Semin intervent Radiol 2009; 26(4): 315-323
DOI: 10.1055/s-0029-1242205
© Thieme Medical Publishers

Tibial Intervention for Critical Limb Ischemia

Bret N. Wiechmann1 , 2
  • 1Vascular and Interventional Physicians, Gainesville, Florida
  • 2Medical Director, VIP Outpatient Interventional Center, Gainesville, Florida
Further Information

Publication History

Publication Date:
17 November 2009 (online)


Diagnosis and treatment of critical limb ischemia (CLI) is increasingly important as the average age of the world population and the incidence of diabetes and metabolic syndrome increases. Fortunately, most patients will not progress to this stage of peripheral arterial disease, yet if left untreated, there is a high risk of future cardiovascular events. At the point of ischemic rest pain or tissue loss, there are significant implications for morbidity and mortality. There is a high prevalence of multisegment occlusive disease in the CLI patient with the infrapopliteal vessels frequently involved. Revascularization of the affected limb is of utmost importance as the prospects of wound healing and relief of ischemic rest pain are poor without reestablishing continuous flow to the distal extremity. With the advent of endovascular devices designed to treat this vexing problem, the ability to successfully treat this difficult patient population with less procedural morbidity has been greatly enhanced.


  • 1 Allie D E, Hebert C J, Lirtzman M D et al.. Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI.  Euro Intervention. 2005;  1 75-84
  • 2 Nehler M R, Coll J R, Hiatt W R et al.. Functional outcome in a contemporary series of major lower extremity amputations.  J Vasc Surg. 2003;  38 7-14
  • 3 Lumsden A B, Peden E K, Mohiuddin I. Current advantages and limitations of below-the-knee revascularization techniques and technologies.  Vasc Dis Management. 2007;  4 (Suppl D) 4-7
  • 4 Landry G J. Functional outcome of critical limb ischemia.  J Vasc Surg. 2007;  45(Suppl A) A141-A148
  • 5 Adam D J, Beard J D, Cleveland T BASIL trial participants et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial.  Lancet. 2005;  366 1925-1934
  • 6 Hoffmann U, Schulte K-L, Heidrich H, Rieger H, Schellong S. Complete ulcer healing as primary endpoint in studies on critical limb ischemia? A critical reappraisal.  Eur J Vasc Endovasc Surg. 2007;  33 311-316 discussion 317-318
  • 7 Tsetis D, Belli A-M. The role of infrapopliteal angioplasty.  Br J Radiol. 2004;  77 1007-1015
  • 8 Kudo T, Chandra F A, Ahn S S. The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience.  J Vasc Surg. 2005;  41 423-435 discussion 435
  • 9 Rastogi S, Stavropoulos W. Infrapopliteal angioplasty.  Tech Vasc Interv Radiol. 2004;  7 33-39
  • 10 Romiti M, Albers M, Brochado-Neto F C, Durazzo A ES, Pereira C AB, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia.  J Vasc Surg. 2008;  47 975-981
  • 11 Giles K A, Pomposelli F B, Hamdan A D, Blattman S B, Panossian H, Schermerhorn M L. Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcomes in 176 limbs.  J Vasc Surg. 2008;  48 128-136
  • 12 Cardon J M, Jan F, Vasseur M A et al.. Value of cutting balloon angioplasty for limb salvage in patients with obstruction of popliteal and distal arteries.  Ann Vasc Surg. 2008;  22 314-318
  • 13 Kiesz R S, Scheinert D, Peeters P J et al.. Results from the International Registry of the AngioSculpt scoring balloon catheter for the treatment of infra-popliteal disease.  J Am Coll Cardiol. 2008;  51(10 suppl B) 75
  • 14 Scheinert D, Graziani L, Peeters P et al.. Results from the multi-center registry of the novel AngioSculpt scoring balloon catheter for the treatment of infra-popliteal disease.  Cardiovasc Revasc Med. 2007;  8 147
  • 15 Das T, McNamara T, Gray B et al.. Cryoplasty therapy for limb salvage in patients with critical limb ischemia.  J Endovasc Ther. 2007;  14 753-762
