Lower limb ischemic diseases, also known as peripheral arterial obstructive disease (PAOD), are commonly caused by atherosclerotic occlusive disease (ASO), thrombo-occlusive vasculitis (Buerger’s disease) and acute arterial embolism caused by atrial fibrillation, rheumatic heart disease, etc., among which ASO is the most common, PAOD is a serious threat to people’s health, with high disability and mortality rates. According to statistics, the mortality rate of PAOD patients with intermittent claudication can be as high as 50% within 5 years, and that of those with severe limb ischemia (CLI) can be as high as 70%. Therefore, the goal of PAOD treatment is to restore blood flow to the occluded artery as much as possible in order to relieve symptoms and save the limb. In recent years, with the development of endovascular technology, the endovascular technology represented by percutaneous transluminal angioplasty (PTA) has become increasingly mature and widely used in PAOD treatment, which has brought a series of revolutionary changes in the concept and method of PAOD treatment. Junmin Bao, Department of Vascular Surgery, Shanghai Changhai Hospital
1. Endoluminal therapy is increasingly becoming the first choice for PAOD treatment. Endoluminal treatment can be completed by puncture under local anesthesia, which has the advantages of less trauma, faster recovery and repeatability compared with traditional surgical procedures. More importantly, the current philosophy of treatment of PAOD has evolved from pursuing the rate of vascular patency to pursuing the rate of symptom improvement and limb preservation. Therefore, endoluminal treatment should be attempted first for most PAOD lesions whenever possible. This is in line with the current trend of minimally invasive and endoluminal surgical treatment.
2. The indications for intracavitary treatment of PAOD have been greatly expanded. Only in 2000, the internationally accepted indications for endoluminal treatment were type A and type B lesions in TASC staging, i.e., mainly short segments of the iliac and femoral arteries. Nowadays, with the application of techniques such as subendoplasty, long segmental occlusions of more than 10 cm can be fully opened by endoluminal techniques. At the same time, the application of endoluminal therapy has expanded beyond the knee plane to include the arteries of the lower leg and even the fine arterial branches of the ankle and foot. This has greatly expanded the indications for endoluminal treatment of PAOD.
3. Combination of traditional surgery and endoluminal treatment. Advocating endovascular treatment does not mean abandoning traditional surgery. For patients whose endoluminal treatment fails or whose lesions are too long for endoluminal treatment, surgery is still an important means of treatment. At the same time, endoluminal therapy can be combined with surgery in some cases. For example, if the iliac artery stenosis or occlusion is accompanied by long segment occlusion of the femoral artery, traditional surgery requires open bypass of the main-femoral-N artery, but if the combination of endoluminal therapy and bypass surgery is used, i.e., PTA with stenting of the iliac artery segment and femoral-N bypass of the femoral artery segment, the surgery can be greatly simplified and the surgical trauma reduced.
In 1964, Charles Dotter pioneered endoluminal treatment, and in 1974, Andreas Gruntzig was the first to use balloon dilation, which laid the foundation for PTA. 1985, Julio Palmaz invented the metal stent, which effectively improved the efficacy of endoluminal treatment. With the development and application of new devices such as nickel-titanium stents, overmolded stents, drug-eluting stents, and small OD high-pressure balloons, the means of endoluminal therapy have become more and more abundant. At present, endovascular treatment has developed from simple balloon dilation to a comprehensive treatment method that combines balloon dilation, stenting, intra-arterial thrombolysis, double-lumen Fogarty catheter and other technical means, which can be used in combination according to different lesions to improve the efficacy and long-term patency rate.
5. Diabetic lower limb vasculopathy has become a hot spot for treatment. Diabetic foot lesions (diabetic foot) are one of the most common and serious complications of diabetes mellitus. It is a foot lesion specific to diabetes caused by peripheral neuropathy, vasculopathy (mainly lower extremity atherosclerosis occlusion), infection and other reasons. In the past, it was generally believed that the vascular lesions of diabetic foot occurred in the tiny blood vessels at the end of the limbs. In recent years, with the improvement of vascular diagnosis and treatment technology, it has been found that a significant proportion of diabetic patients have vascular lesions located in the arteries above the ankle joint, and this part of the vascular lesions has full opportunities to be treated by endovascular techniques or surgical procedures. The main method of endoluminal minimally invasive treatment is to open and dilate the narrowed or occluded calf arteries by applying micro-guide wires and small balloons, and if necessary, small caliber stents can also be placed. At present, non-compliant high-pressure balloons with an outer diameter of only 2.8F, a balloon caliber of 2mm and a length of 120mm are available to dilate the arteries of the lower leg and even the tiny arteries of the ankle and foot, opening up a new and effective way for the treatment of diabetic arterial occlusion.
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