Retrograde tibial access has long offered technical advantages in peripheral vascular procedures, but a new study raises concern that its use in patients with claudication may be driving treatment decisions that exceed what current guidelines recommend, creating a clinically significant downside.
That is the study’s central concern, examining retrograde tibial access during peripheral angiography in patients with intermittent claudication, a population for which both the Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS) expressly discourage tibial-level intervention, according to Jordan Stern, MD, senior author on the study and associate professor at Weill Cornell Medicine.
Intermittent claudication is a manifestation of peripheral artery disease characterized by reproducible leg pain with exertion that resolves with rest. Unlike CLTI, claudication does not place the limb at immediate risk and current guidelines reflect that distinction, steering practitioners toward conservative management and reserving intervention for patients who have failed structured exercise therapy and medical optimization. Stern said tibial-level procedures in this setting carry particular concern, as they introduce procedural risk to a population that may derive limited benefit.
“In patients with intermittent claudication, a ‘first do no harm’ approach is critical for optimal outcomes as these patients are not in a limb-threatening situation,” said Stern, who will present the findings during the SVS-VESS Scientific Session @ VAM: Session 1a (1:30-2:10 p.m.). “The use of retrograde access, while itself not necessarily harmful, may be associated with harmful practices.”
Drawing on the Vascular Quality Initiative (VQI) with VISION linkage to Medicare data, investigators analyzed 26,672 peripheral angiograms performed for claudication and found that 3.6% utilized tibial access (alone or in combination with femoral access) most frequently in the ambulatory or office-based laboratory setting. The tibial intervention rate among patients in whom tibial access was used reached 43.7%, compared with only 13.9% in those treated via femoral-only access. Tibial access was also associated with higher rates of repeat procedures and progression to CLTI.
“Tibial access can certainly be an important procedural adjunct for crossing and treating complex lesions,” said Stern. “However, caution should be exercised, as this seems to be a risk factor for treatment outside accepted guidelines and worse clinical outcomes.”
Stern said the findings carry particular weight given the setting in which tibial access was most commonly employed. Office-based laboratories and ambulatory surgical centers have grown rapidly as sites for peripheral vascular intervention and the data suggest tibial access use in these environments warrants close scrutiny, particularly given the substantially elevated tibial intervention and reintervention rates observed among patients who, by guideline standards, should rarely require either.
Stern acknowledged the study’s limitations, chief among them being the absence of anatomic detail and uncertainty around why tibial intervention was pursued in these cases. Those gaps, Stern argues, define the agenda for future research. “This study confirms some of our previous findings using a more robust, Medicare-linked dataset,” he said. “We do not know anatomic details, why these patients are undergoing tibial intervention, or what actually leads to disease progression. These are important questions that may help to clarify who is most at risk.”
Stern said the broader takeaway is a call for heightened procedural discipline, not a prohibition on tibial access. However, a recognition that its use in claudicants appears to set in motion a clinical trajectory inconsistent with guideline-recommended care. “In patients with intermittent claudication, tibial access should be used with caution as it appears to be associated with tibial intervention, repeat intervention and progression to CLTI,” he said. “Further study is needed to determine which patients are most at risk and how to best align procedural decision-making with what the evidence supports for this population.”
