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We believe that a substantial experience demonstrating the effectiveness and safety of infrapopliteal artery PTA has been accumulated. It is clear that the results of tibial PTA and femoropopliteal PTA are closely associated for most patients undergoing limb salvage procedures. Anatomic selection is most important; patients with focal disease and restorable runoff will generally benefit, and interventional radiologists should concentrate on treating this group of patients. PTA and surgery for limb salvage patients are indeed complementary procedures, and patients will benefit most by a methodical team approach to treatment. Problems with reporting of data in the literature have obscured the true effectiveness of distal PTA, with such deficiencies leading to both overestimation and underestimation of clinical utility. Nevertheless, the preponderance of evidence (as we see it) suggests a clinical effectiveness of about 80% at 2 years in appropriately selected patients. Like Dr. Fraser and his co-authors, we would welcome randomized trials of tibial PTA versus surgery, but even in the absence of these, the reporting of indications and results needs to be standardized: severity of symptoms at presentation and the extent of conservative treatments employed before intervention; life-table methodology on an intent-to-treat basis with clear delineation of end points; stratification by important variables such as lesion length, runoff status, extent of preexisting tissue loss, presence of diabetes and ESRD, and ideally, functional outcome and quality-of-life measures. Finally, we should learn from our surgical colleagues that close surveillance and early reintervention will probably increase the effectiveness of our percutaneous treatment methods.

Tunis and colleagues attempted to assess the effect of peripheral angioplasty in a large population with descriptive epidemiologic methods. Their study suffered from a vague statement of purpose, inappropriate and inadequate outcome measures, undetermined differences in prevalence of peripheral vascular disease and prevalence of risk factors for bypass/amputation in 1989 versus 1979, no differentiation between levels of amputation or between primary and secondary amputation, lack of a unique ICD-9-CM code indicating angioplasty for peripheral vascular disease of the lower extremities, lack of unique patient identifiers, a mistaken perception of the adoption of angioplasty as "widespread" in Maryland, and the assumption of uniform coding accuracy throughout the period of study. We conclude that the study design of Tunis et al was inadequate to determine the beneficial effects of angioplasty or bypass surgery in the treatment of peripheral vascular disease. Moreover, the conclusion by Coffman (2) that "invasive procedures are indicated only for the severely ischemic limb" is completely unsupported by the study data. Physicians should not attempt to apply the results of the study by Tunis et al to individual case situations. It should be further appreciated that the study findings do not provide an adequate basis for policy-making decisions. It is clear that important clinical questions concerning the roles of angioplasty, bypass, and amputation should be answered with more definitive studies.

Subclavian and axillary artery stenoses may lead to axillofemoral bypass graft failure. These arteries were assessed preoperatively with arch aortography performed after conventional high translumbar peripheral aortography by exchanging the initial 16-gauge sheath for a 5-F pigtail catheter. Thirty-two diagnostic translumbar runoff and arch (TLR-arch) aortograms were obtained in 30 patients with advanced lower extremity ischemia. In six patients (20%), the results of the arch study influenced the choice of an inflow site. These patients were compared with 70 control subjects who underwent conventional translumbar aortography without arch studies. In the TLR-arch group, two major complications occurred in one patient, while in the control group 11 major complications occurred in 10 patients. One retroperitoneal hematoma occurred in the TLR-arch group; two occurred in the control group. The mean change in hematocrit for the TLR-arch group was -3.81% (-0.0381), and for the control group it was -4.17% (-0.0417). This difference was not statistically significant. Arch aortography is a valuable adjunct to the translumbar aortofemoral study. It can be simply performed without increasing the morbidity of the peripheral study.