The predictors of clinical outcome after endovascular intervention for lower extremity peripheral arterial disease

Abstract Background Patients with peripheral arterial disease (PAD) have a higher mortality rate than age-matched patients without PAD. Also more than half of patients with symptomatic PAD have polyvascuar disorder including coronary artery disease (CAD). Purpose This study aimed to identify the predictors of mortality outcomes in patients with peripheral artery disease undergoing lower extremity endovascular intervention. Methods We studied 300 consecutive patients admitted for symptomatic low extremity arterial disease. A total of 196 patients without angina and prior coronary revascularization (72±10 years, 156 men) who underwent lower extremity endovascular intervention (claudication, n=74; critical limb ischemia, n=122) were retrospectively analyzed. All patients underwent coronary angiography but not simultaneous coronary revascularization. CAD was defined as angiographically significant (≥50%) stenosis of coronary arteries and severity was classified as none, 1-, 2-, or 3-vessel disease (VD). All-cause mortality and major adverse cardiac and cerebrovascular event (MACCE) rate were compared between the patients with CAD and those without CAD. MACCE included any of the following adverse events: cardiac death, cerebrovascular death, acute myocardial infarction, stroke, and congestive heart failure. Results Mean duration of follow-up was 3 years. All-cause mortality and MACCE were 16.3% and 19.8%, respectively. The independent risk factors for all-cause mortality were old age (HR=1.05, P=0.043), lower body mass index (HR=0.83, P=0.016), critical limb ischemia (HR=3.74, P=0.033) and the presence of CAD (HR=2.85, P=0.027). This variable surpassed all classical risk factors (including smoking and history of hypertension or diabetes mellitus). Of the 196 patients, 101 patients (52%) had asymptomatic CAD; 1-VD (n=35, 18%); 2-VD (n=32, 16%); 3-VD (n=28, 14%). Patients with CAD had significantly higher all-cause mortality (19% vs. 11%, P=0.018) and higher MACCE rate (26% vs. 8%, P=0.001) compared to those without CAD. Furthermore, the severity of CAD had graded associations with the all-cause mortality and MACCE rate (Figure). Independent predictors of CAD were critical limb ischemia (CLI) (OR = 2.43, P=0.018) and presence of the below-the-knee lesions (OR = 2.04, P=0.019). In addition, CAD was more prevalent in the patients with lower BMI (61% vs. 41%, p=0.007). Conclusion Asymptomatic coronary artery disease (CAD) was found in half of the patients undergoing endovascular intervention for lower extremity arterial disease and associated with higher mortality and MACCE rate. Therefore, detection of CAD might be important for risk stratification for these patients, especially with lower body mass index or critical limb ischemia. Funding Acknowledgement Type of funding source: None

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Rivaroxaban Plus Aspirin Versus Standard Dual Antiplatelet Therapy Following Angioplasty for Lower Extremity Peripheral Arterial Disease in Patients With Critical Limb Ischemia and Claudication (RIVAL-PAD): 12-Month Results of a Randomized Trial

Journal of Vascular Surgery ◽

10.1016/j.jvs.2018.06.135 ◽

2018 ◽

Vol 68 (3) ◽

pp. e67

Author(s):

Prasad Jetty ◽

Dalibor Kubelik ◽

Sudhir Nagpal ◽

Andrew Hill ◽

George Hajjar ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Lower Extremity ◽

Randomized Trial ◽

Antiplatelet Therapy ◽

Critical Limb Ischemia ◽

Dual Antiplatelet Therapy ◽

Limb Ischemia ◽

Arterial Disease ◽

Peripheral Arterial

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Evolution of Major Amputation Risk in Patients Hospitalized in France for Critical Limb Ischemia: The COPART Registry

Angiology ◽

10.1177/0003319720976823 ◽

2020 ◽

pp. 000331972097682

Author(s):

Alice Coudene ◽

Francois-Xavier Lapébie ◽

Ileana Desormais ◽

P Lacroix ◽

Valerie Aurillac ◽

...

Keyword(s):

