The Natural History of Chronic Limb-Threatening Ischemia After Technical Failure of Endovascular Intervention

Abstract

We sought to explore the natural history of patients with chronic limb-threatening ischemia who had technical failure of endovascular interventions at a multidisciplinary limb salvage center. Data from 2013 to 2019 on all patients who had attempts at limb salvage at our center, including comorbidities categorized per Society of Vascular Surgery reporting standards and clinical outcomes including mortality, limb salvage, wound healing, and patency, were collected retrospectively. The t and χ2 tests assessed the differences between groups and product-limit Kaplan-Meier estimated survival functions. A total of 212 limbs underwent attempted endovascular intervention and 30 underwent primary bypass. Of the 212 attempted endovascular interventions, 181 were successful, for a technical failure rate of 14.6%. The technical failure group was older, more likely to be male, and more likely to be current smokers compared with the technical success group. No differences in ethnicity, diabetes, hypertension, renal status, hyperlipidemia, cardiac or pulmonary status, Wound, Ischemia, foot Infection score, or level of disease were found. Mean survival in the technical success and failure groups was 58 and 42 months, respectively (P = .087). Mean time to major amputation was longer in the technical success group compared with the technical failure group, 58 vs 45 months, respectively (P = .047) (Fig 1). Mean time to wound healing was shorter in the technical success group compared with the technical failure group, 25 vs 38 months, respectively (P = .028). Of the 31 technical failures, 18 underwent medical management and 13 underwent secondary bypass. Compared with the primary bypass group, the secondary bypass group was older and less likely to have tibial disease. There were no significant differences in sex, ethnicity, diabetes mellitus, smoking, hypertension, renal status, hyperlipidemia, cardiac status, pulmonary status, or Wound, Ischemia, foot Infection score. The secondary bypass group trended toward decreased survival, limb salvage, and wound healing compared with the primary bypass group (P = .059, .083, .051) (Fig 2). Not surprisingly, survival, limb salvage, and wound healing are relatively poor after technical failure of endovascular intervention, even when bypass is performed afterward. Furthermore, secondary bypass after technical failure of endovascular intervention trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.Fig 2Kaplan-Meier curve depicting limb salvage in the primary bypass vs secondary bypass groups.View Large Image Figure ViewerDownload Hi-res image Download (PPT)