Endovascular revascularization for tibial artery obstructions of patients with critical limb ischemia (CLI) remains a platform for ongoing debate. We appreciate the thoughtful considerations in the commentary by Mwipatayi and Picardo1 that accompanied our article in the June issue of the JEVT.We agree with the authors that there is a lack of insight regarding the impact of risk factors on peripheral artery disease (PAD) morphology in the lower limb. A variety of cardiovascular risk factors may affect the progression of PAD and ultimately lead to the clinically most severe presentation that is CLI. In an earlier article,3 we assessed the individual contribution of different cardiovascular risk factors to the anatomical level of symptomatic lower limb atherosclerosis in 2659 patients. In that study, we found that various cardiovascular risk factors influenced the anatomical level of symptomatic PAD lesions. Hyperlipidemia and cigarette smoking, for example, were predominantly found in patients with iliac artery obstructions, whereas increased age and diabetes mellitus were independent risk factors for the presence of tibial artery obstructions. Thus, although the presence of hyperlipidemia and arterial hypertension may contribute to atherosclerotic lesions in the iliac and femo-ropopliteal segments, their importance in tibial artery disease seems minor.
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