Impact of impaired ambulatory capacity on the outcomes of peripheral vascular interventions among patients with chronic limb-threating ischemia

Abstract

ObjectiveDespite prior literature recommending against limb salvage in patients with poor functional status such as nonambulatory patients with chronic limb-threatening ischemia (CLTI), peripheral endovascular interventions continue to be carried out in this group of patients. Clinical outcomes following these interventions are, however, not well-characterized. MethodsA retrospective review was conducted on all patients treated for CLTI in the Vascular Quality Initiative from September 2016 to December 2019. Logistic regression, Kaplan-Meier survival estimates, log-rank tests, and Cox regression analyses were used as appropriate to study outcomes. The primary outcomes were 30-day mortality and 1-year amputation-free survival. The secondary outcomes were in-hospital death, postoperative complications, 1-year freedom from major amputation, and 2-year survival. ResultsOf the 49,807 patients studied, 28,469 (57.2%) were ambulatory, 15,148 (31.0%) were ambulatory with assistance, 5395 (10.8%) were wheelchair bound, and 525 (1.1%) were bedridden. There was a 2-fold increase in the odds of 30-day death in patients who were ambulatory with assistance (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.77-2.34; P < .001) and wheelchair-bound patients (OR, 2.09; 95% CI, 1.74-2.51; P < .001), and a more than 6-fold increase in bedridden patients (OR, 6.28; 95% CI, 4.55-8.65; P < .001) compared with ambulatory patients. There was a significantly higher odds of postoperative complications in patients who were ambulatory with assistance or bedridden, but no difference with wheelchair-bound patients. Among ambulatory patients, the risks of major amputation and death within 1 year were only 10% and 12%, respectively, whereas that of bedridden patients were as high as 30% and 38%, respectively. A stepwise decrease in amputation-free survival from 81% with full ambulatory capacity to less than 50% (47.7%) in bedridden patients was observed. The risk of major amputation or death within 1 year was 35% higher for ambulatory with assistance (hazard ratio [HR], 1.35; 95% CI, 1.26-1.44; P < .001), 65% higher for wheelchair-bound (HR, 1.65; 95% CI, 1.51-1.79; P < .001) and 2.6-fold higher for bedridden (HR, 2.64; 95% CI, 2.17-3.21; P < .001) compared with ambulatory. A similar association was seen for 1-year freedom from major amputation and 2-year survival. ConclusionsAmbulatory impairment in patients with CLTI is associated with a significant increase in 30-day mortality and significant decrease in amputation-free survival after peripheral endovascular intervention. Bedridden patients had a 6-fold increase in the 30-day death rate, whereas their amputation-free survival dropped to less than 50% at 1 year. These risks should be considered during shared decision-making regarding management options for nonambulatory patients with CLTI.