UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
Updated Management for Limb Salvage in
Patients with Critical Lower Limb Ischemia:
Surgical or Endovascular Treatment?
A " &
n72:uiuimi~amk%aa~%uSnqm(Critical limb ischemia: CLI) ~~u~numzn7~n~iinnei1-1snd-11~a'~
~ ~ n ~ a a ( i l t 8 a ~ ~ ~ m ~ a i ~ u d a ~(Peripheral
u ~ u m ' u ~arterial
~ ' i ) % "occlusive
~
disease) a7kwydala%~t!J
~ i i ( i l 3 i n n i ' I ~ a n ~ ~ 4 t ~ ~ ~ ' Z ' 1 1 f i ~ d(Atherosclerosis
~ l a ' 4 ~ ~ ~ @obliterans)
1 ~ ~ @ ~ 1~'7aw'finl%?cilfiIA
fl
~ ~ d L ~ ~ L ~ ~ c i l . i l ~ ~ d t f l u ~ w a ~ j i a n ~ : : u ~ u n ~ a ~ u m ~ ufliI~ufinBain7ad7mtfli
a~duua~u~wa~un~a~dn~
1uunr:rY"n (Rest pain), Gtrwauicilrfiacir (Ischemic ulcer), ~c%afifi~iM"~iuimiu
(Digital gangrene)
T m u ~ ~ l d a i n i ~ ~ n ~ i i ( i l2~ ~TLI~IM'
~ u ~ ~ nn in ~i i' j i i ~ u ~ ~ ~ n ~ ~ n a i ~ u n i a m a ~ ~ w u n ~ s " u ~ ~ t
!ULL'I-IZlil.I'UI j ~ u 6 u n i ~ m a ~ i l f 3 u o ' uNoninvasive
6~u
test oi~qqidu Ankle pressure 4 0 mmHg,
Toe pressure 130 mmHg ~ P j aABI ~ 0 . 4 0m ~ m d1. a~mn~szu:c~i1-1~ua~ni~zu1?111~~m~~a~9
niuniar~u-15ji~kunua4
Fontaine (1954) k~az Rutherford (1997) ~~eroz4Co~ud7<ilaufinia:
ui~tant~acilu"u~nqm~daWa~n1'16~~ol~t~i
Grade I1 (Fontaine) \La: Category 4 (Rutherford) "fj1d
W I M . 1.
~ ~Stages of
r*
Fontaine
Grade
chronic limb ischemia
Rutherford
Category
Clinical Description
Asymptomatic
Mild Claudication
I
2
11*
3
Moderate Claudication
Severe Claudication
4'
T--L--:~
5'
Minor l'issue Loss
Rest Pain
Nonhttalirig ulcer or focal grin
.
*
willl _rime
1:
peaar isclternin
.
6'
?-
.
Major Tissue Loss
-
Objective Criteria
Normal treadmill or reactive hyperemia tesl
Completes treadmill exercise; AP after
exercise >50 mmHg but at least 20 mmHg
lower than at rest
Behveen Rutherford I and3 disease
Cannot comple~estandard treadmill exercise:
AP after exercise 4 0 mmHg
.- ........
Resting AP <40 mrnHg; ankle or metatanal
PVR flat or barely pulsatile; T P 40 m m
Resting AP <60 rnmHg; ankle gr mi:latarsal
PVR flat or barely pulsatile; TP <4 0 mmHg
Same as Rutherford category 5
Exfending above fransmelafarsnl level,
or fool no longer salvageable
-..-___-_______-___--.----~__,___._.____I.__-
I
*Correspond to critical llmb ischemia
AP, ankle pressure: PVR, pulse volume recording; TP, toe pressure.
( 6 ~ l l d ~ 4 ~White
7 f I JV. Lower Extremity Arterial Disease: General Considerations. In: Cmnenweft JL, editor. RUTHERFORD'S
VASCULAR SURGERY, 7 ed. Philadelphia. PA: SAUNDERS ELSEVIER; 2010. P. 1588.)
~
~
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
A
U
&
rjil~ud8n1~zuiuim~3am~'50~~vu~nq~~n1~~1~~u~~n~ia~wu?n~~~?n
~ian~uClfi~nwize~n~,damv~~uvm:~Gu
(Claudicants) uin wuii 25% vaq@aunriudsz
~flud5mn7ulu1 7l Lraz 32% tBu;il?nniu?u2 7lniu~k~6%nis4fis~u
(rrwu~fld1) Riiwquaq
n 7 q ~ ~ i ~ a ' i ~ d ~ d ~ ~ ~ f i m 0 7 n T uans~niwu~mn'lriI6%"un1'14'n~.1~da~~~~~~m
' ~ n ~ 3 a s ~ 7 r n ~ ~ ~
@d2ur:fil.nni~qnKmviq.1R~40% nwlu 6 ~Rau'(nwuqfld 2)
'@
0
I
0
I
cll
I
5
10
Follow up (years)
1
15
~ruuqfid1. Survival of patients with intermittent claudication (IC) and critical limb ischemia (CLI).
(fnrana7n Norgren L, Hiatt WR, Dorrnandy JA, Nehler MR. Harris KA, Fowkes FG. Inter-Society Consensus
for the Management of Peripheral Arterial Disease (TASC 11). Journal of vascular surgery. 2007;45 Suppl S:S567,)
Alive with
amput:ation
40'%
rl~uqnd
2. Outcome of patients with critical limb ischemia 6 months after diagnosis.
( d i n l ~ d ~ r ~Norgren
~ o i n L, Hiatt WR, Donandy JA. Nehler MR. Harris KA, Fowkes FG. Infer-Society Consensus
for the Management of Peripheral Arterial Disease (TASC I/). Journal of vascular surgery. 2007;45 Suppl S:S567.)
u a n i l ~ n b ~ m r r a o n ~ l a m ~ ~ m - ~ d ~ u d ~ ~ u 6 ~ l ~ u d ~ uSystemic
? t 9 ~ W 1 1atherosclerosis
~~~~1sin
@ l l ~ u ~ ~ 8 ~ 1 ~ ? ~ ~ d u ~ q - 1 M " ~ z ~ n ' m " L ~ n ~%.rn~aacjlitacjla~ad,
1 ~ a m ~ 3 a m i s " a ? ~~, L P : ~ ~ R ' U O ~ M ~ ~ ~ L B B W
~~i'lJt~u.re?ln:mu?u
(Visceral arteries) h u h u ~ n f i ~ w u i ~ @ ~ ~ u i r r h d f l n d ~ " ~ n i ~ u y I a ~ o a t i
L Z ~ UL U I M ~ U n-~1~6uTa~'mqd,
,
' I : G Y u I " u ~n~i au%~vun ~L. iQ
~ ~~
~ ~F~ fIl~
u ,~
'a~~ir~aiu3diaun"u
16un n i s n ~ u q u f l a a " o ~ d u ~ ~ i 4 i s " a a a ~ ~ a z ~ a o(Cardiovascular
m~8am
risk modification),
n i - ~ < n ~ i ~ ? - .(Pharmacologic
~ui
treatment), ni%s"nwi~da~6utBam
(Revascularization) \\a:
n7'56mu7 (Primary amputation) L L W U Q U P ~
3. ~~arn~~~u7~1-s~~'ld"Iun14%"nw.7fld3uM"~n
esanm~~amr~n~alaudaiuG~lGu
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
Peripheral arterial disease
Risk factor modification:
Smoking cessation
LDL cholesterol 4 0 0 mgldL (2.59 mmollL)
LDL <70 mgIdL (1.81 mmoVL) if high risk
* HbAtc <7.0%
BP <I40190 mmHg
BP <130/80 mmHg with diabetes or renal disease
Antiplatelet therapy
I
A
I
I
No limitation to
quality of life or
reduced exercise
capacity:
Monitor patient
for loss of
function
5%
CLI confirmed
qualily of life:
History of significant
exercise limitation
Reduced treadmill
performance
or
* Reduced function by
questionnaire
Candidate f o r
revascularizatlon
revascularizatlon
MRA. CTAl
Supervised exercise
or pharmacotherapy
symptoms
P-
Continue
improved or
deteriorated
I
Localize the lesion:
Conventional angio
M R A o r CTA
Ultrasound
Hernodynamic localization
Revascularization
a s appropriate
treatment
(nonoperative)
I
I
Endovascular
Surgical
Overview of the management of lower extremity peripheralarterial disease. angio, angiography; BP,blood pressure;
CLI,critical limb ischemia; CTA, computed tomographic angiography; HbAlc, hemoglobin Alc; LDL, low-density lipoprotein: MRA,
I I W U I ] ~ ~ 3.
magnetic resonance angiography. (Kmaone?n York JW, Taylor SM. Lower Extremity Arterial Disease: Decision Making and Medical
Treatment. In: Cronenwett JL. editor. RUTHERFORD'S VASCULAR SURGERY, 7 ed. Philadelphia, PA: SAVNDERS ELSEVIER;
2010. P. 1602.)
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
Disease Location
sn~nn~~~s~ami~~on~~n~4inwl~~a~~~~~ama7~u61~~~u-~ua~~u1s"~n
qm&umulu~aomtbam~flu~~n
~ u ~ 3 ~ h u s n u m r n a m n " u ' 1 1 a 4 ~ w a m ~ ~ a m ~ ~ 3m 4ufin
~~tjd~6~flu
Inflow disease, Outflow disease rLa: Combined inflow-outflow disease
Inflow disease vluiuh.~n?Tqm$uvo-l~aam~~am~~m~~sndadn
Inguinal ligament d?uhlqjrin\fin
~waamt~ami1m-1
Infrarenal aorta LLa:
Iliac artery n7?qmn"uaz6~6finuil~ts'in7aama4~a~~~tlm
ddfiq Common femoral artery
O~@ow disease vl1.17uii-r n 7 ~ q m ~ u u o ~ s n s a a ~ ~ a m
Inguinal
~ ~ m ~ ligament
~rn'
Annisqmm"u&~ttcii
snaamtBam~tm-3 Common femoral artery 'adsun"s~aamtBamttmqfild~$~.1~M'7
(Pedal vessels)
Outflow disease 1~li4~6ifluni%~m6uu?iatLL~a'i)mt3am1~m~
Femoral-popliteal arteries t ~ a z
n7?qmrfiu~rn'davla~m~~am~~m~
Popliteal artery (Infrapopliteal arteries)
Combined inflow-outflow disease vluiuff-~niaqm6uuadvle~lmrQ~m~~m~fi~ma~'1zCui~un"u~-~
Inflow tLaz Outflow disease w u i s ' a n 7 w ~ n u ~ : f i f i n ~ i ~ ~ ~ f i m v i u i m ~ ~ a m ~ u ~ ~ ? . )
~i1au~in~~~~iuimt~am~~as"-l~u~nqm~n~niaqmn"uua~~a~m~Zan~~m~dui
(Diffuse & multilevel) Tmuni~qmGuo7o~n^m"1ua:6ud~4u-1~i'i)~do~n"u
(Sequential vascular beds)
rzlu 8niaqm6ud-xn"fl Aortoiliac i a u k Femoropopliteal ~ " Femoropopliteal
a
5aun"EITibial
artery w~a~~m~u~x6uM"~u1~an"u
(Parallel beds)
rdu n1-lqcilm"uua.~~aamt8amitm-1
Superficial femoral artery 5aun"uDeep femoral artery 1flu6u
TransAtlantic Inter-Society Conscnsus (TASC) 11 ~ u i d e l i n e s ~
TASC I1 Guidelines ~n$~uu7<uauq
n.a.2007 (sa
i1
ta
i4s7n
TASC Guidelines (2000) tflu?:uu
ni~d~~~un<nunr~n~~~mGuua~snaam~~am~~m~d~fi~u~~~~u~i~~~1~~nia
uinw"qmT m u t t d ~ ~ ~ ~ ~ ~ ~ s n ~ a q m ~ u a a n ~ D u a : ~(SuprainguinallAortoiliac
u~~GavisnGu
lesions)
~~axsxGu%6uisnEu
(InfrainguinallFemoropopIiteal lesions) ua r<7~runwu7f3wn~wn~'1~mm"um7u
naiu?uk~amantflu
5 aG
: u 6a Type A-D ( ~ ~ w u q f4l d1161:: 5)
ni~flo7am7tWan5Snis%"nu1
riuzt-i7i7aauTsn Type A ~ ~ ' I ~ ' ~ W ~ ~ ~ ~ % ~ M I ~ W I ~ W ~
=saer%=sn
T e D n2%ldnisw16m~Bu7ZvlCn,=iauT.rn Type B ~ T T ~ " ~ w I ~ ? ~ ? Z M ~ . I W ~ U W ~ U
P
i~~uaTu"uwozl~a0u~~41Zanlun7a%"n~7~flu~Z~~n
~ i a : ailuT?n Type C ni'IEJi&md~~u2TJu
f i a z l f l u n 7 a 4 ' n l ~ . 7 ~ B u 4 Saudx$.du%ouT.rn
~~~n
Type B uag C Ch~a.iisnCnng?utflu~wa$o:
r n q d ~ ~ i ~ n a - r i n u i G a u ~ ~ %Mm" 9~ f~iua w
i o~6na 4 6 o 4 ~ m a 1 ~ 1 ~ o ~ ~ ~"11
~ u ~nniwji.miu
~3~63u
~~~u~~a:Tanbau%un~~d~:nouni~6mAul~~5ani5ni~s'n~1
aau%anuf~~nr
Infrapopliteal disease ~dfini?dit~unlflu
T A X I1 ~~ciifinisd7uunlYrau
Society of Interventional Radiology Standards of Practice Committee (2003)~(rn1m-d2)
UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH
CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
TYPE A LESIONS
-
Unilateral or bilateral stenoses of CIA
Unilateral or bilateral single short (c3 cm) stenosis of EIA
TYPE B LESIONS
Short (<3crn) stenosis of infrarenal aorta
Unilateral CIA occlusion
Single or multlple stenoses totaling 3-10 cm involving the
EIA not extending to the CIA
Unilateral EIA occlusion not involving the origins of
internal iliac or CFA
TYPE C LESIONS
Bilateral CIA occlusions
Bilateral EIA stenoses 3-10 crn long not extending into
the CFA
Unilateral EIA stenosis extending into the CFA
* Unilateral EIA occlusions that involves the origins of
internal iliac andlor CFA
* Heavily calcified unilateral EIA occlusion with or without
involvement of origins of Internal iliac andlor CFA
TYPE D LESIONS
lnfrarenal aortoiliac occlusion
Diffuse disease involving the aorta and both iliac arteries
requiring treatment
Diffuse multiple stenoses involving the unilateral CIA,
EIA, and CFA
Unilateral occlusions of both CIA and EIA
Bilateral occlusions of EIA
Iliac stenoses in patients with AAA requiring treatment
and not amenable to endograft placement or other
lesions requiring open aortic or iliac surgery
ll~w]fld4. TASC classification of aortoiliac lesions. AAA, abdominal aortic aneurysm; CFA, common femoral artery; CIA, common
iliac artery; EIA, external iliac artery. (n'nronoln Norgren L, Hiatf WR. Dormandy JA. Nehler MR. Harris KA, Fowkes FG. Inter-Society
Consensus for the Management of Peripheral Alterial Disease (TASC 11). Journal of vascular surgery. 2007;45 Suppl S:S5-67.)
UPDATED MANAGEMENT FOR LlMB SALVAGE I N PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
TYPE A LESIONS
Single stenosis 510 cm in length
Single occlusion 55 cm in length
TYPE B LESIONS
Multiple lesions (stenoses or occlusions), each 55 cm
Single stenosls or occlusion 4 5 cm not involving the
infrageniculate popliteal artery
Single or multiple lesions in the absence of continuous
tibia1 vessels to improve inflow for a distal bypass
Heavily calcified occlusion 55 cm in length
Single popliteal stenosis
TYPE C LESIONS
Multiple stenoses or occlusions totaling >15 cm with or
without heavy calcification
Recurrent stenosis or occlusions that need treatment
after two endovascular interventions
TYPE D LESIONS
Chronic total occlusions of CFA or SFA (>20 cm,
involving the popliteal artery)
Chronic total occlusion of popliteal artery and proximal
trifurcation vessels
~ ~ ~ u5. ~TASC
f l classiOcation
d
of femoropopliteal lesions. CFA, common femoral artery: SFA, supefflclal femoral anery. (K~aona?~
Norgren L. Hiat! WR, Dormandy JA, Nehler MR. Harris KA. Fowkes FG. Inter-Society Consensus for the Management of Peripheral
Arterial Disease (TASC 11). Journal of vascular surgery. 2207;45 Suppl S:S567.)
UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
mimd 2. Summary of recommendations for infrapopliteal disease
Lesion category/recomrnerzdatiotz
2
3
PTA preferred
Surgery preferred
I
Usually PTA
Focal stenosis 51 cm
Multiple stenoses,
each 51 cm or focal
stenoses 51 cm at
trifurcation or
stenoses treated at
Fem-pop bypass
4
Usually surgery
Occlusions >2 cm or
diffuse discase
Stenoses 1-4 cm or
occlusions 1-2 cm or
extensive slenoses at
trifurcation
Fern-pop. Femoral-popliteal (Lltrla~o?n
Guidelines for percutaneoustransluminal angioplasty. Journal of vascular and
interventionalradiology: JVIR. 2003;14(9 Pt 2):S209-17.)
Lower Extremity Grading System (1,EGS) Score7
LEGS Score q n h u i d u ? u ' l n.n.2002 ~ ~ u 5 n . 1 z u u n i a ~ i ~ ~ ~ n n ~ i ~ ~ u ~ ~ a s u a ~ n i ~ z % i ~
~fa?s~dalfltUu~~u3~1sn7'1?nu.i
'bmufioias~~1Yo.3'~~4n
5 d1zn7-3 l 6 ~ ~nn " n u m z a n u ~ a n d ~ f f u ~ i n
niwriiukfl (Angiographic pattern of disease), aini~t.iiuas~il?u(Presenting complaints),
1617wjisn7ufl?u (Functional status of the patient), T a n i w (Medical co-morbidities) rLwz
I Y ~ ~ . ~ ' U Y I ~ ~ L M R ~ ~ R O( ~Q- I JI~ ' I ~3)~ ~ L ~ u ? ' ~ ~ I Q U I J Y ~ I U L LLEGS
M ~ ~ I ~Score
S / ~ ?~uni=s?n'nl~.i
.~~
d " C
n i 3 ~ u i u ~ ( i l ~ f l a m ~ ~ n ~ ~ v u ' i n qTASC
m ~ i n nI1j 7Guidelines ~dasaindniado7amifloQu~i~q
P-
in~aunq~~7nni7'
m?md 3. Lower Extremity Grading System (LEGS) Score
Functional Status
Presentation
. --.--.-r-..
Arteriographic Flndings
.... - . . . . .
.....
1
Aonic
<3 cm aortic:stenosisl
occlusion or 3-5 ctn
i stenosis of aortoiliac
I bifurcation
>3 cm aortic stenostw
/ occlusion or >5 cm
stenosis of aortoiliac
bifurcation
1
1
I
..r.-...-.........-...
: Ston
,
,
,
:swm..
,
. . . .
1
Co-morbidities
5
Ambulatory
I
Obesity
0
,
SCo'e
/
i
audlcation
)
..............
--I-_
Scan
2
10
:
Li1mb-
I
!' 2
threathening 1
1
schemia
1
i
Ambulatory
at homeonly
1
2
'
-2
1I
i
I
I
i
Technical Factors
. . . . . . .
: All cases
! "Redo" surgery
/
I
,
' 2
I
I
3
High-risk
/
"Redo" mngioplasty
'
CAD
I
1
1
j
l Lac
TASC type
TASC type
!
lnfrainguinal cases
Blind segment (arget
No venouscond~t
No vein
infeetic
i
j -2
I
!
TASC type
Femoral-popliteal-tibia1
<5 cm occl
stenosis
>5 cm occlusion with
distal large:t
Isolated CO~UULUU"1
deep femoral stenosis
>5 cm occlusion
withour distal target
..-....
- ......
Possible set
:
!
I
!
!
I
---"--
I
._
__
_
.~ossiblescore
I
i
,
1
j/
jI
i
I
I1
I
I
........
. . . .I . .2-5 : Posslble score 1 0 to
20
....
'
Possible
score
I....
1
i
.....
-'--I
..
0'
!
,
Recomm ended Treatrnent
- - .-. - .-.-.----
-
Sum of totra1 score from each column
)pen surgery
10lo 19:= EndovasculsII treatment
220 = Pri rnary ruuputatio~t
II .
If a hocl ulcer and end-stage rennl disease a n present.double the scon.
Trans-~tlantic
,ntc&icty Consensus: CAD,,nary
awry d i m ,
..
.
.
. . . . . . .
. . . . . .
;MC
_
.
.
.
_
.
. .
...
& I I L / ~ J JTaylor
~
SM, Kalbaugh CA. Gray BH, MackreN PJ, Langan EM. 3rd. Cull DL, el a/. The LEGS score: a proposed grading
system to direct treatment of chronic lower extremity ischemia. Annals of surgev. 2003;237(6):812-8; discussion 8-9.
J
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
8!!
Trends of Revascularization:
Surgical versus Endovascular Treatment
mimd 4. Cumulative morbidity and mortality of surgical bypass in CLI
Short term
(First year)
15-20 weeks
15-25%
10-20%
20%
10-20%
Parameter
Time for healing
Wound complications
Persistent lymphedema
Graft stenosis
Graft occlusion
Graft infection
Major amputation
Perioperative death
AIl.death (primary cardiovascular)
Long term
(3-5 years)
Unknown
20-30%
20-40%
1-3%
5-10%
1-2%
10%
10-20%
30-50%
viiil~dtwamNorgren L, Hiatt WR, Dormandy JA, Nehler MR. Harris KA, Fowkes FG. Inter-Society Consensus for the Uanagement of
Peripheral Arterial Disease (TASC 11). Journal of vascular surgery. 2007;45 Suppl S:S567.
Aortoiliac Occlusive Discasc
Surgical Treatment
Aortobifemoral bypass (ABFB)
t~u~~n~~4'n~iuimcj~1~~~a~fldaz~~~n7~u7nw"~m"1un1
nispm~ua~aam~ansz6ud
~~
~n~nn~~w~6mdszna~6aun1'1~16m~flcj\11a~M"a~~~a~
Abdominal aorta l l ~ ~ d 7 ~ ~ ~ f L ? ~ ~ l ~ ~ ~ MCommon
" 4 ~ ~ 4
femoral
u ' l 4 artery
1 ~ ~ ~sinudu
1 7
~daaantDsmtRuu(Graft) LfluLdauda Proximal anastomosis oln Aorta 11~aaamlnm461u
~ k u a . n ~ a 4 l i o ~ u i ~ u i ~ a m w 1 Distal
~ ~ u t ~anastomosis
aka
u%am Common femoral artery
sinn7ainwuuu eta-analysisI0 ~ ~ h ? " ~ ( i i j m i ~ n 4 ~ ~ ' u ~ ~ n Primary
7 a ~ i r .patency
f1~'11~~
l u a z u z 5 O q4ii4 8037% 1~a:1u.r:uz~aai 10 O q464 7241% (mmd 5 ) kuWCmmn7.r
i W u ~ 7 m ~ ~ a z n i . r ~ f i a n 1 a ~ ~ ~ ~ % n ~ a u ~ 13%
n n LLaz
1 a w8%
1 ~ mmiuii6u
t~d
a"mainiatn"u?num
(Limb salvage) l u ~ a a5i il Lraz 8 KI 'bauiabu 76% uaz 68% miu6i~Yu"
mmd 5. Primary patency at-5 and 10years
-andxerative
mortality after aortobifemoral
Primary patency
5-year
__ .___ __-- 10-year
-----.
Claudication
Per limb
Per patient
Critical limb ischemia
Per limb
Per patient
-
.
-
Mortality
1%
91%
86%
87%
79%
88%
80%
82%
3%
.~..
72%
UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH
CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
Aortoiliac endarterectomy fin~fld7vls'unia~mm"uu~-1~aa(;1b~amu~~ana
Aortic bifurcation M%I
Common iliac artery diin'na~iaw7:fi (Localized disease) r~cri~~a4il7n~il2uM"u"n7as~iuimi~am
r~aku"u~nqcild~u?~~fin~n~aqmCuuas~aanr~am?ua:6uM"d~niidda~6au
M'l?ts"n?3~7h%f!
f i n 7 3 ~ ~ l ~ u 7 n f i n l u ~ i l a u na ~u 1~4d~~3 i i m 7 ~ ~ u i 1 ? ~ d ~ t ; i ~ a n 1 ~ % " n w 7 d 6 b m u ~ n a 1 ~ n 4 ~ u ' ~ 0 4
n7abLnuufim Primary patency lu~:u: 5 D aa$u 75-90%'~
n l ~ d 7 6 F 1 d t i hExtra-anatomic bypass 1n'r~f-iAxillounijemoral bypass, Axillobifernoral bypass,
Fernorofernoral bypass f i n ~ ° i l d 1 ~ f u ~ i l ? u ~ ~ a n 1 ~ i 1 - 1 n 7 u ~ b j a ~ ~ ~ ~ ~ ~ ~ u 4 ~ a d 7 ~ ~ u n 7 a w 7 m " m
13 ABFB t r P i 9 i ~ ~ ~ d ~ d f l d a z ~ ~ 9 n 1 w a ~ ~ a ~ ~ ~ i ~ ~ ~ ~ n ~ a ~ ~n3 ~. 1 2~- 1n4 i ~ ~ ( j l ~ ~ ' ~ a
(417md 6) t ~ ~ i ' i l d i ~ l a i iLimb
~ 1 7 ~salvage wui7ldtimndi.uYuazwi14 Extra-anatomic bypass
uaz A B F B ' ~ , ' ~
~7714d6. Primary patency at 5 years after extra-anatomic bypass3.12
Procedure
Axillounifemoral bypass
Axillobifemoral by pass
Fernorofemoral bypass
5-year primary patency
Limb salvage
5 1%
71%
73%
89%
90 %
75%
Endovascular Treatment for Aortoiliac Occlusive Disease
r ~ n ~ n n 1 ? s V n w 1 ( i 1 ' ~ u 7 9 ~ 1 ~ ~ 1 u a ~ u d 1 ~ ~ u n 1 Aortoiliac
s q u a a n di a ~un a u 6 2 u
n ~ ~ b i 1 ~ ' ~ 0 1 ~ ~ ~ ~ ( i l ~ ~ 0 ~ ~ ( j l u ~ i l(Percutaneous
a i u w ? u q n ~ i ltranslurninal
-l
angioplasty: PTA),
n i d d u c i l a a n d u (Endovascular stent) 1 ~ a z n ~ % ? d ~ a o ~ r ~ o n r ~ u u ~ ~ " u (Stent-graft)
cila~m6~o"w
n 7 a % u i n 7 a q n ~ u 2 ] a . ~ ~ ~ a m t ~ aAortic
m ~ % ~bifurcation
a1~
%u~:~1z~~-rn~n1~?$7s"n7abi74"11uiu
6 a u w ~ u m a u q n ~ i l ~ ~ u m ' i ~ i v l u ~ u ~Iliac
~ ~ a artery
~ ) m ~ 3M&-laa~.ii~.swToufYu
am
(Kissing balloon)
rrviwud7~6walbjRJntda~ilinn~a~mo'uu~~a(~t"rfln~flu~uu~~n~z~~n
6au74~An7ati7umaa(il
6 1 h 2 $uuildflvlaami3an Iliac artery fi~fla4u'i4(Kissing stents) ~~~~~~~~~~~~~~~~idRni1
I m u u " n ~ ~ u n ~ ~ u u o - ~ nPrimary
~ ~ l ~ ~patency
~ u ~ . il ui m
a s u z 3 D radu<aua: 7915
I-
nvAnwt-7 Meta-analysis rd5uu~fluun1ad1~uuiu~aan~Qanu5~am
Aortoiliac Tmu%UYaiuaau
g n T i l ~ r d u m l i 7 ~ r (Stand-alone
~u~
PTA) n"Ynialildumilaam61U'uiau62~(PTA plus stenting)
wuiin71-vii PTA i?u~un~a?dunaa~ild1o'u~w"w~n1a?nl"nlll.ib[u61una1~n~~u~~ni~n~ss"nl"nlll.1~7
FTA i W ' u ~ a u 7 ~ ~ 4 i(017md
~a'~
7) u a n ~ i n f ! ~ ~ ~ ~ d ~ w ~ ~ ~ a n i w M (Occlusion)
"~fl~n~aa~mCu
i~un'un~a~n~~zu1u1(ilr~amu"u~nqo1~Uu~0~~d~6~iM'1~w'na~~n-1~~1'~a~n1a~$
n7~5"nw11$~wa~3564niji7
Definition of patency for surgical re~onstruction'~
Patency ~ ~ i u i i ~- 1~ I U ~ Q M U . U ~ ) ~ ~ ~ ~ ~ ~ ~ ~ ~ ~U~ a~n~d lU? ~M ~~o 7~ : u. ~J~ ~? aIl ~'~ Ia E~) m
' ~~ ~~E )Im~ ~ U
u31~nsfl6jl~n~.rTnw.iii~n-1aniw6Tmul~~ni~~mm'u
Patency rtri.1~2itflu3
16trt-i Prirrrary patency, Assisted-primary patency Lra: Secondary patency
Primary pnterlcy M U I U R ~ ~ a a ~ ~ ~ a m d ~ ~ n ~ ~ w (Graft)
~ c n ' mu"~n.raniwAtta:lfiCni'~r!mGu
~d~uoi~
~mu~rjm'w~3ini.r4nwi~m7tW"u~4u
un~a'u ni~jlnviu4~~md7umYu
(Proximal) ~4od?uda1u (Distal)
o i a ' 1 a u ' l m ~ ~ u ~Graft
4a
Assisted prirrrnry patemy MUIUR-I Graft ~ ~ n ~ f i a n 1 ~ ~ 6 n ~ u ~ ~ . r n 1 ~ i n w . 1 1 w " u ~ ~ i i u 6 ? ~ 7 ~ ~ 1 - 1 a ?
