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Objective: Tibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remain barriers to durability after intervention. The aim of this study was to examine the patient-centered outcomes of open and endovascular reintervention for symptomatic recurrent disease after a primary isolated tibial endovascular intervention., Methods: A database of patients undergoing isolated primary lower extremity tibial endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with recurrent critical ischemia (Rutherford 4 and 5) were identified. Outcomes in this cohort were analyzed, and three groups were defined: endovascular reintervention (ie, a repeated tibial or pedal endovascular intervention), bypass (bypass to a tibial or pedal vessel), and primary amputation (ie, above- or below-knee amputation) on the ipsilateral leg. Patient-oriented outcomes of clinical efficacy (absence of recurrent signs or symptoms of critical ischemia, 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, such as new bypass graft or jump or interposition graft revision) were evaluated after the reintervention., Results: There were 1134 patients (56% male; average age, 59 years) who underwent primary tibial intervention for critical ischemia, and 54% presented with symptomatic restenosis and occlusion. Of the 513 patients with recurrent disease, 58% presented with rest pain and the remainder with ulceration. A repeated tibial endovascular intervention was performed in 64%, open bypass in 19%, and below-knee amputation in 17%. Bypass was employed in patients with a good target vessel, venous conduit, and good pedal runoff. Patient-centered outcomes were better in the bypass group compared with the reintervention group (amputation-free survival, 45% ± 9% vs 27% ± 9% [P < .01]; major adverse limb events, 50% ± 9% vs 31% ± 9% [P < .05]; clinical efficacy, 60% ± 7% vs 30% ± 9% [P < .01], mean ± standard error of the mean at 5 years)., Conclusions: Tibial interventions for critical ischemia are associated with a high rate of reintervention. In patients with good target vessel, venous conduit, and good pedal runoff, bypass appears more durable than repeated tibial endovascular intervention., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of pedal runoff on patient-centered outcomes after tibial endovascular intervention., Methods: A database of patients undergoing lower extremity endovascular interventions at a single urban academic medical center between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford 5 and 6) were identified. Preintervention angiograms were reviewed in all cases to assess pedal runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, half or less of the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1-10). Two runoff score groups were identified: good vs poor, <7 and ≥7, respectively. Patient-oriented 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., Results: There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia, with a mean of two vessels treated per patient and a mean pedal runoff score of 6 (47% had a runoff score ≥7). Overall major adverse cardiac events were equivalent at 30 days after the procedure in both groups. At 5 years, vessels with compromised runoff (score ≥7) had significantly lower ulcer healing (25% ± 3% vs 73% ± 4%, mean ± standard error of the mean [SEM]) and a lower 5-year limb salvage rate (45% ± 6% vs 69% ± 4%, mean ± SEM) compared with those with good runoff (score <7). Patients with poor pedal runoff (score ≥7) had significantly lower clinical efficacy (23% ± 8% vs 38% ± 4%, mean ± SEM), amputation-free survival (32% ± 6% vs 48% ± 5%, mean ± SEM), and freedom from major adverse limb events (23% ± 9% vs 41% ± 8%, mean ± SEM) at 5 years compared with patients with good runoff (score <7)., Conclusions: Pedal runoff score can identify those patients who will not achieve ulcer healing and patient-centered outcomes after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Tibial interventions for critical limb ischemia are frequent in patients with end-stage renal disease (ESRD) presenting with critical ischemia. The aim of this study was to examine impact of ESRD on the patient-centered outcomes following tibial endovascular Intervention for rest pain., Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with rest pain (Rutherford 4) were identified. Patients with claudication (Rutherford 1 to 3) and tissue loss (Rutherford 5 and 6) were excluded. Patients were categorized by the presence or absence of ESRD. 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 (MALEs; above ankle amputation of the index limb or major reintervention new bypass graft, jump/interposition graft revision) were evaluated., Results: A total of 829 patients (56% male, average age 59 years; 658 nonhemodialysis [non-HD] and 171 HD) underwent isolated tibial intervention in one leg for rest pain. Technical success was 99% with a median of 2 vessels treated per patient. There was no difference in the distribution of Trans-Atlantic Inter-Society Consensus I lesions, but both the modified Society for Vascular Surgery (SVS) runoff score and the pedal runoff score were worse in the HD group. The 30-day major adverse cardiac events and 30-day MALEs were equivalent in both groups. CE was 38 ± 9% and 19 ± 8% at 5 years for the non-HD and HD groups, respectively (P < 0.01). Overall, AFS was 45 ± 8% and 18 ± 9% at 5 years for the non-HD and HD groups, respectively (P < 0.01). Freedom from MALE was 41 ± 9% and 21 ± 8% at 5 years for the non-HD and HD groups, respectively (P < 0.01)., Conclusions: Patients with ESRD who present with rest pain have equivalent short-term outcomes to those not on dialysis but do not achieve long-term satisfactory CE and AFS after isolated tibial intervention for rest pain., (Copyright © 2017 Elsevier Inc. All rights reserved.)