Outcomes of Reintervention after Tibial Endovascular Intervention

Tibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remains barrier to durability after intervention. The aim of this study was to examine the patient centered outcomes of reintervention following tibial endovascular Intervention. 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. Patient-orientated outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation) and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. A total of 1134 patients (56% male, average age 59 years) underwent tibial intervention for critical ischemia and 54% presented with symptomatic restenosis and occlusion, Of the 513 patients with restenosis, 58% presented with rest pain; the remainder with ulceration. A repeat tibial endovascular intervention was performed in 64%, below-knee amputation in 17%, open bypass in 19%. Bypass was employed in patients with a good target vessel, venous conduit, and good pedal runoff. Although primary and repeat tibial interventions had equivalent patency and early symptom relief, longer term patient-centered outcomes were worse in the reintervention group (Table). Those undergoing bypass had significantly superior outcomes albeit with a higher major adverse cardiovascular event (Table). The rate of repeat intervention after the first reintervention was 56%. Presentation with new onset ulceration, Hispanic, diabetes, end-stage renal disease, and poor pedal runoff were significant poor predictors for clinical efficacy and amputation-free survival. Tibial interventions for critical ischemia are associated with a high rate of reintervention and in patients with good target vessel, venous conduit and good pedal runoff bypass appears more durable than repeat tibial endovascular intervention.TableOutcomesPrimary endovascular interventionsRepeat endovascular interventionsBypass after primary interventionNumber limbs at risk, n113432997Male sex, %56%55%50%Age, mean ± SD, years59 ± 1162 ± 1260 ± 10High-risk PIII score (%)18%25%10%b,cMortality (%)1%4%∗4%aMorbidity (%)3%7%∗11%a,c5-year CE, mean ± SEM%48 ± 430 ± 768 ± 9a,d5 year AFS, mean ± SEM%45 ± 327 ± 9∗65 ± 7a,d5-year MALE, mean ± SEM%50 ± 541 ± 6∗60 ± 8a,cAFS, Amputation-free survival; CE, clinical efficacy; MALE, major adverse limb event; SEM, standard error of the mean.aP < .05 and bP < .01 compared with primary intervention; cP < .05 and dP < .01 compared with repeat endovascular intervention. Open table in a new tab