~'iani-rdim'nTnuB(fq~fifin7Tqmol'u(Thrombosis) Iiindu
Secondary pstency ~u-~ufi.!Graft r " i n - ~ ~ ~ m m ' u ~ i i(Throlnbosed)
rn~u~~~-~ ~ r o i n ? u ~ k i l ~ n ~ ~ ' n ~ ~ T n v ~
~ d u ~ m " u 6 a u ~ ~ M i - 1 a 7 u 1 ~ ~ ~ ~ ~ n~ 7I'U1 w~lTc n~'~m ~ S U U I G ~ ~ ? W R ~ ~ E ~ Q ~ - ~
UPDATED M A N A G E M E N T FOR LlMB SALVAGE I N PATIENTS W I T H CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
n - ~ m 7.
d Primary patency of FTA vs FTA plus stenling for aortoiliac occlusive d i ~ e a s e ' ~
4-year primary patency
PTA
PTA plus s'tenting
Claudication
65%
77%
Stenosis
54%
65%
Occlusion
Critical limb ischemia
54%
67%
Stenosis
44%
53%
Occlusion
n~%flnuiRandomized controlled trial Tmer Dutch Iliac Stent Trial Study (DIST) Group
~d"aur~uun~s"lvmaam61fiuM"uG~wun1aGu~~nu
(Primary stenting) n'un73lilaiuma~m&vTu
~doflQo~~8niuvlGqn14$7
PTA (Selective stenting) %uqfl?oClaudicants h'hq.rqcilm"uua4 Iliac
artery w u i i n i ~ % w ~ d a~s ~ w
f ~ ~ u 6 i u n 3 1 ~ a 4 ~ u u o 4 n 1 f ~ ~ - l 1 u ~ b j ~uannnd
~mn0i1~n"u~~
~d~fli114m-1
Cost-effectiveness wui7ni@ Selective stenting ~~1liiiiulun1~s'nw7dcn'1nii~~
oei~~l~iim~uwani~Anwi
Meta-analysis lull a.a.2011 wui7~ufld?u~Aw013an1wva-r
niqmdiud?u~l.r4(Extensive disease) i~uriurim~~u~uin~fl~~1u"u7nr\mj~u6~u
ni3fnuiAu75
Primary stenting ~flwani%~nw161ua31ua4~ud~ni1
Selective stenting20 (0\7mQ( 8)
0117wtl 8.
20
Primary stenting vs selective stenting for extensive aortoiliac occlusive disease
Primarv ~ a t e n c v(%)
Primary stenting
Selective stenting
92
82
87
72
82
64
79
64
67
63
~ ~ ~ ~ ~ ~ I J " M L ~ U ~ U B B J ? U ~ ~Aortoiliac
W U I ~ ~ d
~ l~d~? Wu ~
U~
? (TASC
sL J~ W type A and
B lesions)
~ ~ ~ 1 a n l t s " n 1 ~ s " n w 1 m " ~ u 7 5 ~ 1 - l ~ 1 ~ a ~ u ~ ~ ~ ~ ~ r i d s ~ ~ ~ 1L5Ln~ i~ ~~ iM ~? ~I Ji 1 ~ ~ ~ ~ n U
a o ~ ' i r n $ ? u ~(TASC
~ w type C and D lesions) n i ~ w i 6 m ~ ~ n ~ ~ a ~ ~ ~ ~ n ~ ~ ~ u o ~ n i '
oti~.slaRm~uni~Anwi
Systematic review22 lud2-1 10 Blndw-1~~7
wud~finiati175~1~-r~iu~~u
u ~ l f l u n i ~ ~ n ~ ~ a a u T ~ c l w " f l ~ u ~ ~ a n 1 w ~ ~i ~~~~~ ~ lu6~d ~a ~~~i~~~ ni n~'~f ;u U' ~ a ~ n 1 '
d~bUd1.4(Primary patency l u ~ a a i5 fl lato 60-85%) uanilin6ruuiin~~~iicil
Restenosis
n i o v l 6 ~ n i s % ' n w i n i u 1 ~ n % f i n i 5 ~ n ~ l ~ ~ u ~ 6 u ' 1 6 6 'bmufl
a ~ 7 ~Assisted~i~~i~a~~~~~~
primary patency LLa: Secondary patency N i n n i i 90% \La: Limb salvage rate ~ a d 95-97%24
u
Criteria for Patency: Endovascular ~ r e a t r n e n t * ~
iiuiuvo4 Patency
~1~~uni.r~nl~.i6~u5Z~i~~~u~~~~aa(il~Ga(ilGn~~~~~nm'1~
~mu~~iiaTdni~m~aoiimol~u~?u~~n?~%'dflS~u~n?u~I~n7'1a'n~1~w"a~.r::1fiui1~n1~~(jlm'~
(Occlusion) M%
n ~ - r ~ u ~ ~ c l u d i a u ~ ~ G(significant
u " u d i 6 ~ restenosis) uf~~nr~aan~lom~ln'Tun1'1in~.i~?a1bj
Tmuozfiai7
W Significant restenosis rfiaolsaowuni~Gu1~nudiu7nnii30-50% ua-r~~uwiuquu'n~1~6iu~u'~o-r
~ a o n i a m% ~ u i d ~ i u ' i ~ u a i o ~ a a i ) a
n "a ~
7 ui ]~~f ~ ~ o n M " ~ ~ a E i ~ u u 3 ~ ~ ~ d(Velocity
~ 6 i u n ~ratio)
a % ' ~n w? . io
%dAnkle-brachial index %uni-id-izIGu b u i l z ~ o Significant
i~~
restenosis ~ i o GVelocity ratio >2
es"sonr?owu ABI amamu7nni-10.15
Primary putency tlu7ufi.l M a ~ ( i l l ~ i ] m ~ ? ~ ? W d ~ n ' i ~ n 7 ' 1 5 " n ~Restenosis
.?1$fi
~ ' i a Occlt~sion 'Inud
'lbj~o~~M"ni~a'n~~Im7~du16~
Assisted prinrary patency ~~~uii\l~aa(il~8aclu~~?~d~d5"un~5in~.1fi
Restenosis d-ro-~a~flu
Significant
M?D Nonsignificant restenosis a6 r~cjiu'.lbltfi(il Occlusion f~ufluS~tflu6od~~n~.rTn~i~du~m^u6~u?3
M I ~ W I ~ W ~ U M
~Wd~flo.l~W~~~6liim
~ ~ ~ I ~ E ~ Occlusion
I ~ ~
W~J.IB.~-I
Seconclary patency esu?ufi-~esao~r~o~1u^s~?~~~cil'4'un~-r~n~~~
Occlusion L R ~ $ U L L Q~~~ v i n i u ~ k a i n n - ~ a
s ' n w i 6 ~ u 4 Z n ~ ~ w i u w ~ u ~ ~ ~ nfiiui~nn~uui~.il~iu~cil'8dnclf4
i~ei1m'~1
UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
n i d 6 Stent-graft ~uniaa"nuini-l?m~uu5iamAortoiliac ~ n i % % i u - l i u n + J a n.q.2003
~ln~
l r j l u ~ i l ~ u ~ ~ u l v l ~ i f l u n ~ ~ w " f l ~ u i(8570
~ a n ~TASC
~ " ~ ~ atype
~ T 'C~ n&~ ~D~ a lesions)
wani-l-Enwi~ui?ai1 fl wuiifi Primary iiaz Assisted-primary patency ~viin"tl70% \La:: 88%
mi~i-16~~''
dabl'llufl n.m.2008 S j n i ~ ~ i u ~ i u w a n i ~ ~ n w ~ " \ u ~ ; ~ :Stent-graft
~ i a ' ~ o ~ au
nia~~
Complex aortoiliac occlusive disease wuiifi Primary patency lu~7a'l3 Lie: 5 P] q-lfi.1 80%
LLa: 80% miudi5u Lta: Assisted-primary patency lut?ai 3 iiaz 5 fl q4G-l 95% iia; 95%
~ ~ f i ~ ~ ~ : W ~ ~ ~ ~ l ~ ~ i i ~ : : l f i c . li iadnui~au~ in~wvi~~~~ n i f P ltent-graft
ij
- Iu
Aortoiliac disease ~ u f l o g k ~ ~ ~ i ~ u M " i i w 8~iloiilb~ui~%i::~~~n~adn'13-ia'i)~S"u~duin
i~~iuu"n
Comparison Between Surgical and Endovascular Treatment: Aortoiliac Diseasc
nia~nwiud%uu~~uun1'1~nwi~~uniawi6miia:S~~1~~1~aa~divls'~nia~mfiuu4~71~
Aortoiliac
luih?lJ'wfliw"u4 3 nilflnui Tmu~~unia6lnwiiiuu
Randomized controlled trial 1 niadnwi iiaz
Retrospective cohort study 2 ni'ldnwi
lug n.a.1993 f i n i a d n ~ i i i u u Multicenter, prospective, randomized controlled trialz8
\ d ~ ~ ~ i M ' ~ ~ n i ~ s ' n M i (Surgical
~ ~ ~ ~ l bypass)
4 n i l ~iia:ni1sii~buuiu~aorjli~am6~uwiua~u
i 6 ~
qnTil4 (PTA) lu@hu 255 nuMdfln?lqmfiuvil~~aomil~~om
Ilio-Femoro-Popliteal arteries
~rjluSj~~d~u~il~uw"~ni~:'~i'~i(il~~ilmu"~~n~mi~du2'~ua:
30 wani~~n'13-11~'1zu:~7ai
4 Bwuii
~daa~?8fl1J7:~~finiw~vi1~fluufiuM"~~u61~
Primary patency riaz Limb salvage uonoinil
~uii~m-1ini-1i~u.i]~m~~u'1~~~bjiim
i i dn fdl i i~un~"~u~ ~ w " n ~ u M " ~ 6 a ' u n i ' 1 w ' i m ' ~ o z ~ ~ m l i n i l
~ ~ u . i ] ? m q ~ n i i r d ~ ~ ~ a i w3i fl
~ l(nin-rd
d ~ i n n9)i i
m?md9. Clinical results comparing surgical and endovascular treatment of aortoiliac disease
Ar~tlzor
WOI~L"
Study design
(year)
Multicenter,
prospective,
randomized
study
( 1993)
N
225
rn
~ a l l a r d ~ ' Prospective,
nonrandomized
study
( 1998)
119
Kashyap3'
288*
Retrospective
cohort study
(2008)
Results
Author's conclrrsior~
Primary patency (surgery vs PTA) at 4 years
Iliac:
IC 85.2% vs 70.8% @ = 0.055)
CLI 57.0% vs 57.6% @ = 0.66)
Fempop: IC 57.7% vs 59.5% @ = 0.43)
CLI 56.3% vs 52.5% (p = 0.86)
Limb salvage (surgery vs PTA) at 4 years
Iliac:
IC 94.7% vs 90.5% @ = 0.39)
CLI 72.5% vs 74.8% (p = 0.77)
Fempop: IC 85.1% vs 92.7% (p = 0.38)
CLI 59.7% vs 90.9% (p = 0.12)
Overall survival was not different but there
was a trend toward higher annual mortality
rates in after 3 years in the surgery group.
