Endovascular Balloon Angioplasty in Management of Infragenicular Critical Lower Limb Ischemia
Mohamed Mahmoud Mohamed Zaki Ali;
Abstract
As we embarked upon this quest, our research question was “have we a better alternative for tackling difficult tibial artery lesions to conventional angioplasty?” We conducted a literature review on tibial angioplasty and we originally postulated that the Laser tibial angioplasty would be superior to conventional balloon angioplasty.
Our study demonstrated no statistically significant difference between the Excimer Laser assisted tibial angioplasty and conventional balloon angioplasty in the overall outcome that might justify the high cost of adopting the Laser angioplasty as an evolutionary successor of conventional tibial balloon angioplasty with bailout stenting.
Although a systematic cost analysis was not conducted in this study, keeping into consideration that the Laser catheter costs about 3000 Euros for single use, we could not find adequate benefit or superiority in Laser assisted angioplasty that would justify the grave cost it superimposes.
In the era of minimally invasive procedures, and in the age of greying of nations as well as the exponential increase in prevalence of diabetes, the quest for novel technological tools to enrich the armament of the vascular surgeon is proceeding, and the competition to excel is vicious. With the evolution of newer techniques every day, the need for level one evidence through randomized controlled studies to support the modality of choice in tackling different anatomical lesions remains imperative.
Although several studies have shown promising results in using the drug eluting technology; be it DUBs and DUSs, in infragenicular disease; no solid data was concluded from our literature review to support its superiority in long term outcome. In addition, no cost benefit analysis has been published to justify the use of DUSs and DUBs on the long run.
The use of different atherectomy devices has also proven minimal benefit if not harm; especially in the realm of infragenicular disease where the vessel diameters are limited and heavily calcified.
On the contrary, distal bypass surgeries have and will be a solid ground for managing distal disease, with best long term outcome; however, certain limitations might hinder open bypass surgery such as the patients’ age, multiple co-morbidities, poor general condition, absence of a runoff, prolonged in hospital stay and recovery period and in-availability of a suitable conduit, all of which lead to a general trend in adopting an “angioplasty first” concept towards distal disease, as suggested by the BASIL trial.
We conclude from our study that the conventional transluminal angioplasty with occasional bailout stenting remains the gold standard in management of critical limb ischemia due to infragenicular disease; especially in absence of a definitive run off and in critically ill patients where a distal bypass is not an option.
Our study demonstrated no statistically significant difference between the Excimer Laser assisted tibial angioplasty and conventional balloon angioplasty in the overall outcome that might justify the high cost of adopting the Laser angioplasty as an evolutionary successor of conventional tibial balloon angioplasty with bailout stenting.
Although a systematic cost analysis was not conducted in this study, keeping into consideration that the Laser catheter costs about 3000 Euros for single use, we could not find adequate benefit or superiority in Laser assisted angioplasty that would justify the grave cost it superimposes.
In the era of minimally invasive procedures, and in the age of greying of nations as well as the exponential increase in prevalence of diabetes, the quest for novel technological tools to enrich the armament of the vascular surgeon is proceeding, and the competition to excel is vicious. With the evolution of newer techniques every day, the need for level one evidence through randomized controlled studies to support the modality of choice in tackling different anatomical lesions remains imperative.
Although several studies have shown promising results in using the drug eluting technology; be it DUBs and DUSs, in infragenicular disease; no solid data was concluded from our literature review to support its superiority in long term outcome. In addition, no cost benefit analysis has been published to justify the use of DUSs and DUBs on the long run.
The use of different atherectomy devices has also proven minimal benefit if not harm; especially in the realm of infragenicular disease where the vessel diameters are limited and heavily calcified.
On the contrary, distal bypass surgeries have and will be a solid ground for managing distal disease, with best long term outcome; however, certain limitations might hinder open bypass surgery such as the patients’ age, multiple co-morbidities, poor general condition, absence of a runoff, prolonged in hospital stay and recovery period and in-availability of a suitable conduit, all of which lead to a general trend in adopting an “angioplasty first” concept towards distal disease, as suggested by the BASIL trial.
We conclude from our study that the conventional transluminal angioplasty with occasional bailout stenting remains the gold standard in management of critical limb ischemia due to infragenicular disease; especially in absence of a definitive run off and in critically ill patients where a distal bypass is not an option.
Other data
| Title | Endovascular Balloon Angioplasty in Management of Infragenicular Critical Lower Limb Ischemia | Other Titles | توسيع الشراين الطرفيه باستخدام القسطرة البالونية التداخلية لعلاج القصور الحرج في الدورة الدموية الناتج عن ضيق الشراين الطرفية أسفل الركبة | Authors | Mohamed Mahmoud Mohamed Zaki Ali | Issue Date | 2015 |
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