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Impact Of Extent Of Revascularization On Limb Salvage For Chronic Limb Threatening Ischemia
Yash K. Pandya, Breanna Franklin, Katherine Reitz, MD, Robert Handezel, MD, Hasan Nassereldine, Edith Tzeng, MD.
UPMC, Pittsburgh, PA, USA.
Objectives:Appropriate revascularization can mean the difference between limb salvage and major amputation for chronic limb threatening ischemia (CLTI). Among patients with multilevel disease with tissue loss, we evaluated the outcomes of isolated inflow procedure vs. inflow with concurrent outflow procedure for CLTI.
Methods:We conducted a retrospective multi-hospital, single center study of adults who underwent an index inflow (endovascular or open) procedure for ischemic tissue loss (2016-2020). We compared patients undergoing inflow-only procedures to those undergoing inflow with concurrent outflow (inflow+outflow) procedures. The primary outcome was one-year major amputation. Secondary outcomes included repeated ankle brachial index (ABI), toe pressure (TP), and Wound, Ischemia, and Foot Infection (WIfI) scores compared from a change at baseline. Descriptive statistics and classical tests of hypotheses compared groups.
Results:We included 102 patients (70.511.1 years, 64.7% male, 84% White). The 48 (47.0%) who underwent inflow-only procedures had more frequent ESRD and COPD than inflow+outflow. Preoperative ABI (0.4 v 0.40.2; P=0.2), TP (15.423.5 v 20.323.4; P=0.4), and WIfI (WIfI1-2.7% v 4.88%, WIfI2-8.1% v 4.88%, WIfI3-43.2% v 26.8%, WIfI4-46% v 63.4%; P=0.2) scores were similar for both groups. Overall, 10.8% underwent one-year major amputation and was similar between groups (10.4% v 11.1%; P=0.3).
Twenty-seven percent of inflow-only patients underwent subsequent unplanned outflow procedures, yet none had a major amputation at one-year follow-up. Among all inflow-only patients, the preoperative ABI (0.30.3 vs 0.40.3), TP (14.324.1 vs 18.722.3), and WIFI (WIfI1-0% v 11.1%, WIfI2-10.7% v 0%, WIfI3-46.4% v 33.3%, WIfI4-42.9% v 55.6%; P-all>0.05) were similar between those with and without subsequent outflow procedure, respectively. However, those requiring subsequent outflow had lower one-month post-operative ABI (0.70.3 vs 0.90.3; P=0.08) and TP (31.22 vs 70.741.4; P=0.009) (Figure 1).
Conclusions:Inflow-only revascularization was prevalent in patients with more comorbidities and was associated with similar amputation rates and improvement in WIfI stage as those who underwent inflow+outflow procedures. In inflow-only patients who required subsequent revascularization, major amputation was not increased. These findings support that inflow-only revascularization may be acceptable in CLTI patients, reserving outflow procedures for those who do not demonstrate improved toe pressures at one-month.
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