Comparison of Interventional Outcomes According to Preoperative Indication: A Single Center Analysis of 2,240 Limb Revascularizations

Abstract

Conclusion: Patients undergoing leg revascularization with tissue loss have significantly worse outcomes than those patients undergoing leg revascularization for ischemic rest pain. Summary: The authors correctly point out that frequently in an analysis of revascularizations for critical limb ischemia (CLI), patients with tissue loss and ischemic rest pain are combined in the analysis. The authors hypothesize that combining such patients for assessment of both graft-related and patient-related outcomes may be inappropriate in that one group may fare worse than the other. Rather than stratify their results according to the level of peripheral arterial disease such as aortoiliac or infrainguinal, or the method of revascularization—open vs endovascular surgery—they sought to stratify results according to indication for procedure: claudication, ischemic rest pain, and tissue loss. They evaluated the outcomes of 2240 consecutive limb revascularizations in 1732 patients from January 1998 through December 2005. The patients were stratified and examined according to preoperative indication: claudication (999 limbs), ischemic rest pain (464 limbs), or tissue loss (777 limbs). Their end points included primary and secondary interventional or operative patency, limb salvage, survival, amputation-free survival, maintenance of independence, maintenance of ambulation, and resolution of presenting symptoms. There was a mean follow-up of 1089 days (range, 0-3689 days). Overall outcomes at 5 years declined according to indication for intervention—claudication, rest pain, or tissue loss—for all end points measured, including secondary reconstruction patency (93%, 80%, 66%, respectively; P < .001), limb salvage (99%, 81%, 68%, respectively; P < .001), survival (78%, 46%, 30%, respectively; P < .001), amputation-free survival (78%, 42%, 25%, respectively; P < .001), maintenance of ambulation (96%, 78%, 68%, respectively; P < .001), maintenance of independence (98%, 85%, 75%, respectively; P < .001), and resolution of presenting symptoms (79%, 61%, 42%, respectively; P < .001). Comment: The authors chose an unusual method of analyzing their results of lower extremity revascularization. The concept of analyzing results according to indication for operation seems reasonable, and the conclusion that patients with tissue loss do worse than those patients with ischemic rest pain is likely correct. Nevertheless, the article would have been strengthened by a more proper statistical analysis, stratifying patients according to method of revascularization (endovascular, autogenous vein, or prosthetic grafts) and level of revascularization (aortoiliac, femoropopliteal, or infrapopliteal). As written, the results are useful for analyzing the practice pattern at the authors' institution, but without proper multivariable analysis, the results cannot be extrapolated to other institutions where practice patterns likely differ.