Eur Radiol 
DOI 10.1007/s00330-006-0526-5 

INTERVENTIONAL
Gunnar Tepe 
Thomas Zeller 
Stephan Heller 
Jakub Wiskirchen 
Arne Fischmann 
Stephan Coerper 
Bernd Balletshofer 
Stefan Beckert 
Claus D. Claussen 

Received: 5 February 2006 
Revised: 15 October 2006 
Accepted: 3 November 2006 
# Springer-Verlag 2006 

G. Tepe (*). S. Heller . 
J. Wiskirchen . A. Fischmann . 
C. D. Claussen 
Department of Diagnostic Radiology, 
University of Tuebingen, 
Hoppe-Seyler-Str. 3, 
72076 Tuebingen, Germany 
e-mail: gunnar.tepe@med.unituebingen.
de 
Tel.: +49-7071-2982087 
Fax: +49-7071-295845 
S. Coerper . S. Beckert 
Department of Surgery, 
University of Tuebingen, 
Tuebingen, Germany 
B. Balletshofer 
Department of Angiology, 
University of Tuebingen, 
Tuebingen, Germany 
T. Zeller 
Heart Center, 
Bad Krotzingen, Germany 
Self-expanding nitinol stents for treatment 
of infragenicular arteries following 
unsuccessful balloon angioplasty 

Abstract The feasibility of self-expanding 
nitinol stents for treatment of 
infragenicular arteries following unsuccessful 
balloon angioplasty was 
assessed. Options for lower limb percutaneous 
revascularization are limited, 
especially for complex vessel 
obstruction. Depending on the lesion 
and the experience of the interventionalist, 
the failure rate of balloon 
angioplasty (PTA) ranges between 10 
and 40%. Until recently, no selfexpanding 
stent for the use in the 
infragenicular arteries was available. 
This is the first report of the results for 
18 consecutive patients who received 
4F sheath compatible self-expanding 
nitinol stents following unsuccessful 
PTA or early restenosis. Twenty-four 
stents were implanted in 21 lesions for 
various indications residual stenosis 
>50% due to heavy calcification, 
flow-limiting dissection, occluding 
thrombus resistant to thrombolyis, 
thrombaspiration, and PTA, and early 

restenosis after previous PTA. Stent 
implantation was feasible in all cases. 
No complications occurred. After the 
stent implantation, all primarily unsuccessful 
interventions could be 
transformed into successful procedures 
with no residual stenosis >30% 
in any case. After 62 months, two of 
the 18 patients died, and 14 of the 16 
remaining patients improved clinically. 
At follow-up, the patency could 
be assessed in 14 stented arteries. 
Three stents were occluded, one stent 
showed some neointimal hyperplasia 
(5070% restenosis), the remaining 
ten stents showed no restenosis (0 
30%). The use of self-expanding 
nitinol stents in tibioperoneal and 
popliteal arteries is a safe and feasible 
option for the treatment of unsuccessful 
PTA. The 6-months patency is 
high. 

Keywords Chronic limb ischemia . 
Intervention . Vascular . Stent 

Introduction ous transluminal balloon angioplasty (PTA) of the lower 

limbs was increasingly performed over the past 10 years 
Interventional treatment in patients with peripheral vascu-[713]. Endovascular specialists adopted the endovascular 
lar disease (PVD) is widely accepted in the iliac arteries techniques for the small infragenicular vessels, also using 
and in the femoropopliteal region [14]. In contrast, the stents if the antegrade blood-flow could not be restored 
number of treated patients in below the knee arteries is still with PTA alone [14]. Until now, there have been no 
low. Encouraging results have been obtained in patients dedicated stents available for infragenicular use. In cases 
with critical ischemia of the lower limb, particularly in in which stenting of tibioperoneal arteries was necessary, 
patients with diabetes mellitus and patients not suitable for coronary premounted balloon expandable stents were 
bypass surgery [2, 5, 6]. used. Since May 2005, the first self-expanding nitinol 

With the introduction of low-profile catheters, new stent especially dedicated for the use in small arteries 
devices, and hydrophilic steerable guidewires, percutane-below the knee has been available. To our knowledge, this 


is the first report which describes the use of this stent in a 
series of consecutive patients who failed with conventional 
PTA. 

