Endovascular Revascularization of Symptomatic Infrapopliteal Artery Occlusive Disease: Are there Short-term Differences between Atherectomy and Angioplasty?

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Elie S. Semaan, MD¹, Alik Farber, MD¹, Wael Nasr, MD¹, Robert Eberhardt, MD¹, Sophia Jones¹, Gheorghe Doros, PhD², Palma Shaw, MD¹, Kathryn Collins, MD¹, Jonathan Woodson, MD¹, Gary Gibbons, MD¹.
¹Boston University Medical Center, Boston, MA, USA, ²Boston University, School of Public Health, Boston, MA, USA.

Objective: Traditional treatment of symptomatic infrapopliteal disease has been surgical bypass. Although increased utilization of endovascular procedures has challenged this paradigm, results in the tibial arteries are mixed and the optimal endovascular modality of choice uncertain. We evaluated short-term outcomes of endovascular revascularization of symptomatic infrapopliteal arterial occlusive disease and further compared atherectomy with angioplasty.
Methods: A retrospective review was conducted of all patients who underwent endovascular treatment of infrapopliteal artery lesions between 2003 and 2007. Data collected included risk factors for atherosclerosis, indication for intervention, extent of disease, runoff, and complications. Outcome measures included technical success, change in ankle-brachial index (ABI), freedom from target lesion revascularization (TLR), and limb salvage (LS).
Results: Thirty patients were identified. Twenty-one patients (28 lesions) were treated with atherectomy (Group 1) and 9 patients (15 lesions) with angioplasty (Group 2). Mean duration of follow-up was 262 days. Demographic characteristics were similar between the two groups although Group 1 had more cerebrovascular disease (66.7% vs. 22.2%, P=0.046). Both groups were similar in terms of indication for intervention, lesion anatomy, and runoff. Eight patients in Group 1 and one patient in Group 2 had isolated infrapopliteal lesions treated (P=NS). Both groups resulted in similar procedural complication rates (7.1% vs 6.7%, respectively, P=NS), all three of which were thromboembolic events. Technical success rates were similar between both groups (85.7% vs. 86.7%, P = NS). The reasons for failures in Group 1 were inability to pass the device beyond lesion (3) and device malfunction (1). Both technical failures in Group 2 were a result of significant residual stenosis. Outcomes including change in ABI, LS, and freedom from TLR were similar among the groups (see table).


Outcomes	Overall	Group 1	Group 2	P-value
Mean (Median) Increase in ABI	0.21 (0.18)	0.20 (0.19)	0.22 (0.16)	NS
LS at 250 days (%)	75	70	85	NS
Freedom from TLR at 250 days (%)	68	72	59	NS

Conclusions: Endovascular intervention in the infrapopliteal vascular bed has acceptable immediate and short-term success rates. Both atherectomy and angioplasty can be used with success.

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