Surgical Bypass Summit — Session 2:
There are negative consequences that persist after failed endovascular treatment of CLI — Ross Milner, MD

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Ross Milner, MD

Patients often prefer endovascular therapy because the treatment can be performed in angiography suites and does not require hospitalization. Endovascular therapy may also be preferred because surgeons may be reluctant to perform bypass due to a previous failed ipsilateral percutaneous endovascular intervention, which is an established negative predictor for future lower-extremity bypass success.1 We investigated these assumptions at our institution.2

We performed a retrospective review of patients with failed endovascular therapy at both a university medical center as well as a US Department of Veterans Affairs (VA) hospital. Approximately one-third of patients were claudicants, whereas approximately 45% had tissue loss and approximately 17% had ischemic rest pain.

Figure 1.  Primary patency by TASC classification. Reprinted from J Vasc Surg, 56, Al-Nouri O, Krezalek M, Hershberger R, et al, Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvage, 106-110, 2012, with permission from Elsevier. 

Figure 1.  Primary patency by TASC classification. Reprinted from J Vasc Surg, 56, Al-Nouri O, Krezalek M, Hershberger R, et al, Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvage, 106-110, 2012, with permission from Elsevier. 

Primary patency overall was 24% at 1 year and secondary patency was 51%. Patients in the TASC A group had the best primary patency results (Figure 1). Although TASC C patients had better outcomes than TASC B patients, the study numbers were so small in every group that the difference did not reach statistical significance. With regard to primary assisted and secondary patency, patients in TASC A and B groups had better outcomes than patients in TASC C and D groups. While it was difficult to reach firm conclusions, smoking was shown to have a negative effect on treatment success. Of the failed interventions, 76% were current smokers. The results suggest that it may be a mistake to perform endovascular therapy on smokers. A review of the failed interventions, and the consequences for patients who failed treatment, revealed that 70% of those patients developed claudication or recurrent claudication, while the rest of the patients developed ischemic rest pain.

Summary

Stenting for TASC C and TASC D lesions is more likely to fail than stenting for TASC A and TASC B lesions. The failure in TASC C and TASC D lesions is also more likely to lead to either bypass or amputations than failures in TASC A and TASC B lesions. Moreover, when endovascular therapy is performed on a TASC C or TASC D lesion, there can be negative effects on limb salvage. In addition, a patent peroneal artery does not increase the likelihood of patency from endovascular intervention on the femoropopliteal segment.

Patients with TASC A and TASC B lesions can be safely treated with endovascular therapy. In contrast, while it is technically feasible to treat TASC C and TASC D lesions, it may not be optimal for the patient because the failure of a TASC C or TASC D intervention can potentially compromise future bypass success. In addition, repeat interventions can be expensive.

Ross Milner, MD, is Professor of Surgery and Director, Center for Aortic Diseases, University of Chicago in Chicago, Illinois. He has disclosed that he has received compensation from Gore for participating in the Summit and has received honoraria from Gore for writing this article. Dr. Milner may be reached at rmilner@surgery.bsd.uchicago.edu.

  1. Nolan BW, De Martino RR, Stone DH, et al. Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass. J Vasc Surg. 2011;54:730-735; discussion 735-736.
  2. Cheng SW, Ting AC, Ho P. Angioplasty and primary stenting of high-grade, long-segment superficial femoral artery disease: is it worthwhile? Ann Vasc Surg. 2003;17:430-437.

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