Aiming for full revascularisation “may not be the best solution” for treating patients with critical limb ischaemia (CLI) according to Thomas Zeller (Bad Krozingen, Germany), who advises that it is favourable to pursue a strategy offering the “best chance for patency.” The comments came during a presentation from Zeller on limb salvage at the 2019 Vascular Interventional Advances conference (VIVA) in Las Vegas, USA (4–7 November).
“One vessel providing direct flow to the wound may be enough,” Zeller told the VIVA audience, after presenting a case example of an 80-year-old female patient treated for Rutherford category 5 CLI, by Zeller and colleagues. Opening his presentation, Zeller commented: “The challenges in CLI treatment in general are that these patients are mainly old, frail [and] with limited mobility. The question is, how frequently can we ask them to come back into the institution and into the lab to re-perform procedures?”
The case detailed by Zeller—dating back to April 2019—saw the patient present occlusion of the anterior, posterior and peroneal tibial arteries, with gangrene of the first to third toe in her left foot. “Collateral was providing the distal segments of the peroneal artery with the posterior and anterior perforating artery going down to the dorsalis pedis artery,” Zeller explained. He detailed the intervention, which involved an “extensive” combined anterograde and retrograde recanalisation procedure of the anterior tibial artery in April 2019. This resulted in a “full metal jacket” of drug-eluting stents, Zeller said, noting that there was a dissection left after balloon angioplasty of the dorsalis pedis artery, but that blood flow into the medial aspect of the forefoot, where the majority of the wounds were located, was good. “So, if we agree with the angiosome concept, this was the correct decision to reopen the anterior tibial artery because the major target of the dosalis pedis is basically the medial part of the forefoot including the toes.”
Zeller said after one month there had been evidence of progress in wound healing, which he described as a “sufficient response” to the revascularisation. However, he noted that the patient was then referred back for treatment in September 2019, as there had been a delay in further healing progress. This was due, he said, to the development of restenosis in areas of the anterior tibial and dorsalis pedis arteries where stents had not been implanted. Zeller placed another drug-eluting stent into the proximal anterioe tibial artery, after it became evident that the proximal part of the artery was severely dissected, he explained.
“There was restenosis at the level of the dorsalis pedis artery,” Zeller noted, adding that the area was treated again, this time with balloon angioplasty and a drug-coated coronary balloon. Addressing the VIVA audience, Zeller said: “The key question is: ‘is this enough?’ If we consider the wound distribution, it was the big toe, the second and third toe, so it should have been enough.” However, he pointed out the occurrence of retrograde filling of the plantar artery, which he said raised questions as to whether it is worthwhile going for a “second target” in order to guarantee prolonged, improved fore-foot perfusion.
Zeller then asked the VIVA audience if they would have ended the treatment at this point, or whether they would have targeted the posterior artery as the second tibial artery if faced with this situation—noting that the response from the audience was inconclusive.
Returning to his case example, Zeller said that it became worthwhile to approach the posterior tibial artery, describing this as the “very complex intervention”. The final part of the recanalisation procedure involved the treatment of the entire plantar artery, including the posterior tibial artery, with plain balloon angioplasty and drug-coated balloon angioplasty. Despite this intervention, Zeller said that non-selective angiogram showed that the flow was better through the anterior tibial artery, and there was delayed flow in the posterior tibial artery—which was reoccluded the day after the procedure.
Discussing his observations from the case example, Zeller commented that clinical reevaluation is particularly relevant in the aftermath of an intervention. “Even if it looks very nice,” Zeller commented, “If you do selective injections into a recanalised vessel, and the flow looks good, go back with your catheter into the proximal part of the vessel segment, and check there is still adequate flow.” He added that if a good blood flow has already been established through a primary vessel, opening a secondary vessel can potentially result in competitive flow, “impairing the outcome of the recanalisation of the second vessel,” Zeller said, adding: “We aim sometimes to achieve a full revascularisation at the end of the procedure, [but that] may not be the best solution in some specific patient conditions.” One vessel providing direct flow to the wound may be enough, he concluded.