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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

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


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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