SLR - March 2017 - Melissa Millili

Clinical Effects of Single or Double Tibial Artery Revascularization in Critical Limb Ischemia Patients with Tissue Loss

Reference:
Kobayashi N, Hirano K, Yamawaki M, Araki M, Takimura H, Sakamoto Y, Mori S, Ito Y. Clinical Effects of Single or Double Tibial Artery Revascularization in Critical Limb Ischemia Patients with Tissue Loss J Vasc Surg. 2017 Mar;65(3):744–753.

Scientific Literature Review

Reviewed By: Melissa Millili, DPM
Residency Program: University Hospital, Newark, NJ

Podiatric Relevance: In the field of vascular surgery, achieving single vessel runoff to the foot in patients with critical limb ischemia (CLI) and tissue loss is considered an acceptable end outcome. From the podiatry perspective, many of these people with CLI are mutual patients who are facing foot amputation and potentially limb loss. Many of these patients with tissue loss present with multivessel disease below the knee in the peroneal, anterior and posterior tibial arteries. The authors in this study set out to determine if revascularization of the anterior and posterior tibial arteries or two vessel runoff to the foot would improve clinical outcomes in these patients with CLI and tissue loss.

Methods: This article was a retrospective Level VI study at a single center in Japan that looked at limbs with CLI between April 2007 and January 2015. A total of 137 limbs met inclusion criteria for the study, with 84 patients achieving single vessel runoff and 53 patients achieving double vessel runoff to the foot. The primary outcome measure was degree of wound healing at one year postoperatively. Secondary outcome measures included time to healing in a healed wound, whether the patient required repeat revascularization, limb salvage rate at three years and survival rate without major amputations, which included any amputation above the ankle.

Results: The authors found that the rate of wound healing was higher and the time to full healing was significantly shorter in patients in the double revascularization group (83 day median: double and 142 day median: single). The need for revascularization due to recurrent stenosis was lower in the double revascularization group (15 percent double compared to 35 percent single). Limb salvage rate at three years was higher in the double revascularization group but was not found to be statistically significant (93.9 percent double and 85.6 percent single). Amputation free survival rate was also found to be higher in the group of patients with double vessel revascularization.

Conclusions: It was found that revascularization of both the anterior and posterior tibial arteries positively affected wound healing when compared to patients that had achieved only single vessel run off after endovascular intervention. It was therefore concluded that double vessel revascularization should be attempted for patients with critical limb ischemia and subsequent tissue loss. Some valid limitations to the study included the small sample size in a single hospital center as well as the fact that it was a retrospective study. Furthermore, only balloon angioplasty was available at this center, so the surgeons did not have access to stenting technology. In the future, further studies that are prospective in nature and perhaps including other vascular techniques, such as stenting and bypass, should be performed to perhaps change the viewpoint in achieving single vessel runoff as adequate in patients with CLI and tissue loss. 

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