Multivessel tibial revascularization does not improve outcomes in patients with critical limb ischemia

Role of single peroneal versus single non-peroneal tibial angioplasty in limb salvage

BACKGROUND

The peroneal artery is known to give branches to the anterior and posterior tibial arteries. Scattered reports in the literature over the last decade failed to provide solid evidence as to the optimum strategy for below-knee targeted revascularization in limited-option patients with critical limb-treating ischemia (CLTI). We sought to determine the benefit of performing single peroneal tibial artery angioplasty revascularization compared with single non-peroneal angiosome-targeted tibial artery angioplasty revascularization for patients presented with CLTI.

METHODS

We performed a two-center, retrospective cohort study of patients presented with CLTI treated with below-the-knee endovascular intervention from January 2020 to January 2022. Group 1 included patients who were treated with single peroneal tibial artery angioplasty revascularization. Group 2 included patients who were treated with single non-peroneal tibial artery angioplasty revascularization. Patients had no proximal lesions or previous intervention to tibial arteries. The primary endpoint is limb salvage. The secondary endpoints include wound healing and all-cause mortality.

RESULTS

This study included 45 patients presented with critical limb ischemia, they were treated with single angiosome-targeted tibial angioplasty revascularization, they were divided into 13 patients (28.9%) with single peroneal revascularization (group 1) and 32 patients (71.1%) with single non-peroneal revascularization (group 2), 20 patients (44.4%) had target anterior tibial artery, while 12 patients (26.7%) had target posterior tibial artery. The follow-up duration was 6 months. No difference was found in limb salvage between the two groups (92.3% vs. 87.1%; P=1). No differences were found in wound healing rates between the two groups (76.9% vs. 81.3%; P=0.281). The overall 30-day survival rate was 100% in both study groups.

CONCLUSIONS

Single peroneal tibial revascularization mostly is non-inferior to single non-peroneal angiosome targeted tibial artery revascularization regarding limb salvage and wound healing for patients with critical limb ischemia.

A prospective, multicenter, real-world observational study evaluating the impact of tibial runoff on clinical outcomes after endovascular therapy for femoropopliteal lesions: Research protocol

Introduction

Current evidence indicates endovascular intervention is a safe and effective treatment for peripheral artery disease of the lower extremity. However, the clinical outcome of endovascular intervention for femoropopliteal lesions has been shown to be affected by the status of tibial runoff. It remains unclear whether endovascular intervention for tibial runoff is associated with additional benefits.

Methods and analysis

This prospective, multicenter, real-world observational study is carried out from January 2021 to December 2022 in 8 designated centers across China with an estimated sample size of 1200 patients with severe femoropopliteal disease. The pre-procedural status of tibial runoff is evaluated with the modified SVS score and categorized as good (SVS <5), compromised (SVS 5–10) or poor (SVS >10). Whether the patient will be treated with endovascular intervention for tibial runoff is determined by the treating vascular surgeons. Patients are dichotomized into the intervention group and the non-intervention group, with each group further divided into the good, compromised and poor tibial run-off subgroup, yielding 6 subgroups in total. Patients within various subgroups are compared with regard to the primary patency rate of the femoropopliteal artery, changes in quality of life, changes of Rutherford category, improvement of the Wound, Ischemia, and Foot Infection Classification, and incidence of major adverse events over 24-months follow-up. The results of this study may provide important information to help vascular sspecialists to decide whether the tibial runoff should be endovascularly intervened and which patient population benefits most from tibial runoff intervention.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04675632?id=NCT04675632&draw=2&rank=1, NCT04675632.

Below the knee percutaneous transluminal angioplasty for claudicants: One vessel is enough to relieve symptoms

Among patients with lower extremities arterial disease (LEAD), treatment of below the arteries has been historically limited to the treatment of chronic limb-threatening ischemia (CLTI), as recommended by available guidelines. In this study, the authors provided new data on the role of different endovascular revascularization anatomical strategies of the below the knee (BTK) arteries adopted in claudicant LEAD patients. The revascularization of the anterior tibial artery seems more effective for symptoms relieves than of the posterior territories and most of the adverse events occurred in the follow up period were target vessel revascularization, suggesting that revascularization of single vessel is enough to achieve clinical success.

Anterior, posterior, or all-vessel infrapopliteal revascularization in patients with moderate-severe claudication: Insights from the LIBERTY 360 study

BACKGROUND

Little data guides revascularization of infrapopliteal peripheral arterial disease (PAD) in patients with claudication. We assessed outcomes after infrapopliteal-only intervention for claudication in the LIBERTY 360 observational study.

METHODS

In this post hoc analysis, LIBERTY 360 patients (N = 128) with claudication and isolated infrapopliteal disease undergoing endovascular revascularization were divided by territory into anterior-vessel, posterior-vessel, or all-vessel groups. Patients were followed for periprocedural, in-hospital, and long-term outcomes. Logistic regression for odds ratios, Cox proportional hazard models, ANOVA, and Kaplan-Meier estimates were utilized to compare outcomes.

RESULTS

Patients underwent anterior (N = 37), posterior (N = 76), or all-vessel (N = 15) infrapopliteal revascularization. Initial procedural success was 86%, 86%, and 69% for anterior, posterior, and all-vessel groups, respectively. Each group had improvements in Rutherford classification (RC) from baseline to 2 years (mean RC change: -1.3, -1.5, and -1.5, respectively). Compared with all-vessel intervention, both anterior and posterior groups had lower rate of major adverse events (MAE) and target vessel revascularization (TVR) at 3 years (MAE: 12% and 15% in anterior and posterior groups, respectively compared with 51% in the all-vessel group; hazard ratios and 95% CIs 0.22 [0.06-0.74], p = .015; 0.24 [0.09-0.64], p = .004). Other outcomes were similar among the three groups. The anterior group showed more improvement in pain subdomain and total VascuQoL scores compared with posterior and all-vessel groups at 2 years (p = .016, p = .020 and p = .068, p = .009, respectively).

CONCLUSIONS

Both anterior or posterior revascularization have favorable outcomes and may be beneficial for improvement of symptoms in claudicants with isolated infrapopliteal PAD.

Revascularization of multiple tibial arteries is not associated with improved limb salvage

OBJECTIVE

We sought to determine the benefit of performing multiple tibial artery revascularization compared with single vessel revascularization for patients with chronic limb-threatening ischemia (CLTI).

METHODS

We performed a single-center, retrospective cohort study of all patients with CLTI treated with below-the-knee endovascular intervention from 2012 to 2019. Group 1 included patients who had undergone single tibial artery revascularization. Group 2 included patients who had undergone multiple (two or more) tibial artery revascularization. More proximal disease, if present, was treated, in addition to the tibial disease. The primary endpoint was freedom from amputation. The secondary endpoints included the reintervention rates and all-cause mortality.

RESULTS

A total of 527 limbs in 470 patients with CLTI (nonhealing ulcers, 62%; gangrene, 33%; and ischemic rest pain, 5%) were included in the present study. Of the 527 limbs, 245 (46%) had undergone single vessel revascularization and 282 (54%) had undergone multiple vessel revascularization. The mean follow-up was 19 ± 18 months. No difference was found in freedom from amputation between the two groups (68% vs 63%; P = .109). On multivariable analysis, the factors associated with amputation included dialysis (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.16-2.45), dyslipidemia (OR, 1.37; 95% CI, 0.96-1.94), and gangrene (OR, 2.08; 95% CI, 1.50-2.98). No differences were found in the reintervention rates between the two groups (21.2% vs 16.7%; P = .13). The overall survival rate was 73% in both study groups.

CONCLUSIONS

The results from the present large, single-center study have demonstrated that multiple below-the-knee vessel revascularization is not associated with improved limb salvage compared with single vessel revascularization.

Single versus Multiple Vessel Endovascular Tibial Artery Revascularization for Critical Limb Ischemia: A Review of the Literature

Vascular interventionalists have long debated on whether one or multiple patent tibial arteries (run-off) are necessary to treat critical limb ischemia, including ischemic rest pain and tissue loss. This review article seeks to clarify data surrounding this topic by including literature from retrospective studies, prospective studies, meta-analyses, and randomized controlled trials. Our conclusion is that revascularizing a single tibial artery to the foot is adequate for wound healing.

WITHDRAWN: One-Year Freedom from Amputation, Survival, and Cost of Care following Tibial and Pedal Endovascular Interventions for Critical Limb Ischemia: The Role of Atherectomy and Drug-Eluting Stents

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