We see that there is role for bare metal stents, drug eluting stents (DES), drug eluting Balloons (DEB) in the management of below knee vascular steno-occlusive lesions producing the critical ischemia. The cost of below knee endovascular revascularization is dependent on the number of lesions and vessels involved. The CLI in diabetic patients has a major amputation of 30%, mortality rate of 25%, and chronic pain of 20% at one year. Because of these risks, below knee angioplasty and stenting has been found to be effective in CLI with minimal risks when compared to the surgical therapies. But endovascular therapies are not recommended for the intermittent claudication in TASC-2 recommendations. The endovascular therapies are often limited due to the re-stenosis of the treated segments. We assume that the cost of re-treatment of stenosed segments may be more expensive and associated with complications. So, one would look towards drug eluting stents, drug eluting balloons as alternatives to bare metal stents. This again increases the cost of primary therapies. However in the current scenario we are still depending on the Prostaglandin E-1 infusion therapies as least expensive and at the same time it is relieving the rest pain, healing ulcers. It may be necessary to spread the knowledge of Inj. PGE-1 infusions in our clinical practice. Recently a review is published by Trombert D et al collecting the evidence for the use of drug eluting stents in below-the-knee lesions in journal of cardiovascular surgery.
J Cardiovasc Surg (Torino). 2015 Feb;56(1):67-71. Epub 2014 Nov 27.
Peripheral arterial disease has become more and more present in daily practice, mostly due to the increase of cardiovascular risk factors, especially in below the knee (BTK) area in diabetic patients. Critical limb ischemia (CLI) is the most usual clinical presentation with a major amputation rate of 30%, mortality rate of 25%, and chronic pain of 20% at one year. Nowadays, endovascular treatment is usually the first choice, given the high comorbidity of those patients. Angioplasty and stenting in BTK lesions have already proven their efficacy in CLI treatment. However, BTK revascularization remains highly controversial in the treatment of intermittent claudication in TASC 2 recommendations. Restenosis being the major pitfall in BTK procedures, the use of drug-coated devices is one of the actual answers. We performed an extensive review of the literature over the last 15 years on the use of drug-eluting stents (DES) in BTK revascularization. DES has been compared to balloon angioplasty, in the ACHILLES trial, bare metal stents (BMS), in the DESTINY and YUKON trials, drug eluting balloons, in a trial guided by Siablis, and paclitaxel has even been compared to sirolimus in the PARADISE trial. In conclusion, DES is one of the solutions to the increase of BTK arteriopathy in CLI patients. Angiographic results are better, compared to BMS, in terms of primary patency, restenosis and TLR rates. However clinical results are missing. Treated lesions in the literature are short lesions. And DES is a metal balloon expandable stent with greater risks of compressions and stent fractures than nitinol self expandable stents, and such complications are known to increase post operative restenosis rates. Further reports are still needed on this matter.
J Cardiovasc Surg (Torino). 2015 Feb;56(1):67-71. Epub 2014 Nov 27.
Evidence for the use of drug eluting stents in below-the-knee lesions.
Abstract
