Functional prognosis of critical limb ischemia and efficacy of restoration of direct flow below the ankle

Abstract

Objective Patients with critical limb ischemia have serious systemic comorbidities and are at high risk of impairment of limb function. In this study, we assessed the prognostic factors of limbs after revascularization. Methods In this retrospective single-center cohort study, from April 2008 to December 2012, we treated 154 limbs of 121 patients with critical limb ischemia by the endovascular therapy-first approach based on the patients' characteristics. The primary end point was amputation-free survival. Secondary end points were patency of a revascularized artery, major adverse limb events, or death. Furthermore, we investigated the ambulatory status one year after revascularization as prognosis of limb function. Results Endovascular therapy was performed in 85 limbs in 65 patients as the initial therapy (endovascular therapy group) and surgical reconstructive procedures (bypass group) were performed in 69 limbs in 56 patients. Early mortality within 30 days was not observed in either group. The primary patency rate was significantly better in the bypass group than in the endovascular therapy group ( p < 0.0001). Furthermore, the secondary patency rate was similar between the two groups ( p = 0.0096). There were no significant differences in amputation-free survival and major adverse limb event between the two groups. Univariate analysis showed that ulcer healing ( p < 0.0001), no hypoalbuminemia ( p = 0.0019), restoration of direct flow below the ankle ( p = 0.0219), no previous cerebrovascular disease ( p = 0.0389), and Rutherford 4 ( p = 0.0469) were predictive factors for preservation of ambulatory status one year after revascularization. In multivariate analysis, ulcer healing ( p < 0.0001) and restoration of direct flow below the ankle ( p = 0.0060) were significant predictors. Conclusions Ulcer healing and restoration of direct flow below the ankle are independently associated with prognosis of limb functions in patients who undergo infrainguinal arterial reconstruction.

Inframalleolar bypass for chronic limb-threatening ischemia

“…Our aggressive surgical first approach in Rutherford category 5 and 6 patients with extensive distal arterial disease appears justified in light of recent studies which have showed better results for bypass surgery compared to an endovascular approach. 10 We believe that revascularization is feasible in all patients with advanced CLTI, letting only permanently bedridden patients and patients with extensive gangrene or infection undergo primary amputation. Kalra et al reported amputation as a significant independent risk factor for higher long-term mortality.…”

“…Besides relief of ischemic pain, ulcer healing, prevention of limb loss, and survival, functional recovery is a major objective of CLTI treatment, being strictly related to quality of life. 10 Infrainguinal bypasses are recommended for TASC D lesions. 12 The new Global Vascular Guidelines for treating CLTI, support surgical revascularization in those patients with extensive steno-occlusions of leg arteries and with WIfI stages 3 to 4.…”

“…Secondary outcomes included 2-year overall survival, amputation-free survival, assisted primary patency, secondary patency, and functional status. 10,11 Outcomes were defined according to Rutherford reporting standards. 1 Demographic variables and cardiovascular risk factors, such as smoking, hypertension, diabetes, and renal insufficiency were recorded.…”

Long-Term Results of Below-The-Knee Bypass Using a Prosthetic Graft with a Distal Arteriovenous Fistula Interposition

“…Primary outcomes included primary patency, limb salvage, and overall survival rate. Secondary outcomes included amputation-free survival, assisted primary patency, and functional status [ 7 ]. Outcomes were defined according to Rutherford reporting standards [ 2 ].…”