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Background: Tibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remains barrier to durability after intervention. The aim of this study was to examine the patient centered outcomes of re-intervention following tibial endovascular Intervention
Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford 4 and 5) were identified. Patient orientated outcomes of clinical efficacy (CE; absence of recurrent symptoms, maintenance of ambulation and absence of major amputation), amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated.
Results: 1134 patients (56% male, average age 59 years) underwent tibial intervention for critical ischemia and 54% presented with symptomatic restenosis and occlusion, Of the 513 patients with restenosis , 58% presented with rest pain and the remainder with ulceration. A repeat tibial endovascular intervention was performed in 64%, below knee amputation in 17%, open bypass in 19%. Bypass was employed in patients with a good target vessel, venous conduit and good pedal runoff. While primary and repeat tibial interventions had equivalent patency and early symptom relief, longer term patient centered outcomes were worse in the re-intervention group (Table). Those undergoing bypass had significantly superior outcomes albeit with a higher MACE (Table). The rate of repeat intervention after the first re-intervention was 56%. Presentation with new onset ulceration, Hispanic, diabetes, ESRD and poor pedal runoff were significant poor predictors for clinical efficacy and amputation-free survival.

TABLE	Primary Endovascular Interventions	Repeat Endovascular Interventions	Bypass after primary intervention
Number Limbs at Risk (n)	1134	329	97
Male Gender (%)	56%	55%	50%
Age (mean±SD) yrs	59±11	62±12	60±10
High Risk PIII score (%)	18%	25%	10%**
Mortality (%)	1%	4%*	4%*
Morbidity (%)	3%	7%*	11%*
5yr-CE (Mean±SEM %)	48±4	30±7	68±9*
5yr-AFS (Mean±SEM %)	45±3	27±9*	65±7*
5yr-MALE (Mean±SEM %)	50±5	41±6*	60±8*

* P<0.05 and **p<0.01 compared to primary intervention P<0.05 and p<0.01 compared to Repeat Endovascular Intervention.
Conclusions:
Tibial interventions for critical ischemia are associated with a high rate of re-intervention and in patients with good target vessel, venous conduit and good pedal runoff bypass appears more durable than repeat tibial endovascular intervention.