Materials and methods 

Between May and December 2005, 18 consecutive patients 
were treated with self-expanding nitinol stents, following 
unsuccessful PTA or early restenosis after previous PTA. 
All patients had an indication for stent insertion because of 
unsuccessful PTA (during intervention or at short-term 
follow-up). Therefore, an IRB approval was not obtained. 
The stent administration was performed subsequent to the 
PTA which did not show a satisfying interventional result 
(either residual stenosis >50%, remaining occlusion, early 
restenosis after previous PTA). Insufficient PTA was 
defined as PTA with a residual stenosis due to early recoil 
or heavy calcified plaque. This was distinguished from a 
flow-limiting dissection, which was also due to an 
insufficient result of the intervention. Before the intervention, 
12 of the arterial lesions were stenosed, and nine 
lesions were totally occluded. The indication for the 
treatment ranged from Rutherford 3 to 5. The majority of 
the patients had who were treated in our series had 
ulcerations (Rutherford 5). 

Procedure 

For all indications self-expanding nitinol stents (Abbott 
Vascular, San Francisco, Calif., USA) were used. The 
Xpert stent is a self-expanding nitinol stent intended to use 
for peripheral vasculature available in lengths up to 6 cm 
with a diameter ranging between 3 and 6 mm. The stent is 
integrated at the distal end of the delivery system inside 
the outer tube and rests onto an inner tube in which the 
guidewire channel runs. The required guidewire for the 
stent is 0.018 inch. To facilitate positioning, two radiopaque 
markers indicate the stents proximal and distal 
end. Due to the thin outer diameter for deployment only a 
4 F vascular access is mandatory. 

If not already receiving aspirin and clopidogrel, all 
patients were premedicated 6 24 h prior to the intervention 
with a loading dose of 300500 mg of aspirin and 
300 mg of clopidogrel. This regimen was followed by 
100 mg aspirin recommended for life and 75 mg 
clopidogrel for 46 weeks. In addition, a bolus of 70 U/ 
kg body weight of heparin was given, followed by a 
heparin infusion for 24 h, adjusted to an ACT between 50 
and 70. 

Vascular images had already been obtained from all 
patients 14 days prior to the intervention [either magnetic 
resonance imaging (MRI) or conventional digital subtracted 
angiography (DSA)]. Arterial access was gained 
from the antegrade approach using a 4 F sheath (Brite tip, 

Cordis, Miami, Fla., USA). In general, the puncture site 
was the common femoral artery. Due to the anatomic 
conditions, a direct puncture of the SFA was carried out in 
two cases and a puncture of a femoropoplital bypass graft 
was performed in one patient. The initial passage of the 
lesion was always performed with a 0.035-inch Terumo 
Glidewire, which was supported by a 4 F catheter [in 
occlusions or high grade stenosis, a hydrophilic catheter 
(Terumo, Glidecath, Tokio, Japan) were used]; otherwise 
normal 4 F diagnostic catheters were taken (Cordis). 
After crossing the lesion, the diagnostic catheter or the 
glide catheter was advanced distally into the patent 
segment in order to exchange the guidewire to a 0.018inch 
wire (either Steelcore by Guidant, Santa Clara, 
Calif., USA or PTFE-coated guidewire by Optimed, 
Ettlingen, Germany). All lesions were primarily dilated 
with a pressure of 610 atm for 12 min using low 
profile balloons of 2.54 mm in diameter and lengths of 
4-6 cm [either Savvy (Cordis) or Star (Optimed)]. The 
various indications for the stent administration are listed 
in Table 1 of the result section. The Xpert stent was 
advanced on the 0.018-inch guidewire and deployed at 
the side of the lesion. All stents apart from the stents 
used for the indication treatment of thrombus formation 
were postdilated with a balloon adjusted to the 
vessel size (no or slight overdilatation). The sheath was 
removed under continuous infusion of heparin. 