Critical Limb Ischemia ◽

Limb Ischemia ◽

Arterial Disease ◽

Major Amputation ◽

The Past ◽

Significant Difference ◽

Before And After ◽

Secondary Outcomes ◽

Artery Disease ◽

Peripheral Arterial

Over the past decade, improvements in medical treatment and revascularization techniques have been beneficial for patients with peripheral artery disease in the late stage of critical limb ischemia (CLI). We evaluated the putative reduction in the number of major amputees in the Cohorte des Patients ARTeriopathes (COPART) cohort over time. Patients were selected from this multicenter cohort, from 2006 to 2016, for CLI according to Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease II criteria. Patients included before and after 2011 were compared. Patients were followed for 1 year. Primary outcome was the rate of major amputations. Secondary outcomes were minor amputations, deaths from all causes, cardiovascular deaths; 989 patients were included, 489 before 2011 and 450 after 2011. There was a significant decrease in rates of major amputation after 2011 (17% vs 25%), confirmed in multivariate analysis (odds ratio [OR]: 1.5 [1.1-2.2]), an increase in revascularization, particularly distal angioplasty (OR: 2.7 [1.7-4.4]) and increased statin intake (OR: 1.6 [1.1-2.1]). For secondary outcomes, there was no significant difference. Limb prognosis of CLI patients has improved over the past decade, possibly due to more revascularizations, particularly distal ones, and increased statin use.

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Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia

Molecular Imaging and Biology ◽

10.1007/s11307-019-01425-3 ◽

2019 ◽

Vol 22 (2) ◽

pp. 245-255 ◽

Cited By ~ 1

Author(s):

Ting-Heng Chou ◽

Mitchel R. Stacy

Keyword(s):

Peripheral Arterial Disease ◽

Lower Extremity ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Arterial Disease ◽

Clinical Applications ◽

Peripheral Arterial ◽

Radiotracer Imaging

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New techniques for endovascular treatment of peripheral artery disease with focus on chronic critical limb ischemia

VASA ◽

10.1024/0301-1526.38.1.3 ◽

2009 ◽

Vol 38 (1) ◽

pp. 3-12 ◽

Cited By ~ 10

Author(s):

Zeller ◽

Sixt ◽

Rastan

Keyword(s):

Limb Salvage ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Arterial Disease ◽

Limb Loss ◽

Infrapopliteal Artery ◽

Below The Knee ◽

Chronic Critical Limb Ischemia ◽

Artery Disease ◽

Peripheral Arterial

Chronic critical limb ischemia (CLI) represents the most advanced stage of peripheral arterial disease. CLI is associated with a high risk for limb loss and revascularization, either by surgical or endovascular means, is absolutely mandatory. With traditional techniques such as balloon angioplasty, limb salvage was reported in 80 to 90%. However, in case of failed revascularization attempt, limb loss was 40 to 50% and mortality approximately 20%. This review summarizes new developments in endovascular techniques which increase the acute and chronic success rate of endovascular procedures and therefore potentially further improve limb salvage rates. Special crossing and re-entry devices designed for femoro-popliteal application may even facilitate recanalization of long chronic occlusions. Improved stent design, atherectomy devices and drug coated balloons improve patency rates and may result in improved wound healing rates. Moreover, downsizing the catheter tools for infrapopliteal artery disease opens new horizons also for the treatment of complex below-the-knee lesions representing an increasing patient population due to the increasing prevalence of diabetes and end-stage renal failure.

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The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-020-01315-8 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Linda Renata Micali ◽

Massimo Bonacchi ◽

Daniel Weigel ◽

Rosie Howe ◽

Orlando Parise ◽

...

Keyword(s):

Lower Limb ◽

Coronary Revascularization ◽

Artery Bypass ◽

Limb Ischemia ◽

Arterial Disease ◽

Lower Limb Ischemia ◽

Acute Kidney Disease ◽

History Of ◽

Artery Disease ◽

Peripheral Arterial

Abstract Background Patients with a history of peripheral arterial disease (PAD) undergoing coronary artery bypass grafting (CABG) exhibit higher rates of complications. There are conflicting data on the survival benefits for bilateral thoracic artery (BITA) grafting compared with left internal thoracic artery (LITA) CABG in patients with PAD. The aim of the study was to explore the influence of the use of BITA grafts vs. LITA for CABG on post-operative acute lower limb ischemia (ALLI) and main post-operative complications in patients with concomitant PAD. Methods We used a propensity-score (PS) based analysis to compare outcomes between the two surgical procedures, BITA and LITA. The inverse probability of treatment weighting PS technique was applied to adjust for pre- and intra-operative confounders, and to get optimal balancing of the pre-operative data. The primary outcome was the estimate of postoperative ALLI. Secondary outcomes included overall death and death of cardiac causes within 30 days of surgery, stroke and acute kidney disease (AKD). Results The study population consisted of 1961 patients. The LITA procedure was performed in 1768 patients whereas 193 patients underwent a BITA technique. The estimate of ALLI was 14% higher in the BITA compared to the LITA (p < 0.001) group. Thirty-day mortality, cardiac death, occurrence of stroke and AKI did not differ significantly between the groups. Conclusions The use of both ITAs led to a significant increase in ALLI. This result was most likely caused by the complete disruption of the ITA collateral providing additional blood supply to the lower extremities. Based on our data, BITA should be used with extreme caution in PAD patients. Further research on this topic is necessary to confirm our findings.

