Skip to main content
SpringerLink
Log in

Endovascular Treatment of Below-the-Knee Chronic Total Occlusions

  • Chapter
  • First Online:
Practical Approach to Peripheral Arterial Chronic Total Occlusions

  • 694 Accesses

Abstract

With the aging of the US population as well as the epidemic of obesity, metabolic syndrome, and diabetes, it is expected that lower extremity peripheral arterial disease (PAD) and specifically critical limb ischemia (CLI) will continue to be a major healthcare challenge. Although a full discussion of the epidemiology and pathophysiology of CLI is beyond the scope of this chapter, a few points will help provide perspective for the reader. An important concept to convey is that the relationship between diabetes and CLI is not casual, but rather causal in nature. The associations between diabetic prevalence, complications, and mortality track closely with the rates of CLI and of nontraumatic amputations. Over the course of a lifetime, a diabetic patient is significantly more likely to undergo limb loss than a nondiabetic – with over 60% of nontraumatic amputations being performed in diabetic individuals. Although the pathophysiology leading to CLI in these patients is multifactorial – neuropathy, deformity, impaired immune response, and inflammation – the role of diffuse below-the-knee (BTK) atherosclerosis remains central to the failure of healing of foot ulcers. Traditionally, diabetic foot ulcers were classified as neuropathic or ischemic in nature. We now know that 50% of “neuropathic” ulcers may have impaired healing due to underlying ischemia. This ischemia is often microvascular, but in many cases due to distal BTK disease involving the plantar circulation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 54.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Mendes JJ, Neves J. Diabetic foot infections: current diagnosis and treatment. J Diabet Foot Complications. 2012;4:26–45.

    Google Scholar 

  2. Rosfors S, Kanni L, Nystrom T. The impact of transcutaneous oxygen pressure measurements in patients with suspected critical lower limb ischemia. Int Angiol. 2016;35(5):492–7.

    Google Scholar 

  3. Manzi M, Cester G, Palena LM, Alek J, Candeo A, Ferraresi R. Vascular imaging of the foot: the first step toward endovascular recanalization. Radiographics Rev Publ Radiol Soc N Am Inc. 2011;31:1623–36.

    Google Scholar 

  4. Faglia E, Clerici G, Caminiti M, Curci V, Clerissi J, Losa S, Casini A, Morabito A. Mortality after major amputation in diabetic patients with critical limb ischemia who did and did not undergo previous peripheral revascularization Data of a cohort study of 564 consecutive diabetic patients. J Diabetes Complicat. 2010;24:265–9.

    Article  PubMed  Google Scholar 

  5. Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, Mantero M, Caminiti M, Curci V, Quarantiello A, Lupattelli T, Morabito A. Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care. 2009;32:822–7.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Goodney PP, Travis LL, Nallamothu BK, Holman K, Suckow B, Henke PK, Lucas FL, Goodman DC, Birkmeyer JD, Fisher ES. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes. 2012;5:94–102.

    Article  PubMed  Google Scholar 

  7. Gray BH, Diaz-Sandoval LJ, Dieter RS, Jaff MR, White CJ. Peripheral Vascular Disease Committee for the Society for Cardiovascular A and Interventions. SCAI expert consensus statement for infrapopliteal arterial intervention appropriate use. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2014;84:539–45.

    Article  Google Scholar 

  8. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, Group TIW. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45 Suppl S:S5–67.

    Article  CAS  PubMed  Google Scholar 

  9. Norgren L, Hiatt WR, Harris KA, Lammer J, Group TIW. TASC II section F on revascularization in PAD. J Endovasc Ther Off J Int Soc Endovasc Spec. 2007;14:743–4.

    Google Scholar 

  10. Lyden SP, Smouse HB. TASC II and the endovascular management of infrainguinal disease. J Endovasc Ther Off J Int Soc Endovasc Spec. 2009;16:II5–18.