In all patients, clinical assessment and ankle brachial 
index (ABI) measurements were performed both prior to 
the intervention and after the intervention. In addition, 
all patients received follow-up at 62 months. If the 
patients agreed either ultrasound (US), computed tomographic 
angiography (CTA), or DSA was performed to 
assess the degree of restenosis. 

Results 

Nine female and nine male patients, mean age 7011 years 
(range 5491 years) were prospectively enrolled in this 
registry. In the course of 18 interventional procedures, 24 
Xpert stents were deployed in one to three different vessels. 
We used 24 stents in 18 patients. In three patients 
(numbered 3, 12, and 17), one lesion was treated with 
two stents. These stents were implanted with an overlap of 

0.5 cm. In patients 2 and 6, more than one stent were also 
implanted. Because the lesions were apart from each other 
or in a different vessel they were counted undependably. 
The baseline characteristics were as follows: hypertension 
56%, diabetes 72%, tobacco use 22%, hypercholesterolemia 
50%, coronary artery diseases 44%. The indications 
were: insufficient result of the PTA due to restenosis in 11 
arterial lesions, follow limiting dissection in three cases, 
and thrombus formation in two cases. In addition, five 
lesions were treated for prevention of restenosis in patients 
with early restenosis after previous PTA (Table 1). 

Table 1 Lesion characteristics and interventional data 

Clinical Location Lesion Lesion Indication Stent Run-offa 
stage artery characteristics length 
(Rutherford) 
Patient 1 3 Peroneal Stenosis 4 cm Insufficient PTA 4/60 1 
Patient 2 4 Peroneal Occlusion 2 cm Restenosis after 3/40 2 
2 months 
Posterior Occlusion 4 cm Restenosis after 4/60 
tibial 2 months 
Posterior Stenosis 2 cm Restenosis after 3/40 
tibial 2 months 
Patient 3 5 Popliteal II/III Stenosis 7 cm Insufficient PTA 5/60+ 1 
6/40 
Patient 4 3 Tibofib. tract Occlusion 3 cm Thrombus 4/40 2 
Patient 5 5 Tibiofib. tract Stenosis 2 cm Insufficient PTA 3/40 2 
Patient 6 4 Popliteal II Stenosis 2 cm Dissection 5/40 1 
Anterior Occlusion 3 cm Thrombus 3/40 
tibial 
Patient 7 3 Peroneal Stenosis 5 cm Insufficient PTA 4/60 1 
Patient 8 5 Anterior Occlusion 10 cm Dissection 4/60 1 
tibial 
Patient 9 5 Anterior Stenosis 4 cm Restenosis after 6 mo 4/50 1 
tibial 
Patient 10 5 Peroneal Stenosis 5 cm Insufficient PTA 4/60 1 
Patient 11 5 Popliteal III/ tibiofib. tract Stenosis 2 cm Insufficient PTA 3/40 2 
Patient 12 5 Peroneal Stenosis 10 cm Insufficient PTA 4/60+ 1 
5/60 
Patient 13 5 Peroneal Occlusion 14 cm Insufficient PTA 5/60 1 
Patient 14 5 Peroneal Occlusion 12 cm Insufficient PTA 5/60 1 
Patient 15 5 Peronal Stenosis 5 cm Restenosis after 4/60 2 
3 months 
Patient 16 5 Anterior Stenosis 4 cm Insufficient PTA 3/40 2 
tibial 
Patient 17 5 Popliteal III/anterior tibial Occlusion 12 cm Insufficient PTA 6/40+ 1 
4/60 
Patient 18 5 Popliteal III/ tibiofib. Occlusion 12 cm dissection 5/60 1 
tract/ peronal 

aThe number indicates the number of patent vessels to the foot after the intervention 

