VESS01 - Tibial Access for Peripheral Vascular Interventions is Associated with Tibial Intervention, Reintervention, and Conversion to Chronic Limb-Threatening Ischemia in Patients with Claudication

Objectives: Tibial intervention for claudication is discouraged by societal guidelines, but the impact of retrograde tibial access (TA) remains unclear. We aimed to evaluate the association of TA with disease progression and outcomes among patients with claudication undergoing a peripheral vascular intervention.

Methods: We analyzed the VQI PVI registry linked to the VISION Medicare dataset. Adults undergoing index PVI for claudication from 2017-2023 were included. Patients receiving PVI via TA were compared to those receiving femoral-only access. Primary outcomes included ipsilateral repeat PVI, ipsilateral progression to CLTI, and ipsilateral major amputation. Time-to-event outcomes were assessed using Kaplan-Meier analysis. Multivariable logistic regression was used to evaluate the association of TA with each outcome.

Results: Among 26,672 patients undergoing index PVI for claudication, TA was used in 3.6% (n=949) of cases. TA patients were more often male (69.9% vs. 59.4%), Hispanic (4.3% vs. 3.3%), and non-Hispanic Black (12.4% vs. 9.8%;all p< 0.001). Comorbidities were largely similar, although TA patients had more dysrhythmia (23.1% vs. 18.9%,p=0.001), less COPD (23.5% vs. 26.9%,p=0.02), and were more likely never smokers (22.9% vs. 16.8%,p < 0.001).

TA was more frequently performed in ambulatory/office-based settings (17.3% vs. 12.6%,p < 0.001) and had a higher rate of tibial intervention (43.7% vs. 13.9%,p < 0.001). At 1 and 3 years post-intervention, TA was associated with higher cumulative incidence of ipsilateral repeat PVI (1-yr: 13.6% vs. 8.3%; 3-yr: 22.3% vs. 15.2%,p < 0.001), progression to CLTI (1-yr: 20.7% vs. 13.3%; 3-yr: 29.2% vs. 19.7%,p < 0.001), and major amputation (1-yr: 1.6% vs. 0.8%; 3-yr: 2.5% vs. 1.4%,p=0.029). (Figures 1 and 2)

After adjusting for patient demographics, comorbidities, tibial intervention, number of vessels treated, and site of service, TA was associated with higher odds of ipsilateral repeat PVI (aOR 1.36, 95%CI 1.16-1.60) and conversion to CLTI (aOR 1.23, 95%CI 1.06-1.43). Although point estimates for ipsilateral major amputation suggested higher odds with TA, this did not reach statistical significance (aOR 1.02, 95%CI0.66-1.57).

Conclusions: The use of tibial access during intervention for claudication is associated with more tibial interventions and increased long-term risk of ipsilateral reintervention and conversion to CLTI. Caution should be used when considering this approach in patients with claudication.