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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
PERIPHERAL ARTERIAL DISEASES
Italian Journal of Vascular and Endovascular Surgery 2014 December;21(4):173-82
Current management of below-the-knee arterial critical ischemia
Caradu C., Brizzi V., Berard X., Midy D., Ducasse E.
Unit of Vascular Surgery, Hopital Tripode, Universitary Hospital of Bordeaux, University of Bordeaux, Bordeaux, France
Peripheral arterial disease (PAD) usually presents with claudication or critical limb ischemia (CLI), burdened by high morbi-mortality. One-third of CLI patients have isolated infra-popliteal disease and need below the knee (BTK) interventions. 42% are diabetic and 50% will benefit from a revascularization procedure during their lives with major amputation required within 6 to 12 months in the absence of significant hemodynamic improvement. Early revascularization, to obtain direct blood flow to the foot, is increasingly considered a first-line strategy. But with multiple comorbidities, short life expectancy and lack of venous graft or good distal target vessel, most patients are unsuitable for open bypass surgery. Endovascular therapy is expanding in BTK lesions, thanks to new intervention techniques, like the retrograde approach (via BTK arteries) in cases of failed antegrade recanalization; and new devices such as specific guidewires (0.018 and 0.014 inch) to cross the target lesion, support catheters or low-profile balloons for additional wire support, and in cases of suboptimal balloon angioplasty, drug eluting balloons (DEB), bare metal stents (BMS), drug eluting stents (DES) and new nitinol stents with potential similar primary, secondary patency and limb salvage rates than with open bypass. Moreover, even if the subsequent durability of endovascular treatment seems limited due to high restenosis rates over the long term, this could be overcome by an aggressive surveillance program, making endovascular a safe and effective method to address CLI, especially in high comorbidity patients.