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Published on: September 22, 2020
Predictors of Amputation-free Survival after Endovascular Intervention for Chronic Limb-Threatening Ischemia in the
Gaurang S Joshi1, Suyue M Zhang1, Kathy Wang1
1Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL.
Insights
Chronic limb-threatening ischemia (CLTI) remains deadly, with nearly half of patients losing their limb or life within a year despite endovascular treatment. Non-White race and advanced wounds predict worse outcomes.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Chronic limb-threatening ischemia (CLTI) carries high risks of limb loss (25%) and mortality (25% at 1 year).
- Major amputation for CLTI further increases lethality to 45% within one year.
- Percutaneous peripheral intervention (PPI) offers a less morbid alternative for CLTI management.
Purpose of the Study:
- To evaluate amputation-free survival (AFS) in a contemporary cohort of CLTI patients treated with endovascular revascularization.
- To identify predictors of AFS in patients undergoing percutaneous peripheral intervention for CLTI.
Main Methods:
- Retrospective review of 137 limbs in 111 CLTI patients undergoing endovascular revascularization (2015-2019).
- Data collected included demographics, Wound, Ischemia, and foot Infection (WIfI) stage, and technical details.
- Primary endpoint was AFS, with univariate screening and multivariable modeling (P < 0.05).
Main Results:
- The cohort had prevalent comorbidities (diabetes 65%, CHF 21%) and advanced disease (WIfI 3-4: 66%, Rutherford 6: 47%).
- Independent predictors of reduced AFS were non-White race (HR 2.96) and WIfI stage 4 wounds (HR 2.23).
- One-year AFS was 59% ± 1% following successful revascularization.
Conclusions:
- CLTI remains a severe condition with high mortality and limb loss rates, even with advances in endovascular techniques.
- Late-stage presentation is common, and while endovascular intervention restores arterial patency, it is often insufficient for overall patient recovery.
- Non-White race and advanced WIfI stage are critical factors associated with poorer amputation-free survival after endovascular treatment for CLTI.
Background:
Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1-year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention (PPI) constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival (AFS) in a contemporary cohort treated with endovascular recanalization and assess its predictors.
Methods:
Patients with CLTI undergoing endovascular revascularization at a single regional hospital between 2015-2019 were reviewed. Baseline demographic characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, technical details, and clinical outcomes were tabulated. The primary endpoint was AFS; a P-value < 0.05 was used for univariate screening and inclusion in a multivariable model.
Results:
A total of 137 limbs in 111 patients were studied. Comorbidities were prevalent and included diabetes (65%), congestive heart failure (21%), and dialysis dependence (18%). The majority of revascularized limbs presented with advanced wounds (66% WIfI stages 3-4; 47% Rutherford category 6). Presenting WIfI stages were similar across races (P = 0.26). Peripheral interventions most commonly targeted femoropopliteal disease (69%), although 26% were multilevel. Percutaneous atherectomy, stenting, and paclitaxel-coated or eluting devices were utilized in 68%, 28%, and 15% of cases, respectively. After a median follow-up of 16 months (interquartile range IQR = 4-29 months), significant independent predictors of reduced AFS included nonWhite race (HR = 2.96 [1.42-6.17]; P = 0.004) and WIfI stage 4 wounds (HR = 2.23 [1.10-4.52]; P = 0.026). At one year following successful revascularization, only 59% ± 1% of patients were alive with their limb intact.
Conclusions:
Despite considerable and consistent advances in urban health care delivery and the techniques of PPI, CLTI remains a morbid and deadly disease. Even in the endovascular era, nearly half of all patients presenting with CLTI will lose their limb and/or life within the first year. Unfortunately, late-stage presentation continues to be commonplace. Although endovascular intervention can reliably restore patency to affected arteries, this appears insufficient to restore most patients to health.
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