Both treatments
are comparable
Primary patency (surgery vs stenting) at
12 months: 93% vs 77%
30 months: 93% vs 68%
42 months: 93% vs 68%
(All p values = 0.002)
Procedure-related morbidity was similar.
but the surgery group had more systemic
complications whereas the stent group had
more vascular complications.
Surgery
preferred
3-year primary patency* (surgery vs endo)
Endovascular
93% vs 74% @ = 0.002)
treatment.
3year- secondary patency* (surgcry vs endo)
preferred
97% vs 95% (NS)
3-year limb salvage rate (surgery vs endo)
98% v s 98% (NS)
Mortality and procedure-related morbidity
not different in both groups
Critical limb ischemia at presentation has
hazard ratio 8.1 @ < 0.001)
N. Numbers of patients; Fempop, Femoropopliteal; IC, intermittent claudication; CLI, critical limb ischemia;endo, endovascular
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
dnw%ufl n.fl.1998 fin?afinl~.7~~uu
Prospective, nonrandomized study2' rd?uu~fiuuwani-i
%"nu7~:~i7.m?aci16m (Direct reconstruction) ~iazn?sl#umaam&io"u (Primary stenting)
lu#hu 119 nuda Severe aortoiliac occlusion hufirinli~u@~uM"fin7~:"~1~1n~tanu"u~n~m
h u a z 40 wu~7nirjwin'nfi~rn41na~61n.]~u'IIiin
Primary patency l u i ? a i 12, 30, 42 ~ R a u
rariiqmiinid$vna2mdiCu ~ ~ a z ~ m ~ i n i a r i m m ~ : r i ~ ~ n d a ~ o ~ n n ~ - i ~ n w ~ l m u a ~
~idv~uiin@uflTnwid2un14ej76mfi
Systemic complications qm11 luuna:$?nquM"s'nw~Giao
unaamd-~GufiVascular complications qqnii
n i d n u 7 Retrospective cohort study3' lug n.fl.2008 ~d4uu~~uu~anis5Unu~6~uni'iwim"m
(Direct bypass) ~ ~ ~ z n i a s i i ~ u u ~ u d a ~ ~ a ~ u a ~ ~ q n T f l ~ ~ (PTA
a ~ n " with
u ~ l i stenting)
?~na~md~Cu
l u ~ d ~ u - i h u a u169 nu (288 limbs) i f i Severe aortoiliac occlusion ~mufi<m~7dauGd2udfi
ni?zu~uini5anu"u~nqa.h"aua:
50 wuiin@u Direct bypass fi Primary patency \ur?ai 3 fl
y n d i n a u PTA with stenting a u ' i - ~ l ~ i i r n ~ ~ i d n f i Secondary
o 1 ~ 1 ~ 7 patency ua: Limb salvage
wuii1d~rmn~iqn"u u a n o i n d w u i ~ n ~ ~ f i n i a z u i u i n ~ ~ a n u " u ~ n q m G ~ ~ ~ d r ~ " 1 n ~ u ~ 3 u f l o ~ u d
~ 7 % t f " ~ ~ l 6 1 ~ 4 ~ ~ ~ D ~ n 7 ~ ~ $ 4 7 ~ ~ ~ ~ 4 d 7 ~ ? ~ n l 4 ? n ~ l M " 9 f l D 4 ~ ~
4mu54'4d niaa"n~~n?aqnn"uu5baslbAortoiliac ~u~ogliudr~u?~u"ui~z~#'i~~i~aiorn2uuinifiu
~ 1 ~ i ~ n 7 a w i G m o z ~ t f " w a n 7 ~ ? nPrimary
w . i 6 7 ~ patency i 6 i n i i ~~in7sfnw1~7-lrn7ua2uiifl
Assisted
primary patency, Secondary patency ira: Limb salvage rate i~vii~M"u~n"Elni~w~m"nTnu~nia
%"nwi~w"a~~6ui~~ibli4blM'i~6wiu~14~iufl2u~~~d?u~~~
~ ~ W ~ U L M ~ G F ~ ~ W ~ ~ ~ ~ J P ~ ~ M
~ m u ~ a w i z o d - dStent-graft
~
f i r ~ u ~ ~ f i u M " o z ~ 9 j i d a z ~ ~ ~ n i w d ~ v i ~iidfi-~6~4sa
~fluuni-i~j~~n~6
niaAnu7tiu~6uiorP1 ~ ~ ~ u ~ n m ~ i ) ~ ~ ~ ~ ~ ~ q i b 4 n i ~ z v i v i ( j l i ~ ~ ( i l u " ~ ~ n q ~ 1 ~ ~ a ~ ~ T
~.ii43niaa"nu~wiuwi~a~ua~urOu~9~n
o~~~~.iiirni~divls"~l~il~u~fi~i~~~a~~~a:~aniw
aa~~adar;iu4woM"~:~#i%"uniaci7~mld
niaM'~w16m Aortobifemoral bypass C4n4"lwan-r-j4'nui
w"Wnaiuaswuqq 1 ~ w z ~ d a u ~ ~ i i 1 O u 6 a ~ ~ 6 s ' u n 7 ~ % ' n u i ~ 1 ~ i u n % " ~
Fcmoropopliteal Disease
Surgical Treatment
~ I ~ ~ ~ I G ~ L ~ ~ ~ ~ ~ ~ ~ M I ~ L Femoropopliteal
~ M V I ~ D iiu.1~6iUu
~ L ~ O ~
Above-knee femoropopliteal bypass 118: Below-knee femoro opliteal bypass bmu$?ld
vlaomrtonwdalnl4'~OuInflow site RD Common femoral artery ~iu u 7 ~ n s ~ a ~Superficial
o~fi
M% Deep femoral artery ~LMul6 ~ ~ U W U ~ ~ ~ ' ~ L L M U ~ ' U O Inflow
J
site ~a.ifiwaian7-is"n~.7~
' I I f i m u a ~ ~ a a n ~ ~ a m 8 d ~ (Conduit)
d o u ~ a l6~Lriwaomt#onn'imuro4 (Autogenous vein graft),
~a~ntLond~rius'nu~'l?'6aun'11u~du
(Cryopreseved vein) ~ ~ a : a a a a ~ t a m d u (Prosthetic
lr
graft)
L I ~ ~
f'
wudi~o~u~1fi'n$?6~acsi~~1a761~14~u~un7~~u"4iudl~a'~n7aw1m"m~dduu~l~r6uvlaanl~~mn'1
16~rriConduit type \La: Patetlcy of olrrflow tract5 w a n i ~ d n w i ~ ~ ~u eu t a - a n a l ~ s i s ~ ' ~ ~
~ra:nmwuw~u?-s%mnaa~~mu
Cochrane ata abase^^ wuiin~--sl$ Autogenous vein graft
%ts"wani-i%"nwidiunai61n-4wuq~nii
Graft 6uynufin ~aid~o~tUuni-ir~oud~-i:~u
Above-knee
~ 3 Below-knee
n
femoropopliteal bypass u a n o i n d w u i i n i r l ~Prosthetic graft o:fi Patency
ana~uin~una~drda~da"1u~:&u
Below-knee bypass3' (g11714d 10)
n l m d lo. Five-year primary patency after infrainguinal bypass3'
5-year primary patency
Femoro-poplireal
Claudication
Critical limb ischemia
Femoro-tibia1
Femoro-pedal or popliteal-pedal
Vein (AK)
PTFE (AK)
PTFE (BK)
80%
75%
65%
66%
67%
50%
47%
33%
PTFE, Polytetrafluoroethylene; AK, above knee; BK, below knee.
