Infrainguinal revascularization because of claudication: total long-term outcome of endovascular and surgical treatment.

OBJECTIVE: This study was undertaken to define total long-term outcome achievable with invasive treatment, ie, endovascular or surgical, in patients with claudication with infrainguinal lesions. Priority in primary treatment was given to percutaneous transluminal angioplasty. METHODS: Data were analyzed for 233 consecutive patients with claudication in whom primary infrainguinal revascularization was performed in 304 limbs between 1989 and 1992. Patients were followed-up to May 2001 (mean, 81 months). Treatment included primary endovascular therapy when applicable (n = 272 limbs) or primary surgical treatment (n = 32; 10.5%). Type of further revascularization, if required, was selected on an individual basis for each patient. All procedures performed because of limb ischemia were recorded. Clinical outcome at the end of follow-up was compared with the preoperative condition. Cumulative primary, secondary, and total patency rates and development of chronic critical ischemia (CCI) were defined. Total patency reflects the ultimate achievable benefit of invasive treatment and refers to patency maintained at the primarily treated segment by means of any invasive (endovascular or surgical) therapy, including potential crossover to another treatment group. RESULTS: A mean of 2 (median, 1) operations per limb were performed during follow-up. No additional operations were needed in 50.3% (n = 153) of limbs. Fontaine classification at the end of the study was better compared with the preoperative value (P <.0005). Crossover between endovascular and surgical treatment was recorded in 21.1% (n = 64) of limbs. At 5 years, primary, secondary, and total patency rates (plus or minus standard error of estimate [SEE]) were 27% +/- 3%, 45% +/- 3%, and 61% +/- 3%, respectively, and at 10 years these rates were 16% +/- 3%, 27% +/- 3%, and 41% +/- 3%. CCI developed in 37 limbs (12.2%), of which 15 (41%) had been treated with endovascular methods only. Type II diabetes and hypertension were statistically significant predictors of increased risk for CCI. CONCLUSION: Combining endovascular and surgical methods when necessary improved total outcome of invasive infrainguinal treatment of claudication. Crossover between endovascular and surgical treatment was required in 21% of limbs over the long term.

Long-term outcome of patients with claudication after balloon angioplasty of the femoropopliteal arteries.

PURPOSE: To report the long-term outcome of patients with lifestyle-limiting claudication after percutaneous transluminal angioplasty (PTA) of the femoropopliteal arteries. MATERIALS AND METHODS: Between 1989 and 1992, 173 consecutive claudicant patients (mean age, 65 years; age range, 41-90 years) underwent PTA in 218 limbs; all interventions included femoral and/or popliteal arterial segments, and additional iliac (n = 27) and infrapopliteal (n = 11) arterial lesions were also treated. Patients were followed up for 7-10 years. Altogether, 37 (17%) limbs were classified as Fontaine class 2A, and 181 (83%) were class 2B. Average length of the primary lesion was 5.2 cm. Reinterventions were analyzed. Patency rates and patient survival were assessed by means of life table analysis. Cox-Mantel tests and Cox proportional hazards models were used to define associated independent determinants. Development of chronic critical ischemia (CCI) and its determinants was assessed by using the Pearson chi(2) test and multiple logistic regression analysis. RESULTS: The primary and secondary patencies (+/- standard error of the estimate), respectively, were 46% +/- 3 and 63% +/- 3 at 1 year, 25% +/- 3 and 41% +/- 4 at 5 years, and 14% +/- 3 and 22% +/- 4 at 10 years. One-third (71 of 218) of the limbs required repeat interventions, including surgical revascularization in 35 limbs. Fourteen (6.4%) limbs developed CCI, resulting in a 0.8% incidence per year. In multivariate analysis, poor postinterventional peripheral runoff was an indicator of increased risk of CCI development (P =.03). CONCLUSION: Although the long-term patency rates of PTA of the femoropopliteal arteries in claudicant patients were poor, the acceptable number of reinterventions and the low frequency of development of CCI imply the long-term benefits achievable with this treatment.

Failure of prolonged dilation to improve long-term patency of femoropopliteal artery angioplasty: results of a prospective trial.

PURPOSE: To determine long-term patency of femoropopliteal artery percutaneous transluminal angioplasty (PTA) in a prospective trial during which prolonged balloon inflation was used for optimization of initial results. MATERIALS AND METHODS: Femoropopliteal PTA was performed in 112 limbs of 97 patients. The mean total length of the treated segments was 7.2 cm (95% CI: 5.99-8.46; median: 5.5 cm). In cases of unsatisfactory primary results after standard dilation for 1-3 minutes, the procedure was continued with prolonged dilation (93 limbs; mean balloon inflation time: 31 min; 95% CI: 24.2-37.7; median: 15 min) with use of the same balloon catheter (77 limbs) or a perfusion balloon catheter (35 limbs). Thirty-four proximal infrapopliteal artery stenoses were treated to improve peripheral runoff and 12 short stents were placed because of flow-limiting dissections. RESULTS: Primary hemodynamic success established by Doppler ultrasound (US) criteria was achieved in 92.9% (104 of 112) of the limbs. Three major complications were encountered; none were related to prolonged balloon inflation. The primary patency rate according to Kaplan-Meier analysis was 42% (+/-5% SE) at 1 year and 39% (+/-5%) at 2 and 3 years. The corresponding secondary patency rates were 51% (+/-5%) and 47% (+/-5%). Large numbers of diseased vessels in the treated limb (four to 10 instead of one to three), eccentric lesions (as opposed to concentric morphology), and additional treated segments (instead of only femoropopliteal lesions) were associated with poorer long-term patency. The duration of balloon dilation was not a determinant of long-term patency. CONCLUSION: Although prolonged dilation is safe and feasible in femoropopliteal artery PTA, its routine use is not warranted because it does not result in superior long-term patency rates.