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Impact of Pedal Runoff on clinical and anatomic outcomes of Endovascular Tibial Artery Interventions
Javier E. Anaya-Ayala, MD, Matthew K. Adams, MD, Scott S. Saunders, BS, Jean Bismuth, MD, Eric K. Peden, MD, Alan B. Lumsden, MD, Mark G. Davies, MD, PhD, MBA, Christopher J. Smolock, MD.
Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

Background: While there has been a significant increase in primary endoluminal therapy for tibial artery occlusive disease, the implications of pedal runoff on the outcomes of these interventions is unclear. The purpose of this study is to examine the impact of pedal runoff on long-term clinical and anatomic outcomes of tibial interventions.
Methods: A prospective database of patients undergoing endovascular treatment of the tibial vessels for rest pain and tissue loss between 2000 and 2011 was queried. Angiograms were reviewed in all cases to assess tibial runoff. Each dorsalis pedis (DP), lateral plantar (LP), and medial plantar (MP) artery was assigned a score according to the reporting standards of the SVS (0,no stenosis >20%;1,21%-49% stenosis;2,50%-99% stenosis;2.5,<half the vessel length occluded; 3,>half the vessel length occluded). A foot score (DP+MP+LP) was calculated for each foot (1to10). Two run-off score groups were identified: <5 and >5. Clinical success was defined as a patient that satisfied all three criteria: absence of recurrent symptoms, maintenance of ambulation and absence of major amputation. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time dependent variables.
Results: 220 limbs in 198 patients (60% male, average age 70 years) underwent endovascular tibial artery interventions for tissue loss. 87% had hypertension, 73% had diabetes mellitus, 59% had hyperlipidemia and 23% had chronic renal insufficiency (76% of these on hemodialysis). Technical success was 99% with a mean of vessels treated per patient and a mean pedal runoff score of 6. Overall mortality was 9 % and overall morbidity was 32% at 90 days after the procedure. At 3 years, vessels with compromised runoff (scores >5) had significantly lower ulcer healing and a lower limb salvage rate (Table). Patencies were significantly worse in patients with a runoff score >5 (Table). Occlusion was correlated with major limb loss (p<0.05). (Table).
Runoff Score<5>5p-value
Number Limbs at Risk78 (35%)142 (65%)-
MACE (%)2 (3%)2 (1.4%)
MALE (%)13 (16%)60 (42%)
Conversion to open bypass within 3 months (%)210 (7%)
Patient survival (%by life table)68%62%
Minor Amputation (Toe and TMA) (% of n)7 (8%)24 (16%)
Major Amputation (BKA and AKA) (% of n)2 (3%)43 (30%)
Primary Patency (% by life table)81%56
Assisted Primary Patency (% by life table)73%58%
Secondary Patency (% by life table)758%
Limb Salvage (% by life table)82%36%
Clinical success (% by life table)43%39%

Mean±SEM at three years follow up

Conclusions: Pedal runoff score can easily identify those patients who will not achieve ulcer healing and limb salvage after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions.

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