Current indications of endovascular management of infrai̇nguinal cli

1. Current Indications of Endovascular
Management of Infra-inguinal CLI:
Cairo University Report
Amr Ahmed Gad, MD
Prof. of Vascular Surgery
Cairo University

2. The Consensus Document of the European Working
Group Defined CLI as The Most Severe Clinical
Manifestation of PAD
• Persistent rest pain ( 74%) :
Requiring analgesics for 2 weeks
Resting Ankle pressure < 50 mmHg
Resting Toe pressure < 30 mmHg
OR
• Presence of gangrene (34%) or
ulcer (32%) of the foot / toes :
With the same resting pressure

3. Prognosis of CLI is often Poor
1- One - year mortality is 25 % ( directly or indirectly )
[Balmer etal, 2002]
2- Quality of life indices (psychological testing) ,
similar to terminal phases of cancer
3- 150000 pat. require LL amputation in USA
4- Prognosis after amputation is worse
- Periop. mortality [ 5% -10% for BKA ]
[ 15%-20% for AKA]
- After amputation : - 2 years mortality 40%
- Sec. amputation 30%
- Full mobility 50% in BKA
25% in AKA
[ Schainfeld & Inser (1999) CLI: Nothing to give at the office?]

4. Infra-inguinal CLI
Common Femoral Artery Lesions
• Only 13.1% of CLI
• Surgery(Endarterectomy)
Long term patency: 91% to 96%
Sec. patency & Limb salvage: 100%
Maintains the artery for endovascular access
( Schrijver , etal , 2010 )
• Endovascular treatment
- PTA : poorer results (? 100% tech success)
- Prim stent : Accepted midterm results
Limits future endovascular access
Risk of fracture(Hip joint)
very old & fragile pt
Isolated lesion
No limit for subsequent surgery
[Stricker ,etal , 2004]

5. Infra-inguinal CLI
Femoro-Popliteal Lesions
Approx 60% of CLI
Historically Surg. was primary strategy ,
NOW increasingly replaced by
Endovascular treatment as 1st line
therapy
The ideal bypass conduit is LSV
Femoro-pop. Bypass
- Primary 5-year patency rates (63-75%)
- Secondary patency rates (80-83%)
- Limb salvage rates (84-92%)
( Rutherford ,2000)

6. Femoro-Popliteal Lesions
BASIL Trial ( Bypass versus Angioplasty in Severe Ischaemia of the
Leg )
-Stand as benchmark for current surgical practice
-Reflects current results of limb salvage procedures
Conclusion :
Non-inferiority of Endovascular therapy compared to Surgery
. Identical rates of 2-year
amp. free survival
. Lower mortality rate
. Lower complication rate
. Lower cost
. Higher Reintervension rate

7. Femoro-Popliteal Lesion
Stent Implantation:
May improve initial technical success
1- Create homogenous tubular lumen by abolishing effect of :
- Obst. Dissections.
- Occluding intimal flaps.
- Residual stenosis.
2- Prevent elastic recoil & delayed constrictive remodeling
3- But increases the amount of myointimal hyperplasia

8. Endovascular Therapy in Infra-inguinal CLI
Cairo university
Total No. : ( Jan. 2010 – June 2013 ) 262 Limb
Group (A) : Femoro-popliteal Disease 136 Limb
Group (B) : Infra-popliteal Disease 126 Limb

9. • 136 limbs
• Males (67.64%)
• Mean age : 62.5(50-75 Y)
• Diabetics : 63.23%
• TASC Class : A (0.00% )
B (22.05%)
C (22.05%)
D (55.9% )
PTA for Femoro-Popliteal Segment in
CLI (Group A)
Cairo university

10. 3 subgroups according to the length of the lesion
• < 5 cm : 16.17%
• 5 to 10 cm : 44.11 %
• > 10 cm : 39.7 %
PTA of Femoro-Popliteal Segment in
CLI(Group A)
(Cairo University )

11. • Technical success : 97.05 %
• Prim. Patency at 1&2 Y : 79.41% & 67.64%
• Sec. patency at 1&2 Y : 84.55% & 75.00%
• Limb salvage rate at 1&2 Y
: 92.00% & 83.80%
• Comp. 8.82%
PTA for Femoro-Popliteal Segment in CLI
(Group A)
Cairo university

12. PTA for femoro-popliteal segment in CLI(Group A)
Cairo University
Length of lesion 1ry patency 2ry patency
1 year 2 year 1 year 2 year
<5 cm 92.0% 85.3% 95.6% 88.23%
5-10 cm 80.88% 70.5% 83.8% 78.0%
>10 cm 55.00% 0.00% 62.5% 33.8%
Patency rates in relation to the length of the lesion