    Google Scholar 

  11. Romiti M, Albers M, Brochado-Neto FC, Durazzo AE, Pereira CA, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg. 2008;47:975–81.

    Article  PubMed  Google Scholar 

  12. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H, BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366:1925–34.

    Article  CAS  PubMed  Google Scholar 

  13. Rocha-Singh KJ, Jaff M, Joye J, Laird J, Ansel G, Schneider P, VIVA Physicians. Major adverse limb events and wound healing following infrapopliteal artery stent implantation in patients with critical limb ischemia: the XCELL trial. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2012;80:1042–51.

    Article  Google Scholar 

  14. Katib N, Thomas SD, Lennox AF, Yang JL, Varcoe RL. An Endovascular-First Approach to the Treatment of Critical Limb Ischemia Results in Superior Limb Salvage Rates. J Endovasc Ther Off J Int Soc Endovasc Spec. 2015;22:473–81.

    Google Scholar 

  15. Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM, Participants B. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: analysis of amputation free and overall survival by treatment received. J Vasc Surg. 2010;51:18S–31S.

    Article  PubMed  Google Scholar 

  16. Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM, Participants B. 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.

    Article  PubMed  Google Scholar 

  17. Menard MT, Farber A. The BEST-CLI trial: a multidisciplinary effort to assess whether surgical or endovascular therapy is better for patients with critical limb ischemia. Semin Vasc Surg. 2014;27:82–4.

    Article  PubMed  Google Scholar 

  18. McCoach CE, Armstrong EJ, Singh S, Javed U, Anderson D, Yeo KK, Westin GG, Hedayati N, Amsterdam EA, Laird JR. Gender-related variation in the clinical presentation and outcomes of critical limb ischemia. Vasc Med. 2013;18:19–26.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Iida O, Soga Y, Yamauchi Y, Hirano K, Kawasaki D, Tazaki J, Yamaoka T, Suematsu N, Suzuki K, Shintani Y, Miyashita Y, Takahara M, Uematsu M. Anatomical predictors of major adverse limb events after infrapopliteal angioplasty for patients with critical limb ischaemia due to pure isolated infrapopliteal lesions. Eur J Vasc Endovasc Surg J Off J Eur Soc Vasc Surg. 2012;44:318–24.

    Article  CAS  Google Scholar 

  20. Alexandrescu V, Hubermont G. Primary infragenicular angioplasty for diabetic neuroischemic foot ulcers following the angiosome distribution: a new paradigm for the vascular interventionist? Diabetes Metab Syndr Obes Targets Ther. 2011;4:327–36.

    Article  Google Scholar 

  21. Iida O, Nanto S, Uematsu M, Ikeoka K, Okamoto S, Dohi T, Fujita M, Terashi H, Nagata S. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2010;75:830–6.

    Google Scholar 

  22. Munce NR, Yang VX, Standish BA, Qiang B, Butany J, Courtney BK, Graham JJ, Dick AJ, Strauss BH, Wright GA, Vitkin IA. Ex vivo imaging of chronic total occlusions using forward-looking optical coherence tomography. Lasers Surg Med. 2007;39:28–35.

    Article  PubMed  Google Scholar 

  23. Ruzsa Z, Nemes B, Bansaghi Z, Toth K, Kuti F, Kudrnova S, Berta B, Huttl K, Merkely B. Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2014;83:997–1007.

    Article  Google Scholar 

  24. Mustapha JA, Saab F, McGoff T, Heaney C, Diaz-Sandoval L, Sevensma M, Karenko B. Tibio-pedal arterial minimally invasive retrograde revascularization in patients with advanced peripheral vascular disease: the TAMI technique, original case series. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2014;83:987–94.

    Article  CAS  Google Scholar 

  25. Palena LM, Manzi M. Extreme below-the-knee interventions: retrograde transmetatarsal or transplantar arch access for foot salvage in challenging cases of critical limb ischemia. J Endovasc Ther Off J Int Soc Endovasc Spec. 2012;19:805–11.

