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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
Italian Journal of Vascular and Endovascular Surgery 2016 September;23(3):148-59
The management of below-the-knee arterial critical ischemia: update, systematic review and meta-analysis
Caroline CARADU, Dorothée TROMBERT, Dominique MIDY, Eric DUCASSE
Unit of Vascular Surgery, Hopital Tripode, Universitary Hospital of Bordeaux, Bordeaux, France
INTRODUCTION: Percutaneous transluminal angioplasty (PTA), with bailout bare metal stenting (BMS) is currently the treatment of choice in below the knee (BTK) lesions, as drug eluting stents ‘(DESs) results on limb salvage remain controversial.
EVIDENCE ACQUISITION: The present review and meta-analysis was carried out based on a PubMed (Medline), Embase and CENTRAL search to determine the results of the different strategies available to date in the BTK area and to help select an optimized endovascular approach.
EVIDENCE SYNTHESIS: DESs significantly decreased the risk of target lesion revascularization (TLR) compared to BMSs (9.7% vs. 29.0%; OR: 0.26; 95% CI: 0.15-0.46; P<0.00001) and the risk of in-segment binary restenosis compared to PTA (21.9% vs. 41.7%; OR: 0.38; 95%CI: 0.23-0.63; p=0.0002), BMSs (19.9% vs. 50.3%; OR: 0.25; 95%CI: 0.15-0.39; P<0.00001) or DEBs (28% vs. 57.9%; p=0.046). Primary patency was significantly improved compared to PTA (64.9% vs. 49.3%; OR: 0.48; 95% CI: 0.29 to 0.77; P=0.003) or BMSs (85.6% vs. 63.9%; OR: 0.26; 95% CI: 0.14 to 0.49; P<0.0001). There was no significant difference in terms of major amputation rate, Rutherford Class (RC) improvement or mortality.
CONCLUSIONS: About 35% of BTK lesions are long lesions (5-20 cm) and are best treated by balloons with bailout stenting. For this purpose, BMSs are still preferred over DESs. Thirty percent of BTK lesions are focal proximal lesions (length ≤ 5 cm) and according to this meta-analysis, in such lesions, DESs are safe, significantly reduce TLR compared to BMSs and binary restenosis compared to BMSs, DEBs or PTA, improve primary patency compared to PTA or BMSs with durable results and could potentially reduce major amputations in patients with focal BTK lesions, without any significant impact on mortality and RC.