  • 16 Siablis D, Karnabatidis D, Katsanos K et al.. Sirolimus-eluting versus bare stents after suboptimal infrapopliteal angioplasty for critical limb ischemia: enduring 1-year angiographic and clinical benefit.  J Endovasc Ther. 2007;  14 241-250
  • 17 Rand T, Basile A, Cejna M et al.. PTA versus carbofilm-coated stents in infrapopliteal arteries: pilot study.  Cardiovasc Intervent Radiol. 2006;  29 29-38
  • 18 Commeau P, Barragan P, Roquebert P O. Sirolimus for below the knee lesions: mid-term results of SiroBTK study.  Catheter Cardiovasc Interv. 2006;  68 793-798
  • 19 Rosales O R, Mathewkutty S, Gnaim C. Drug eluting stents for below the knee lesions in patients with critical limb ischemia: long-term follow-up.  Catheter Cardiovasc Interv. 2008;  72 112-115
  • 20 Peregrin J H, Smírová S, Koznar B et al.. Self-expandable stent placement in infrapopliteal arteries after unsuccessful angioplasty failure: one-year follow-up.  Cardiovasc Intervent Radiol. 2008;  31 860-864
  • 21 Kickuth R, Keo H H, Triller J, Ludwig K, Do D D. Initial clinical experience with the 4-F self-expanding XPERT stent system for infrapopliteal treatment of patients with severe claudication and critical limb ischemia.  J Vasc Interv Radiol. 2007;  18 703-708
  • 22 Peeters P, Bosiers M, Verbist J, Deloose K, Heublein B. Preliminary results after application of absorbable metal stents in patients with critical limb ischemia.  J Endovasc Ther. 2005;  12 1-5
  • 23 Bosiers M. On behalf of the AMS INSIGHT investigators. Absorbable metal stent implantation for treatment of below-the-knee critical limb ischemia: 6-month analysis.  Cardiovasc Intervent Radiol. 2008 , December 18 (Epub ahead of print)
  • 24 McKinsey J F, Ramaiah V G, Runyon J P et al.. 1 year results of treatment of infrapopliteal arterial occlusive disease using the Silverhawk Plaque Excision Device. Available at: Accessed January 2009
  • 25 Keeling W B, Shames M L, Stone P A et al.. Plaque excision with the Silverhawk catheter: early results in patients with claudication or critical limb ischemia.  J Vasc Surg. 2007;  45 25-31
  • 26 Zeller T, Sixt S, Schwarzwälder U et al.. Two-year results after directional atherectomy of infrapopliteal arteries with the SilverHawk device.  J Endovasc Ther. 2007;  14 232-240
  • 27 Zeller T, Rastan A, Schwarzwälder U et al.. Midterm results after atherectomy-assisted angioplasty of below-knee arteries with use of the Silverhawk device.  J Vasc Interv Radiol. 2004;  15 1391-1397
  • 28 Safian R D, Niazi K, Runyon J P OASIS Investigators et al. Orbital atherectomy for infrapopliteal disease: device concept and outcome data for the OASIS trial.  Catheter Cardiovasc Interv. 2009;  73 406-412
  • 29 Laird J R, Zeller T, Gray B H LACI Investigators et al. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial.  J Endovasc Ther. 2006;  13 1-11
  • 30 Botti Jr C F, Ansel G M, Silver M J, Barker B J, South S. Percutaneous retrograde tibial access in limb salvage.  J Endovasc Ther. 2003;  10 614-618
  • 31 Ingle H, Nasim A, Bolia A et al.. Subintimal angioplasty of isolated infragenicular vessels in lower limb ischemia: long-term results.  J Endovasc Ther. 2002;  9 411-416
  • 32 Montero-Baker M, Schmidt A, Bräunlich S et al.. Retrograde approach for complex popliteal and tibioperoneal occlusions.  J Endovasc Ther. 2008;  15 594-604
  • 33 Spinosa D J, Leung D A, Harthun N L et al.. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion.  J Vasc Interv Radiol. 2003;  14 1449-1454
  • 34 Gandini R, Pipitone V, Stefanini M et al.. The “Safari” technique to perform difficult subintimal infragenicular vessels.  Cardiovasc Intervent Radiol. 2007;  30 469-473
  • 35 Fusaro M, Agostoni P, Biondi-Zoccai G. “Trans-collateral” angioplasty for a challenging chronic total occlusion of the tibial vessels: a novel approach to percutaneous revascularization in critical lower limb ischemia.  Catheter Cardiovasc Interv. 2008;  71 268-272

Bret N WiechmannM.D. 

Medical Director, VIP Outpatient Interventional Center, 6685 Northwest 9th Boulevard

Gainesville, FL 32605