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Limb Salvage Following Isolated Percutaneous Balloon Angioplasty of the Tibial Arteries
Andrew M. Bakken, MD, Manju Kalra, MBBS, Gustavo S. Oderich, MD, Michael A. McKusick, MD, Audra A. Duncan, MD, Jeremy L. Friese, MD, Thomas C. Bower, MD, Peter Gloviczki, MD.
Mayo Clinic, Rochester, MN, USA.
Objective
Patients with critical limb ischemia (CLI) due to atherosclerotic occlusive disease isolated to the infrapopliteal vessels are beset by diabetes, chronic kidney disease, and cardiac disease. Although percutaneous therapy seems an ideal option in this comorbid population, data suggest worse outcomes compared with multilevel disease. This study reviewed our experience with percutaneous angioplasty (PTA) for atherosclerotic disease isolated to the tibial vessels.
Methods
All patients undergoing PTA exclusive to the tibial vessels from 2001 through 2010 were retrospectively reviewed. Limb salvage and survival were assessed by Kaplan-Meier analysis. Additional clinical outcomes were subjected to Cox proportional hazards analysis.
Results
Among 399 primary tibial interventions over the study period, 129 limbs in 122 patients (mean age 73) were treated for isolated tibial vessel disease. Average follow-up was 25 months. Eighty-one percent were diabetics, 23% had renal insufficiency, 16% required hemodialysis, and 5% were prior renal transplant recipients. Eighty-nine percent were treated for tissue loss, while 4% were treated for rest pain. Fifty-three percent of treated vessels were occluded. The TP trunk, AT, peroneal, and PT were treated in 17%, 54%, 27%, and 29% of limbs, respectively. Multiple vessels were treated in 23%. Technical success was 85%. Thirty-day peri-operative mortality was 2.3 ± 1% due to 3 post-operative mortalities, 1 of which was attributable to the intervention. Median pre-operative TcPO2 was 15. Median post-operative TcPO2 was 33. Forty percent of limbs had a TcPO2 increase ≥ 20. Freedom from major amputation was 66 ± 5% at 1 year and 63 ± 5% at 3 and 5 years. Overall survival was 78 ± 4% at 1 year, 52 ± 5% at 3 years, and 35 ± 6% at 5 years. Major amputation-free survival was 56 ± 6% at 1 year, 38 ± 5% at 3 years, and 27 ± 5% at 5 years. Diabetes and renal disease were not associated with limb salvage, nor was the specific vessel of intervention. Post-operative TcPO2 ≥ 20 was strongly associated with limb salvage (LR 9.3, P = 0.0023).
Conclusions
Tibial vessel PTA is relatively safe in the higher-risk population of patients with CLI due to isolated tibial disease, though not without risk. Unfortunately, meaningful mid- to long-term limb salvage is achieved for only a minority of these patients.
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