Drug-Eluting Stents (DES) for Infrapopliteal Interventions

  • Andrew J. Feiring


When treating critical limb ischemia (CLI), the primary objective is to increase oxygen delivery to a level commensurate with wound healing and relief of ischemic pain. The most direct way of achieving this goal is to maximize and then sustain conduit flow to the jeopardized angiosome. The hallmark of CLI is the presence of severe below-the-knee (BTK) arterial disease, yet for more than 40 years, the guiding principle of surgical limb salvage has been the establishment of single-vessel, straight-line pulsatile flow to the foot. However, this construct evolved from the surgical limitation of not being able to bypass more than one artery. In contradistinction, modern endovascular techniques afford the potential of delivering a more complete arterial revascularization thus improved limb salvage. In this chapter, we will focus on the use of balloon-expandable coronary drug-eluting stents (DES) which, in this author’s opinion, is the safest, most expedient, and most effective method of establishing and maintaining BTK artery patency.


Stent Thrombosis Limb Salvage Bare Metal Stents Total Occlusion Lesion Length 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, Mingardi R, De Giglio R. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Endovasc Surg. 2007;(4):453–60.CrossRefGoogle Scholar
  2. 2.
    Parsons RE, Suggs WD, Lee JJ, Luis A, Sanchez LA, Lyon RT, et al. Percutaneous transluminal angioplasty for the treatment of limb threatening ischemia: do the results justify an attempt before bypass grafting? J Vasc Surg. 1998;28:1066.PubMedCrossRefGoogle Scholar
  3. 3.
    Giles K, Pomposelli FB, Hamdan A, Blattman SB, Panossian H, Schermerhorn ML. Infrapopliteal angioplasty for critical limb ischemia: relation of transatlantic intersociety consensus class to outcomes in 176 limbs. J Vasc Surg. 2008;48:128–36.PubMedCrossRefGoogle Scholar
  4. 4.
    Schmidt A, Ulrich M, Winkler B, Klaeffling C, Bausback Y, Bra¨unlich S, et al. Angiographic patency and clinical outcome after balloon-angioplasty for extensive infrapopliteal arterial disease. Catheter Cardiovasc Interv. 2010;76:1047–54.PubMedCrossRefGoogle Scholar
  5. 5.
    Schmidt A, Piorkowski M, Werner M, Ulrich M, Bausback Y, Bräunlich S, et al. First experience with drug-eluting balloons in infrapopliteal arteries: restenosis rates and clinical outcome. J Am Coll Cardiol. 2011;58(11):1105–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al. BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multi-centre randomised controlled trial. Lancet. 2005;366:1925–34.PubMedCrossRefGoogle Scholar
  7. 7.
    Bradbury AW, Adam DJ, Bell J, Forbes JF, Golkes FR, Billespie I, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51:5s–17s.PubMedCrossRefGoogle Scholar
  8. 8.
    Bittl JA, Chew DP, Topol EJ, Kong DF, Califf RM. Meta-analysis of randomized trials of percutaneous transluminal coronary angioplasty versus atherectomy, cutting balloon atherectomy, or laser angioplasty. J Am Coll Cardiol. 2004;43:936–42.PubMedCrossRefGoogle Scholar
  9. 9.
    Dorros G, Hall P, Prince C. Successful limb salvage after recanalization of an occluded infrapopliteal artery utilizing a balloon expandable (Palmaz-Schatz) stent. Cathet Cardiovasc Diagn. 1993;28:83–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Feiring AJ, Wesolowski AA, Lade S. Primary stent-supported angioplasty for treatment of below-knee critical limb ischemia and severe claudication. Early and one-year outcomes. J Am Coll Cardiol. 2004;44:2307–14.PubMedCrossRefGoogle Scholar
  11. 11.
    Rastan A, Schwarzwalder U, Noory E, Taieb FH, Beschorner U, Sixt S, et al. Primary use of sirolimus-eluting stents in the infrapopliteal arteries. J Endovasc Ther. 2010;17:480–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Siablis D, Karnabatidis D, Katsanos K, Kagadis GC, Kraniotis P, Diamantopoulous A, et al. Sirolimus-eluting versus bare stents after suboptimal infrapopliteal angioplasty for critical limb ischemia: enduring 1-year angiographic and clinical benefit. J Endovasc Ther. 2007;14:241–50.PubMedCrossRefGoogle Scholar
  13. 13.
