2:10 PM - 2:40 PM
[IL-1] Current status of endovascular therapy for lower limb ischemia in U.S.A.
Patients with symptomatic peripheral artery disease(PAD) are candidates for revascularization if they have an inadequate response to medical therapy. Revascularization strategies consist of open vascular surgery and endovascular options but there are few comparative studies of these two approaches. In patients with severe limb ischemia The BASIL trial demonstrated similar outcomes for surgery and angioplasty at 6 months, while long-term follow-up demonstrated a numerical trend for better amputation-free survival for the vein bypass group compared with the angioplasty group. The initial revascularization strategy for disease below the inguinal ligament usually involves an endovascular-first approach. Depending on center expertise, lesion complexity, conduit, and patient condition, hybrid procedures may be favored, while bypass surgery should be used for complex, extensive lesions with an expected patient survival of at least 2 years.
Since BASIL there has been an evolution of new endovascular technologies including patency enhancing drug coated balloons and stents and adjunctive endovascular devices including atherectomy, cryoplasty, cutting balloons and LASER. These new devices are feasible and safety in the infrapopliteal vessels, but have failed to show superior efficacy when compared to conventional, less expensive therapies. In patients with claudication who have above the knee lesions, angioplasty with bare metal bailout stenting is the preferred option over an angioplasty-only approach. In this setting, bare metal stenting has a slight advantage over angioplasty alone on the endpoints of 12 month target lesion revascularization and restenosis while angioplasty along has slight advantage for overall mortality at 12 months. In patients with critical limb ischemia who have below the knee lesions, a primary angioplasty strategy is favored on the endpoints of target lesion revascularization and restenosis compared with bare metal stents which should be used only for bail out purposes.
Since BASIL there has been an evolution of new endovascular technologies including patency enhancing drug coated balloons and stents and adjunctive endovascular devices including atherectomy, cryoplasty, cutting balloons and LASER. These new devices are feasible and safety in the infrapopliteal vessels, but have failed to show superior efficacy when compared to conventional, less expensive therapies. In patients with claudication who have above the knee lesions, angioplasty with bare metal bailout stenting is the preferred option over an angioplasty-only approach. In this setting, bare metal stenting has a slight advantage over angioplasty alone on the endpoints of 12 month target lesion revascularization and restenosis while angioplasty along has slight advantage for overall mortality at 12 months. In patients with critical limb ischemia who have below the knee lesions, a primary angioplasty strategy is favored on the endpoints of target lesion revascularization and restenosis compared with bare metal stents which should be used only for bail out purposes.