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C H A P T E R 1 1
BelowKneeRevascularization
RishiPanchalDO
I.Introduction
A.PatientsatRiskforPeripheralArterialDisease
B.Examination
C.RevascularizationConsiderations
III.MedicalTherapyforPatientsWithPeripheralArterialDisease
A.ExercisePrograms
B.Pharmacotherapy
C.SmokingCessation
IV.InterventionsforPatientsWithPeripheralArterialDisease
A.PrinciplesofCatheter-BasedInterventions
C.VascularAccess
D.LesionCrossing
E.PercutaneousTransluminalAngioplastyforSuperficialFemoralArteryDisease
F.PercutaneousTransluminalAngioplastyforSuperficialFemoralArteryDiseaseWithDrug-CoatedBalloons
G.TrialsComparingtheUseofDrug-CoatedBalloonWithPercutaneousTransluminalAngioplastyinSuperficialFemoral
Artery/FemoropoplitealDisease
V.StentinginSuperficialFemoralArtery
A.BareMetalStents
B.BareMetalStentStudiesandTrials
C.Polytetrafluoroethylene(PTFE)-CoveredStents
D.Drug-ElutingStentStudiesandTrials
VI.ClinicalTrialUpdateinSuperficialFemoralArteryDisease
A.Follow-Up
B.ACC/AHARecommendations
VII.Summary
KeyPoints
■Belowkneediseasegivesrisetocriticallimbischemiawithrestpainorulcers.
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■Belowkneediseaseisoftencombinedwithinflowdiseaseoftheiliacandfemoropopliteal
segments.
■Contralateral femoral, ipsilateral femoral, and pedal access can be undertaken for
infrapoplitealinterventions.
■Balloonangioplastyis themainstayoftreatment.Drug-coatedballoontherapy anddrug-
elutingstentssofarhavenotproventobesignificantlybeneficialinbelowkneedisease.
I.IndicationsandConsiderations
A.ChronicLimbIschemia
1.Chroniclimbischemia(CLI)isdefinedaslimbpainthatoccurs“atrestorimpendinglimblossthatis
caused by severe compromise of blood flow to the affected extremity.”1 In CLI, a cascade of
pathophysiologic events results from a chronic lack of blood supply over several weeks to months,
ultimately leading to rest pain and/or trophic lesions in the legs.18 Rutherford and Fontaine’s
classificationcriteriaplaceCLIattheendofthespectrumofchronicperipheralarterialdisease(Table
11.1).
Table11.1
FontaineandRutherfordClassificationsofChronicPeripheralArterialDiseaseSeverity
FontaineClassification RutherfordClassification
Stage ClinicalSymptoms Grade Category ClinicalSymptoms
I Asymptomatic 0 0 Asymptomatic
IIa Mildclaudication
(symptomswithwalking>200m)
I 1 Mildclaudication
IIb Moderatetosevereclaudication
(symptomswithwalking<200m)
2 Moderateclaudication
3 Severeclaudication
III Ischemicrestpain II 4 Ischemicrestpain Criticallimbischemia
IV Ulcerationorgangrene III 5 Minortissueloss
6 Majortissueloss
2. Classic symptoms and clinical manifestations of CLI include the following: lower extremity rest
pain, nonhealing ulcers, tissue loss, gangrene, pallor of thefoot,and rubor dependency.1 CLI places
patients at a significant risk for amputation and cardiovascular events, thereby making it the most
importantclinicalindicationforbelow-the-kneerevascularization.16RiskfactorsofCLIarethesameas
that of general atherosclerosis and include cigarette smoking, diabetes mellitus (DM), dyslipidemia,
hypertension,obesity,metabolicsyndrome,hyperhomocysteinemia,increasedfibrinogen,andhighlevels
ofC-reactiveprotein.ThediagnosisofCLIismadebasedonclinicalmanifestationsandobjectivedata
including the following hemodynamic parameters: ankle-brachial index of 0.4 or less, ankle systolic
pressureof50mmHgorless,toesystolicpressureof30mmHgorless,1andtranscutaneousoxygenless
than20mmHg.12ThegoalofrevascularizationinCLI,whethersurgicalorendovascular,istoprovide
in-lineblood flowtothefootthroughatleast1patentartery,inanefforttopreserveafunctionallimb,
while decreasing ischemicpain, minimizing tissue loss, facilitating wound healing,9improving patient
functionandqualityoflife,andprolongingsurvival.
