title: Tibial angioplasty for limb salvage in high-risk patients and cost analysis.
abstract: BACKGROUND
  We examined the efficacy and cost of tibial angioplasty in patients with critical limb ischemia (CLI) at high operative risk.
  
  
  METHODS
  A retrospective analysis of all consecutive patients who underwent tibial angioplasty with critical ischemia Rutherford class 4 and 5 from January 2001 to April 2007 was performed. Demographic information, presentation, and angiographic characteristics of the lesions were analyzed. The primary end point was freedom from major amputation. Secondary end points were overall survival and recurrence. Cost comparison was performed between the endovascular group and a matched group of high-risk patients submitted to femoral tibial bypass in the same period.
  
  
  RESULTS
  Forty-five patients, with mean age of 69.6 years and a 2.5:1 (male:female) ratio, had 49 limbs treated. The mean follow-up was 7.7 months (range 1-61.5). Eighty percent of the patients were Rutherford class 5. Incidence rates were as follows: diabetes 90%, chronic renal failure 73%, end-stage renal disease (ESRD) on hemodialysis 45%, and coronary disease 69%. Single vessel run-off to the foot was present in 57% of patients and complete occlusion of all tibial vessels in 12%. Only the tibial vessels were angioplastied in 55% of patients. Angiographic success rate was 84%. Thirty-day mortality was 2% and major complications occurred in 6.1%. A poor angiographic result was a statistically significant predictor (p = 0.009) of symptomatic recurrence (43%) (worsening of preexisting symptoms and/or signs or new ones). Cardiac disease was the major cause of mortality beyond 30 days (12.5%). Freedom from major amputation in the entire group was 75.5%, with no difference between tibial and diffuse infrainguinal angioplasty (p = 0.61). Recurrence, especially early recurrence, was a significant predictor of amputation (p = 0.04 and p = 0.0008, respectively). There was a trend toward presence of ESRD and recurrence (p = 0.06). Both average hospital cost ($2,910.60 vs. $17,703.50) and length-of-stay (LOS) (<1 vs. 9 days) were significantly reduced in the angioplasty group (p < 0.0001).
  
  
  CONCLUSIONS
  Tibial angioplasty has acceptable rates of limb salvage in patients with CLI considered to be at high risk for surgery, despite high recurrence rates. The presence of diabetes or ESRD did not reduce the rate of success in this series, although ESRD seemed to predict recurrence. The procedure has low morbidity and mortality with lower cost and LOS compared with open revascularization. Aggressive angioplasty should be an option to patients who otherwise would face primary amputation.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, UHN, University of Toronto, Toronto, Canada. cwerneck@thc.on.ca
authors.forename: Christiane C F
authors.initials: CC
authors.lastname: Werneck
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Lindsay
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000191:economics; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D016638:Critical Illness; D048909:Diabetes Complications / Q000191:economics / Q000628:therapy; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000191:economics* / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000150:complications / Q000191:economics / Q000628:therapy; D007902:Length of Stay; D023821:Limb Salvage / Q000191:economics*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D016016:Proportional Hazards Models; D011859:Radiography; D012008:Recurrence; D006435:Renal Dialysis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D016909:Tibial Arteries / Q000000981:diagnostic imaging / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality