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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
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.