One-year Outcomes Among Patients Undergoing Tibial Endovascular Reinterventions for Recurrent Critical Limb Ischemia

Abstract

Angioplasty, stenting, and atherectomy for tibial occlusive disease are commonly performed among critical limb ischemia patients, but restenosis and occlusion significantly hinder long-term durability. For patients requiring reintervention for recurrent tibial occlusive disease, the impact on clinical benefit and patency equivalence is unclear. We compared 1-year outcomes following repeat tibial endovascular intervention(s) to the first (primary) tibial endovascular intervention. Procedural and long-term data from the Vascular Quality Initiative database were queried for patients with critical limb ischemia (Rutherford Class 4-6) undergoing endovascular intervention for isolated tibial occlusive disease (2010-2020). Outcomes included 1-year change from baseline in ambulatory status, functional status (Eastern Cooperative Oncology Group), disposition, minor amputation, and major adverse outcomes (death, below-knee amputation, above-knee amputation). Statistically significant and clinically relevant variables were included in multivariate logistic regression. We included 1871 patients underwent primary isolated tibial endovascular intervention for critical limb ischemia. Of those, 433 (23.1%) patients underwent tibial endovascular reintervention for recurrent disease (tissue loss 35.0%). 81.6% and 14.5% of patients underwent angioplasty and atherectomy, respectively, for primary intervention. Patients requiring repeat intervention(s) had significantly decreased clinical improvement after primary intervention (67.4% vs 77.9%; P < .001) and repeat intervention (67.8% vs 77.9%; P < .001) compared to patients with no reintervention (Table). Among the three groups, a minority of patients achieved improvement in functional status (22.2% vs 20.7% vs 21.9%; P = .84) and ambulatory status at 1-year (20.0% vs 18.6% vs 17.1%; P = .54). Approximately 50% of patients were fully ambulatory at 1 year (Table). After multivariate adjustment, patients with reintervention were 50% less likely to have a patent target vessel at 1-year after primary endovascular treatment vs patients having no reintervention (odds ratio [OR], 0.50; 95% CI, 0.31-0.79; P = .03). Patients with reintervention were also found to have increased risk for minor amputation compared to patients without reintervention (OR, 1.64; 95% CI, 1.20-2.23; P = .002). Repeat interventions significantly increased risk of minor amputation at 1-year compared to primary intervention (OR, 2.41; 95% CI, 1.53-3.80; P < .001). There was no significant difference in death or major amputation (below or above knee) (Table). Atherectomy was associated with significant reduction in high-grade stenosis at 1 year (>50%) after primary treatment compared to angioplasty (OR, 0.097; 95% CI, 0.018-0.52; P = .006). Major adverse outcomes after repeat endovascular tibial intervention for recurrent tibial occlusive disease were similar to those after primary tibial endovascular intervention. However, patients with recurrent tibial occlusive disease requiring reintervention had decreased symptom improvement after primary and repeat treatment, decreased target lesion patency, and increased risk of minor amputation.TableOne-year outcomes following tibial endovascular intervention for critical limb ischemiaPrimary endovascular intervention (no future intervention), n = 1438Primary endovascular intervention (future reintervention), n = 433Repeat endovascular intervention (2+ interventions), n = 143P valueDeath335 (23.3)86 (19.9)39 (27.3).14Symptom improvementn = 1094n = 380n = 115 Regression72 (6.6)35 (9.2)13 (11.3)<.001 No change170 (15.5)89 (23.4)24 (20.9) Improvement852 (77.9)256 (67.4)78 (67.8)Patency (patent)755/827 (91.3)259/298 (86.9)77/89 (86.5).05>50% Stenosis27/160 (16.9)14/75 (18.7)2/20 (10.0).66Functional status changen = 517n = 198n = 64.87 Regression173 (33.5)72 (36.4)25 (39.1) No change229 (44.3)85 (42.9)25 (39.1) Improvement115 (22.2)41 (20.7)14 (21.9)Ambulation status (ambulatory)565/1075 (52.6)200/377 (53.1)60/112 (53.6).69Ambulatory status changen = 1072n = 377n = 111.54 Regression303 (28.3)113 (30.0)26 (23.4) No change555 (51.8)194 (51.5)66 (59.5) Improvement214 (20.0)70 (18.6)19 (17.1)Disposition changen = 358n = 137n = 40.28 Needs advanced care206 (57.5)68 (49.6)23 (57.5) No change152 (42.5)69 (50.4)17 (42.5)Postoperative ABI1.15 ± 0.501.12 ± 0.541.09 ± 0.62.63Amputationn = 1168n = 396n = 118 All cause370 (31.7)152 (38.4)56 (47.5)<.001 Below knee173 (14.8)58 (14.6)15 (12.7).83 Above knee44 (3.8)16 (4.0)8 (6.8).29 Minor amputation (toe/ray/transmetatarsal)153 (16.1)78 (24.2)33 (34.7)<.001Values are number (%) or mean ± standard deviation. Open table in a new tab