Peroneal-only runoff after endovascular revascularization and the impact on limb salvage outcomes

<h2>Abstract</h2><h3>Background</h3> Hispanic patients with chronic limb-threatening ischemia (CLTI) have more advanced infrapopliteal arterial disease compared with other ethnic groups. This pattern often results in fewer available target vessels for revascularization and a greater dependence on a single runoff artery to achieve limb salvage. Among the infrapopliteal vessels, the peroneal artery, typically terminating above the ankle and supplying the foot through collateral branches, has traditionally been considered the least favorable target due to its indirect contribution to pedal perfusion. This study evaluated outcomes of peroneal-only runoff after endovascular revascularization in an exclusively Hispanic CLTI cohort. <h3>Methods</h3> A retrospective cohort study was conducted at a tertiary medical center in Puerto Rico, including all limbs with post-revascularization arteriograms demonstrating sole peroneal artery runoff (January 2020 to July 2025). Demographics, comorbidities, and outcomes were analyzed. The primary endpoint was limb salvage; secondary outcomes included amputation-free survival (AFS), limb event-free survival (LEFS), and reintervention. The predictive utility of Rutherford classification; Wound, Ischemia, and foot Infection (WIfI) score; and Global Limb Anatomic Staging System (GLASS) staging was assessed. <h3>Results</h3> A total of 120 limbs from 117 Hispanic patients (median age, 74 years; 87.5% with diabetes) were included. At 1 year, limb salvage was 78.3%, AFS was 69.2%, and LEFS was 55.8%; 32.5% required reintervention. Rutherford classification, WIfI score, and GLASS stage were not significantly associated with outcomes (all <i>P</i> > .05). In multivariable Cox regression, no variable independently predicted major amputation. Patients with a reintervention in the first year were 2.35 times more likely to have a major amputation or death (hazard ratio, 2.35; <i>P</i> = .031). <h3>Conclusions</h3> In this high-risk Hispanic CLTI cohort, peroneal-only runoff revascularization achieved acceptable limb salvage and survival outcomes. Conventional risk stratification systems (Rutherford, WIfI, GLASS) were not good predictors of outcomes, suggesting limited utility in patients with isolated peroneal perfusion. These findings support the peroneal artery as a viable revascularization target when other tibial vessels are unavailable.