Infrageniculate Interventions in Female Patients: Improved Patency Rates but Higher Rates of Postoperative Complications

Introduction:
Infrageniculate arterial disease is increasingly treated with endovascular management as an alternative to open surgery. While previous studies have analyzed the effect of gender on the success of other arterial interventions, little is known about outcomes of infrageniculate interventions between men and women. 

Methods:
Infrageniculate interventions were retrospectively reviewed in a prospectively maintained database from 1999 to 2009.  Primary endpoints included technical success, limb salvage, primary patency, and secondary patency rates. Secondary endpoints included access site complications (i.e.: hematoma, thrombosis) and systemic complications (i.e.: myocardial infarction, death).  Statistical analysis was conducted with SPSS software (SPSS Inc. Chicago, IL).

Results:
Between July 1999 and November 2009, 329 tibial lesions in 277 patients (152 men, 125 women) were treated. Mean age of men and women were 71.4 ± 13.1 years vs. 70.0 ± 11.2 years, respectively (p = ns).  Women were more likely to be treated for critical limb ischemia 87.7% vs 77.7% (p = 0.028) and less likely to be treated for claudication 12.3% vs. 22.3% (p = ns)  Women were also more likely to undergo balloon angioplasty (57.5% vs. 68.9%; p=0.043).  On the other hand, men were more likely to have coronary disease, history of coronary bypass surgery, and chronic renal insufficiency.   TASC distribution, incidence of smoking, and diabetes were equivalent in both sexes.  When adjusted for co morbidities, 24-month primary patency rates and limb salvage rates for tibial lesions with concurrent proximal disease was higher in women compared to men (46.0±6.1% vs 30.4±5.9%; p =0.016 and 87.5±4.1% vs 82.9±5.4%; p=0.041, respectively).  The difference in 24-month patency between women and men was more pronounced for isolated tibial lesions (50.1±10.1% vs 28.8±10.4%; p =0.002). While overall complication rates were similar, females were found to have comparatively higher rates of postoperative access site thrombosis compared to men (8.9% vs 0.6%, p =0.001). 

Conclusion:
Overall, endovascular interventions below-the-knee are safe and effective in women and should be considered first line modality for the management of critical tibial occlusive disease.  However, further investigation and development of technique to better fit the female anatomy is necessary to improve gender related disparity in access site related complications.