PMID- 35697305 OWN - NLM STAT- MEDLINE DCOM- 20220928 LR - 20221207 IS - 1097-6809 (Electronic) IS - 0741-5214 (Linking) VI - 76 IP - 4 DP - 2022 Oct TI - Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia. PG - 997-1005.e2 LID - S0741-5214(22)01622-6 [pii] LID - 10.1016/j.jvs.2022.04.042 [doi] AB - OBJECTIVE: In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway after intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events (MALE) after infrainguinal revascularization for CLTI. METHODS: Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aortoiliac disease, prior infrainguinal stents, or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of reintervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. MALE included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation. RESULTS: We analyzed 184 unique limbs in 163 patients. This cohort was composed of 66.9% male patients with a mean age of 72 years. Baseline characteristics included diabetes (66%), tissue loss (91%), and advanced WIfI stages (30% stage 3, 51% stage 4). Global Limb Anatomic Staging System stage 3 anatomic patterns were common (n = 119 [65%]). Sixty limbs were treated with open bypass (65% involving tibial targets) and 124 underwent endovascular intervention (70% including infrapopliteal targets). The 12-month freedom from MALE and loss of LBP were 74.0% +/- 3.7% and 48.6% +/- 4.2%, respectively. Diabetes (hazard ratio [HR], 2.56; 95% confidence interval [CI], 1.13-5.83; P = .025) and loss of LBP (HR, 4.12; 95% CI, 1.96-8.64; P < .001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR, 4.97; 95% CI, 1.89-13.09; P = .001). Loss of LBP impacted both intermediate-risk limbs (HR, 2.85; 95% CI, 1.02-7.97; P = .047 in WIfI stages 1-3) and high-risk limbs (HR, 3.99; 95% CI, 1.32-12.11; P = .014 in WIfI stage 4). However, the loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs 8% major limb amputation at 12 months in limbs without vs with maintained LBP). CONCLUSIONS: The anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4). CI - Copyright (c) 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. FAU - El Khoury, Rym AU - El Khoury R AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. FAU - Wu, Bian AU - Wu B AD - Division of Vascular Surgery, Department of Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, CA. FAU - Kupiec-Weglinski, Sophie A AU - Kupiec-Weglinski SA AD - School of Medicine, University of California San Francisco, San Francisco, CA. FAU - Liu, Iris H AU - Liu IH AD - School of Medicine, University of California San Francisco, San Francisco, CA. FAU - Edwards, Ceazon T AU - Edwards CT AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. FAU - Lancaster, Elizabeth M AU - Lancaster EM AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. FAU - Hiramoto, Jade S AU - Hiramoto JS AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. FAU - Vartanian, Shant M AU - Vartanian SM AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. FAU - Schneider, Peter A AU - Schneider PA AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. FAU - Conte, Michael S AU - Conte MS AD - Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA. Electronic address: michael.conte2@ucsf.edu. LA - eng PT - Journal Article DEP - 20220610 PL - United States TA - J Vasc Surg JT - Journal of vascular surgery JID - 8407742 SB - IM MH - Aged MH - Amputation, Surgical MH - Chronic Limb-Threatening Ischemia MH - *Endovascular Procedures/adverse effects MH - Female MH - Humans MH - Ischemia/diagnostic imaging/surgery MH - Limb Salvage MH - Lower Extremity/blood supply MH - Male MH - *Peripheral Arterial Disease/diagnostic imaging/surgery MH - Retrospective Studies MH - Risk Factors MH - Treatment Outcome OTO - NOTNLM OT - Amputation OT - Bypass OT - Chronic limb-threatening ischemia OT - Endovascular OT - Limb-based patency OT - Peripheral artery disease EDAT- 2022/06/14 06:00 MHDA- 2022/09/28 06:00 CRDT- 2022/06/13 19:33 PHST- 2022/02/04 00:00 [received] PHST- 2022/04/12 00:00 [revised] PHST- 2022/04/24 00:00 [accepted] PHST- 2022/06/14 06:00 [pubmed] PHST- 2022/09/28 06:00 [medline] PHST- 2022/06/13 19:33 [entrez] AID - S0741-5214(22)01622-6 [pii] AID - 10.1016/j.jvs.2022.04.042 [doi] PST - ppublish SO - J Vasc Surg. 2022 Oct;76(4):997-1005.e2. doi: 10.1016/j.jvs.2022.04.042. Epub 2022 Jun 10.