The Association of Preoperative Characteristics with Reintervention Risk in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

Abstract

To investigate the associations between preoperative characteristics and the risk of reintervention in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI) in a contemporary realworld setting. Methods: We retrospectively analyzed data from a clinical database formed by the Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study, which was a multicenter, prospective, observational study. The study population was composed of 520 CLTI patients with the wound, ischemia, and foot infection (WIfI) classes I-3 with resting pain or classes I-2/3 with ulcers/gangrene. Of the 520 patients, 192 had surgical reconstruction planned, whereas 328 had endovascular therapy (EVT) alone planned at the time of registration. The current analysis was conducted to explore the associations between preoperative characteristics and the risk of reintervention. Results: A total of 452 participants (87%) completed the 3-year follow-up regarding reintervention. The competing risk analysis estimated that the three-year cumulative incidence rates for reintervention and reintervention-free deaths were 44.0% and 28.7%, respectively. No preoperative characteristics had a significant interaction effect with EVT versus surgical reconstruction. The risk analysis identified the following independent risk factors for reintervention: 1) EVT instead of bypass reconstruction, 2) renal dysfunction, 3) history of revascularization after CLTI onset (i.e., requirement of redo revascularization for CLTI), and 4) bilateral CLTI. Patients with more than one of these risk factors had an increased risk of reintervention. Conclusions: The current study identified preoperative characteristics associated with an increased risk of reintervention. No preoperative characteristics had any significant interactions with EVT or surgical reconstruction. chronic limb-threatening ischemia (CLTI) 1, 2). Its safety and effectiveness are acknowledged in current guidelines, and it plays an increasingly important role in the management of CLTI 3-5

Clinical Impact of Measures for Frailty Severity in Poor-Risk Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

“…Prognosis of chronic limb-threatening ischemia (CLTI) is generally poor, and frailty, commonly seen in CLTI patients, is associated with a poorer prognosis in the population [1][2][3][4] . For frail CLTI patients, primary amputation may be indicated 1,5) ; however, the treatment will further impair their activities of daily living (ADL), not only deteriorating their frailty severity but of independence 7) , ambulation, home-boundness, and the Life-Space Assessment (LSA) 8) .…”

Variation in treatment and outcomes for patients with chronic limb‐threatening ischaemia in New South Wales, Australia

“…A Swedish study had a mean age of 76.8 years old for patients with CLTI undergoing revascularization, similar to our median age of 71.3 years 17 . Compared to younger patients, older patients had higher rates of diabetes, end‐stage renal disease, chronic heart failure and longer smoking histories, contributing to higher mortality rates and adverse perioperative outcomes 13,17–19 . Because of a lack of anatomical or detailed clinical variables in routinely collected health data, we are unable to assess the appropriateness of surgical procedures; however, the high rates of endovascular surgery, especially in older patients, may reflect the high operative risk and frailty of this cohort 6 .…”

“…Procedures of interest were open revascularization, endovascular surgery for PAD, minor amputations and debridement for PAD in patients with a concurrent diagnosis code for CLTI (rest pain, ulceration or necrosis, including diabetes‐related ulceration). As patients with CLTI commonly have more than one surgical procedure, 13 a primary procedure was allocated based upon the following hierarchy: open revascularization, endovascular revascularization or minor amputation (including debridement). Figure 1 describes the patient selection methods.…”

Commentary: Limb-Based Patency for Chronic Limb-Threatening Ischemia Treatment: Do We Face a Threshold for Redefining Current Revascularization Practice?

“…Their analysis is based on a large database initially generated for the S urgical Reconstruction vs P eripheral In tervention in P a tients With Critical Limb Is ch emia (SPINACH) prospective, multicenter, observational study. 6…”

“…Their analysis is based on a large database initially generated for the Surgical Reconstruction vs Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) prospective, multicenter, observational study. 6 Dr Utsunomiya's article acknowledges the inferior LBP rates observed in the endovascular vs the bypass groups of CLTI patients (p<0.001). It also reveals an inverse proportionality for both techniques concerning initial technical failure compared to LBP.…”