Heart failure is associated with reduced patency after endovascular intervention for symptomatic peripheral arterial
Andrew J Meltzer1, Gautam Shrikhande, Katherine A Gallagher
1Division of Vascular Surgery, New York Presbyterian Hospital, the University Hospital of Columbia and Cornell, New York, NY, USA. andrewjmeltzer@gmail.com
Insights
Congestive heart failure (CHF) significantly reduces the success of endovascular peripheral arterial interventions, especially with reduced ejection fraction (EF). Patients with CHF and EF <40% face higher risks of patency loss and poorer limb salvage outcomes.
Area of Science:
- Cardiovascular Medicine
- Vascular Surgery
- Interventional Cardiology
Background:
- Congestive heart failure (CHF) is a common comorbidity in patients with symptomatic peripheral arterial disease (PAD).
- The impact of CHF on the outcomes of endovascular PAD treatment is not well understood.
- Systolic dysfunction and altered peripheral vasculature in CHF may negatively affect endovascular intervention success.
Purpose of the Study:
- To investigate the effect of congestive heart failure (CHF) on the procedural success and long-term outcomes of endovascular peripheral arterial interventions.
- To identify if CHF is an independent risk factor for reduced patency and limb salvage in PAD patients undergoing endovascular treatment.
Main Methods:
- Retrospective analysis of a prospectively maintained database of patients undergoing endovascular peripheral arterial intervention between 2004 and 2009.
- Comparison of outcomes between patients with and without CHF, and stratified by ejection fraction (EF).
- Statistical analysis using Kaplan-Meier and Cox proportional hazards models to assess risk factors for primary patency, secondary patency, and limb salvage.
Main Results:
- Patients with CHF (22% of 1220) had significantly lower primary patency at 1 year (51.9% vs. 64.6%) and throughout follow-up compared to those without CHF (P < .001).
- CHF was an independent predictor of reduced primary and secondary patency (HR 1.2 and 1.5, respectively).
- Reduced ejection fraction (EF <40%) in CHF patients was associated with even worse outcomes: 1-year patency of 43.2% vs. 56.6% (CHF, EF >40%), and was an independent predictor of patency loss (HR 1.4-1.8) and worse limb salvage (P = .038).
Conclusions:
- Congestive heart failure (CHF) is associated with significantly reduced patency rates after peripheral endovascular interventions.
- CHF is an independent risk factor for loss of primary and secondary patency.
- CHF with a reduced ejection fraction (EF <40%) represents a strong independent risk factor for adverse outcomes, including patency loss and impaired limb salvage.
Objective:
Congestive heart failure (CHF) is a highly prevalent comorbidity among patients with symptomatic peripheral arterial disease. The effect of CHF on the procedural success of endovascular treatment, however, remains unknown. Theoretically, poor inflow secondary to systolic dysfunction and peripheral vascular alterations may predispose endovascular interventions to failure.
Methods:
A retrospective review of a prospectively maintained database was performed to identify CHF patients undergoing endovascular peripheral arterial intervention from 2004 to 2009. Demographics, comorbidities, procedural details, and outcomes were analyzed. Patients underwent duplex ultrasound imaging and clinical follow-up at scheduled intervals. Kaplan-Meier and Cox proportional hazards models were used to evaluate risk factors for loss of primary patency, secondary patency, and limb salvage.
Results:
Of 1220 patients undergoing intervention, 271 (22%) with documented congestive heart failure (CHF) underwent an intervention for claudication (22.5%) or critical limb ischemia (77.5%). Primary patency at 1 year was 51.9% ± 2.5% among those with CHF vs 64.6% ± 1.3% in those without CHF (P < .001); this disparity continued throughout follow-up (P < .001). Patients with CHF also had reduced secondary patency throughout follow-up. Multivariate analysis showed CHF was an independent predictor of reduced primary patency (hazard ratio [HR], 1.2; 95% confidence interval [CI] 1.0-1.4; P = .038) and secondary patency (HR, 1.5; 95% CI, 1.2-1.8; P < .001). In the setting of CHF, 1-year patency was 56.6% ± 4.1% if the ejection fraction (EF) was >40% (n = 147) vs 43.2% ± 3.5% if the EF was <40% (n = 124; P < .001). Secondary patency was also significantly reduced in patients with EF <40% throughout follow-up compared with patients without CHF (n = 949) as well as those with CHF and EF >40% (P < .001). CHF with EF <40% was an independent predictor of reduced primary patency (HR, 1.4; 95% CI, 1.2-1.8; P < .01) and secondary patency (HR, 1.8; 95% CI, 1.3-2.3; P < .001). Limb salvage was also worse in patients with EF <40% (P = .038).
Conclusions:
CHF is associated with reduced patency after peripheral endovascular intervention and is an independent risk factor for patency loss. Specifically, CHF and reduced EF (<40%) is a strong independent risk factor for patency loss.
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