Effect of Lesion Characteristics and Tibial Vessel Run-off on Outcome of Lower Extremity Percutaneous Interventions

Brian G. DeRubertis, MD, Rabih A. Chaer, MD, Susan Trocciola, MD, Russell Lam, MD, James McKinsey, MD, John Karwowski, MD, Nicholas J. Morrissey, MD, K. Craig Kent, MD and Peter L. Faries, MD
New York Presbyterian - Weill Cornell Medical College, New York, NY

Objectives: Percutaneous endovascular therapy is being used with increased frequency as a fist-line modality for lower extremity occlusive disease. Although percutaneous treatment is an acceptable alternative to open surgical bypass, it is unclear which patients are best suited for this modality. This study analyzed factors predictive of successful treatment outcomes, focusing specifically on lesion characteristics and distal tibial runoff.
Methods: We retrospectively reviewed treatment modality, lesion characteristics, complications, and outcomes for percutaneous interventions performed for peripheral occlusive disease between 2002-2006. Lesion characteristics and tibial vessel run-off were assessed by angiography, and lesions were graded according to the Trans-Atlantic Inter-Society Consensus (TASC) criteria. Patency (assessed arterial duplex) was expressed by Kaplan-Meier method and log-rank analysis. Mean follow-up was 13.2 months (range 1 to 54 months).
Results: A total of 292 interventions for peripheral occlusive disease with claudication (51%), rest pain (12%), or tissue loss (37%) were analyzed, including 247 primary interventions and 45 re-interventions in 210 patients (mean age 73 years, 57% male). Comorbidities included DM (47%), CRI (16%), hemodialysis (4%), HTN (77%), hypercholesterolemia (47%), CAD (49%), tobacco use (76%). TASC lesion grades on available patients included: A (2.5%), B (27.1%), C (48.4%) and D (22%). Isolated femoral, popliteal, and tibial intervention was performed in 39%, 4.5%, and 25.4% of patients respectively, while combined femoropopliteal, femorotibial, popliteal-tibial, and 3-level disease (both femoropopliteal and tibial) intervention was performed in 24.7%, 2.7%, 4.1%, and 15% of patients, respectively. Overall primary patency (± SE) at 6, 12 and 18 months was 88.1±0.02%, 74.0±0.04% and 64.4±0.05% respectively. Primary assisted patency at 6, 12 and 18 months was 90.1±0.02%, 85.4±0.03 and 81.9±0.03% respectively. Secondary patency at 6, 12 and 18 months was 96.2±0.01%, 91.7±0.02%, and 87.8±0.03%. One-year limb salvage rate was 87% for patients with limb-threatening ischemia. Lesion characteristics significantly affected patency on log-rank analysis (Figure 1), as increasing TASC severity was inversely related to patency (TASC B: 79.2±0.08%, C: 77.6±0.05%, D: 54.0±0.09%; P=.02 for TASC B+C v TASC D). Tibial vessel run-off was directly related to patency (3 vessel: 83.2±0.06%, 2 vessel: 76.2±0.07%, 1 vessel: 59.±0.08%, P<0.01, Figure 2).
Conclusions: While percutaneous treatment of lower extremity occlusive disease is an acceptable alternative to open surgical bypass in selective patients, patients with more complex lesions (TASC C and D) and poor distal tibial vessel run-off demonstrate reduced patency rates. These patients may be considered for earlier surgical bypass if medical condition permits.