Endovascular Interventions for Isolated Popliteal Lesions in Chronic Limb Threatening Ischemia

The Best-CLI trial confirmed the superiority of infra-inguinal bypass with single-segment great saphenous vein (ssGSV) over an endovascular-first approach for chronic limb-threatening ischemia (CLTI). However, for patients without suitable ssGSV conduit, and those who are not appropriate surgical candidates, an endovascular-first approach is preferred. Despite the voluminous literature regarding percutaneous interventions in the lower extremity, there is a paucity of data evaluating endovascular therapies in patients with isolated popliteal disease. The objective of this study was to examine outcomes of endovascular therapies for isolated popliteal CLTI. The Vascular Quality Initiative (VQI) database was queried for all isolated popliteal artery endovascular interventions performed for CLTI in 2017-2021. Patients who survived the index hospitalization with available long-term follow-up data were included. The primary endpoint was freedom from above-ankle amputation. Procedures were also stratified by presenting symptom and intervention. A total of 2978 procedures were included. Of these, 778 (26.1%) were plain balloons (POBA), 799 (26.8%) were special balloons (drug-coated, cutting, or lithotripsy), 825 (29.5%) were stents, and 501 (16.9%) were atherectomy. Overall, 2219 (74.5%) interventions were for wounds or tissue loss (TL), and there were 217 (7.3%) major amputations. Patients treated with stents (95.0% vs 93.4%; P = .003) and atherectomy (95.2% vs 92.2%; P = .011) had higher freedom from amputation than the remaining cohort (Table 1). The superiority of the stent group was driven primarily by lower utilization of stents in patients with TL (67.8% tissue loss in the stent group vs 77.1% tissue loss in the non-stent group; P < .001). When stratifying for presenting symptom, atherectomy was associated with higher freedom from amputation among patients with TL on both univariate (95.6% vs 90.9%; P = .001) (Table 1; Fig1) and multivariable analysis (HR, 0.497; P = .026) (Table 3), but stents were not (93.7% vs 91.0%; P = .059) (Table 2). Stents and atherectomy were associated with a higher freedom from amputation among patients with CLTI than balloon therapy alone, but stents were more often used in patients presenting with rest pain, which likely contributes to their favorable outcome. When selecting for TL specifically, atherectomy is associated with higher freedom from amputation than all other interventions. Table IAbove-ankle amputation among all patients with CLTI (n = 2978)AmputationNo AmputationTotalP-valueStent41 (5.0%)784 (95.0%)825.003Atherectomy24 (4.8%)478 (95.2%)502.011POBA64 (8.2%)714 (91.8%)778.180Special balloon74 (9.3%)725 (90.7%)799.023Total217 (7.3%)2761 (92.7%)2978 Open table in a new tab Table IIAbove-ankle amputation among patients with wounds or tissue loss (n=2219)AmputationNo AmputationTotalP-valueStent35 (6.3%)524 (93.7%)559.059Atherectomy17 (4.4%)368 (95.6%)385.001POBA53 (8.7%)559 (91.3%)612.650Special balloon66 (11.0%)536 (89.0%)602.009Total184 (8.3%)2035 (91.7%)2219 Open table in a new tab Table IIICox proportional hazards model for above-ankle amputation among patients with wounds or tissue loss (n = 2219)HR95% CIP-valueAge0.9900.980 – 1.010.220Male0.7950.560 – 1.127.201Caucasian0.7260.507 – 1.041.081CHF1.2710.896 – 1.822.179Diabetes1.3630.852 – 2.160.194ESRD2.0961.433 – 3.004< .001Anticoagulation1.3360.914 – 1.935.131Re-do intervention1.6651.185 – 2.340.004Runoff0.6000.423 – 0.844.003Treatment length0.9900.970 – 1.010.347Atherectomy0.4970.273 – 0.923.026 Open table in a new tab