The Impact of Isolated Tibial Disease on Outcomes in the Critical Limb Ischemic Population

BACKGROUND: Most patients with critical limb ischemia (CLI) have multilevel infra-inguinal peripheral arterial disease (M-PAD). However, one-third of CLI patients will have isolated tibial disease (ITD). The treatments for multilevel disease or ITD differ whether open or endovascular procedures are used, but are outcomes from these procedures different? We evaluated outcomes of CLI patients who underwent open and/or endovascular revascularization for CLI and assessed the impact of disease distribution.
METHODS: Four hundred and forty-six CLI patients (Rutherford 4-6) who underwent revascularization between 2001-2005 were evaluated arteriographically and followed after revascularization with non-invasive testing. Based on arteriographic data all patients having ITD (occlusions in one or more tibial arteries) were compared to patients with occlusive femoral-popliteal disease with or without concomitant tibial occlusions (M-PAD). Patients with disease solely above the inguinal ligament were excluded. Clinical data (survival, amputation free survival, primary patency, secondary patency, limb salvage, maintenance of ambulation, and maintenance of living status) were acquired from a prospective vascular data base allowing the comparison of revascularization outcomes according to disease distribution.
RESULTS: In this study, 36% of patients had ITD and 64% presented with M-PAD. The severity of ischemia at presentation was: rest pain (28.5%), ulceration (42.3%), and gangrene (29.1%). In this study, 92% presented exclusively with infra-inguinal disease, and 8% presented with both supra and infra-inguinal disease. Risk factors included: Diabetes Mellitus (61.2%), smoking (61.0%), CAD (57.9%), HTN (84.3%), hyperlipidemia (40.4%), obesity (15.5%), COPD (19.3%), CVA (19.5%), CVD (22.9%).

CONCLUSIONS: After revascularization for CLI, ITD carries a worse prognosis (amputation-free survival, limb salvage, survival, maintenance of ambulation, and independent living status) compared to patients with M-PAD, despite the “greater” disease burden in M-PAD patients. These differences are most pronounced in non-diabetic ITD patients. Risk assessment must go beyond severity of ischemia, placing ITD patients in the highest risk category.