Improving Limb Salvage Rate with Multiple Vessel Recanalization

New endovascular techniques and devices are enabling the salvage of limbs and the restoration of ambulation in diabetic patients with critical limb ischemia who previously would have required amputation. The approach involves arterial and venous recanalization prior to addressing diabetic ulcers….

Marco Manzi, MD, from Policlinico Abano Terme, Vicenza, Italy, reported a salvage rate better than 97% with his multiple-vessel recanalization technique in 1,019 diabetic patients with critical limb ischemia treated at his institution.

“The old concept was to recanalize 1 vessel. Now we know that is not enough. We need to revascularize at least 2 or 3 vessels and, when possible, the foot arteries for inflow to the limb and outflow to the foot,” he explained. The new approach relies on wound-related artery recanalization and foot vessel revascularization, he emphasized.

“You need to identify the wound-related artery and treat that vessel first. This will give you a shorter recovery time and is the best surgical treatment,” he explained. “This different clinical approach rests on the observation that it is not enough to reopen a vessel. You need to think about the areas of blood supply to the wound.”

To identify the wound-related artery, Dr. Manzi studies different angulations of the foot/limb on angiography with contrast to show the area(s) of occlusion.

Of 1,019 patients treated in the past 3 years, 319 were completely revascularized and 207 were partially revascularized. Complete or partial success rate was 51.6%.

The failure rate was 48.4%. Dr. Manzi attributes the failure to revascularize to a number of technical limitations of his technique, including severe calcifications and anatomic variations that made treatment challenging. Despite incomplete revascularization in this group, Rutherford class improved in nearly 30%, he said.

Patients were followed for a mean of 9.7 years. Limb salvage was 97.2%, and ambulatory function was restored in 78% of patients. Unplanned major amputations occurred in 2.5% of patients, and planned minor amputations (below the ankle) were performed in 32.3%.

Dr. Manzi’s technique involves a pedal-plantar loop technique, which uses 2 wires to improve and maintain outflow in the wound-related arteries and to rescue patients who have failed on other treatments.

“Even if you avoid amputation, the important end point is whether you can walk again. This is a different end point from limb salvage,” he noted.

Claudio Rabbia, MD, an interventionalist from Hospital Molinette, Turin, Italy, stated that, Dr. Manzi’s results are impressive. However, he pointed out that Dr. Manzi works at a specialized diabetic foot center with multidisciplinary support, performing about 800 of these procedures each year.

“He performs extreme interventions involving foot circulation. Others should follow his lead and incorporate his techniques for distal surgery [i.e. below the knee],” Dr. Rabbia said.

Presented November 18, 2010, at the 37th Annual VEITH Symposium