Endovascular treatment for arterial recanalisation in diabetic patients with critical limb ischaemia and foot lesions is currently accepted and indicated as the first choice treatment, Marco Manzi, Policlinico Abano Terme, Vincenza, Italy, told delegates at the VEITHsymposium in New York, USA.
In most cases, different or multiple arterial access must be considered, and antegrade common femoral artery is the treatment of choice. Other options include retrograde popliteal, proximal retrograde anterior tibial, distal retrograde or antegrade pedal, and distal retrograde posterior tibial. “These treatments can also be explored in combination,” he said.
Manzi pointed out that different kinds of techniques must be considered for a “tailored” endovascular approach related to the grade of arterial disease. The length of lesions, wound related artery and the anatomical site of foot wounds are some considerations. The initial differentiation is between non-calcificated and calcificated arteries. With calcified arteries, it is mandatory to use a coronaric-like strategy in order to avoid any intimal dissection in both focal and long stenosis/occlusions.
“It is possible to decide for a subintimal dissection as ‘the last resort’ but we must know that we will have few probabilities to get the true lumen distally and many to compromise collaterals. Most failed procedures will be in this group, in our experience around 12–15% of all patients,” explained Manzi.
In non-calcificated arteries both subintimal and intraluminal techniques can be performed with a very high acute success rate and final limb salvage rate.
Low profiles, balloons and guidewires can be used for tibial vessels in non-calcificated situations; 0.014 platforms are mandatory for foot arteries and calcificated tibial vessels. Pedal-plantar Loop techniques, when possible, avoid retrograde distal punctures and permit the rescue of ruptures or dissections with a statistical significative improvement in TcPO2 post-procedural measurements.