Comparison of Tibial Transverse Transport Angiogenesis Versus Vascular Surgery in Patients with Chronic Limb Threatening Ischemia: A Systematic Review and Meta-Analysis.

Peripheral arterial disease (PAD) is one of the most common underlying causes of major lower extremity amputations (LEAs). Often revascularization is not adequate to save the leg. Tibial Transverse Transport (TTT) represents a revolutionary approach to increase angiogenesis in people with critical limb threatening ischemia (CLTI). A systematic review and meta-analysis was conducted across six databases. Inclusion criteria required studies to evaluate TTT combined with revascularization versus revascularization or TTT alone as a monotherapy. Outcomes analyzed included tarsal-metatarsal amputation (TMA), wound healing, and change in visual analogue scale (VAS) for pain. A total of five studies were identified across four databases that met inclusion criteria. TTT + Revascularization was shown to have a protective effect in reducing follow up TMA, O.R = 0.44 [0.23, 0.81], p = 0.009. TTT + Revascularization was also found to have an association with wound healing, OR = 3.25 [1.84,5.73], p = 0.0001. Four studies observed the change in Visual Analogue Scale (VAS), and the cumulative effect showed no association between either TTT + Revascularization or monotherapy with change in VAS pain pre and post procedure, standard mean difference = -0.05 [-0.16, 0.05], p = 0.33. TTT in combination with peripheral endovascular revascularization offers a promising addition for patients with CLTI with lower incidence of TMA increase rates of wound healing. However, considering the limited studies available and overall small sample size, further trials are necessary to understand the relationship between this novel therapy and CLTI management.