title: Multilevel versus isolated endovascular tibial interventions for critical limb ischemia.
abstract: OBJECTIVE
  Endovascular interventions for critical limb ischemia (CLI) continue to have variable reported results. The purpose of this study is to determine the effect of disease level and distribution on the outcomes of tibial interventions.
  
  
  METHODS
  A retrospective analysis of all tibial interventions done for CLI between 2006 and 2009 was performed. Outcomes of isolated tibial (group I) and multilevel interventions (group II) (femoropopliteal and tibial) were compared.
  
  
  RESULTS
  Endovascular interventions were utilized to treat 136 limbs in 123 patients for CLI: 54 isolated tibial (85% tissue loss), and 82 multilevel (80% tissue loss). Mean age and baseline comorbidities were comparable. The mean ankle-brachial index (ABI) was significantly lower prior to intervention in group II (0.53 vs 0.74; P < .001) but was similar postintervention (0.86 vs 0.88; P = NS). Wound healing or improvement was achieved in 69% in group I and in 87% in group II (P = .05). Mean overall follow-up was 12.6 ± 5.3 months. Time to healing was significantly longer in group I: 11.5 ± 8.8 months vs 7.7 ± 6.6 months (P = .03). Limb salvage was achieved in 81% of group I and 95% of group II (P = .05). The rate of reintervention was similar (13% vs 18%, P = NS), so was the rate of late surgical conversion (0% vs 6%; P = NS). Limb loss resulted from lack of conduit or initial target vessel for bypass and high-risk systemic comorbidities. Overall mortality rates were similar among both groups. An isolated tibial intervention was a predictor of limb loss at 1 year on multivariate analysis and resulted in a lower rate of limb salvage at 1 year compared with multilevel interventions. Additionally, despite comparable primary patency rates, there was improved secondary patency with multilevel interventions compared with the isolated tibial interventions. Predictors of limb loss in patients treated with isolated tibial intervention included multiple synchronous tibial revascularization (P = .005) and advanced coronary artery disease requiring revascularization (P = .005).
  
  
  CONCLUSIONS
  Adequate rates of limb salvage can be achieved in patients undergoing multilevel interventions for CLI, and improved patency is seen with multilevel compared to isolated tibial interventions. Patients with isolated tibial disease appear to have a higher incidence of limb loss secondary to poor initial pedal runoff, more extensive distal disease, and severe comorbidities precluding surgical bypass. Other therapeutic strategies should be considered in these patients, including primary amputation or pedal bypass when applicable.
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
authors.forename: Nathan
authors.initials: N
authors.lastname: Fernandez
authors.forename: Ryan
authors.initials: R
authors.lastname: McEnaney
authors.forename: Luke K
authors.initials: LK
authors.lastname: Marone
authors.forename: Robert Y
authors.initials: RY
authors.lastname: Rhee
authors.forename: Steven
authors.initials: S
authors.lastname: Leers
authors.forename: Michel
authors.initials: M
authors.lastname: Makaroun
authors.forename: Rabih A
authors.initials: RA
authors.lastname: Chaer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D055109:Ankle Brachial Index; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D003251:Constriction, Pathologic; D016638:Critical Illness; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D005263:Femoral Artery / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010414:Pennsylvania; D011150:Popliteal Artery / Q000503:physiopathology / Q000601:surgery; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016909:Tibial Arteries / Q000503:physiopathology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures; D014945:Wound Healing