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The Impact Of Preoperative Anemia On Long Term Survival, Amputation-free Survival, Limb Salvage In Patients With Chronic Limb Threatening Ischemia
Rose Gooding, MD, Mariel Rivero, MD, Brittany Montross, MD, Sikandar Khan, MBBS, Linda Harris, MD, Maciej Drjski, MD,
Hasan H. Dosluoglu, MD;
SUNY at Buffalo, Buffalo, NY, USA
OBJECTIVES: Preoperative anemia is common in patients with chronic limb threatening ischemia (CLTI). Hematocrit <30 was found to be associated with decreased one-year amputation-free survival (AFS) in PREVENT III, but was not adopted for risk assessment. Recently, worse one-year AFS and limb salvage (LS) was reported following vascular surgery for PAD with moderate/severe anemia. The goal of our study was to assess the impact of anemia on early and long-term survival, AFS, LS and patency rates in patients undergoing revascularization for CLTI.
METHODS: Patients with CLTI who had revascularization for Rutherford 4-6 between 1/2007-12/2021 were included. Patients with preoperative Hct ≥39 (Group I, N=275(335 limbs)) were compared to those with mild anemia (Hct 33.0-38.9, Group II, 266(338 limbs)) and moderate/severe anemia (Hct ˂33.0, Group III, N=199(266 limbs)). As only 15% of patients had Hct<30, we used the WHO classification for anemia.
RESULTS: Patients in Group I were younger (70.4±9.9vs73.1±9.7vs72.9±10.9, P<0.01) with less hypertension (74%vs83%vs84%, P=0.006), DM (50%vs67%vs69%, P<0.001), CKD (21%vs42%vs52%, P<0.001), nonambulatory (8%vs21%vs26%), and higher active smoking (47%vs23%vs25%, P<0.001) than Group II and III. Patients in Groups II and III more commonly had tissue loss (70%vs85%vs92%, P<0.001), underwent infrapopliteal interventions (46%vs56%vs65%), and ev interventions (61%vs78%vs84%, P<0.001). Postoperative 30-day mortality/MI were significantly greater in Group II and III (1.4%vs6.0%vs4.0%, P=0.013). Overall survival (5-year 52±3vs30±3vs22±3, P<0.001), AFS (5-year 47±3vs25±3vs16±3, P<0.001, Figure) were significantly different in groups. Multivariate analysis showed CAD (HR 1.4 (95% CI 1.1-1.6)) , CKD (1.5 (1.2-1.8), nonambulatory status (1.7 (1.3-2.1)), tissue loss (1.5 (1.2-2.0)), and Hct <39 (Group II 1.4 (1.2-1.8), Group III 1.8 (1.4-2.2)) to be independently associated with survival and AFS (all P<0.001). LS rates were similar after open revascularization (P=0.737) however, was significantly different in patients who had ev revascularization (5-year 90±2%vs83±3%vs75±4, P=0.002). Primary patency was similar in all Groups (5-year PP 58±4vs58±4vs63±4, P=0.973)
CONCLUSIONS: Preoperative anemia (Hct<39) is associated with poorer early postoperative events and independently associated with late survival and AFS in patients with CLTI after revascularization. LS seem to be impacted by the level of anemia in patients treated with ev interventions, and not after open revascularization.
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