    Google Scholar 

  26. Palena LM, Brocco E, Manzi M. The clinical utility of below-the-ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2014;83:123–9.

    Article  Google Scholar 

  27. Lorenzoni R, Roffi M. Transradial access for peripheral and cerebrovascular interventions. J Invasive Cardiol. 2013;25:529–36.

    PubMed  Google Scholar 

  28. Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, Lembo N, Pershad A, Kandzari DE, Buller CE, DeMartini T, Lombardi WL, Thompson CA. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5:367–79.

    Article  PubMed  Google Scholar 

  29. Banerjee S, Sarode K, Patel A, Mohammad A, Parikh R, Armstrong EJ, Tsai S, Shammas NW, Brilakis ES. Comparative assessment of guidewire and microcatheter vs a crossing device-based strategy to traverse infrainguinal peripheral artery chronic total occlusions. J Endovasc Ther Off J Int Soc Endovasc Spec. 2015;22:525–34.

    Google Scholar 

  30. Spinosa DJ, Leung DA, Harthun NL, Cage DL, Fritz Angle J, Hagspiel KD, Matsumoto AH. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. J Vasc Interv Radiol JVIR. 2003;14:1449–54.

    Article  PubMed  Google Scholar 

  31. Mustapha JA, Saab F, Diaz L, Karenko B, Richards L, Laeder T, Heaney CM, Das T. Utility and feasibility of ultrasound-guided access in patients with critical limb ischemia. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2013;81:1204–11.

    Article  CAS  Google Scholar 

  32. Mustapha JA, Diaz-Sandoval LJ. Balloon angioplasty in tibioperoneal interventions for patients with critical limb ischemia. Tech Vasc Interv Radiol. 2014;17:183–96.

    Article  CAS  PubMed  Google Scholar 

  33. Sarode K, Spelber DA, Bhatt DL, Mohammad A, Prasad A, Brilakis ES, Banerjee S. Drug delivering technology for endovascular management of infrainguinal peripheral artery disease. JACC Cardiovasc Interv. 2014;7:827–39.

    Article  PubMed  Google Scholar 

  34. Trombert D, Caradu C, Brizzi V, Berard X, Midy D, Ducasse E. Evidence for the use of drug eluting stents in below-the-knee lesions. J Cardiovasc Surg. 2015;56:67–71.

    CAS  Google Scholar 

  35. Liistro F, Porto I, Angioli P, Grotti S, Ricci L, Ducci K, Falsini G, Ventoruzzo G, Turini F, Bellandi G, Bolognese L. Drug-eluting balloon in peripheral intervention for below the knee angioplasty evaluation (DEBATE-BTK): a randomized trial in diabetic patients with critical limb ischemia. Circulation. 2013;128:615–21.

    Article  CAS  PubMed  Google Scholar 

  36. Zeller T, Baumgartner I, Scheinert D, Brodmann M, Bosiers M, Micari A, Peeters P, Vermassen F, Landini M, Snead DB, Kent KC, Rocha-Singh KJ, Investigators IPDT. Drug-eluting balloon versus standard balloon angioplasty for infrapopliteal arterial revascularization in critical limb ischemia: 12-month results from the IN.PACT DEEP randomized trial. J Am Coll Cardiol. 2014;64:1568–76.

    Article  PubMed  Google Scholar 

  37. Bhatt P, Parikh P, Patel A, Chag M, Chandarana A, Parikh R, Parikh K. Orbital atherectomy system in treating calcified coronary lesions: 3-year follow-up in first human use study (ORBIT I trial). Cardiovasc Revasc Med Incl Mol Interv. 2014;15:204–8.

    Article  Google Scholar 

  38. Staniloae CS, Korabathina R. Orbital atherectomy: device evolution and clinical data. J Invasive Cardiol. 2014;26:215–9.

