Print this pageImpact Of Tibial Runoff On Superficial Femoral Artery Endoluminal Interventions For Rest Pain And Tissue Loss.
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Mark G Davies*, Wael E Saad*, Eric K Peden, Imran T Mohiuddin*, Joseph J Naoum*, Alan B Lumsden
Methodist Debakey Heart Center / The Methodist Hospital, Houston, TX
Background: While aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of tibial vessel runoff on long term outcomes of these interventions in patients with rest pain and tissue loss is unclear. Runoff is known to negatively effect graft patency but no data is available on the impact of runoff on percutaneous SFA interventions
Purpose: To examine the impact of tibial runoff on longterm outcomes of SFA interventions for critical ischemia
Methods: A prospective database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried. Patients with Rutherford symptom classification 4, 5 and 6 were selected. Patients with concomitant tibial interventions were excluded. Angiograms were reviewed in all cases to assess tibial runoff. Post procedure runoff was scored according to the SVS criteria such that a higher score implies worse runoff. Three run-off score groups were identified : 10. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time dependent variables. Data are presented as mean±SEM
Results: 306 limbs in 241 patients (57% male, average age 68 years) underwent endovascular treatment for critical ischemia (44% rest pain and 56% tissue loss; Table). 89% had hypertension, 68% had diabetes mellitus, 60% had hyperlipidemia and 36% had chronic renal insufficiency (50% on hemodialysis). Technical success was 96% with 61% SFA undergoing angioplasty, 37% SFA had primary stenting and 2% SFA had an atherectomy. Overall mortality was 1% and overall morbidity was 16% at 90 days after the procedure. At 5 years, vessels with runoff scores of 5 or greater had significantly worse cumulative patency (Table). Freedom from recurrent symptoms and limb salvage were incrementally curtailed by worsening runoff with significant decreases as runoff scores went from 10 (Table).
| Runoff Score | <5 | 5-10 | >10 |
| Number Limbs at Risk | 92 | 137 | 77 |
| Rest Pain | 51% | 33% * | 30% * |
| Tissue Loss | 49% | 67% * | 70% * |
| Freedom from Recurrent Symptoms (%) | 65±8 | 39±9 * | 18±9 * † |
| Limb Salvage (%) | 65±5 | 41±4 * | 20±6 *† |
| Primary SFA Patency (%) | 61±6 | 39±6 * | 18±7 * † |
| Assisted Primary SFA Patency (%) | 64±7 | 48±8 * | 45±6 * |
| Secondary SFA Patency (%) | 82±9 | 56±4 * | 52±7 * |
Mean±SEM at five years follow up * p<0.05 compared to <5 score† p<0.05 compared to 5-10 score
Conclusions: In patients presenting with rest pain and tissue loss, who are treated with SFA percutaneous interventions, patency is negatively affected by a runoff scores of >5. More importantly, freedom from recurrent symptoms and limb salvage are incrementally curtailed as runoff scores worsen suggesting that in these patients more aggressive tibial intervention or bypass should be undertaken.
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