Javier E. Anaya-Ayala, Mitul S. Patel, Matthew K. Adams, Christopher J. Smolock, Joseph J. Naoum, Jean Bismuth, Eric K. Peden, Alan Lumsden, Mark G. Davies
Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston, TX.
OBJECTIVES: To examine the outcomes of tibial endovascular interventions with respect to ulcer healing and prevention of major limb loss.
METHODS: A database of patients between 2001 and 2011 was queried. Patients presenting with tissue loss (Rutherford class 5 and 6) were selected. Immediate success of the intervention was defined as healing of the ulcer or a successful forefoot amputation after intervention. Clinical efficacy was defined as absence of recurrent symptoms, maintenance of ambulation and absence of major amputation.
RESULTS: Two-hundred forty-eight limbs in 245 patients (60% male, mean age 67) underwent tibial artery interventions for tissue loss. 68% had diabetes, 63% hyperlipidemia and 24% chronic renal insufficiency. The mean patent tibial vessels at presentation were 1.2±0.6 (SD). Seventy-six percent of the tibial lesions were TASC C. Technical success was 98% with a mean of 2 vessels treated per patient. 388 tibials were treated. Overall mortality was 1% and overall morbidity was 14% at 90 days after the procedure. Seventy-six percent of ulcers healed after the intervention at a mean of 9 months. Thirty-four percent required either toe or trans-metatarsal amputation, while 24% of the limbs underwent major amputation. Cumulative patency was 68±5% at five years. Thirty-one percent of patients necessitated two or more re-interventions. At 5 years, freedom from ulcer recurrence and major limb amputations were 54±4% and 48±6%, respectively. Clinical efficacy was 34±4% at 5 years. On Cox proportional hazard analysis, greater tissue loss at presentation, BMI>30, diabetes, hemodialysis, low mobility at presentation, higher tibial TASC lesion and poor pedal runoff were associated with decreased ulcer healing and lower limb salvage.
CONCLUSIONS: Tibial interventions do allow for ulcer healing within one year with a low mortality and morbidity; however, one in four patients will require a major amputation within 5 years.
AUTHOR DISCLOSURES: M. K. Adams, Nothing to disclose; J. E. Anaya-Ayala, Nothing to disclose; J. Bismuth, Nothing to disclose; M. G. Davies, Nothing to disclose; A. Lumsden, Nothing to disclose; J. J. Naoum, Nothing to disclose; M. S. Patel, Nothing to disclose; E. K. Peden, Nothing to disclose; C. J. Smolock, Nothing to disclose.
Posted April 2012