title: Increased preoperative pulse pressure predicts procedural complications and mortality in patients who undergo tibial interventions for critical limb ischemia.
abstract: BACKGROUND
  Pulse pressure is a noninvasive measure of arterial stiffness. Increased pulse pressure is associated with an increased risk of cardiovascular events and death. The effects of pulse pressure on outcomes after endovascular interventions for critical limb ischemia (CLI), however, are unknown. We thus evaluated whether increased preoperative pulse pressure was associated with adverse outcomes and mortality in patients who underwent endovascular tibial artery intervention.
  
  
  METHODS
  All patients who underwent endovascular tibial intervention for CLI at a single institution from 2004 to 2014 were included in this study. Preoperative pulse pressure was derived from measurements obtained in the holding area before the procedure. Patients were divided into two groups on the basis of pulse pressure, <80 or ≥80 mm Hg. Patient demographic characteristics and comorbidities were documented, and outcomes including procedural complications, repeat intervention, amputation, and mortality were recorded. Multivariable logistic regression was used to account for patient demographic characteristics and comorbidities.
  
  
  RESULTS
  Of 371 patients, 186 patients had a preoperative pulse pressure <80 mm Hg and 185 had a preoperative pulse pressure ≥80 mm Hg. No significant differences in patient demographic characteristics or comorbidities were identified; however, there was a trend toward older age in patients with increased pulse pressure (70 vs 72; P = .07). In univariate analysis, procedural complications (21% vs 13%; P = .02), reinterventions (26% vs 17%; P < .01), and restenosis (32% vs 23%; P = .03) were more common among patients with pulse pressure ≥80. Procedural complications remained significant in multivariate analysis (odds ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). There was no difference in 30-day mortality; however, increased mortality was seen at 5 years of follow-up (odds ratio, 1.6; 95% confidence interval, 1.0-2.5; P = .04) in multivariable analysis.
  
  
  CONCLUSIONS
  Increased preoperative pulse pressure is associated with procedural complications and increased mortality in patients who undergo endovascular tibial intervention for CLI. It is a marker of increased risk, and might be a suitable target for interventions aimed at improving outcomes in this high-risk population.
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Zettervall
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
authors.forename: Dominique B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Darling
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Lee
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
authors.forename: Raul J
authors.initials: RJ
authors.lastname: Guzman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D017130:Angioplasty / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D001794:Blood Pressure; D001900:Boston; D016009:Chi-Square Distribution; D016638:Critical Illness; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D016016:Proportional Hazards Models; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D016909:Tibial Arteries / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome