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Published on: January 18, 2018
Outcomes after endovascular intervention for chronic critical limb ischemia
Monica S O'Brien-Irr1, Hasan H Dosluoglu, Linda M Harris
1Division of Vascular Surgery, Department of Surgery, University at Buffalo, NY, USA.
Insights
Endovascular intervention for critical limb ischemia (CLI) shows better outcomes for Rutherford category 4 (rest pain) than category 5 (tissue loss). Patient selection is crucial for improving endovascular intervention success rates in CLI.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Critical Limb Ischemia
Background:
- Chronic critical limb ischemia (CLI) presents significant challenges in limb salvage and patient outcomes.
- Rutherford categories (RC) 4 (rest pain) and 5 (tissue loss) represent advanced stages of CLI requiring intervention.
Purpose of the Study:
- To evaluate the outcomes of endovascular intervention (EVI) for CLI stratified by Rutherford category (RC) 4 and RC-5.
- To identify predictors of success and failure after EVI in patients with advanced CLI.
Main Methods:
- Retrospective review of medical records for patients undergoing EVI for RC-4 to RC-5 CLI over a 3-year period.
- Sustained clinical success (SCS) defined as Rutherford improvement score (RIS) ≥2 without target extremity revascularization (TER).
- Secondary sustained clinical success (SSCS) included patients with TER; RC-5 outcomes also assessed for healing time and recurrence.
Main Results:
- RC-5 patients (74%) had more comorbidities (diabetes, dialysis dependence) than RC-4 patients.
- Limb salvage was significantly better for RC-4 (100%) versus RC-5 (83%) at 24 months.
- Sustained clinical success (SCS) was 48% for RC-4 versus 21% for RC-5; secondary SCS (SSCS) was 85% for RC-4 versus 39% for RC-5.
- Diabetes, congestive heart failure (CHF), and RC-5 were independent predictors of failed SSCS.
Conclusions:
- Rutherford category 4 CLI patients exhibit fewer comorbidities and superior outcomes compared to RC-5 patients after EVI.
- While limb salvage is acceptable, early wound healing without reintervention (SCS) is limited, particularly in RC-5.
- Individualized patient evaluation and selection are essential to optimize outcomes for EVI in CLI, especially considering comorbidities like diabetes and CHF.
Objective:
This study evaluated outcomes after endovascular intervention (EVI) for chronic critical limb ischemia (CLI) by Rutherford category (RC) 4, rest pain; and 5, tissue loss.
Methods:
The medical records of all EVI performed for RC-4 to RC-5 by vascular surgeons at a single institution during a 3-year period were reviewed for sustained clinical success (SCS), defined as Rutherford improvement score (RIS) 2(+), without target extremity revascularization (TER). The RC-5 group was evaluated for patency until healing and healing ≤4 months without recurrence or new ulceration. Secondary sustained clinical success (SSCS) was a RIS of 2(+) with TER. The RC-5 group was evaluated for patency until healing and healing at any time during follow-up, without recurrent or new ulceration. Significance was established at the 0.05 level.
Results:
Of 106 EVI performed for CLI, 78 (74%) were RC-5. There were 39 (37%) men. Mean age was 73 ± 12 years. Mean follow-up was 19 months (range, 1-44 months). RC-5 patients were significantly more likely than RC-4 to be diabetic (58% vs 32%; P = .020), dialysis dependent (14% vs 0%; P = .036), and to require distal EVI (53% vs 29%; P = .029). RC-4 patients were more likely to be current smokers (57% vs 32%; P = .023). At 24 months, survival was comparable, with RC-4 at 84% ± 8% vs RC-5 at 62% ± 7% (P = .09), but limb salvage was significantly better for RC-4 (100%) vs RC-5 (83% ± 4%; P = .026), as was SCS (48% vs 21%; P = .006) and SSCS (85% vs 39%; P < .001). Independent predictors of failed SSCS were diabetes (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.07-7.46; P = .036), congestive heart failure (CHF; OR, 3.62; 95% CI, 1.19-10.99; P = .023), and RC-5 (OR, 5.5; 95% CI, 2.4-30.3; P = .001). SSCS was 94% in RC-4 patients without diabetes mellitus (DM) or CHF and 10% in RC-5 with DM or CHF (P < .001) but improved to 67% in RC-5 when neither CHF nor DM were present (P = .004).
Conclusions:
RC-4 have fewer comorbidities, less advanced ischemia, and better outcome than RC-5. These groups should be evaluated individually. Limb salvage was acceptable, yet early wound healing without TER (SCS) occurred in only 21%. RC-5, DM, and CHF were predictors of poor SSCS. Careful selection of patients should improve outcome.
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