13. Infra-Popliteal Disease
BTK
• About half of pt. with CLI(diabetic & aging population)
• Meta-analysis of studies (1992-1998) of distal bypass vein graft
reported:
5 year graft prim patency ( 63 %)
5 year graft sec. patency (70 %)
5 year limb salvage rate (78 %)
LSV 1st choice /any autologous vein
PTFE is not recommended
(Singer & Baumgartner , CX , 2013)
• BASIL trial did not report
subgroup data on distal revascularization

14. Infra-Popliteal Disease
BTK
• Primary aim of PTA in BTK :
- Restore at least one straight line of
blood flow to the ischaemic foot
- Maintain patency of treated A. for as
long as possible or at least to allow:
- ulcer healing
- pain relief
- avoid rec. of CLI
(TASC I&II)

15. Infra-Popliteal Disease
BTK
• Recently there is switch to :
- Maximal revascularization:
“the more the better”= higher
chance to keep at least one
vessel patent over time
- Angiosome concept :
focus on wound related
artery rather than to
maximize the flow

16. Infra-Popliteal Disease
BTK
• Due to evolution of techniques & availability
of dedicated materials , The ENOVASCULAR
1st- line approach to BTK should be preferred
over bypass for nearly all kinds of lesions
(Singer & Baumgartner, CX , 2013)
• It remains that case load & training are
important factors for best possible outcome

17. PTA of BTK vessels in CLI(Group B)
Cairo university
• 126 limbs
• Males : 72.2%
• Mean age : 62.5 (50-75 Y)
• Diabetics : 91.2%
• TASC Class
A (9.50%)
B (19.5%)
C (38.1%)
D (33.3%)

18. PTA of BTK vessels in CLI(Group B)
Cairo university
-Technical success is 93.6 %
-Primary patency at 1 & 2
year is 74.6 % & 63.4 %
-Secondary patency at 1 & 2
year is 83.33% & 71.42 %
- Limb salvage rate at 1&2 year
is 91.27% & 82.53%
- Procedure comp. rate is 9.5%

19. Endovascular Management of CLI
Group(A&B)
Cairo University
Multilevel occlusion
No. 53
% 20.23
Prim. Patency 75.47% ( 1Y) 50.94% (1Y)
Second.
Patency
81.13% ( 2Y) 66.03% (2Y)
Outcome of endovascular treatment of Multilevel
disease .

20. Endovascular Management of CLI
Group(A&B)
Cairo University
No. of runoff
Vessels
Frequency Percentage Limb salvage
at 2 years
1 125 47.7% 80.00%
2 39 14.9% 85.22%
3 98 37.4% 100.00%
Runoff status as a prognostic factor in outcome of
endovascular intervention:

21. Redo Cases
Femoro-Pop. Segments

22. Redo fem. Pop. Bypass after stent
occlusion

23. Current Indications in CLI
Summary
• CLI is the most severe clinical manifestation of PAD &
associated with high M. & M.
• Revascularization has to be attempted as soon as
possible
• Endovascular therapy should be the 1st line approach
in the majority of pt. with CLI
• Bypass can be an alternative, but should primarily
be considered in younger & healthier pt. if
autologous vein is available

24. • Patency rates & limb salvage are sig. higher in short
SFA lesions compared to long lesions > 10 cm
• Multilevel lesions have lower patency rates than
single level lesions
• Runoff status is an important prognostic factor in the
outcome of endovascular therapy
• Prevalence of diabetes is higher in group B (91.2%)
than in group A (63.23%) , and infra-popliteal PTA
showed satisfactory results
Current Indications in CLI
Summary

25. Recommendations
Technical Recommendations
1- Proximal lesions treated before more
distal ones
2- Sequential revascularization
procedures are indicated in
tissue loss
3- Combination of a bypass & PTA
may be employed
4- At least one run-off vessel in
the calf to serve as an outflow

26. Conclusions
• Stronger , randomized data has to be created ,
supporting the evidence for best endovascular
treatment specifically for CLI pt.
• Research has to be focused & intensified on the
development of specific peripheral arterial devices as
anatomy & pathophysiology of the limb lesion differs
significantly from Coronaries.

27. • Many extremities with CLI that would certainly have
been amputated just a few years ago, can now be
salvaged by a variety of techniques available to the
trained vascular surgeon.
• Proper selection of the appropriate procedure
requires a considerable degree of training , clinical
experience and technical skills to achieve optimal
results.
Conclusions

28. Thank You