Effects of Remote Ischemic Preconditioning on Restenosis Post Lower Limb Revascularization Angioplasty: A Pilot Randomized Control Trial

Rationale:

The father of interventional radiology Charles Dotter (1920-1985) performed the first percutaneous transluminal angioplasty in university of Oregon hospital on Laura Shaw in 16th of January 1964. She presented with typical rest pain and foot gangrene on left leg and her angiogram show distal superficial femoral artery focal stenosis. He saved her leg and she was walking for the next 3 years of her life using his experimental dilating catheter Later in 1977 Zurich witnessed the first coronary angioplasty by German cardiologist Andreas Gruentzig (1939-1985) using same technique .

The angioplasty utilized gradually in the next years after Dotter to provide less invasive option for the growing number of peripheral vascular disease patients estimated to be in the range of 3% to 10%, increasing to 15% to 20% in persons over 70 years. Early diagnosis remains difficult because patients tends to be asymptomatic up to 50% or more of vessel narrowing. the strong association between prevalence of peripheral vascular disease and age increase the demand with world population ageing specially in western Europe and USA. The lower extremity revascularization USA statistics in year 2000 was 40/100,000 and increasing.

Restenosis or the gradual narrowing of the re vascularized vessel remains one of the main problems usually it occurs within 6 months of angioplasty . Restenosis percentages varies between 12% up to 63 % in different studies largely depends on the lesion type and site with below knee interventions being more liable for restenosis.

The restenosis phenomena can be explained by the physiological response to the trauma caused by the balloon when inflated to compress the atheroma. Many factors can influence the process e.g. patient , procedure and vessel condition before intervention.it can be considered as hypertrophic wound healing from the interaction between monocyte-derived macrophages , T cells and arterial wall .the inflammatory response lead to Neointimal Hyperplasia the terminology uses to describe the proliferation and migration of vascular smooth muscle cells . Elevated inflammatory and coagulation factors markers levels after angioplasty has been suggested as predictors for the possibility of restenosis . The inflammatory theory was more supported when using immunosuppressive drugs like Sirolimus shows positive effects on reducing restenosis rate.