Endovascular-first strategy in patients with critical limb ischemia

Purpose: To assess outcomes of percutaneous infrainguinal endovascular interventions as the initial therapeutic modality in patients with critical limb ischemia (CLI). Materials and Methods: We performed a retrospective review of 33 consecutive interventions in 29 patients over a period of 24 months at a single center. Mean follow-up was 11.4 months. Technical success was defined as the ability to obtain in-line arterial flow into the foot with less than a 20% residual stenosis using percutaneous techniques. Limb salvage was defined as the ability to avoid major level amputation (below or above knee). Follow-up included clinical examination and noninvasive vascular evaluation by color-flow duplex ultrasound. Results: Thirty-three limbs were treated for disabling claudication (n = 2), rest pain (n = 10) or ulceration/gangrene (n = 21). All patients were male. Technical success was achieved in 31 limbs (93.9%). Intra-procedural complications included clinically significant embolization (n = 2, successfully treated by thrombolysis) and acute respiratory failure (n = 1). Post-procedure complications included puncture site pseudoaneurysm necessitating operative repair (n = 1), and acute renal failure (n = 1). Two patients died within 30 days post-procedure of cardiac related events. Of those patients who had a technically successful procedure, 5 underwent a major level amputation during the follow-up period. The limb salvage rate was 83.9%. Conclusions: An "endovascular-first" strategy can yield good limb salvage rates in patients with advanced lower extremity limb ischemia.