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Objectives:
Endovascular procedures have become commonplace in the treatment of infrainguinal peripheral arterial disease (PAD). Despite this, there is a paucity of long term data on tibial interventions. Our study analyzes data from patients receiving endovascular tibial interventions for critical limb ischemia (CLI) in order to elucidate the factors that impact outcomes.
Methods:
We completed a retrospective review of tibial interventions completed from 2008 to 2010. Factors affecting patient outcomes were analyzed using single and multivariate analysis, Cox regression, and Kaplan-Meier curves.
Results
480 tibial interventions were completed in 421 limbs: 87% (n=418) presented with critical limb ischemia (CLI) and 13% (N=62) with claudication. The CLI cohort of 418 limbs was selected for analysis. These patients had a mean age of 71 years with 60% male and a mean follow-up time of 16±15 months (0-59 months). 333 were PTA alone, 6 were PTA+stent, and 79 were atherectomy. 178 were isolated tibial interventions and 240 were multisegment interventions.
Renal Insufficiency (RI) patients (n=162) were defined as creatinine >1.5 if male and >1.2 if female, or end stage renal disease and were compared to patients without RI (n=256). Patients with RI had a significantly higher proportion of diabetes (81% versus 66%, p<.001) and TASC A lesions (8% versus 1%, p=.003). Other demographics, risk factors, and TASC classifications did not differ significantly between groups.
Early outcomes (30 day) for the entire cohort demonstrated a 10% complication rate, 5% reintervention rate, and 3% mortality rate and were not significantly different between groups.
On Kaplan Meier analysis at 12 and 36 months, patients with RI compared to those without RI had worse primary patency (65%, 40% versus 69%, 59%, HR 1.5 for loss, p=.045), limb salvage (68%, 58% versus 86%, 78%, HR 2.2 for loss, p<0.0001), and survival (61%, 33% versus 88%, 70%, HR 3.1 for mortality, p<0.0001). Analysis of secondary outcomes revealed that RI worsened symptomatic improvement (54% versus 67%, p=.01), Rutherford score improvement (61% versus 76%, p=.002) and toe amputation rate (26% versus 17%, p=.03).
Conclusions
RI significantly worsened short and long term patency outcomes in patients who underwent endovascular tibial interventions for CLI. Despite this, patients with RI had a satisfactory limb salvage rate, making tibial interventions in these patients a worthwhile endeavor.