Influence of Heel Ulceration on Limb Salvage After Open and Endovascular Intervention for Limb-Threatening Critical Ischemia

Abstract

Infrapopliteal disease is documented in 50% of patients presenting with tissue loss. The implications of heel ulceration on index limb outcomes is still unclear. The aim of this study was to impact the outcomes of heel ulceration after endovascular and open intervention for limb-threatening critical ischemia A database of patients undergoing lower extremity open and endovascular interventions between 2001 and 2017 was retrospectively queried. We identified 608 patients with isolated infrapopliteal disease and heel ulceration. Heel ulceration was further stratified as less than 5 cm, 5 to 10 cm, and greater than 10 cm in diameter. An intention-to-treat analysis by patient was performed. Amputation-free survival (survival without major amputation) and freedom from major adverse limb events (above ankle amputation of the index limb) or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. There were 384 patients (58% male; average age, 65 years; 2898 vessels) who underwent endovascular tibial intervention and 124 patients (45% male; average age, 59 years) underwent superficial femoral artery or popliteal tibial bypass for limb-threatening critical ischemia (Table). There was no difference in 30-day outcomes (Table). Outcomes of amputation-free survival and freedom from major adverse limb event were superior in the open group. Patients with heel ulcers of less than 5 cm and 5 to 10 cm had similar outcomes. Heel ulcers greater than 10 cm diameter were associated with worse 30-day and 5-year outcomes (Table). The presence of end-stage renal disease, osteomyelitis, and uncontrolled diabetes (glycosylated hemoglobin of >10) were associated with poor 30-day and 5-year outcomes. The combination of one or more of these variables with a heel ulcer greater than 10 cm in diameter was associated with a higher 30-day amputation rate (50% endo vs 45% open; P < .02). Heel ulceration of greater than 10 cm is associated with early major adverse limb event and early amputation in both open and endovascular interventions. The presence of end-stage renal disease, osteomyelitis, and uncontrolled diabetes (glycosylated hemoglobin of >10) in combination with a large heel ulcer is predictive of early major amputation.TableOutcomesEndovascularOpenP valueNo. of limbs at risk384124–High-risk PIII score, %41%43%NSWIfI stage 3/443%41%NSTASC I C/D, %79%85%.1230-day MACE, %2%3%.1530-day MALE, %11%10%.2330-day amputation, %27%26%.255-year amputation-free survival, mean ± SEM %27 ± 937 ± 8.055-year freedom from MALE, mean ± SEM %21 ± 835 ± 7.05MACE, Major adverse cardiac events; MALE, major adverse limb events; PIII, PREVENT III; SEM, standard error of the mean; TASC, TransAtlantic Inter-Society Consensus; WIfI, Society for Vascular Surgery Wound, Ischemia, foot Infection. Open table in a new tab