Outcomes of Tibial Endovascular Interventions in patients with Poor Pedal Runoff
Hallie E. Baer-Bositis, MD, Taylor D. Hicks, MD, Georges M. Haider, MD, Lori L. Pounds, MD, Matthew J. Sideman, MD, Maureen K. Sheehan, MD, Mark G. Davies, MD PhD MBA.
University of Texas Health Science Center - San Antonio, San Antonio, TX, USA.
Background: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine impact of poor tibial runoff on the patient centered outcomes following tibial endovascular Intervention
Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford 4 and 5) were identified. 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 + 1) was calculated for each foot (1 to 10). Two run-off score groups were identified: < 7 and >7. Patient orientated outcomes of clinical efficacy (CE; absence of recurrent symptoms, maintenance of ambulation and absence of major amputation), amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated.
Results: 1134 patients (56% male, average age 59 years) underwent tibial intervention for critical ischemia, 94% had hypertension, 70% had diabetes mellitus, 63% had hyperlipidemia and 33% had chronic renal insufficiency (47% of these on hemodialysis). Technical success was 99% with a mean of 2 vessels treated per patient and a mean pedal runoff score of 6. Overall MACE was equivalent at 90 days after the procedure. At 5 years, vessels with compromised runoff (scores >7) had significantly lower ulcer healing and a lower limb salvage rate. Patients with poor runoff had significantly lower CE, AFS and MALE at 5 years (Table)
|Runoff Score <7||Runoff Score ≥7||P-Value|
|Number Limbs at Risk||600||534||-|
|High Risk PIII score (%)||18%||30%||0.01|
|Ulcer healing without Amputation (%)||73±4||25±3||0.01|
|5yr-CE (Mean±SEM %)||48±4||20±8||0.01|
|5yr-AFS (Mean±SEM %)||45±3||17±9*||0.01|
|5yr-MALE (Mean±SEM %)||50±5||11±6*||0.01|
* P<0.05 and **p<0.01 compared to Runoff Score <7
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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