Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up.

BACKGROUND: In a prospective, nonrandomized, consecutive series of tibioperoneal vessel angioplasty (TPVA), critical limb ischemia (CLI) patients' data were analyzed with regard to immediate and follow-up success. METHODS AND RESULTS: TPVA was successful in 270 of 284 critically ischemic limbs (95%), with 167 limbs (59%) requiring dilatation of 333 ipsilateral inflow obstructions to access and successfully dilate 486 of 529 (92%) tibioperoneal lesions. A clinical success (relief of rest pain or improvement of lower-extremity blood flow) was attained in 270 limbs at risk (95%). Clinical 5-year follow-up of 215 of 221 successful CLI patients (97%) with 266 successfully revascularized limbs revealed that bypass surgery occurred in 8% and significant amputations in 9% of limbs; 91% of the limbs were salvaged. The cohort's probability of survival was 56%: 58% for Fontaine class III and 33% for class IV patients. Class III compared with class IV patients had significantly (P<0.05) fewer surgical bypasses (3% versus 16%) and amputations: above-knee, 1% versus 4%; below-knee, 3% versus 12%; and transmetatarsal, <1% versus 21%. CONCLUSIONS: TPVA, often in combination with inflow lesions, is an effective primary treatment for critical limb ischemia. The poor cumulative survival reflects the existence of severe comorbidities, which could potentially be affected by aggressive and effective cardiovascular diagnostic and therapeutic strategies.

Transseptal guidewire stabilization facilitates stent-graft deployment for persistent proximal ascending aortic dissection.

PURPOSE: To report endovascular repair of a DeBakey type I ascending aortic dissection. CASE REPORT: Five months after aortocoronary bypass grafting, a 56-year-old woman demonstrated a persistent ascending aortic type I dissection whose entry tear proximal to the innominate artery spiraled down the descending thoracic aorta into the iliofemoral arteries. Repair was facilitated with a guidewire passed through a transseptal sheath in the right femoral vein. The guidewire traversed the right and left atria and the left ventricle and then exited into the ascending aorta and was exteriorized through the right femoral artery. A right brachial catheter aided contrast visualization of the innominate artery. Adenosine-induced elective cardiac arrest promoted precise placement of a customized polyester-covered balloon-expandable stent, which closed the aortic rent. CONCLUSIONS: A transseptal approach enables the guidewire to follow the curvature of the aortic arch, providing precise control of the stent-graft delivery system. This case illustrates the applicability of endovascular techniques to repair ascending aortic pathologies using readily available techniques, equipment, and drugs.