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Index Below-knee Intervention For Intermittent Claudication Is Associated With Increased Amputation Risk
Gurbani Suri, MD, Patricia E. Chan, MD, Nitn Jethmalani, Christopher Agrusa, MD, Peter Connolly, MD, Sharif H. Ellozy, MD, Brian DeRubertis, MD, Jordan R. Stern, MD.
NewYork-Presbyterian Weill Cornell Medical Center, New York, NY, USA.
OBJECTIVES:Guidelines advise against infrapopliteal peripheral vascular intervention (PVI) for intermittent claudication (IC). We hypothesized that below-knee intervention at index PVI for IC confers higher future amputation risk than above-knee-only treatment.
METHODS:From the VQI PVI registry (2015-2025), we identified elective, initial PVIs for IC and compared those patients undergoing above-knee-only treatment (AK) to those having any below-knee intervention (BK). Using our previously described methodology, long-term amputation data were obtained by linking the PVI and amputation registries via unique patient identifiers. Demographic and procedural data were analyzed descriptively. Kaplan-Meier Analysis estimated risk of major and any (major+minor) amputation, with independent predictors identified by multivariable Firth logistic regression.
RESULTS:Among 92,899 treated limbs (81,338 AK; 11,561 BK), BK patients had increased rates of diabetes (54% vs. 41%), CHF (18% vs. 13%), and ESRD/dialysis (4.7% vs. 1.7%). BK patients were more likely to be Black (21% vs. 13%), Hispanic (8.8% vs. 4.3%), and Asian (1.5% vs. 1.0%) (p<0.001). Smoking history predominated in AK (89% vs. 67%,p<0.001). 16,086 limbs required repeat PVI, 13,831(17%) AK vs. 2,255(20%) BK (p<0.001). At reintervention, BK patients were more likely to have progressed to CLTI (41% vs. 25%;p<0.001), and undergo ≥2 repeats (32% vs. 27%;p<0.001). Initial below-knee intervention was associated with greater ipsilateral major (OR 2.65;1.91-3.67) and major+minor (OR 2.29;1.70-3.09) amputation. Kaplan-Meier showed increased major [1-year (0.3% vs 0.1%);5-years (0.4% vs 0.1%)] and any amputation risk [1-year (0.5% vs 0.1%); 5-years (0.7% vs 0.2%)] (Fig1).
CONCLUSIONS: Index below-knee intervention for IC portends greater risk of progression to CLTI, repeat PVI, and ipsilateral amputation, highlighting the potentially dangerous treatment trap of infrapopliteal intervention in claudicants.
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