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Increased Pulse Pressure in Patients with Critical Limb Ischemia predicts Procedural Complications and Reinterventions.
Dominique B. Buck, MD, Vanessa Lee, Jeremy D. Darling, BA, John C. McCallum, MD, Sara L. Zettervall, MD, Peter A. Soden, MD, Marc L. Schermerhorn, MD, Raul J. Guzman, MD.
BIDMC, Boston, MA, USA.

OBJECTIVES:
Pulse Pressure (PP) is a non-invasive measure of arterial stiffness. Because it reflects lower arterial elasticity and compliance, it is thought to limit the success of endovascular interventions. In this study, we sought to determine whether increased PP was associated with worse long-term outcomes in patients undergoing endovascular infrapopliteal interventions.
METHODS:
From 2004 to 2014, 596 patients underwent infrapopliteal angioplasty for critical limb ischemia (CLI). PP was derived from blood pressure measurements obtained within 24 hours of the procedure. Patients were divided into 2 groups, those with PP < 80 and those with PP ≥ 80. Outcomes included procedural complications, reintervention, major amputation, and mortality. Predictors were identified using multivariable logistic regression, Cox regression models, and Kaplan-Meier survival estimates.
RESULTS:
Of 596 patients, 323 patients had a PP<80 and 273 had a PP≥80. Patients with PP≥80 were more likely to have hypertension (88 vs 82%, P=0.04), however, no other significant differences in patient demographics and comorbidities were identified. Three year reintervention rates and mortality were significantly more common in patients with PP ≥ 80 (29% vs. 20%, P=.02; 55% vs 45%, P=.01, respectively). (Table) A cox proportional hazards model illustrated that, over time, mortality was significantly higher in patients with PP ≥ 80 (Hazard Ratio [HR], 1.1; 95% CI, 1.3-2.0). In multivariable analysis, a PP ≥ 80 was a predictor of procedural complications (OR1.8, 95% CI 1.2-2.8, p=<.01) and reinterventions (OR 1.7, 95% CI 1.2-2.6, p=<.01).
CONCLUSIONS:
Increased pulse pressure is associated with increased procedural complication rates, reintervention, and 3 year mortality suggesting that arterial stiffness plays an important role in outcomes after endovascular intervention for CLI.
Patient outcomes for patients with PP<80 and PP≥80. (* based on proportional hazards)
Outcomes, No. (%)PP < 80
N=323
PP ≥ 80
N=273
P-value
Stent91 (28)91 (33)0.17
Procedural complications46 (14)60 (22)0.01
Length of stay (days) (mean[SD])8.1 [7.7]6.1 [6.4]<.01
3-year reintervention58 (20)69 (29)0.02 *
3-year repeat PTA/S34 (12)48 (16)0.15 *
3-year bypass23 (8)32 (13)0.04 *
3-year restenosis79 (27)82 (34)0.07 *
3-year major amputation45 (15)30 (12)0.36 *
3-year mortality145 (45)150 (55)0.01 *


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