Tibial access is associated with tibial intervention in claudicants

Although the Society for Vascular Surgery guidelines support revascularization in select patients with lifestyle-limiting intermittent claudication (IC), infrapopliteal intervention is discouraged owing to questionable benefit and potential harm. Retrograde tibial/pedal access is increasing in peripheral vascular interventions (PVIs) in general, their its use and appropriateness in IC have not been studied or codified. This study aimed to analyze national practice patterns of tibial access in PVI for IC, and its potential association with tibial interventions.

Elective IC cases from the VQI PVI module between 2010 and 2024 were identified. Cases were stratified into femoral-only cases and those involving any tibial access. Patient demographics, procedural setting, and interventional details were compared using descriptive statistics. Multivariable logistic regression was used to identify independent predictors of tibial intervention, and specifically assess the contribution of tibial access to this practice.

Of 107,822 cases, 4204 involved any tibial access (3.9%) and 103,618 (96.1%) were performed with femoral-only access, with tibial access increasing over time at a rate of 0.62% per year (R² = 0.95). Tibial access was more frequently used in ambulatory and office-based settings compared with hospital (8.2% vs 3.2%; P < .001). Tibial access was less commonly used in females than males (3.2% vs 4.3%; P < .001), and more commonly in Hispanic (5.4%) and non-Hispanic Black (4.9%) than non-Hispanic White (3.6%) and non-Hispanic Asian (2.8%) patients (P < .001). Compared with femoral-only access patients, those with tibial access more frequently underwent femoropopliteal (91% vs 66%) and below-knee interventions (39% vs 12%), but fewer aortoiliac interventions (9.1% vs 40%; all P < .001). Tibial access more frequently involved the treatment of multiple vessels (50% vs 41%; P < .001). Multivariable regression adjusting for demographics, relevant comorbidities, and procedural factors demonstrated tibial access to be independently and highly predictive of tibial intervention (odds ratio, 4.65; 95% confidence interval, 4.28-5.05). Among tibial interventions, atherectomy and stenting were more prevalent in patients who had tibial access.

Retrograde tibial access for IC has increased over time and is most prevalent in outpatient settings. Tibial access appears to be highly predictive of tibial intervention, with higher rates of atherectomy and stenting, raising the critical question of whether this strategy is leading to inappropriate use and deviation from evidence-based societal guidelines.