UPDATED MANAGEMENT FOR LIMB SALVAGE
IN PATIENTS WITH CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
~aam~bameiiB/~~u:d11fl$~itlu
Conduit ~u6u~~anawuaeia
Autogenous greater saphenous vein
(GSV) u a ~ u i u ' 1 ~ ~ ~ u ~ n ' u ~ ' 3 a ~ 1 1 n ' ~ i n "lun?t-Cd~dnibli3611$
iurna~u'iu~
GSV am13 Alternative
autogenous vein #uy rdu Arm vein u4a Lesser saphenous vein lrnul6 ~ I M < U
Nonautogenous conduit lramdu l6m-i Cryopreserved vein, Human umbilical vein, Prosthetic
graft a :
Composite autologous-prosthetic graft o i i l w ' 8 i a m i ~ d ~ d u n a f l w " ~ i ~ ~ u
r ~ d w u d i ~ a ' n ? ~ n ? ~ u n ~ ~ Alternative
w u ~ ~ nautogenous
~ a ~ ~ ~vein
~ u graft34-36
~n
r~nflnn73rdabloia~aomibamdafl
2 %l.rZn 3 " n ~ ~ ~ , n B s a U u ~ ~ u i m ~Reversed
g 7 ~ 8 i 3 vein graji LON
nlan"(il~aamrbamei7aan~lM"~d3u~~~~~1u1n~u~'~~7-lriauti1u1~dauoia
1j5Mdna~l$~aam~fiam6+1
~ ~ o i i ~ ~ ~ u ~ r ~ ~ ~ r d ~ ~ ~ n ~ (Valvulotolny)
a ~ ~ a M ' i ariau
i u d~~5-adauCiu3adauda
un~uu
r7unii
In situ vein graff ~ ~ n n i ~ ~ n u i w u d i 4 6 ~ ~ w a ~ ~ ~ " w a n i a ~ n ~ - 1 6 i u n ~ i ~ n ~ ~ ~ ~ d ~ ~ m n
Prosthetic graft fkiuu?Liln"~~riPolytetrafluoroethylene (PTFE) Iln: Polyesther (Dacron)
71nn73finwi Meta-analysis wud7 Graft ~ ~ a a ~ u f l a ~ n ~ 7 u n ~ ~ u " ~ a ~ n i a ~ i l ~ i u ~ b j ~ ~ r n n d i ~ n
n v 1 d Interposition vein cuff w u i i " l j u ~ $Primary
~
patency a~a: Limb salvage rate l u n i %
rda~oia~aom~'io(i\azn'u
Below-knee bypass ar~i~d.i~waoian?a9'nuiii~%'u
Above-knee bypass3'
P
nmflnui ~ e t a - a n a l ~ s i s ~1~~~~~uiu~(jl~~amu"~1jn~md~fibani~uu1n~l6T~n1'1w16(ila1Jdu
'
ni~ifl~~aa(ilt'iamu%~3m
Infrainguinal disease w'~li~wani%a'nui~u&iu
Graft patency Lanz Limb
~~Fia~i~~l~iim1uwui1~il~una~d~~maini~aW~.ilSm~Z~w1
salvage rate a~7ua:n'LIMdR
~ m u d ~ ~ l ~ ~ r W u ~ ' i m i ) i n(m77wd
T ' ~ n i ~11)
u fin~~:-]%u"llq
2 fl~tanniu~$.mi~%"nw-i
Wtjilau
a'iu2u~d4fi~n6(il'u7i~fiii
Graft o:u'-lfianiwiRafl (Amputation with patent graft) (i~wur~fld
6)
wan~~~nwi~~n~i~~~~fl~R~n~ib~1~~~'~a~n1a~Wan@fl~udi~%"~l~~i9'~n1
~aanr'inmi~nq ~ u n ~ G ~ ~ i l ~ u ~ f i n i w ~ ~ ~ n 1 u ~ a j ~ u ~ ~ d ~ i a : i ~ ~ ~ ~ b ~ ~ ~ ~ : f l
M ~ ~ ~ ~ G ~ ~ ~ ~ ~ ~ M ~ W ~ I ~ ~ ~ L ~ ~ ~ U L L ' I ~@ilau
LLW~~~L~~
n~uu"ldn33M'in73w7rn'm~dduu~i\ti6u~a~(il~ba(il
L ~ F ~ o I ~ ~ ~ I ~ ~ I ~ ~- idu
v ~ ~ ~ u T ~ ~ u
n i ~ r ~ u t R a m w 1 u ~ i ~ ~ 1 ~ ~ ~tDu6u
~~4an1~6a"~1
~ 7 ' l ~
11.d Patency, limb salvage, and
survival of patients with critical ischenlia and com~rbidities~~
Results (%)
Primary patency
Secondary patency
Limb salvage
Survival
1-Mo
3-Mo
6-Mo
1-Yr
2-Yr
3-Yr
4-Yr
5-Yr
94
95
-. 93 -.
95
88
91
89
90
81
75
81
79
72
70
75
75
53
60
67
69
41
56
58
67
33
50
88
84
83
t-
Months
lluuqfld 6. Pooled survival curves of primary (gray) and secondary (black) graft patency,
limb salvage (red), and patient survival (blue). (Knr~dfmlnAlbers M. Romiti M, De Luccia N.
Brochado-Neto FC, Nishimoto I.Pereira CA. An updated meta-analysis of infrainguinal arterial
reconstruction in patients with end-stage renal disease. Journal of vascular surgery. 2007;45(3):536-42.)
51
67
28
UPDATED M A N A G E M E N T FOR LIMB SALVAGE I N PATIENTS W I T H CRITICAL LOWER L I M B ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
Endovascular Treatment for Femoropopliteal Disease
ni~%"nu16au'iSniasi7-1uvlaam~~am6aum1uwau~n~nll~
(Balloon angioplasty, PTA) d7vlTunia
a,naiuuT~mFemoropopliteal artery ~ d w a n i a T n w i ~ i A t R u u ~ V ; ~ n ~ a ~ n~wo~r ~t ouiul i~a~ca~m~
nisa"nui63u PTA d i ~ % n i ~ a , n C i u u b u ~ ~ m
Primary
dfi
patency % u n a i 5 fl ta~ua"auaz26-4525
flo~uiiwaciiawnniaa"nui'I6~~ri
~n"num:wu15wniwtBu~~uuStenosis M% Occlusion, ~ X N ? U L L W
u a ~ n i a u i m ~ 3 a(Claudication
m
vs CLI), n a i b ~ u i ? u a ~ w u i ~ ~ n ~ w n ~(Length
a q m 6 uof lesions)
a
Patency of distal runoff5 o i a u i ~ ~ a f l n ~ s ~ 1 ~ m a ~ m 6 ~ C u u 1 1 ~ u n ~ ' 1 T n w . ~ ~ a u T ~ n u ~ ~
s~ui~"lju~d~Cm~inaiun-~~u%u~u15an1w~~lu
Occlusive lesion i ~ a ~ u t j i l ~ u n ~ u $ i i n 7 a
uim%~n?u\tsd(Critical i ~ c h e m i a ) s~ 'e i 7 ~ ~ r i i m i ~ d i ~ ~ u $Stenotic
i l a u ~ flesion
l
vl?a$ilaunqu
Claudicants w u i i n i a % f iStent %fi~ab.i~~rnndidn"EI
Balloon angioplasty (611~1-d
12)
rn1'1-d
12. Pooled results of femoral-popliteal dilatations4'
Primarv oatencv (%)
Claudication
FTA: stenosis
PTA: occlusion
FTA+stent: stenosis
PTA+stent: occlusion
Critical limb ischemia
PTA: stenosis
PTA: occlusion
FTA+stent: stenosis
- FTA+stent: occlusion
PTA, Percutaneous Transluminal Angioplasty.
