Safety and Effectiveness of Concurrent Below- and Above-the-ankle Intervention in Patients with Critical Limb Ischemia

Tuesday, March 7, 2023

3:36 PM – 3:45 PM

Location: Phoenix Convention Center, 225AB

Presenting Author(s)

YB

Yonatan B. Babore, BA (he/him/his)

Medical Student
Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA

Disclosure information not submitted.

Author/Co-author(s)

XL

Xin Li, MD

Resident Physician
Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
Timothy Clark, MD

Professor
University of Pennsylvania
MT

Michael Troiano, DPM

Attending Physician
Department of Orthopedics, Division of Foot and Ankle Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
AP

Andrew Peacock, DPM

Attending Physician
Department of Orthopedics, Division of Foot and Ankle Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
MM

Mark P. Mantell, MD

Attending Physician
Department of Surgery, Division of Vascular Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
Ansar Z. Vance, MD (he/him/his)

Attending Physician
Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA

Disclosure(s):

Xin Li, MD: No financial relationships to disclose

Timothy Clark, MD: No relevant disclosure to display

Ansar Z. Vance, MD: No relevant disclosure to display

Purpose: Endovascular revascularization is an established treatment modality for Rutherford 5-6 critical limb ischemia (CLI), with the goal of establishing in-line arterial flow to the wound bed. Although there is abundant evidence for above-the-ankle (ATA) procedures, below-the-ankle (BTA) procedures are not well studied. The present study aims to assess the safety and efficacy of BTA interventions in patients with Rutherford 5-6 CLI.

Materials and Methods: A retrospective search identified 48 CLI patients who underwent 79 BTA procedures in 57 limbs. Mean age was 62.6 years (36 to 88 years). There were 20 females (41.7%) and 28 males (58.3%). Thirty-six patients (75%) had diabetes, and 13 (27.1%) had end-stage renal disease. All procedures were performed by two operators at a single tertiary medical center. Adverse events (AE) and technical outcomes were assessed per procedure. Technical success was defined as successful revascularization of the target artery. Limb salvage was assessed per limb and defined as freedom from major amputations (above the ankle).

Results: There were concurrent ATA interventions in 75 procedures, including 25 femoropopliteal and 75 tibial interventions. BTA treated arteries included 52 dorsalis pedis, 26 lateral plantar, 4 medial plantar, 21 pedal arches, and 2 metatarsal arteries. Mean follow-up time was 13.1 months (0.2 to 48.8 months). AE rate was 13.9%, all of which were minor, including 3 arterial dissections, 2 thrombotic events, 3 arterial perforations, and 1 arteriovenous fistula, all successfully managed with intraprocedural thrombectomy and/or angioplasty. There was 1 groin access hematoma managed conservatively. There was a single minor AE related directly to a BTA intervention; perforation managed with balloon tamponade. The technical success rate was 93.7%. Following revascularization, there were 22 repeat BTA percutaneous vascular interventions. Minor amputation rate was 28.1% including 12 toe/ray and 4 transmetatarsal amputations. There were 13 major amputations resulting in a limb salvage rate of 77.2% (44/57) at a mean follow-up time of 11.1 months (2.9 to 41.3 months).

Conclusion: Concurrent BTA and ATA revascularization procedures were safe and technically feasible, with a high limb salvage rate. Further research is needed to determine the added benefit of BTA interventions in comparison to ATA interventions alone.