Optional management of failed endovascular intervention for infrainguinal arterial occlusive disease

Endovascular treatment is increasingly chosen as the first option for treating infrainguinal peripheral arterial disease. Although open surgical bypass provides the most durable option for limb salvage, it has substantial morbidity and mortality. The aim of the study is to determine the causes of failure of endovascular intervention and treatment modalities of failed endovascular intervention and results of each modality. A prospective case series study that addresses the outcomes of managing 40 patients with chronic limb ischemia due to femoropopliteal disease treated by endovascular intervention, and the intervention was failed. Causes of failure within 30 days were analyzed. We had 13 (27.5%) females and 27 (72.5%) males; their age ranged from 45 to 77 years with a mean of 62.20±7.44. Presentation with rest pain: three (7.5%) patients, minor tissue loss: 18 (45%) patients, major tissue loss: 19 (47.5%) patients the length of lesion was between 5 and 10 cm in three (7.5%) patients and more than 10 cm in 37 (92.5%) patients. Runoff in anterior tibial artery: 23 (57.5%) patients, posterior tibial artery: 19 (47.5%) patients, and peroneal artery: 15 (37.5%) patients. We had no complications in 26 (65%) patients, failure to pass in 12 (30%) patients, and distal embolization in two (5%) patients as intraprocedural complications. During the 30-day follow-up: Acute stent thrombosis in 7 (17.5%) cases, flow-limiting dissection in 8 (20%) cases, residual stenosis in 3 (7.5%) cases, acute thrombosis in 2 (5%) cases, missed iliac lesions in 2 (5%) cases, post-procedural distal arterial tree embolization in 2 (5%) cases, and clinical failure was the cause in 2 (5%) cases. The management was: Redo endovascular in 18 (45%) patients, surgical bypass in 14 (35%) patients, primary amputation in six (15%) patients, and medical treatment in two (5%) patients. After 6 months follow-up limb salvage was in 57.5% of the cases with transmetatarsal amputation in 69.6% of them and major amputation was in 42.5% of the cases Failed endovascular intervention procedures within 30 days were associated mainly with long lesions. So, surgical bypass appeared to be superior to endovascular intervention for long lesions. Improvements in endovascular equipment and angioplasty technique might ultimately improve the outcome results and decrease the failure rate of endovascular interventions