The Natural History and Outcomes of Endovascular Therapy for Claudication
Julia T Saraidaridis1, Emel A Ergul1, W Darrin Clouse1
1Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
Insights
Peripheral vascular intervention (PVI) for claudication shows good long-term outcomes, with a 5-year survival rate of nearly 80%. However, complex lesions (TASC C/D) and angioplasty without stenting increase the need for reintervention.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Peripheral Artery Disease
Background:
- Claudication management traditionally involves conservative measures, reserving revascularization for severe cases.
- Endovascular therapy's lower morbidity has expanded its use for moderately limiting claudication.
- Assessing the long-term outcomes of peripheral vascular intervention (PVI) for claudication is crucial.
Purpose of the Study:
- To evaluate the natural history of patients undergoing PVI for claudication.
- To identify risk factors associated with reintervention after PVI for claudication.
Main Methods:
- Retrospective review of 515 patients undergoing PVI for claudication (2007-2013).
- Outcomes assessed: secondary interventions (endovascular/bypass), amputation, survival.
- Cox proportional hazards models used to identify risk factors for reintervention.
Main Results:
- 5-year actuarial survival was 79.9%; primary patency was 62.5%; limb salvage was 97.2%.
- 21.8% of patients required further intervention (17.7% endovascular, 7.2% bypass).
- Risk factors for reintervention included angioplasty-only (HR 1.36) and TASC C/D lesions (HR 1.52).
Conclusions:
- 5-year primary patency after PVI for claudication is comparable to open bypass.
- Secondary patency exceeds 90%, with a major amputation rate under 3%.
- TASC C/D lesions predict endovascular therapy failure, suggesting consideration for surgical bypass.
Background:
The natural history of claudication is well-characterized and traditional therapy includes risk factor modification and exercise protocols with revascularization reserved for patients who are severely impaired. However, the reduced periprocedural morbidity with endovascular therapy has led physicians to broaden the indications for intervention for peripheral artery disease, and more claudicants are undergoing procedures for disease that is moderately limiting to their lifestyle. This study sought to assess the natural history of patients who have undergone peripheral vascular intervention for claudication.
Methods:
All patients who underwent at least 1 peripheral vascular intervention (PVI) for claudication at a single institution from January 2007 to December 2013 were identified. Patient demographics were assessed using the hospital record. Outcomes included secondary endovascular intervention, secondary bypass intervention, amputation, and survival. Cox proportional hazards models were created to assess risk factors for further intervention.
Results:
Five hundred fifteen patients were identified as having undergone PVI for claudication during the study period. Forty-three percent were female, 37% had diabetes, 31% had coronary artery disease, 26% were current smokers, 6.6% had congestive heart failure, 8.2% had a tibial lesion that was intervened upon, and 35% had a Trans-Atlantic Inter-Society Consensus Document (TASC) II C/D lesion. Actuarial survival at 5 years was 79.9% and 62.5% of patients had primary patency. The limb salvage rate was 97.2%. Over the follow-up period, 21.8% required some type of further intervention: either endovascular (17.7%) or open bypass (7.2%). A Cox proportional hazards model adjusting for age, sex, and other comorbidities showed that the two largest risk factors for requiring reintervention were angioplasty only (no stent; hazard ratio [HR] 1.36, P = 0.02) and TASC C/D lesion (HR 1.52, P = 0.03).
Conclusions:
With 5-year follow-up, patients have a primary patency that is comparable to an open prosthetic bypass to an above knee target. In addition, the secondary patency rate was over 90% and the major amputation rate as less than 3%. The presence of a TASC C/D lesion was predictive of failure of endovascular therapy, and surgical bypass should be considered in these patients.
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