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Contemporary outcomes with percutaneous vascular interventions for peripheral critical limb ischemia in those with
Venkat Krishnamurthy1, Kahn Munir2, John E Rectenwald1
1Department of Surgery, University of Michigan, USA.
Insights
Patients with critical limb ischemia (CLI) and polyvascular disease had higher mortality after percutaneous vascular interventions (PVIs) but similar amputation rates compared to those with peripheral arterial disease (PAD) alone. PAD patients also showed lower cardioprotective medication use.
Area of Science:
- Vascular Surgery
- Cardiology
- Interventional Radiology
Background:
- Critical limb ischemia (CLI) poses significant challenges for limb salvage, particularly in patients with polyvascular arterial disease.
- Percutaneous vascular interventions (PVIs) are utilized for limb salvage in patients with peripheral arterial disease (PAD).
Purpose of the Study:
- To evaluate the outcomes of PVI in patients with CLI, comparing those with polyvascular disease to those with PAD alone.
- To identify predictors of amputation and death following PVI in CLI patients.
Main Methods:
- A prospective, multi-institutional registry of 4459 CLI patients undergoing endovascular interventions for PAD between January 2008 and December 2011.
- Patients were categorized into polyvascular disease (coronary, cerebrovascular, and PAD) or PAD-only groups.
- Six-month follow-up data were collected, including mortality, repeat PVI, amputation rates, and vascular complications.
Main Results:
- Polyvascular patients (n=3141) experienced higher 6-month mortality (6.7% vs. 4.1%) and repeat PVI rates compared to PAD-only patients (n=1318).
- Amputation rates at 6 months were similar between the polyvascular and PAD-only groups.
- Predictors of amputation/death included age, anemia, diabetes, congestive heart failure, and end-stage renal failure; female sex was protective.
- PAD patients demonstrated lower cardioprotective medication use pre- and post-procedure.
Conclusions:
- While polyvascular disease is associated with increased mortality after PVI in CLI patients, it does not significantly impact limb amputation rates.
- Peripheral arterial disease patients require improved adherence to cardioprotective medication regimens.
- Risk stratification for CLI patients undergoing PVI should consider multiple comorbidities.
Abstract:
Given the very ill nature of patients with critical limb ischemia (CLI), the use of percutaneous vascular interventions (PVIs) for limb salvage may or may not be efficacious; in particular, for those with polyvascular arterial disease. Herein, we reviewed large, multi-institutional outcomes of PVI in polyvascular and peripheral arterial disease (PAD) patients with CLI. An 18-hospital consortium collected prospective data on patients undergoing endovascular interventions for PAD with 6-month follow-up from January 2008 to December 2011. The patient cohort included 4459 patients with CLI; of those, 3141 patients had polyvascular (coronary artery disease, cerebrovascular disease and PAD) disease, whereas 1318 patients suffered from only PAD. All patients were elderly and with significant comorbidities. The mean ankle-brachial index (ABI) was 0.44 and was not different between those with and without polyvascular disease. Polyvascular patients had more femoropopliteal and infra-inguinal interventions and less aortoiliac interventions than PAD patients. Pre- and post-procedural cardioprotective medication use was less in the PAD patients as compared with polyvascular patients. Vascular complications requiring surgery were higher in PAD patients whereas other access complications were similar between groups. At 6-month follow-up, death was more common in the polyvascular group (6.7% vs 4.1%, p<0.001) as was repeat PVI, but no difference was found in the amputation rate. Considering the group as a whole at the 6-month follow-up, predictors of amputation/death included age (HR=1.01; 95% CI=1.002-1.02), anemia (HR=2.6; 95% CI=2.1-3.2), diabetes mellitus (HR=1.6; 95% CI=1.3-1.9), congestive heart failure (HR=1.6; 95% CI=1.4-1.9), and end-stage renal failure (HR=1.9; 95% CI=1.5-2.3), while female sex was protective (HR=0.7; 95% CI=0.6-0.8). In conclusion, from examination of this large, multicenter, multi-specialist practice registry, patients with polyvascular disease had higher 6-month mortality than PAD patients, but this was not a factor in 6-month limb amputation outcomes. This study also underscores that PAD patients still lag in cardioprotective medication use as compared with polyvascular patients.
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