Problems and Questions

The following discussion will stick to the problems and questions that arise in the area of lower limb arterial recanalization. It is generally accepted that IC is not indicated for lower limb IR. Recent reports favour subintimal angioplasty (SA) in patients with IC [24], but satisfactory results can be obtained in the hands of a highly skilled and experienced interventionalist, as well as under the conditions of conscientious surveillance, enabling the early treatment of any complication. Other reports support the fact that in a selected group of patients SA is feasible with a high technical success rate as a good alternative in patients who are poor candidates for by-pass surgery [18, 31, 75, 88]. It can be used for limb salvage [73]. The outback catheter for true lumen re-entry after subintimal guidewire passage offers an effective tool for complicated recanalization procedures [32]. CL ischaemia in patients unfit for surgery emerged as the only proper indication for IR of lower limb arteries. Unfortunately, in many publications on infra-inguinal IR, the study population consists of patients with different degrees of ischaemia, varying from IC to true CLI [12, 82]. Subcritical limb ischaemia (SCLI) is, however, included in the indication criteria [86], but with an uncertain number of patients.

CLI is a major burden on vascular services, estimated at 1 patient in 2500 of the population on an annual basis. In Croatia, 45 CLI patients can be found per 100,000 of the population per year. The average burden on each vascular surgeon in the country is >130 lower limb revas-cularizations per year [72]. CLI poses a significant problem for the vascular services, with a mean mortality and amputation rate of 13.5% and 21.5% respectively [61]. In a retrospective series of patients, repeated procedures to maintain patency, the treating of wound complications, or the treating of recurrent or contralateral ischaemia is needed in 54% of cases. Large studies identified the risk factors associated with postoperative mortality in patients undergoing femoro-distal by-pass. Compared to patients who survived, patients who died at the time of surgery were older, were diabetic (30%), were 4 times more likely to have had a recent MI, were 2 times more likely to have had heart failure, were 4 times as likely to be on dialysis, had multisegmental lesions and were admitted as an emergency. For these reasons, consideration should be given to an endovascular technique. The endovascular technique offers an alternative to patients unfit for surgery, and SA has been reported with promising results from an increasing number of centres [7, 47, 50 53, 61, 63, 69]. Hybrid procedures with intraoperative balloon superficial femoral artery (SFA) angioplasty and popliteal/distal by-pass graft can be performed in a selected group of patients [64].

At the present time, the problems named here can be classified as solved, unsolved or permanent.

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