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A comparison of operative approaches and parameters predictive of success in multilevel arterial occlusive disease
T J Nypaver1, M I Ellenby, O Mendoza
1Division of Vascular Surgery, University of Illinois College of Medicine at Chicago.
Insights
For multilevel arterial occlusive disease (MLAOD), isolated inflow operations may require a second procedure, compromising limb salvage. Synchronous inflow-outflow operations offer comparable outcomes to inflow alone, avoiding delayed treatment for critical limb ischemia.
Area of Science:
- Vascular Surgery
- Peripheral Arterial Disease
- Limb Salvage
Background:
- Multilevel arterial occlusive disease (MLAOD) poses challenges for limb salvage.
- Isolated inflow correction may be insufficient for severe limb ischemia.
Purpose of the Study:
- Compare operative approaches for MLAOD.
- Identify predictors of limb salvage in MLAOD patients.
Main Methods:
- Retrospective analysis of 194 patients with limb-threatening MLAOD.
- Compared outcomes of inflow alone, inflow with delayed outflow, and synchronous inflow-outflow operations.
Main Results:
- Synchronous inflow-outflow had similar limb salvage to inflow alone.
- Delayed outflow procedures significantly reduced limb salvage rates (p=0.0184).
- Predictors for salvage with inflow alone included no prior surgery, no tissue loss, and poor runoff.
Conclusions:
- Synchronous inflow-outflow operations are safe and effective for MLAOD.
- Delayed "expectant management" after inflow alone can compromise limb salvage.
- Careful patient selection and surgical planning are crucial for limb preservation.
Background:
The correction of abnormal inflow alone in patients with multilevel arterial occlusive disease (MLAOD) may be inadequate to relieve limb-threatening ischemia. This study was undertaken to compare operative approaches and attempt to define preoperative parameters predictive of limb salvage in patients with MLAOD.
Study Design:
The outcome after revascularization for 194 patients with limb-threatening ischemia MLAOD was assessed retrospectively. One hundred fifty-one patients initially underwent an inflow operation alone. Based on whether or not these patients required an outflow operation within one year, they were divided into two groups: group 1, no outflow operation (121 patients, 121 limbs), and group 2, outflow operation required for continued ischemic symptoms (30 patients, 30 limbs). A separate group of forty-three patients (43 limbs) underwent synchronous inflow-outflow operations, or multilevel revascularization, as their initial operative procedure (group 3).
Results:
Perioperative complications and mortality rates did not differ between groups. Limb salvage rates were similar for groups 1 and 3, whereas in group 2, limb salvage rates were significantly reduced (p = 0.0184). Long-term limb salvage after an isolated inflow procedure was associated with lack of prior vascular reconstructions (p = 0.0002), the absence of tissue loss (p = 0.0019), and an infrageniculate angiographic runoff score of less than 6 (p = 0.054).
Conclusions:
In patients with limb-threatening MLAOD, synchronous inflow-outflow operations can be performed with resultant morbidity and mortality rates comparable with inflow alone. After an inflow operation, the approach of "expectant management" may ultimately compromise limb salvage if a subsequent outflow operation is required.