Endovascular treatment of TransAtlantic Inter-Society Consensus II D femoropopliteal lesions in patients with critical limb ischemia

Clinical question
Is endovascular treatment technically feasible and effective in treating TASC II D femoropopliteal lesions in patients with critical limb ischemia?

Take-away point
Endovascular treatment of TASC II D femoropopliteal lesions is feasible and with good results. The primary patency in patients with popliteal artery occlusions involving the trifurcation vessels was better but the need for stent in this subgroup was associated with a low rate of limb salvage.

Reference
Biagioni RB, Brandão GD, Biagioni LC, Nasser F, Burihan MC, Ingrund JC. Endovascular treatment of TransAtlantic Inter-Society Consensus II D femoropopliteal lesions in patients with critical limb ischemia. J Vasc Surg. 2019 Jan 2. pii: S0741-5214(18)32245-6. doi: 10.1016/j.jvs.2018.08.176. [Epub ahead of print] PubMed PMID: 30611581.

Click here for abstract

Study design: Retrospective

Funding source: Self-funded or unfunded

Setting: Single center

Summary

Researches from Brazil published their results on endovascular approach to treat TASC II D lesions involving the femoropopliteal segment. The primary objective was to evaluate limb salvage and primary patency. A total of 91 patients were included (91 procedures). All patients had critical limb ischemia and were considered poor surgical candidates. The mean length of occlusions was 27.2 cm +/- 7.6 cm. Plain balloon angioplasty was performed in all patients and stenting in 61 patients. Limb salvage at 30 days, 1 year, 2 years, 3 years, and 4 years was 95.2%, 82.2%, 76.9%, 71.8%, and 63.7%, respectively. Primary patency at 30 days, 1 year, 2 years, and 3 years was 91%, 60.1%, 55.7%, and 50.6%, respectively. Unsuccessful recanalization occurred in 4 patients (4.3%). Reintervention rate was 11.1%. Complications occurred in seven patients (7.7%), including acute thrombosis, perforation and slow-flow phenomenon. All successfully resolved after appropriate management. Sub-analysis demonstrated significant higher 60-day primary patency in patients with popliteal/infra-popliteal lesions compared to SFA lesions (standard error, <10%; log-rank, P = .039). Nevertheless, when stents were used in the popliteal/infra-popliteal segment the rate of major limb loss was significantly higher(log-rank, P = .033). The authors concluded that endovascular treatment of TASC II D femoropopliteal lesions is feasible and with good results. The primary patency in patients with popliteal artery occlusions involving the trifurcation vessels was better compared to the isolated SFA lesions, but the need for stent in the popliteal group was associated with a low rate of limb salvage.



Fig 1. A, Initial angiogram. A 20-cm occlusion from the middle superficial femoral artery (SFA) to the P2 popliteal segment. B, Arteriography after 5- 100-mm balloon inflation. Limiting flow dissection of the SFA. C, Nitinol 6- 200-mm stent. D, Completion angiogram. E, Diagnostic angiogram. F, After dilation. Note the limiting flow dissection at P3 popliteal segment. G, Spotting stent with a nitinol 4- 8-mm stent. H, Completion angiogram.

Commentary

This paper presents the results of a retrospective analysis of 91 patients with critical limb ischemia submitted to endovascular treatment of TASC II D lesions involving the femoropopliteal segment. These types of lesions are better suited to surgical repair according to the most recent TransAtlantic Inter-Society Consensus. However, ideal surgical candidates would present with acceptable overall state of health and an appropriate autologous bypass. Therefore, endovascular treatment is the only option for many patients with this condition. The study shows that this approach has high successful recanalization rate (95.7%) and acceptable low complication rate (7.7%). Overall limb salvage, which is the critical clinical outcome in this patient population was comparable to surgical repair. In addition, sub-analysis demonstrated that primary patency in patients with popliteal artery occlusions involving the trifurcation vessels was better compared to isolated SFA lesions, but the need for stent in the popliteal group was associated with low rate of limb salvage. Limitations of the study included the selection bias (only non-surgical candidates) and the utilization of conventional angioplasty balloons and stents instead of drug-coating balloons and drug-eluting stents. However, clinical results were still comparable to surgical repair reinforcing that even complex lesions are suitable for endovascular recanalization which will eventually become the first therapeutic option for all patients.

Post Author:
Ricardo Yamada, MD
Assistant Professor
Department of Radiology
Division of Vascular and Interventional Radiology
Medical University of South Carolina