    Siablis D, Kranioti P, Karnabatidis D, Kagadis GC, Katsanos K, Tsolakis J. Sirolimus-eluting versus bare stents for bailout after suboptimal infrapopliteal angioplasty for critical limb ischemia: 6-month angiographic results from a nonrandomized prospective single-center study. J Endovasc Ther. 2005;12:685–95.PubMedCrossRefGoogle Scholar
  14. 14.
    Scheinert D, Ulrich M, Scheinert S, Sax J, Braunlick S, Biamino G, et al. Comparison of sirolimus drug-eluting vs. bare metal stents for the treatment of infrapopliteal obstructions. EuroIntervention. 2006;2:169–74.PubMedGoogle Scholar
  15. 15.
    Balzer JO, Zeller T, Rastan A, Sixt S, Vogl TJ, Lehnert T, et al. Percutaneous interventions below the knee in patients with critical limb ischemia using drug-eluting stents. J Cardiovasc Surg (Torino). 2010;51(2):183–91.Google Scholar
  16. 16.
    Bosiers M, Deloose K, Verbist J, Peeters P. Percutaneous transluminal angioplasty for treatment of “below-the-knee” critical limb ischemia: early outcomes following the use of sirolimus-eluting stents. J Cardiovasc Surg. 2006;47:171–6.Google Scholar
  17. 17.
    Commeau P, Barragan P, Roquebert PO. Sirolimus for below the knee lesions: mid-term results of SiroBTK study. Catheter Cardiovasc Interv. 2006;68:793–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Feiring AJ, Krahn M, Nelson L, Wesolowski A, Eastwood D, Szabo A. Preventing leg amputations in critical limb ischemia with below-the-knee drug-eluting stents. The PaRADISE (Preventing Amputations using Drug-eluting StEnts Trial). J Am Coll Cardiol. 2010;55:1580–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Feiring AJ, Wesolowski AA. Antegrade popliteal artery approach for the treatment of critical limb ischemia in patients with occluded superficial femoral arteries. Catheter Cardiovasc Interv. 2007;69:665–70.PubMedCrossRefGoogle Scholar
  20. 20.
    Grant AG, White CJ, Collins TJ, Jenkins JS, Reilly JP, Ramee SR. Infrapopliteal drug-eluting stents for chronic limb ischemia. Catheter Cardiovasc Interv. 2007;71(1):108–11.CrossRefGoogle Scholar
  21. 21.
    Karnabatidis D, Spillopoulous S, Diamantopoulos A, Katsanos K, Kagadis G, Stavros K, et al. Primary everolimus-eluting stenting versus balloon angioplasty with bailout bare metal stenting of long infrapopliteal lesions for treatment of critical limb ischemia. J Endovasc Ther. 2011;18:1–12.PubMedCrossRefGoogle Scholar
  22. 22.
    Fischman AM, Shah SS, Kim E, Stangl P, Nowakowski F, Weintraub JL, Lookstein R. Single-center experience with drug-eluting stents for infrapopliteal occlusive disease in patients with critical limb ischemia. SIR. 2010; Abstract 208.Google Scholar
  23. 23.
    Rosales OR, Mathewkutty S, Gnaim C. Drug-eluting stents for below the knee lesions in patients with critical limb ischemia: long-term follow-up. Catheter Cardiovasc Interv. 2008;72:112–5.PubMedGoogle Scholar
  24. 24.
    Siablis D, Karnabatidis D, Katsanos K, Diamantopoulous A, Christeas N, Kagadis G. Infrapopliteal application of paclitaxel-eluting stents for critical limb ischemia: midterm angiographic and clinical results. J Vasc Interv Radiol. 2007;18:1351–61.PubMedCrossRefGoogle Scholar
  25. 25.
    Siablis D, Karnabatidis D, Katsanos K, Diamantopoulous A, Christeas N, Kagadis G. Infrapopliteal application of sirolimus-eluting versus bare metal stents for critical limbs ischemia: analysis of long-term angiographic and clinical outcomes. J Vasc Interv Radiol. 2009;20:1141–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, Rutherford RB et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007; 45(Suppl S):9aTASC II.Google Scholar
  27. 27.
    Biondi-Zoccai GGL, Sangiorgi G, Lotrione M, Feiring A, Commeau P, Fusaro M, et al. Infragenicular stent implantation for below-the-knee atherosclerotic disease: clinical evidence from an international collaborative meta-analysis on 640 patients. J Endovasc Ther. 2009;18:251–60.CrossRefGoogle Scholar
  28. 28.
    Scheinert D. Achilles study–randomized comparison of Sirolimus eluting stents vs PTA for BTK obstructions. LINC 2011.
  29. 29.
    Bosiers M, Scheinert D, Peeters P, Torsello G, Zeller T, Deloose K, et al. Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease. J Vasc Surg. 2012;55:390–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Rastan A, Tepe G, Krakenberg H, Zahorsky R, Beschorner U, Noory E, et al. Sirolimus-eluting stents vs. bare-metal stents for treatment of focal lesions in infrapopliteal arteries: a double-blind, multi-centre randomized clinical trial. Eur Heart J. 2011;32:2274–81.PubMedCrossRefGoogle Scholar
  31. 31.
    Chakavarty T, Whit AJ, Buch M, Naik H, Doctor N, Schapira J, et al. Meta-analysis of incidence, clinical characteristics and implications of stent fracture. Am J Cardiol. 2010;106(8):1075–80.CrossRefGoogle Scholar
  32. 32.
    Karnabatidis D, Katsanos K, Spiliopoulous S, Diamantopoulous A, Kagadis GC, Siablis D. Incidence, anatomical location, and clinical significance of compressions and fractures in infrapopliteal balloon-expandable metal stents. J Endovasc Ther. 2009;16:15–22.PubMedCrossRefGoogle Scholar
  33. 33.
    Serruys PW, de Bruyne B, Carlier S, Sousa JE, Piek J, Muramatsu T, et al. Randomized comparison of primary stenting and provisional balloon angioplasty guided by flow velocity measurement; on behalf of the Doppler Endpoints Balloon Angioplasty Trial Europe (DEBATE) II Study Group. Circulation. 2000;102:2930–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Romiti M, Albers M, Brochado-Neto BC, Durazzo AES, Pereira CAB, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg. 2008;47:975–81.PubMedCrossRefGoogle Scholar
  35. 35.
    Mauri L, O’Malley AJ, Popma JJ, et al. Comparison of thrombosis and restenosis risk from stent length of sirolimus-eluting stents versus bare metal stents. Am J Cardiol. 2005;95:1140–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Colmenarez HJ, Escaned J, Ferna´ndez C, Lobo L, Cano S, del Angel JG, et al. Efficacy and safety of drug-eluting stents in chronic total coronary occlusion recanalization a systematic review and meta-analysis. J Am Coll Cardiol. 2010;55:1854–66.PubMedCrossRefGoogle Scholar
  37. 37.
    Holmes DR, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG, et al. Stent thrombosis. J Am Coll Cardiol. 2010;56:1357–65.PubMedCrossRefGoogle Scholar
  38. 38.
    Laird J, Zeller T, Gray BH, Scheinert D, Vranic M, Reiser C, et al. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther. 2006;13:1–11.PubMedCrossRefGoogle Scholar
  39. 39.
    Bosiers M, Deloose K, Verbist J, Peeters P. Nitinol stenting for treatment of below-the-knee critical limb ischemia: 1-year angiographic outcome after Xpert stent implantation. J Cardiovasc Surg. 2007;48(4):455–61.Google Scholar
  40. 40.
    Bosiers M, Kallakuri S, Deloose K, Verbist J, Peeters P. Infragenicular angioplasty and stenting in the management of critical limb ischaemia: one year outcome following the use of the MULTI-LINK VISION stent. EuroIntervention. 2008;3:470–4.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Andrew J. Feiring
    • 1
  1. 1.Vascular Institute and Cardiac and Interventional LaboratoryColumbia-St. Marys Medical CenterMilwaukeeUSA

Personalised recommendations