All patients who received a stent for the indication of 
insufficient PTA had heavily calcified lesions which did 
not respond well to balloon angioplasty alone. In those 
cases, a second balloon inflation for a prolonged time 
(5 min) was performed with a residual stenosis ranging 
from between 50 and 70%. Due to this residual stenosis, the 
blood flow was limited, demanding stent administration. In 
some patients most of the treated artery did respond well to 
the balloon angioplasty, whereas some parts showed 
residual stenosis. In those cases, only the parts resistant 
to PTA were stented. The stent placement was easily 
possible and, furthermore, successful in all cases. In 
general, the same balloon which had already been used 
for the primary PTA was used for postdilation. After the 

procedure, no relevant residual stenosis was observed in 
any of the patients. The stent administration was no more 
difficult in patients who presented with total occlusions 
prior to the intervention as to those with only stenotic 
lesions. Because the radiopacity of the self-expanding 
Xpert stent is relatively low, a higher magnification and 
angulations in the case of superimposed bones were used 
for the postdilation. In most of the patients, there was only 
one patent vessel to the foot (also shown in Table 1). If 
there was more than one artery, only one artery was treated 
when not indicated differently (patient 2). 

Three patients received stents as they presented with 
flow limiting dissections. In those cases, it was easy to 
cross the lesion with the stent. In all of these patients, prior 


to the intervention below the knee, a chronic occlusion of 
the SFA was successfully recanalized in the subintimal 
space. Due to the fact that these patients presented with a 
non-healing wound or rest pain, respectively, putting the 
leg at high risk for amputation, we further decided to 
recanalize occlusions of the anterior tibial artery, which 
was the only existing feeding vessel. Again, this was only 
possible in the subintimal space leaving a dissection in the 
distal part of the ATA which limited the blood flow. 

In two additional cases, the stents were used to treat 
residual thrombus formations which were resistant to 48-h 
thrombolysis and thrombaspiration. The total occlusions 
due to the thrombus formation could be easily passed with 
the stent. Even though no post-dilatation was performed in 
these cases the antegrade blood flow was restored with no 
residual stenosis. 

In five lesons of three additional patients, stents were 
implanted for prevention of restenosis. This was carried out 
due to both legs being at risk of amputation. The PTA was 
performed 2 months (patient 2), 3 months (patient 15), and 
6 months (patient 9) before subsequently resulting in 
restenosis or reocclusion at the time of the intervention. 
After pre-dilatation, the lesions could be crossed and the 
stents were deployed successfully. 

At 62 months, two patients died and in 14 of the 
remaining 16 patients the clinical situation improved 
compared with the pre-interventional status. Four patients 
refused to receive a follow-up assessment for the evalua-

Table 2 Lesion characteristics and follow-up data 

tion of the patency of the treated artery, and one patient 
moved to a different location and therefore was not 
available for follow-up. In the other patients, CTA (n=1) , 
DSA (n=6), or US (n=4) was performed. In total, the 
restenosis rate could be evaluated in 14 stented segments. 
Three stents were occluded, one stent was stenosed (50 
70%), and in the other ten stents hardly no neointimal 
narrowing could be detected (see Table 2). 

Summarizing the results, the use of the self-expanding 
Xpert stent resulted in a 100% success rate with no 
reststenosis independent of the indication (insufficient 
PTA, dissection, thrombus formation), the length of lesion 
and the lesion characteristics (occlusion or stenosis, 
calcification). No adverse events or technical failures 
were observed. The ABI increased from a mean of 0.20 
prior to the intervention to a mean of 0.68 after the 
intervention. Three out of 14 stents were occluded at 
follow-up. Figures 1 and 2 illustrate examples of the 
various indications for stent placement. 

Discussion 

The average age of the western world population is 
increasing, as is the number of elderly patients with myriad 
illnesses. With the elderly population, it is estimated that 
nearly 610% will have intermittent claudication, and of 
these 1020% will be at risk for severe limb-threatening 

