Combining Tibial Cortex Transverse Transport (TTT) and Endovascular Therapy (EVT) for Limb Salvage in Chronic Limb-Threatening Ischemia

Abstract

Objective: The clinical management of patients with chronic limb-threatening ischemia (CLTI) faces great challenges. Enhancing wound healing and limb preservation rates in this cohort is a critical objective. This study investigates the effectiveness of combining tibial cortex transverse transport (TTT) and endovascular therapy (EVT) for the treatment of patients with severe CLTI. We aim to evaluate the therapeutic results of this combined approach on the specified patient group.

Methods: We conducted a retrospective study to compare EVT with the combination of TTT and EVT in patients (Rutherford category 5 and above) with CLTI at Guangxi Medical University’s First Affiliated Hospital from June 2017 to June 2023. This cohort was subjected to a follow-up period ranging from a minimum of 6 months to a maximum of 12 months. The primary outcome measures included amputation-free survival (AFS) (avoidance of above-ankle amputation or death from any cause), overall mortality, limb salvage rates, wound healing efficiency, and the technical efficacy of the applied treatments. A variety of statistical analyses including chi-square tests, Fisher’s exact tests, and Pearson’s and Spearman’s correlation analyses.

Results: In this study, 131 patients with CLTI were included: 76 in the control group receiving only EVT treatment and 55 in the TTT + EVT group. The two groups were matched on demographic and clinical characteristics. In the TTT + EVT group, after more than 6 months of follow-up, 85.5% of patients achieved AFS, and wound healing was observed in 54.5% (30 of 55 patients). After more than 12 months of follow-up, 81.9% achieved AFS, with wound healing in 32 patients. Furthermore, after more than 24 months, 74.2% of patients remained amputation-free, with wound healing in all surviving patients. In the control group, after more than 6 months of follow-up, 72.4% of patients achieved AFS, and wound healing was observed in 51.3% (39 of 96 patients). After more than 12 months, 48.9% achieved AFS, with wound healing in 21 patients.

Conclusion: We found that combining therapy of TTT and EVT is safe and can be successfully administered in patients with CLTI and it enhances wound healing and AFS.

Keywords

Chronic Limb-Threatening Ischemia / Endovascular Therapy / Limb Salvage / Tibial Cortex Transverse Transport

References

[1] Farber A. Chronic limb-threatening ischemia. N Engl J Med. 2018; 379(2): 171–180.

[2] Nehler MR, Duval S, Diao L, Annex BH, Hiatt WR, Rogers K, et al. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg. 2014; 60(3): 686–695.e2.

[3] Farber A, Eberhardt RT. The current state of critical limb ischemia: a systematic review. JAMA Surg. 2016; 151(11): 1070–1077.

[4] Duff S, Mafilios MS, Bhounsule P, Hasegawa JT. The burden of critical limb ischemia: a review of recent literature. Vasc Health Risk Manag. 2019; 15: 187–208.

[5] Marsico G, Martin-Saldana S, Pandit A. Therapeutic biomaterial approaches to alleviate chronic limb threatening ischemia. Adv Sci (Weinheim, Baden-Wurttemberg, Germany). 2021; 8(7): 2003119.

[6] Allie DE. Creative limb-salvage surgical and endovascular revascularization strategies in treating critical limb ischemia. Surg Technol Int. 2008; 17: 97–104.

[7] Goktay AY, Senturk C. Endovascular treatment of thrombosis and embolism. Adv Exp Med Biol. 2017; 906: 195–213.

[8] Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019; 69(6S): 3S–125S.e40.

[9] Ishikawa S, Arai K, Kurihara T, Sato T, Ichioka S. Endovascular therapy and free flap transfer in chronic limb-threatening ischemia. J Plast Surg Hand Surg. 2023; 57(1–6): 422–426.

[10] Nie X, Kuang X, Liu G, Zhong Z, Ding Y, Yu J, et al. Tibial cortex transverse transport facilitating healing in patients with recalcitrant non-diabetic leg ulcers. J Orthop Transl. 2021; 27: 1–7.

[11] Chen Y, Kuang X, Zhou J, Zhen P, Zeng Z, Lin Z, et al. Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers. Clin Orthop Relat Res. 2020; 478(4): 836–851.

[12] Chen Y, Ding X, Zhu Y, Jia Z, Qi Y, Chen M, et al. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: a prospective multicenter cohort study. J Orthop Transl. 2022; 36: 194–204.

[13] Hinchliffe RJ, Brownrigg JRW, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, et al. IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes Metab Res Rev. 2016; 32(Suppl 1): 37–44.

[14] Yang Y, Li Y, Pan Q, Bai S, Wang H, Pan XH, et al. Tibial cortex transverse transport accelerates wound healing via enhanced angiogenesis and immunomodulation. Bone Joint Res. 2022; 11(4): 189–199.

[15] Qin W, Nie X, Su H, Ding Y, He L, Liu K, et al. Efficacy and safety of unilateral tibial cortex transverse transport on bilateral diabetic foot ulcers: a propensity score matching study. J Orthop Transl. 2023; 42: 137–146.

[16] Hata Y, Iida O, Asai M, Masuda M, Okamoto S, Ishihara T, et al. Risk stratification for 2-year mortality in patients with chronic limb-threatening ischemia undergoing endovascular therapy. J Atheroscler Thromb. 2021; 28(5): 477–482.

[17] Bradbury A, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, et al. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet. 2023; 409: 1798–1809.

[18] Xiong S, Liu L, Lin F, Shi J, Han L, Liu H, et al. Clinical characteristics of 116 hospitalized patients with COVID-19 in Wuhan, China: a single-centered, retrospective, observational study. BMC Infect Dis. 2020; 20(1): 787.

[19] Fabiani I, Calogero E, Pugliese NR, di Stefano R, Nicastro I, Buttitta F, et al. Critical limb ischemia: a practical up-to-date review. Angiology. 2018; 69(6): 465–474.

[20] Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989; 239: 263–285.

[21] Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989; 238: 249–281.

[22] Ou S, Wu X, Yang Y, Xia C, Zhang W, Qu Y, et al. Tibial cortex transverse transport potentiates diabetic wound healing via activation of SDF-1/CXCR4 signaling. PeerJ. 2023; 11: e15894.

[23] Shishehbor M, Powell RJ, Montero-Baker MF, Dua A, Martínez-Trabal JL, Bunte MC, et al. Transcatheter arterialization of deep veins in chronic limb-threatening ischemia. N Engl J Med. 2023; 388(13): 1171–1180.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.