18
3. The gold standard for revascularization for CLI has long included opensurgical revascularization,
endartectomy,andsurgicalinfrainguinalbypass.
1
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a. Withadvancementsintechniques,devices,andresearchdemonstratingthesafety,efficacy,andlower
cost of endovascular treatment of lower extremity peripheral arterial disease, there has been a
paradigm shift over the recent years to an endovascular-first approach.16 The endovascular-first
approachtothetreatmentofCLIiscurrentlyconsideredtobethestandardtreatmentforsymptomatic
infrainguinal atherosclerotic disease, with regard to good technical and clinical outcomes.
11
Endovascular revascularization is preferred over surgical revascularization in patients with
comorbidities includingcoronaryischemia, cardiomyopathy, congestive heart failure, severe lung
disease,andchronickidneydisease,whichallincreaseriskofperioperativesurgicalcomplications.
b. Endovascular revascularization is also indicated in patients without suitable autologous vein for
bypass grafts, inpatients with restpain and disease atmultiple levels whocan undergo astaged
intervention,9andin patientswith severe infection near the site ofplannedsurgical anastomosis,
previouslyfailed bypass, andshortlesions.Notonlydoes endovascular revascularization offer a
less invasive and cost-effective option forthe treatment ofCLI butis also associatedwith faster
recovery time, fewer complications, and shorter length of hospital stay.16 As illustrated by the
BASIL(BypassversusAngioplastyinSevereIschemiaoftheLeg)study,endovascularintervention
isaneffectiveoptionfortreatingCLI,whencomparedwithsurgicalintervention,astheamputationfreesurvivalratesweresimilar9(Fig.11.1).
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FIGURE11.1: Managementalgorithmforpatientswithsuspectedcriticallimbischemia.
From
ShisheborM ,WhiteC,BruceG,etal.Criticallimbischemia.JACC.2016;68(18):2002-2015.
II.Anatomy
A.PoplitealArtery
Thepoplitealarterydividesbelowthekneejointintotheanteriortibialarteryandthetibioperonealtrunk.
Theanteriortibialarterydescendsalongtheinterosseousmembrane,becomesthedorsalispedisarteryas
itcrossestheanklejoint,andsuppliesthedorsumofthefoot.Thetibioperonealtrunkarisesdistaltothe
anteriortibialarteryandbranchesintotheposteriortibialarteryandtheperonealartery.Theposterior
tibialarterycontinuesalongthetibialisposteriormuscleandsuppliestheplantaraspectsofthetoesand
sole,thewebspacesbetweenthetoes,andthemedialaspectoftheheel.Theposteriortibialarteryhas
three mainbranches;thecalcanealbranch whichsuppliesthemedialankle andlateral plantar heel,the
medialplantararterywhichsuppliestheplantarinstep,andthelateralplantararterywhichsuppliesthe
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lateralandplantarforefootandplantarmidfoot.3Theperonealarteryhastwomainbranches:theanterior
perforatingbranchsupplyingpartoftheupperankleandthecalcanealbranchsupplyingtheplantaraspect
oftheheel(Figs.11.2and11.3).
13
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FIGURE11.2 Arteriesofthelowerleg.
From
SilverM,AnselG.InfrapoplitealIntervention.In:CasserlyIP,SacharR,YadavJS,eds.PracticalPeripheralVascularIntervention.2nded.
Philadelphia,PA:Lipp incottWilliams&Wilkins;2011:265-277.
FIGURE11.3 Angiosomes.
B.Approach
When determining the approach to intervention in patients with CLI, it is important to consider the
conceptsofangiosome-directedrevascularizationversusindirectrevascularization.Anangiosomeis an
anatomicunitoftissue,consistingofskin,subcutaneoustissue,fascia,muscle,andbone.3Thefootand
ankleconsistofsixangiosomes,witheachangiosomebeingfedbyasourceartery.Theposteriortibial
arteryfeeds three angiosomes, the anterior tibial arteryfeeds one angiosome,and theperoneal artery
feedstwoangiosomes3(Fig.11.3).InpatientswithCLI,acquiringdirectflowbasedontheangiosome
conceptisimportantforlimbsalvage.Researchhasdemonstratedastatisticallysignificantincreaseinthe
rate of limb salvage, skin perfusion pressure, and freedom from amputation with angiosome-directed
revascularizationwhencomparedwithindirectrevascularizationinpatientswithCLI.
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