Subintimal Angioplasty for Below-the-Ankle Arterial Occlusions in Diabetic Patients With Chronic Critical Limb Ischemia

Purpose: To assess the feasibility and efficacy of subintimal angioplasty (SA) in the treatment of below-the-ankle arterial occlusion in diabetic patients with chronic critical limb ischemia (CLI). Methods: SA was applied in 37 diabetic patients (24 men; mean age 70.9 +/- 8.5 years, range 52-88) with chronic CLI and occlusive disease of the dorsalis pedis artery (DPA) and/or plantar artery (PA) but were poor candidates for intraluminal angioplasty or bypass surgery. Tissue loss was present in 31 (54.4%) of 57 afflicted limbs, and rest pain was reported in 51 (89.5%) limbs. SA was performed to create continuous arterial flow to the foot for limb salvage. The clinical symptoms, DPA or PA pulse volume scores, and ankle-brachial index ABI) were compared before and after SA. Wound healing, amputation, and restenosis of target vessels were also evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and freedom from amputation. Results: Below-the-ankle SA was performed successfully in 55 (83.3%) of 66 arteries in 57 limbs. Median pulse volume scores and ABIs were 0.33 +/- 0.55 and 0.31 +/- 0.19 before SA and 2.04 +/- 1.05 and 0.80 +/- 0.14 after SA, respectively (p<0.0001 for both). The 30-day mortality was 2.7%. Median follow-up was 9.1 +/- 6.1 months (range 1-18). Major complications occurred in 1 (2.7%) patient and minor complications in 3 (8.1%). Twelve months after SA, Kaplan-Meier analysis showed that the limb salvage rate was 94.6%, the freedom from amputation was 89.2%, and the survival rate was 97.3%. Conclusion: SA of the dorsalis pedis artery and/or plantar artery is a useful technique for lower limb salvage in diabetic patients with chronic CLI who are not candidates for bypass surgery. J Endovasc Ther. 2009;16:604-612