Angioplasty in critical limb ischaemia: one-year limb salvage results.

Introduction: Lower extremity amputation prevention (LEAP) is an ongoing programme in our institution aimed at limb salvage in patients with critical limb ischaemia (CLI). Patients in the LEAP programme with reconstructible anatomy on initial Doppler imaging received either bypass surgery or percutaneous transluminal balloon angioplasty (PTA). We describe the 1-year limb salvage rates in 46 consecutive patients with CLI who received PTA in 2005.

Clinical Picture: A total of 46 patients, 28 women and 18 men, between the ages of 40 and 91 years old (mean age, 70.8) received PTA in 2005. The most common presenting symptom was rest pain (n = 23), followed by pre-existing gangrene (n = 20), non-healing ulcer (n = 17) and cellulitis (n = 8). The majority of the patients (57%) had 3 to 4 risk factors. Diabetes mellitus (91%) and hypertension (80%) were the 2 most common risk factors. The patients were kept under surveillance for periods ranging from 12 to 21 months with a mean of 13.3 months, both clinically and with haemodynamic measurements [ankle-brachial index (ABI), toe pressure (TP) and digital-brachial index (DBI)].

Treatment: The aim of PTA is to achieve straight-line flow from the abdominal aorta down to either a patent dorsalis pedis or plantar arch with limb salvage as the ultimate goal. The patterns of the treated segments were as follows: aorto-iliac occlusions (n = 3), pure infrapopliteal disease (n = 5), femoropopliteal disease with at least 1 good infrapopliteal run-off vessel (n = 16) and combined femoropopliteal and infrapopliteal disease (n = 25). Technical success was achieved in 89% of patients (41 out of 46 patients). The most common cause of technical failure is the inability to cross long chronic total occlusions.

Outcome: Paired T test was performed and showed statistically significant improvement in haemodynamic markers within the technically successful group. This included increase in the mean ABI from 0.62 (preangioplasty) to 0.91 (Day 1 post-angioplasty), an increase of 0.29 [95% confidence interval (95% CI), 0.1953 to 0.3875; P <0.001]. One year post-angioplasty, the mean ABI was 0.84, an increase of 0.22 (95% CI 0.1512 to 0.3121; P <0.001). There was also significant increase in the mean DBI of 0.17 from 0.23 to 0.41 (pre-angioplasty versus Day 1 post angioplasty - 95% CI of 0.1006 to 0.2433; P <0.001). In addition, significant increase in the mean TP of 28.2 mmHg from 36.8 to 63.2 mmHg (pre-angioplasty versus Day 1 post angioplasty - 95% CI, 18.493 to 37.939; P <0.001) was also noted. Of the 23 patients who presented with rest pain, total abolishment of symptoms was achieved in 21 patients (91%). Healing of pre-existing gangrene was attained in 15 patients (66%). Five patients subsequently received minor amputation for pre-existing gangrene. Clinical improvement in all the patients who presented with non-healing ulcers (n = 17) and cellulitis (n = 8) was attained. More importantly, all healed ulcers remained healed throughout the study period. The limb salvage rates were 93% at 1 month, 87% at 3 months, 82% at 6 months and 78% at 1 year.

Conclusion: Angioplasty is a safe and effective limb salvage method in patients with CLI and has a high 1-year limb salvage rate.