IP181. Factors Affecting Limb Salvage Following Open and Endovascular Revascularization for Critical Limb Ischemia in a 10-Year Population-Based Study

Abstract

In a population-based study (1990-2009), we previously reported adverse long-term limb related outcomes after endovascular first (ER) compared to open first (OR) revascularization in patients with critical limb ischemia (CLI). The aim of this study was to limit the comparison to a time period (1999-2009) with better developed endovascular techniques and available imaging to study the effect of vascular anatomic variables on long-term outcomes in the same patient cohort. A retrospective cohort study of residents with CLI in a single county was conducted. Procedures were identified by ICD9/CPT codes and clinical, procedural and vascular imaging data collected through chart review. Patients (limbs) were categorized into OR or ER based on the index intervention. Reconstructions were classified as suprainguinal and infrainguinal (SI/II): TASC II classification and Rutherford runoff scores (ROS; range, 1-10) were calculated on review of imaging by an independent observer. Data were analyzed using the Cox proportional hazards model. End points were major adverse limb events (MALE), major amputations (AMPU), amputation-free survival (AFS), and mortality. There were 229 person limbs (193 patients) with CLI; mean age 70.3 years (range 26-97 years). The index intervention was OR in 132 limbs and ER in 97. Medical comorbidities included diabetes mellitus (DM; 48.7%) coronary artery disease (CAD; 50.3%), congestive heart failure (CHF; 20.2%), and end-stage renal disease on hemodialysis (ESRD on HD; 9.3%). SI reconstruction was performed in 60 limbs (OR, 30; ER, 30) and II in 169 (OR, 102; ER, 67). Limbs were classified as TASC A/B (OR, 19; ER, 58) and TASC C/D (OR, 108; ER, 35); ROS <4 (OR, 39; ER, 36) and ≥4 (OR, 88; ER, 57) based on available data in 220 limbs. Median follow-up was 5.8 years. Major amputations were performed secondarily in 38 limbs. On univariate analysis, the most significant risk factors associated with AMPU were ER, ESRD on HD, DM, and CHF. Factors associated with worse AFS and mortality included ER, age >75 years, and CHF; Table). II reconstruction and poor ROS were associated with higher AMPU (P = .07), but only poor ROS predicted significantly lower AFS after OR (P = .006; Fig). Based on this population-based study ER is associated with significantly worse limb-related outcomes in the long-term in patients with CLI. The level of reconstruction did not significantly affect outcome, but poor runoff predicted worse limb related outcomes after open revascularization.TableUnivariate analysis of preoperative factors affecting outcomes with lower extremity revascularization procedures in limbs with critical limb ischemiaMALE (n = 66)P valueAmputations(n = 38)P valueAFS (n = 123)P valueMortality (n = 94)P valueHR (95% CI)HR (95% CI)HR (95% CI)HR (95% CI)Surgery type Endo (ER)1.578 (0.9-2.6).0752.394 (1.1-4.8).0141.800 (1.2-2.6).0021.793 (1.1-2.7).007 Open (OR)1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)Age >75 years0.801 (0.4-1.3).4060.960 (0.4-1.9).9072.006 (1.3-2.9)<.0012.674 (1.7-4.0)<.001 ≤75 years1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)ESRD on HD Yes2.1 (1.1-4.0).0232.740 (1.1-6.3).011.440 (0.7-2.8).2991.515 (0.7-2.9).222 No1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)Diabetes Yes1.577 (0.9-2.6).0832.341 (1.1-4.8).0221.321 (0.8-1.9).1611.247 (0.8-1.8).289 No1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)CHF Yes1.238 (0.6-2.2).4962.567 (1.2-5.1).0082.182 (1.3-3.5).0012.613 (1.6-4.1)<.001 No1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)Level of reconstruction Infrainguinal0.993 (0.5-1.7).9812.398 (0.9-6.2).0751.367 (0.8-2.2).2261.248 (0.7-2.0).381 Suprainguinal1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)TASC A/B1.446 (0.7-2.6).2292.064 (0.9-4.4).0671.811 (1.1-2.8).0071.842 (1.1-2.9).01 C/D1.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)Runoff score ≥41.557 (0.8-2.8).1422.279 (0.9-5.5).0711.487 (0.9-2.3).0871.445 (0.9-2.2).109 <41.0 (Ref)1.0 (Ref)1.0 (Ref)1.0 (Ref)AFS, Amputation-free survival; CHF, congestive heart failure; CI, confidence interval; ESRD, end-stage renal disease; HD, hemodialysis; HR, hazard ratio; MALE, major adverse limb event. Open table in a new tab