Endovascular treatment of TransAtlantic Inter-Society Consensus II D femoropopliteal lesions in patients with critical limb ischemia

Objective: The outcomes of endovascular treatment of femoropopliteal atherosclerotic lesions have been improving recently. Although open repair is indicated for class D femoropopliteal lesions based on the TransAtlantic Inter-Society Consensus II (TASC II) document, in some cases, it is reasonable to use the endovascular approach for these lesions. The aim of this study was to retrospectively analyze the technical aspects and outcomes of treating TASC II D femoropopliteal disease with endovascular approaches. Methods: In total, 91 procedures between January 2011 and December 2016 were retrospectively analyzed. We collected data corresponding to the technical aspects and outcomes of treatment from an electronic database. Images and videos of all procedures were reviewed. Among the 91 procedures, 70 were for popliteal artery occlusions involving the trifurcation vessels, and 12 were for superficial femoral artery (SFA) occlusions of > 20 cm in length; 9 procedures for occlusions meeting both criteria were also performed. The chi(2) test was employed for statistical analyses, and logistic regression analyses were conducted to identify risk factors. Patency, wound healing, and survival were analyzed using the Kaplan-Meier method. Statistical significance was considered at P < .05. Results: Approximately 44.4% of all patients were male. The mean age was 67.3 +/- 20.7 years. Hypertension, diabetes, current smoker, kidney impairment, coronary disease, and cardiac insufficiency were identified in 92.3%, 66.6%, 21.7%, 7.6%, 25.6%, and 62.8% of the patients, respectively. All included patients had critical limb ischemia (11.5%, 84.6%, and 3.8% of cases corresponding to Rutherford categories 4, 5, and 6, respectively). Technical failure was observed in three patients (3.3%). The mean number of stents used was 0.7 +/- 0.65 per patient. Primary patency at 30 days, 1 year, 2 years, and 3 years was 91%, 60.1%, 55.7%, and 50.6%, respectively. Limb salvage at 30 days, 1 year, 2 years, 3 years, and 4 years was 95.2%, 82.2%, 76.9%, 71.8%, and 63.7%, respectively. Reinterventions were necessary in 11.1% of the patients. Comparison of curves revealed significant differences in the 60-day primary patency for the SFA and popliteal groups (standard error, < 10%; log-rank, P = .039). Analysis of the risk and technical factors affecting primary patency, limb salvage, and overall survival indicated that female sex was associated with poor survival (odds ratio, 8.942; 95% confidence interval, 1.105-72.36) and that the use of stents was associated with high rates of limb loss in the popliteal group (log-rank, P = .033). Conclusions: For endovascular treatment of TASC II D femoropopliteal lesions, primary patency was better in patients with popliteal artery occlusions involving the trifurcation vessels than in those with SFA occlusions > 20 cm in length. Female sex was associated with the risk of major amputations, and the use of stents in patients with popliteal occlusions was associated with major limb loss.