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Abstract 15184: Prevalence, Predictors and Clinical Outcomes of Unknown Coronary Artery Disease Among the Patients Undergoing Lower Extremity Endovascular Intervention

Circulation ◽

10.1161/circ.132.suppl_3.15184 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Sung-Jin Hong ◽

Byung Ok Kim ◽

Hye Young Lee ◽

In Hyun Jung ◽

Young Sup Byun ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Lower Extremity ◽

Clinical Outcomes ◽

Coronary Revascularization ◽

Endovascular Intervention ◽

Cerebrovascular Event ◽

Below The Knee ◽

All Cause Mortality ◽

Artery Disease

Introduction: The prevalence and clinical outcomes of unknown coronary artery disease (CAD) among the patients with peripheral artery disease, particularly for those undergoing lower extremity endovascular intervention, were not well evaluated. Methods: Between 2006 and 2014, a total of 208 consecutive patients (73±10 years, 165 men) without angina and prior coronary revascularization, were underwent lower extremity endovascular intervention. All patients evaluated coronary angiography without simutaneous coronary revascularization. CAD was defined as angiographically significant (≥50%) stenosis. All-cause mortality and major adverse cardiac and cerebrovascular event (MACCE) rate were compared between the patients with CAD and those without CAD. MACCE included cardiac death, cerebrovascular death, myocardial infarction, stroke, or heart failure. Results: Of the 208 patients, 103 patients (50%) had CAD; 1-VD (17%); 2-VD (17%); 3-VD (15%). Independent predictors of CAD were critical limb ischemia (OR=2.4) and below-the-knee lesions (OR=2.0). During the median follow-up of 1.2 years, all-cause mortality and MACCE rate at 3 year were 16.3% and 19.8%. At 3 year, patients with CAD had significantly higher mortality (19% vs. 14%, P=0.018) and higher MACCE rate (28% vs. 9%, P=0.001) compared to those without CAD. The severity of CAD had graded relations with the mortality and MACCE rate (Figure). Presence of CAD was an independent predictor of mortality (HR=1.5, P=0.025) and MACCE rate (HR=1.9, P<0.001). Conclusions: Previously unknown CAD was detected in half of the patients undergoing lower extremity endovascular intervention and associated with higher mortality and MACCE rate. Detection of CAD might be important for risk stratification for these patients, especially with below-the-knee lesions.

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Abstract P250: Incidence of Hospitalized Peripheral Arterial Disease and Critical Limb Ischemia: The Atherosclerosis Risk in Communities (ARIC) Study

Circulation ◽

10.1161/circ.125.suppl_10.ap250 ◽

2012 ◽

Vol 125 (suppl_10) ◽

Author(s):

Corey A Kalbaugh ◽

Anna Kucharska-Newton ◽

Laura Loehr ◽

Elizabeth Selvin ◽

Aaron R Folsom ◽

...

Keyword(s):

Risk Factors ◽

African Americans ◽

Peripheral Arterial Disease ◽

Lower Extremity ◽

Limb Ischemia ◽

Arterial Disease ◽

Atherosclerosis Risk In Communities ◽

Atherosclerosis Risk ◽

Baseline Characteristics ◽

Peripheral Arterial

Introduction: Lower extremity peripheral arterial disease (PAD) affects between 12% and 20% of Americans over the age of 65. PAD compromises quality of life, contributes a high burden of disability and its related health care costs exceed $4 billion/year, yet this preventable CVD outcome remains understudied. Aims: Assess the incidence of hospitalized PAD, and of the most severe form of PAD, critical limb ischemia (CLI), in middle-aged men and women, and evaluate their risk factors in a bi-ethnic, population-based cohort. We hypothesized that incidence of hospitalized PAD and CLI are higher in African Americans, and that modifiable atherosclerosis risk factors in middle age predict these sequelae of PAD. Methods: We analyzed data from 13,865 participants from the Atherosclerosis Risk in Communities Study aged 45–64 without PAD at baseline (1987–89). Incident PAD and CLI events were identified using ICD-9 codes from active surveillance of all hospitalizations among cohort participants from 1987 through 2008. All estimates are incidence rates per 10,000 person-years; nominal statistical significance was achieved for all baseline characteristic comparisons reported. Results: There were 707 incident hospitalized PAD during a median of 18 years of follow-up (249,570 person-years). The overall age-adjusted incidence of PAD and limb-threatening CLI were 26.0 and 9.6 per 10,000 person-years, respectively. Incidence of hospitalized PAD was higher in African Americans than whites (34.7 vs. 23.2) and in men compared to women (32.4 vs. 26.7). Baseline characteristics associated with age-adjusted incident PAD (per 10,000 person-years) compared to their referent groups were diabetes (91.2 vs. 19.0), history of smoking (33.6 vs. 16.2), hypertension (42.6 vs. 18.6), coronary heart disease (81.4 vs. 24.1), and obesity (41.5 vs. 20.2). Incidence of CLI also was higher among African Americans (21.0 vs. 5.9) and in men (10.5 vs. 8.9 per 10,000 person-years). Baseline characteristics associated with incident CLI were similar to those for PAD. Conclusions: The absolute risk of hospitalized lower extremity PAD in this community-based cohort is of a magnitude similar to that of heart failure and of stroke. As modifiable factors are strongly predictive of the long-term risk of hospitalized PAD and CLI, particularly among African Americans, our results highlight the need for effective risk factor prevention and control.

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Impact of Kidney Disease on Peripheral Arterial Interventions: A Systematic Review and Meta-Analysis

American Journal of Nephrology ◽

10.1159/000508575 ◽

2020 ◽

Vol 51 (7) ◽

pp. 527-533

Author(s):

Mahesh Anantha-Narayanan ◽

Azfar Bilal Sheikh ◽

Sameer Nagpal ◽

Kim G. Smolderen ◽

Jeffrey Turner ◽

...

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Meta Analysis ◽

Limb Ischemia ◽

Arterial Disease ◽

Major Amputation ◽

Early Mortality ◽

Comorbid Condition ◽

Increased Risk ◽

Peripheral Arterial

Background: There are limited data on outcomes of patients undergoing peripheral arterial disease (PAD) interventions who have comorbid CKD/ESRD versus those who do not have such comorbid condition. We performed a systematic review and meta-analysis to analyze outcomes in this patient population. Methods: Five databases were searched for studies comparing outcomes of lower extremity PAD interventions for claudication and critical limb ischemia (CLI) in patients with CKD/ESRD versus non-CKD/non-ESRD from January 2000 to June 2019. Results: Our study included 16 observational studies with 44,138 patients. Mean follow-up was 48.9 ± 27.4 months. Major amputation was higher with CKD/ESRD compared with non-CKD/non-ESRD (odds ratio [OR 1.97] [95% confidence interval [CI] 1.39–2.80], p = 0.001). Higher major amputations with CKD/ESRD versus non-CKD/non-ESRD were only observed when indication for procedure was CLI (OR 2.27 [95% CI 1.53–3.36], p < 0.0001) but were similar for claudication (OR 1.15 [95% CI 0.53–2.49], p = 0.72). The risk of early mortality was high with CKD/ESRD patients undergoing PAD interventions compared with non-CKD/non-ESRD (OR 2.55 [95% CI 1.65–3.96], p < 0.0001), which when stratified based on indication, remained higher with CLI (OR 3.14 [95% CI 1.80–5.48], p < 0.0001) but was similar with claudication (OR 1.83 [95% CI 0.90–3.72], p = 0.1). Funnel plot of included studies showed moderate bias. Conclusions: Patients undergoing lower extremity PAD interventions for CLI who also have comorbid CKD/ESRD have an increased risk of experiencing major amputations and early mortality. Randomized trials to understand outcomes of PAD interventions in this at-risk population are essential.

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Article Commentary: Current Status of Heroic Limb Salvage for Critical Limb Ischemia

The American Surgeon ◽

10.1177/000313480807400401 ◽

2008 ◽

Vol 74 (4) ◽

pp. 275-284

Author(s):

Spence M. Taylor

Keyword(s):

Critical Limb Ischemia ◽

Current Method ◽

Limb Ischemia ◽

Arterial Disease ◽

Current Status ◽

Limb Amputation ◽

Vascular Intervention ◽

Ambulatory Ability ◽

Original Measure ◽

Peripheral Arterial

The treatment of chronic lower extremity peripheral arterial disease is in a state of flux. During the past decade, vascular surgeons have assumed the responsibility for the endovascular care of patients needing vascular intervention. Once surgeons began performing these procedures, a change in attitude toward angioplasty resulted in an “endovascular explosion” and an overall reassessment of the traditional approaches to critical limb ischemia. Our current method of assessing outcomes is also in a state of flux. The original measure of procedural success, reconstruction patency, has been found to be a poor predictor of both patient palliation and functional success. A shift toward determining more accurate, patient-oriented outcome measures is ongoing. Until then, evidence would suggest that there are patients with such severe medical comorbidities, which include impaired ambulatory ability at presentation, that the benefits of revascularization seem to be insignificant. As our patient population ages and our healthcare system continues to fail financially, economic rationing motivated by lack of evidence-based data to the contrary may dictate that these patients are best served by primary limb amputation.

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