    PubMed  Google Scholar 

  39. Zeller T, Krankenberg H, Steinkamp H, Rastan A, Sixt S, Schmidt A, Sievert H, Minar E, Bosiers M, Peeters P, Balzer JO, Gray W, Tubler T, Wissgott C, Schwarzwalder U, Scheinert D. One-year outcome of percutaneous rotational atherectomy with aspiration in infrainguinal peripheral arterial occlusive disease: the multicenter pathway PVD trial. J Endovasc Ther Off J Int Soc Endovasc Spec. 2009;16:653–62.

    Google Scholar 

  40. Laird JR, Zeller T, Gray BH, Scheinert D, Vranic M, Reiser C, Biamino G, Investigators L. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther Off J Int Soc Endovasc Spec. 2006;13:1–11.

    Google Scholar 

  41. Henry M, Amor M, Ethevenot G, Henry I, Allaoui M. Percutaneous peripheral atherectomy using the rotablator: a single-center experience. J Endovasc Surg Off J Int Soc Endovasc Surg. 1995;2:51–66.

    Article  CAS  Google Scholar 

  42. McKinsey JF, Zeller T, Rocha-Singh KJ, Jaff MR, Garcia LA, DEFINITIVE LE Investigators. Lower extremity revascularization using directional atherectomy: 12-month prospective results of the DEFINITIVE LE study. JACC Cardiovasc Interv. 2014;7:923–33.

    Article  PubMed  Google Scholar 

  43. Shammas NW, Shammas GA, Dippel EJ, Jerin M, Shammas WJ. Predictors of distal embolization in peripheral percutaneous interventions: a report from a large peripheral vascular registry. J Invasive Cardiol. 2009;21:628–31.

    PubMed  Google Scholar 

  44. Reeves R, Imsais JK, Prasad A. Successful management of lower extremity distal embolization following percutaneous atherectomy with the JetStream G3 device. J Invasive Cardiol. 2012;24:E124–8.

    PubMed  Google Scholar 

  45. Zafar N, Prasad A, Mahmud E. Utilization of an aspiration thrombectomy catheter (Pronto) to treat acute atherothrombotic embolization during percutaneous revascularization of the lower extremity. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2008;71:972–5.

    Article  Google Scholar 

  46. Shammas NW, Dippel EJ, Shammas G, Gayton L, Coiner D, Jerin M. Dethrombosis of the lower extremity arteries using the power-pulse spray technique in patients with recent onset thrombotic occlusions: results of the DETHROMBOSIS Registry. J Endovasc Ther Off J Int Soc Endovasc Spec. 2008;15:570–9.

    Google Scholar 

  47. Keo H, Diehm N, Baumgartner R, Husmann M, Baumgartner I. Single center experience with provisional abciximab therapy in complex lower limb interventions. VASA Zeitschrift fur Gefasskrankheiten. 2008;37:257–64.

    Article  CAS  PubMed  Google Scholar 

  48. Manzi M, Palena LM. Treating calf and pedal vessel disease: the extremes of intervention. Semin Intervent Radiol. 2014;31(4):313–9.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Texas Health Science Center, Department of Medicine, Division of Cardiology, San Antonio, TX, USA

    Anand Prasad MD & Fadi Saab MD

Authors
  1. Anand Prasad MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fadi Saab MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anand Prasad MD .

Editor information

Editors and Affiliations

  1. University of Texas Southwestern Medical Center, Dallas, Texas, USA

    Subhash Banerjee

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer Science+Business Media Singapore

About this chapter

Cite this chapter

Prasad, A., Saab, F. (2017). Endovascular Treatment of Below-the-Knee Chronic Total Occlusions. In: Banerjee, S. (eds) Practical Approach to Peripheral Arterial Chronic Total Occlusions. Springer, Singapore. https://doi.org/10.1007/978-981-10-3053-6_5

Download citation

  • DOI: https://doi.org/10.1007/978-981-10-3053-6_5

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-10-3052-9

  • Online ISBN: 978-981-10-3053-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation