Predictors of amputation-free survival after endovascular intervention for chronic limb-threatening ischemia in the modern era

Affiliations

Advocate Lutheran General Hospital

Abstract

Objective: 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 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 amputation-free survival; a p-value < 0.05 was used for univariate screening and inclusion in a multivariable model.

Results: 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 (IQR=4-29 months), significant independent predictors of reduced AFS included non-white 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.

Document Type

Article

PubMed ID

35595207

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