Textbook outcomes after revascularization for chronic limb-threatening ischemia remain rare

Suggested performance outcome metrics and traditional surgical benchmarks may be inadequate proxies for evaluating the quality of revascularization in chronic limb-threatening ischemia (CLTI). Textbook outcomes (TOs) following revascularization in CLTI are poorly described and limited to cohorts studying open bypass only. We aim to propose a TO in CLTI to provide a more comprehensive evaluation of modern CLTI outcomes.

A 9-year retrospective, single-center analysis of consecutive patients with CLTI undergoing revascularization (open, endovascular, or hybrid) was performed. Data on demographics; length of stay; comorbidities; procedural data; Wound, Ischemia, and foot Infection (WIfI) scores; limb salvage; postoperative complications; wound healing; and return to baseline and/or normalized ambulatory status and survival were collected. TO was defined as a composite of survival, limb-salvage, without reinterventions (wound or vascular), freedom from major complications and reinterventions, ≤1 wound-related procedure, return to baseline function, and complete wound healing. Descriptive statistics and binary logistic regression were used to evaluate factors associated with TO.

Over 9 years, 702 patients with CLTI (n = 445 male [63.4%]; median age, 66.6 years [interquartile range (IQR), 59.2-73.9 years]; 915 limbs; median follow-up, 25 months [IQR, 11-47 months]) were studied. Significant patient-level comorbidities include diabetes mellitus (n = 458; 65.3%); chronic kidney disease (n = 451; 64%), and dialysis dependence (n = 225; 32%). Initially, 915 limbs were treated with 646 endovascular (71%), 215 open (24%), and 49 hybrid (5%) procedures. TO was achieved in 225 limbs (24.6%). For the overall cohort, each component of TO at 1 year were as follows: survival (n = 610; 86.9%), limb salvage (n = 787; 86%), freedom from major postoperative complications (n = 788; 86%), freedom from reinterventions (n = 513; 56%), ≤1 wound procedure (n = 607; 66%), return to baseline and/or normalized ambulatory status (n = 587; 64.2%), and complete wound healing (n = 347; 62%). Multivariable analysis identified factors associated with TO as follows: anticoagulant use (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.4-0.8; P < .01); WIfI stage 1 (OR, 2.6; 95% CI, 1.5-4.5; P < .001), diabetes (OR, 0.42; 95% CI, 0.29-0.60; P < .001), and residence in an assisted living facility (OR, 0.13; 95% CI, 0.03-0.55; P = .006).

Despite excellent survival and limb-salvage, TO was achieved in less than one-fourth of patients undergoing revascularization for CLTI. Patients with WIfI stage 1 have a greater than two-fold odds of having a TO compared with all other WIfI stages, whereas those living in an assisted living facility, who were diabetics, and/or were taking oral anticoagulants were less likely to achieve a TO. Our data highlight the fact that current performance metrics fail to capture the true procedural burden associated with revascularization, which merits consideration when educating patients, selecting patients for intervention, and outcome adjudication in clinical trials and quality assessments.