Cheun Tracey J, Hart Joseph P, Davies Mark G
Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Anesthesia, Long School of Medicine, San Antonio, TX.
Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI.
Ann Vasc Surg. 2025 Mar;112:266-277. doi: 10.1016/j.avsg.2024.12.038. Epub 2024 Dec 25.
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.
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.
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).
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.
针对慢性肢体威胁性缺血（CLTI）的胫骨介入治疗如今已很常见，足部血流灌注不佳与更差的预后相关。本研究旨在探讨改善足部血流灌注不佳的足部介入治疗对胫骨介入治疗后预后的影响。
回顾性查询2010年至2022年在单一中心接受CLTI胫骨介入治疗的患者数据库。确定患有严重缺血（卢瑟福分级5级和6级）的患者。对所有病例的术前和术后血管造影进行评估以评估足部血流灌注（共10例），从而形成两个血流灌注评分组，如下：良好与不佳，分别为<7分和≥7分。是否进行足部介入治疗将血流灌注不佳组进一步细分。评估3个月时的伤口愈合情况、无截肢生存率（AFS；无大截肢的生存）以及无主要肢体不良事件（MALE；指数肢体的踝关节以上截肢或主要再次干预（新的旁路移植和跳跃或间置移植修复））。
1768例CLTI患者（63%为男性，年龄67±12岁，均值±标准差）接受了平均2条胫骨血管的单纯胫骨介入治疗。所有患者均患有伤口、缺血和足部感染（WIfI）3级和4级疾病。术前，40%的病例足部血流灌注良好（4.4±1.1，均值±标准差），38%的病例足部血流灌注不佳且未进行足部介入治疗（8.6±0.8；与血流灌注良好组相比，P = 0.01），22%的病例足部血流灌注不佳且同时进行了足部介入治疗（8.7±0.6；与血流灌注良好组相比，P = 0.01）。平均对2条跗骨血管进行了足部介入治疗，技术成功率为91%，总体上改善了足部血流灌注（6.5±2.1；与术前相比，P = 0.01）。与足部血流灌注不佳且未进行足部介入治疗的组相比，成功进行了同时性足部介入治疗的患者30天MALE发生率（7%对12%；P = 0.001）和30天截肢率（5%对11%；P = 0.001）有所改善，且与足部血流灌注良好且未进行足部介入治疗的组相当（分别为7%和5%）。与足部血流灌注不佳且未进行足部介入治疗的组（25%；P = 0.001）相比，进行了介入治疗的足部血流灌注不佳组3个月时溃疡愈合情况有所改善（55%），但仍显著低于足部血流灌注良好组（73%）。在足部血流灌注不佳的患者中，5年时足部介入治疗改善了无MALE情况（41±8%对17±8%，均值±均值标准误（SEM）；P = 0.008）和AFS（38±6%对11±6%，均值±SEM；P = 0.003），且这些与足部血流灌注良好组相当（分别为46±4%和51±5%，均值±SEM；无MALE情况和AFS）。
在CLTI胫骨介入治疗期间，对足部血流灌注不佳的患者进行同时性足部介入治疗以改善足部血流灌注，可改善短期和长期预后，应考虑用于有效的肢体挽救。
