Gabriele Testi

What's next after optimal infrapopliteal angioplasty? Clinical and ultrasonographic results of a prospective single-center study.

Purpose: To evaluate arterial patency and factors influencing outcomes after successful tibial artery angioplasty in patients with critical limb ischemia (CLI). Methods: From January 2005 to August 2007, a prospective single-center study was conducted involving 80 CLI patients (56 men; mean age 71.7±8.8 years) who underwent successful tibial artery angioplasty (<30% residual stenosis) in 87 limbs. Eighty (92%) limbs showed ischemic ulcers or gangrene at baseline. In two thirds, a more proximal lesion was treated, and a secondary stent was implanted in 14 (16%). Follow-up included clinical examination for wound healing (WH), limb salvage (LS), and duplex-documented target vessel patency or restenosis at discharge and at 1, 3, 6, 9, 12, 18, and then every 6 months. Patency rates, WH, and LS were assessed with the Kaplan-Meier method, and factors influencing these outcomes were analyzed using Cox proportional hazards models. Results: Mean follow-up was 10.9 months (range 2 days — 29 months). At 12 months, the primary and assisted primary patency rates were 37.9% and 71.2%, respectively. Restenosis was significantly correlated with smoking (HR 3.58, 95% CI 1.15 to 11.18; p=0.02), infected ulcers (HR 2.04, 95% CI 1.02 to 4.09; p=0.04), and posterior tibial artery angioplasty (HR 3.76, 95% CI 1.59 to 8.87; p=0.003). Rates of LS and WH at 12 months were 92.7% and 74.9%, respectively. Peroneal angioplasty was significantly correlated with WH (HR 1.83, 95% CI 1.04 to 3.25; p=0.03), and wound healing increased with classes of age (HR 1.60, 95% CI 1.07 to 2.39; p=0.02). Conclusion: One-year restenosis after optimal tibial artery angioplasty is significant and positively correlated with smoking, infection of trophic lesions, and posterior tibial artery angioplasty. Close ultrasound surveillance provides good limb salvage after optimal infrapopliteal angioplasty in patients with CLI.

Substent Anchor Technique for Recanalisation of a Full Metal Jacket Femoropopliteal In-Stent Occlusion

Purpose To report the endovascular treatment of a full metal jacket (FMJ) femoropopliteal chronic total occlusion (CTO) using a new ancillary retrograde technique. Case report An 80 year old woman with type 2 diabetes presented to the Diabetic Foot Clinic with critical limb ischaemia with tissue loss in the right leg. Her comorbidities included coronary artery disease, morbid obesity, hypertension, dyslipidaemia, and active smoking habit. The patient had been treated at another hospital by femoropopliteal FMJ stenting six years before this presentation. The duplex ultrasound showed a full length in-stent re-occlusion. An antegrade recanalisation was attempted via contralateral femoral access, but was unsuccessful. An ultrasound guided retrograde puncture of the popliteal artery in the P2 segment was performed very close to the distal occluded stent. A 0.018 guidewire was pushed in the substent plane, functioning as an anchor to achieve a stable system. The FMJ was then retrogradely recanalised with a second guidewire. The procedure was completed by antegrade angioplasty with drug coated balloons. Conclusion The substent anchor technique can help to achieve stability even if close to the occluded stents, and spares the distal landing zone for surgical revascularisation if the endovascular approach fails. This technique could be useful in retrograde treatment of long in-stent CTO.