Two-year outcome with preferential use of infrainguinal angioplasty for critical ischemia

Objective: Infrainguinal angioplasty provides a minimally invasive alternative to bypass surgery in patients with critical ischemia. This study aimed to determine the 2-year patency, limb salvage, and survival rates in patients who underwent infrainguinal angioplasty in a unit where angioplasty is used preferentially whenever possible for critical ischemia. Methods. A total of 333 consecutive patients who presented with rest pain, tissue loss, or both and who underwent an infrainguinal intervention in the 4-year period between January 1998 and January 2002 were divided into femoropopliteal and femorodistal groups. The TransAtlantic Inter-Society Consensus angiogram scoring system was used to classify the lesions. Angioplasty was the preferred procedure in all patients for whom a stump or portion of a superficial femoral artery was patent. Exclusion criteria included the concomitant or sequential treatment of iliac lesions. Patients were followed up after surgery with ankle-brachial indices and duplex ultrasonography. Results: A total of 180 patients underwent 198 angioplasties. Primary cumulative patency, limb salvage, and survival for femoropopliteal angioplasty (n = 166) at 2 years were 75%, 90%, and 88%, respectively, and 60%, 76%, and 82% for infrapopliteal angioplasty (n = 32). At 30 days, mortality was 2.7%, and the complication rate was 8.3%. There was a restenosis rate (> 50%) of 68% and 65% at 2 years for the femoropopliteal and infrapopliteal angioplasty groups, respectively. Seven patients required repeat angioplasty of the same site, 30 underwent subsequent bypass, and 16 of 43 occluded limbs were amputated. A total of 153 comparative control patients underwent 162 bypass procedures during the same period. Primary cumulative patency, limb salvage, and survival for femoropopliteal bypass (n = 80) at 2 years were 69%, 87%, and 76%, respectively, and were 53%, 57%, and 64% for infrapopliteal bypass (n = 82). The 30-day mortality for bypass was 5.2%, the complication rate was 35%, and 31 limbs were amputated. Conclusions. The results of this study on the intermediate-term outcome of angioplasty suggest that angioplasty, when used preferentially for critical ischemia, in anatomically suitable patients provides very acceptable limb salvage and survival despite a relatively high restenosis rate.