Current And Emerging Options For Intervention In CLI

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Author(s): 
Levester Kirksey, MD, and Michael Troiano, DPM

   However, heparin-bonded prosthetic conduits have recently demonstrated impressive patency rates in comparison to previous prosthetic conduits. In the absence of a vein conduit, catheter-based treatment may be an option to improve tibial blood flow. The caveat is that diligent post-revascularization follow up is essential and, at the first sign of stalling or regression of wound healing, re-imaging is necessary.

   When adequate vein length is not present, a catheter-based intervention can shorten the length of vein necessary to revascularize infrapopliteal vessels directly to the wound bed. This is permitted by minimally invasive treatment of the femoral-popliteal arteries. In the femoral-popliteal anatomy, various catheter-based modalities including self-expanding stents yield acceptable patencies (50 to 60 percent at two years). The concern in this configuration is that there is a distal vein bypass dependent upon the sometimes unpredictable restenosis pattern of a femoral popliteal stent.

   For patients suffering from lifestyle limiting claudication, percutaneous revascularization offers a less morbid solution to their illness while preserving vein conduit for future infrainguinal or coronary revascularization. In the absence of severe tissue loss, vascular surgeons may perform palliative percutaneous interventions and can often repeat these interventions on the femoral and popliteal arteries when and if failure does occur for the patient who develops new symptoms.

   For patients with rest pain or small superficial ulcerations, our decision-making is guided by the premise that these pathologies may not require the durability of traditional open bypass patency necessary to heal CLI with significant tissue loss. Additionally, these patients will frequently carry a high-risk operative profile that one must carefully consider. With CLI and rest pain, even an incremental increase in perfusion will often ameliorate the patient’s pain. In the case of superficial ulcerations, revascularization of a single level or “partial revascularization” frequently permits wound healing to occur, provided one implements diligent wound care.

In Summary

Catheter-based options for revascularization of CLI currently play an important role. Available technology continues to improve and leads to significant innovations. These innovations include biodegradable stents, drug eluting balloons and stent platforms. They hold great promise to improve our options in the infrapopliteal territory. We must have clearly articulated treatment goals that are communicated with our multidisciplinary teams as we set out to successfully manage the challenging process of severe limb threatening ischemia.

   Dr. Kirksey is affiliated with the Department of Vascular Surgery at the University of Pennsylvania School of Medicine in Philadelphia.

   Dr. Troiano practices at the Center for Foot and Ankle Disorders in Philadelphia.




References:

1. McKinsey JF, Goldstein L, Khan HU, et al. Novel treatment of patients with lower extremity ischemia: use of percutaneous atherectomy in 579 lesions. Ann Surg 2008; 248(4):519-28.

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Anonymoussays: September 19, 2010 at 8:22 am

Reading this article made me think of this idea. The Council of Podiatric Medical Education (CPME), the Council of Teaching Hospitals (COTH), the American Podiatric Medical Association (APMA, and the National Board of Podiatric Medical Examiners (NBPME) should meet together to recommend that podiatric residents should learn vascular bypass surgery techniques, namely the popliteal-dorsalis pedis bypass surgical procedure.

I feel that podiatry residencies should not only perform orthopedic and plastic surgeries on the foot, ankle, and leg but also neurological and vascular surgeries on those gross anatomical structures as well. Podiatry residents should perform vascular bypass surgeries on the popliteal artery, posterior tibial artery, and the dorsalis pedis artery, and peripheral nerve surgeries such as the tibial nerve, deep peroneal nerve, sural nerve, saphenous nerve, and superficial peroneal nerve, and the peripheral nerves to the foot.

Podiatry residencies should incorporate plastic surgery, orthopedic surgery, vascular surgery, and neurosurgery techniques relevant to the leg, ankle, and foot. This way, podiatrists will become better surgeons.

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