Femoropopliteal percutaneous transluminal angioplasty. Effect of a policy dictated by the availability of resources

For some femoropopliteal atherosclerotic stenoses and occlusions, percutaneous transluminal angioplasty (PTA) is an acceptable alternative to a vascular reconstructive operation (VRO). The availability of resources dictated a policy of preferring PTA as the first choice for all lesions judged amenable to such treatment. Patients were assessed for operative risk and the likelihood of success of a VRO by an experienced observer who examined the angiograms and the patient's chart. Of 71 limbs with severe ischemia treated by PTA and followed for a mean of 27 months, there were 52 successful outcomes (73%) and 14 amputations (7 after a failed VRO); the remaining 5 limbs showed no improvement. After PTA had failed, 14 VROs were carried out, 7 of which were successful. Had PTA been unavailable, a hypothetical total of 58 VROs would have been done with a minimal estimated amputation rate of 10%. Of the other 13 limbs, 8 would have been subjected to primary amputation and 5, to no surgery. Thus, the number of major amputations that would have resulted from a hypothetical 'VRO first' policy was subjectively estimated to be the same as that achieved with the 'PTA first' policy. Our policy of preference for 'PTA first' (over VRO) yielded an 'expenditure' of 58 PTAs for a 'saving' of 44 VROs and the same results in terms of limb salvage. This approach proved to be beneficial from the point of view of resource use because it saved precious time in our operating room schedules. This type of analysis can be applied in different health-care delivery systems according to the specific characteristics of each system.