Indication Clinical stage 6-months clinical stag 6-months Follow-up with: 
(Rutherford) e(Rutherford) Restenosis 
Patient 1 Insufficient PTA 3 0 050% CTA 
Patient 2 Restenosis after 2 months 4 0 050% DSA 
Restenosis after 2 months 4 0 100% DSA 
Restenosis after 2 months 4 0 100% DSA 
Patient 3 Insufficient PTA 5 5, healing Refused  
Patient 4 Thrombus 3 2 050% US 
Patient 5 Insufficient PTA 5 0 050% DSA 
Patient 6 Dissection 4 0 050% DSA 
Thrombus 4 0 050% DSA 
Patient 7 Insufficient PTA 3 3 5170% DSA 
Patient 8 Dissection 5 0 Moved  
Patient 9 Restenosis after 6 months 5 Died   
Patient 10 Insufficient PTA 5 0 050% US 
Patient 11 Insufficient PTA 5 0 050% US 
Patient 12 Insufficient PTA 5 5 Refused  
Patient 13 Insufficient PTA 5 3 050% US 
Patient 14 Insufficient PTA 5 Died   
Patient 15 Restenosis after 3 months 5 0 100% DSA 
Patient 16 Insufficient PTA 5 5, healing 050% DSA 
Patient 17 Insufficient PTA 5 0 Refused  
Patient 18 Dissection 5 0 Refused  


Fig. 1ad Angiograms of a 
patient who presented with PVD 
Rutherford stage 5. a, b Prior to 
the intervention a total chronic 
occlusion of the distal SFA, and 
the popliteal artery with refill of 
the anterior tibial artery was 
observed. c After recanalization 
and PTA of the lesion two high 
grade reststenosis remained 
which did not respond to repeat 
balloonangioplasty (circle). d 
After implantation of self-expanding 
stents good antegrade 
flow could be obtained 

ischemia, requiring revascularization or even amputation 
[15]. Age, diabetes, and hypertension are factors that 
hinder the healing of ischemic wounds. The elderly with 
critical chronic limb ischemia (CCLI) are especially 
challenging patients to be treated due to the relatively 
higher surgical risk involved [16, 17]. The operative 
mortality for elective surgical patients over 80 is more than 
twice as high as that for patients of 6569 years of age [18, 
19]. In addition, surgical bypass grafting is often not 
possible due to the lack of a distal vessel which is suitable 
for an anastomosis providing sufficient distal run-off. 

Several studies indicate that the postinterventional 
angiographic result is very important for long-term success. 
This seems to be especially true in small peripheral arteries. 
Schillinger et al. [10] reported a restenosis rate of 40% after 
6 months in 89 consecutive patients who underwent 
balloon angioplasty in arteries below the knee. Besides 
the pre-and postinterventional CRP level, a suboptimal 
PTA result was the only other parameter associated with an 
increased risk of restenosis. A residual stenosis ranging 
between 30% and 40% was defined as a suboptimal result. 
This occurred in 50 of their 89 patients. In addition, 6% of 
the interventions were rated as unsuccessful defined as a 
residual stenosis of greater than 50%. Compared with other 


studies [6, 8, 20, 21], the incidence of unsuccessful PTA is 
relatively high; nevertheless it shows the need to achieve a 
good angiographic result. In our series of infragenicular 
interventions, all stents were capable of translating a 
suboptimal or even unsuccessful interventional procedure 
into a successful intervention. If this is the case, then longterm 
patency superiority over PTA has to be proven by a 
prospective randomized trial comparing PTA and stenting 
in below-the-knee arteries. There are two possible goals for 
the use of stents in the infragenicular arteries: unsuccessful 
result after PTA as a bailout situation, which was 
investigated in our series, and prevention of restenosis 
for improvement of long-term patency. Depending on the 
case selection, the experience of the interventionalist, and 
the type of catheters, wires and balloons, which have 
improved significantly during the past years, there is a wide 
range of reported interventional success rates. Soder et al. 

[8] described in a series of 60 patients a primary 
angiographic success rate of balloon angioplasty for 
stenotic lesions of 84% and for occlusions of 61%. He 
did not use any stents. With the introduction of stents, the 
results might have improved. Still unanswered is the need 
of long-term patency for patients with CCLI and nonhealing 
ulcers. Atar et al. [15] reported a low clinical 

Fig. 2ad Angiograms of a 
patient who was admitted to the 
hospital due to an acute thrombotic 
occlusion of the SFA. The 
SFA could be successfully reopened 
by thrombolysis and 
thrombaspiration. aAs an ad-
verse effect, a thombembolic 
occlusion occurred occluding 
the anterior tibial artery. This 
occlusion was resistant to 
further thrombolysis, PTA, and 
aspiration. Therefore, a self-expanding 
stent was placed (b), 
which finally restored the blood 
flow (c). d At 6 months the 
stented vessel was still open 

patency rate of 14.8% following balloon angioplasty after 1 
year. Nevertheless, this temporary vascular patency 
enabled wound healing or improvement in 74% of the 
patients. 

