Below The Ankle Angioplasty Is Emerging As An Effective And Safe Treatment Option To Improve The

Results Of Revascularization

Ahmed Sayed MD, MRCS

Vascular Surgery Division

Kasr Alainy Hospital - Cairo University

Disclosure

Speaker name:

Ahmed Sayed

I do not have any potential conflict of interest√

• Endovascular revascularization is a mainstay in themanagement of CLI patients

• Nonetheless, when employing standardapproaches, success rate remain suboptimal.

Obstructive disease distributionFerraresi et al. 2015 PanVascular Medicine

Due to the well-known inability of diabetics increating efficient collaterals, plantar arch arteriesbecome in fact functional end arteries sofavoring the chance of necrosis formation even incase of a single tibial artery occlusion or plantararch interruption.

• Many patients with CLI will need minor forefoot ormidfoot amputations.

• The original foot vessel distribution can be interruptedbecause the surgical wound can cut or close thenatural connections between the main dorsal andplantar blood supply.

• The dorsal and plantar systems, well connected beforethe amputation, can become “terminal” systems afterfoot surgery.

Patients & Methods

• 49 patients with infragenicular diseaseassociated with a diseased pedal and/or plantarartery (>70% stenosis or occlusion).

• Patients with lesions proximal to theinfragenicular arteries were excluded.

• Rutherford categories 5&6

• Ipsilateral femoral accessusing a 6F sheath.

• Any infragenicular lesionwas treated in astandard way using theappropriate-sized semi-compliant balloon.

• BTA Angioplasty wasperformed using an0.014" platform througha Transluminal route

• wound debridements/minor amputationswithin 48 hours.

• Risk factors control

• Medications: acetyl salicylic acid 150 mg/ day for life,

enoxaparine for 2-3 days, Clopidogrel 75 mg/ day for at least 3months.

ResultsNumber (%)

Males 33 (67%)

Females 16 (33%)

Diabetes mellitus 49 (100%)

Hypertension 44 (90%)

Smoking 32 (65%)

coronary artery disease 24 (49%)

Rutherford category 5 32

Rutherford category 6 17

Occlusions 42

Stenoses 7

Results• Technical success was achieved in 46 patients (94%).

Two of the unsuccessful cases underwent a below knee amputation and thethird remained salvaged with incomplete wound healing.

• 3 other patients underwent a BKA (total 5 cases)

• Mean time to wound healing was 162 days

At one year0

10

20

30

40

50

0 2 4 6 8 10 12

1ry patency 62%

2ry patency 69%

LS 89%

BTA was associated with angioplasty of thecorresponding tibial vessel in all cases , and withangioplasty of an additional tibial vessel in 10cases.

Complications

Arterial wall dissection 9

Puncture site hematoma 1

Vessel perforation with dye extravasation 1

Loss of the completeness of the foot arch 1

Morphologic types

Technical success

p=.575

Complications

p=.570

limb salvage

p=.389

Stenoses (n=7) 100% 1 100%

Occlusions (n=42) 93% 11 88%

Treated artery

Technical success

p=.302

Complications

p=.076

1ry patency

p=.143

Limb salvage

P=.386

Planter angioplasty 97% 5/31 65% 87%

Dorsalis pedis

angioplasty

89% 7/18 44% 94%

• Technical success was achieved in 88% of cases

• limb salvage was 81.9%

• technically feasible with good medium-term clinical outcome and limb salvage in a group of patients with poor surgical options.

compared infrapopliteal angioplasty alone to infrapoplitealangioplasty with added planter artery angioplasty (PAA).

• The success rate of additional PAA was 93%.

• amputation-free survival (79% vs 53%, p=0.102),

• freedom from reintervention (64% vs 73%, p=0.668)rates were similar in both groups.

• Wound healing rate (93% vs 60%, p=0.05)

• Time to wound healing (86.0±18.7 vs 152.0±60.2 days,p=0.05)

Nakama et al. J Endovasc Ther 2016;23(1):83-91

• Endovascular revascularization of leg and foot arteriesis an aggressive strategy that could be a salvageprocedure for patients with CLI

• Non-ambulatory status, wound depth, and dailyhemodialysis were identified as independentpredictors of delayed healing.

Nakama et al. J Endovasc Ther 2016;23(1):83-91

Summary

• A good distal distributionsystem must always berespected and, if possible, nottouched.

• The benefit of BTA angioplastymust be balanced with the riskof damaging the forefootdistribution system by thecrossing with wires andballoons

Conclusion

• Midterm results show satisfactory outcome ofthe BTA angioplasty.

• Marked development in tools and techniques

• The technique is emerging as an effective andsafe treatment option to improve the results ofrevascularization.

Thank you for your attention!

Kasr Alainy

Cairo University

Below The Ankle Angioplasty Is Emerging As An Effective And Safe Treatment Option To Improve The

Results Of Revascularization

Ahmed Sayed MD, MRCS

Vascular Surgery Division

Kasr Alainy Hospital - Cairo University