title: Clinical efficacy of concomitant tibial interventions associated with superficial femoral artery interventions in critical limb ischemia.
abstract: BACKGROUND
  Combined superficial femoral artery (SFA) and tibial angioplasty (TA) are a common treatment for critical limb ischemia. Poor tibial runoff significantly compromises durability and clinical effectiveness of SFA interventions. The aim of this study is to determine clinical and anatomic outcomes of SFA interventions in patients with equally compromised runoff, with and without concomitant TA.
  
  
  METHODS
  The database of patients undergoing endovascular treatment of SFA (1999-2009) was retrospectively queried. Patients with poor runoff, scored>10 by modified Society for Vascular Surgery criteria, were selected. Preoperative angiograms were reviewed to assess distal popliteal and tibial runoff. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed for time-dependent variables.
  
  
  RESULTS
  A total of 162 limbs with a runoff score>10 (56% men; average age, 69 years) underwent endovascular intervention for symptomatic SFA disease: 61 (54% men) underwent TA but the remaining 101 (57% men) did not. The groups were matched for age, sex, and SFA anatomy (Trans-Atlantic Inter-Society Consensus II C/D lesions: 56% no TA vs 62% TA; P=.5). Presenting symptoms were similar between no TA and TA groups (rest pain: 40% vs 32%; tissue loss: 60% vs 68%; P=.3). Three-year survival favored the TA group (79%±5%) vs no TA (68%±5%; P=.06). Three-year anatomic outcomes in no TA vs TA group, including primary patency (45%±6% vs 63%±8%; P=.04), assisted primary patency (55%±6% vs 75%±7%; P=.03), and secondary patency (57%±6% vs 77%±7%; P=.03) were all superior in the TA group. Target vessel revascularization in no TA vs TA (61%±6% vs 74%±8%; P=.002) and target extremity revascularization (42%±6% vs 59%±8%; P=.06) also favored the TA group. However the comparison of no TA vs TA for clinical success (39%±6% vs 47%±8%; P=.6), freedom from recurrent symptoms (59%±6% vs 60%±9%; P=.1), amputation-free survival (46%±5% vs 63%±7%; P=.06), and limb salvage at 3 years (63%±6% vs 74%±7%; P=.6) were similar.
  
  
  CONCLUSIONS
  TA in patients with poor runoff has a positive effect on SFA anatomic outcomes. However, clinical success was not affected. Concomitant TA appears not to add clinical benefit to SFA intervention in critical limb ischemia.
authors.affiliation: Methodist DeBakey Heart & Vascular Center, Department of Cardiovascular Surgery, The Methodist Hospital, Houston, TX 77030, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Smolock
authors.forename: Javier E
authors.initials: JE
authors.lastname: Anaya-Ayala
authors.forename: Hosam F
authors.initials: HF
authors.lastname: El-Sayed
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Naoum
authors.forename: Alan B
authors.initials: AB
authors.lastname: Lumsden
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D017130:Angioplasty / Q000009:adverse effects; D016638:Critical Illness; D005163:Factor Analysis, Statistical; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011859:Radiography; D012008:Recurrence; D012189:Retrospective Studies; D016909:Tibial Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency