eMedicine Specialties > Vascular Surgery > Medical Topics

Infrainguinal Occlusive Disease: Follow-up

Author: Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Contributor Information and Disclosures

Updated: Jun 24, 2008

Outcome and Prognosis

Outcome and prognosis are considered separately for patients treated medically and for patients treated surgically.

Outcome of the medical management of claudication

Infrainguinal arterial disease is associated with a risk of limb-threatening ischemia. However, most patients improve with medical treatment. Approximately 10% of patients with intermittent claudication develop findings necessitating vascular reconstructive procedures.

Outcome of endovascular management

 Patency rates following endovascular treatment of infrainguinal occlusive disease vary significantly among published series. Overall, primary patency is somewhat inferior to that of bypass surgery. Nonetheless, successful endovascular management improves quality of life and patient satisfaction.53 Furthermore, further endovascular or surgical management can often correct a failed endovascular intervention.54,55

Outcome of vascular surgery

Graft patency rates vary widely among series. One study in which graft patency was assessed by using MRA disclosed an 84% limb salvage rate and a 78% primary graft patency rate at 21 months of follow-up. Prosthetic grafts carry a primary 3-year patency rate of 39% and a 3-year secondary patency rate of 59%, with a 25% risk of amputation within 3 years.56

Limb salvage rates are lower among patients with insulin-dependent diabetes.57 Infrainguinal reconstructive surgery is associated with a mortality rate of somewhat less than 5% despite the high-risk nature of these patients.58 The likelihood of coexisting coronary artery disease is a major risk factor.

The overall survival rate for patients with lower extremity arterial occlusive disease is approximately 50% over 10 years. For patients who require bypass surgery, the survival rate drops to approximately 50% over 5 years.

Future and Controversies

Technological enhancements and wider availability of existing technology should continue to improve the safety and efficacy of endovascular and vascular surgical techniques.59,60

Improvements in imaging technology

Imaging technology continues to improve.61

Three-dimensional ultrasound visualization can help better detect early plaque formation to allow for even more timely correction of vein graft stenoses.

Gadolinium-enhanced 3-dimensional MRA images can provide highly detailed views of the arterial system. The applications of MRA, including MR-guided endovascular interventions,62 will expand with continuing improvements in hardware, software, and nonnephrotoxic contrast agents.

Improvements in endovascular techniques

Endovascular procedures continue to benefit from improved technology both in imaging modalities and instrumentation.63

When performing in situ bypass, endovascular technology allows valvulotomy and coil occlusion of side branches by direct angioscopic visualization.

Endoscopic assistance

As in other surgical fields, endoscopy may have a greater role in infrainguinal vascular surgery. For example, endoscopic harvesting of the saphenous vein limits the extent of the dissection required for bypass procedures.64

Arterialization of the distal venous bed

Recent studies suggest that in patients with limb-threatening ischemia but inoperably diseased distal arteries, arterialization of the distal venous bed may be of benefit.54,65

Prevention of restenosis

Gene therapy holds promise for inhibiting vascular restenosis after endovascular procedures or bypass surgery. Rat and rabbit models suggest that neointimal hyperplasia after arterial injury is inhibited by overexpression of the GAX gene and that adenovirus-mediated delivery of the GAX gene diminishes proliferation of intimal cells in animal models. Gene therapy may be suitable for vein grafts prior to implantation.

Some research is underway on inhibitors of smooth muscle proliferation, such as drugs that block E2F transcription factors.3,66 Unfortunately, a multicenter, randomized, double-blinded study of 1,404 patients revealed no benefit from the use of edifoligide, an E2F inhibitor.67,68

Low-dose intravascular beta-irradiation may inhibit restenosis by blocking early medial and adventitial cell proliferation.69

 


More on Infrainguinal Occlusive Disease

Overview: Infrainguinal Occlusive Disease
Workup: Infrainguinal Occlusive Disease
Treatment: Infrainguinal Occlusive Disease
Follow-up: Infrainguinal Occlusive Disease
Multimedia: Infrainguinal Occlusive Disease
References
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Further Reading

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Keywords

infrainguinal occlusive disease, peripheral atherosclerotic disease, peripheral vascular disease, chronic arterial insufficiency, femoropopliteal occlusive disease, aortoiliac occlusive disease, stent, stenting, ischemic lower extremity disease, arteriosclerosis obliterans, complex regional pain syndromes, CRPS, posttraumatic pain syndromes, causalgia, mimocausalgia, Sudeck atrophy, reflex sympathetic dystrophy, intermittent claudication, gangrene, amputation

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Contributor Information and Disclosures

Author

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Medical Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Travis J Phifer, MD, Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport
Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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