Author + information
- Robert S. Dieter, MD, RVT⁎ (, )
- Aravinda Nanjundappa, MD, RVT and
- John J. Lopez, MD
- ↵⁎Loyola University Medical Center, 2160 South First Avenue, Maywood, Illinois 60153
Feiring et al. (1) presented very compelling data regarding the use of small diameter (coronary) drug-eluting stents (DES) for the treatment of infrapopliteal lesions in patients with critical limb ischemia. Their long-term outcomes in regard to patency and limb salvage suggest that this may become the preferred method of treatment for these often-challenging patients.
The investigators are correct in noting that their data raise several important questions that should be addressed in an industry-supported randomized prospective trial to better define the role of DES for peripheral arterial disease with the goal of obtaining additional U.S. Food and Drug Administration indications for the use of such stents. These issues can be summarized as follows.
First, the biological mechanisms by which DES in the tibial arteries are able to limit restenosis, whereas in the larger-caliber superior femoral artery most DES trials have been less promising, needs to be better studied. Second, in this patient population, ultimately clinical outcomes (limb salvage and the relief of rest pain) and not long-term patency should be the goal. The classic teaching that “less blood is required to heal tissue than to keep it healed” can be applied to the notion that restenosis in this setting may occur without clinical consequences. The relationship between angiographic patency rates and improved clinical outcomes remains an unanswered question. Finally, the study by Feiring et al. (1) is similar to nearly every published series of critical limb ischemia patients in regard to the extraordinarily high mortality rates of this population. This particularly sick population requires aggressive, multidisciplinary, secondary prevention strategies, and more comprehensive approaches to develop data and strategies to decrease this high mortality.
We thank Feiring et al. (1) for publishing this data. His efforts and treatment strategies have the potential to lead to more comprehensive, larger-scale efforts to improve the care of this population of ill patients.
- American College of Cardiology Foundation