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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY

A Journal on Vascular and Endovascular Surgery


Official Journal of the Italian Society of Vascular and Endovascular Surgery
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Giornale Italiano di Chirurgia Vascolare 1998 June;5(2):111-21

Copyright © 2000 EDIZIONI MINERVA MEDICA

language: English, Italian

Indications and techniques of endovascular treatment for critical leg ischemia

Bernardo B., Migliucci N., Porcellini M., Capasso R., Barone E., Raimondi G.

From the Chair and Postgraduate School of Vascular Surgery (Head: Prof. G. C. Bracale) Faculty of Medicine and Surgery “Federico II” University of Naples, Naples, Italy


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Background. To eval­u­ate the pos­sibil­ity of ­using endo­vas­cu­lar revas­cu­lar­isa­tion tech­niques in chron­ic crit­i­cal leg ische­mia, an extreme­ly ­severe pathol­o­gy ­which ­calls for the use of ­limb sal­vag­ing pro­ce­dures. Major ampu­ta­tion is nor­mal­ly regard­ed as the ­only alter­na­tive for ­patients who ­fail to ­respond to sur­gi­cal revas­cu­lar­isa­tion giv­en ­that the ­results of pros­tan­oid treat­ment and alter­na­tive epi­du­ral stim­u­la­tion tech­niques are ­still not ­well ­defined.
Methods. The ­study ­reports a ­series of 7 ­male ­patients, ­with a ­mean age of 65.5 ­years old (­range 44-72), pre­sent­ing man­i­fest symp­toms of chron­ic crit­i­cal leg ische­mia ­with ­onset rang­ing ­between 16 and 40 ­days; all ­patients com­plied ­with the req­ui­sites of the European con­sen­sus doc­u­ments and did not ­respond to con­ven­tion­al revas­cu­lar­isa­tion sur­gery. Combined endo­vas­cu­lar treat­ment was per­formed ­with loco­re­gion­al throm­bol­y­sis ­using the ­intrathrom­bus throm­bol­y­sis (ITT) tech­nique fol­lowed, ­once rec­a­nal­isa­tion was ­assured, by one or ­more trans­lu­mi­nal angio­plas­ties of the ste­not­ic ­lesions respon­sible for the ­onset of ­acute throm­bo­sis (throm­bol­y­san­gio­plas­ty - TLA).
Results. No ­major com­pli­ca­tions ­occurred as a ­result of the pro­ce­dure. In 1 ­case the pro­ce­dure ­failed, lead­ing to ear­ly ampu­ta­tion. Limb sal­vage, the ­main aim of treat­ment, was ­achieved in 6 out of 7 ­patients ­with pri­mary paten­cy in 71.4% of cas­es and sec­on­dary paten­cy in 85.7% (­mean fol­low-up of 13.4 ­months). The prog­nos­tic fac­tors ­which had the great­est influ­ence on ­results ­were ­time ­since ­onset and the ­degree of hemo­dy­nam­ic defi­cien­cy (ABI - ­ankle-bra­chi­al ­index ­less ­than 0.40); ­vice ver­sa, the clin­i­cal ­stage and pres­ence of ischem­ic cuta­ne­ous ­lesions did not ­appear to be par­tic­u­lar­ly impor­tant, pro­vid­ed ­that ­they ­were ­minor.
Conclusions. In select­ed cas­es, endo­vas­cu­lar sur­gery may rep­re­sent a val­id alter­na­tive to ­major ampu­ta­tion ­using the sequen­tial asso­ci­a­tion of loco­re­gion­al throm­bol­y­sis and trans­lu­mi­nal angio­plas­ty (TLA). However, it is ­also impor­tant to under­line the con­tro­ver­sial ­aspects of TLA: ­delayed ­action (48-72 ­hours), ­high ­cost, the fre­quent ­need for addi­tion­al ­long-­term angio­plas­ty to pre­serve ves­sel paten­cy and ­limb sal­vage, lead­ing to a pos­sible ­increase in com­pli­ca­tions. Lastly, it is ­worth con­sid­er­ing the pos­sibil­ity ­that dis­tal throm­bo­sis is ­caused by low-­flow ­while the cath­e­ter is in posi­tion lead­ing to a pos­sible ­rise in the pri­mary ampu­ta­tion ­rate fol­low­ing ­failed ­attempts at revas­cu­lar­isa­tion, ­although the lat­ter is ­still con­tro­ver­sial in a sim­i­lar way to the fail­ure of dis­tal by-pass sur­gery.

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