Treatment of Infrapopliteal Disease in Critical Limb Ischemia

Revascularization for critical limb ischemia (CLI), the most advanced form of peripheral artery disease, is the only treatment that has shown to reduce amputations.1 Indeed, all societal guidelines have given a class I indication for revascularization in patients with CLI.2,3 However, individuals with CLI frequently present with multilevel disease where >70% have some degree of infrapopliteal involvement, and these lesions are typically occluded and long.4 Although there have been significant advances in the femoropopliteal segment with drug-eluting stents (DES) and drug-coated balloons, little progress has been made for the treatment of infrapopliteal disease.5 Yet, the rates of amputation and mortality continue to decline in patients with CLI, whereas surgical bypass has significantly decreased.6 Given the paucity of advances for infrapopliteal disease, Mustapha et al,7 in this issue of Circulation: Cardiovascular Interventions , examined the current state of angioplasty for the treatment of infrapopliteal disease through conducting a meta-analysis and a systematic review of all studies from 2005 to 2015.7 See Article by Mustapha et al The authors analyzed 52 contemporary studies of 6769 patients with ≈9400 infrapopliteal atherosclerotic lesions in patients with CLI (97%). They found a technical success rate of 91% with a 63% primary patency. Rates of major amputation (15%) and all-cause mortality (15%) were also similar to those of Romiti et al,8 previously published in 2008. The authors concluded that there were suboptimal short- and long-term clinical outcomes with angioplasty in patients with CLI. The authors should be congratulated for conducting this contemporary analysis of patients with CLI undergoing angioplasty alone. However, as indicated by the investigators, the robustness of this meta-analysis is markedly limited because of the incompleteness …