By: Mario Luiz Furlanetto Junior
The ability of endovascular surgeons to treat complex tibial (distal) and inframallolar (ultradistal) lesions has expanded greatly in recent years with the dissemination of contemporary techniques and the development of new endovascular devices. The number of patients with peripheral arterial disease with distal and ultradistal lesions will only increase in the future, especially with the increasing prevalence of diabetes and kidney disease in the elderly population worldwide.
Chronic limb-threatening ischemia (CLTI), defined as ischemic pain at rest or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease, with distal and ultradistal levels being very frequent and severe. Although open surgical bypass remains a robust option for the treatment of complex tibial lesions, endovascular approaches are increasingly being employed in the tibial segment, often with promising results. The Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL-2) and Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trials and other international protocols recommend endovascular treatment initially, and bypass surgery for complications and very extensive lesions.
Discussion
A study from the American College of Surgeons’ National Surgical Quality Improvement Program from 2012 to 2015 compared a bypass-first versus an endovascular-first revascularization strategy in patients with CLTI due to distal arterial disease and found no significant difference at 30 days. They evaluated 1355 patients with CLTI who underwent first-time revascularization of the infrageniculate arteries (821 endovascular-first revascularizations and 534 bypass-first revascularizations) over a three-year period. However, the incidence of transtibial or proximal amputation was lower in the bypass-first cohort.
Patients with bypass-first revascularization had higher rates of wound complications compared with patients in the endovascular-first cohort. Compared with the endovascular-first cohort, the incidence of 30-day MACE was significantly higher in bypass-first patients, and 30-day mortality rates were 3.23% vs 1.8%. There was no difference in untreated 30-day loss of patency, reintervention of the treated arterial segment, readmissions, and reoperations between the two cohorts.
A study compared the outcome of distal bypass-first surgery versus ultradistal bypass-first surgery in patients with critical leg ischemia from 2004 to 2010, with two hundred and thirty bypasses performed, of which one hundred and seventy-nine (78%) bypasses were classified as distal and 51 (22%) as ultradistal, and found that the bypass-first approach has a significantly lower 30-day amputation. At 1 year, the primary, assisted primary, and secondary patency rates of the distal group were 61.7%, 83.1%, and 87.4%, compared with 61.9%, 87.4%, and 87.4% in the ultradistal group, respectively. Amputation-free survival at 12 and 48 months was 82.9% and 61.5% in the distal group, compared with 83.0% and 64.9% in the ultradistal group.
Conclusions
Although large randomized studies demonstrate robust results for bypass surgeries to treat distal segments, few studies address endovascular treatment for ultradistal segments. With the technological advances in endovascular revascularization materials, such as new intravascular recanalization catheters and drug-eluting balloons, distal and ultradistal endovascular revascularization should be initial and secondary intervention strategies, with bypass surgery as a secondary strategy, and limb amputation always as the last approach.
References
Feldman ZM, Mohapatra A. Endovascular management of complex tibial lesions. Semin Vasc Surg. 2022 Jun;35(2):190-199. doi: 10.1053/j.semvascsurg.2022.04.008. Epub 2022 Apr 21. PMID: 35672109.
Dayama A, Tsilimparis N, Kolakowski S, Matolo NM, Humphries MD. Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease. J Vasc Surg. 2019 Jan;69(1):156-163.e1. doi: 10.1016/j.jvs.2018.05.244. PMID: 30579443; PMCID: PMC8906190.
Slim H, Tiwari A, Ahmed A, Ritter JC, Zayed H, Rashid H. Distal versus ultradistal bypass grafts: amputation-free survival and patency rates in patients with critical leg ischaemia. Eur J Vasc Endovasc Surg. 2011 Jul;42(1):83-8. doi: 10.1016/j.ejvs.2011.03.016. Epub 2011 Apr 22. PMID: 21514854.
Patel SD, Zymvragoudakis V, Sheehan L, Lea T, Padayachee S, Donati T, Katsanos K, Zayed H. The efficacy of salvage interventions on threatened distal bypass grafts. J Vasc Surg. 2016 Jan;63(1):126-32. doi: 10.1016/j.jvs.2015.07.093. Epub 2015 Oct 21. PMID: 26482998.