%uY n.fl.2006 Gniafinwib1uu Randomized controlled
~d~~~i~u~nia~dunaa(ildiu"~~'ui
niuvli'.m~aM'i PTA (Routine stenting) n"EIunia%dunaandi~uniuvl~.~
PTA ~ a w ~ : r d a ~ u ' a ~ i d f
(Optional stenting) ~ u ~ i l a u ~ f l n i ~ q ~ ~ u ~ u ~ t a ~ uSuperficial
a ~ v l a afemoral
m ~ ~ aartery
m
iiu-~u
154 nu (Severe claudication or Critical ischemia) w u i i n t j u Optional stenting WCma7ni-i
a,mCu67 (Restenosis) %u1 D q ~ n i i n b uRoutine stenting aeiidfioa"uii6y (63% versus 37%)42
uonoindwuiiniuvl~~ni~%"nui
w"flaunauivii Routine stenting w i u i a n ~ 6 ~ ~ 6 a z u z ~ i . 1 1 n a
nii.nbu Optional stenting
waniaflnwimn Meta-analysis %uY n.fl.2008 wudin7sTnui62u Balloon angioplasty ~ ~ a z
Stenting ul@?ludlf
Femoropopliteal occlusion ~ ~ w a n i s s " n w i ~ u 6 i u n - ~ i u n ~ ~
1 uTI~ u t ~ a 1
l b j ~ ~ m n P i i 4 n '~
U ~~~ ~ 0 7 ~ 6 ~ ~ ~ i n 7 ~ ldu
L f Stent
i ~ nfracture
i ~ ~ wbu bl l ~
d a7
u n
(37%)44
~ ~ ~
5n$qwuiiniaA Stent fracture t~uflo~ud76~fibw"ua"rnainiatftm
Restenosis m ~ u m
~ku"un7~14
Routine stenting diw%"uniaa,mCuuS~amFemoropopliteal ~ J " ~ ~ . I ~ ~ ~ ~ U ' O W ~UIYO~UUU
~ ~ M " ~ ~ L F ~ U
u"aEi4bilua4 Stent d.rrOu~uaa-15u1Bu8.~1m~~iufl~w"u~
Suboptimal angioplasty ~V;i6u
Slrbinrirnal angioplasry (SIA) b ~ u b w n 6 n ~ v l b i u a ~ ~ ~ ~ 1 d ~ i u m a u d 1 ~ % " ~ a ~ ~ ~ a n f i i n 1 a q m
L ~ Chronic
U
total occlusion (TACS type D lesion) d~~biwiuiaod~:wam1d
Balloon catheter
kXau75dnGi ~ n n 8 n d % f l m d d a i u a ? u u P nAngled hydrophilic guide wire ihijnaamtGsm
b ~ ~ a ~ 1 r i : ~ ~ Intima
l i i d u u 3 2 m Proximal da%aulan o?n<uvi7n7dd Guide wire ldn?u
Subintimal plane ounszv?dfi.ru%am Distal dosauT-in%ntYu~+itj True lumen brazviin?suu~u
a i u a - J u g n l i l ~ d a n i 4 ~ a a m ~ 3 a m ~ qwaniaa"nw162uf
nCu
3(i97n Systematic review45 wuhi
Technical success 80-90% ~ n u f l ~ ~ ~ ~ ~ n ~ f i w a o i a c l ~ 7 u d 7 t ~ ~
5 dl u~ a 6s-n1 i~~v?l dnqw
u ai f4
v l a o n ~ ~ o m d r l n 6 u 5 ~ aProximal
m
Lka:: Distal n ' a ~ a u l a a~mufin?iuu~aua~n~aqmn"u~i%rwaaia
FYn%idit% ~ a n ~ i n d ~ u d i 1 u ~ f l a u i f i nCritical
ia:
ischemia ~ia~~d.rn~aqm6uflwaTmuma-f~a
Technical success rate TmuFYn~iii~%~%u
Fernoropopliteal > Mixed lesions > Crural vessels
miuii6u 3S SIA Gfi Primary patency %uI fl ~ a i 50%
u r ~ a z fLimb
i
salvage 80-90%
UPDATED NIANAGEMENT
FOR LIMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
~ulro~u'u~n~ati~una~(jlcl'~u'uui~n3~u6~uu
(Sirolimus) d-.u4ai-huawn7a~iicjr Neointimal
hyperplasia d-.m'dwa~fiacilnia~ficjrRestenosis 16 ~?ernumaaercl'if7udu6nf!diDrug-eluting stent
DES %.hbmnaii-rein
(DES) o7nwan7a~n~~~u~8~u'uwuiiwan1-ia"nu~~u6iun~?~n~~uua-1
Bare metal stent (BMS)~"~'
n74iin~7 Randomized controlled trial ~d~uu~fluusswi?.~n1716
Stent-graft ~~~:n?~wivYn
k4n77a"n~7Superficial femoral artery (SFA) occlusion wuLli7n7alfl stent-graft flna~undwu
~ ~ o i 7 ~ a i n n l 3 wOpen
i ~ n femoral above-knee PTFE bypass4' dilu7%jnisn"nu7~d~uu~Guu
Stent-graft (Viabahnm) n"u BMS 1un73~nu-1
Complex SFA occlusion (TASC type C and D)
niu~k~inmiu%J~fluna7
3 D wui~8-1na-lnGufiPrimary patency l a j ~ n n ~ i i -wdn~u
~ f u ~Stent~
Stent fracture fiauniint@ BMS af.i7-18u'u-d16~
(2.6% vs 50.0%)
graft fl~m~in7'1lfim
~ ~ n i t ~ n 1 3 a ' n u ? F i i u ~ ~ d ~ 1I6r1fl
1 u a ~Debulking
u~u~
device (atherectomy), Cryoplasty,
Cutting balloon fln1#di~?uwui5'an7wfl~u~~'1-1
luflo~lJ'u75~\si16u'-18n7a~#-17uay"1ua-fj7n"n
Comparison Between Surgical and Endovascular Treatment: Femoropoplitcal
Disease
F-
n77Anw Randomized controlled trial d ~ ~ d ~ ~ ~ ~ ~ u u n ~ s a " n u 1 6 ~ u n 7 ' 1 ~ i ? ~ w ~ ~ a z n i ' 1 a ' n ' 1 3 1 ~ 1 ~
a~ua3ulusauTan Infrainguinal disease ~d~u~~rda-1~i~~~i-1n1'1%"n13-~n~~su~u1cjr~3acjr~~a%
~tbfla?~au?~bl7n?ia
Bypass verslrs angioplasty in severe iscllaemia of tlre leg (BASIL) trial5'
n i ~ n " n w ~ d d s z n a u ~ ~ u ~ f452
l ~ unu$i%~! u ~Severe
u
chronic lower limb ischemia d-l~iinaqn
Infrainguinal occlusive disease nw8nuirtu.t~il1urUu2 n 4 ~n ~ u ~ ~ ~ n l 6 ~ u n i ~ w 1 6 n ~ I J i u u
~7diRu~aani3an~~m-ldau
(Bypass-first) uaz n ~ u d a a ~ ~ 6 ~ ~ n ~ ~ 5 " n w 1 6 ~ ~ i 5 ~ 1 - 1 a 1 u a 7 ~ n a ~
(Balloon angioplasty-first) Primary outcome luni%flnwi6fio Amputation-free survival
Secondary outcome daznau6ii7u All-cause mortality, 30-day morbidity/mortality, Reinterventions, Quality of life LLaz Use of hospital resources
wan71flnw7lu.lla.I 6 ~Gbu~ban
wuii$~aa-1ntjuGMortality Liaz Amputation rate 'l%iLt~ndl4fh
(AmputationIDeath: 21% bypass-first vs 26% in balloon angioplasty-first; P = not significant)
ilviwui?n$uBypass-first fl.ir"ma?ni-1bfimEarly morbidity n ~ u l u
30 kLbsnm-1nii s?uM"-l1~t2al
lwn~~~nui1u1~-1wu1u~nu~uni~
~doduqnni~flnr~-7dt3ai
5 fl wuii8q~~c;i
2 'lu"uld~5-1n17%'n13-?
nau Bypass-first fl Mortality
~
~UI-I~~~U~IFYQ ( m i n d 13)
(all-cause) 119s Amputation rate d ~ n i i n aAngioplasty-first
P
uana~n~~~wui~~~h~fl~~~U~m~n-l~dduu~~n~~%'nu~n~u~5~16a"uns%
(Crossover treatment: 30% in Bypass-first, 50% in Angioplasty-first)
mwwd 13. Comparison of hazard of amputation-free survival and all-cause mortality
Adjusted hazard ratio*
. .Number of events
Angioplasty
(95% CI) of surgery
Surgery
(n=2=)
relative to angioplasty
(n=228)
Amputation
50
46
1.04 (0.69-1 -56)
Up to 6 months
48 --..
60
0.73 (0.49-1.07)
After 6 months . - -, .~fter-2years
16
28" 0.37 (0.17-0.77)
Mortality
31
26
1.27 (0.75-2.15)
Up to 6 months
48
61
0.81 (0.55-1.19)
After 6 months
11
27
0.34 (0.17-0.71)
After 2'years
~
'~dlusted for aqe, sex, cllnlcal strat~flcat~on
group, body-mass ~ndex,current or ex-smoker status, creatinine
concenlration,diabetes, and stalin use at baseline.
50
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
, f j n i ~ ~ i ~ g n i - - $ &BASIL
n ~ ~ y trial
a q ~7?i~--$i:cs/dFKI%°ir
Intention-to-treat analysis wui1nluMih
ni~%"nui&diivi
2 fl$uld nau Bypass-first fl Overall survival ( 0 s ) q-lniinqu Angioplasty-first
in& 7.3 tRou (P=0.02) k~a:fl Amputation-free survival (AFS) qdniinqu Angioplasty-first
5.9 iGou ( ~ = 0 . 0 6 ) ~m'au7fini~dnw-7iiu~6u6au
'
Subgroup analysis52 wui? nqu
Angioplasty-first f i ~ mTreatment
~ ~
failure q ~ n i i n q u Bypass-first (20% vs 2.6%)
3nv%wui1niqt.iiGm Bypass surgery ~ k m Failed
n
angioplasty l6walbj~ivi7nqud7G?un7a~'1
Initial bypass 6 4 1 ~ 6 1AFS
~ \\a: OS (rrwuqfld 7) d ? ~ $ u ~ ~ n f i n Angioplasty
vil~
5z~ii.~
Transluminal iaa: Subintimal %cs'~an?Ta"nui~dikmnm'746u
(rrwuqfld 8) l u n q u Bypass-first
w u i i n q u f l ~Autogenous vein graft fl Amputation-free survival qdniinqufi4 Prosthetic
graft (P=0.003) i d Overall survival ~ d ~ t n n d i . r f (~rwuqfid
lu
9) ido~d4uu~fiuuniu
Prosthetic
bypass fhnqu Angioplasty-first wdfi Successful treatment w u i i n i u Prosthetic bypass fi
Amputation-free survival d ~ n i l n a uAngioplasty (rrwuqad 10)
niadnw-7 Meta-analysis n.a.2013 id?uuifiulrni~Yn~.76au
Bypass surgery iiaz Endovascular
treatment l u Femoropopliteal occlusive disease dqaauaau RCTs 4 n-nAnu7 iraz
Observational studies 6 ni7Anui %uGd?u6'4~um2,817 n u wuiin~uil6Tun7qTnu7GauS8
n77w?GT(jl Bypass surgery ,fj Amputation-free survival iia: Overall survival Iu-1:u:iaa7 4 fl
q - t n i i n ~ ~ i % " n ~ iEndovascular
6au
treatment53 uene?n6wui?~m3?na?un-1~~21fim
Primary
lunqu Bypass surgery g-lniinqu Endovascular treatment
patency l u ~ ? a i1, 2 iia: 3
oeii~l~iimiutdafimmiuld
4 91 wui7 Primary patency
lmun7d
0:~flu~6iin1~a"nw-~nia:vi~imi~a(ilu"~Snqm"1~flo~u"u~~iu'~~dM"~an~aa"nw-i~~6
Survival L L F I ~ Amputation rate u i n d u ~ 1 . i ~ e r " f l = ~ 7 7 Patency
r n i ~ ~ u ~ild141uilGm wan71idnw7vilq
BASIL trial flts~i~uii~ilauifit~uaToa'~M"e:fid~~1a~~6~1uni
2 fl naaTnu~6auniqt.ii6m
dau~d~uM"fii~u~T~uM"o:~iudTmniu%u
2 fl n a % s " n w - i 6 a u ~ ~ ~ ~ ~ n idui f~l ?a uuConduit
~~~~~
%unia~jiGmna%Iij
Autogenous vein graft rf_luCu6u1isn lun3ciidlbjmiuianl.i1 Autogenous
vein 16 a i o ~ o ~ ~ r n ~ ~ n ~ i 6 a u ' i ~ ~ ~ ~ ~ i u n a ~ u i n n iProsthetic
i M " o : t .graft5'
i~6~~mu~ij
--
lnllial bypass
Bypass aller failed at~~loplasly
1
2
3
4
Years from randomization
5
- - - -I
- lnillal bypass
'-I-----
--
I
I
6
I
Bypass afler falled angloplasly
I
I
I
2
3
4
5
Years from randomization
ttnul]fld 7. A. Amputation free survival B. overall survival in patients randomized to and undergoing bypass surgery and in
patients undergoing bypass surgery after failed balloon angioplasty.