Stenting of thrombus formation especially below the 
knee is fairly uncommon. The three patients who received a 
self-expanding stent for such an indication suffered from a 
thrombembolic event prior to the intervention. The main 
parts of the thrombus could be successfully treated by a 
combination of thrombaspiration and thrombolysis. The 
remaining intraarterial material did not even respond to 
PTA but behaved like rubber. Interestingly, the nitinol stent 
was able to restore the blood flow. A balloon dilatation 
after stent administration was not performed, because that 
might have activated the platelets again, forming a new 
thrombus. Due to the long thrombolysis prior to stent 
administration, those patients were at high risk of bleeding 
complications. Therefore, we wanted to prevent the risk of 
further thrombolysis and were confident with the good 
result after stenting. 

Anecdotal reports exist which deal with the use of 
coronary balloon-expandable stents in the tibioperoneal 
arteries [14]. If the use of those stents are correlated with 
different technical success and a distinct patency rate 
compared with self-expanding nitinol stents is not 


answered. In the superficial femoral artery (SFA), the 
patency rate of stainless steel stents has shown to be below 
the restenosis rates of self-expanding nitinol stents [22]. 
This has also to be questioned if further found for the 
infragenicular arteries. The grade of calcification and the 
mechanical forces are different from the SFA. Nevertheless, 
the Xpert stent is the first self-expandable stent 
specially designed for the small arteries. It is very helpful 
that this stent is also available in sizes up to 60 mm in 
length, due to the fact that many lesions in the 
infragenicular arteries are longer and more diffuse and 
might not be covered by one coronary stent, which is 
normally limited to a length of 38 mm. In addition, the selfexpanding 
stent which we used in our series needs only a 
4 F sheath. This makes an antegrade ipsilateral approach 
possible even if the anatomic conditions are not so 
favourable. In our series, despite directly puncturing the 
SFA in two cases and a prosthetic bypass graft in one case, 
no complications at the access site were observed. 

Most of the recent publications of stenting small belowthe-
knee arteries report only intervention on tibial and 
peroneal arteries. In fact, we did not exclude patients who 
received stents in the popliteal artery because a lot of the 
lesions stretched from the popliteal artery into the 
infrapoplital region. One of the main advantages of a 


self-expanding small nitinol stent for infragenicular use is 
that the stent might also be placed in the popliteal artery, 
where one expects more movement and therefore stainless 
steal stents should not be used. This might be the reason 
that the publications which deal with the implantation of 
stainless steal stents are limited to the infrapopliteal artery 
region. 

Up to now there are only a few publications with followup 
patency data after stenting of the small below-the-knee 
arteries available. Rand et al. [23] compared carbon film 
coated stents with PTA infrapoplital arteries. At the 50% 
restenosis threshold, the patency rate of the stents was 
79.7% versus 45.6% after PTA in a total of 51 patients. 
Clinical data were not provided in this publication. Only 
recently, Siablis et al. [24] reported their mono-center data 
with bare metal versus drug eluting stents in arteries below 
the knee for bail out revascularization. In their series, the 
whole stenotic lesion of the artery was pre-treated with 
PTA, stent administration was performed in the region 
which did not respond well to balloon angioplasty only. At 
6 months, the in-segment restenosis (including the stent 
edges) was 66% in the group who received the bare metal 
stents. Interestingly, the sirolimus coated stents showed an 
in-segment restenosis of only 32%. To our knowledge, 
until now no data with self-expanding stents for the same 
indication exist. In our series, clinical success was observed 
in 14 of 16 patients independently of whether the artery 
was patent or reoccluded at 6 months. Three reocclusions 
occurred. Interestingly, these reocclusions were only 
observed in patients who already presented with early 
reocclusion after previous PTA. One might speculate that 
these arteries were so prone to develop neointimal 

hyperplasia that even stent insertion failed to preserve a 
mid-term patency. In contrast, all the other stented 
segments showed nearly no neointimal hyperplasia. 

