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Utility of runoff scores and direct angiosome revascularization in predicting outcomes in patients undergoing revascularization for critical limb ischemia (CLI)
Marcus R. Kret, MD, Erica L. Mitchell, MD, Timothy K. Liem, MD, Amir Azarbal, MD, Gregory L. Moneta, MD, Gregory Landry, MD.
Oregon Health & Science University, Portland, OR, USA.
OBJECTIVES: Runoff scores and direct (DR) vs indirect revascularization (IR) for CLI according to pedal angiosomes have unclear utility. We compared DR vs IR and runoff scores in CLI patients undergoing infrapopliteal bypass for foot wounds.
METHODS: Patients who had tibial/pedal bypass for a foot/ankle wound from 2005 -2011 were identified and operations classified DR or IR based on wound location and bypass target. A blinded observer reviewed angiograms for an intact pedal arch and calculated standard Society for Vascular Surgery (single tibial) and modified (composite tibial) runoff scores. Co-morbidities, wound characteristics, wound healing, major amputation and overall survival were determined.
RESULTS: 106 limbs were revascularized in 97 patients. 54 limbs had DR and 52 had IR, although only 33% of wounds corresponded to a single, distinct angiosome. Wound characteristics and co-morbidities were similar between groups. Mean standard (7.9 vs 6.6, p=0.003) and composite (22.2 vs 20.0, p=0.02) runoff scores were worse (higher number indicates worse runoff) in the IR vs DR groups. 33% had a complete pedal arch. Complete wound healing (78% vs. 46%; p=0.001) and time to complete healing (99 vs. 195 days, p=0.002) were superior with DR vs IR but were not influenced by runoff score, modified runoff score or presence of complete plantar arch. In multivariate models controlling for runoff scores, DR remained a significant predictor for wound healing (OR 2.9, 95%CI 1.1-7.4, p=0.028) and reduced healing time (HR 2.1, 95% CI 1.2-3.7,p=0.012). Mean amputation-free survival (75/71 months DR/IR, p=.82) and median survival (36/33 months DR/ IR, p=.22) were not different DR vs IR.
CONCLUSIONS: DR according to pedal angiosomes provides more efficient healing of wounds but is possible in only half the patients and does not affect amputation-free or overall survival. DR is associated with improved runoff scores, but current runoff scores have little
clinical utility in predicting outcomes in CLI patients.
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