SLR - May 2023 - Pranav Phadtare, DPM
Title: Below-the-Ankle Orbital Atherectomy in Chronic Limb-Threatening Ischemia Patients as a Bailout Strategy for Limb Salvage: Early Clinical ExperienceReference: Palena LM, Saad PF, Piccolo E, et al. Below-the-Ankle Orbital Atherectomy in Chronic Limb-Threatening Ischemia Patients as a Bailout Strategy for Limb Salvage: Early Clinical Experience. Cardiovasc Revasc Med. 2022; 42:121-126.
Level of evidence: IV
Reviewed by: Pranav Phadtare, DPM
Residency program: Community Medical Center, Toms River
Podiatric relevance: Blood supply is a major factor for healing of a Diabetic foot ulcer. Diabetes causes a progressive obstructive arterial disease in foot arteries which is associated with an increased rate of amputation in diabetic patients. Intervention for arterial diseases below ankle will increase the rate of healing of a foot ulcer thus reducing rate of amputations in these patients.The purpose of the study is to evaluate the feasibility and early outcome of below ankle orbital atherectomy in chronic limb threatening ischemia with calcified foot arteries.
Methods: Data was collected retrospectively from prospective database. 12 patients (mean age 69.4 ± 14.7; range 57 to 85 years) who were affected by diabetes underwent orbital atherectomy below the knee and ankle arterial segments. Patients with combination of iliac, femoral popliteal and BTK-BTA Disease were excluded from this analysis video. Technical success was defined as orbital atherectomy passage and debulked the calcified lesion, delivery of adjunctive therapy, and < 30% residual stenosis at final angiogram. Follow up of revascularization done at 30-days and 6-months
Procedure: Access to below ankle artery were done through ultrasound guided antegrade access to common femoral artery. Specialized guidewire call Viper wire was utilized and passed as distal as possible in the arch when severe calcification seen in BTK-BTA arteries. A Stealth 360®TM Peripheral orbital atherectomy system crown was chosen and prepared for the debulking.
Results: All 12 patients had diabetes and presented with CLTI clinical diagnosis. The transcutaneous oxygen pressure was under 30mm hg in all patients. Peripheral orbital atherectomy system was performed in 3 cases in Anterior tibial (AT) and dorsalis pedis (Ped) arteries + Posterior tibial (PT) and Lateral Plantar (Lat Plan), 5 cases in PT and Lat Plantar arteries, 1 case of PT and Medial Plantar (Med Plan), 1 case of Peroneal (Per) and Plan Lat, following the anatomical variation and 2 cases of AT and Ped. No major procedure related complication such as distal embolization, perforation, or dissection of arteries was noted. The limb salvage rate was 100% and no major amputation was registered.
Conclusion: Endovascular revascularization is first line of treatment in patient with symptomatic peripheral arterial disease affected by CLTI and ulcer of foot. In diabetic patient’s arterial wall calcification can be diffused, this compromises the blood supply. The high calcium burden represents one of the leading technical challenges, yielding an estimated technical failure rate up to 15% if angioplasty done alone. A major advantage of orbital atherectomy is selective artery recanalization depending upon the ulcer site location on the foot. The main limitation of this article is a small study group and a short-term follow-up till six months. Long term follow up should be considered. Perforation of artery this is one of the major complications though it was not seen in this study group. Thus, below ankle orbital atherectomy and angioplasty appear feasible and promissory treatment option with high rate of amputation free survival.