importance as currently there are self-expanding drug eluting tibial stents that will be shortly available for use, and we all need more understanding as to the appropriateness of stent placement other than as a bailout or clear refractory lesions despite aggressive interventions with differing balloon types and atherectomy.

Post Author:
Kumar Madassery, MD
Assistant Professor, Vascular & Interventional Radiology
Rush University Medical Center
Rush Oak Park Hospital
@kmadass