The manuscript is limited due to the low number of 
patients, different indications for stent administration, and 
the lack of standards for the follow-up. The reason why the 
follow-up measurements were different was based upon the 
patient characteristics. Some patients refused the arterial 
puncture; others were not candidates for both CTA and 
DSA because of renal failure. Especially in patients with 
CCLI, it is not uncommon that because of co-morbidities 
no clinical follow-up is possible. These patients often rely 
on help for transportation to the hospital and refuse to come 
back for follow-up investigation, especially when they feel 
better. 

Conclusions 

In conclusion, we could show that the self-expanding 
nitinol stent was feasible to restore the blood flow in 
patients with failed PTA for various indications (dissection, 
calcified reststenosis, and thrombus formation). This 
interventional success translates in high clinical success 
and good patency rates. Whether a balloon-expandable 
stainless steel stent might be different in terms of success 
and patency rates, as well as the question of primary 
stenting of complex lesions for prevention of restenosis, 
has to be investigated in upcoming trials. Because CCLI 
is an increasing healthcare and economic problem in 
western society, this topic will gain more and more 
importance. 

Reference 

1. Duda SH, Poerner TC, Wiesinger B, 
Rundback JH, Tepe G, Wiskirchen J, 
Haase KK (2003) Drug-eluting stents: 
potential applications for peripheral 
arterial occlusive disease. J Vasc Interv 
Radiol 14:291301 
2. Bates MC, Aburahma AF (2004) An 
update on endovascular therapy of the 
lower extremities. J Endovasc Ther 11 
(Suppl 2):II107II127 
3. Tepe G, Duda SH, Hanke H, Schulze S, 
Hagmeier S, Bruck B, Schott U, Betz 
E, Schmahl FW, Claussen CD (1996) 
Covered stents for prevention of restenosis. 
Experimental and clinical results 
with different stent designs. Invest 
Radiol 31:223229 
4. Wiesinger B, Beregi JP, Oliva VL, 
Dietrich T, Tepe G, Bosiers M, Huttl K, 
Muller-Hulsbeck S, Bray A, Tielemans 
H, Duda SH (2005) PTFE-covered selfexpanding 
nitinol stents for the treatment 
of severe iliac and femoral artery 
stenoses and occlusions: final results 
from a prospective study. J Endovasc 
Ther 12:240246 
5. Ouriel K, Fiore WM, Geary JE (1988) 
Limb-threatening ischemia in the 
medically compromised patient: amputation 
or revascularization? Surgery 
104:667672 
6. Mousa A, Rhee JY, Trocciola SM, 
Dayal R, Beauford RB, Kumar N, 
Henderson P, McKinsey J, Morrissey 
NJ, Kent KC, Faries PL (2005) Percutaneous 
endovascular treatment for 
chronic limb ischemia. Ann Vasc Surg 
19:186191 
7. Biamino G (2004) The excimer laser: 
science fiction fantasy or practical tool? 
J Endovasc Ther 11(Suppl 2):II207 
II222 
8. Soder HK, Manninen HI, Jaakkola P, 
Matsi PJ, Rasanen HT, Kaukanen E, 
Loponen P, Soimakallio S (2000) 
Prospective trial of infrapopliteal artery 
balloon angioplasty for critical limb 
ischemia: angiographic and clinical 
results. J Vasc Interv Radiol 11:1021 
1031 
9. Krankenberg H, Sorge I, Zeller T, 
Tubler T (2005) Percutaneous transluminal 
angioplasty of infrapopliteal arteries 
in patients with intermittent 
claudication: acute and one-year results. 
Catheter Cardiovasc Interv 
64:1217 

