Title : Immediate recoil after percutaneous balloon angioplasty of below the knee arteries in patients with critical limb ischemia
Abstract:
Introduction: Chronic limb ischemia (CLI), the terminal manifestation of peripheral artery disease, has an estimated prevalence of 6.5 million in the United States and Japan, with an annual incidence of 2.3% per year. Patients diagnosed with CLI have a 1-year mortality rate of approximately 20% to 25%, and 5-year all-cause mortality rates exceeding 50%.Percutaneous transluminal angioplasty [PTA]) of below the knee arteries in critical limb ischemia (CLI) is a common, established practice worldwide. Recoil and restenosis remain major drawback of balloon angioplasty. Durable below the knee vessel patency may promote faster, more sustained, complete wound healing and limb preservation, and is a desired revascularization goal. Plain balloon (PB) angioplasty for below the knee artery disease has a high rate of procedural success and an acceptable safety profile, however, rates of recoil and restenosis are considerable. Balloon dilatation of the diseased artery causes fracture and separation of the media from the intima and stretching of the media and adventitia. Severely fibrotic lesions or heavily calcified lesions are more resistant to balloon dilation, and intimal dissection or elastic recoil may be observed.
Purpose: To assess the extent and Percentage of immediate recoil in patients with critical limb ischemia (CLI) undergoing below the knee balloon angioplasty. Elastic recoil of the arterial wall has been shown to be responsible for a significant loss of luminal area after balloon angioplasty in the coronary arteries, but it has not been well studied in the peripheral arteries. Because elastic recoil depends on the presence of elastin in the arterial wall, and the amount of elastin varies by artery and proximity to the aorta, the importance of this response to angioplasty may be different in peripheral arteries.
Methods: Our hypothesis was that Immediate recoil, defined as lumen compromise >10%, is frequent and accounts for considerable luminal narrowing after below the knee angioplasty, promoting restenosis. To test this theory, 25 consecutive CLI patients (17 men and 8 women; mean age 69.2±12.1 years) were angiographically evaluated immediately after balloon angioplasty and 15 minutes later. 96% of the patients were diabetics. Target lesions included anterior and posterior tibial arteries and the peroneal artery with / without the tibioperoneal trunk. Early elastic recoil was determined on the basis of minimal lumen diameter (MLD) measurements at baseline (MLDbaseline), immediately after balloon angioplasty (MLDpostdilation), and 15 minutes thereafter (MLD15min). Percentage of the recoil was determined by comparing Minimal Luminal Diameter (MLD) Post angioplasty and then MLD at 15 min using Fluoroscopic Markers in Catheterization Lab. The degree of recoil was correlated with six variables: patient age and sex, comorbidities including diabetes, lesion location, lesion length, and length of the peripheral balloon used.
Results: Immediate Elastic recoil was observed in 19 (79%) patients with a mean luminal compromise of 31% according to MLD measurements (MLDbaseline 0.25 mm, MLD postdilation 2.0 mm, MLD immediately 1.55 mm and MLD15min 1.57 mm).
Conclusion: Immediate recoil is frequently observed in CLI patients undergoing below knee angioplasty and may significantly contribute to restenosis. These findings support the role of dedicated mechanical scaffolding approaches for the prevention of restenosis in below the knee arteries.
