Infrainguinal Percutaneous Intentional Extraluminal Recanalization (PIER) Does Not Provide Durable Long-Term Patency

Gerald S. Treiman, MD, VA Salt Lake City Health Care System, Surgery, VA Salt Lake City Health Care System, Salt Lake City, UT; Richard L. Treiman, MD, Salt Lake City, UT; Stephanie Hatton-Ward, Salt Lake City, UT; John H. Whiting, MD, Pocatello, ID;

Purpose:
Assess the long-term patency and clinical success of PIER in patients (pts) with limb-threatening ischemia
Methods:
From 1999-2004, 29 pts with femoropopliteal occlusion and rest pain or tissue loss underwent PIER. Pts had subintimal wire placement followed by PTA and stents. The occlusions ranged from 6-18 cm and 1-10 stents were placed. Technical success required no stenosis greater than 30% by arteriography, velocity ratio less than 1.5 by duplex and improvement in the ABI greater than .15. Follow up duplex was obtained every 3 months for 2 years and every 6 months or for recurrent symptoms thereafter.
Results:
Initial success was obtained in 26 of the 29 pts (90%) with an improvement in the mean ABI of 0.25. Mean FU was 38 months (range 28-54 months). Overall 16 arteries (55%) occluded (3 initial failures, 13 during FU). 6 of the 16 pts had recurrent symptoms, 6 required major amputation (4 BKA, 2 AKA) and 4 died with an intact limb. Following failure 2 pts had attempted TPA and 4 had prosthetic tibial bypass. Overall 15 pts (52%) died and only 2 of the 14 remaining alive (14%) had a patent artery. 1 of the 2 required PTA of the recanalized artery. By life table analysis, primary patency was 85, 64,18 and 9% at 1,2,3 and 4 years. Peri-procedural complications occurred in 2 pts (1 MI and 1 groin hematoma). Of the 13 pts with wounds, 6 died (2 healed), 5 had limb loss and 2 were alive with healed wounds. Of 16 pts with rest pain, 14 developed recurrent symptoms after reocclusion, 1 was alive without pain and 1 had amputation.
Conclusions:
PIER is technically successful in most pts with few complications. Most procedures provided short-term clinical success and have allowed for successful wound healing. However long term patency is poor with a high rate of clinical failure and symptom recurrence. Most pts will eventually have recurrent pain or require major amputation. It is not superior to prosthetic infragenicaluate bypass and, in contrast to the conclusions of recent reports, should be reserved for patients with limited life expectancy or major contraindications to operation.