Discrepancy in Outcomes after Revascularization for Chronic Limb-Threatening Ischemia Warrants Separate Reporting of Rest Pain and Tissue Loss

Abstract

Chronic limb-threatening ischemia (CLTI) manifests as rest pain (RP) and tissue loss (TL). Outcomes of lower extremity revascularization (LER) for CLTI have traditionally been evaluated as a single entity and compared with claudication. We hypothesize that patients presenting with TL have worse short-term outcomes after LER, compared to patients with RP. The National Inpatient Sample was reviewed between 2009 and 2013. All patients undergoing LER for TL and RP were identified. Patient characteristics, Charlson Comorbidity Index (CCI), length of stay, rates of inpatient major amputation, and mortality after LER were noted. Multivariable regression analysis was performed to identify predictors of inpatient mortality and major amputation between the 2 groups. A total of 218,628 patients underwent LER (RP=76,108, TL=142,519). Patients with TL were more likely to undergo endovascular LER (RP=31.3% vs. TL=48.7%; P<0.001). Patients with TL had higher comorbidities as suggested by increased likelihood of having CCI ≥3 (RP=22.9% vs. TL=40.3%; P<0.001). The mean costs were significantly higher in the TL group (RP=$23,795 vs. TL=$31,470; P<0.001). There was a significantly higher rate of major amputation (RP=1.3% vs. TL=6.6%; P<0.001) and inpatient mortality (RP=0.9% vs. TL=1.9%; P<0.001) after LER for TL. On multivariable analysis, TL was independently associated with increased major amputation (odds ratio [OR] 4.93, 95% confidence interval [CI] 4.18-5.81) and increased mortality (OR 1.42, 95% CI 1.16-1.74) compared to RP. There is significant discrepancy in outcomes of LER for TL and RP. TL is independently associated with major amputation and inpatient mortality. Outcomes of LER for TL and RP should be reported separately for better benchmarking.