Below-the-Knee Endovascular Revascularization: Key Points

Li J, Varcoe R, Manzi M, et al.
Below-the-Knee Endovascular Revascularization: A Position Statement. JACC Cardiovasc Interv 2024;17:589-607.

The following are key points to remember from a position statement on below-the-knee (BTK) endovascular revascularization:

  1. Patients with chronic limb-threatening ischemia (CLTI), the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease.
  2. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is often times necessary to avoid limb loss.
  3. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization is intended to prevent major amputation and promote wound healing. This position statement provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.
  4. The primary goals of revascularization in CLTI are to heal wounds, alleviate pain, and prevent major amputation. Due to the complexity of patient-specific comorbidities, a collaborative approach among interventionalist and vascular surgery, as well as with wound care associates and other medical specialists (e.g., infectious disease, endocrinology, and social work), is imperative for successful limb salvage.
  5. Percutaneous transluminal angioplasty has been the mainstay of endovascular treatment for BTK arteries since it was first described in the early 1990s. It can achieve excellent immediate angiographic results after both intraluminal and subintimal crossing, with no observed difference in patency rates.
  6. No-option chronic limb-threatening ischemia (NOP-CLTI) is a loosely utilized term that describes a patient with a limb at risk of amputation, who is considered to not be a candidate for conventional endovascular or surgical revascularization. Typical patients are long-standing diabetics, dialysis dependent, and elderly with multiple failed attempts at surgical or endovascular revascularization in the past.
  7. In recent times, surgical and hybrid approaches to deep vein arterialization have been reported and are increasingly popular alternatives to amputation with admirable rates of limb salvage in the NOP-CLTI patients.
  8. The LimFlow system was recently approved by the Food and Drug Administration for transcatheter arterialization of deep veins (TADV), and serves as the first CLTI disease-specific technology to be available. TADV may provide new hope for thousands of NOP-CLTI patients.
  9. The decision between endovascular versus surgical revascularization should be made by the CLTI team and based on patient characteristics, anatomy, availability of native venous conduit, and the skill sets of the local limb salvage team.
  10. A comprehensive multidisciplinary team approach with expertise in BTK endovascular skill set remains vital in a CLTI practice. The use of maximal guideline-directed medical therapies throughout the treatment course of any CLTI patient is indicated to mitigate the burden of cardiovascular-related adverse outcomes.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and Vascular Medicine

Keywords: Endovascular Procedures, Myocardial Revascularization

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