Wound Severity Score In Patients With Critical Limb Ischemia And Tissue Loss Undergoing Tibial Revascularization With Coronary Drug Eluting-stents With And Without Adjunctive Hyperbaric Oxygen Therapy
Naiem Nassiri, MD RPVI, Dustin Crystal, BS, Lauren A. Huntress, MS, Jones Thomas, Saum Rahimi, MD, Cathy Hoyt, DPM, Khanjan Nagarsheth, MD, MBA, Randy Shafritz, MD, FACS.
Rutgers-RWJMS, New Brunswick, NJ, USA.
Objectives: Despite promising clinical results, the use of drug-eluting coronary stents (DECS) in tibial revascularization remains limited. Through a retrospective review of our experience with tibial DECS in patients with critical limb ischemia (CLI) and tissue loss, we evaluate patency and TLR rates, wound severity score (WIfI), freedom from major amputation, and all-cause mortality. The adjunctive use of hyperbaric oxygen therapy (HBOT) in a subgroup of these patients is reviewed and analyzed.
Methods: Over a 3-year period, 35 tibial revascularization procedures were performed in 28 patients. Two patients were excluded given non-atherosclerotic indications. Ankle-brachial index (ABI) and WIfI scores before and after DECS deployment were examined. Paired t-tests were used to compare WIfI scores before and after DECS with and without adjunctive HBOT.
Results: 69 tibial DECS were deployed in 26 patients. Average age was 68.2 years (76.9% male, 23.1% female). Average follow-up was 10.2 months (range: 2-31.5). 38.5% received HBOT. When calculable, average pre-op ABI was 0.65 +/- 0.21 which improved to 0.96 +/- 0.21 post-operatively (p=0.037). Mean pre-op WIfI scores were 2.0, 2.24, 1.56 which improved to 1.04, 0.61, 0.88 post-operatively (p=0.10, p=0.4, p=0.11). WIfI scores for DECS alone vs. DECS with adjunctive HBOT were 1.2, 0.71, 0.93 and 1.08, 0.2, 0.83, respectively (p=0.12, p=0.02, p=0.4). Overall mortality was 0.04% (1/26) and no patient required TLR. Freedom from major amputation was 92%. 4 stents failed in one patient, for a total failure rate of 5.8% and a primary patency rate of 94% at the time of last follow-up.
Conclusions: Despite lack of an infrapopliteal peripheral indication and limitations in stent design, tibial DECS patency rates and clinical outcomes continue to be promising in appropriately selected patients. While we cannot demonstrate at this time a statistically significant improvement in WIfI score with the use of DECS, adjunctive HBOT in these patients can be a significant factor in alleviating wound ischemia. Expanding the indication and configuration of DECS to the tibial realm can lead to a larger clinical experience and more accurate evaluation of clinical outcomes.
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