The Importance of Patency of Tibial Run Off Arteries on Clinical Outcomes After Stenting for Chronic Total Occlusions in the Superficial Femoro-popliteal Artery

Abstract

WHAT THIS PAPER ADDS After angioplasty of an occluded superficial femoral or popliteal artery, interventionalists face the dilemma of what to do with occlusive disease of the tibial arteries. This study shows that the patency of the tibial arteries is an important predictor of mid-term patency of the femoropopliteal artery and that a successful tibial percutaneous transluminal angioplasty improves clinical outcome. These findings suggest that percutaneous transluminal angioplasty for chronic total occlusions in the superficial femoropopliteal artery should be accompanied by an effort to improve tibial runoff.Objective/background: The aim was to evaluate the impact of patent tibial arteries on stenting for chronic total occlusions (CTO) in superficial femoropopliteal artery (SFA) lesions. Additionally, the efficacy of additive tibial percutaneous transluminal angioplasty (PTA) was evaluated. Methods: A total of 238 limbs in 199 patients with de novo SFA CTO lesions treated with bare nitinol stents between 2009 and 2015 were retrospectively identified. These limbs were divided into two groups (group A [number of patent tibial arteries at baseline angiogram ! 2, 127 limbs in 104 patients] vs. group B [number of patent tibial arteries at baseline angiogram 1, 111 limbs in 95 patients]). Furthermore, the efficacy of additive tibial PTA on stenting for SFA CTO lesions was evaluated by comparing subgroups (group B with tibial PTA vs. without tibial PTA). The primary end point was freedom from major adverse limb events (MALE) two years after PTA, defined as a composite of ischaemic driven target lesion revascularisation (TLR) and major amputation. Results: Group A had a significantly higher MALE free survival rate two years after PTA compared with group B (80.9% vs. 43.5%; p < .001), which was mainly driven by higher TLR free survival rates (80.9% vs. 45.9%; p < .001). In subgroup analysis, patients in group B with tibial PTA had significantly higher MALE free survival rate at two years compared with those without tibial PTA (65.5% vs. 26.2%; p ¼ .001). Conclusion: The presence of patent tibial arteries was an important predictor of MALE after PTA for SFA CTO lesions. Furthermore, additional tibial PTA on SFA CTO stenting might be beneficial for clinical outcomes.

Cardiovascular and Limb Events Following Endovascular Revascularization Among Patients ≥65 Years Old: An American College of Cardiology PVI Registry Analysis

“… 1 Certain characteristics have been demonstrated to confer higher risk of major adverse cardiovascular events (MACE) or major adverse limb events (MALE) following PVI, such as diabetes, 2 , 3 , 4 chronic kidney disease (CKD), 5 , 6 concomitant coronary artery or cerebrovascular disease, 7 , 8 and certain lesion characteristics. 2 , 9 , 10 , 11 However, the relationships between these factors have not been well explored in high‐quality, multi‐center data sets, with most reports focusing instead on the contribution of isolated high‐risk features to outcomes. 3 , 4 , 6 , 9 , 10 , 11 Other studies have described contributions of multiple risk factors, though with limited outcomes, single center data, or with minimal PAD‐ and procedure‐specific data.…”

Pre-procedural color duplex ultrasound evaluation predicts restenosis after long-segment superficial femoral artery stenting

“…A study demonstrated that additional angioplasty of poor runoff vessels is beneficial for clinical outcomes of SFA stenting; they defined the runoff according to the number of patent tibial arteries detected on the baseline angiogram. 8 The current study suggests a more precise approach that patients with poor runoff (runoff score >10), may benefit from additional methods to help increase patency such as angioplasty of the runoff tibial vessels, although this clearly requires additional study and validation.…”

“…Runoff affects the result of SFA interventions, 8,11,20 but there is little quantitative data describing the impact of runoff on the patency of long-segment SFA stents. We followed up the long-segment stents using ultrasound, determining the quality of the runoff with modified SVS criteria; 13 binary ISR was significantly higher in patients with poor quality outflow vessels (runoff score > 10) (Figure 3(b)).…”

“…Although some risk factors of ISR after SFA stent placement have been extensively investigated such as age, diabetes mellitus, hemodialysis, and tibial runoff arteries, [8][9][10] there are relatively few data about the predictors for long-segment SFA lesions to guide clinical practice. Furthermore, most studies evaluate lesions with computed tomography angiography (CTA) or digital subtraction angiography (DSA).…”

A Plumbing Principle for Vascular Surgeons

“…This principle is well known by plumbers and stated in the plumbing principle of the World Health Organisation 1 : "drains should be of adequate capacity and should be designed, constructed and maintained to convey wastewater rapidly from the building without fouling, depositing solids or clogging." Watanabe et al 2 have highlight the validity of this plumbing principle in vascular surgery. The authors compared the outcomes of stenting for femoropopliteal recanalisation according to the runoff status ( 2 patent tibial vessels versus 1 patent tibial vessel).…”