CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 256 AFRICA loss including non-healing ulcer or focal gangrene; 6, major tissue loss extending above the trans-metatarsal level.11 Dual anti-platelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/ day) and cilostazol 200 mg/day were prescribed to all patients scheduled for ET unless contra-indicated. The lower extremity arterial structures were evaluated with colourDoppler ultrasonography (DUS) (PhilipsEpiq5ultrasound with L12-4 12-4 MHz linear probe, Philips Healthcare), and computed tomography angiography (CTA) was performed on the patients who were scheduled to undergo ET. Lesion lengths were calculated from the CTA. The number of run-off vessels was evaluated. All procedures were performed in the interventional angiography laboratory (Siemens AXIOM Artis dTA, Siemens Healthcare, Erlangen, Germany). All procedures were performed percutaneously under local anaesthesia. Percutaneous endovascular access was obtained under ultrasound guidance via the antegrade common femoral artery. However, in unsuccessful attempts, it was combined with a retrograde approach via the pedal arteries, if possible. While a 6- or 7-Fr standard vascular sheath was sufficient for antegrade approaches in most cases, a long sheath was placed into the popliteal segment to increase trackability and torquability of the wire and catheters in some cases. Intra-arterial 1 mg/kg heparin (Poliparin, Polifarma, Istanbul, Turkey) was administered. In all cases, an intimal approach was adopted to cross the lesion. An initial angiograph was obtained to determine the location and extent of the lesions. We attempted to cross the lesions, including the distal superficial femoral artery and popliteal arterial segments, with a ZIPwire 0.035-inch hydrophilic guidewire (ZIPwire, Boston Scientific, Natick, MA) and CTO guidewire and support catheters (Navicross, Terumo, Somerset, NJ or Rubicon35, Boston Scientific, Natick, MA). In trifurcation arteries, if possible, we attempted to revascularise at least one of the anterior tibial arteries (ATA) or the posterior tibial artery (PTA), or the peroneal artery (Fig. 2). Thereafter, pedal vascularisation was evaluated and the ATA was attempted as a priority if the dorsalis pedis artery was visible, or the PTA was attempted as a priority if the medial and/or lateral plantar artery were visible. Plain old balloon angioplasty (POBA) was used for predilatation with low atmospheric pressure (six atmospheres) for at least one minute. POBA and drug-eluting balloon (DEB) angioplasty were the two main methods for revascularisation. In both methods, the balloon was inflated for at least three minutes under nominal pressure (eight to 10 atmospheres). In the case of more than 30% of residual stenosis or flow-limiting dissection, the procedure was repeated with high-pressure dilatation (12–14 atmospheres) Also, to prevent vasospasm, cold saline was not used and intra-arterial nitrate (Perlinganit, ADEKA Pharmaceuticals, Istanbul, Turkey) was selectively injected during the procedure. The ultimate angiogram was performed to demonstrate re-established vessel patency. Access site haemostasis was provided with a closure device (Angio-seal™ VIP, Terumo Medical Corporation Somerset, NJ) for the femoral approach and a pressure dressing for the pedal approach. Primary success was complete revascularisation of at least one of the below-theknee arteries. Patients who needed inevitable amputation due to Rutherford 6 lesions and osteomyelitis were consulted with the orthopaedic clinic after the procedure and the amputations were performed. Parenteral prostanoid therapy was given to patients with unsuccessful interventions for pain palliation and wound healing (Iloprost 20 mcg/day) (Ilomedin®, Bayer Healthcare, Germany). Also, patients whose could not be palliated with medical therapy underwent either surgical lumbar sympathectomy in our clinic or lumbar sympathetic blockage in consultation with the pain clinic of the anaesthesia department. Dual antiplatelet therapy and cilostazol were prescribed to all patients at discharge unless there were contra-indications. In the postoperative period, follow up of the patients was done at one week, one month, three months, six months, one year and two years with DUS (Fig. 3). Primary CLI-free rate is the duration following the initial procedure during which the patient remained CLI symptom free and required no intervention. The secondary CLI-free rate is defined as the duration of patency after successful re-intervention. Primary endpoints of the study were major amputation and wound healing without pain. Secondary endpoints were reduction of wound size, one stage of improvement in the Rutherford classification and the requirement of other types of treatment such as sympathectomy, sympathetic blockage and hyperbaric oxygen therapy. Fig. 2. A, B. Initial and ultimate angiogram of a 27-year-old patient with popliteal and tibio-peroneal involvement. C, D. Comparative angiograms of a 43-year-old patient with TAO who underwent peroneal revascularisation before and after the procedure.
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