6
0
21
A
O
2
3
4
Years from randomization
5
6
1
6
angloplasty
- - Trans-luminal
Sub-intlrnal angioplasty
1
BO
-
2
3
4
Years from randomization
5
llnur]fld 8. A. Amputat~onfree survival and 6.overall survival for patients undergoing transluminal and subintimal angioplasty
6
UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LIMB \SCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
with vein
- - Bypass
Bypass with prosthetic malerial
I---
I,---
2-
Bypass with vein
- - Bypass with prosthetic
---
I--_-
I
1
3
4
Years from randomization
2
AO
l
~ 9. dA.
l
5
I
I
I
I
3
4
Years from randomization
1
0
6
material
2
B
5
6
Amputation free survival and B. overall survival for patients undergoing bypass surgery according to type of bypass
conduit.
.........
........,..........
.'C
-.-.-
1.
1.SucccssM surgery
2,SuoessM angloplasly
3.Falled surgery
4.Failed angioplasty
5.No Intervention
1
0
---
3
2
A
i
--.-.-.
5
s
5
4
6
0
B
Years from randomization
1.Successful surgery
2 S u m w b l angloplasty
3.Faded surgery
4 Felled angioplasty
5.No interventton
1
2
3
4
5
6
Years from randomization
l 1 ~ f l 1 0A.. Amputation-free survival and 6. overall survival for the five treatment groups during follow-up.
(rlu@M 7-10, 6nrvnnn Bradbury A W Adem DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I,e l a/. Bypass versus Angioplasty in
Severe lschaemia of the Leg (BASIL) trial: Analysis of emputation free and overall survival by treatment received. Journal of vascular
surgery. 2010;51(5 Suppl):IBS-31s.)
Infrapopliteal Disease
t@'-
~ I J W I ~ ~ ~ ~ ~ ~ ~ M I J Infrapopliteal
L R U ~ ~ d%:nnu6?u55
~ ~ ~ L E ~ Femoral-distal
~ U ~ L ~ I ua:
~ ~
Poplifeal-distal bypass w u i i Conduit type ~ w a a d i - l u i n c j i a n ~ i ~ n - ~ ~ u " ~ a - ~ n ~ ~ ~ d . ~ ~
d i ~ ~ u n i ~ d ~ d t m ~ d d ~ ~ ~ i ~ ~ ~ ~ ~rnuM"?ld~~u:Gi"I~di(
~ a a m r $ a m " IIpsilateral
~ d i r ~ greater
~~~d~~
saphenous vein (GSV) ~ f l u ~ u 6 u u a n ~ wrwnfinniaoia~nan~8amldiio:~Uu
rn~
Reversed vein
graft M T In
~ situ vein graft IlsYwan1~7"nuilajr~~1noii~n"u~~~~~
ltdn%6ifh-iwi~i~nl3 IpsiIateraI
GSV 16 n2-i~Zanlil Alternative autogenous vein ~ d u
Contralateral GSV, Lesser saphenous
vein M%I Arm vein ~ f l u ~ u 6 u o i o urdi~yu
1
Spliced vein LLa: Composite sequential graft
a i o f l ~ i a 6 ~ 1 1 f l m ? u n ~Alternative
f l ~ ~ ~ ~ vein 6 ~ n d i ?rra:~in41~flu6o~l$Prosthetic graft
n3svii Adjunctive procedure rdu Vein cuff 5 3 ~ 6 7 ~d d1 ~ ~ i i ~ ~ ~ a n i l ' r ' n ~ . 1 ~ 6 n i l n 1 ' 1 " I i (
Prosthetic graft l d u ~ a ~ l ~ l f i~ u? n?q~Q~14.
( ~ Li
~a:~ 15. ~~am-3
Patency kra:: Limb salvage ~IM%"U
Infrapopliteal, Ankle \La: Below-ankle bypass rra:nia"Ii( Conduit ufinvii~q
Distal
~ Y ~anastomosis
4 ~ ~ ~fl23?dMaWlL$TlcilM"fl
~ ~ ~ ~ ~ ~ 7 ~ ~ ~
~ n u ~ 7 n r i o u d ~ n u a ~ d ~ f i n 1 7 ~ ~ i 3 ~ 0 (Good
~ ~ f i acontinuous
n ~ d ~ ~ ~ flow
' 1 ~ 6to foot) lmud Level
ua.1~aomr~am~ajiio~~fl~d~u6~ttTad~~dai~~~~~aoi0n1~a"n~1~~~~~
n
l
~
l
~
~
n
m
'
l
l
L
t
t
~
~
UPDATED MANAGEMENT FOR LlMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LlMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
mwud 14. Patency of infrapopliteal grafts
Graft and PatencylType
54.55.59.60
Patency (%)
2-Yr
3-Yr
1-Yr
4L~r
Primary Patency
82
70
76
66
74
62
68
84
89
73
52
46
80
87
62
46
32
78
84
58
40
76
81
85
91
68
83
88
60
82
83
56
82
83
48
77
Reversed saphenous vein
In situ vein bypass
Secondary Patency
Reversed saphenous vein
In situ vein bypass
Arm vein
Human umbilical vein
Polytetrafluoroethylene
37
21
Limb Salvage
Reversed saphenous vein
In sitti vein bypass
Polytetrafluoroethylene
m?~i.rd
15. Patency of ankle and below-ankle grafts55
1-Mo
6-Mo
Patency (%)
1-Yr
95
85
81
Reversed saphenous vein
In situ vein bypass
96
93
90
93
85
92
81
82
76
72
Limb Salvage
99
94
93
87
84
Graft and PatencyIType
'
.
2-~r
'
-
3-Yr
Primary Patency
Reversed saphenous vein
Secondary Patency
n i a ? n " n u 7 F j i u ~ i ~ m i u m a u 1 ~ ~ ? ~ ~ n i a q ~Infrapopliteal
~u~l3~ab~
Infrapopliteal
angioplasty
t.T~Wn7~Anl~.i-lo~%'uM"41n"(il
l~floqGufiQofisB~isw7:"1un~rii,~Du
Limb salvage procedure
% u ~ f l a u i ~ d ~ ~ n i u ~ r j ~ 8 . ~ q c j ~ ~ f l u ~ w a ~ ~ ~ ~ u ' i %wani~Anw-I
" u n a F j ~ neta-analysis6'
"(jl~6~viila"u~
W U ~ I Infrapopliteal PTA f i n ? i 8 . ~ ~ ~ ~ u u o ~ n i ~ ~ ~ ~ i u t ~ u a ~Primary
~ o 7 n nitn:~ a w 1 ~ ~ w " ~ %
Secondary patency o t i i 4 ~ a f i m i uLimb salvage rate wui?%.I~Lolncii14n"or
( r n i q i d 16) n?adnu7
1d4uutw"utrnia%iiPTA iLa= Stenting iivls"fl Infrapopliteal wtri~filla:Bw3niwt~itM"u~n"u~~
mimd 16. Meta-analysis results of crural PTA versus popliteal-to-distal bypass6'
Patencv (%)
Primary patency
PTA
R ypass
Secondary patency
- PTA
Bypass
Limb salvage
PTA
By pass
77
93
65
86
58
82
51
77
49
72
All P <0.05
83*
95*
74*
89*
68*
86*
64
82
63
77
* P <0.05
93
95
88
90
86
89
84
85
82
All NS
PTA, percutaneous transluminal angioplasty
82
UPDATED MANAGEMENT FOR LIMB SALVAGE I N PATIENTS WITH CRITICAL LOWER LIMB \$CHEM\A!
SURGICAL OR ENDOVASCULAR TREATMENT?
T m u a ~ d n i a ~ n w i w u ~ ~ a n i w u fInfrapopliteal
~~na
disease naa~.ilni7wiGmtflu?5~a'n Imu
Autogenous vein graft tdu Conduit M%Ciwani=s%'nwiMdRM"ym n i % ' i Y n u 7 w i ~ ~ l 4 f l 7 ~ ~ 2 ~ 1 u
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UPDATED MANAGEMENT FOR LIMB SALVAGE IN PATIENTS WITH CRITICAL LOWER LIMB ISCHEMIA:
SURGICAL OR ENDOVASCULAR TREATMENT?
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