Pedal Arch Integrity is Independently Associated With Limb Salvage in Chronic Limb-Threatening Ischemia With Isolated Peroneal Artery Runoff

Background: Although current revascularization paradigms emphasize direct inline flow through the target arterial pathway (TAP), the prognostic importance of distal pedal connectivity in this anatomical setting remains uncertain. Methods: Clinical, anatomical, procedural, and follow-up characteristics were analyzed. Kaplan-Meier methods were used for time-to-event analyses, and multivariable logistic regression identified independent predictors of major amputation. Results: During follow-up, major amputation occurred in 29 limbs (25.7%). After multivariable adjustment, increasing Wound, Ischemia, and foot Infection (WIfI) stage was independently associated with a higher risk of major amputation (adjusted odds ratio [OR] 4.47, 95% confidence interval [CI], 2.11-9.45; P < .001), whereas each additional patent deep pedal arch was independently associated with a lower risk of limb loss (adjusted OR 0.23, 95% CI, 0.10-0.53; P < .001). Kaplan-Meier estimates demonstrated significantly better limb salvage in limbs with preserved pedal arch integrity (log-rank P = .003). At 12 months, estimated amputation-free survival was 68.1%, whereas freedom from major adverse limb event among revascularized limbs was 79.7%. Conclusions: In patients with isolated peroneal artery runoff, distal pedal connectivity, reflected by pedal arch integrity, and clinical severity are the principal independent predictors of limb salvage. The peroneal-based global limb anatomic staging system classification improves anatomical stratification in this selected anatomical population but does not provide independent prognostic information beyond WIfI stage and distal pedal connectivity. These findings support the systematic assessment of distal pedal circulation when planning revascularization in this challenging anatomical subgroup. Clinical Impact In patients with chronic limb-threatening ischemia and isolated peroneal artery runoff, revascularization planning should extend beyond proximal anatomical complexity and include systematic assessment of distal pedal circulation. This study demonstrates that pedal arch integrity provides clinically relevant prognostic information for limb salvage, while WIfI stage remains a major determinant of amputation risk. Although application of the original GLASS framework using the peroneal artery as the target arterial pathway improves anatomical stratification, it does not independently predict limb loss. These findings support integrating clinical severity and distal pedal connectivity into treatment planning and prognostic assessment in this challenging anatomical subgroup.