The role of infrapopliteal angioplasty in the treatment of critical limb ischemia

In the last several years, percutaneous revascularization of the tibial arteries has become the predominant treatment modality for critical limb ischemia despite limited evidence to supports its clinical efficacy and cost-effectiveness compared to surgical bypass. Mid- and long-term outcomes from retrospective reports have documented inferior durability and higher rates of reintervention but favorable wound healing rates and comparable long-term limb salvage rates for all but the most severe lesions. Comparison of endovascular outcomes with bypass is difficult since many patients undergoing angioplasty are not candidates for bypass and studies show that results are inferior in this group. Thus infrapopliteal angioplasty has an established role in treating critical limb ischemia, particularly for patients with limited life expectancy or contraindication to bypass. However, despite popular beliefs that endovascular therapy is associated with lower morbidity and mortality, recent analyses suggest that this may not be the case. However, complications with tibial angioplasty or bypass must be considered in the context of the morbidity and mortality associated with major amputation. Whenever possible, efforts should be targeted to restore flow to the affected angiosome while assuring the best possible flow to the entire foot.