What are the considerations for additional atherectomy of the Tibio-Peroneal (TP) Trunk?

Considerations for Atherectomy of the Tibio-Peroneal (TP) Trunk

Atherectomy of the tibio-peroneal trunk should generally be avoided as it offers no significant benefit over conventional angioplasty while potentially increasing procedural complications, particularly in femoropopliteal segments. 1

Indications and Evidence Base

• Atherectomy in tibial vessels, including the TP trunk, has received lower ratings in clinical guidelines due to lack of comparative data supporting its use over conventional techniques 1
• The 2019 ACC/AHA/SCAI/SIR/SVM guidelines specifically note that atherectomy in below-the-knee vessels lacks comparative evidence to support general use 1
• Exceptions where atherectomy might be considered include cases with severe calcification and undilatable lesions, though even in these scenarios, evidence remains limited 1

Procedural Considerations and Risks

• Atherectomy in the femoropopliteal segment is associated with higher rates of target vessel dissection (4.5% vs 2.6%), distal embolization (1.5% vs 0.7%), and need for provisional stent placement (1.5% vs 0%) compared to plain balloon angioplasty 2
• However, in tibial vessels, atherectomy has shown fewer intraoperative vessel dissections (0.8% vs 2.3%) compared to angioplasty alone, though still requiring more provisional stent placements 2
• Long-term outcomes data from Medicare-linked VQI registry shows patients treated with atherectomy experienced higher risk of major amputation (HR: 3.66) and any amputation (HR: 2.73) compared to stenting 3

Anatomical and Technical Considerations

• The tibio-peroneal trunk is a critical vessel for maintaining inline flow to the foot in patients with chronic limb-threatening ischemia (CLTI) 1
• When revascularization is needed, the goal should be to rapidly restore direct blood flow to the foot 1
• The most distal artery with continuous flow from above and without significant stenosis (>20%) should be used as the point of origin for distal bypass 1

Alternative Approaches

• For below-knee interventions, including the TP trunk, current guidelines recommend:
  • Autogenous vein bypass when surgical revascularization is chosen 1
  • Plain balloon angioplasty as the primary endovascular approach 4
  • Consideration of stenting only in select cases where angioplasty results are suboptimal 1

Clinical Outcomes

• A comparative study of tibial interventions for critical limb ischemia found no significant differences between atherectomy and angioplasty in terms of:
  • Primary patency at 12 months (61% vs 69%) 4
  • Limb salvage rates (81% vs 79%) 4
  • Survival rates (80% vs 77%) 4
• High reintervention rates have been observed after tibial-peroneal atherectomy, with 46.5% of office-based and 38.9% of hospital outpatient-based patients requiring repeat intervention within one year 5

Cost Considerations

• The additional cost and increased procedural time associated with atherectomy must be weighed against the lack of demonstrated clinical benefit 4
• Given similar outcomes between atherectomy and angioplasty but higher costs with the former, routine use of atherectomy for the TP trunk is difficult to justify 4

Conclusion

Based on current evidence and guidelines, atherectomy of the tibio-peroneal trunk should not be routinely performed as it offers no clear advantage over conventional angioplasty while potentially increasing costs and complications 1, 4. Standard angioplasty should be the primary endovascular approach for TP trunk lesions, with stenting reserved for suboptimal results. For severe disease requiring revascularization, surgical bypass with autogenous vein remains the gold standard when feasible 1.