Outcomes after Lower Extremity Revascularization for Treatment of Critical Limb Ischemia with Tissue Loss in Patients with Chronic Immune-Mediated Inflammatory Disease

Abstract

To evaluate outcomes after lower extremity revascularization for critical limb ischemia with tissue loss in patients with chronic immune-mediated inflammatory disease. A retrospective medical record review of all lower extremity revascularization for critical limb ischemia with tissue loss at a university-affiliated hospital over a 3-year period was completed for demographics, comorbidities, lower extremity revascularization indication, angiogram results, complications, mortality, limb salvage, and reintervention. Chronic immune-mediated inflammatory disease (CIID) and control (no autoimmune disease) were compared by chi-squared test, Student's t-test, Kaplan-Meier, and Cox Regression. There were 349 procedures performed (297 patients): (1) 44 (13%) primary amputations and (2) 305 (87%) lower extremity revascularizations, in which 83% were endovascular interventions; 12% was bypass; and 5% was hybrid, in which 40% was infrainguinal and 60% was infrageniculate, 72% Wounds Ischemia Infection Score System (WIFi) tissue loss class 2-3, 35% CIID. No differences were noted between CIID and control for primary amputation (P=0.11), lower extremity revascularization type (P=0.50), or lower extremity revascularization anatomic level (P=0.43). Mean age was 71+13years, and 56% of the patients were of male gender. Those with CIID were of similar age as controls (71±14 vs. 71±13; P=0.87) and presented with comparable runoff: (1) ≤1 vessel (52% vs. 47%; P=0.67), (2) WIFi tissue loss classification class 2-3 (66% vs. 76%; P=0.09), and (3) WIFi infection classification class 2-3 (29% vs. 30%; P=0.9). They were also less likely to be male (47% vs. 61%; P=0.022) or current smokers (13% vs. 27%; P=0.008). Postoperative mortality (P=0.70) morbidity and reoperation (0.31) were comparable. Twenty-four-month survival was similar for CIID and control (83%±5% vs. 86%+3%; P=0.78), as was the amputation-free interval (69%±5% vs. 61%±4%; P=0.18) and need for target extremity revascularization (40% vs. 53%; P=0.04). Use of steroids and other anti-inflammatory medications was associated with improved 24-month amputation-free interval (87%±9% vs. 63%±3%; P=0. 05). Dialysis (odds ratio: 2.6; 1.5-4.7; P=0.001), WIFi infection class 2-3 (odds ratio: 2.8; 1.6-4.9; P<0.001), prerunoff vessel (0-1 vs. 2-3) to the foot (odds ratio: 0.52; 0.37-0.73; P<0.001), steroids/other anti-inflammatory agents (0.29; 0.06-0.96; P=0.04), and statins (0.44; 0.25-0.77; P=0.005) were independent predictors of 24-month amputation-free interval (Cox proportional hazard ratio). Patients with critical limb ischemia, tissue loss, and concomitant CIID can be successfully treated with lower extremity revascularization with similar limb salvage and need for reintervention. Steroid/anti-inflammatory use appears beneficial.