Concomitant Pedal Interventions Improve Outcomes for Tibial Interventions in Chronic Limb-Threatening Ischemia

Background: Tibial interventions for chronic limb-threatening ischemia (CLTI) are now commonplace, and poor pedal runoff is associated with worse outcomes. This study aimed to examine the impact of pedal interventions to improve poor pedal runoff on the outcomes following tibial interventions. Methods: A database of patients undergoing tibial interventions for CLTI at a single center between 2010 and 2022 was retrospectively queried. Patients with critical ischemia (Rutherford 5 and 6) were identified. Preintervention and postintervention angiograms were reviewed in all cases to assess pedal runoff (total = 10), resulting in 2 run-off score groups as follows: good versus poor, <7 and > 7, respectively. The presence or absence of a pedal intervention then segmented the poor runoff group. Outcomes of wound healing at 3 months, amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention (new bypass graft and jump or interposition graft revision) were evaluated. Results: 1,768 patients (63% male, age 67 +/- 12 years, mean +/- SD) with CLTI underwent isolated tibial intervention on a median of 2 tibial vessels. All patients had Wound, Ischemia, and foot Infection (WIfI) grade 3 and 4 disease. Preoperatively, 40% of cases had good runoff (4.4 +/- 1.1, mean +/- SD), 38% had poor runoff and no pedal intervention (8.6 +/- 0.8; P = 0.01 compared to good runoff), and 22% had poor runoff with a concomitant pedal intervention (8.7 +/- 0.6; P = 0.01 compared to good runoff). Pedal intervention was performed on a median of 2 tarsal vessels with a technical success of 91% and overall improved pedal runoff (6.5 +/- 2.1; P = 0.01 vs. preoperative). Patients with a successful concomitant pedal intervention had improved 30-day MALE rate (7% vs. 12%; P = 0.001) and 30-day amputation rate (5% vs. 11%; P = 0.001) compared to the poor runoff and no pedal intervention group and were comparable to the good runoff and no pedal intervention group (7% and 5%, respectively). Ulcer healing at 3 months was improved in the poor runoff group with intervention (55%) compared to the poor runoff and no pedal intervention group (25%; P= 0.001) but remained significantly below the good runoff group (73%). At 5 years in patients with poor runoff, pedal intervention improved freedom from MALE (41 +/- 8% vs. 17 +/- 8% mean +/- standard error of the mean (SEM); P = 0.008) and AFS (38 +/- 6% vs. 11 +/- 6%, mean +/- SEM; P = 0.003) and these were equivalent to the good runoff group (46 +/- 4% and 51 +/- 5%, mean +/- SEM; freedom from MALE and AFS, respectively). Conclusion: Concomitant pedal intervention to improve pedal runoff in patients with poor pedal runoff during a tibial intervention for CLTI results in improved short-term and long-term outcomes and should be considered for effective limb salvage.