10. Schillinger M, Exner M, Mlekusch W, 
Haumer M, Rumpold H, Ahmadi R, 
Sabeti S, Wagner O, Minar E (2003) 
Endovascular revascularization below 
the knee: 6-month results and predictive 
value of C-reactive protein level. 
Radiology 227:419425 
11. Laird J Jr, Reiser C, Biamino G, Zeller 
T (2004) Excimer laser assisted angioplasty 
for the treatment of critical limb 
ischemia. J Cardiovasc Surg (Torino) 
45:239248 
12. Henry M, Henry I, Klonaris C, Hugel 
M (2003) Clinical experience with the 
OptiMed sinus stent in the peripheral 
arteries. J Endovasc Ther 10:772779 
13. Sabeti S, Mlekusch W, Amighi J, Minar 
E, Schillinger M (2005) Primary patency 
of long-segment self-expanding 
nitinol stents in the femoropopliteal 
arteries. J Endovasc Ther 12:612 
14. Feiring AJ, Wesolowski AA, Lade S 
(2004) Primary stent-supported angioplasty 
for treatment of below-knee 
critical limb ischemia and severe claudication: 
early and one-year outcomes. 
J Am Coll Cardiol 44:23072314 
15. Atar E, Siegel Y, Avrahami R, Bartal G, 
Bachar GN, Belenky A (2005) Balloon 
angioplasty of popliteal and crural 
arteries in elderly with critical chronic 
limb ischemia. Eur J Radiol 53:287 
292 
16. Ansel GM, Sample NS, Botti IC Jr, 
Tracy AJ, Silver MJ, Marshall BJ, 
George BS (2004) Cutting balloon 
angioplasty of the popliteal and infrapopliteal 
vessels for symptomatic limb 
ischemia. Catheter Cardiovasc Interv 
61:14 
17. Kudo T, Chandra FA, Ahn SS (2005) 
The effectiveness of percutaneous 
transluminal angioplasty for the treatment 
of critical limb ischemia: a 10year 
experience. J Vasc Surg 41:423 
435 
18. Ballotta E, Renon L, Toffano M, 
Piccoli A, Da Giau G (2004) Patency 
and limb salvage rates after distal 
revascularization to unclampable calcified 
outflow arteries. J Vasc Surg 
39:539546 
19. Ballotta E, Renon L, Toffano M, Da 
Giau G (2003) Prospective randomized 
study on bilateral above-knee femoropopliteal 
revascularization: polytetrafluoroethylene 
graft versus reversed 
saphenous vein. J Vasc Surg 38:1051 
1055 
20. Kalbaugh CA, Taylor SM, Cull DL, 
Blackhurst DW, Gray BH, Langan EM 
III, Dellinger MB, McClary GE Jr, 
Jackson MR, Carsten CG III, Snyder 
BA, York JW, Youkey JR (2004) 
Invasive treatment of chronic limb 
ischemia according to the Lower Extremity 
Grading System (LEGS) score: 
a 6-month report. J Vasc Surg 39:1268 
1276 
21. Jamsen T, Manninen H, Tulla H, Matsi 
P (2002) The final outcome of primary 
infrainguinal percutaneous transluminal 
angioplasty in 100 consecutive patients 
with chronic critical limb ischemia. J 
Vasc Interv Radiol 13:455463 
22. Grenacher L, Saam T, Geier A, Muller-
Hulsbeck S, Cejna M, Kauffmann GW, 
Richter GM (2004) PTA versus Palmaz 
stent placement in femoropopliteal artery 
stenoses: results of a multicenter 
prospective randomized study 
(REFSA). Rofo 176:13021310 
23. Rand T, Basile A, Cejna M, 
Fleischmann D, Funovics M, 
Gschwendtner M, Haumer M, Von 
Katzler I, Kettenbach J, Lomoschitz F, 
Luft C, Minar E, Schneider B, Schoder 
M, Lammer J (2006) PTA versus 
carbofilm-coated stents in infrapopliteal 
arteries: pilot study. Cardiovasc Intervent 
Radiol 29:2938 
24. Siablis D, Kraniotis P, Karnabatidis D, 
Kagadis GC, Katsanos K, Tsolakis J 
(2005) Sirolimus-eluting versus bare 
stents for bailout after suboptimal 
infrapopliteal angioplasty for critical 
limb ischemia: 6-month angiographic 
results from a nonrandomized prospective 
single-center study. J Endovasc 
Ther 12:685695 

